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IPN • March 2012 1

March 2012 Volume 1 Issue 41


In this issue: NEWS:

Pharmacies amongst some of the best managed companies in Ireland page 4


This month’s profile features Marian Shanley, Chairperson of the National Forum, who explains the reasoning behind the creation of the National Forum and her role in its delivery page 9



The lapse of the HSE/IPHA pricing agreement on March 1, 2012 is discussed in this month’s debate Page 16

REDUCING FEVER Reduces high temperatures (over 39.2ºC) more effectively than paracetamol.2


Continuing Professional Development focus on Anxiety Disorders Page 29



to relieve fever in just 15 minutes.




Provides fever relief for up to 8 hours.2

The baby care market in Ireland Page 36

*IMS OTC Sales NFC Jan 2012 Item No: NFC-IE-04-12. Date of Prep: March 2012.


COMES WITH SYRINGE FOR ACCURATE DOSING. Abbreviated Prescribing Information for Nurofen for Children Strawberry 100mg/5ml Oral Suspension. Active ingredient: Ibuprofen 100 mg/5 ml (equivalent to 2.0% w/v) Pharmaceutical Form: An off-white strawberry flavoured syrupy oral suspension. Indications: Reduction of fever and relief of mild to moderate pain, such as cold and flu symptoms, teething pain, headache, sprains and strains and to ease the pain of sore throats and earache. Dosage: For pain and fever: The daily dosage of Nurofen for Children is 20 to 30 mg of ibuprofen/kg bodyweight in divided doses. This can be achieved as follows: 3-6 months (weighing over 5kg): 2.5ml, 3 times a day. 6-12 months: 2.5ml, 3 times a day. 1 to 3 years: 5 ml, 3 times a day. 4 to 6 years: 7.5 ml, 3 times a day. 7 to 9 years: 10 ml, 3 times a day. 10 to 12 years: 15 ml, 3 times a day. Do not dose more frequently than at 6 hourly intervals. Not suitable for children under 3 months of age unless advised by your doctor. For oral administration. For short term use only. Contraindications: severe hepatic failure, severe renal failure or severe heart failure. History of GI bleeding or perforation related to previous NDAID therapy. History of, or existing peptic ulceration, or other gastrointestinal disorders. Known hypersensitivity to any of the ingredients. History of bronchospasm, asthma, rhinitis, urticaria, associated with aspirin or other non-steroidal anti-inflammatory drugs. Special Warnings and Special Precautions for Use: Concomitant use of NSAIDs including cyclooxygenase-2 selective inhibitors should be avoided. Undesirable effects may be minimised by using the minimum effective dose for the shortest duration necessary to control symptoms The elderly have increased frequency of adverse reactions to NSAIDs especially GI bleeding and perforation which may be fatal. GI bleeding, ulceration or perforation, which can be fatal, has been reported with all NSAIDs at any time during treatment, with or without any warning symptoms or a previous history of serious GI events. The risk is higher with increasing NSAID doses, in patients with a history of ulcer, particularly if complicated with haemorrhage or perforation and in the elderl y. Combination therapy with protective agents should be considered for these patients and also for patients requiring low dose aspirin or other drugs likely to increase GI risk. Patients with a history of GI toxicity, particularly when elderly, should report any unusual abdominal symptoms, particularly in the initial stages of treatment. Caution should be advised in patients receiving concomitant medications which could increase the risk of ulceration or bleeding, such as oral corticosteroids, anticoagulants, selective serotonin reuptake inhibitors or anti-platelet agents such as aspirin. Treatment should be withdrawn if GI bleeding or ulceration occurs. Caution is required in patients with a history of GI diseases, cardiac impairment or a history of hypertension and/or heart failure (see SmPC). Use of ibuprofen may be associated with a small increased risk of arterial thrombotic events. Overall, epidemiological studies do not suggest that low dose ibuprofen (e.g. < 1200mg daily) is associated with an increased risk of myocardial infarction. Caution is required in patients with renal or hepatic impairment. Elderly patients are particularly susceptible to the adverse effects of NSAIDs. Prolonged use is not recommended. Where prolonged therapy is required, patients should be reviewed regularly. Caution is required in patients with idiopathic thrombocytopenic purpura (ITP), intracranial haemorrhage and bleeding diathesis. Serious skin reactions, some of them fatal, including exfoliative dermatitis, Stevens-Johnson syndrome and toxic epidermal necrolysis, have been reported very rarely in association with the use of NSAIDs. Treatment should be discontinued at the first appearance of skin rash, mucosal lesions, or any other sign of hypersensitivity. May impair female fertility by an effect on ovulation. This is reversible on withdrawal of treatment. Bronchospasm may be precipitated in patients suffering from, or with a history of, bronchial asthma or allergic disease. Caution is advised in patients with systemic lupus erythematosus, and connective tissue disease. Patients with rare hereditary problems of fructose intolerance should not take this medicine. Interactions: Please see SmPC for full details: Other NSAIDs (including low dose aspirin), Corticosteroids, Anti-coagulants, Anti-platelet agents and selective serotonin reuptake inhibitors (SSRIs), warfarin or heparin, ACE inhibitors and Angiotensin II Antagonists, Cardiac glycosides, Lithium, Methotrexate, Cyclosporin, Aminoglycosides, Probenecid, Oral hypoglycemic agents & Zidovudine. Pregnancy and Lactation: Not recommended in the first 6 months of pregnancy. Do not use in the last trimester of pregnancy. It is not necessary to interrupt breast-feeding for short-term treatment with the recommended dose for mild to moderate pain and fever. Undesirable Effects: The list of the following adverse effects relates to those experienced with the product at OTC doses, for short-term use. In the treatment of chronic conditions, under long-term treatment, additional adverse effects may occur. Gastrointestinal Disorders: Uncommon: Abdominal pain, dyspepsia and nausea. Rare: diarrhoea, flatulence, constipation and vomiting. Very rare: maelaena, haematemesis, ulcerative stomatitis. Exacerbation of colitis and Crohn’s disease. Peptic ulcers, perforation or bleeding, sometimes fatal, particularly in the elderly may occur. Less frequently, gastritis. Nervous System Disorders: Uncommon: Headache. Kidney and Urinary Disorders: Very rare: Decrease of urea excretion and oedema can occur. Also, acute kidney failure. Papillary necrosis, especially in long-term use, and increased serum urea concentrations. Liver Disorders: Very rare: Liver disorders, especially in long-term treatment. Blood and Lymphatic System Disorders: Very rare: Haematopoietic disorders. First signs are: fever, sore throat, superficial mouth ulcers, flu-like symptoms, severe exhaustion, nose and skin bleeding. Skin and Subcutaneous Disorders: Very rare: severe forms of skin reactions such as erythema multiforme, epidermal necrolysis and Stevens-Johnson syndrome can occur. Immune system Disorders: Very rare: In patients with existing auto-immune disorders during treatment with ibuprofen, single cases of symptoms of aseptic meningitis, such as stiff neck, headache, nausea, vomiting, fever or disorientation have been observed. Hypersensitivity Reactions: Uncommon: Hypersensitivity reactions with urticaria and pruritus. Very rare: severe hypersensitivity reactions. Symptoms could be facial, tongue and larynx swelling, dyspnoea, tachycardia, hypotension, (anaphylaxis, angioedema or severe shock). Exacerbation of asthma and bronchospasm. Cardiac Disorders: Very rare: Oedema, hypertension and cardiac failure. Respiratory system disorders: asthma, aggravated asthma, bronchospasm or dyspnoea. Cardiovascular and Cerebrovascular: May be associated with a small increased risk of arterial thrombotic events (particularly at high doses and in long term treatment). Overdose: symptoms of overdose can include nausea, vomiting, abdominal pain, headache, dizziness, drowsiness, nystagmus, blurred vision, tinnitus and, rarely, hypotension, metabolic acidosis, renal failure and loss of consciousness. No specific antidote is available. Patients should be treated symptomatically as required. Use supportive care where appropriate. Legal Category: Retail sale through pharmacies only. Pack Sizes: 100ml bottle with spoon, 150ml bottle with syringe. PA Holder: Reckitt Benckiser Ireland Ltd., Citywest Business Campus, Dublin 24. PA number: PA 979/32/9 Date of preparation: September 2009. For full prescribing information, please consult the SmPC which is available on For product queries please call (01) 630 5429 or contact Reckitt Benckiser Ireland Ltd., Citywest Business Campus, Dublin 24. References: 1. Pelen F, Verriere F et al. Treatment of fever: Monotherapy with ibuprofen. Ibuprofen paediatric suspension containing 100mg per 5ml, Multi centre acceptability study conducted in hospital. Annales de Pédiatrie 1998; 45 (10): 719-28. 2. Kelley M, Walson P, et al. Pharmacokinetics and pharmacodynamics of ibuprofen isomers and acetaminophen in febrile children. Clinical Pharmacology and Therapeutics 1992; 52: 181-9.

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Pain... It’s a personal thing! ABBREVIATED PRESCRIBING INFORMATION. Please refer to the Summary of Product Characteristics before dispensing: Buplex 200 mg and 400 mg Film-coated Tablets. Indications: Mild to moderate pain, such as headache including migraine headache, dental pain. Primary dysmenorrhoea. Fever. Dosage: Short-term use only, not longer than 7 days. Dose depends on the patient’s age and body weight. Tablet should be swallowed with a glass of water during or after a meal. Primary dysmenorrhoea: Adults and adolescents over 12 years of age: 200-400 mg 1-3 times a day, every 4-6 hours, as required. Maximum daily dose: 1200 mg. Mild to moderate pain and fever: Adults and adolescents older than 12 years (≥40 kg): 200-400 mg as a single dose or 3-4 times a day every 4 to 6 hours. In migraine, 400 mg as a single dose, if necessary 400 mg every 4-6 hours. Maximum daily dose: 1200 mg. Buplex 200 mg only: Children 6-9 years (20-29 kg): 200 mg 1-3 times a day every 4 to 6 hours as required. Maximum daily dose: 600 mg. Children 10-12 years (30-40 kg): 200 mg 1- 4 times a day every 4 to 6 hours as required. Maximum daily dose: 800 mg. Contraindications: Hypersensitivity, History of gastrointestinal bleeding or perforation related to previous NSAID therapy, Active or recurrent peptic ulcer/haemorrhage, Severe hepatic or renal insufficiency, Severe heart failure or coronary heart disease, Last trimester of pregnancy, Significant dehydration, Cerebrovascular or other active bleeding, Dishaematopoiesis of unknown origin, Children younger than 6 years of age. Warnings and Precautions: Use the lowest effective dose for the shortest duration necessary. Asthmatic patients should seek doctor’s advice. Avoid concomitant use with other NSAIDs, including COX-2 inhibitors. Strict benefit-risk ratio consideration in the following conditions: SLE or other autoimmune diseases, Congenital disturbance of porphyrin metabolism, First and second trimesters of pregnancy and Lactation. Special care in following cases: GI diseases including chronic inflammatory disease (ulcerative colitis and Crohn’s disease), Cardiac insufficiency, Cardiac insufficiency and hypertension, Hepatic dysfunction, Disturbed haematopoiesis, Blood coagulation defects, Allergies and respiratory disorders, After major surgical interventions. GI bleeding, ulceration and perforation may occur with or without warning symptoms or previous history of GI events. Consider combination therapy with protective agents (e.g. misoprostol or proton pump inhibitors) for at risk patients. All patients, particularly the elderly and patients with impaired hepatic and renal function, on long term NSAID treatment should be kept under regular surveillance with monitoring of renal, cardiac and hepatic function and of haematological parameters. High dose and long term use may be associated with a small increased risk of arterial thrombotic events. Careful consideration before long term use in patients with cardiovascular disease or risk factors. Discontinue at first sign of skin rash, mucosal lesion or other sign of hypersensitivity. Symptoms of an infection may be masked. May impair female fertility. Avoid consumption of alcohol. Interactions: Avoid: Low dose aspirin; Other NSAIDs; Anti coagulants; Ticlopidine; Methotrexate. Caution: Moclobemide; Phenytoin; Lithium; Cardiac glycosides; Diuretics and antihypertensives; Captopril; Aminoglycosides; SSRIs; Ciclosporin; Cholestyramine; Tacrolimus; Zidovudine; Ritonavir; Mifepristone; Probenecid; Sulfinpyrazone; Quinolone antibiotics; Sulphonylureas; Corticosteroids; Anti-platelet aggregation agents; Alcohol; Bisphosphonates; Oxpentifylline; Baclofen. Pregnancy and Lactation: Pregnancy - During the first and second trimester of pregnancy Buplex should not be given unless clearly necessary. Buplex is contraindicated during the third trimester of pregnancy. Lactation - With therapeutic doses during short term treatment the risk for infant seems unlikely. If longer treatment is prescribed, early weaning should be considered. Side Effects: Headache, somnolence, vertigo, fatigue, agitation, dizziness, insomnia, irritability, GI disturbances, flatulence, constipation, dyspepsia, abdominal pain, gastrointestinal ulcers, sometimes with bleeding and perforation, occult blood loss which may lead to anaemia, melaena, heamatemesis, ulcerative stomatitis, colitis, exacerbation of inflammatory bowel disease, complications of colonic diverticula. Shelf Life: 3 years. Pack Sizes: Blister: (200 & 400mg) 12, 24 & (200 mg only) 50 film-coated tablets. Marketing Authorisation Holder: Actavis Group PTC ehf, Reykjavikurvegi 76-78, 220 Hafnarfjordur, Iceland. Marketing Authorisation Number: PA 1380/87/1-2. Legal Category: Product not subject to medical prescription. Retail sale through pharmacies only. Further information including the SPC 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 at Date of Generation of API: November 2011. Date of Preparation: December 2011. FADHCP-010-02

IPN • March 2012 3



4 Pharmacies amongst some of the best managed companies in Ireland


9 This month’s profile features Marian Shanley, Chairperson of the National Forum, who explains the reasoning behind the creation of the National Forum and her role in its delivery

Bridget Casey


12 La Roche Posay introduce new Cicaplast Baume B5 16 The lapse of the HSE/IPHA pricing agreement on March 1, 2012 is discussed in this month’s debate



26 Feature - Parkinson’s Disease

If pharmacists were to run their businesses in any such manner, they would be struck off the register but, as it is, because they do not want to be stuck with losses, their stocks are being depleted, which is not in the interests of the health of the Irish public.

29 Continuing Professional Development Series - Anxiety Disorders 36 Feature - The baby care market in Ireland


44 Shop Front- Keith Harford discusses category management in the baby section of the pharmacy 57 Product Profiles 54

58 Appointments

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The words: 'party', 'organise' and 'brewery' immediately spring to mind regarding the fact that the Health Services Executive and the Irish Pharmaceutical Healthcare Association have not replaced the last pharmacy pricing agreement, which lapsed at the beginning of March. The situation is one that is totally inexcusable and utterly disgraceful, not to mention inefficient and negligent.

Not only are pharmacists aware that any price changes will probably be dropped on them like an atomic bomb in the hands of an irresponsible dictator but they are also being asked to secondguess what is in the minds of the authorities. This is a purely one-sided affair, where the husband/ wife holds all the assets in their hands and expects the rest of the family to go and beg off the State for subsistence. Only in reverse. Everyone understands that the Government is having to make cuts. Everyone understands that the HSE is looking for savings. Everyone knows that this is a necessity but the simple courtesies of life seem to be flying out of the window. Would that we are wrong. Pharmacies are at the mercy of governments. They have to plan ahead in order to look after their patients in a courteous and professional manner and it certainly is not reasonable for them to be expected to underpin the health service by having to subsidise their patients' drugs. Incidentally, hats off to all those pharmaceutical manufacturers, who have offered pharmacies a guarantee that they will be reimbursed if there are any shortfalls caused by an official decrease in reimbursement of any of their products. However, they too must be getting a little tired of being constantly tapped for money by the various government departments and also for being unable to implement their business plans as accurately as they would like. Most of these companies are responsible to their shareholders and this is a situation that any resident cartoonist could make a meal of in the AGM Annual Report and Accounts.

4 March 2012 • IPN

News news brief Competition Act delays new pharmacy contracts The Irish Pharmacy union has been told by the Department of Health that it will enter into discussions with pharmacists regarding new contracts within the next few years.

Pharmacies some of the best managed companies in Ireland

The Department of Health is currently clarifying issues around the Competition Act in order to determine what form of engagement with pharmacists would be acceptable. The Irish Pharmacy union has been told by the Department of Health that it will enter into discussions with pharmacists regarding new contracts within the next few years. Sam McCauley Chemist - Patrick McCormack Sam McCauley and Dr Phil Nolan Executive Chairman IMI

Receiver puts five pharmacy investments on market A number of properties involving pharmacies in Cork, Tipperary and Kildare have gone up for sale on the instructions of receiver Paul McCann of Grant Thornton. Patricia Ward of DTZ Sherry FitzGerald handled the sale of the pharmacies which offered long unexpired lease terms with upward-only rent reviews and the ability to increase rental income from ancillary accommodation in several locations. DTZ sought in the region of €425,000 for a commercial building at Duke Street, Athy, Co Kildare, which is producing €32,500 from a pharmacy and €15,000 from three apartments. A price of €425,000 was sought for a pharmacy investment at Togher shopping centre in Cork. The 141sq m (1,518sq ft) retail premises was let on a 27-year lease from 2004 at a rent of €60,000. In Thurles, a figure of about €300,000 was being quoted for a pharmacy producing €35,000 a year under a 35year lease from 2004. The estate agent was looking for €255,000 for a pharmacy at North Square in Macroom, Co Cork, which is rented at €45,000 a year under a 31year lease from 2008. And at Blarney Shopping Centre another pharmacy producing €32,000 a year was available for €230,000 under a 35-year lease from 2004.

Cara Pharmacy - Canice and Ramona Nicholas

Sam McCauley Chemist - Patrick McCormack Sam McCauley and Dr Phil Nolan Executive Chairman IMI

The Deloitte Best Managed Companies were announced at an awards gala dinner at the Burlington Hotel in Dublin this month. Pharmacy fared well, with three pharmacies being recognised in these awards. Cara Pharmacy was one of the twenty overall winners whilst Sam McCauley Chemist and Medicare Pharmacy Group were recognised as being two of 16 gold standard companies.

a major difference to the performance of our indigenous businesses, but which has not been adequately targeted by recent governments.

The independent judging panel, chaired by Liam O’Mahony, measured the companies’ performance by looking at a broad range of criteria including strategy, capability, commitment, financials and management performance across all key functions of the business. Commenting on the announcement of the winners, Minister for Jobs, Enterprise and Innovation, Richard Bruton, TD, said, “If we are to achieve the levels of employment and economic growth we so badly need, we must create a powerful engine of indigenous businesses. The quality of management in Irish companies is an issue which can make

“Through the Action Plan for Jobs we are determined to change this. We will deliver a series of measures in 2012, including improved mentoring, €1.2million per annum in additional funding for management development networks and more businesses benefiting from management programmes. “Today’s event shows what is possible in Irish businesses with proper management and I congratulate all involved.” David Harney, CEO, Irish Life Corporate Business, and fellow judging panel member said, “Ireland's best natural resource is still our people and as a country we have a huge demographic advantage particularly over our European neighbours. Best in class management of our companies is key to capitalising on this resource. Seeing the progress of companies in this programme would make one very optimistic about the future.”

IPN • March 2012 5


Sam McCauley Chemists group brings jobs to Clonmel

news brief Pharmacy Technicians strengthen Local Pharmacy Services A total of 104 pharmacy technicians were awarded with a level-three National Vocational Qualification (NVQ) from City and Guilds at a special ceremony held in Dublin. In a statement, the Irish Pharmacy Union said that pharmacy technicians provide a vital supporting role to pharmacists in the delivery of a high-quality front-line healthcare service in the community.

Approximately twenty new jobs will be created in Clonmel following the announcement that Sam McCauley Chemists will be opening a new 4000 sq ft store in the Showground’s Shopping centre there in March.

Presenting the graduates with their certificates, President of the Irish Pharmacy Union, Darragh O'Loughlin, 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.

Making the announcement, Managing Director, Patrick McCormack, said, “We are delighted to announce a good news story about an Irish brand which has its roots in the south east region. The Sam McCauley Chemists group continues to grow from strength to strength and the opening in Showground’s will be our 26th store. “Not only will this Pharmacy and health and beauty store be an exciting addition for the shoppers of Clonmel, but it will also create much needed jobs in the area. Sam McCauley Chemist estimates that this store will create employment for up to 20 people, which is fantastic news for the County.” McCormack also announced that their pharmacy at Davis road will reopen in April, creating further employment. He said, “When we re-open our Davis road store at the Dunnes Stores shopping centre in addition to our existing stores in Carrick on Suir, Poppyfields and Showground’s we will

“It is only in developing our professional role that we can maintain our position as an integral part of primary health care and secure the future of the essential services we provide to our patients.”

Patrick McCormack

be employing almost 60 people in County Tipperary.” The Sam McCauley Chemist group now employs over 550 people in its 26 locations throughout Ireland and has further plans for expansion.

The comprehensive two-year training course for pharmacy technicians is ten years in the running and, is delivered and administered by the Irish Pharmacy Union in conjunction with the National Pharmacy Association in the UK and City and Guilds.

Pharmacy success at RCSI College Ball! The Pharmacy Students Society of the Royal College of Surgeons Ireland scooped a number of awards at the recent College Ball held in the Burlington Hotel. Over 600 students partied the night away at a 'Fire and Ice' themed event. The main focus of the night were the presentation of awards to the hard working Student Societies. This year close to 40 Societies represented their nationality, culture, interests and shared pastimes and often giving up a great deal of their spare time to do so. With close to 40 societies in the College, some events have to take place away from the College and this year saw a new award in the form of ‘Off Campus Event of the Year'. This award went to the Pharmacy Society and Society President Martin Lanigan was on hand to receive this award on behalf of Pharm Soc. It is important to remember that Societies are a great place for new students to find their feet when new to RCSI. It was this in mind that the "Fresher of the Year" award is made. The competition was fierce and the competition so close that a joint award was made to Mohini Gadre for her work with the Art Society and to Angela Verelli who has worked hard for the Pharmacy Society.

Aine O'Keeffe, Sharon Sutton, Martin Lanigan, Rachel Cuddihy, Aoife Forde and Katie O'Neill, RCSI Pharmacy Society, who were winners of the 'Off Campus Event of the Year' Award

6 March 2012 • IPN

News news brief Problem solved - back to square one

Government needs to recognise dilemma

The Department of Health has announced that any patient, whose medical card has been cancelled, may continue to use their out-of-date card until new cards have been issued. In January, Paddy Burke, Head of the PCRS, denied that a significant number of cards had been cancelled after patients had complained that their medical cards had not been renewed. Apparently, the IPU says that it has been working with the PCRS for some time to try to resolve this issue, in order to ensure that patients can continue to get their medicines under the medical card scheme. The HSE has accepted that there are a number of issues in relation to the processing of medical card applications and reviews at this time. In line with the centralisation plan, the HSE is taking a number of steps to streamline operations in the central office and to make the process for renewing a medical card simpler and easier for the public. As part of this, the HSE is moving towards a self-assessment review for medical card holders who are 66 years or over. Darragh O’Loughlin, president of the IPU said, “This (DoH announcement) will come as a relief to a significant number of patients, especially those who are worried about getting their medicines whilst waiting for their medical cards to be renewed. “The health and wellbeing of patients is our main concern. Nobody benefits if people stop taking their medicines. In fact, it could end up costing the State even more money if patients end up becoming seriously ill or are hospitalised as a result.”

Barry O’Leary, IDA Ireland chief executive, David Gallagher, IPHA President, Anne Nolan, IPHA Chief Executive, Minister of State John Perry, T.D.

The Irish Pharmaceutical Healthcare Association (IPHA) and PharmaChemical Ireland (PCI) have called on the Government to work alongside the industry to develop sustainable policies to secure the future of Ireland’s biopharmaceutical industry, which is facing unprecedented challenges. According to the IPHA and PCI at a special meeting held to discuss the situation, the sustainability of the sector in Ireland will require innovative and strategic health, economic and education policies and a collaborative joint approach. The meeting was chaired by PCI Director Matt Moran, whilst Minister of State at the Department of Jobs, Enterprise and Innovation, John Perry, T.D., joined IBEC Director General Danny McCoy, IDA chief executive Barry O’Leary and IPHA President David Gallagher. Opening the meeting, Moran said, “Government policy needs to urgently recognise the very serious challenges facing the industry. A number of blockbuster drugs are coming off patent, with some commentators estimating the resulting fall in worldwide revenues to be as much as €100bn. Many of these blockbuster drugs are manufactured in Ireland. The key challenge is to continue to develop the sector as a global centre of excellence for

innovation and development. “Our healthcare policy must support access to innovative medicines and medical technologies that are developed in Ireland. It is vital that the Government continues to take a long-term view of the overall cost of healthcare and views it as an investment in the nation’s health and economic prosperity. Such an approach will send a positive signal to pharmaceutical companies.” O’Leary highlighted how important it is that Ireland protects its reputation as a choice investment for multinational pharmaceutical companies and called for deeper and broader engagement of all stakeholders to work together to ensure this remains the case. He said, “Ireland is now home to 9 out of the top 10 global pharmaceutical companies. Ireland is a key global location for pharmaceutical activities, including manufacturing, services, research and development. As a result, a number of excellent pharmaceutical investments have been made in Ireland in recent months. Between them Abbott, Allergan and Pfizer have invested €630 million just recently, not to mention the jobs aspect and Amgen, the world's largest biotechnology company has acquired manufacturing facilities in Dun Laoghaire."

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In the event of any potential price reduction, credit for returned stock will be issued at the full price paid before reductions. Send your order electronically and receive our full service on over 200 lines. Order your PIâ&#x20AC;&#x2122;s daily, weekly or monthly. For further details contact: Richard on 086 024 4622, for pharmacies in Cork and Kerry. Keith on 087 770 0212, for pharmacies in Dublin South, Wicklow, Wexford and Waterford. Kieran on 086 049 0487, for pharmacies in Dublin North, Louth, Monaghan and Meath. Tadhg on 087 283 1528, for pharmacies in Limerick, Tipperary, Laois, Carlow and Kilkenny. Genevieve on 086 049 0991, for pharmacies in Kildare, Westmeath, Donegal, Leitrim, Longford, Cavan and Offaly. Pearse on 086 104 8600, for pharmacies in Galway, Mayo, Sligo, Clare and Roscommon.

IPN • March 2012 9


Introducing Marian Shanley, Chairperson of the National Forum for Pharmacy Education and Accreditation in Ireland At first, I was attracted to the idea of being part of an implementation programme. The National Forum is not just another reportwriting body. It is charged with effecting change and I wanted to be a driver of change.

Following the virtually simultaneous launch of the National Forum for Pharmacy Education and Accreditation and the Irish Institute of Pharmacy, Irish

Pharmacy News talked to the Chairperson of the National Forum, Marian Shanley about her responsibilities in delivering a new framework for pharmacy education.

Shanley, a solicitor is also known as a Law Reform Commissioner and it was her work at the Law Reform Commission of Ireland that precipitated her appointment by the Council

of the PSI and, as she said, “I have an understanding of the process of building consensus for change.” Shanley’s relationship with

10 March 2012 • IPN

Profile There is no doubt that offering your experience to the development of your profession is a fundamentally altruistic act and that will remain the case, whatever supports are put in place.

pharmacy is slight; her only other connection to it being that she chaired the first ever public hearing of the PSI’s Professional Conduct Committee. In her capacity as Chairperson of the ‘National Forum’, she is responsible for putting in place the framework within which the Schools of Pharmacy in Ireland can develop their own curriculae. She added, “The National Forum is essentially a forum for stakeholder engagement.” So, what persuaded the (parttime) Law Reform Commissioner to decide to take on such a responsible position? Shanley said, “At first, I was attracted to the idea of being part of an implementation programme. The National Forum is not just another report-writing body. It is charged with effecting change and I wanted to be a driver of change. “As I have grown into the role, my overwhelming motivation has been a strong belief that what is proposed by the PSI for the development of Pharmacy (of which education is a part) is in the National Interest. I think the PSI initiatives will be good for the country and will be good for both patient care and the profession and I am totally committed to doing what I can to support that.” Shanley is mainly concerned about successfully delivering a truly integrated curriculum. She explained, “By that, I don’t just mean work-placements dispersed throughout the years. The entire learning experience must be integrated. When the student learns the science and therapeutics of a module, that knowledge must be immediately contextualised into a workplace/ problem solving setting. When this is done properly, it greatly increases the student’s ability to absorb information and will result in better informed and practice-ready graduates, for a variety of practice settings and for the multi-professional healthcare environment.

“I am also focussed on ensuring that the current high standards of pharmacy education are not compromised in any way.”

said that she, alongside the other members of the National Forum, are working towards implementation by 2013.

Shanley strongly believes that integrated education will bring 'added value' to the pharmacy degree and that it will not, in any way, involve a diminution of what is already there.

She added, “We would like to see the schools allow a crossover for first year students who are entering in 2012, which would mean that our first graduates would be in 2017.”

According to Shanley, the National Forum is unique to Ireland and is wholly based on the recommendations made by the authors of the PEARs report. This begs the question; since the report was written by two UK academics, why is it that these recommendations have not been adopted by the Schools of Pharmacy across the pond?

Funding is one area that has caused much concern amongst academics in the Schools of Pharmacy throughout Ireland, most notably Professor Marek Radomski, Head of the School of Pharmacy at Trinity College Dublin (TCD). He told IPN in September that the School of Pharmacy at TCD was running at a budget deficit of €700,000 for the year 2011. He added that he has expressed these concerns quite candidly to the PSI and the National Forum that his school simply lacks the funds to carry out an extensive reformation of the pharmacy curriculum.

Shanley answered, “The team at Aston University was commissioned by the PSI to carry out the PEARs project. I cannot comment on what developments may happen in the UK – the new pharmacy regulator there is even more recently established than the PSI. But I do know that many countries are watching our progress with great interest to see how they might learn from it as, indeed many other professions and sectors here in Ireland are interested in the model of the Forum and how it might be applied in their particular field.” She added that the National Forum was suggested by the authors of the PEARs report as a way of introducing change in a consultative and constructive way. She said, “My experience of the process so far would suggest that they were correct in suggesting that this would allow the curriculum to develop in a way that would accommodate the needs of as many stakeholders as possible. “It is also interesting to note that similar concepts are arising in some international thinking about the network governance of higher education.” The length of time it will take for the new programme to be delivered is unclear but Shanley

He said, “I want a clear-cut idea as to who is going to pay, otherwise it would be lunacy to jump into a swimming pool that contains no water!” In response to these concerns, Shanley said, “Funding issues are being considered by the funding sub-committee of the National Forum, which will make recommendations to the Council of the PSI. But ultimately, this is a matter for the academic institutions and the Forum is working to facilitate progress in this area.” Another question that remains outstanding is: Why can the National Forum not be responsible for developing Continuing Professional Development (CPD) as well as reforming the undergraduate curriculum? In other words, why is there a need for two separate institutions to develop the area of pharmacy education? Shanley answered this question by saying that the National Forum and the Irish Institute of Pharmacy are two very different ventures.

IPN • March 2012 11

Profile She said, “While the Forum has a specific mandate, the new Institute will have an on-going and long-term role in delivering professional development to the profession and facilitating the development of pharmacy practice in Ireland.” In calling for an integrated system of education that combines excellence in academic teaching with relevant practical experience, it is clear that community pharmacists will, at some stage be called upon to provide work experience to the new generation of pharmacy students. At present, many pharmacists are opposed to

working as pharmacy tutors for no payment and there is no sign that this sentiment is likely to change any time soon. Shanley is of the belief that the role played by tutor pharmacists will be pivotal to the development of the next generation of the profession, in that they will act as mentors and role models for their interns and students and she believes that the value of tutor pharmacists cannot be underestimated. “Pharmacist tutors enable pharmacy students to become competent pharmacists, with all the skills necessary to contribute to patient care and safety and

be valuable members of the healthcare team,” she said. "And," she added, “Their role is important for the pursuit of excellence in the practice of pharmacy generally. “It can be argued that a stipend paid to tutors could not reflect the hours and dedication they give to this role but I think that appropriate recognition of their contribution and support for them in carrying out this role is vital.”

the tutor, a career path into academia and the development of teaching pharmacies. On this point she concluded, “There is no doubt that offering your experience to the development of your profession is a fundamentally altruistic act and that will remain the case, whatever supports are put in place.” However, whether or not pharmacists on the ground share these same values, remains to be seen.

Shanley recommended some methods for rewarding tutors for their time and effort, which include: CPD recognition for

An Taoiseach Enda Kenny, Paul Fahey, PSI President, Marian Shanley, Chairperson of the National Forum for Pharmacy Education and Accreditation in Ireland

12 March 2012 • IPN

News news brief Receipt of Formal Notice from the European Commission

The European Commission has issued the State with a Letter of Formal Notice under Article 260 TFEU. The notice comes following the European Court of Justice’s judgement against Ireland on September 29, 2011 which found that the State had failed to apply EU law relating to non-life insurance equally to all insurance undertakings.

La Roche Posay introduce new Cicaplast Baume B5

The effect of the ruling is that VHI healthcare can no longer derogate from the requirement to be authorised by the Central Bank of Ireland (CBI). In response to this judgement on September 29, 2011, the Government agreed to: • Engage with the Commission to address the ruling. • Work with the VHI and the Central Bank of Ireland on an application for authorisation by the CBI, with a decision then to be taken regarding the question of capitalisation. • Examine the legal and legislative requirements to allow for the incorporation of the VHI as a limited company. • Examine other options for the future status of the VHI.

La Roche Posay- Janette Ryan, La Roche Posay Pharmacy Trainer

The Sunday Business Post reported in advance of the Formal Notice being made, that the commission was set to reject government proposals put forward before Christmas for reforming the Stateowned health insurer.

La Roche Posay launched its latest product, Cicaplast Baume B5 to the Irish market at the Science Gallery in Dublin this month.

The Letter of Formal Notice that was received by the government is a procedural notification that the Commission is obliged to issue within six months of a judgement. The letter had been expected and the Department has been in regular contact with the Commission in relation to the case. The Department of Health will continue to work with the Commission to progress a range of issues relating to the legal status of the VHI. It is making good progress in relation to these and will press ahead with them as planned. Dr James Reilly, Minister for Health said that he will consider the terms of the Formal Notice in the normal way and respond to the Commission within the two month period given by it.

Janette Ryan, pharmacy training manager at Vichy and la Roche Posay said, “This product is a must have for everyone in the family, from the most sensitive of babies to the most hard-core tattoo enthusiasts. Mothers in particular have found this product to be extremely useful as it can be used as a hand moisturiser while also being used to prevent and treat nappy rash in their babies.” Dr Geraldine Morrow, Consultant Dermatologist said, “I found that Cicaplast Baume B5 really helped to relieve my patients of the effects of cheilitis (cracked lips) and was most effective in treating irritative and cracked dermatitis. “I would be happy to continue using this product and my patients would certainly recommend using it.”

Toni Haberland, Patricia O’Shea, Doc Morris, Clonskeagh

Guest speakers at the launch included Dr Geraldine Morrow, Consultant Dermatologist and Selene Daly, Dermatology Clinical Nurse Specialist at the HSE. They each discussed the results of their respective clinical observational trials using the new product and their findings were extremely positive.


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14 March 2012 • IPN


Irish Pharmacy Awards Supporting Community Pharmacy & the Jack and Jill Foundation Nominations for the 2012 Irish Pharmacy Awards have been coming into the IPN offices from right across the country with heart-warming stories of Pharmacists and their teams who have been delivering a service well beyond the expectations of customers.

Indeed it is the recognition of fellow health professionals that has elevated the quantity of nominations above what we would normally expect from pharmacy practitioners’ though-out the country. GP’s, Health Visitors, District Nurses and many other allied health professionals have been sharing their stories of excellence in service and practice and are delighted to be able to recognise the value that their community pharmacy brings to the people they all serve. Despite the hard pressures on pharmacy businesses it is very clear that whether pharmacies are owner managed, are part of a small independent chain or one of the large multiples, there has been continued investment in people and services. It is crucial that this investment is recognised and promoted to continue to drive support from customers on a local basis. Community pharmacy in tandem with our GP network is the backbone of our national health provision and that is why we and our sponsors are determined to recognise success within the sector and in the public domain. National Weekly Paper Pharmacy Competition The partnership with The Jack & Jill Children’s Foundation will be the subject of a national weekly paper competition in the coming weeks. This is aimed at giving the public a unique opportunity to nominate and praise their local pharmacist.

Hardship comes in many forms, whether it is manifest in the immediate needs of pharmacists and their families in real distress through death, illness or business failure or the plight of hundreds of pharmacies throughout the country fighting to maintain their business and operating on wafer thin margins. At IPN we recognise all of those needs and are taking up the fight for the future of hundreds of pharmacies throughout the country. The general public do not realise that if they don’t support their local pharmacy it may not be there in the future to support them. Promoting excellence through the IPN Awards and publicising the winners will drive awareness of the best we have to offer in professional terms. The competition aimed at the general public will give them the opportunity to share their stories of individual pharmacists and pharmacy practices that have gone the extra mile for them. It is our opportunity to ensure that Pharmacists have their day in the sun as community heroes. There are many ways to support the business of pharmacy in Ireland. What we at IPN are doing is just one part of the wide spectrum of support that is required. Our sponsors and judges are doing their part to support those working at the coalface of Pharmacy in Ireland and we know that they will not limit their support to these awards.

The support of the Jack and Jill Children’s Foundation demonstrates that the wider voluntary and community sector recognises the value of the profession and we should embrace that support. The Pharmacy profession cannot operate alone. We need the support of the wider public but most especially the continued support of those who use their local pharmacy and ensure that thousands of those working in our profession throughout the country have a safe and secure future.

IPN • March 2012 15

Award Categories Nexazole 20 mg & 40 mg gastro-resistant capsules, hard


Business Development of the Year Award (Independent) Sponsored by Actavis Academy

Business Development of the Year Award (Chain) Sponsored by Irish Pharmacy News


Innovation in Service Development Award (Independent) IPN Communications Ltd Sponsored by IPN Communications Ltd

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.

Innovation in Service Development Award (Chain) Sponsored by Clonmel Healthcare

Health Promotion Award Sponsored by Pfizer Healthcare Ireland

Ireland’s No. 1 Generic Healthcare Specialists

Community Pharmacist of the Year Award Sponsored by Pinewood Healthcare

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Young Community Pharmacist of the Year Award Sponsored by Teva Pharmaceuticals Ireland

Community Pharmacy Team of the Year Award Sponsored by McNeil Healthcare (Ireland) Ltd

Counter Assistant of the Year Award Sponsored by Sanofi

Hospital Pharmacist of the Year Award Sponsored by Roche Products (Ireland) Limited

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27/07/2010 11:40:05

16 March 2012 • IPN


In the dark The pricing agreement between the Health Services Executive (HSE) and the Irish Pharmaceutical Healthcare Association (IPHA) lapsed at the beginning of March and, as yet no-one knows what the next pricing agreement will bring. Both the IPHA and HSE are playing their cards close to their chest. 'Which medicines will be cut and when?' are all questions that remain unanswered. However, one thing that is known is that the HSE needs to save €112 million and, as such, drastic cuts will inevitably be made and pharmacists and pharmacies will suffer. Pharmacists have already been badly affected by the sudden price cuts that were agreed between the IPHA and the HSE in December 2010 when the HSE announced €200 million worth of price cuts during Christmas week, a period when many pharmacies would have had high stock levels to meet increased patient demand at this time of year. The Irish Pharmacy Union (IPU), having learned the hard way, is now advising that pharmacists should manage their stock rotation of medicines carefully over the next few weeks, in order to minimise any losses that may be incurred. The IPU said, “The IPU has highlighted to both the Department of Health and IPHA that any decrease in the

price of medicines will have significant implications on the value of pharmacy stock and a knock-on effect on pharmacy income. Pharmacists must be given (good) advance notice of any change(s) that may happen. However, given the lack of notice for previous reductions, it would be sensible (for pharmacists) to closely monitor (their) stock at this time.” Pharmacists fear getting their fingers burnt once again. One pharmaceutical sales rep said, “Pharmacies have been pulling back on purchases since December. They are too afraid to carry stock lest they be penalised for it.” Obviously, the greatest concern amongst pharmacists is not knowing when the price cuts will be announced or when the price cuts will take effect. There is simply no clear indication as to when the pricing reductions will occur. While the rumour mill has some pharmacists building up April 1, 2012 as a new deadline, the reality is, it could be another three to five months before the HSE and IPHA finalise their deal.

“If the IPHA cannot agree on what medicines to cut, I would not be surprised if the HSE were to take the heavy-handed approach and simply tell the pharmaceutical companies what to cut so that it can make the necessary €112 million-worth of savings” announce price reductions on medicines that we have in stock.”

One pharmacist in Dundrum, Co. Dublin, said, “We don't want to be caught out by having our stock devalued overnight.

Another pharmacist in Co. Wicklow said that whilst he had heard various rumours, he remained in the dark as to what and when any cuts would be made. He said, “Rumour has it that the HSE demanded of the IPHA a price decrease by March 1 and this led into difficult talks, in which the IPHA resisted any reduction in prices and, instead asked the HSE to reimburse a range of newly licensed innovative medicines.

“It is comforting to know that some companies, such as Eurodrug have offered us a guarantee that they will reimburse us, should the HSE

“Obviously, these are only stories that I have heard but no-one knows when and what is going to happen. I would suspect that the price cuts will

be announced April 1, 2012 and that the IPHA will try to reduce the price of drugs that are due to come off patent, or else they will try to reduce the prices of as few medicines as possible across a broad range of products. “If the IPHA cannot agree on what medicines to cut, I would not be surprised if the HSE were to take the heavy-handed approach and simply tell the pharmaceutical companies what to cut so that it can make the necessary €112 millionworth of savings. Under the Financial Emergency Measures in the Public Interest (FEMPI) Act, the Minister can do what he likes. So far, only professional fees have been cut but, theoretically the Minister has the power to

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Debate reduce the price of drugs. There is a first time for everything.” Another Co. Louth pharmacist was critical of the lead-in time that the HSE has given pharmacists in the past. He said, “In recent years, pharmacists have only been given three to four days' notice and were then left with medicines that were only worth half of what was paid for them. Five years ago, we would have been given three or four months' notice. The approach of the HSE in recent times has been tight-fisted and very badly organised. “As more pharmacies are carrying the absolute minimum of stock, patients will have to wait longer to get their medicines. We will be portrayed as the ‘bad guys’ for a while but that is better than trading recklessly. It is what we have to do in order to keep our businesses afloat. After all, profit is an essential part of running any pharmacy business.” Even though pharmacists regard the recent report by the Economic and Social Research Institute (ESRI) as simply a ‘softening-up exercise’, it may well be that the IPHA/HSE and APMI/HSE agreements will be replaced by a different mechanism for calculating the price of multi-source, off-patent pharmaceuticals. The ESRI recommended that market forces should be used to a greater extent to price pharmaceuticals instead of by the current administrative pricing arrangements. One pharmacist in County Mayo commented, “Although we do not know what form the imminent pricing agreement will be, we can be certain that it will come in the form of more cuts. The implications are going to be serious for us and we remain totally in the dark.” Another pharmacist in Co. Dublin is extremely cynical of the HSE and said, “They can do whatever they want and we are just told at the last minute and expected to accept our position. “The IPHA agreed voluntary price reductions in December 2010. It was a case of them ‘throwing the dog a bone’ but now the HSE has come back for more. “The HSE makes it up as it goes along. There is no long-term plan. They don’t care how they make their savings, so long as the savings are achieved at the end of the day.

“Now, three years after the HSE ripped up all of our contracts, the IPHA is now realising that it is being treated like the pharmacists. They are big multinationals, used to being taken seriously, but right now, the HSE is only interested in cost-saving and not interested in offering a good health service. “I am going to run down my stocks before I order anything more as it does not make business sense to be stuck with devalued products. Yes, there may well be out-of-stock situations but I simply cannot afford to carry any stock, which has been devalued. Come the end of the month, nobody will be buying anything.” Another pharmacist in Co. Wicklow said that his major concern, regarding the imminent HSE/IPHA price agreement is that an announcement could be made at any time. He said, “If I buy something in at a certain price and its value is decreased overnight, that has a direct impact on the viability of my business. “One solution would be for the HSE to give us an advance warning of any cuts or else, they should compensate us for our losses. “I understand that the HSE are engaged in a cost-cutting exercise but this should be done in partnership with the pharmacies. Those sitting around the negotiating table are not pharmacists and yet, their decision will directly impact on our businesses. All we get is a statement of the outcome. “If the HSE were to engage with us through our Union alongside the IPHA, that could result in an agreement that would be acceptable to everyone.” He concluded, “Pharmacists have been forced to take numerous price cuts already. As a result, it is difficult to maintain viability or to plan budgets for the year. Ultimately the HSE are

subjecting us to a ‘death by a thousand lashes’.” Parallel import companies are also wary of the imminent IPHA/HSE pricing agreement. Eurodrug is one such company that is only too aware of the negative impact an overnight reduction in the price of medicines will have on the pharmacy sector and has developed a solution to meet Irish pharmacists’ growing concerns. A Eurodrug spokesperson said, “The current negotiations and the lack of information provided to important stakeholders, such as the pharmacists, has created an uncertainty in the market. Pharmacists are unsure of the future - it is a case of once bitten, twice shy. “One major concern that pharmacists have is that they are not maximising their margins and profit. The Parallel Import companies have created a vibrant and dynamic market whereby pharmacies can receive deals from all of their suppliers. Such deals were not on offer prior to the establishment of the PI business. It is in the interests of pharmacies throughout Ireland to continue to order their medicines from PI companies and avail themselves of extra discounts. This will help to maintain the competitive wholesale market in Ireland.” Eurodrug has promised that they will continue to offer their price guarantee to their customers. The Eurodrug spokesperson concluded, “This will allow pharmacies to continue purchasing from us. Any risks are negated as we will credit the customer for any shortfalls. Credits would be given for the prices paid before any reductions were made.” Only time will tell what the outcome will be but it is rather an unsatisfactory state of affairs, to say the least.

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From left to right. Don Cronin, Philip Little, Louise Martin, Liam Daly, Mervyn Kneasfsey, Erica Dunne.



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20 March 2012 • IPN


The Irish brand of CASACOL Not many of these are developed here in Ireland. Most of our much quoted pharmaceutical industry is based on inventions made somewhere else, and owned by someone else, mostly the USA. But not all. CASACOL, an iconic brand in the cough/cold sector is unique in origin as well as formulation. Back in the 70’s medicines were made and sold by foreign MNCs. There were very few, if any ,truly Irish companies competing in the market, where the revenues stayed here, and the jobs were based here.

Then two combative Donegal men, John Burns MPSI and Jim O’Leary and a methodical Mayo pharmacist, Tom Moran MPSI decided to break out on their own, and formed Birex Pharmaceuticals, with a small plant in Sandyford. Tom Moran MPSI made first lots of Casacol in small facility in Sandyford.

Medicines have been made a key element of life in the developed world. They have contributed to improved health and longevity for citizens and we take for granted access to such high quality, registered and controlled medicines to treat disease and symptoms.

The formulation was inspired by Fintan Molloy MPSI, who went on to prosper in the US with The Wellcome Foundation. His idea was to combine a mucolytic with a bronchodilator, thereby making the expulsion process more efficient. Mr. Tom Moran MPSI, a Mayo pharmacist with long experience in formulation, set about the task in his kitchen in South Dublin. Once the formulation was finalized

he moved to their small production facility in Sandyford Industrial Estate where he scaled up the process to commercial batch level. A key element was to include Sodium Citrate which served as a preservative and a stimulus for the cough reflex. This addition made the product unique in terms of formulation. It now had three active components, unlike any other cough medicine. They wanted a name that indicated what the product was for. In a moment of inspiration, and with a strong knowledge of her own language, Elaine OLeary, Jim’s better half, suggested Casacol, from the Irish verb “Casadh” to cough. Her mother had often said, “Ná bi ag casadh!” To this day, Casacol is the only pharmaceutical medicine on the planet whose name is derived from the Irish language. Casacol is now on the market for nearly 30 years. It was developed, registered, owned and manufactured here in Ireland. There are now five different Casacol products, and exports of the product are commencing to other EU territories in 2012. The livery has changed, the marketing differs, but the formulation remains constant and unique.

Alchemy launches new website Alchemy has recently launched a new website for its hospital and retail customers. The new web site (retail) and (hospital) enables customers to easily place an order for exempt medicinal products electronically, thus removing the need to fax an order through. This new

site enables pharmacists to manage all aspects of the exempt medicines part of their business including: Checking the availability of stock, pricing, re-printing of invoices and checking if a product is GMS/DPS reimbursable. Contact Alchemy for login details: (01-6305432). Placing your order has never been easier.


Panadol Extra Soluble provides your patients with a non-codeine soluble solution *When compared to standard Paracetamol, Panadol Extra Soluble can give 30% more pain relieving power. CONTAINS PARACETAMOL. ALWAYS READ THE LABEL/LEAFLET.

Exclusive to pharmacy Product Information for Panadol Extra 500mg/65mg Soluble Effervescent Tablets. Therapeutic Indications The tablets are recommended for use as an analgesic in the relief of mild to moderate pain such as is associated with rheumatism, neuralgia, musculoskeletal disorders, headache, and of discomfort associated with influenza, feverishness and feverish colds, toothache and dysmenorrhoea. Posology and Method of Administration For oral administration. Panadol Extra Soluble should be dissolved in at least half a tumbler full of water. Adults (including the elderly) and children aged 12 years and over: 2 tablets up to four times daily. Do not exceed 8 tablets in 24 hours. Children under 12 years: Not recommended for children under 12 years of age. Minimum dosing interval: 4 hours. Do not exceed the stated dose. Should not be used with other paracetamol-containing products. Patients with renal or hepatic impairment should seek medical advice before taking this medicine. Contraindications Known hypersensitivity to paracetamol, caffeine or any of the other ingredients. Special Warnings or Precautions for Use. Patients who have been diagnosed with liver or kidney impairment must seek medical advice before taking this medication. Underlying liver disease increases the risk of paracetamol related liver damage. Excessive intake of caffeine (e.g. coffee, tea and some canned drinks) should be avoided while taking this product. Prolonged use except under medical supervision may be harmful. Do not exceed the stated dose. Take only when necessary. If symptoms persist, consult your doctor. Each tablet contains 425 mg of sodium. To be taken into consideration by patients on a controlled sodium diet. Each tablet contains sorbitol powder (E 420) at 50 mg per tablet. Patients with rare hereditary problems of fructose intolerance should not take this medicine. Keep out of reach and sight of children. Interactions with other Medicaments and other forms of Interactions Paracetamol may increase the elimination half-life of chloramphenicol. The absorption of paracetamol may be increased by metoclopramide and decreased by cholestyramine. Oral contraceptives may increase the rate of clearance of paracetamol. The anticoagulant effect of warfarin and other coumarins may be enhanced by prolonged regular daily use of paracetamol with increased risk of bleeding; occasional doses have no significant effect. Pregnancy and Lactation Pregnancy Paracetamol Human and animal studies have not identified any risk of paracetamol in pregnancy or embryo-foetal development. Caffeine Paracetamol-caffeine is not recommended for use during pregnancy due to the possible increased risk of spontaneous abortion associated with caffeine consumption

Lactation Paracetamol and caffeine are excreted in breast milk. Paracetamol Human studies with paracetamol at the recommended doses have not identified any risk to lactation or the breast-fed offspring. Caffeine Caffeine in breast milk may potentially have a stimulating effect on breast fed infants but significant toxicity has not been observed. Side Effects of paracetamol: All very rare: Thrombocytopaenia, Anaphylaxis, Cutaneous hypersensitivity reactions including skin rashes, angiodema, and Stevens Johnson syndrome, Bronchospasm in patients sensitive to aspirin and other NSAIDs, Hepatic dysfunction. Side Effects of caffeine: Nervousness, Dizziness. When the recommended paracetamol-caffeine dosing regimen is combined with dietary caffeine intake, the resulting higher dose of caffeine may increase the potential for caffeine-related adverse effects such as insomnia, restlessness, anxiety, irritability, headaches, gastrointestinal disturbances and palpitations. Overdose Paracetamol Immediate medical attention (in-hospital, if possible) is required in the event of overdose, even if there are no significant early symptoms. Caffeine Symptoms and Signs Overdose of caffeine may result in epigastric pain, vomiting, diuresis, tachycardia or cardiac arrhythmia, CNS stimulation (insomnia, restlessness, excitement, agitation, jitteriness, tremors and convulsions). MARKETING AUTHORISATION HOLDER GlaxoSmithKline Consumer Healthcare (Ireland) Ltd, Stonemasons Way, Rathfarnham, Dublin 16. Further information is available on request from: GlaxoSmithKline, Consumer Healthcare, Stonemasonâ&#x20AC;&#x2122;s Way, Rathfarnham, Dublin 16. Tel: 01 495 5000 | Fax: 01 495 5525. Marketing Authorisation Number PA 678/39/10. Date of (Partial) Revision of the Text December 2010. Legal Category: Pharmacy Only.

GSKCH 2011/0362

22 March 2012 • IPN

News news brief Flu cases double The HSE Health Protection Surveillance Centre has urged people in 'highrisk' groups to get vaccinated against influenza, as the number of reported cases of influenza-like illness (ILI) has jumped in Ireland and, according to Dr Joan O’Donnell, Specialist in Public Health Medicine, influenza is now actively circulating in the community. She said, “Health professionals should be offering to use antiviral drugs for the treatment or prevention of influenza in highrisk groups. People who are at risk of the complications of flu need to get vaccinated against the disease now.” The vaccine is available free of charge from GPs for all people in 'at risk' groups, and from pharmacists for everyone aged 65 and over. Those at risk include: • Everyone aged 65 years and over • Anyone over six months of age with a long-term illness requiring regular medical follow-up, such as chronic lung disease, chronic heart disease and diabetes • Pregnant women • Those with lower immunity due to disease or treatment • Children or teenagers on long-term aspirin therapy • Residents in nursing homes and other long stay facilities • Healthcare workers and carers Flu is different from the common cold and usually develops quickly over a matter of hours. Symptoms include a high temperature, sore muscles, dry cough, headache and sore throat. The common cold tends to come on gradually and symptoms usually include a runny nose and a normal temperature. The weekly influenza surveillance reports are available at: AZ/Respiratory/Influenza/SeasonalInfluenza/ Surveillance/InfluenzaSurveillanceReports/2 0112012Season/

New policies for Irish health

Dr James Reilly A single-tiered health system supported by universal health insurance, the Government’s latest plan to overhaul the health service. The Minister for Health has appointed a new group, to be known as the 'Implementation Group’ under the chairmanship of Fergal Lynch, assistant secretary at the Department of Health. The Department of Health says that, because of the pragmatic focus of the group, its membership will be flexible and subject to periodic review, as different stages in the implementation process are reached. The Minister, Dr James Reilly said that the group is not intended to represent all stakeholders but that he is committed to consulting widely and will take on board the best advice available.

Under its terms of reference, the group will consider the range of services and functions provided in the public health sector and ‘provide detailed recommendations in relation to the future provision of these services and functions, and the basket of services to be covered by the insurance system’. The first meeting of the group took place at the end of February. Membership of the Implementation Group is as follows: • Dr. Fergal Lynch, Department of Health (Chair). • Paul Barron, Department of Health. • Tom Heffernan, Department of Public Expenditure and Reform. • Liam Woods, National Director of Finance, HSE. • Dr. Barry White, National Director for Clinical Strategy and Programmes, HSE. • Brian Fitzgerald, Director of Finance, St. James' Hospital and Joint Director of the HSE Patient Level Costing Project. • Mark Moran, Former CEO of the Mater Private Hospital and former Chairman of the DoH/HSE Working Group on Reference Pricing and Generic Substitution. • Prof. Reinhard Busse and Sarah Thomson, international experts working with the World Health Organisation, the European Observatory on Health Systems and Policies. • Dr. Fergus O’Ferrall, Lecturerin Health Policy, Trinity College Dublin. • Dr. Martin Connor, Special Adviser to the Department of Health with international experience in healthcare management.

Pharmacies up their retail game Pharmacies are boosting their competitiveness by up-skilling in retail studies at Dublin Institute of Technology (DIT) thanks to a new Diploma in Retail Management. Organised through Retail Excellence Ireland, DIT's Diploma in Retail Management is providing 25 retailers with important new skills, amongst them a number of pharmacies including DocMorris Unicarepharmacy, Adrian Dunne Pharmacies, Cloughjordan Pharmacy, Health Express, Peter Fox Pharmacy, Rathwood, and Walsh’s Pharmacy, Fermoy.

David Fitzsimons, CEO, Retail Excellence Ireland commented, “Times are very tough for many retailers currently. It is only through improving skills, performance and standards continuously that Ireland’s retail sector will continue to grow and thrive into the future. We’re delighted to have Energia (sponsor) on board to re-energise this year’s retailers with new skills.” Picturered: Michael Nugent, Energia, David Fitzsimons, REI, Kevin Haughey, Colortrend (REI/DIT student) and Linda Boucher, Adrian Dunne Pharmacies (REI/DTI student).

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24 March 2012 • IPN

News news brief Pharmacists welcome new children's dosage The Irish Pharmacy Union has welcomed new recommendations by the Irish Medicines Board (IMB) to introduce new dosage instructions for liquid paracetamol medicines for children. The medicines affected include Calpol®, Panadol Baby®, Paralink® and other Paracetamol products.

Pharmacovigilance information day

The new, clearer, instructions will assist parents and carers in providing the optimal dose of liquid paracetamol to children for their age. The recommendations divide doses of paracetamol liquid for children into narrower age bands with a specific dose for each band. Commenting today, IPU President, Darragh O’Loughlin, said, “The change in recommendations is not in response to any safety concerns. Paracetamol continues to be a safe and effective method of short-term pain and fever relief in children when used according to the patient information supplied with the medicine."

PSI on the lookout for new member of PSI Council The Pharmaceutical Society of Ireland (PSI) recently announced that it is seeking a new member to sit on the PSI Council. The PSI is governed by a twenty one member Council established under Section 10 (1 to 7) of the Pharmacy Act. The primary role of the PSI Council is to protect the public interest through the effective regulation of the profession and practice of pharmacy. The term of office of Council members is four years. Council members are entitled to remuneration of €7,695 per annum and to claim travel and subsistence allowances in accordance with approved public sector rates. The type of person required must hold qualifications and expertise that is valued by the Minister for Health and must not be or have been registered as a pharmacist, pharmaceutical chemist, dispensing chemist and druggist either in Ireland or any other country. The deadline for applications was March 13, 2012.

Dr. Peter Arlett, Head of Pharmacovigilance and Risk Management, European Medicines Agency; Dr. Joan Gilvarry, Director of Human Products Monitoring, IMB and Dr Almath Spooner (Acting Human Products Vigilance Assessment Manager, IMB).

The New EU pharmacovigilance legislation which is intended to further protect public health by strengthening the current European-wide system for monitoring the safety of medicines will come into effect in July 2012. To discuss the implications representatives from the Irish Medicines Board were joined by colleagues from the Department of Health, European Medicines Agency, the UK’s Medicines and Healthcare products Regulatory Agency (MHRA) and the European Organisation for Rare Diseases (EURORDIS), in delivering presentations to delegates. Participants included industry representatives, patient organisations, healthcare professionals, academic institutions and professional bodies. The legislation is intended to enhance the current pharmacovigilance system in the EU, making the reporting of adverse drug reactions easier, improving transparency and introducing special provisions for medicines that need additional monitoring. The legislation also aims to ensure that members of the public become better informed about the benefits and risks of taking medicines. The amendments will result in a more

transparent and seamless European vigilance system with assessment of the benefit, harm, effectiveness and risk of all medicines to all patients at the centre of its activities. The sessions involved reviewing the amendments and discussing relevant implications for pharmacovigilance processes, marketing authorisations and the impact on the pharmaceutical sector, healthcare professionals, patients and the IMB.

Pat O’Mahony, Chief Executive, Irish Medicines Board and Dr. Peter Arlett, Head of Pharmacovigilance and Risk Management, European Medicines Agency.

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26 March 2012 • IPN

Parkinsons Disease

Parkinson’s Disease Parkinson’s disease was first documented by James Parkinson in 1817 when he wrote the essay The Shaking Palsy. Parkinson's is the second most common chronic neurodegenerative disease and it is progressive and disabling in its development. It is characterised by the degeneration of neurons in the Basal Ganglia, which synthesise and store the neurotransmitter, dopamine. It is thought that, by the time someone is diagnosed with the disease, they will have already lost between 60-80% of their dopamine cells. Dopamine is necessary for the execution of movements, as well as motivation and thinking. The cause of Parkinson’s disease is generally unknown but there have been links identified to genetic disposition, environmental toxins, drugs, viruses or head injuries. . It is slow and insidious in its progression and it is always asymmetrical in as much as it only affects one side of the body. It is estimated that Parkinson’s disease affects two people in every hundred and, for those in nursing homes, one in ten. Approximately one in seven of those diagnosed will be under the age of 50.

There are two types of symptoms of the disease: Motor Symptoms and Non-Motor symptoms. The former includes the classic tremors, stiffness, slowness, shuffling gait and stooped posture. There are numerous Non-Motor symptoms, which include constipation, depression, anxiety, sweating and insomnia to name but a few. Patient’s often report that the Non-Motor symptoms are more troublesome and reduce their quality of life more than those with the Motor symptoms. As yet, there is no cure for Parkinson’s disease. Treatment is symptom management through medication. Levodopa is most often prescribed - and has been for over 40 years. It helps to replace lost dopamine. Levodopa in its natural state is not particularly effective and only approximately 1% reaches the brain. However, when it is combined with a dopamine decarboxylase inhibitor (DDCI), its effectiveness increases so that 5-10% will reach the brain. Levodopa can be introduced in the initial phase of treatment or when the patient’s function is impaired.

Dopamine Agonists stimulate the dopamine receptors directly, catechol O-methyltransferase (COMT) inhibitors boost the function of dopamine and monoamine oxidase type B (MAO-B) inhibitors try to prevent and keep the dopamine, which is present in a patient, working to its full potential. It often takes eight to ten weeks after starting treatment to see any improvements in the symptoms. Because of the nature of Parkinson’s disease, most people will be on a tailormade medication management plan, which has been devised by the treating specialist as no one Parkinson's patient is the same. Medication doses are frequently changed and altered over time to ensure as much control over the symptoms as possible. Also, due to the Non-motor aspects of Parkinson’s disease, patients will more than likely be on other medications to treat these symptoms. As a result, tablet burden, polypharmacy and compliance are huge issues in the successful treatment of Parkinson’s disease. The most common side effect for people

IPN • March 2012 27

Parkinsons Disease on Levodopa, particularly when they start taking it, is nausea/vomiting. This is normally resolved with domperidone. Pharmacists should be aware of and be particularly vigilant in respect of non-prescription medicines containing domperidone. Whilst the risk of QTc prolongation and ventricular arrhythmias are known cardiac risks of domperidone-containing medicines, recent epidemiological studies have provided some evidence that domperidone may be associated with an increased risk of serious ventricular arrhythmias or sudden cardiac death. These risks may be higher in patients older than 60 years of age or those taking daily oral doses of more than 30mg. It is essential that people who have Parkinson’s are not given Prochlorperazine and Metoclopramide as these are dopamine antagonists, which can cause extrapyramidal symptoms, and make Parkinson’s symptoms significantly worse. It is also important that patients who are prescribed Levodopa take it correctly. It should be taken 30-40 minutes prior to a meal or up to one and a half hours afterwards, with a full glass of water or juice. Levodopa should not be taken with milk as protein from food can disrupt the absorption of the levodopa from the jejunum. Levodopa medication must not be stopped suddenly as this can cause Neuroleptic Malignant Syndrome, which can result in coma, or even death. Dopamine agonists, available in orally disintegrating (OD) and three times a day (TDS) tablets (pramipexole, ropinirole), or transdermal patch (rotigitine), are also often used as the initial treatment in Parkinson’s disease, as well as in combination with other medications. There is also a subcutaneous injectable form (apomorphine, subcutaneous rescue pen or infusion), which is usually used in later stages of Parkinson’s disease to help control motor fluctuations and dyskinesias. The standard side effects caused by dopamine agonists are well documented, such as nausea/vomiting, postural hypotension and somnolence. However, more recently, Impulsive-Compulsive Behaviours (ICB), which cause excessive spending, hoarding, gambling, eating and an increased sex drive, to name but a few, have been documented. According to the UK Parkinson’s Society, 17% of people on a dopamine agonist will develop ICB. It is essential that if a patient

is displaying any of these side-effects that they should see their GP or Consultant, as a reduction or withdrawal of the medication often resolves the problem. It is very important that these drugs are not stopped suddenly but that the patient is weaned off them over time.

keep the remaining dopamine there longer. Again, this drug can be used alone or with other medications. Common side effects of MAO-Bs are headaches, indigestion and flulike symptoms. It has been documented that Selegiline can sometimes cause insomnia, so it is best taken in the morning.

Catechol-o-methyltransferase inhibitors (COMT-I) boost the function of levodopa by reducing the breakdown of the drug by enzymes in the body. The two most common types of COMT-I are Entacapone and Tolcapone. In the past, Tolcapone was associated with hepatic failure and was taken off the market, but was reinstated in 2005 and it is now stipulated that regular blood tests are carried out whilst patients are on this drug. Entacapone is known to discolour urine and stools (orangey colour) and can cause prolonged diarrhoea and may result in non-compliance and/or discontinuation of the medication.

Surgical options are limited. Deep Brain Stimulation (DBS) is possible, so too is the insertion of a Percutaneous Jejunostomy (PEJ) which allows a continuous infusion of Levodopa gel directly into the bowel. Both these treatment options or the use of an apomorphine subcutaneous infusion can cut down the use of medicines.

It is important that if a person is prescribed a COMT-I in addition to Levodopa that they are made aware that they must take the two together at the same time, before meals. Entacapone is now available combined with levodopa to reduce this burden.

It is, therefore tremendously important that patients are given as much information about their disease and their medications as possible, in order to maximise compliance and minimise risks. And, of course pharmacists will frequently be asked about this debilitating disease when the patient come into the pharmacy to collects his or her prescription.

Monoamine oxidise type B (MAO-B) inhibitors (selegiline and rasagiline) work by preventing the enzyme MAO-B from breaking down the dopamine, and help to

Parkinson’s is an incurable disease. Changes to the prescribed medicines will inevitably occur due to the progressive nature of the disease in the patient. These changes may cause complications, intolerance being a major one.

AZILECT ® once-daily 1mg no titration


The four trials that have made Azilect® an effective choice for Parkinson’s Disease monotherapy and adjunct therapy*1-5 Abbreviated Prescribing Information. For full prescribing information refer to the Summary of Product Characteristics. Name: Azilect® 1mg tablets. Active Substance: Rasagiline mesilate. Indication: Treatment of idiopathic Parkinson’s disease (PD) as monotherapy (without levodopa) or as adjunct therapy (with levodopa) in patients with end of dose fluctuations. Dosage: 1 mg tablet orally once-daily with or without levodopa. It may be taken with or without food. Elderly: No change in dose is required for elderly patients. Children and adolescents(< 18yrs): Not recommended due to lack of data on safety and efficacy. Contraindications: Hypersensitivity to the active substance or to any of the excipients. Concomitant treatment with other monoamine oxidase (MAO) inhibitors, including medicinal and natural products without prescription (e.g. St. John’s Wort) or pethidine. At least 14 days must elapse between discontinuation of rasagiline and initiation of treatment with MAO inhibitors or pethidine. Rasagiline is contraindicated in patients with severe hepatic impairment. Special warnings and precautions: The concomitant use of rasagiline and fluoxetine or fluvoxamine should be avoided. At least five weeks should elapse between discontinuation of fluoxetine and initiation of treatment with rasagiline. At least 14 days should elapse between discontinuation of rasagiline and initiation of treatment with fluoxetine or fluvoxamine. The concomitant use of rasagiline and dextromethorphan or sympathomimetics such as those present in nasal and oral decongestants or cold medications containing ephedrine or pseudoephedrine is not recommended. Caution should be used when initiating treatment with rasagiline in patients with mild hepatic impairment. Rasagiline use in patients with moderate hepatic impairment should be avoided. Parkinson’s disease is associated with a higher risk of skin cancer, any suspicious skin lesion should be evaluated by a specialist. Interactions: In view of the MAO inhibitory activity of rasagiline, antidepressants should be administered with caution. Co-administration of rasagiline and ciprofloxacin (or other potent inhibitors of CYP1A2) is cautioned. There is a risk that the plasma levels of rasagiline in smoking patients could be decreased. See also interactions listed in the contraindications and special warning sections. Pregnancy and lactation: Caution should be exercised when prescribing to pregnant women. Caution should be exercised when rasagiline is administered to a breast-feeding

*Monotherapy (without levodopa) or as adjunct therapy (with levodopa)


mother. Driving: Patients should be cautioned about operating hazardous machines, including motor vehicles until reasonably certain Azilect does not affect them adversely. Adverse reactions: Monotherapy: Very common (≥1/10): headache. Common (≥1/100 to <1/10): Influenza, skin carcinoma, leucopenia, allergy, depression, hallucinations, vertigo, conjunctivitis, angina pectoris, rhinitis, flatulence, dermatitis, musculoskeletal pain, neck pain, arthritis, urinary urgency, fever, malaise. Uncommon (≥1/1000 to <1/100): Decreased appetite, cerebrovascular accident, myocardial infarction, vesiculobullous rash. Adjunctive therapy: Very common (≥1/10): Dyskinesia. Common (≥1/100 to <1/10): Decreased appetite, hallucinations, abnormal dreams, dystonia, carpal tunnel syndrome, balance disorder, orthostatic hypotension, constipation, abdominal pain, nausea, vomiting, dry mouth, rash, arthralgia, neck pain, decreased weight, fall. Uncommon (≥1/1000 to <1/100): Skin melanoma, confusion, cerebrovascular accident, angina pectoris. Post-marketing- serotonin syndrome was reported with use of antidepressants and rasagiline. Elevated blood pressure and rarely hypertensive crisis have been reported with concomitant ingestion of rasagiline and tyramine rich foods. Overdose: Symptoms reported with Azilect doses ranging from 3mg to 100mg included dysphoria, hypomania, hypertensive crisis and serotonin syndrome. There is no specific antidote. Patients should be monitored and the appropriate symptomatic and supportive therapy instituted. Legal Category: POM. Marketing Authorisation Holder: Teva Pharma GmbH, Germany. Marketing Authorisation Numbers: EU/1/04/304/003 Tablets 1mg 28 pack. Further information may be obtained from Lundbeck (Ireland) Ltd., 7 Riverwalk, Citywest Business Campus, Citywest, Dublin 24, Ph: 01-4689800. Date of Preparation: November 2010. References: 1. Azilect Summary of Product Characteristics 2. The Parkinson Study Group (2002) TEMPO study, Arch Neurol; 59:1937-1943 3. Parkinson Study Group (2005) PRESTO Study, Arch Neurol; 62:241-248 4. Rascol et al (2005) LARGO study, The Lancet; 365:947-954 5. Olanow et al (2009) NEJM; 361:1268-1278

CPD 15: ANXIETY DISORDERS in situations where the person could be criticized (3). For example, the patient may be very anxious eating in a restaurant, speaking at a meeting or attending a dinner party. The patient tends to avoid such situations. If they do encounter the situation any of the usual symptoms of anxiety can occur, but blushing and trembling are common. Some patients use alcohol to relieve symptoms and alcohol misuse is more common in social phobia compared to the other phobias. Co-morbid depression is common. 2c. Agoraphobia

Types of anxiety disorders 1. Generalised anxiety disorder (GAD) Generalised anxiety disorder is characterized by persistent anxiety symptoms that are not triggered by any particular event or situation(3). It is sometimes described as “free floating” anxiety. The patient experiences the physical and psychological symptoms of anxiety which can be disabling due to their chronic, unremitting time course. GAD affects up to 5% of the population and accounts for around 30% of psychiatric consultations in general practice. 2. Phobic anxiety disorders Patients with phobic anxiety disorders experience the same symptoms as someone with generalized anxiety, but they only show symptoms in response to particular circumstances (3). This could be a certain situation (eg a crowded place), an object (eg spiders) or a natural phenomenon (eg thunderstorms). Clinically phobic anxiety disorders are split into three subtypes; Specific phobia, social phobia and agoraphobia. 2a. Specific phobias If a patient has a specific phobia, they are inappropriately anxious if they encounter one or more object or situation (3). Anticipatory anxiety is common, as is avoidance of the particular situation. For example, a patient who has a phobia of dental treatment may avoid going to the dentist and develop caries. Sometimes patients seek treatment shortly before a particular event – a patient who has a phobia of flying may request treatment before a holiday. In this situation a short course of benzodiazepines may be appropriate. Long term treatment of phobias includes desensitization therapy (gradual exposure to the feared article or situation).

Patients with agoraphobia experience anxiety symptoms when they are away from home, in a crowded place or somewhere that they cannon leave easily (3). Panic attacks are common and anxiety relating to fear of fainting or loss of control can also occur. The syndrome usually begins with a period of anxiety while in a public place. Anticipatory anxiety can then occur the next time a visit to a similar place is planned. Avoidance is common, causing the patient to remain at home, relying on family or friends for help with activities. 3. Panic Disorder This illness is characterized by sudden attacks of the physical symptoms of anxiety accompanied by the fear of a serious consequence such as a heart attack (3). It sometimes accompanies agoraphobia. 4. Obsessive compulsive disorder (OCD) Patients may have obsessional thoughts, where words, ideas or beliefs intrude forcibly into the mind (3). These thoughts may lead to compulsive rituals. For example, an obsessional thought that hands are contaminated can lead to the compulsion to wash the hands many times each day. Depression often accompanies OCD. 5. Post traumatic stress disorder (PTSD) Symptoms of post traumatic stress disorder involve an intense, prolonged and sometimes delayed response to something that an individual perceives as traumatic (3). This could be a natural or man-made disaster such as an earthquake or war, or could be a personal trauma such as a rape or assault. The patient experiences emotional numbness and detachment, followed by flashbacks and vivid dreams. There is considerable co-morbidity with depression, suicide and substance misuse. 6. Mixed anxiety and depressive disorder (MAD)

2b. Social phobia

Patients with a diagnosis of mixed anxiety and depressive disorder do not suffer from either syndrome severely enough to have a diagnosis of either depression or anxiety (3). However the mild symptoms of anxiety and depression together are disabling enough for the patient to be diagnosed with this minor affective disorder. Treatment is generally with antidepressants.

Patients with social phobia experience anxiety

Most people with anxiety disorders will

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probably experience more than one form. For example, someone with panic attacks may develop agoraphobia. If left untreated this could then further develop into generalized anxiety disorder. Anxiety disorders commonly have a comorbid diagnosis of depression. In patients who present with anxiety alone, effective treatment may prevent the later development of depression. Clinical guidelines relating to anxiety disorders There are several clinical guidelines for primary and secondary care treatment of patients with anxiety disorders. Three key guidelines for Irish pharmacists are; • “Guidelines for the management of depression and anxiety disorders in primary care” Published in 2006 by the Irish College of General Practitioners.(2) • “Evidence-based guidelines for the pharmacological treatment of anxiety disorders: recommendations from the British Association for Psychopharmacology” published in 2005 (UK guidelines).(4) • National Institute for Health and Clinical Excellence (NICE) Management of anxiety (panic disorder, with or without agoraphobia, and generalised anxiety disorder) in adults in primary, secondary and community care. 2007 (UK guidelines). (5) Treatment of anxiety disorders Pharmacological Treatments for Anxiety Disorders For the majority of anxiety disorders benzodiazepines are used for emergency, short term, management. An antidepressant such as an SSRI is used for long term management. Benzodiazepines Benzodiazepines are commonly prescribed in Ireland and across Europe. In a 2008 Europeanwide study it was noted that over 9% of adults had taken a benzodiazepine over the course of 12 months. (6) Benzodiazepines provide rapid relief from anxiety states and are useful for immediate relief of symptoms. However, all current guidelines state that they should be reserved only for anxiety states that are severe and disabling due to their potential for physical dependence (4,5). They should only be used for up to four weeks while long term strategies for management are put into place. Benzodiazepines can be classified as short acting, such as lorazepam, or long acting like diazepam. They can all cause sedation and affect driving performance. Disinhibition is a possible side effect as benzodiazepines increase GABA transmission. This can lead to aggression or a paradoxical increase in anxiety in some patients. (7) Physical dependence on benzodiazepines is common following long term use. At least one third of patients will experience withdrawal symptoms after taking benzodiazepines for more than 4-6 weeks (7). Symptoms of sudden withdrawal include tension, panic attacks, palpitations and sweating – symptoms which

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CPD 15: ANXIETY DISORDERS are similar to the anxiety that was initially being treated. Slow discontinuation can help to manage withdrawal symptoms. Some patients respond to being switched to a long acting benzodiazepine such as diazepam before starting the discontinuation process.

discontinuation symptoms so slow withdrawal is recommended.

NICE recommends that benzodiazepines should not be used in panic disorder as they have been shown to be less effective than SSRIs. (5)

Mirtazepine is a centrally acting antidepressant which has sedative properties which may be helpful for patients with co-existing insomnia. It is not currently licensed for anxiety disorders in Ireland, but is recommended as an alternative to SSRIs in the Maudsley Prescribing Guidelines (7).

Selective Serotonin Reuptake Inhibitors


Selective Serotonin Reuptake Inhibitors (SSRIs) are listed as first line treatments in the majority of anxiety disorders (7). Individual SSRIs have licenses for different anxiety states but this is probably more to do with the marketing strategies of the manufacturer than the effectiveness of the particular medication in that disorder. A summary of the current anxiety disorder licenses of SSRIs is shown in Figure 2.

Pregabalin (a gamma-aminobutyric acid analogue) is licensed for the treatment of generalized anxiety disorder. It has a rapid onset of action (approximately one week) (10) which is an advantage when compared to the SSRIs. Side effects include dizziness and somnolence in the early stages of treatment. Weight gain has been reported from trial data. It seems to be associated with fewer withdrawal symptoms than lorazepam, when compared in trial patients.

Figure 2 Anxiety licenses for commonly prescribed SSRIs in Republic of Ireland Antidepressant Generalised Anxiety Disorder

Panic Disorder



Citalopram Escitalopram

Obsessive Compulsive Disorder

Social Phobia

Post Traumatic Stress Disorder


Sertraline Paroxetine

Beta blockers













Doses of SSRIs When starting treatment for anxiety disorders with an SSRI the dose should be approximately half that used to treat depression (9). This is because anxiety is a possible side effect of SSRIs in the early stages and may exacerbate the original symptoms (called activation syndrome). Adding a benzodiazepine for the first two weeks can help to counteract this initial anxiety. Titrate the SSRI dose upwards into the normal antidepressant dose range. The patient may take up to six weeks to show a response and treatment may be needed for at least one year. Patients with anxiety disorders tend to be particularly sensitive to discontinuation symptoms with SSRIs. Doses should be titrated slowly downwards before stopping over several weeks or months. Side effects of SSRIs Side effects tend to occur in the first weeks of treatment then subside. Common side effects include restlessness, dizziness, Gastrointestinal (GI) upset and increase in sweating. A paradoxical increase in anxiety is sometimes seen in the first two weeks. In rare cases

suicidal ideation can occur in the early stages of treatment with SSRIs. Long term side effects include sexual dysfunction and weight changes (increase or decrease have been reported). Discontinuation symptoms Discontinuation symptoms are seen by approximately one third of patients who stop taking antidepressants. Symptoms begin within five days of stopping SSRIs abruptly (7) and include flu like symptoms, “shock-like” sensations, dizziness, insomnia, vivid dreams and irritability. The symptoms can be explained by a “receptor rebound” effect. Paroxetine is most commonly associated with discontinuation symptoms, probably due to its short half life. Other antidepressants used to treat anxiety states Venlafaxine and duloxetine both act on serotonin and noradrenaline (as do tricyclic antidepressants such as amitriptyline.). Both are licensed for generalized anxiety disorder and venlafaxine has additional licenses for panic disorder and social anxiety disorder. Venlafaxine should be avoided in patients at risk of cardiac arrhythmia. It has also been associated with

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Beta blockers such as propranolol are used to treat the physical symptoms of anxiety. They control symptoms such as palpitations, tremor sweating and shortness of breath. They do not cause physical dependence so can be used for long term treatment. They are sometimes used in combination with other anxiolytics that treat the psychological aspects of anxiety. Other pharmacological treatments Hydroxyzine is an antihistamine which is related to the phenothiazine antipsychotics. There are few studies to show efficacy but it does seem to be of some benefit in the treatment of anxiety. (9) Antipsychotics are sometimes used as adjunctive treatments for anxiety (usually added to an antidepressant or benzodiazepine). There is little evidence for efficacy, but a significant risk of side effects. Their use should be reserved for treatment resistant cases. (9) Non-pharmacological treatments The 2007 NICE guidelines (5) recommend psychological therapies such as cognitive behaviour therapy (CBT) as first line treatment for anxiety disorders. However the guidelines do acknowledge that pharmacological therapies are also effective and that the preference of the patient should be taken into account. In some areas of Ireland CBT may not be readily available so pharmacological treatments may be more suitable. Self help using bibliotherapy based on CBT principles is also recommended by NICE. Lifestyle considerations for patients with anxiety The NICE guidelines for anxiety (5) recommend that the benefits of exercise as part of good general health should be discussed with all patients as appropriate High caffeine intake can worsen the symptoms of anxiety and trigger panic attacks. Patients with anxiety should be advised to reduce intake of drinks and food containing caffeine and to be aware that some over the counter analgesics contain caffeine.

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CPD 15: ANXIETY DISORDERS Figure 3 – Non-pharmacological treatments for anxiety disorders. (7) Generalised anxiety disorder

Panic disorder

Reassurance, CBT, Anxiety Anxiety management, management, Relaxation training Exposure therapy, Cognitive behaviour therapy (CBT)

Post traumatic stress disorder Debriefing if desired, Counselling, Anxiety management, CBT, especially for avoidance behaviour or intrusive images

Nicotine stimulates physiological arousal, increasing the heart rate. Smokers tend to be more anxious and sleep less soundly than their non smoking counterparts. Alcohol is often used as a relaxant by patients with anxiety. However it can lead to dependence and the onset of physical illness such as liver disease if it is chronically misused. Recreational drugs of misuse such as cocaine and amphetamines can aggravate anxiety and induce panic attacks. They should obviously be avoided. Advice for the treatment of special patient groups British Association for Psychopharmacology has the following advice for patients who are in these special groups; (4) 1. Children and adolescents Use psychological treatments first line. If medication is needed, use an SSRI as first choice – avoid benzodiazepines and tricylics due to risk of side effects. Start with low doses and monitor carefully for side effects. 2. Elderly patients Follow same treatment strategy as for adult patients but use lower doses of medication and monitor carefully for side effects. Be aware of physical co-morbidities and increased sensitivity to side effects of medication. 3. Cardiac disease and epilepsy Avoid tricyclic antidepressants and venlafaxine in patients with cardiac disease. Avoid antidepressants that lower seizure threshold in patients with epilepsy. Be mindful of possible drug interactions between anxiety treatments and antiepileptics. 4. Pregnancy and Breastfeeding. Consider potential risks and benefits of treatments, avoiding drug treatment if possible. Fluoxetine or tricyclics are considered first line as there is most evidence surrounding the use of these drugs in pregnancy. Consider SSRIs (apart from fluoxetine and citalopram) or tricyclics for breastfeeding mothers as secretion into milk is low. Further information for patients and families Choice and Medication website – an internet site written by UK pharmacists for patients in

Obsessive compulsive disorder

Social Phobia

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the UK and Ireland. Discusses the different types of medication available for psychiatric illnesses. Printable leaflets on different medications. Contains useful comparison charts for different treatments. Reach Out – an Irish website for young people with mental health difficulties. Has a section on anxiety disorders. Royal College of Psychiatry website – has a range of printable leaftlets on mental health issues, including types of medication and information about counselling and alternative remedies. Overcoming Anxiety by Helen Kennerley, a selfhelp guide using Cognitive Behavioural Therapy (CBT) techniques. Other similar books are available and are useful if patients cannot attend CBT therapy in person. Practice points for community pharmacists • Be aware of the overuse of benzodiazepines. Look out for patients on long term benzodiazepine treatment. Consider that some patients may attend more than one GP and pharmacy to obtain supplies of benzodiazepines. • Inform patients of the lag time between starting antidepressants and seeing a benefit. Up to six weeks may be needed to see maximum effect. However side effects can start from day one. • Encourage compliance with long term preventative treatments such as SSRIs. Early discontinuation could lead to a recurrence of anxiety symptoms. Treatment may be needed for one year or more. • Counsel patients with regards to the withdrawal effects or discontinuation symptoms when near the end of a course of treatment. Encourage slow downwards titration of doses rather than sudden stopping of medication. • Give lifestyle advice to reduce the risk of further episodes of anxiety. References 1. McDonagh, M. Don’t let anxiety get you down. Irish Times 2.8.2011. 2. Irish College of General Practitioners. Guidelines for the management of depression and anxiety disorders in primary care. 2006. 3. Gelder M, Mayou R. Cowen P. Shorter Oxford Textbook of Psychiatry Fourth Edition. 2001. Oxford University Press.

4. Baldwin D S et al. Evidence-based guidelines for the pharmacological treatment of anxiety disorders: recommendations from the British Association for Psychopharmacology. J.Psychopharm19(6) (2005) 567–596 5. National Institute for Health and Clinical Excellence (NICE) Management of anxiety (panic disorder, with or without agoraphobia, and generalised anxiety disorder) in adults in primary, secondary and community care. Clinical guideance 22. Amended April 2007 www.nice. 6. Demyttenaere K et al. Clinical factors influencing the prescription of antidepressants and benzodiazepines: results from the European study of the epidemiology of mental disorders (ESEMeD).J Affect Disord. 2008 Sep;110(1-2):84-93. 7. Taylor D, Paton C, Kapur S. Maudsley Prescribing Guidelines 10th Edition. 2009 Informa, London. 8. Summary of Product Characteristics for each product accessed on February 2012. 9. Bazire S. Psychotropic Drug Directory. 2007. Healthcom UK Ltd. Aberdeen. 10. Strawn JR, Geracioti TD. The treatment of generalized anxiety disorder with pregabalin, an atypical anxiolytic. Neuropsychiatric Disease and Treatment.2007, 3(2), 237-243.

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 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. EPEU/2012/022

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36 March 2012 • IPN

Infant Care Analgesics

Baby Care in Ireland In 2010, the baby care market reached value sales of €23 million, according to the latest available figures. While in the past, this market had been somewhat neglected by the pharmacy profession, it has increasingly become of greater importance to the community pharmacy sector. The continued increase in birth rates, which, according to figures from the Central Statistics Office (CSO), currently stands at 17 per every 1,000 of the population, can only be a positive development. While the supermarkets may hold the lion’s share of the baby care market in Ireland, pharmacy still has a major role to play in advising parents on how to care for their babies properly. Undoubtedly, new parents will continue to visit the pharmacies in the future, in order to obtain free advice on what best to do for their baby. In these harsh economic climes, pharmacists should recognise the value of the baby care category to their pharmacy. Whilst pharmacies may not have the shelf space to store rows upon rows of nappies, the one arsenal pharmacists do have over their supermarket counterparts is their ability to give free and sound advice to concerned/ clueless parents of young children. If a pharmacy can make a good impression on a family at that important stage of their life, then they have secured patients for life. Market overview Of the €23 million spent on baby care products, baby skin care was the top selling category with value sales of €5.8 million with sales of medicated skin care amounting to €1.5 million. Baby toiletries saw value sales of €5.3 million and was closely followed by baby hair care products, which accounted for €5.2 million of Baby Care sales. It is expected that sales of paediatric cough, cold and allergy remedies will experience some decline this year, following the Irish Medicines' Board decision that children under the age of six should no longer be given over-the-counter cough and cold

medicines. Last year, the market was worth €4.2million. Also, as a result of this decision, sales of paediatric analgesics experienced significant growth in 2011, reaching sales worth €3.3 million. Child-specific paracetamol alone experienced 8% value growth last year to reach sales of €1.5 million. Calpol was the most popular child-specific analgesic brand in Ireland, followed by Nurofen, which achieved value shares of 35% and 23% respectively. Paediatric vitamins and dietary supplements

performed well and reached sales amounting to €5.2million. It would seem that parents are becoming more aware of the importance of vitamins in their child’s development and pharmacists can encourage further sales in this area by stressing their importance. For healthy bone development, vitamin D3 is hugely important. Research has also shown that vitamin D3 plays an important role in helping the immune system and may also help prevent illnesses like diabetes, heart disease, rheumatoid arthritis, multiple sclerosis as well as some forms of cancer.

Oral dosing syringe provided

38 March 2012 • IPN

Infant Care Analgesics prices in their pharmacies. Pharmacist Eamonn Brady said, “Patients are looking for the best value for their money. As such, there is no point in stocking anything that can be bought in the supermarket at a lower price. Even though many pharmacists may be part of various different buying groups, we cannot compete with the supermarkets when it comes to the sale of diapers, baby wipes and shampoos. I do not stock any diapers in my pharmacy because I do not have the space and because I would have to sell them at cost price and even that wouldn’t be competing with the supermarket prices. Sales of the old reliables such as cough, cold and flu medicines have been affected by the IMB recommendation but Calpol and Nurofen are selling as normal.” One pharmacist in County Cork said, “Having come from New Zealand originally, I was surprised when I came to Ireland to find that people still buy baby care products in pharmacy. In New Zealand, the supermarkets have completely taken over that market. In my pharmacy here, I have found that ‘NUK’ and ‘Avent’ products are quite popular and we get customers who come in especially to buy the NUK products as they are not stocked in the other pharmacies on our street. I have noticed that parents like to come into a pharmacy when they are buying products for their babies because they can talk to a pharmacist and ask for their advice. ”

The HSE recommends that from birth to twelve months, all babies should be given 5 micrograms (5µg) of vitamin D3 every day. Vitamin D3 (cholecalciferol) is the preferred form of vitamin D for infants. The vitamin D3 product used should be in a liquid form suitable for infants and contain only vitamin D3. Products that contain other vitamins as well as vitamin D (such as multivitamin products) should not be used. Mothers should take vitamin D supplements throughout their pregnancy and whilst breast feeding to ensure that their baby has enough vitamin D stored in their body for the first

few months of their life. Vitamin A is another important vitamin for babies and young children because it strengthens their immune system and maintains a healthy skin. Whilst vitamin C is important for the infant’s general health and immune system, it may also help the child's body to absorb iron. Consumers and patients are now actively seeking better value for money and discounted prices all round. It is, therefore recommended that pharmacists should stock reputable products at affordable

Johnson & Johnson Ireland Ltd is the market leader in the baby care market and in 2010 it accrued a 59% value share of the baby care category. The brand’s presence in the maternity hospitals has given it a distinct advantage, especially among first-time parents and its dominance is partly due to the fact that sample packs of Johnson’s Baby Oil are supplied both before and after delivery, alongside other sample products in ‘Mother-to-Be’ and ‘New Family Packs’. However, J & J has been seeing increased competition, particularly from private label products which can offer similar products and packaging at much lower prices. The Future Although birth rates are expected to decline due, in large part, to the continuing recessionary conditions and reduced standards of living in Ireland, the large expected fall in birth rates has, as yet failed to materialise. So, for the moment, sales should not fluctuate too much in the coming year. However, good value-for-money products will continue to perform best in the market place.

40 March 2012 • IPN

Baby's Skin

Nappy Rash Most babies experience nappy rash at some time in their life. It is a condition, which is so common, that it is thought to affect up to a third of nappy wearing babies at any given time. Pharmacists are likely to be the first port of call for parents looking for a fast and efficacious solution. What does nappy rash look like? The rash can affect the genitals, the outer skin on the folds of the thighs and the buttocks. The affected areas can appear either dry or moist and may sometimes look shiny or pimply. What causes nappy rash? Nappy rash usually occurs when the baby’s skin comes in contact with urine and faeces. Ammonia When a baby soils or wets itself and the nappy is left on for a longer time than usual, the urine and faeces can encourage the production of the chemical ammonia, which can irritate the baby's skin, causing it to become sore and inflamed. Fungal infection Nappy rash can also be caused by a fungal infection. If the baby's skin is warm and damp for long periods of time, it can cause the fungus ‘candida’, to grow. Like ammonia, candida can irritate the baby's skin. Often, the baby's rash will begin as a reaction to the ammonia and is then further complicated by a fungal infection. Exacerbating conditions In rare cases, the baby's nappy rash may be caused by an underlying condition and if it is not treated immediately, it can develop into something more serious, including: • Eczema - Eczema causes the baby's skin to be dry and sore. The sore skin may appear in other parts of the body beyond the nappy area. If the baby has nappy rash often, despite regular nappy changes, and there is a family history of eczema, the nappy rash may be the first signs of eczema. • Seborrhoeic dermatitis - Seborrhoeic dermatitis causes red, scaly skin and may aggravate the baby’s nappy rash. It usually occurs when the baby is between two weeks and six months old. Reddened skin on the baby's scalp, ears, eyebrows, armpit and neck may become noticeable. Normally, seborrhoeic dermatitis lasts for a few weeks, and does not reoccur or disturb the baby again. • Bacterial infection – In some cases, the baby's nappy area can become infected

with bacteria. This can cause a bright red, painful rash that will need to be treated with antibiotics. • Allergic dermatitis - Sometimes, the baby's rash may be caused by an allergic reaction to an allergen. Many different types of allergen can cause the baby to have an allergic reaction, including: soap, fragrances, preservatives, detergents, oils and powders. • Zinc deficiency - Zinc deficiency is more common in premature babies. It causes a rash, which appears around the nappy area and the mouth and hands. Treating nappy rash • Leave the nappy off for as long as possible in order for the baby to stay dry and by laying them on an absorbent towel on a just-in-case basis. • Avoid using soaps when cleaning the baby's skin. Parents should be advised to only use water when they are cleaning the baby. • Apply a barrier cream every time the baby’s nappy is changed. Zinc cream, zinc oxide ointment and petroleum jelly are all suitable barrier creams. But, there are advantages and disadvantages to every product. - Matricaria Chamomilla (chamomile) is effective in that it is both a demulcent and antibacterial. - Dexpanthenol (pro-vitamin B5) is the most advantageous ingredient in baby care products as it encourages the regeneration of the skin, is a demulcent, activates the lipid synthesis and strengthens the skin’s protective barrier. Whilst the above mentioned preparations are effective in treating nappy rash, one pharmacist said that they have even advised parents to spread butter on their child’s nappy if there is nothing else in the house and if the baby’s skin is too sore to handle any cream.

• Topical anticandidals An anticandidal medicine helps to treat any fungal infection that may cause a rash. Some commonly prescribed anticandidal medicines include: Clotrimazole, econazole, ketoconazole, miconazole and nystatin. These are creams that usually have to be applied to the baby's bottom two or three times a day. However, unlike topical corticosteroids, which should not be used once the baby's rash has cleared up, anticandidals have to be used for 7 to 10 days after the rash has healed. This ensures that the infection is completely treated. Prevention Ultimately, prevention is key and, in order to avoid painful nappy rashes, pharmacists should advise parents to follow the same steps involved in treating a mild nappy rash. To reiterate, this involves: • Leaving the nappy off for as long as possible. • Changing the nappy regularly. • Using only water to wash the baby's bottom.

Severe nappy rash If the baby has severe nappy rash, they will usually require a medication prescribed by a GP.

• Applying a barrier cream after each nappy change.

• Topical corticosteroids

• Powders (such as talcum powder) should not be used when changing nappies.

Corticosteroids help to reduce the inflammation of the skin and relieve any itching and redness. Hydrocortisone cream, which should only be applied once a day should not be used for more than seven days

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

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IPN • March 2012 43

Shop Front

Baby Section and Category Management What does this mean in your pharmacy? Let us look at a simple method that you can use to help get more margin from the existing space in your pharmacy and the category we will look at is “Baby”. That is, we will take a look at a simple model of Category Management for you to introduce. Baby is an important category because of the importance of creating a link with mums and mums-to-be, which can develop into loyal relationships that should last very many years.

Keith Harford, Commercial Director Pharbiz, 087 946 4446,

As I so often note, most good practices are about good planning. Indeed, there is an old adage which says that “failing to plan is planning to fail!” And there are many more which will give you the same message. Category Management is often quoted as being so helpful to the retail part of Community Pharmacy, but implemented only rarely. This is because it is often misunderstood, as its description can regularly be ….a bit of a yawn. It sounds boring BUT it can deliver real added margin to your business. Let us get the definition out of the way first. Category Management is, “The strategic management of product groups through trade partnerships which aims to maximise sales and profit by satisfying consumer and shopper needs” (Source: IGD). They go on to note that “There are two key elements of category management: • Category management aims to provide the shopper and consumer with what they want, where they want it, and when they want it. • Products are grouped together into categories to reflect customers’ needs based on how the product is used, consumed or purchased.”

There are a number of steps we will look at to make the process as easy as possible to follow: Define the category: Categories can be a combination of “like” items, such as shampoos and conditioners, hand-creams, etc. A category can also be a combination of “event” related items, such as Christmas, Gifts and as in this case, Baby. Baby is a combination of all baby related items, foods, consumables for baby such as bottles, teats, etc. and consumables for mum too. These are often called sub-categories. Define sub-categories: For Baby, these will include Food, Nappies & wipes, bottles & teats, baby creams & lotions. Try to think of the obvious, naturally, but also the less obvious. That is, think of items which might “link” to the baby category and create additional sales. Examples might include “cuddly toys” or baby listening devices. Use EPoS reports: Most, but not all, pharmacies now use Electronic Point of Sale, a cash register that will also keep records of what your pharmacy sells for a given time. The relevant reports to look at here are the sales and margin for each of the items you include in the baby category and sub-categories. Analyse Market Research: Ask your suppliers to keep you informed of the major trends in the category. Google it too, and find out the things that you need to know to make any informed decisions. Large supermarket multiples spend a lot of money

and have whole departments given over to the category management process. In your case, keep it simple and don’t be afraid to walk the baby section of the multiples to see if your market research looks correct. Set Category Goals: Decide on objectives for the category. I would not suggest treating this lightly. For example, you could decide to have as a goal that the category will grow by, say, 10% over the next period of months. However, you should have one large goal with a number of objectives feeding into that. Example again: Goal: The baby section is going to be a “destination” category in our pharmacy. That is, we will create a baby section so good that customers will pass other pharmacies, and retailers, to come to our baby section. The objectives might then include: 1. Be the best at Baby in our area 2. Have a credible offering in terms of selection 3. Have a credible offering in terms of value 4. Appoint “champions” in the pharmacy, so that there is always someone available who can advise customers 5. Grow sales by 10% over the next 6 months 6. Grow volume to help improve buying power Range review: Do exactly what this says. Having looked at competitors, see what you need to add to your range and also use your EPoS to identify products that are not selling and are just taking up space. Review space allocation: Following your review of the range and having looked at the EPoS sales and margin reports, decide what space will be given to what products. This can be the “really boring” bit, but suppliers will help (just don’t let them dictate). These suppliers are often referred to as Category

44 March 2012 • IPN

Shop Front

Captains. Be sure to allow volume products to have enough space while at the same time ensuring that items with higher margins which have potential to grow sales are given higher profile locations on shelf. Formulate your plan: This should be a list of actions you will take following your analysis above. It might look like this: • Select and stock a premium brand and a value brand • Be able to provide for all of a customer’s “baby” needs (No, you will not be able to compete 24/7 on nappies) • Provide value for money (through special offers, ideally on a gondola end) • Appoint Baby “champions” who will manage the category day to day for you • Hold regular information days (sponsored by suppliers)

• Hold Mother & Baby events (again sponsored by suppliers) • Etc. Monitor & Review: This is the essential step that most people often forget about. In many of the large supermarket multiples, they will monitor the changes that have been made in a category and will review and modify every six weeks. This is an essential step in the process. A more logical time frame can be chosen for the pharmacy, but on review, it will be found that some of the actions taken will have delivered and some will have achieved less than planned. Changes need to be considered and made. Therefore, the process is never ending. The positive side of this process is that as trends and customers’ tastes change, your pharmacy will be picking up those changes and reacting to them. At the same time, you should see growth in sales and in margin. It is that simple….seriously, it is a lot of work, but once category management has been introduced, it is a case of modifying

only, at each review. Use the team around you to make it work and to work it for you. Break it down into the following steps and then “just do it”. Those steps again are: • Define the category • Define sub-categories • Use EPoS reports • Analyse Market Research • Set Category Goals • Range review • Review space allocation • Formulate your plan • Monitor & Review


20 mg & 40 mg gastro-resistant capsules, hard


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.

Ireland’s No. 1 Generic Healthcare Specialists

46 March 2012 • IPN

Pharmacy Profile

Progressive thinking helps sufferers injuries supports and surgical instruments. “We have thinned out the business in the last few years but we still offer a catalogue service from our medical supply store, from which our patients can order and because we are limited in space in the pharmacy. “We also have our own warehouse out in Clondalkin. For large items, such as wheelchairs, we will deliver them directly to the patient from the warehouse and we supply other pharmacies throughout the country from there as well.”

Marta Jozefczuk, Lynda Green, Donal Cullinane, superintendent pharmacist, Noreen Reilly,Tatiana Vasiliuk

O’Hara’s Pharmacy offers a unique range of services to its patients, including mastectomy fittings to mobility supports. In fact, O’Hara’s Pharmacy has pretty much every angle covered. Located on Aungier Street in Dublin’s City Centre, O'Haras Pharmacy began trading nine years ago in what was the old Fannin Healthcare premises. The company quickly established itself as a regular community pharmacy and, subsequently introduced a medical supplies service to the public.

Irish Pharmacy News went to find out what makes O’Hara’s Pharmacy different to many other pharmacy outlets. Donal Cullinane, Superintendent Pharmacist, oversees the running of the pharmacy, including the medical supply store and said, “Offering the medical supply service has proved to be very positive for the business and the company now provides a full range of surgical products, including diagnostic equipment, homecare aids and appliances, incontinence and ostomy/ileostomy/urostome products, first aid kits, sports

The pharmacy and the medical supply store work in tandem, although the medical supplies have now moved to premises opposite the pharmacy because, as Cullinane said, “It became confusing for our patients because we had shampoo bottles, sitting on a shelf beside walking sticks.” According to Cullinane, O’Hara’s Pharmacy owes a huge amount of its business to Fannin Healthcare, because Fannin’s had already established a supply chain to the hospitals when O’Hara’s bought the premises. Cullinane said, “We have benefited hugely from the reputation Fannin Healthcare created. We have contracts with Health Boards and we are also a listed vendor with the HSE, so patients with medical cards are directed to us.” Cullinane sees the provision of medical supplies as an excellent way for pharmacies to try to claw back some of the profit

that has been eroded in the past and is likely to be eroded in the future. He said, “Every time we dispense a fridge item, we lose money on it. Add that to the FEMPI cuts and the imminent introduction of reference pricing and generic substitution, I would say that pharmacy businesses are probably going to have to start consolidating as the market gets tougher and tougher. “Providing medical supplies, mobility aids and homecare is quite easy to get involved in, even if it is just putting up a stand of walking sticks or orthopaedic pillows in the window.” Of all the services provided by O’Hara’s Pharmacy, Cullinane believes that the mastectomy service is the pharmacy’s most unique. Noreen Reilly, is a bra enthusiast and the nurse responsible for the mastectomy service, which is provided free of charge and usually by appointment. However, Reilly will always make an exception for anyone who has travelled up from the country or has made a big effort to come in and be fitted. She said, “I have had many foreign visitors come in here, amazed by the service we provide. I recently had nurses in from Australia and New Zealand and they could not believe that there is a service like this available in Dublin.” Providing the mastectomy fitting service certainly keeps Reilly on her toes. Whether she is dealing

IPN • March 2012 47

Pharmacy Profile make them feel as though they do not have a problem at all, or at least one which is easy to manage so, as a result O'Hara's is stocking a more specialised range. “We have pull-up pads, for example,” said Green, “which make the patient feel comfortable and confident about going out for lunch or a business meeting as the pants help to diminish their stress levels. For the more serious cases, we stock ‘feel dry’ diapers that dry up evenly and eliminate the occurrence of sores and rashes.” Noreen Reilly

with a customer on the phone, who is looking for a particular item from O’Hara’s wide ranging catalogue or fitting a customer in-store, Reilly is always on the go. She said, “I have, on average, six to nine fittings a day. Some people take a long time as they are very particular about the type of bra they want and its colour. “We stock a huge range of bras and prostheses. I like to merchandise the products so that people can come in, as if they are going into an ordinary shop; buy what they came in for and go home satisfied. We offer everyone individual attention and treat them as though there is nothing wrong with them. I really like them to be able to go out with the product that they came in for.” Stock is expensive and, in view of the recession in Ireland, O'Hara's decided to create their own brand of prostheses. Reilly said, “We had to source our own prostheses so that we could offer more affordable products for our patients but we also stock premium brands, including an Irish brand.” Reilly is well suited to the job. Being a nurse, she is able to counsel those patients who are unable to accept their situation

very well. She said, “I have had a number of patients break down in here. You just have to be patient and listen because there is an awful lot more hidden behind what they are actually saying. “Patients do not want to go back to hospital for something as simple as a bra. They dread their check-ups and they do not need to be reminded again of the operation and all the trauma that goes with it, just to buy a bra and prostheses. “Many patients are still in denial when they come in.”

When O’Hara’s first began providing the incontinent service, they had about five men a week pop in. Now there are between thirty and forty who visit on a regular weekly basis.

Green has found that there is also an increased demand for compression stockings. She said, “The HSE has recently changed the rules on who is eligible for free stockings. Now, many patients are buying them privately because they do not qualify for the free items.” Following the closure of many care homes across the country, O’Hara’s Pharmacy is now offering a service to advise those people returning to their own home how to live with greater independence and in a safer environment by giving them advice and suggestions for their day-to-day living.

“The word has got out that O'Haras can help,” said Green. “One man came in recently and told me that he had only just found out about us when he was sitting, having a drink with a friend in a bar.

Green said, “We provide mobility aids and devices that are easy to dismantle and even easier to put together, so that patients returning from care homes can have that extra little bit of independence and their families can have some peace of mind.”

“People of all ages come in with incontinence problems,” she continued. “It can affect anyone at any age. Incontinence can be brought on by a kidney or liver problem or it may be inherited. In many cases, the problem may

Evidently, O’Hara’s Pharmacy game plan seems to be succeeding and their attitude towards healthcare is actively covering every eventuality.

Reilly explained, “A lot of patients find weight a problem - and very difficult to handle. Someone might be on hormonal treatment and have put on weight but they still think that they are, say a 34B. They want to be a 34B. They want to be transported back to a time when they were a 34B - and healthy.” Reilly works alongside Lynda Green, who is responsible for the incontinence and mobility aid aspect of the business. Whilst most pharmacies stock a range of incontinence pads, Green explained that O’Hara’s has gone one step further and, in addition it offers a more specialised range of incontinence products. Sufferers require products which

have started during the patient’s childhood and remained untreated.”

Lynda Green

48 March 2012 • IPN


How to Promote your Pharmacy Christine Whelen, Premium Distribution Marketing Approach - Key Steps Get Closer to your Customer Base Survey your current and potential customers to ascertain what they want from your pharmacy. This can be easily done in store and/or after hours. You can have a simple one-page questionnaire asking them to comment on and rank the importance of various factors in the purchasing decision • Price • Product range • Brands- their influence and range offered in key categories • In Store Service and Quality of engagement with staff

Christine Whelen Bio - Christine Whelan’s career has been immersed in the beauty business at both product and service level. Her background is with blue chip brands at a service and consumer level. Currently working with Premium Distribution as a sales representative on brands like St Tropez, Yes to Carrots and Sanctuary, Christine combines her product knowledge with a sales and retail approach.

To increase footfall, secure repeat business and consequently improve profit performance, it is necessary to continuously promote your product and service to current and potential customers. Most pharmacies essentially offer the same service – the filling of prescriptions and the sale of medicines and beauty products. So how can your pharmacy stand out from its main competitors in the minds of existing and potential customers? A well-planned, targeted and consistent marketing programme can provide a real change in your business performance. The plan should include external and internal communications with customers, potential customers and doctors.

• After Sales Service – Requirement for prescription delivery or online ordering for refills • Relevance and effectiveness of promotions e.g. Money off, bogof, loyalty club, direct mail offers etc.? Network and Build Relationships with Key Channels - Build relationships with doctors calling and quickly getting to know new doctors in your area. Engage with nursing homes and other health related organisations, education facilities, HR departments of larger companies and relevant SMEs in your catchment area. Expand the Range of services offered in store - Expanding the range of services you offer in store will help you to build a loyal customer base. For example, offer personal weight loss clinics, smoking cessation programmes and style clinics. And, depending on the space available, you could present expert advice on relevant topics through “customer evening” promotions. Community Involvement - Sponsor a neighbourhood health fair or have a stand at a local community event. Sponsor local sports clubs, even if it is with a product or advice. Volunteer to talk about health in local schools, breast feeding groups and other community groups.

Gift Cards - These can be used for health and beauty purchases. A customer may be unsure about a perfume choice but will happily give a gift card. A flu shot gift card would make a very useful and practical gift. Loyalty Cards - These are very useful to ensure repeat business. They also provide a track record of customers spending habits. In larger stores, this can be used for targeted mailings. Social Media - Facebook is free and if used properly can be a valuable communications tool with existing and potential customers. Set up a page for your store and post every day on relevant health and beauty matters. You can then build up your audience. Cross promotions with other complementary but not competing businesses will also help to build up your audience. In Store Marketing / Promotion Continuously review the effectiveness of product projection through in store and window displays. Window displays should be seasonal and themed for maximum impact on “passing traffic”. In store, product presentation should obviously account for consumer purchase behaviour in terms of grouping and presenting product categories to optimise purchase potential. Staff - Pharmacy staff are the most valuable resource you have in building sales and retaining customer loyalty. Staff should be trained to be welcoming and encouraged to use customer’s names. Ensure your sales team can provide customers with all relevant information. Develop a regular schedule of product training for full time and part time staff. Develop and refine selling techniques including how to sell. For example suggest skin exfoliator and /or an illuminator to a purchaser of self-tan. Remember - Pharmacies provide a vital service and must sell the benefits of their service to customers and potential customers. As prescription drugs grow more complex and the health and beauty market continues to proliferate, pharmacies need to let customers aware of the range of their expertise.

ch to op a io o r id p p lge sia

Powerful­on­Pain ­reduced­risk­of­ opioid-induced­ constipation

Targin® tablets contain an opioid analgesic TARGIN® 5mg/2.5mg, 10mg/5mg, 20mg/10mg and 40mg/20mg prolonged release tablets Prescribing Information Republic of Ireland Presentation: Film-coated, oblong, prolonged release tablets containing oxycodone hydrochloride and naloxone hydrochloride, marked OXN on one side and the oxycodone strength on the other. Colours: Blue - 5mg (oxycodone hydrochloride)/2.5mg (naloxone hydrochloride), white - 10mg (oxycodone hydrochloride)/5mg (naloxone hydrochloride), pink - 20mg (oxycodone hydrochloride)/10mg (naloxone hydrochloride) and yellow - 40mg (oxycodone hydrochloride)/20mg (naloxone hydrochloride). Indications: Severe pain, which can be adequately managed only with opioid analgesics. The opioid antagonist naloxone is added to counteract opioid-induced constipation by blocking the action of oxycodone at opioid receptors locally in the gut. Dosage and administration: Adults over 18 years: Usual starting dose for opioid naïve patients is Targin® 10mg/5mg, taken orally at 12-hourly intervals. Patients requiring a higher dose are recommended Targin 20mg/10mg tablets. Targin 5mg/2.5mg is intended for dose titration when initiating opioid therapy and individual dose adjustment. The dosage is dependent on the severity of the pain and the patient’s previous history of analgesic requirements. Patients already receiving opioids may be started on higher doses of Targin depending on their previous opioid experience. The maximum daily dose of Targin is 80mg oxycodone hydrochloride and 40mg naloxone hydrochloride. Targin tablets are not intended for the treatment of breakthrough pain. For the treatment of breakthrough pain, a single dose of “rescue medication” should amount to one sixth of the equivalent daily dose of oxycodone hydrochloride. Please refer to the SmPC for further details on dose titration. Targin tablets must be swallowed whole and not broken, chewed or crushed which leads to a rapid release and absorption of a potentially fatal dose of oxycodone. Children under 18 years: Not recommended. Contraindications: Hypersensitivity to the active substances or excipients, any situation where opioids are contraindicated, severe respiratory depression with hypoxia and/or hypercapnoea; severe chronic obstructive pulmonary disease, cor pulmonale, severe bronchial asthma, non-opioid induced paralytic ileus, moderate to severe hepatic impairment. Precautions and warnings: Respiratory depression, elderly or infirm, opioid-induced paralytic ileus, severely impaired pulmonary function, hypothyroidism, adrenocortical insufficiency, toxic psychosis, cholelithiasis, prostate hypertrophy, alcoholism, delirium tremens, history of alcohol and drug abuse, pancreatitis, hypotension, hypertension, galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption, pre-existing cardiovascular diseases, head injury (due to risk of raised intracranial pressure), epileptic disorder or predisposition to convulsions, patients taking MAO inhibitors, renal impairment, mild hepatic


a uni qu e




impairment, pre-operative use or within the first 12 – 24 hours post–operatively. Not suitable for the treatment of withdrawal symptoms. Not recommended in cancer associated with peritoneal carcinomatosis or sub-occlusive syndrome in advanced stages of digestive and pelvic cancers. Interactions: Substances having a CNSdepressant effect (e.g. alcohol, other opioids, sedatives, hypnotics, anti-depressants, sleeping aids, phenothiazines, neuroleptics, anti-histamines and anti-emetics) may enhance the CNS-depressant effect of Targin (e.g. respiratory depression). Interaction with coumarin anticoagulants may increase or decrease INR. Pregnancy and lactation: Not recommended. Side-effects: Common adverse drug reactions are decreased/loss of appetite, restlessness, headache, vertigo, decrease in blood pressure, abdominal pain, diarrhoea, dry mouth, constipation, flatulence, vomiting, nausea, dyspepsia, increased hepatic enzymes, hiccups, altered mood, decreased activity, psychomotor hyperactivity, agitation, dysuria, pruritus, skin reactions, hyperhidrosis, dizziness, drug withdrawal syndrome, feeling hot and cold, chills, asthenic conditions. Some side-effects which are uncommon but could be serious are hypersensitivity, confusion, depression, halluc-inations, disturbance in attention, somnolence, speech disorder, convulsions, syncope, visual disturbances, palpitations, angina pectoris, tachycardia, increase in blood pressure, dyspnoea, respiratory depression, biliary colic, erectile dysfunction, urinary retention, peripheral oedema, abdominal distension and chest pain. Please refer to the SPC for further details of other uncommon side-effects and oxycodone class-effects. Tolerance and dependence may occur. It may be advisable to taper the dose when stopping treatment to prevent withdrawal symptoms. Legal category: CD (Sch2) POM. Package quantities: Blisters of 56 tablets. Marketing Authorisation numbers: PA913/025/001-4. Marketing Authorisation holder: Napp Pharmaceuticals Limited, Cambridge Science Park, Milton Road, Cambridge CB4 0GW, UK. Member of the Napp Pharmaceutical Group. Further information is available from: Mundipharma Pharmaceuticals Limited, Millbank House, Arkle Road, Sandyford, Dublin 18, Tel: +353 (0)1 2063800. Date of preparation: April 2011. (UK/UNA-11115). References: 1. Simpson K, Leyendecker P, Hopp M, et al. Fixed-ratio combination oxycodone/naloxone compared with oxycodone alone for the relief of opioid-induced constipation in moderate-to-severe noncancer pain. Curr Med Res Opin 2008;24(12):3503-3512. 11144TRG

Adverse events should be reported to Mundipharma Pharmaceuticals Limited on 1800 991830

® The Napp device (logo) is a Registered Trade Mark. ® Targin is a Registered Trade Mark. © 2010-2011 Napp Pharmaceuticals Limited.

➞ ➞ ➞

Targin® provides pain relief that is as effective as oxycodone alone1 Targin® reduces the risk of opioid-induced constipation when compared to oxycodone alone1 Targin® is GMS re-imbursable Targin® is indicated for severe pain, which can be adequately managed only with opioid analgesics. The opioid antagonist naloxone is added to counteract opioid-induced constipation by blocking the action of oxycodone at opioid receptors locally in the gut.

50 March 2012 • IPN

Cash Control

“Cash is King”

Tim o Brien CubIt Software The Pharmacy EPoS People

I worked hard for it. I have my staff and lot of bills to pay with it. I would prefer if nobody took it from me without my permission. Agreed? If so, why is it that so many pharmacies in Ireland are a tad lax when it comes to securing the cash that comes through the till? Why do many pharmacists accept shortages as a customary part of business? Cash security experts say that while a cash shortage should be a cause for concern, a cash overage should be a cause for even greater concern. Do you allow/accept a discrepancy of €5 per float, like many of your peers do? If you do, in a two till pharmacy you allow the possibility of an annual shortage of €3,100. What does it cost you to earn that €3100 through your till? Are you still happy to accept a shortage of €5 per float? It is important to point out that you can never have proper cash control without having live stock figures. In theory, if a cash discrepancy should occur, there should be a corresponding stock discrepancy in the main. If you do not have correct stock control you will never be able to spot these

anomalies. What this effectively means is that, not only will you be unaware of a situation when it occurs, but you will not even be able to tell if it was accidental or not. Stock control really is quite easy • Order your stock • Enter your stock to your EPoS system. • Sell your stock. • Reorder stock. • Record your returns, damaged goods, not for sale stock, etc. on your EPoS system. Many people tend to put up barriers to proper stock control. A common excuse is, “It is too hard, there are too many products, etc.” However, it always amazes me when I go in to a shoe shop or a sports shop and, when they do not have what I am looking for, they tell me that they will check if any of their other shops have the product in stock. Not alone do they have live stock at their own store but they have it at every store. It is not too hard to do. The mistake many pharmacies tend to make is around the compliance side of things.

And finally, whenever it is possible, try to use an integrated credit / debit card payment system. Many of the credible EPoS systems now work with integrated systems. A substantial amount of discrepancies / fraud is around card payment. An integrated system may be slightly more expensive but is absolutely cost justifiable. It is another cash headache removed forever. In summary: 1. Do not accept cash discrepancies and ensure that your staff are aware that you will always examine discrepancies. 2. Understand the relationship between cash and stock. 3. Try to use an integrated credit / debit card payment system. In my experience, the store that does not accept discrepancies, has good stock control and uses an integrated card payment system, is the store that almost never has discrepancies. If you have an issue surrounding cash or stock then talk to your EPoS provider as they should be able to offer advice on how best to deal with the issue. Happy trading!

IPN • March 2012 51

Cost Effective

Convenience Quality and Service To place your order or to make an enquiry please contact: SAM McLERNON DUBLIN LTD. Fox & Geese House, Naas Road, Dublin 22. Orderline: 01-450 4121 Faxline: 01-456 9217 E-mail:

Manufacturers of ■ ■ ■ ■ ■

Counter Bags Dispensing Bags Dispensing Labels Tablet Vials & Tablet Bottles Overprinted Carrier Bags in small quantities

Your one stop shop for

The well known 7 Day Plus Pak domiciliary card Care home blister cards De-Blister Machines o support care homes, All the ancillaries you need to MAR charts, trolleys, dividers etc. ■ Full range of Gift Wrapping and gift packaging We have over 60 years manufacturing experience in our facility on the Naas Road and more recently our new factory in Ballymote Co. Sligo. ■ ■ ■ ■

- Over 75 Years of Service to Pharmacy!

52 March 2012 • IPN

I.T. Update Meeting the IT needs of Irish pharmacists and confident operating it, is second to none. These are supported by our engineers who carry with them a full complement of hardware in order to ensure that you have minimal ‘down time’ should a fault occur with your system. both our trainers and our engineers are allocated on a regional basis, allowing you to build up a personal relationship with your local McLernons staff, and allowing them to develop a better understanding of the way you work. We offer free accredited training for all locum pharmacists, and with our donation of systems to Trinity College Dublin our MPS Dispensing systems are now in every School of Pharmacy in Ireland, ensuring that the next generation of pharmacists are fully conversant with MPS. Our McLernons Pharmacy Systems (MPS) Our suite of products included MPS dispensary management system, MPS Retail, our Windows-based EPoS system and MPS Head Office, to help you manage more than one pharmacy system. Robin Hanna

In 2012, McLernon Computers is celebrating its 30th anniversary - three decades of finding innovative ways to meet the IT needs of community pharmacists across the island of Ireland No other pharmacy vendor has this history with its customers, and we believe no other pharmacy vendor can help you in the future. We believe we are different to other IT vendors in that McLernons pride themselves on being your IT business partners - we listen to our customers, meet their needs and anticipate new ways of working in the future. Customer focused - In our thirty years of business perhaps the single thing of which we are most proud is our customer service, which lies at the heart of everything we do. Our Customer Services department who man our helpline are the first point of call for our customers and they are highlyqualified professionals who understand the importance of your system to your business and your patients. Our dedicated team of trainers all have experience of working in community pharmacies, and their dedication to ensuring that your staff are fully familiar with all aspects of the system, and are comfortable

All of our systems give the pharmacist the ability to translate data into information, which gives you knowledge you need to better inform the way you run your business. Everything from dispensing figures to key prescribers, identification of purchasing patterns and staff performance is available from your system, and our systems are designed to help you maximise the number of revenue streams which your business can access MPS Dispensing - The MPS Dispensing system is more than a ‘label and reorder’ system, but is a business tool you cannot afford to be without. Helping pharmacists adapt to new ways of working has been the driving force behind everything we do - from writing interfaces with robotic dispensing and monitored dosage systems to on-line back ups and extensive financial OLAP reporting tools We work closely with leading providers of other pharmacy technology - such as producers of monitored dosage systems, GP systems, and manufacturers of robotic dispensing solutions and anti-counterfeit drug technologies. Recent products launched include: • MPS Script Store, which gives you the ability to document and scan prescriptions and other notes, and link these scanned documents to patients’ histories

• 2D barcode scanner, which reads prescriptions and automatically populates the patient history, speeding up labelling process and updating PMR. • Text Messaging service, allowing you to send patients a text message when their script is available and advertise additional pharmacy services to your existing customers • TicTac and drug identification, including photographs • BNF Live Link, proving instant access at the point of dispensing to the BNF, and other online reference sources such as NF for Children, Martindale, Stockley’s, etc MPS Retail, our EPoS system - MPS Retail takes your till, your back-office reports and your stock inventory and puts them all under the one roof. From these you can run live up-to-theminute reports such as sales, margin and stock reports, connect with your financial package and, if you have more than one pharmacy, link all of your branches together. MPS Head Office - McLernon Computers were the first pharmacy software supplier on the island of Ireland to develop a centralised head office support programme. CeDAC (Centralised Data Analysis and Control System) offers the facility for complete control of stock and reinforcement of purchasing policies across a group of pharmacies. There is a reason why more pharmacy groups use McLernons MPS rather than any other pharmacy software system - no one else knows your business like we do and our MPS CeDAC Head Office system gives you the tools you need to maximise your profitability. A head office system is not just for large multiples - smaller groups can also benefit from the central command and control that this can provide. Our CeDAC head office system is a sophisticated mulit-location ICT solution which will help you retain control over your stock and your dispensing. It gives you the tools you need to consolidate and analyse business data. With this detailed information you can boost business efficiency, control compliance throughout the group and maximise profitability. We will be supporting both the IPU Conference and the UD Pharmacy Show as exhibitors, so why not come along and see us there?

McLernon Computers are delighted to celebrate its 30th year of delivering innovative pharmacy management systems to Irish community pharmacists. The world was a very different place in 1982, when the McLernon Richardson system was launched- not least the increase in memory capacity from 10Mb! – but the ethos of McLernon Computers hasn’t changed in the intervening three decades and we continue to deliver high quality systems which help you run your business and care for your patients.

Brian Bothwell, Financial Controller, Graham Henderson, Operations Director, Keith McLernon, Managing Director and Robin Hanna, Sales Director.

Recent products launched include:

No other pharmacy vendor has this history with its customers, and we believe no other pharmacy vendor can help you in the future.

• MPS Script Store, which gives you the ability to document and scan prescriptions and other notes, and link these scanned documents to patients’ histories

Our suite of products included MPS dispensary management system, MPS Retail, our Windows-based EPoS system and MPS Head Office, to help you manage more than one pharmacy system.

• Text Messaging service, allowing you to send patients a text message when their script is available and advertise additional pharmacy services to your existing customers

• 2D barcode scanner, which reads prescriptions and automatically populates the patient history, speeding up labelling process and updating PMR.

• TicTac and drug identification, including photographs • BNF Live Link, proving instant access at the point of dispensing to the BNF, and other online reference sources such as NF for Children, Martindale, Stockley’s, etc.

We shall be exhibiting at the IPU Conference in April or the UD Pharmacy Show in May, where you will have an opportunity to see our MPS systems. For further information on any of our products, please do not hesitate to contact Robin Hanna on (01) 450 1916 or by emailing

54 March 2012 • IPN

Out and About

Pharmacists pose at La Roche Posay launch La Roche Posay launched its latest product, Cicaplast Baume B5 to the Irish market at the Science Gallery in Dublin this month. Cicaplast Baume B5 is an ‘all-in-one’ product which soothes and repairs all irritated or damaged skin. It is indicated for use in treating eczema, dry patches, cutaneous dryness, infant redness, grazes, cracks, sensitive skin, chapped lips, itching, heating sensations, rough patches, sunburn, breast feeding (cracked nipples) and nappy rash. Its primary ingredients include Panthenol (5%) which acts to soothe irritation and redness; Madecassoside, which accelerates epidermal repair for faster and more aesthetic scarring; Shea butter and glycerine, which serve to nourish the skin barrier and it also includes a combination of Copper, Zinc and Magnesium for their antibacterial properties. The product is also paraben, fragrance and lanolin free and will retail at €12.50. Selen Ryan, Dermatology Nurse, Sligo General Hospital

Dr. Geraldine Morrow, Consultant Dermatologist, Beacon Clinic

Nicoleta Matei, Aneta Paluck, Pharmacy O’Regan

Aoife Cooper, Marisa Foody, Moran’s Pharmacy, Firhouse, Co Dublin

Michelle Flood, pharmacist, Bradley’s Pharmacy KCR, Catherine Fahy, pharmacy intern, Bradley’s Pharmacy Stillorgan, Catherine Flanagan, Manager, Bradley’s Pharmacy KCR

Deborah O’Reilly, Gina Eastwood, Rafferty’s Pharmacy, Stillorgan

Out and About World Diabetes Day World Diabetes Day saw Derek Davis, former RTE broadcaster joining with Diabetes Ireland and MSD in the launch of “Lets Talk Diabetes” , a campaign on the effect of hypoglycaemia – low blood sugar . The campaign urges people with diabetes to understand and recognise the symptoms of low blood sugar so that they can be treated quickly. While we often think of diabetes patients as working to control blood sugar and prevent them getting too high – low blood sugar – or hypoglycaemia is equally important to manage as it can have serious consequences, if left untreated. For further information visit

Ms Jenny Lee; Mr Derek Davis; Ms Sinead Tuite, MSD

Lollipop Day 2012

Lean on Me

Ireland has one of the highest rates of Oesophageal Cancer in Europe amongst men and women, with approximately 450 new cases diagnosed each year.

Performance coach Caroline Currid and former Irish rugby player Alan Quinlan recently promoted positive mental health by discussing the role that mind management can have in enhancing performance and managing mental health.

The Oesophageal Cancer Fund hosted its annual nationwide Lollipop Day, calling on the public to buy a lollipop to support the Oesophageal Cancer Fund and to create awareness of the symptoms. This year, the Oesophageal Cancer Fund was supported by the Department of Health and Minister for Health, Dr James Reilly.

Dr Mary Henry; Dr Pixie McKenna; Ms Geraldine O’Connor, Pfizer Healthcare Ireland

Health Index launch

Three year old Muireann Cooper Edgeworth from Tallaght licks off the Lollipop Day 2012 campaign

“The Lean on Me- To Win” events were held at four locations across the country to promote positive mental health and introduce techniques to help people get the best out of themselves day-to-day. The events were part of the successful “Lean on Me” campaign that is supported by Aware. For further information visit

Former Independent Senator Mary Henry and presenter of Channel 4’s “Embarrassing Bodies”, and Cork born Dr. Pixie McKenna were on hand to launch the latest Pfizer Health Index which details the findings of a nationally representative quantitive market research survey of the health and wellbeing of the Irish population. This year, the study looked at the health status of women in Ireland, and found that 36% of working women are the sole earners for their household, indicating the increasing pressure on women to juggle family and work demands. The study also showed that the current economic climate is beginning to impact on people’s health. For further information visit

Ms Caroline Currid and Mr Alan Quinlan

56 February 2012 • IPN

Product Profiles Emjoi MICRO Pedi Spring has arrived! Instead of worrying about unattractive feet treat them to the revolutionary Emjoi MICRO Pedi. The MICRO Pedi is a beauty innovation device designed to take the chore out of at-home pedicures. It gently, yet effectively buffs away callused and coarse skin with a unique roller action, giving spa results every time. Emjoi MICRO Pedi is available in Boots, leading pharmacies nationwide and online from or phone 1890 25 22 06

Trilogy Helping Hand Wash It’s all in the name In celebration of 10 beautiful years in business, 2012 sees high performance natural skincare brand Trilogy launch a year long campaign to raise funds for Child’s i Foundation, a wonderful charity helping to end the tragedy of baby abandonment in Uganda. Trilogy Helping Hand Wash is a gorgeous, limited edition product created specially for this campaign. Helping Hand Wash is a low foaming liquid soap, with Trilogy’s signature fragrance.The luxurious creamy texture leaves hands feeling deliciously soft and clean. All profits from the sale of Helping Hand Wash will be donated to Child’s i Foundation Trilogy Helping Hand Wash RRP €14.95 (300ml)

Viviscal Maximum Strength

JJ O’Toole Ltd

Viviscal Maximum Strength is a clinically proven2 natural food supplement, that promotes existing hair growth in women suffering from thinning hair. Viviscal’s key ingredient is an exclusive AminoMar C™ - a rich protein compound of marine extracts blended with organic, soluble silica and fortified with vitamin C. Amino acids are the basic structural building units of proteins and are essential in the formation of the hair structure. Viviscal provides those essential nutrients to nourish hair naturally from within.

JJ O’Toole Ltd is proud to be the preferred packaging supplier to Cara Pharmacy, winner of the Deloitte Best Managed Companies Award 2012.

Viviscal Maximum Strength is part of a programme of Ireland’s No1 best selling thinning hair supplements from Lifes2Good, trusted by leading celebrities and recommended by trichologists. Available from leading pharmacies nationwide and online from Lifes2Good. Visit or phone 1890 60 18 01.

Established in 1914, JJ O’Toole Ltd is Ireland’s leading supplier of packaging across all retail sectors. We supply branded and stock packaging to the pharmacy sector which includes grip seal bags, prescription bags, twist and tape carrier bags, luxury carriers, tissue, labels, ribbons and gift boxes. As well as stock items, our in-house graphic designer can create unique designs for bespoke packaging, free of charge. For excellent service, quality and design from JJ O’Toole Ltd please visit our website or call us on 1890 68 66 53.

IPN • February 2012 57

Product Profiles Burt's Bees Baby Bee Bath-time and Skin Care Collection To cleanse, comfort and care for your baby’s delicate skin. A baby’s skin is very delicate and needs special care. That’s why it’s important to use only the mildest and purest natural soaps, lotions, oils and powders to cleanse and care for little ones. Burt’s Bees Baby products are carefully formulated to be more than 98.9% natural with gentle yet effective ingredients so babies can be pampered, worry free. All products are Hypoallergenic and Paediatrician Tested. To find out more about Burt’s Bees Baby Care products, please contact The Natural Medicine Company on 045-891289 or email

EmulsidermTM Emollient Emulsiderm Emollient helps parents to care and protect their children’s eczematous skin, during the normal bath time routine. It contains two emollients to soothe and rehydrate dry skin. It also contains an antimicrobial to provide protection against Staphylococcus aureus, which can aggravate eczema and its associated itch. Emulsiderm Emollient is available, only from Pharmacies in a 300ml and an economy 1 litre pack. Emulsiderm Emollient can also be used under the shower or directly applied to the skin.

Roger&Gallet Limited Edition

UltraLift Swirl

Roger&Gallet Limited Edition Toile de Jouy Travel pouch (RRP 19.90)

UltraLift Swirl RRP €17.99

Roger&Gallet are celebrating 150 years of Perfumer know-how, innovation and artistic collaboration this year. As part of these celebrations, Roger&Gallet have released a limited edition Toile de Jouy Travel pouch. Each exclusive pouch contains a 30ml fresh fragrant water and a 100g perfumed soap delicately wrapped in pleated silk paper. This luxury and unique travel pouch is available in three iconic fragrances: Bois d'Orange, Citron and Fleur d'Osmanthus. Available from March in selected pharmacies nationwide

Garnier introduces UltraLift Swirl - a smart skincare solution for women seeking the efficacy of an anti-wrinkle serum and the comfort and moisturising properties of a cream. Our new formula is enriched with two times more concentrated Pro Retinol derived from nature for a proven anti-ageing effect that reduces even deep wrinkles. Thanks to the spiral distribution of the serum and the creams, the UltraLift Swirl looks as good as it feels and dispenses the perfectly balanced combination of both formulae in every application. Deep anti-wrinkle action and boosts firmness in just ten days.

58 March 2012 • IPN

Appointments Former sales representative Alex Gorsky has been announced as the new Chief Executive Officer of Johnson and Johnson. Mr Gorsky, who will start his new role on 26th April, succeeds Bill Weldon, who has served as Chairman and CEO since 2002.The outgoing CEO, who will remain as chair of the board, says the future of the company is now in “very capable hands”. The new CEO began his career with J&J as a sales representative in 1988 with Janssen Pharmaceutica. He then progressed to positions of increased responsibility and was appointed President of Janssen in 2001 and then Company Group Chairman of J&J’s pharmaceuticals business in Europe, the Middle East and Asia two years later.

Novartis has appointed a new division head of its over-the-counter (OTC) business. Brian McNamara will replace Naomi Kelman with immediate effect after she decided to leave the company. He will be responsible for continuing to drive growth in Novartis OTC and implementing marketing activities. Mr McNamara, who joined Novartis OTC in 2004, has more than 20 years’ experience in consumer marketing. He started his career at Proctor & Gamble before moving to Novartis and becoming European OTC head from 2007 to 2010.

Astellas has recruited a Pfizer VP to lead its new global medical affairs organisation. Dr Charlotte Kremer has moved from Pfizer to Astellas to provide “global leadership for medical excellence and a unified medical perspective”. Dr Kremer has 20 years’ experience in the pharmaceutical industry, most recently as Pfizer’s VP and therapeutic area head for ophthalmology, PVD, rare diseases and neuroscience.

United Drug has announced that Mr Ronnie Kells, who has been a Non-Executive Director of the Company since 1999 and Chairman for the last six years, will retire from the Board following the conclusion of the Company's Annual General Meeting on 7 February 2012. Mr Peter Gray, who has been a Non-Executive Director of the Company since 2004 will succeed Mr. Kells as Chairman. Mr. Gray is Vice Chairman and former Chief Executive of ICON plc and is also a Non-Executive Director of Danica Life Limited.

Chief Operating Officer of the European Association of Hospital Pharmacists (EAHP) Jennie De Greef today announced the appointment of Richard Price to the new position of Policy and Advocacy Officer. Richard will join the EAHP in January to lead the association’s advocacy efforts in Brussels and Strasbourg on important issues such as the Professional Qualifications Directive, the Medical Devices Directive and the Patient Information Directive. Richard has 9 years experience of representing organisations’ interests to European, national, and regional government audiences. He joins from the Pharmaceutical Society of Northern Ireland.

Professor John Fitzpatrick has been appointed Head of Research at the Irish Cancer Society. He will be responsible for developing a strategic plan for cancer research and will co-ordinate research efforts throughout Ireland, while encouraging collaboration through mechanisms such as the Cancer Research UK model of cancer centres. Commenting on the recent appointment, John McCormack, CEO, the Irish Cancer Society said, “Appointing Professor Fitzpatrick as our new Head of Research is a major step forward for us in the fight against cancer. Research is an area of great strategic importance for the Society, and with his expertise, we want the Irish Cancer Society to develop a major leadership role in cancer research in Ireland.”


Let's work together THE FULLY COMPREHENSIVE PHARMACY RECRUITMENT SOLUTION The fastest way to book a locum is through PharmaConex. We now have a new website, with self booking system for registered locums. You can register your request for a locum via our website at any time or by calling either the office or the out of hours 24/7 number. Your request will be published on our website, which is accessed by all our registered locums - most bookings are filled within 24 hours.



STILL NOT USING OUR SERVICE? Just click on our website, or call us to register your booking today. We have over 1000 registered locums in locations all across Ireland and operate an email and text alert system in addition to our on line services. We also provide Permanent, Contract and Part Time Recruitment services with fair and competitive flat fees.

PharmaConex Ltd. 22a Liberty Lane, Dublin 8, Ireland Be in with a chance to win this magnificent prize when you place an order over €250. Terms and conditions apply. Only available to RiceSteele Direct customers.

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A THE COSMETIC Christmas Trade Fair C 2012




A SBallsbridge, S O C I A Dublin T I O N4 The Main Hall, RDS,

Sunday 27th May 10am – 6pm Monday 28th May 9am – 7pm Tuesday 29th May 9am – 5pm w w w.c o s m e t i c a s s o c i a t i o n . i e


In this issue: NEWS: Pharmacies amongst some of the best managed companies in Ireland - PROFILE: This month’s profile features Marian Shanle...