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November 2012 Volume 4 Issue 11

THE INDEPENDENT VOICE OF PHARMACY Shortlisted BUSINESS TO BUSINESS MAGAZINE OF THE YEAR 2009

In this issue: NEWS:

New proposals from IACPT on technician registration page 5

PROFILE:

New IPU President Rory O'Donnell speaks exclusively to Irish Pharmacy News page 9

DEBATE:

Has the pharmacy profession lost confidence in Health Minister Reilly? page 18

CPD:

Management of the asthma patient page 33

FEATURE:

Diabetes management and diagnosis in the pharmacy page 40

NEWS:

Faster payment options offered by pharmacy chain page 48

REPORT:

Helping patients to better help themselves page 54


Reduces Total Cholesterol and LDL Cholesterol1 Helps prevent cardiovascular events in patients at risk of first event1

Ireland has a NEW King of Hearts! Abbreviated prescribing information: Torvan 10 mg/ 20 mg/ 40 mg and 80 mg Film-coated tablets. Presentation: Torvan is supplied as film-coated tablets of 10 mg/ 20 mg/ 40 mg or 80 mg of atorvastatin. Indications: Torvan is indicated as an adjunct to diet for reduction of elevated total cholesterol (total-C), LDL-cholesterol (LDL-C), apolipoprotein B, and triglycerides in adults, adolescents and children aged 10 years or older with primary hypercholesterolaemia including familial hypercholesterolaemia (heterozygous variant) or combined (mixed) hyperlipidaemia (Corresponding to Types IIa and IIb of the Fredrickson classification) when response to diet and other nonpharmacological measures is inadequate. Atorvastatin is also indicated to reduce total-C and LDL-C in adults with homozygous familial hypercholesterolaemia as an adjunct to other lipidlowering treatments (e.g. LDL apheresis) or if such treatments are unavailable. Used for the prevention of cardiovascular events in patients estimated to have a high risk for a first cardiovascular event (see section 5.1), as an adjunct to correction of other risk factors. Dosage: The patient should be placed on a standard cholesterol-lowering diet before receiving atorvastatin and should continue on this diet during treatment with atorvastatin. The dose should be individualized according to baseline LDL-C levels, the goal of therapy, and patient response. The usual starting dose is 10 mg once a day. Adjustment of dose should be made at intervals of 4 weeks or more. The maximum dose is 80 mg once a day. Atorvastatin is for oral administration. Each daily dose of atorvastatin is given all at once and may be given at any time of day with or without food. Contraindications: Hypersensitivity to the active substance or to any of the excipients of this medicinal product. Active liver disease or unexplained persistent elevations of serum transaminases exceeding 3 times the upper limit of normal. During pregnancy, while breast-feeding and in women of child-bearing potential not using appropriate contraceptive measures. Special warnings and precautions for use: Liver function tests should be performed before the initiation of treatment and periodically thereafter and in patients who develop any signs or symptoms suggestive of liver injury (monitor raised transaminase levels until they resolve). Should an increase in transaminases of greater than 3 times the upper limit of normal (ULN) persist, reduction of dose or withdrawal of atorvastatin is recommended. For patients with prior hemorrhagic stroke or lacunar infarct, the balance of risks and benefits of atorvastatin 80 mg is uncertain, and the potential risk of hemorrhagic stroke should be carefully considered before initiating treatment. Torvan should be prescribed with caution in patients with pre-disposing factors for rhabdomyolysis and a CK (creatine kinase) level should be measured before treatment. If CK levels are significantly elevated at baseline (> 5 times ULN), treatment should not be started. Patients with muscle pain, cramps, or weakness especially if accompanied by malaise or fever should have their CK levels monitored. Torvan must be discontinued if clinically significant elevation of CK levels (> 10 x ULN) occur, or if rhabdomyolysis is diagnosed or suspected. If muscular symptoms are severe and cause daily discomfort treatment discontinuation should be considered. The risk of myopathy may also be increased when administered with other medicinal products that have a potential to induce myopathy. In cases where co-administration of these medicinal products with Torvan is necessary, the benefit and the risk of concurrent treatment should be carefully considered. The concurrent use of atorvastatin and fusidic acid is not recommended, therefore, temporary suspension of atorvastatin may be considered during fusidic acid therapy. Exceptional cases of interstitial lung disease have been reported with some statins. If it is suspected a patient has developed interstitial lung disease, statin therapy should be discontinued. Patients with diabetes should be monitored both clinically and biochemically according to national guidelines. Developmental safety in the paediatric population has not been established. Drug Interactions: CYP3A4 inhibitors, CYP3A4 inducers, Transport protein inhibitors, Gemfibrozil / fibric acid, derivatives, Ezetimibe, Colestipol, Fusidic acid, Digoxin, Oral contraceptives, Warfarin, Tipranavir, Ritonavir, Ciclosporin, Lopinavir, Clarithromycin, Saquinavir, Darunavir, Itraconazole, Fosamprenavir, Nelfinavir, Grapefruit Juice, Diltiazem, Erythromycin, Amlodipine, Cimetidine, Efavirenz, Rifampin, Gemfibrozil, Fenofibrate, Phenazone. Pregnacy and lactation: Torvan should not be used in women who are pregnant, trying to become pregnant or suspect they are pregnant. Treatment with atorvastatin should be suspended for the duration of pregnancy or until it has been determined that the woman is not pregnant. Undesirable effects: Common side effects include: nasopharyngitis, allergic reactions, hyperglycaemia, pharyngolaryngeal pain, epistaxis, constipation, flatulence, dyspepsia, nausea, diarrhoea, myalgia, arthralgia, pain in extremity, muscle spasms, joint swelling, back pain, liver function test abnormal, blood creatine kinase increased, headache, abdominal pain, alanine aminotransferase increased, blood creatine phosphokinase increased, For further undesirable effects, please refer to the SPC. Shelf Life: 18 months in bottles, 21 months in blisters. Marketing Authorisation Holder: Pinewood Laboratories Ltd, Ballymacarbry, Clonmel, Co. Tipperary. Marketing Authorisation Holder Numbers(s): PA 281/150/001 - 004. This medicine is a prescription only product. Further prescribing information is available on request. Date of revision: July 2012 Reference 1: Torvan Summary of Product Characteristics, July 2012 Date of preparation: July 2012

Ireland’s No. 1 Generic Healthcare Specialists


IPN • November 2012 3

Contents

Foreword

4 All 'at risk' patient groups to qualify for pharmacy flu jabs 5 Pharmaceutical Society announces carbon monoxide campaign 6 Warning issued over consumers seeking internet health advice 9 Exclusive interview with new IPU President Rory O'Donnell 14 Future business advice for budding pharmacists 24 The benefits of Medicines Use Reviews in asthma management 46 Brendan Loftus pharmacy scoops Drontal window display competition 48 Faster payment options offered by pharmacy chain

EDITOR

Bridget Casey

4

9

Regulars 18 Has the pharmacy profession any confidence left in Health Minister Reilly? We ask the question in this month's debate 33 CPD - Asthma Management, written by Eamonn Brady 40 Diabetes management and diagnosis 50 Over-the-counter digestive remedies 60 Product news 66 Appointments

18

40

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The current Minister of Health has a good understanding of marketing. Whilst in opposition, he trumpeted about how he was going to turn the health service round by changing it entirely. This has not been done but, one of the things he has done, amongst a litany of dithering is short-change the pharmacy profession - literally. In the meantime the nation waits. His latest ‘waiting game’ was, to once again implement last minute reimbursement changes to drugs which, once again left pharmacists out of pocket, looking at stock losses on their dispensary shelves. (See page 12) Reilly is a doctor by profession, as was, coincidentally his counterpart in Health in the last Labour government in the UK and both seem to have a ‘healthy’ disregard for pharmacists. Perhaps this is because they regard them as ‘failed doctors’ or, perhaps they feel threatened that pharmacists are generally more up-to-date than GPs regarding drugs. Gone are the days when doctors could look up the newer drugs in dog-eared crib books in front of their patients. Now, with a flick of a key, they can consult their computer screen nine times out of ten without the patient ever knowing. Pharmacists have a depth of knowledge, which is certainly not appreciated by most doctors. One wonders whether, in terms of efficiency and savings whether the Swedes, until recently, did not have the right system with a governmentrun monopoly on pharmacies, where private retail of pharmaceuticals was banned. The pharmacies were efficient, clean, cost effective and loved by virtually the whole nation. Of course, this could never happen in Ireland because of the EU rules on competition but, unless the Minister can turn around the situation as it currently is, he will lose all the expectations and goodwill that he brought with him, if he has not done so already. A high flying ex senator, lawyer and new Dail TD has been appointed as the successor to the late and, in many quarters lamented Roisin Shortall. It is to be hoped that the new incumbent, Alex White will possess the necessary qualities to be able to understand quickly what is required for a fairer and more positive direction in every quarter of the health service, for the benefit of the patients and the survival of those who serve them, including everyone in the supply chain. As a lawyer, White might even be the one person who could cut through the red tape and satisfy the request of the President of the IPU, who says on page 9 of this edition of IPN that ‘regulations should be proportionate and not require too much time investment’. He also says that he is inundated with communications from many pharmacists, who are struggling to cope with extra paperwork and fewer staff. Reilly has lost the faith of many of his ‘parishioner pharmacists’ (see page 18) so now is the time for him to remove his doctors’ blinkers and to acquire an all round feel of what is required – as the IPU President says: stability, greater stakeholder engagement and further expansion of the pharmacist’s role. Reilly might be able to achieve all this - and more - if only he took off his doctor’s hat.


4 November 2012 • IPN

News news brief All 'at-risk' patients qualify for pharmacy flu jabs In addition to legally being able to vaccinate patients over the age of 65 against influenza, the HSE has now given community pharmacists permission to vaccinate all 'at-risk' patients. This year’s seasonal flu vaccine protects against the three common flu virus strains which, based on advice from the World Health Organization (WHO), are expected to be circulating this year. Pharmacists should advise the following groups of 'at-risk' patients that they will need to be vaccinated against seasonal influenza this winter: • 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, diabetes or those with lower immunity, due to disease or treatment; • Pregnant women; • Children or teenagers on long-term aspirin therapy; • Residents of nursing homes and other long-stay facilities. The HSE advises that patients should be vaccinated on an annual basis and that all healthcare workers, including pharmacists, should also be vaccinated. “We welcome the move to extend the service to all at-risk patients,” said IPU president, Rory O’Donnell. “The aim of this extension is to increase the vaccine uptake in these high-risk groups. Pharmacists are the most accessible part of the health service and are, therefore, ideally placed to provide this service”. The flu vaccine is available free of charge to healthcare workers from their local Occupational Health department. Dr Brenda Corcoran, head of the HSE’s National Immunisation Office, said she hoped the increased access at pharmacies would encourage more people to receive the flu jab.

Scale of necessary reforms presents challenge Dr Ambrose McLoughlin, Secretary General of the Department of Health has recently spoken of leadership challenges within the Irish health care system, stating that there is no doubt 'that the scale of reform required, combined with our financial and economic circumstances will present many challenges over the coming years.' Dr McLoughlin, was speaking at a lecture at the Royal College of Surgeons in Ireland (RCSI) 22nd Leonard Abrahamson Memorial Lecture in the New Park Hotel, Kilkenny. He added: "However, the staff at all levels of our health system are highly trained and committed to delivering the changes that are necessary to provide a system of healthcare that is based on the needs of patients. "The scale of reform that is required presents many challenges for the health services, and central to that is how we lead through this change. Robust governance and financial control are essential to ensure the systems are in place to lead through the changes. "Significant progress has been made in terms of patient safety and quality, primary care, acute hospitals, social and continuing care and structural reform against the backdrop of difficult financial and economic circumstances."

Professor Cathal Kelly, Dr. Ambrose McLoughlin, Secretary General, Dept of Health, Professor Hannah McGee and Professor Paddy Broe.

He continued: "Confidence and trust in leadership, coupled with stronger collaboration and communication between agencies to ensure innovation and buy in are also needed. Additionally, the focus of debate needs to be placed on what is best for the people of Ireland, so that the health system is working together in the national interest." Turn to page 18 for this month's IPN debate on current confidence in our Health Minister Dr James Reilly.

Experience and excellence rewarded

Pictured at a recent Royal College of Surgeons of Ireland prize giving are: Dr Judith Strawbridge, Programme Director for BSc in Pharmacy, RCSI with Amy

Whelan, recipient of the Servier Medal for Experienced Research; Terence Smeaton, Joint winner of the Medal for first place in Intermediate Cycle B; Professor Hannah McGee, Dean of the Faculty of Medicine and Health Sciences, RCSI; Yvonne Boland, joint winner of Leo Medal for Excellence in Pharmaceutics; Karen Jordan, joint winner of Leo Medal for Excellence in Pharmaceutics and recipient of the Boots Medal for Excellence in Pharmacy Practice; Joanne O'Dwyer, Joint winner of the Medal for first place in Intermediate Cycle B; Patricia Halliday, recipient of Pharmacy Union Prize for Community Pharmacy Practice/ Internship; William Whyte and Mary Hopkins, recipients of the Servier Medals for Novice Research.


IPN • November 2012 5

News

Generics awareness campaign launched

news brief Fitness to Practise hearing Following a Fitness to Practise hearing on 28th June 2012, the Statutory Committee of the Pharmaceutical Society of Northern Ireland determined that Mr Craig Eric Bennett (Reg. No. 2888) be struck off the Register of Pharmaceutical Chemists in Northern Ireland under Article 20(1) of the Pharmacy (Northern Ireland) Order 1976 No. 1213 (N.I.22). On the 29th September 2012 the name of Mr Craig Eric Bennett was removed from the Register of Pharmaceutical Chemists in accordance with the direction of the Statutory Committee at its hearing on 28th June 2012.

Keith Hynes, Commercial Manager, Actavis and Pharmacist Paul Whyte of Cooney’s Pharmacy, Athlone are pictured at the launch of 'Just Ask', a new campaign which aims to raise awareness about the benefits of switching to generic alternatives when buying medicines.

A consumer awareness campaign, with the tag line 'Just Ask', has been launched to help pharmacists inform patients about the generic medicines available as alternatives to some branded prescription medications. The Irish Pharmaceutical Healthcare Association believes that, on average, each person in Ireland spends ¤697 a year on their medicines. The 'Just Ask' nationwide campaign has been created to encourage patients to find out the facts about the quality, safety and

value aspects of generic alternatives. A ‘Just Ask’ merchandising kit is available for pharmacies. Each pack contains ‘Generics Explained’ brochures, A3 posters, hanging mobiles for pharmacy window displays, prescription bags and tear-off pads. The awareness campaign is supported by the website www.just-ask.ie. To order the ‘Just Ask’ merchandising packs, pharmacists should contact the Uniphar telesales team at (01) 428 7777 or ask their local Actavis sales representative.

IACPT seeks IPU support The Irish Association of Community Pharmacist Technicians (IACPT) formally asked the Irish Pharmacy Union for endorsement of its campaign to introduce technician registration at the first meeting between the two organisations recently.

The object of the move towards formal technician registration is to create and maintain links between technicians in Ireland and around the world, as well as to promote community pharmacy technicians as an integral part of the patient care team.

This proposal has now been put on the agenda for discussion by the IPU’s Community Pharmacist Council at its next meeting, which is set to take place this month.

"I hope that that there will be support for our proposal and I am looking forward with anticipation to the response of the Council," said Clare Ward, IACPT president. "We also wish to ensure the highest possible standards of technical support to the pharmacy team through CPD."

Technician education and the differences between full-time college attendance and distance learning were also discussed at the meeting.

The Council of the Pharmaceutical Society of Ireland, at its meeting on 19th September 2012, decided that it is in the public interest to give notice of the action taken by the Pharmaceutical Society of Northern Ireland.

Carbon monoxide campaign An information pack, including an updated fact sheet on carbon monoxide poisoning aimed specifically at GPs and healthcare professionals, which is part of a Bord Gáis Networks sponsored information campaign, is being distributed to all pharmacies in Ireland. The pharmacy profession supported a similar campaign in 2010 and community pharmacies in particular played a valuable part in that initiative. Carbon monoxide poisoning is a preventable cause of death in Ireland each year, with many more people suffering non-fatal poisoning, which can lead to lasting neurological damage and other ill effects. Carbon monoxide poisoning can, however, be easily prevented and greater awareness amongst health professionals of the signs and symptoms. Further information is available at www.carbonmonoxide.ie.


6 November 2012 • IPN

News news brief Warning on internet health advice The Irish Pharmacy Union is warning people of the dangers of turning to the internet for healthcare advice and buying medicines. The organisation also warned of the impact on an individual's health from the purchase of counterfeit medicines. A survey carried out on behalf of the IPU earlier this year showed that 40% of people look up medical conditions online while Google Trends shows that Ireland is the seventh highest country worldwide where individuals search for health-related topics. Pharmacists are also concerned about people going online to buy medicines. This is especially the case after recent reports of an 18-year-old girl who bought diet pills online having to have her colon removed after developing a life-threatening illness. It is important that people always seek advice from their pharmacist before taking any medication. A report by Pfizer in 2010, 'Cracking Counterfeit Europe', outlined that Ireland is the sixth worst in Europe for activity concerned with counterfeiting medicines. The research shows how one in five (21%) of the 1,000 people in Ireland surveyed, equating to over 600,000 people in the total population, admitted to buying prescription only medicines from illicit sources, including on-line. Community pharmacists, who are the most accessible part of the health service, are encouraging more patients to ask them for advice on their health and medicines, rather than turning to the internet.

App provides free pharmacy directory A new app developed at NUI Galway now provides a directory of numbers for local pharmacies, as well as hospitals, GPs and support and leisure services. The free app was launched recently by Helplink, a new Irish social enterprise which provides easily accessible and affordable online counselling, as well as other award winning affordable or free health and support services nationwide. Lochlann Scott, Managing Director of Helplink and psychological studies graduate from NUI Galway explains the motivation behind the app: “We at Helplink want to be at the forefront of e-health and telehealth, this App brings us one step closer to achieving this. On a number of occasions over the past few years I have needed to access numbers or addresses for local hospitals, pharmacies, GPs etc but I was frustrated that I had to pay significant amounts of money through my phone to get them. I thought services like these should be easy to find and free.” The technology was developed by researchers at the discipline of Information Technology in NUI Galway. Research engineer Stephanus Meiring explains, “We were able to pack a lot of functionality into

Lochlann Scott MD of Helplink Support Services Ltd with NUI Galway’s Dr Michael Schukat and Stephanus Meiring at the launch of the new app.

this app. You can call your chosen listing’s number directly, send an email, get a Google map up of their location or get the main contact details sent to your phone for free. The main challenge was to enable the app to run across a multitude of smartphone platforms”.

Helix Health acquires PharmaSys Helix Health has announced that it has agreed to acquire the UK and Irish business of PharmaSys, the independent provider of web-based pharmacy management systems. Both companies exhibited at the Pharmacy Show, Sep 30th – Oct 1st 2012 at the NEC Birmingham. Helix Health is adding the PharmaSys web-based pharmacy management system to its product portfolio to complement its existing QicScript PMR locally installed system. Helix will continue to offer a choice of both systems to community pharmacy customers into the future. This will enable customers to select the system which most closely matches their future business needs and user / technical preferences,

introducing a new level of choice into the UK pharmacy software marketplace. Both sets of customers will benefit from a collaborative approach to new feature development and an enhanced level of customer service. Howard Beggs, CEO of Helix Health said: “We are delighted to have secured the acquisition of PharmaSys UK and Ireland and believe the product will be highly complementary to our existing product portfolio in the UK. I strongly believe that Helix Health’s dual product offering sets us ahead of other providers – our fresh approach to the market presents community pharmacists in England and Wales with a genuine alternative to existing systems providers.”


Annette Kennedy is Director of Professional Development with the Irish Nurses and Midwives Organisation. She wants to showcase nursing in Ireland on a global stage. With Failte Ireland’s help she submitted a bid to host the Congress and the International Council of Nurses Conference, which would mean 6,500 international delegates and a potential value of ₏9.1 million to the economy. With our financial assistance and a variety of marketing resources, we are able to support her bid for the conference and are looking forward to a positive prognosis.

To become a Conference Ambassador visit www.meetinireland.com/conferenceambassador or call (01) 884 7169


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IPN • November 2012 9

Profile

Rory reinforces need for pharmacy to 'stick together' Pharmacy has yielded cuts of over ¤400 million in the past few years probably more than in any other sector - and new regulations are also proving challenging.

The recently appointed president of the IPU, Rory O’Donnell says that one of the biggest challenges facing community pharmacy today is the state of the economy in Ireland. “Pharmacy has yielded cuts of over ¤400 million in the past few years – probably more

than in any other sector – and new regulations are also proving challenging," he said. "Pharmacists are struggling to provide the highest levels of service whilst having to cope with fewer resources. With regard to the new regulations, of course, the law must be followed but the regulations do involve a tremendous amount

of extra costs. For instance, practice guidance on sourcing, storage and disposal has generated dozens of extra standard operating procedures (SOPs). “The current regulations produced and increased the amount of bureaucracy and paperwork. Putting these SOPs


10 November 2012 • IPN

Profile in place takes a lot of time – and time is money. In addition, it also takes the pharmacist away from patients. Regulations should be proportionate and not require too much time investment.” Every day, O’Donnell hears from pharmacists, who are struggling to cope with extra paperwork with fewer staff – over 1,600 jobs in the sector have been lost in the past few years. As a result, his goals for his term as president involve achieving stability, greater stakeholder engagement and further expansion of the pharmacist’s role. “In other jurisdictions, pharmacists successfully fulfil many more roles," he said. "In the UK, they have the New Medicines Service, which improves patient adherence, while Scotland has the Minor Ailments Scheme. Many countries, meanwhile, have pharmacist-led medicines use reviews (MURs) and chronic disease management.” O’Donnell wants to see the introduction of MURs in Ireland – and more medications management in general. “There is demonstrable benefit to be gained from proper use of medicines – both in terms of savings to the Exchequer and patient safety. It would also properly utilise pharmacists’ knowledge and expertise. Some US$500 billion is wasted each year around the world due to inappropriate medicines usage. Currently, pharmacists are professionally under-utilised. Successive Governments have made all the right noises regarding expanding the role of the pharmacist, but none have actually actively engaged in the process. I am hopeful that this will change under the current Government.” Switching POMs to P Switching drugs from prescription-only to pharmacistonly supply is another of O’Donnell’s priorities. This

O'Donnell at the launch of a mental health campaign: he believes pharmacists have a greater role to play in chronic disease management.

would, again, yield savings to the Exchequer and to the patient.

properly. Pharmacists are in an ideal position to give this advice,” he said.

“We must encourage greater self-care. To enable patients to do this, they must have more access to medicines and to the healthcare advice they need, in order to take their medications

O’Donnell has high hopes that more switches may be made soon.

that it will be coming down the line very soon – of course, it makes a lot of sense. We have been working closely with the Irish Medicines Board in this regard and have always had a great relationship with them.”

“I think that this is the lowesthanging fruit,” he said. “I feel

Information and communications technology


IPN • November 2012 11

Profile (ICT) is also high on the IPU president’s agenda. According to O’Donnell, electronic prescribing is likely to appear as early as 2013, in some form at least.

become its vice-chairman. This committee is responsible for the promotion and development of pharmacy, together with the development of business policy, training and ICT.

“This will be a new challenge but, if properly implemented will be of tremendous benefit to healthcare,” he said. “The IPU is deeply engaged in this area.”

O’Donnell was also part of the Pharmacy in Primary Care Group, which was responsible for setting up a pilot project for MURs. The initiative was a large success and the IPU is awaiting the final academic study of that pilot. In 2010, he was appointed vice-president of the Union.

With regard to other forms of technical integration, such as patients being able to buy medicines online, O’Donnell is not in favour of this, particularly in view of the difficulties in regulating internet pharmacy. The process of buying online also removes the face-to-face counselling opportunity that currently exists for pharmacists. “The IPU is pushing for other ICT innovation," he continued. "For example, IPU NET is a new, cloud-based support tool for pharmacists, which provides professional support, as well as collecting anonymous data that can be used to provide evidence of the value of community pharmacy and advocating for new roles. “The IPU Product File has been the engine behind all pharmacy systems for the past two decades. The file is continuously upgraded and developed by pharmacists and IT experts, for pharmacists.” IPU Experience O’Donnell has been a member of the IPU since 1991, when he first registered as a pharmacist, and has steadily risen through the ranks. He served on the Pharmacy Contractors’ Committee, which engages and negotiates with the HSE on the terms and agreements of the pharmacy contract, and became the Union’s north-west representative. Later, after taking a break from Union work, O’Donnell was asked to serve on the Community Pharmacy Committee. He accepted the position and he went on to

“The Financial Emergency Measures in Public Interest Act 2009 was a real game-changer when I was vice-president,” said O’Donnell. “Pharmacists were struggling with the cuts that had been implemented and the Union was busy giving business advice and helping with regard to the changes in the regulatory framework. We also offered practical help, such as developing a suite of SOPs for pharmacists to suit their individual needs, in order for them to meet the regulatory requirements.” O’Donnell took up the position of IPU president last April and has been extremely busy since then. “It is a very interesting time to be president,” he said. “I am always on duty, as the position involves many meetings and travel between Donegal and Dublin. I receive fabulous support from all the committees and Union staff, who are incredibly committed. My staff in my own pharmacy in Donegal are equally brilliant. Obviously, their workload has also increased but they are really supportive.” Chronic Disease Management O’Donnell said that, in his official capacity, he will push for greater pharmacist involvement in chronic disease management for conditions such as asthma, hypertension and diabetes. “One in ten adults is expected to have type II diabetes by

2020, so we have to involve more pharmacists in their care – otherwise, primary and secondary care will be swamped. Pharmacists are the most accessible healthcare professionals and pharmacy management of this type of diabetes has been successful in other countries, such as the USA. It would be a great example of joined-up thinking if we did something similar here. “There is no reason why we cannot introduce further initiatives, considering the success of pharmacistadministered flu vaccination, needle-exchange services and the provision of emergency services,” he continued. “Flu vaccination in pharmacies, for example, happened quickly in the end, after we had lobbied for it for years. “Once the Health Minister had sanctioned it, it only took a few months to get pharmacist training sorted out and it showed just how quickly pharmacy can also rise to a challenge, when called upon to do so. All the stakeholders worked well together.” O’Donnell finally cautioned against fragmentation of the community pharmacy sector, especially in the current difficult economic climate. “In spite of these being tough times, the IPU represents the views and agenda in the main of community pharmacy with the Government and other stakeholders. A fragmented profession would be isolated and quickly lose relevance. The strength of any organisation depends on the collegiality of its members. In the case of the IPU, we represent the broad church that is community pharmacy, employee and employer, independent and group pharmacist. “While our members compete with each other in business, there is much more that unites us as healthcare professionals. To advance our common goals requires professional

unity and belief. For instance, we launched a Statement of Strategy last month, outlining the Union’s current status, and also where it is going and how we intend to get there. “Pharmacy is not a large sector and, to stay relevant, we must stick together,” O’Donnell concluded.

PHARMACY BACKGROUND Although Rory O’Donnell has taken over the reins at the IPU at a turbulent time for the Irish pharmacy sector, he has long had an understanding of the issues and challenges involved in running a community pharmacy. “My mother was a pharmacist in West Donegal so I was always in and out of the pharmacy as a child,” he said. “My main ambition was to have my own pharmacy and own my own business, particularly as jobs were scarce in Donegal in the 1980s. It was the obvious career path for me.” O’Donnell went to Trinity College to study Natural Sciences, but he decided to apply to the Robert Gordon University in Aberdeen to follow his first calling. He was accepted onto the Pharmacy course and made the move to Scotland in 1987 after finishing his Trinity degree. After graduating in 1990 with a BSc (Hons) Pharm, O’Donnell did his preregistration in Mansfield, Nottinghamshire, before returning to Ireland in 1991 to run his own pharmacy. He now owns O’Donnell’s Pharmacy in Gweedore.


12 November 2012 • IPN

News news brief Counterfeit drugs seized in Ireland

Drugs agreement to save on average ¤1.25 million annually deal with quality and patient safety in the prescribing and dispensing of medicines. It will also be tasked to deliver savings by achieving more cost-conscious prescribing by doctors. Details of these savings targets are still being negotiated and the estimated cost of establishing the Task Force is as yet unavailable.

As a result of the country's largest-ever clampdown on the sale of online medicines, the Garda Síochána, Customs and the Irish Medicines Board (IMB) seized over 120,000 illegal and counterfeit medicines in just one week. The international Operation Pangea V took place last month with over 100 countries being involved in this Interpol co-ordinated initiative. A total of 79 people were arrested worldwide and around 18,000 illegal online pharmacy websites were shut down through domain name or payment facility removal. The counterfeit drugs were mainly for weight loss and erectile dysfunction, although some were mood stabilisers. In Ireland, a total of 11 search warrants were executed and four people were arrested by the Gardaí. Under Irish law, the sale of prescriptiononly medicines by mail order is prohibited and this includes internet supplies of prescription-only medicines. John Lynch, IMB director of compliance, said that counterfeit and illegal medicines pose a serious and potentially fatal threat to public health. “The IMB strongly advises consumers not to purchase medicines through any unauthorised sources as there can be no guarantee that they are genuine or safe," he said. "Some of these medicines have been shown to contain too little or too much of the active ingredient, while others contain completely the wrong active ingredient altogether. As a result, there is a very real danger that these medicines will actually damage the health of those who use them." Community pharmacists can warn their patients against buying drugs on the internet by saying that however tempting it may be, it may not always be safe. The choice will be theirs.

The deal has been heralded by the Department as an important step in reducing the cost base of the health system, reducing State expenditure on medicines through the various State schemes and providing patients, who pay for their medicines, savings on hundreds of medicines.

Intensive negotiations involving the Irish Pharmaceutical Healthcare Association (IPHA), the HSE and the Department of Health concluded last month with a major new deal that will save an estimated ¤400 million (an average of ¤125 million annually) over the next three years on the State's drugs costs. Under the agreement, the price of medicines marketed by IPHA companies, which were off-patent prior to 1 November this year will be reduced to 50% of their original price by 1 November 2013. The price of up to 400 patent-protected products, which have been available on the HSE Community Drug Schemes prior to 2006 will be subject to a price review. Price reductions averaging up to 16% are expected from this review process. The deal is beneficial in two ways: about half the financial value is related to reductions in the cost of patent and off-patent drugs while the other half is related to the State securing the provision of lower-priced new and innovative drugs for the duration of the agreement. Combined with the IPHA agreement reached earlier this year, this means that ¤16 million in drug savings will be made for the rest of this year alone. The Department has estimated that the deal will generate savings of up to ¤116 million in 2013 and even more after that, to total ¤400 million over the next three years. A National Task Force on Prescribing and Dispensing has also been established to

The Irish Pharmacy Union (IPU) has welcomed the agreement but expressed concern at the short lead-in time. IPU President Rory O'Donnell (see IPN Profile, page 9) said his members were concerned at the short notice of the introduction of the changes, which came into force from the start of November. He said medicines that pharmacists stock on their shelves on behalf of the HSE would be paid for by the Executive at the new lower rates, despite having been purchased by pharmacists at the higher prices. He added that as part of any review of medicines expenditure, the Government must strongly consider expanding the role of the pharmacist to maximise value for money. “Irish pharmacists would like the Minister to engage with them on his healthcare reform agenda as pharmacists are well placed to provide additional services to patients, including chronic disease management, health screening, treating minor ailments and medicine use reviews, which can deliver significant healthcare benefits to patients and further costs savings to the State,” said O'Donnell. This deal comes as the Health (Pricing and Supply of Medical Goods) Bill 2012, which will introduce a system of reference pricing and generic substitution, comes before the Oireachtas. This Bill is expected to be enacted before the end of the year and will deliver further savings to the drugs bill. The Department and the HSE are currently in talks with the Association of Pharmaceutical Manufacturers in Ireland, which represents generic manufacturers, to agree prices for generic drugs.


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14 November 2012 • IPN

News news brief Boots opens new pharmacy in Galway

Future business advice for budding pharmacists

The Boots Ireland chain of pharmacies has opened a new pharmacy in the Galway Shopping Centre on the city’s Headford Road.

Pharmacists such as Keith O’Hourihane from Pharmacy First Plus and Prof Peter Weedle of Weedle’s Pharmacy in Mallow.

Services being offered to patients include: winter flu vaccinations; heart and blood pressure checks; ‘Stop for Good’ smoking cessation programme, emergency contraception; travel health advice; weight management services; and food intolerance testing. The pharmacy is in a 358m2 unit and also houses a photo kiosk. It has a staff of 17, including part-timers.

Hive of Beauty now available in Ireland Graham Anthony & Co Ltd has announced that it is now distributing Hive of Beauty products to the Irish market. Hive of Beauty is a leading provider of professional beauty products to businesses worldwide, including its own formulations and patents that have been developed with specialist chemists and product engineers. Graham Anthony is one of the biggest suppliers of skincare products and cosmetics in Ireland. Started in 1988 with one product, the company quickly expanded and by 1990, a wide range of beauty products and accessories were available to its clients nationwide. Today, Graham Anthony distributes some of the best-known global beauty brands to almost 300 outlets across the county. With the distribution of Hive of Beauty products, Graham Anthony will supply everything from depilatory waxes to eyelash tints. The company says it will now operate as a one-stop shop for all of its customers’ beauty sales requirements. For more information, contact Graham Anthony at (01) 822 2711.

Noreen Moynihan, School of Pharmacy; Ultan O’Callaghan, Domestic Manager of Munster Rugby; and Barry Allen, McNeil Healthcare.

Darren Kelly and Jim Curran discussed the role of the Irish Pharmacy Union (IPU). Ms Bridget Quille from McNeil Healthcare offered her views on the topic of category management. Ms Miranda Horgan MD of Horgan Pharmacy Group offered her expertise on Becoming a good manager and taking extra responsibility: The Do’s, Don’ts and Pitfalls which was followed by a session from Ms Clare Fitzell, Boots Pharmacy Operations Manager on legendary customer care.

The School of Pharmacy at UCC hosted its annual Business Seminar for final year students recently. This year’s seminar was sponsored by McNeil and students participated in a two day programme covering a wide range of topics which started with a presentation from Brenda Nestor of UCC Careers service on a prescription for a great CV. The programme also offered specialist advice on financial planning and investing for the future from Bank of Ireland and sound management advice from other local

J. Crowley, Pharmacy student and Barry Allen, McNeil Healthcare.

Diclofenac linked to ‘small increased cardiovascular risk’

According to the Committee, the risk with diclofenac is similar to the risks of COX-2 inhibitors, another class of painkillers. In relation to naproxen and ibuprofen, the CHMP was of the opinion that the current treatment advice adequately reflects the knowledge regarding the safety and efficacy of these medicines.

The Committee for Medicinal Products for Human Use (CHMP) of the European Medicines Agency has concluded that diclofenac is associated with a consistent but small increase in the risk of cardiovascular side effects, compared with other non-steroidal antiinflammatory drugs (NSAIDs). Diclofenac is a NSAID commonly taken to reduce inflammation and to reduce pain.

The CHMP had previously reviewed NSAIDs in relation to their possible cardiovascular risks in 2005 and 2006. At that time, the Committee concluded that the overall benefit/risk balance of these medicines remained positive but that a small increased cardiovascular risk could not be excluded.

The CHMP made its announcement after it finished its review of the latest published information on the cardiovascular safety of NSAIDs including diclofenac, ibuprofen and naproxen.

Now that the latest review is completed, the European Medicines Agency’s new Pharmacovigilance Risk Assessment Committee will now assess all available data on diclofenac, both published and unpublished, to consider the need for updated treatment advice.


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Superior Symptom improvement Vs tamsulosin or dutasteride monotherapy1,2 66% Relative Risk Reduction in AUR or BPH related surgery Vs tamsulosin at 4 years1,2

COMBODART ABRIDGED PRESCRIBING INFORMATION (API). (Please refer to the full Summary of Product Characteristics before prescribing) PRESENTATIONS: Each hard capsule contains 0.5 mg dutasteride and 0.4 mg tamsulosin hydrochloride, (equivalent to 0.367 mg tamsulosin). INDICATION: Treatment of moderate to severe symptoms of benign prostatic hyperplasia (BPH). Reduction in the risk of acute urinary retention (AUR) and surgery in patients with moderate to severe symptoms of BPH. POSOLOGY & ADMINISTRATION: Adults (including elderly): The recommended dose is one capsule (0.5 mg/ 0.4 mg) taken orally approximately 30 minutes after the same meal each day. The capsules should be swallowed whole and not chewed or opened. Contact with the contents of the dutasteride capsule contained within the hard-shell capsule may result in irritation of the oropharyngeal mucosa. Where appropriate, Combodart may be used to substitute concomitant dutasteride and tamsulosin hydrochloride in existing dual therapy to simplify treatment. Where clinically appropriate, direct change from dutasteride or tamsulosin hydrochloride monotherapy to Combodart may be considered. Renal impairment: The effect of renal impairment on dutasteridetamsulosin pharmacokinetics has not been studied. No adjustment in dosage is anticipated for patients with renal impairment. Hepatic impairment: The effect of hepatic impairment on dutasteride-tamsulosin pharmacokinetics has not been studied so caution should be used in patients with mild to moderate hepatic impairment. In patients with severe hepatic impairment, the use of Combodart is contraindicated. CONTRAINDICATIONS: Combodart is contraindicated in: women, children and adolescents; patients with hypersensitivity to dutasteride, other 5-alpha reductase inhibitors, tamsulosin (including tamsulosin-induced angio-edema), soya, peanut or any of the other excipients; patients with a history of orthostatic hypotension: patients with severe hepatic impairment. SPECIAL WARNINGS & PRECAUTIONS: Combodart should be prescribed after careful benefit risk assessment and after consideration of alternative treatment options including monotherapies. In two 4-year clinical study, the incidence of cardiac failure (a composite term of reported events, primarily cardiac failure and congestive cardiac failure) was higher among subjects taking the combination of dutasteride and an alpha blocker, primarily tamsulosin, than it was among subjects not taking the combination. Digital rectal examination, as well as other evaluations for prostate cancer or other conditions which can cause the same symptoms as BPH, must be performed on patients prior to initiating therapy with Combodart and periodically thereafter. Combodart causes a decrease in mean serum PSA levels by approximately 50%, after 6 months of treatment. Patients should have a new baseline established after 6 months of treatment with Combodart and PSA should be monitored regularly thereafter. Any confirmed increase from the lowest PSA levels while on Combodart may signal the presence of prostate cancer (particularly high grade cancer) or non-compliance to therapy with Combodart and should be carefully evaluated, even if those values are still within the normal range for men not taking α 5 reductase inhibitor (see SPC section 5.1). The relationship between dutasteride and high grade prostate cancer is not clear. Men taking Combodart should be regularly evaluated for prostate cancer risk including PSA testing (see SPC section 5.1). Results of one clinical study (the REDUCE study) in men at increase risk of prostate cancer revealed a higher incidence of Gleason 8 – 10 prostate

In moderate BPH patients

cancers in dutasteride treated men compared to placebo. The relationship between dutasteride and high grade prostate cancer is not clear. Men taking Combodart should be regularly evaluated for prostate cancer risk including PSA testing (see SPC section 5.1). As with other alpha-blockers, a reduction in blood pressure can occur during treatment with tamsulosin, as a result of which, rarely, syncope can occur. Intraoperative Floppy Iris Syndrome (IFIS, a variant of small pupil syndrome) has been observed during cataract surgery in some patients on or previously treated with tamsulosin and may lead to increased procedural complications during the operation. Breast cancer has been reported in men taking dutasteride. Physicians should instruct their patients to promptly report any changes in their breast tissue such as lumps or nipple discharge. Dutasteride is absorbed through the skin, therefore, women, children & adolescents must avoid contact with leaking capsules. Caution should be used in the administration of Combodart to patients with mild to moderate hepatic impairment. The treatment of severely renally impaired patients (creatinine clearance of less than 10 ml/min) should be approached with caution. This medicinal product contains the colouring agent Sunset Yellow (E110), which may cause allergic reactions. INTERACTIONS: There have been no drug interaction studies for Combodart. The following reflect information available on the individual components. Dutasteride: is mainly eliminated via metabolism and studies indicate that this metabolism is catalysed by CYP3A4 and CYP3A5. Longterm combination of dutasteride with drugs that are potent inhibitors of the enzyme CYP3A4 (e.g. ritonavir, indinavir, nefazodone, itraconazole, ketoconazole administered orally) may increase serum concentrations of dutasteride. Tamsulosin: Concomitant administration of tamsulosin hydrochloride with drugs which can reduce blood pressure, including anaesthetic agents and other alpha-1 adrenergic blockers could lead to enhanced hypotensive effects. Dutasteride-tamsulosin should not be used in combination with other alpha-1 adrenergic blockers. Caution should be used when dutasteride-tamsulosin is used in combination with cimetidine and with concomitant administration of warfarin and tamsulosin hydrochloride. Diclofenac may increase the elimination rate of tamsulosin. FERTILITY, PREGNANCY & LACTATION: Combodart is contraindicated for use by women. There have been no studies to investigate the effect of Combodart on pregnancy, lactation and fertility - the following statements reflect the information available from studies with the individual components; Fertility: Dutasteride has been reported to affect semen characteristics in healthy men. The possibility of reduced male fertility cannot be excluded. Effects of tamsulosin hydrochloride on sperm counts or sperm function have not been evaluated. Pregnancy: As with other 5 alpha reductase inhibitors, dutasteride inhibits the conversion of testosterone to dihydrotestosterone and may, if administered to a woman carrying a male foetus, inhibit the development of the external genitalia of the foetus. It is not known whether a male foetus will be adversely affected if his mother is exposed to the semen of a patient being treated with dutasteride (the risk of which is greatest during the first 16 weeks of pregnancy). As with all 5 alpha reductase inhibitors, when the patient's partner is or may potentially be pregnant it is recommended that the patient avoids exposure of his partner to semen by use of a condom. Lactation: It is not known whether dutasteride or tamsulosin are excreted in human milk. ABILITY TO DRIVE & USE MACHINES: No studies on the effects of Combodart on the ability to drive and use machines have

For more information on this and other GSK brands visit www.Health.gsk.ie

been performed. However, patients should be informed about the possible occurrence of symptoms related to orthostatic hypotension such as dizziness when taking Combodart. UNDESIRABLE EFFECTS: DUTASTERIDE AND TAMSULOSIN CO-ADMINISTRATION: The following adverse events have been reported with an incidence of ≥1% during the four years of treatment in the CombAT Study (Combination of Avodart and Tamsulosin-study, a comparison of dutasteride 0.5mg and tamsulosin 0.4mg once daily for four years as co-administration or as monotherapy): Cardiac failure, impotence, altered (decreased) libido, ejaculation disorders, breast disorders (includes breast enlargement and/or breast tenderness), dizziness. Adverse Events identified through post-marketing experience (therefore the true incidence is unknown) with dutasteride monotherapy include allergic reactions, including rash, pruritus, urticaria, localised oedema, and angioedema, skin and subcutaneous tissue disorders. Uncommon: Alopecia (primarily body hair loss), hypertrichosis. The following adverse events related to tamsulosin monotherapy have been reported from both clinical trials and post marketing data: Common (≥1/100 <1/10); dizziness. Uncommon (≥1/1000 <1/100); palpitations, constipation, diarrhoea, nausea, vomiting, asthenia, headache, abnormal ejaculation, rhinitis, rash, pruritis, urticaria, postural hypotension. MA Number PA1077/118/001. Marketing authorisation holder GlaxoSmithKline (Ireland) Limited, Stonemasons Way, Rathfarnham, Dublin 16, Ireland. Legal category POM; S1A. Date of preparation of API: April 2012. Copy Approval Code: IE/COM/0021/12. Further information available on request from GlaxoSmithKline, Stonemasons Way, Rathfarnham, Dublin 16 Ireland. Tel: 01-4955000. The recommended dose of Combodart is one capsule (0.5 mg/ 0.4 mg) taken orally approximately 30 minutes after the same meal each day. The capsules should be swallowed whole and not chewed or opened. * vs either tamsulosin or dutasteride monotherapy † No significant difference was seen between combination and dutasteride monotherapy (RRR 19.6%, p=0.18) References: 1. Combodart Summary of Product Characteristics, 2010. 2. Roehrborn CG et al. Eur Urol 2010; 57: 123-131.

IE/DUTT/0012/12


16 November 2012 • IPN

News news brief Calcitonin to be withdrawn from Irish market Novartis has announced that it is withdrawing Miacalcic 200IU, its calcitonin Nasal Spray, from the market. The withdrawal announcement comes in light of the European Medicines Agency’s recent review of the benefits and risks of calcitonin (see IPN, August issue). The Agency concluded that there was evidence from randomised controlled clinical trials of an increased risk of malignancies with the long-term use of calcitonin compared with placebo-treated patients. “Due to the higher incidence of malignancies, calcitonin should no longer be used in the treatment of established post-menopausal osteoporosis, since the risks associated with calcitonin outweigh the benefits in this indication,” said a Novartis spokesperson. “Patients being treated for osteoporosis with calcitonin (Miacalcic 200IU Nasal Spray, solution) should be switched to alternative treatment during the next scheduled or routine appointment.” Calcitonin is authorised only for treatment of post-menopausal osteoporosis.

FIP 2013 looks forward to Dublin visit

Coming fresh off the heels of the FIP Centennial Congress in 2012, which launched FIP, the profession and partners into a new era of healthcare development, the 2013 FIP Congress in Dublin is dedicated to following through with the agenda set at the previous year’s monumental meeting. This new era brings with it much hope: ground breaking science, innovative treatments and medicines and crossprofessional care. But it also brings with it a level of complexity never seen before in the pharmacy and healthcare environment. As such, the 2013 FIP Congress in Dublin, co-hosted with the Pharmaceutical Society of Ireland (PSI), is focusing on the growing complexity of patient care. The programme addresses this complexity not only in the context of the newest and most advanced treatment methods – how they are being discovered, delivered and discussed – but also in patients themselves; the biology, chemistry, mentality and sociology that affect how patients react to this increasingly complex environment of care. Together, the solutions can be discovered. For further information visit www.fip.org

Social networking is key to hiring top staff "Employers will have to engage with social media if they want to hire the best retail staff," said Arleen Quigg, manager of human resources with recruitment agency CPL. Speaking at the recent Retail Retreat, which was hosted by Retail Excellence Ireland in Kilkenny’s Lyrath Estate Hotel, Quigg said that highly commercial hires were vital to the current market, but there was a shortage of top talent for the retail industry. “The trends in the industry show that social networking is playing an increasingly important role in the recruitment process,” said Quigg. “With more people hearing about jobs through networks like LinkedIn, employers will have to move with the times and engage with these people if they want to hire the best staff for their retail businesses. The upcoming generation is much less likely to reply to a printed job advertisement and will tend to find out about vacancies through their social networks.” According to Quigg, the best hires are generally referrals from someone who has worked for or with an individual and she believes that this ensures that there is a constant pipeline of referrals, which is critical for finding talented employees.

"The cost of a poor hire is threeto-five times the worth of the employee’s annualised compensation," she continued. “You should not seek to hire a replica of the person who is leaving your employ,” Quigg advised. “You need someone for whom the role will stretch their capabilities. “It goes without saying that the line manager should always be actively involved in the recruitment process, not just the human resources department, if there is one,” she continued. “Also, job descriptions should not be vague or too narrow – if you do not state what the key competencies are for the role, do not be surprised if you cannot find the right candidate.” Finally, she advised employers to be honest about the retail role in the job description. “If you mis-represented the role at the start, you may hire a great person but they will not stay. You have already broken the psychological contract with the employee and they may disengage from the start. Be quite open about the role from the beginning of the hiring process,” Quigg concluded. Some 310,000 people were employed in the retail sector in 2007 but this has dropped to 255,000 currently.

A new era for the PSNI From 1st October 2012, the Pharmaceutical Society Northern Ireland embarks on a new era, as new legislation in the form of the Pharmacy (NI) Order 1976 (Amendment) Order (NI) 2012 comes into operation, bringing additional fitness to practise sanctions, statutory CPD and a new Council made up of 50% lay and 50% registrant membership. At the inaugural meeting of the newly constituted Council of the Pharmaceutical Society NI, President of Council, Ms Jacqui Dougan MPSNI, welcomed all members to their new posts. Speaking after the first ‘New’ Council

meeting on 2 October Ms Dougan said:“After several years of hard work, I am delighted to welcome all members of Council to our new role. We are fortunate to have gained such a wealth of knowledge and expertise in our newly appointed members. “These are exciting times, there is much work to be done and many changes lie ahead; these changes I believe will benefit both the public and pharmacists. This new Council with its range of talents and experience will guide this organisation through these changes and the work starts today.”


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18 November 2012 • IPN

Debate

Is James Reilly playing fair? We ask your opinions

James Reilly, Health Minister

When James Reilly took up his position as Health Minister in March 2011, he was viewed by many as a one-man cavalry charge, who held the solutions to all of the health service’s problems. But, since then, he has regularly made the headlines for the wrong reasons. The former Irish Medical Organisation President has had his business dealings laid bare across the media, including his involvement in the nursing home sector and his appearance as a debt defaulter in Stubb’s Gazette. After surviving a motion of no confidence from the Opposition in September, his

junior minister Róisín Shortall resigned as Minister of State for Primary Care, quoting Reilly’s 'lack of support' as her reason and claiming that he blocked many of her reform initiatives. He also faced further controversy over bias, after he added two sites in his constituency to a list of 35 other locations for the establishment of possible new primary care centres (PCCs). A pharmacist from Galway city, was one of those, who had high hopes for Reilly when he became Health Minister. “I heard Reilly making speeches before

Fine Gael got into Government and he was inspirational – the audience was practically at the point of carrying him shoulder high to Dáil Éireann,” he said. “He sounded as if he had everything worked out and that he could fix the health service in about six months.” Despite all of the Minister’s recent troubles, the Galway pharmacist still believes that Reilly is on the right track when it comes to certain aspects of the health service. PHARMACY NOT A PRIORITY “I think he is doing certain things right. From


IPN • November 2012 19

Debate speaking to colleagues in Galway Hospital, they seem happy with how he is handling secondary care. However, I do not think he cares about pharmacy; we are right down his list of priorities. Pharmacists are not taken seriously until someone in the Department of Health decides they want to make a name for themselves and make savings on the drugs bill – but pharmacists have nothing to do with drug prices, so that is just a token nod in our direction,” he continued. The pharmacist also believes that Minister Reilly has been caught in a difficult situation when it comes to the drugs bill because the pharmaceutical industry accounts for half of all Irish exports and employs some 25,000 people. “Minister Reilly had to take this into account during any negotiations and he is also a businessman,” he says. “This does not necessarily mean that he has a conflict of interests, but some people may think that it compromises him somewhat in his ministerial position. He is involved with nursing homes and has appeared in Stubb’s Gazette. This does not read well, even though he has technically done nothing wrong. But it can be interpreted as baggage and the other political parties are seizing on this.” The Galway man believes that Minister Reilly needs to expand the role of the pharmacist if he wants to make real savings to the health budget. “I welcome the introduction of pharmacistadministered flu vaccinations and the morning-after pill but we need more than that. Reilly needs to take pharmacy more seriously. It makes sense to save money by involving pharmacists in health management and he definitely needs to utilise our skills more.”

POACHER-TURNED-GAMEKEEPER? “The Health Minister should be a strong leader, who encourages and empowers the health team. He should inspire trust,” said an independent pharmacy owner in Dublin. “I think James Reilly’s fundamental flaw is that he is not a good leader, who can deliver change in a professional way without compromising. “This is disappointing to everyone in pharmacy, and in the healthcare profession in general, because he ‘talked the talk’ before he became Minister,” he continued. “He is a GP and many people had faith that he understood and knew how to address the problems in the health service. Now it seems he is a ‘poacher-turned-gamekeeper’ – and adding those PCCs to the list of possible sites seems like he might be more interested in looking after his own concerns and his chances of re-election.” The Dubliner expressed concerns about Reilly’s apparent lack of transparency and his ability to manage his own ‘team’. He also agreed with Tobin’s assessment of the Minister’s dealings with Shortall (see panel). “He is the boss of the health service and I do not think that he played fair with her," he said. "Neither do I think that Minister Reilly has been transparent in his explanations regarding how and why those extra PCCs ended up on that list. It seems to be one problem after another with the Minister, and they all seem to be of his own making. A pharmacist in Waterford city summed up the sector’s views on James Reilly, saying that the Minister had an unenviable job but was doing pharmacy no favours.

A locum pharmacist working in the Limerick area said that Minister Reilly has not lived up to her expectations after entering office and that her confidence in him was at a low ebb.

“Minister Reilly has one the toughest jobs in the country, but pharmacy is taking a pummelling and he is doing nothing to help us,” he said. “There is a perception out there that pharmacists are making loads of money but many pharmacies have closed in the last few years and lots of jobs have been lost. Pharmacists are struggling.

“I admire the fact that he negotiated a deal with the Irish Pharmaceutical Healthcare Association (IPHA) and that is good news for patients and the Exchequer (see page 12), but it was implemented far too quickly (from November 1) and pharmacists have lost out. We had stock on our shelves at the start of this month, which we had bought at the higher, pre-deal price and the HSE would only pay for it at the new lower rates.

“The Minister is authorising too many cuts to pharmacy and the message is not getting through that we cannot take any more of these. More FEMPI cuts are in the pipeline, as well as more price restructuring. Pharmacy is viewed as the soft option when it comes to saving money. Minister Reilly must make all healthcare sectors share the pain – specifically primary care, which I think has gotten off relatively lightly so far.”

“I think this is another sign that pharmacy does not really matter to Minister Reilly,” she continued. “I think, sometimes that he views us simply as a sector where he can cut costs, as opposed to the reality that we are clinical experts, who make a real differences to patients.”

An independent pharmacist in Cork city agreed that James Reilly had a very difficult job, but questioned whether he could ever drive reform through the health system in its current form.

NOT MEETING EXPECTATIONS

“I do not envy anyone who takes up the reins

at the Department of Health; he has inherited a very flawed system. I believe that there are too many administrative staff in our health service and too many layers of bureaucracy. Prof Tim Lynch (a consultant neurologist in Dublin’s Mater Misericordiae University Hospital) wrote an article in The Irish Times last month and he said there for every doctor in the health service, there were six administrative staff. The system is bogged down. Can there ever be proper reform when the people on the ground, who know how the system works on a day-to-day basis, are so outnumbered? “We have three different sections governing our health service – the Department of Health, which looks after policy and planning; the Health Service Executive, which puts those plans into practice; and then there is the Health Information and Quality Authority, whose task is to tell those in the health service how good they are at doing their job. “In my opinion, Reilly should ‘crunch’ all of these into one organisation – he should trim the fat. Maybe then he would be able to implement his plans, such as universal health insurance, without meeting what must be an awful lot of administrative obstacles.” He also wondered whether Minister Reilly’s colleagues in Government were losing faith in his ability to make the best decisions for the health service. “When I read that Tánaiste Eamon Gilmore had commissioned his advisors to carry out research on his behalf on locations for the national children’s hospital, I wondered if trust had broken down,” he continued. “It would seem that Gilmore was prepared to over-ride Minister Reilly’s choice of site, if necessary, even though that decision is under Minister Reilly’s remit.” Pharmacists recognise that Reilly heads up a very troubled department, but they believe he has not lived up to his early promise as the leader who could implement positive change, and that he does not fully recognise the importance and potential of front-line community pharmacists in the health service. Whether his actions over the rest of his term can change these views remains to be seen. COMMENT FROM MINISTER FOR HEALTH, JAMES REILLY Pharmacists – and the pharmacy sector in general – add considerable value and considerable opportunities to the Irish healthcare sector. Pharmacists have a very important role in guiding patients to the best possible outcomes in terms of their use of medication. Pharmacists are healthcare professionals whose role is expanding, as exemplified by their ability now to administer the seasonal


20 November 2012 • IPN

Debate flu vaccine – a change which occurred last year with my wholehearted support. In hospitals, pharmacists are playing an increasing role in developing the most appropriate, cost-effective, therapeutic regimes for patients. Working with their colleagues in the hospital setting, pharmacists are part of an overall team delivering higher quality, more cost-effective service. In the community, community pharmacists are advising patients and prescribers on the most appropriate medications and regimes for use. They are particularly important in ensuring adherence and compliance with complex regimes for patients with a chronic illness. The role played by pharmacists will be enhanced further with new legislation on generic substitution. Historically, pharmacists were precluded from providing medications other than that prescribed by a doctor. With the passing of new legislation allowing for generic substitution, patients attending the nation's pharmacies will rely to an even greater degree on their pharmacist's knowledge of medicines in the dispensing of appropriate medications. Pharmacists have played a strong role in the development of the Clinical Programmes in the HSE. The programmes have been enormously beneficial to patients and the wider health services by enhancing the effectiveness of treatment regimes for a range of conditions. An example of the involvement of pharmacists is that of Dr Mark Ledwidge in dealing with the area of heart failure. Dr Ledwidge played a significant role in facilitating and developing the most appropriate, cost-effective, therapeutic protocols – producing the best outcomes. Another crucial area of development, related to the pharmacy sector, is the development of a clear programme for medicines management. I have requested that strong attention now be given to the issue of quality prescribing and supply of medicines. As a result, the Medicines Management Programme has been set up by the HSE involving Prof Michael Barry. The programme will concentrate on prescribing issues across the range of Clinical Programmes, leading to further cost effectiveness in the use of medications across a wide variety of conditions. In conclusion, I will continue with my Department, the HSE and the Pharmaceutical Society of Ireland to explore expanded roles for pharmacy in Ireland, so that we maximise to the fullest extent that resource knowledge and expertise to further improve outcomes for patients.

ANOTHER POINT OF VIEW... Cormac Tobin, managing director of the DocMorris pharmacy chain, refrained from comment about Minister’s business interests, but he also had concerns about the deal struck with the IPHA. “It is good that Reilly has engineered this agreement because it benefits patients and taxpayers and I commend him for that. But there should have been a period of grace around the introduction of the new price structures. Pharmacists should have continued to be reimbursed for a set period of a month after manufacturers dropped their prices – even two weeks would have been a compromise. As it happened, there was a risk that stocks would drop to a level where patients would suffer. The deal was struck with little regard for pharmacists. “After these negotiations with drugs’ manufacturers will come a FEMPI review and it must be taken into account that the new deal negatively affects pharmacies,” Tobin continued. “We have taken a real hit as a result – both in terms of the stock on our shelves and an ongoing loss on our profit margins. I am not fully confident that Reilly recognises this.” BETTER LEADERSHIP REQUIRED Tobin said that Reilly had to display better leadership skills or risk of losing public confidence in his ability to run such an important Government department. “He came into the job promising so many things, but we are still waiting to see proper change. In the past five years, there have only been two innovations introduced into pharmacy by Government. These are pharmacy-administered flu vaccination and the morning-after pill – and the pharmaceutical industry was the driver behind OTC emergency contraception. “We have to look at the health service as a business, with Minister Reilly as the CEO, who is responsible for the biggest budget in the country. No company could survive if it was so slow at introducing beneficial change. Only five years ago, the iPhone was introduced and iPads did not exist, yet they have revolutionised the world. There has been no such comparable change or progress in the health system. “We need a strong leader to bring stakeholders together, to make them work for the benefit of the patient and the taxpayer, instead of having one sector going head to head against the other. I hope Minister Reilly will be able to do that before the Government has to turn its attention to winning the next election,” he said. Tobin also expressed concerns about the situation with Róisín Shortall. He believed she had a positive and refreshing approach to addressing patients’ needs. He is also concerned regarding Minister Reilly’s addition of extra PCCs onto the approved list, which was Shortall’s responsibility. “As a CEO, I liberate my staff and give them clear parameters to make decisions. If I have to over-rule any of their decisions, I am very transparent as to the reasons why. I make sure to get them on board and support any changes that need to be made. It amazes me that Minister Reilly did not do the same with Shortall,” he concluded.


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22 November 2012 • IPN

Clinical Feature

in association with Reckitt Benckiser

THIS WINTER

Educating Patients on Appropriate Antibiotic Treatment Pharmacists will play a crucial part in a new national medical education campaign that seeks to reduce the levels of antibiotic prescribing this winter. The Play Your Part This Winter initiative aims to help pharmacists play a leading role in educating patients on appropriate antibiotic treatment with the introduction of a dedicated suite of informative materials on URTI management. These materials will synthesise important information which you can use to talk about colds and flu

with customers in your pharmacy. The materials will also illustrate the difference between bacterial and viral URTIs. Management of URTIs in Pharmacy A wide range of cold and flu like illnesses are caused by URTIs and they are the most common infectious illnesses in the general public – occurring anywhere in the upper respiratory tract, including the nose, throat, ears and sinuses. There are two types URTI: bacterial and viral, with the vast majority of the cold and flus that you are most likely to encounter being viral. For instance, viruses cause 70% of sore

throats in children aged 5-16 years and 95% of sore throats in children under 5 years1. Despite the efforts to raise the awareness of appropriate antibiotic prescribing there is increasing evidence to suggest that antibiotics are significantly overused in the treatment of viral URTIs, particularly in Ireland2. Indeed, 85-95% of adult URTIs are viral1 and do not benefit in any way from an antibiotic. Unnecessary antibiotic use can cause diarrhoea, rash and stomach upsets amongst your customers. Furthermore, overuse means that they may not work when they are really needed.

The Play Your Part This Winter pack contains an illustrative URTI countertop flip guide featuring clear visuals to help you engage with your customers

What is a URTI?

TONSILLITIS

SINUSITIS

Inflammation of the tonsillar tissue

Inflammation of the sinuses

PHARYNGITIS

LARYNGITIS

Inflammation of the pharynx (“sore throat”)

Inflammation of the larynx

TRACHEITIS

COUGH

Inflammation of the trachea

Inflammation of the larger airways, the bronchi

The Respiratory Tract Treatment Forum www.respiratorytract.ie

The Respiratory Tract Treatment Forum was convened by Reckitt Benckiser. All materials were sponsored by and developed in partnership with Reckitt Benckiser Healthcare and its agency First Medical Communications. The views expressed in the materials are those of the Forum.


IPN • November 2012 23

The Respiratory Tract Treatment Forum The outreach is backed by the Respiratory Tract Treatment Forum, a multi-disciplinary group of healthcare professionals which formed late last year. The group were the driving force behind the development of a widely acclaimed ‘URTI information pack’, which was distributed to GPs and pharmacists. REFERENCES: 1. WORRALL G, ACUTE SORE THROAT. CANADIAN FAMILY PHYSICIAN, 2007; 53, 1961-1962 2. RCPI POLICY GROUP ON HEALTHCARE-ASSOCIATED INFECTION (HCAI) – ANTIBIOTIC USE AND THE IMPLICATIONS FOR HEALTHCARE ASSOCIATED INFECTIONS. 2008. 3. OXFORD, JS, LEUWER, M. ACUTE SORE THROAT REVISITED: CLINICAL AND EXPERIMENTAL EVIDENCE FOR THE EFFICACY OF OVER-THE-COUNTER AMC/DCBA THROAT LOZENGES. INT J CLIN PRACT 2011; 65,(5): 524-530 4. G.G. JACKSON et al; TRANSMISSION OF COMMON COLD TO VOLUNTEERS UNDER CONTROLLED CONDITIONS, J CLIN INVEST., 1959 May, 38(5), 762–769. 5. THE COMMON COLD AS A CLINICAL ENTITY, AMA ARCHIVES OF INTERNAL MEDICINE, Vol. 101, Feb. 1958, 267-278 6. HEALTH SERVICE EXECUTIVE, ANTIBIOTICS ARE WASTED ON COLDS AND FLU, AVAILABLE AThttp://www. healthpromotion.ie/hp-files/docs/HCU00532.pdf, LAST ACCESSED 22/8/2012

-

s

et

• Sneezing • Blocked and runny noses can appear

rly

• Headache can also be experienced • Runny noses

Fe e

gp li n Fee gh u o c -

te r

oo

• Cough continues and can get worse as other symptoms fade • Runny and blocked noses may be experienced

• Cough is getting worse – whole body can be affected: chest, ribs, muscles, head and throat • Runny noses may still be a problem

How long can symptoms last?6 Ear infection

Sore throat

Common cold

approximately 4 days from first signs

approximately 1 week from first signs

approximately 1 week from first signs

Sinus infection approximately 2.5 weeks from first signs

Cough (common after a cold) approximately 3 weeks from first signs

The Play Your Part This Winter pharmacy educational pack will be distributed to pharmacies nationwide over the coming weeks by Reckitt Benckiser, makers of Strepsils Intensive, and will build further understanding of the role of non-prescription medicines for symptom relief. This second stage of the campaign will complement a previously-developed suite of materials featuring informative contributions from the members of the Respiratory Tract Treatment Forum. To order the new Play Your Part This Winter pharmacy pack (or indeed the previously-developed materials mentioned above): Email - info@respiratorytract.ie Telephone - 01- 665 0300

Strepsils Intensive Honey & Lemon 8.75mg Lozenges is a medicinal product licensed for sale in pharmacy only. The full prescribing information is available on request. Should you require any further information or have any product queries please call (01) 6305429 or contact Reckitt Benckiser Ireland Ltd, Citywest Business Campus, Dublin 24.

ALWAYS READ THE LABEL

IRL/SP/0812/0003b. Date of preparation: September 2012.

The Play Your Part This Winter pack will include an illustrative URTI countertop flip guide, which enables pharmacy staff to identify the most effective and appropriate symptom relief for customers as well as assisting with the differentiation between viral and bacterial URTIs and the effects of unnecessary antibiotic usage. Significantly, this tool can also be used to interact with your customers and start a conversation on the most appropriate treatment for them.

– ts at ar thro

b b i t st g a rsi Feelin h pe - co u g

The Resource This newly developed resource – designed specifically for use in the pharmacy setting – will help pharmacists highlight to customers that pharmacy is the best initial port of call for advice and symptom relief and provide education on the appropriate use of antibiotics, particularly as they provide no benefit in 85-95% of all adult URTIs1.

The journey of a cold and flu is complex but it will generally start with a sore throat.

ly oor gp s lin llines i ch

Whilst the HSE continues to advise the public that antibiotics are wasted on colds and flus pharmacists can support that effort by restricting unnecessary referrals.

The Journey of A Cold & Flu4,5

It so st re

Symptom Relief The new materials will help you to explain to your customers that the pharmacy is the best place to go for symptom relief this winter. This is particularly important, because during the winter period an adult can experience 2-3 sore throats over the period of 3 months3.


24 November 2012 • IPN

News

Medicines Use Reviews in Asthma Management Sharon Cosgrove, CEO, Asthma Society of Ireland and Cicely Roche MPSI, Member of the Medical Committee of the Asthma Society of Ireland and Associate Professor at Trinity's School of Pharmacy look at asthma management issues.

Sharon Cosgrove

Cicely Roche

Sharon Cosgrove, CEO, Asthma Society of Ireland and Cicely Roche MPSI, Member of the Medical Committee of the Asthma Society of Ireland and Associate Professor at the School of Pharmacy in Trinity College Dublin We are very pleased to take the opportunity to jointly contribute to this piece in order to highlight our shared concerns and aims in relation to asthma and asthma care in Ireland, from both patient organisation and community pharmacists’ perspectives. The Asthma Society of Ireland is almost 40 years old and, this year we enter a new phase of the organisation’s development. Our new strategic plan for 2012-2015 reminds us that asthma affects 470,000 people in Ireland and has an unacceptably high morbidity and mortality rate, associated with poor control. It is the most common chronic respiratory disease in Ireland and the consequences of poor asthma control, management and care have a wide ranging impact on patients' lives, and on their families. On average, one person dies every week in Ireland from asthma, with devastating effects. Despite the high prevalence of the disease,

the general public remains poorly informed of the health, economic and social burden of the condition. It is estimated that between 35-50% of the total cost of asthma care is associated with the economic impact of poor control. To address these major concerns, the authors will be advocating and campaigning to ensure full implementation of the Global Initiative for Asthma (GINA)guidelines, which were adopted by the Irish Government in 2011. This is reliant on better patient understanding of the disease and knowing how to control it. The role of healthcare professionals in the treatment of asthma and the promotion of self-care is crucial, and community pharmacists are a key component of a coordinated response to the disease. An individual pharmacist collaborates with the patient to seek to achieve the rational, safe and effective use of medicines. In order to do so, the pharmacist reviews a patient’s prescriptions and considers the appropriateness of medicines used, including dosage regimes and any potential interactions between various medicines actually being taken by the patient. Where medicines usage involves the use of medical devices, such as inhalers or spacer devices, the pharmacist can review the use of those devices as part of the overall approach to improving patient outcomes. The English PSNC (Pharmaceutical Services Negotiating Committee) reports, as recently as 25 September 2012, that ‘Results from [an] Inhaler Technique Improvement Project confirms benefits of respiratory MURs (Medicines Usage Reviews). The study,

undertaken found that such interventions led to better asthma control and COPD symptom management. They report that ‘in relative terms, 40% of people with asthma and 55% of people with COPD showed an improvement in disease/ symptom control’ and, in what should be of particular interest to those with responsibility for overall budgetary control of the health service, that ‘analysis of data on emergency hospital admissions caused by asthma and COPD showed a positive association between the introduction of the pharmacy project and a change in emergency admission rates’. The priorities in the Asthma Society in this next phase include a focus on public awareness campaigns which highlight asthma – its impact, how it can be managed and how deaths can be prevented. The Society will campaign and advocate with policy makers and politicians for better public health services for patients, including a free annual GP consultation, free access to medication, especially ‘controllers’, and greater equity of access to asthma treatment. It will endeavour to deliver high-quality patient services through the Society's Asthma Advice Line, its regional clinics and its pharmacy days as a means of addressing the gaps in crucial services to patients. The engagement with patients, pharmacists and other health care professionals through these services will also keep us well informed of the issues for patients, so that they can be highlighted through the Society's patient advocacy work. Finally, the Society will build on its work with healthcare professionals, providing educational resources, the asthma guidelines for primary care and useful tools to assist in the delivery of best practice, through the e-learning programme and the ‘train the trainer’ approach.


*

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 Abbreviated Prescribing Information. Please consult the summary of product characteristics for full prescribing information. 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 Tablets 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. 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 Paracetamol Human and animal studies have not identified any risk of paracetamol in pregnancy or embryo-foetal development. Caffeine Paracetamolcaffeine 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 Overdose of caffeine may result in epigastric pain, vomiting, diuresis, tachycardia or cardiac arrhythmia, CNS stimulation (insomnia, restlessness, excitement, agitation, jitteriness, tremors and convulsions). It must be noted that for clinically significant symptoms of caffeine overdose to occur with this product, the amount ingested would be associated with serious paracetamol-related liver toxicity. 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 5575. Marketing Authorisation Number PA 678/39/10. Date of (Partial) Revision of the Text October 2012. Legal Category: Pharmacy Only.


26 November 2012 • IPN

News news brief Cold and flu behind Irish business’ €1.5bn annual sickie bill

Kelly's Pharmacy unveils new home

Illnesses such as cold and flu are the main reason cited for ‘sick days,’ costing Irish businesses approximately ¤1.5bn a year. There were on average 2.97 million incidences of cold and flu a month in Ireland last winter, equating to nearly nine million cases over the season, it has been revealed, as the flu vaccine becomes available in 64 of Boots' pharmacies across the country. The most common complaints people presented to their pharmacist with were coughing (58%), sore throat (50%) and nasal congestion (45%). The average Irish employee takes 5.98 days off sick each year at an average cost to the employer of ¤818. Mary Rose Burke, Director of Pharmacy, Boots, Ireland said: “Not only does flu affect the individual, but it can also affect their family and fellow work colleagues." Burke noted the difference between the flu and the common cold, explaining: “Cold and flu have many of the same symptoms such as coughing and sneezing but the flu is a much more serious illness and needs for be guarded against."

Pictured are Minister for Children, Frances Fitzgerald (third from left) with the staff of Kelly's Pharmacy in Saggart, Co Dublin. Kelly's Pharmacy recently unveiled its brand new home in Saggart Village. The new store is three times the size of its original premises. Kelly’s Pharmacy opened its doors in 1985 and since then it has been serving the people of Saggart, adapting to cater to their needs and demands. Its Managing Director, Brenda Kelly, was one of the first people to ever complete the Bachelor of Pharmacy degree course in Ireland. Minister Frances Fitzgerald was on hand

to officially open the new pharmacy. “It is a true honour to be here tonight to open this fantastic new pharmacy and pay tribute to my good friend Brenda Kelly, whose vision, commitment and business skills have delivered a fabulous new facility for the people of Saggart,” Minister Fitzgerald said at the official opening night. Kelly’s Pharmacy boasts an attractive cutting edge design, friendly professional staff and offers a huge selection of cosmetics and products as well as prescriptions.

EasyScript makes life easy for patients

Pictured getting ready for winter are triple gold medal winning Paralympian, Michael McKillop and Mary Rose Burke Director of Pharmacy, Boots Ireland.

McCabes Pharmacy have launched a new service, exclusive to the chain, in the format of EasyScript. EasyScript makes it quicker, safer and easier to get a prescription filled than ever before. The key elements involve: Easymed: A personalised tablet tray that organises daily medications, minimises confusion and helps keep patients on track to take their medication at the right time and is free of charge. Delivery: A service that delivers to the patient, for when they are unable to call in to the pharmacy. Ideal for bulky items. Advance Script Preparation Register: To text, email or telephone to order repeat

prescriptions in advance and to be notified when its ready for collection. Out of Hours Telephone Service: Patients can register their details to receive a dedicated patient care telephone number so they can avail of the pharmacists help. Useful for those on complex medication regimes and those with serious illness. Medication Usage Review: Patients can make an appointment with their local McCabes pharmacist for free and confidential medication review. Palliative Care Programme: In conjunction with St. Francis Hospice, Our Ladys Hospital Crumlin and the Lauralynn Foundation, register for emergency access to specialised medicine.


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28 November 2012 • IPN

News Cork and Kerry pharmacists team up to ‘DUMP’ old medicines

the campaign period," said Lane, "but they are not bound to provide this service because there are considerable costs involved if they do this."

The 'Dispose of Unused Medicines Properly' campaign (DUMP), organised by HSE South in conjunction with pharmacies from counties Cork and Kerry, has been going from strength to strength. The campaign originally started five years ago and now some 249 out of the 256 community pharmacies in the two counties are participating in the scheme.

Brosnan’s Pharmacy in Midleton, Co Cork, has been involved in the scheme since its inception.

David Lane, HSE South Addiction Services, told IPN that last year’s DUMP campaign saw the disposal of more than 260 special bins, which contained 4.6 tonnes of unwanted medicines. “We originally started the campaign in 2007 because similar campaigns had been so successful internationally,” he said. “That year, we disposed of 2.5 tonnes and anticipated that there would be a dropoff after the initial response but that has not been the case. People seem to find and return an ever-increasing amount of medicines every year. Similar campaigns have run sporadically around the country but, as far as I know, we are the only area to host a regular disposal campaign.” Louise Creed, HSE South Community Care Pharmacist added, “Medication can pose a real hazard in the home, particularly to children and the vulnerable. People should regularly clear out their medicine cabinets and remove anything that is out of date or no longer required. As well as the hazards posed by overdose, accidental poisoning and damage to the environment, out-of-date medicines can change and may end up harming someone.” Pharmacies are not paid for their participation but all of their costs are covered by the HSE South, Cork City Council, Cork County Council and Kerry County Council, who are co-ordinating the campaign. This includes delivering and collecting the bins, as well as advertising in the local media and supplying the participating pharmacies with promotional posters and leaflets. “Anecdotally, some pharmacists will accept out-of-date or unused medications outside

PHARMACIST INVOLVEMENT Karen Murphy is a pharmacist in Horgan’s Pharmacy, Skibbereen, Co Cork and this is the second year that the pharmacy has been involved with the DUMP scheme. “We accept unused or out-of-date medications throughout the whole year," said Murphy, "and last year there was certainly an upsurge in returned medicines during the DUMP campaign, so we are more than happy to participate again."

“We have always had a brilliant response from our patients,” said pharmacist Niamh Brosnan. “Once the posters go up in the window and people see the advertisements in the papers, we find them flocking in with their unwanted medications. “With the introduction of the 50 cent prescription charge for medical-card patients, we thought there might be fewer drugs returned to us but that has not been the case – there have been just as many, if not more,” she continued. “We usually fill around three bins with returned medications during the two-month campaign.” Brosnan’s Pharmacy also accepts unused medications outside the period of the DUMP campaign. “We are happy to do this for our patients but It does cost us quite a lot to ensure that the medicines are disposed of safely," said Brosnan. "That is why we are so enthusiastic about the DUMP campaign – it would be great if it ran all year!"

– and only that person. Sharing or not completing a course of medication may cause illness, injury or even death. Also, when antibiotics are used inappropriately, not all of the bacteria are destroyed – more resistant bacteria survive and multiply. These drug-resistant bacteria then make it harder to prevent and treat infections because fewer antibiotics are effective against them. • Overdose suicide attempts In 2011, some 12,216 cases of deliberate self-harm presented to hospitals throughout the country. Drug overdose was the commonest method of self harm and was involved in 69 per cent of all cases registered in 2011. Minor tranquilisers, paracetamol-containing medicines and antidepressants were involved in up to 43 per cent of drug overdose attempts. • Damage to the environment Unwanted medicines are often dumped with other household waste, flushed down the toilet or poured down the sink. These methods of disposal can seriously harm the environment, with products ending up in landfill, permeating the soil and entering our food chain and water supplies. Pharmacists should advise customers regarding the correct storage of their medications and the precautions they should take. “The results for the latest DUMP campaign were very encouraging,” Creed concluded. “The campaign gave the HSE and the people of Cork and Kerry the opportunity to work together and raised the public’s awareness of how excess medicines in the home can pose hazards."

STORAGE HAZARDS Pharmacists should advise patients that storing large quantities of medication at home can pose a hazard and put the public at risk of the following: • Accidental poisonings Brightly coloured medications or liquids can easily be mistaken for sweets or drinks by children or other vulnerable people. In 2010, the National Poisons Information Centre received 9,330 enquiries concerning human poisoning, with medicines being the most common cause. Paracetamol and ibuprofen were the most common agents and half of these enquiries involved children under 10 years of age. Some 93 per cent of cases of poisoning occurred in the home. • Inappropriate sharing of medicines It is important that patients understand that medicines should be taken as directed by the person for whom they were prescribed

DUMP encourages safe medicines disposal.


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30 November 2012 • IPN

News news brief Leadership for clinical strategy

Violence in pharmacy common in Ireland

The HSE has announced a new National Director of Clinical Strategy and Programmes. The National Clinical Programmes were established to bring together health professionals to improve and standardise patient care throughout the health services. Dr Áine Carroll's role will be to lead these Programmes, which are setting out how clinical services will be delivered into the future.

the impact of violence on employees and possible consequence for the industry. A two-part survey was distributed to community pharmacies in Ireland in 2011 (n = 200). The first part related to pharmacy demographics, the frequency of various violent events (verbal abuse, threats etc.), the respondents' worry regarding violence and its impact on their co-workers. The second part concerned individual employees' subjective response to a violent event, using the Impact of Event Scale-Revised (IES-R).

Dr. Carroll is a Consultant in Rehabilitation Medicine, immediate past Chair of the Medical Board of the National Rehabilitation Hospital, and Senior Clinical Lecturer at University College Dublin. Prior to her appointment Dr. Carroll was the Clinical Lead of the Rehabilitation Medicine Programme. This Programme is in the process of providing a framework for the delivery of quality, timely and value Rehabilitation services. This is being achieved through the development of regional rehab services and managed clinical rehabilitation networks. They are seeking to break down traditional boundaries between hospitals and the community.

Deirdre Fitzgerald

Chief Executive Officer of the HSE, Mr. Tony O’Brien welcomed the appointment; “Dr. Carroll is well acquainted with the work of the Clinical Programmes. She has demonstrated her capabilities while working as National Lead for Rehabilitation Medicine and she now has the opportunity to implement the objectives of Clinical Programmes in a similar fashion. I am confident in her ability, together with her colleagues across the Programmes, to ensure that we can continue to reform and improve how we deliver services for patients and clients.”

'Violence in community pharmacies in Ireland is thought to be common but under reported. The frequency and consequences of violence has not been studied previously,' states the report.

Dr Áine Carroll

Violence is common in Irish community pharmacies and impacts on employees and the industry, a new report has discovered. The report was titled 'The Frequency and consequences of violence in community pharmacies in Ireland' and authored by Deirdre Fitzgerald and Alex Reid of the Occupational Health Department at Tallaght Hospital.

As a result, the authors decided to establish the frequency and nature of violence in community pharmacies over a 12 month period, and to investigate

57% of the pharmacies responded, with 77% reporting some violent event (verbal or physical), over the past year. 18% reported physical assault, and 63% were worried about workplace violence. There was no association between late night opening hours or pharmacy size and violence frequency. Positive statistically significant correlations were present between all types of violence and absenteeism and employee fear levels. An IES-R score could be calculated for 75 respondents; the median IES-R score was 8 with 19% reporting clinically significant scores.


Symbicort® Turbohaler® (budesonide/formoterol)

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PRESCRIBING INFORMATION. Refer to full Summary of Product Characteristics (SmPC) before prescribing Symbicort® Turbohaler® 100/6; 200/6; 400/12; Inhalation Powder (budesonide/formoterol fumarate dihydrate) Presentations: Inhalation powder. Symbicort Turbohaler 100/6: Each metered dose contains 100mcg budesonide/inhalation and 6mcg formoterol fumarate dihydrate/inhalation. Symbicort Turbohaler 200/6: Each metered dose contains 200mcg budesonide/inhalation and 6mcg formoterol fumarate dihydrate/inhalation. Symbicort Turbohaler 400/12: Each metered dose contains 400mcg budesonide/inhalation and 12mcg formoterol fumarate dehydrate/ inhalation. Uses: Asthma: Treatment of asthma where the use of a combination (inhaled corticosteroid and long acting β2 adrenoceptor agonist) is appropriate. Symbicort 100/6 is not appropriate for patients with severe asthma. COPD (Symbicort 200/6; 400/12): Symptomatic treatment of patients with severe COPD (FEV1 <50% predicted normal) and a history of repeated exacerbations, who have significant symptoms despite regular therapy with long-acting bronchodilators. Dosage and Administration: Asthma (Symbicort maintenance therapy – regular maintenance treatment with a separate rescue medication): Adults (including elderly) 100/6 and 200/6: 1-2 inhalations twice daily. Some patients may require up to a maximum of 4 inhalations twice daily; 400/12: 1 inhalation twice daily. Some patients may require up to a maximum of 2 inhalations twice daily Adolescents (12-17 years) 100/6 and 200/6: 1-2 inhalations twice daily; 400/12: 1 inhalation twice daily. Children 6 years and older 100/6 only: 2 inhalations twice daily. Symbicort is not recommended for children under 6 years. Symbicort 400/12 is not recommended for children under 12 years. Not intended for the initial management of asthma. Dose should be individualised. If an individual patient requires dosages outside recommended regimen, appropriate doses of β2 adrenoceptor agonist and/or corticosteroid should be prescribed. When long-term symptoms are controlled, titrate to the lowest effective dose, which could include a once daily dosage. Asthma (Symbicort maintenance and reliever therapy – regular maintenance treatment and as needed in response to symptoms) for Symbicort 100/6 and 200/6 only (NOT recommended with 400/12 strength): especially consider for (i) patients with inadequate asthma control and in frequent need of reliever medication (ii) patients with asthma exacerbations in the past requiring medical intervention. Close monitoring for dose-related adverse effects is needed in patients who frequently take high numbers of Symbicort asneeded inhalations. Adults (including elderly) 100/6 & 200/6: 1 inhalation twice daily or as 2 inhalations once daily. For some patients a dose of 2 inhalations twice daily may be appropriate (200/6 strength only). Patients should take 1 additional inhalation as needed in response to symptoms. If symptoms persist after a few minutes, an additional inhalation should be taken. Not more than 6 inhalations should be taken on any single occasion. A total daily dose of more than 8 inhalations is not normally needed; however, up to 12 inhalations a day could be used for a limited period. Patients using more than 8 inhalations daily should be strongly recommended to seek medical advice and should be reassessed; their maintenance therapy should be reconsidered. Patients should be advised to always have Symbicort for reliever use. Children and adolescents under 18 years of age: not recommended. COPD (200/6): Adults: 2 inhalations twice daily. (400/12): 1 inhalation twice daily. Contraindications, Warnings and Precautions etc.: Contraindications: Hypersensitivity (allergy) to budesonide, formoterol or lactose (which contains small amounts of milk proteins). Warnings and Precautions: If treatment is ineffective, or there is a worsening of the underlying condition, therapy should be reassessed. Sudden and progressive deterioration in control requires urgent medical assessment. Patients should have their appropriate rescue medication available at all times, i.e. either Symbicort or a separate reliever. If needed for prophylactic use (e.g. before exercise) a separate reliever should be used. Therapy should not be initiated during an exacerbation. Serious asthma-related adverse events and exacerbations may occur and patients should continue treatment but seek medical advice if asthma symptoms remain uncontrolled or worsen after initiation of Symbicort. Paradoxical bronchospasm may occur, with an immediate increase in wheezing and shortness of breath after dosing. This responds to a rapid-acting inhaled bronchodilator and should be treated straightaway. As with any inhaled corticosteroid, systemic effects may occur, particularly at high doses prescribed for long periods. These may include Cushing’s syndrome, Cushingoid features, adrenal suppression, growth retardation in children and adolescents, cataract and glaucoma and more rarely a range of psychological or behavioral effects. Potential effects on bone should be considered especially in patients on high doses for prolonged periods that have co-existing risk factors for osteoporosis. Prolonged treatment with high doses of inhaled corticosteroids, particularly higher than recommended doses, may also result in clinically significant adrenal suppression. Therefore additional systemic corticosteroid cover should be considered during periods of stress such as severe infections or elective surgery. Treatment with supplementary systemic steroids or inhaled budesonide should not be stopped abruptly. During transfer from oral steroid therapy to Symbicort, a generally lower systemic steroid action will be experienced which may result in the appearance of allergic or arthritic symptoms which will need treatment. In rare cases, symptoms such as tiredness, headache, nausea and vomiting can occur due to insufficient glucocorticosteroid effect and temporary increase in the dose of oral glucocorticosteroids is sometimes necessary. Observe caution in patients with thyrotoxicosis, phaeochromocytoma, diabetes mellitus, untreated hypokalaemia, or severe cardiovascular disorders. As with other β2 adrenoceptor agonists, hypokalaemia may occur at high doses. Particular caution recommended in unstable or acute severe asthma as this effect may be potentiated by xanthine-derivatives, steroids, diuretics and hypoxia. Monitor serum potassium levels. Hypokalaemia may increase the disposition towards arrhythmias in patients taking digitalis glycosides. In diabetic patients, consider additional blood glucose monitoring. Symbicort contains lactose monohydrate, as with other lactose containing products the small amounts of milk proteins present may cause allergic reactions. Interactions: Concomitant treatment with potent CYP3A4 inhibitors should be avoided. If this is not possible the time interval between administration should be as long as possible. Symbicort maintenance and reliever therapy is not recommended in patients using potent CYP3A4 inhibitors. Not to be given with beta adrenergic blockers (including eye drops) unless there are compelling reasons. Concomitant administration with quinidine, disopyramide, procainamide, phenothiazines, antihistamines (terfenadine), MAOIs and TCAs can prolong the QTc-interval and increase the risk of ventricular arrhythmias. L-Dopa, L-thyroxine, oxytocin and alcohol can impair cardiac tolerance. Concomitant administration with MAOIs, including agents with similar properties such as furazolidone and procarbazine, may precipitate hypertension. Risk of arrhythmias in patients receiving anaesthesia with halogenated hydrocarbons. Concomitant use of other beta adrenergic drugs or anticholinergic drugs can have a potentially additive bronchodilating effect. Pregnancy and Lactation: Should only be used when the benefits outweigh the potential risks. Budesonide is excreted in breast milk, however at therapeutic doses no effects on the child are anticipated. Undesirable effects: Common: headache, palpitations, tremor, candida infections in the oropharynx, coughing, mild irritation in the throat, hoarseness. Uncommon: tachycardia, nausea, dizziness, bruises, aggression, psychomotor hyperactivity, anxiety, sleep disorders. Rare: hypokalaemia, cardiac arrhythmias including atrial fibrillation, supraventricular tachycardia and extrasystoles, bronchospasm and immediate and delayed hypersensitivity reactions including exanthema, urticaria, pruritus, dermatitis, angioedema and anaphylactic reaction. Very Rare: psychiatric disorders including depression, behavioural changes (predominantly in children), angina pectoris, prolongation of QTc-interval, hyperglycaemia, taste disturbance, Cushing’s syndrome, adrenal suppression, growth retardation, decrease in bone mineral density, cataract and glaucoma and variations in blood pressure. As with other inhalation therapy, paradoxical bronchospasm may occur in very rare cases. Package Quantities: Each Symbicort Turbohaler 100/6 or 200/6 contains 120 inhalations. Each Symbicort Turbohaler 400/12 contains 60 inhalations. Legal Category: Prescription Only Medicine (POM). Marketing Authorisation Number(s): PA 970/28/1-3. Marketing Authorisation Holder (MAH): AstraZeneca UK Limited, 600 Capability Green, Luton, LU1 3LU, UK. Further product information available on request from: The MAH (address above), Freephone -1800 800 899. Abridged Prescribing Information prepared: 04/12. Symbicort and Turbohaler are Trade Marks of the AstraZeneca group of companies.URN: 12/0447 Date of Preparation: October 2012. Reference: 1. Adelphi Respiratory Disease Specific Programme 2009. 2. Olof Selroos et al. Treat Respir Med 2006; 5 (5): 305-315. 3. Engel et al. Br J Clin Pharmacol 1992; 33(4): 439-44. *JIDPO (Japan Industrial Design Promotion Organisation) Good Design Award Japan 2010: http://www.g-mark.org/award/detail.html?id=36 687&sheet=outline&lang=en


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CPD 23: ASTHMA Biography - Eamonn Brady MPSI is the owner of Whelehans Pharmacy in Mullingar. He graduated from the Robert Gordon University in Aberdeen in 2000 with a Masters in Pharmacy. He worked for Boots in the UK before moving back to Ireland in 2002. He bought Whelehans Pharmacy in Mullingar in 2005. He undertakes clinical training for nurses in the midlands.

1. REFLECT - Before reading this module, consider the following: Will this clinical area be relevant to my practice. 2. IDENTIFY - If the answer is no, I may still be interested in the area but the article may not contribute towards my continuing professional development (CPD). If the answer is yes, I should identify any knowledge gaps in the clinical area. 3. PLAN - If I have identified a knowledge gap

- will this article satisfy those needs - or will more reading be required? 4. EVALUATE - Did this article meet my learning needs - and how has my practise changed as a result? Have I identified further learning needs? 5. WHAT NEXT - At this time you may like to record your learning for future use or assessment. Follow the 4 previous steps, log and record your findings.

Asthma Asthma is a long-term condition that can cause coughing, wheezing and breathlessness. The severity of the symptoms varies from person to person. In Ireland, respiratory diseases are the third commonest long-term illness group after cardiovascular and musculoskeletal diseases, with asthma being the second most common single condition reported.1 CAUSES With asthma, the airways become over-sensitive and react to things that would normally not cause a problem, such as cold air or dust. Muscles around the wall of the airway tighten up, making it narrow and difficult for the air to flow in and out. The lining of the airways swells and sticky mucus is produced. This makes it difficult for air to move in and out and the reason the chest has to work so much. Tightening of muscle around the airways can happen quickly and is the most common cause of mild asthma. The tightening of muscle can be eased with a reliever inhaler. However, the swelling and build-up of mucus happens more slowly and needs different treatment. It takes longer to clear up and is a serious problem in moderate to severe asthma. FACTS ABOUT ASTHMA The exact cause of asthma is not known. According to the Asthma Insights and Realities in Ireland report in 2002, some 470,000 people had asthma in Ireland, meaning approximately one in eight of the population suffered from it. Ireland has the fourth-highest prevalence of asthma in the world after Australia, New Zealand and the UK. The Irish Pharmaceutical Healthcare Association reported that there were 600,000 GP consultations for asthma in 1997 and it is likely this figure has risen since then.1 There is a strong genetic link. If a parent has asthma, the risk doubles of their child getting it. If both parents have it, it doubles again.

And, if one in a family has asthma, the risk of the other children getting it increases, but it is not known by how much. In adults, asthma is more common in women than men. Asthma can start at any age, but most commonly it starts in childhood. Adult-onset asthma may develop after a respiratory tract infection. In many cases, asthma disappears during teenage years. Many asthma sufferers also suffer from other allergic conditions, such as hayfever, eczema and hives. Asthmatics often find that their symptoms get worse during hayfever season. In fact, research by Allergy UK found that 69% of asthmatics, who also had hayfever found their symptoms worsened during the hayfever season. Asthma has become more common in recent years. The incidence of asthma among 13 and 14 year olds increased by 40% from 1995 to 2003.14 The exact reason for this is not known. Many aspects of modern living, such as changes in housing, diet and a more sterile home environment may have contributed to the rise in asthma over recent decades. This theory is called the ‘hygiene hypothesis’. ASTHMA IN CHILDREN Asthma in children is more common in boys than in girls. Children who develop asthma at a very young age are more likely to ‘grow out’ of the condition as they get older. If asthma is moderate to severe during childhood, it is more likely to continue into adulthood. During the teenage years, the symptoms of asthma disappear in about three-quarters of all children. Known risk factors for the development of asthma in children include:

• a family history of asthma, or other

related allergic conditions (known as atopic

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Published by IPN and supported with an unrestricted educational grant from Pfizer Healthcare Ireland. Copies can be downloaded from www.irishpharmacytraining.ie Disclaimer: All material published in CPD and the Pharmacy is copyright and no part of this can be used within any other publication without the permission of the publishers and author.

60 Second Summary According to the Asthma Insights and Realities in Ireland report in 2002, some 470,000 people had asthma in Ireland, meaning approximately one in eight of the population suffered from it. Ireland has the fourth-highest prevalence of asthma in the world after Australia, New Zealand and the UK. Many aspects of modern living, such as changes in housing, diet and a more sterile home environment may have contributed to the rise in ast hma over recent decades. This theory is called the 'hygiene hypothesis'. A child with asthma should be taught to recognise the initial symptoms of an asthma attack, how they should respond and when they should seek medical attention. Some children are less likely to develop asthma than others. Studies have found that those children, who are given fewer antibiotics and who live on or near farms have less asthma than children with different backgrounds. Anything that irritates the airways and brings on the symptoms of asthma is called a trigger. Common triggers include house dust mites, animal fur, pollen, tobacco smoke, exercise, cold air and chest infections.

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CPD 23: ASTHMA perhaps brought on by colds or chest infections, exercise, change of temperature, dust or other irritants in the air, or by an allergy e.g. pollen or animals. Episodes at night are common, often affecting sleep. COMMON TRIGGERS Anything that irritates the airways and brings on the symptoms of asthma is called a trigger. Common triggers include house dust mites, animal fur, pollen, tobacco smoke, exercise, cold air and chest infections. Other triggers which are less common include non-steroidal anti-inflammatory drugs, such as ibuprofen and diclofenic; emotional factors, such as stress; sulphites in some foods and drinks (found in certain wines and used as a preservative in some foods such as fruit juices and jam); mould or damp in houses and food allergies (e.g.) nut allergy. WHAT HAPPENS DURING AN ASTHMA ATTACK?

conditions) such as eczema, hayfever or allergic conjunctivitis;

• developing another atopic condition; • being exposed to tobacco smoke, particularly if the child’s mother smoked during pregnancy;

• being born prematurely; • being born with a low birth weight. A child with asthma should be taught to recognise the initial symptoms of an asthma attack, how they should respond and when they should seek medical attention. Some children are less likely to develop asthma than others. Studies have found that those children, who are given fewer antibiotics and who live on or near farms have less asthma than children with different backgrounds. Medical researchers explain this with the ‘hygiene hypothesis’. THE ‘HYGIENE HYPOTHESIS’ The ‘hygiene hypothesis’ is the theory that lack of exposure in early childhood to infectious agents indicates that the child’s immune system has not been activated sufficiently during childhood. This lack of exposure is down to our super clean world of modern living, including anti-bacterial washes, vaccinations and general sterility, where children are not exposed to germs in a similar manner to previous generations of children. The theory behind the ‘hygiene hypothesis’ is that the immune system becomes over-sensitive to triggers like pollen, dust mites and animal fur because it is not subjected to sufficient stimulus during childhood due to an over-sterile environment. This may lead to a higher risk of auto-immune conditions, such as asthma, hafever and eczema. One of the first scientific explanations of this theory was by a lecturer in epidemiology from the London School of Hygiene and Tropical Medicine, David P Strachan, who published a paper on the theory in the British Medical Journal in 1989.15 He noticed that children from

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larger families were less likely to suffer from auto-immune conditions, such as asthma. Families have become smaller in the Western world over the last forty years, meaning that there has been less exposure to germs and infections and it is over the same period that health authorities have seen an explosion in such auto-immune conditions. Further studies have been conducted since, supporting the theory. For example, studies show that auto-immune diseases are less common in developing countries, however when immigrants from developing countries come to live in developed countries, where the living environments are more sterile, these immigrants suffer from increased levels of autoimmune conditions like asthma and the rate of auto-immune conditions increases the longer immigrants live in developed countries.16 It is a difficult issue to tackle for healthcare professional advising parents, who want the best for their children. Common sense tells us all that cleanliness is important. As a pharmacist, it is difficult to advise on the best balance for parents in relation to this theory. No journal or book will give a pharmacist exact advice. In my opinion, a balanced view would be to ensure children are administered important vaccines but ‘allow kids to be kids’. Children should be allowed to play outside with friends and parents and carers should try not to worry about them coming into contact with dirt and germs but care should be taken to watch that children do not develop life threatening food allergies. SYMPTOMS OF ASTHMA

• Difficulty in breathing/shortness of breath; • A tight feeling in the chest; • Wheezing (a whistling noise in the chest); • Coughing, particularly at night; • Hoarseness. These symptoms may occur in episodes,

During an asthma attack, something triggers inflammation, a natural biological process. Inflammation is one of the ways that the body’s immune system fights infection. If the body detects a lung infection, it starts the process of inflammation. White blood cells engulf the infection area to kill the infection and prevent it spreading. The white blood cells cause the airways to swell and produce mucus. In an asthmatic, the airways are over sensitive to the effects of inflammation. As a result, too much mucus is produced and the airways swell more than usual. Also, as a response to the inflammation, the muscles surrounding the airways begin to contract, making the airways narrower and narrower. The combination of excess mucus, swelling and contraction of the airways makes breathing difficult and produces the wheezing and coughing that is associated with asthma. DIAGNOSIS OF ASTHMA The following questions can help ascertain if asthma is the problem.

• Is there a family history of asthma? • Are symptoms frequent and do they affect quality of life?

• Has there been an attack or recurrent attacks of wheezing?

• Is there a regular night time cough? • Does exercise trigger wheezing or coughing? • Is there wheezing, chest tightness, or cough after exposure to airborne allergens or pollutants?

• Does the patient suffer from constant chest infections?

• Do chest infections take a long time to clear up?

• Are symptoms improved by when using a reliever inhaler?

Answering ‘yes’ to a number of these questions indicates asthma. The following tests are often done to confirm the diagnosis of asthma: 1. Spirometry is a simple breathing test that gives measurements of lung function. It is common to measure lung function with a

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CPD 23: ASTHMA spirometer before and after a dose of reliever to see if lung function has improved (a spirometer is the device that is used to make the measurements.) 2. Peak expiratory flow rate (PEFR) is a breathing test. It uses a simple hand held device, called a peak flow meter, which a patient blows into to measure lung function. The PEFR test is only suitable for children over five years of age 3. An exercise test to check if exercise worsens asthma symptoms WHEN TO GET IMMEDIATE HELP The following are signs of a severe asthma attack:

• The reliever inhaler does not help symptoms at all;

• The symptoms of wheezing, coughing, tight chest are severe and constant;

• Too breathless to speak; • Pulse is racing; • Feeling agitated or restless; • Lips or fingernails look blue.

obtain treatment for their worsening asthma symptoms. In exercise-induced asthma, sufferers are advised to use a short acting beta 2-agonist, 10-15 minutes before they exercise and, again after two hours of prolonged exercise, or when they finish. PREVENTER INHALERS Preventer inhalers are slower acting inhalers that reduce inflammation in the airways and prevent asthma attacks occurring. The preventer inhaler must be used daily for some time before full benefit is achieved. The preventer inhaler usually contains an inhaled corticosteroid. Examples of preventer medicines include beclometasone (Becotide®, Beclazone®), budesonide (Pulmicort®), and fluticasone (Flixotide®). Preventer inhalers are often brown, red or orange. The dose of inhaler will be increased gradually until symptoms ease. For example, a patient may start on a beclamethasone 100mcg inhaler and may be put on a beclamethasone 250mcg inhaler if there is insufficient improvement in symptoms. Preventer treatment is normally recommended if the patient:

• has asthma symptoms more than twice a

It is important to obtain immediate medical help when these symptoms occur.

week;

NON-PHARMACOLOGICAL MANAGEMENT

symptoms;

Asthmatics should be advised strongly not to smoke and to lose weight.2 Allergen avoidance measures may be helpful but the benefit of avoiding allergens, such as dust mite, animal fur has not been proven in studies.3, 4 Currently, there is insufficient or no evidence of the clinical benefit of complementary therapy for asthma, such as Chinese medicine, acupuncture, breathing exercises and homoeopathy.5 TREATMENT There is no cure for asthma. Symptoms can come and go throughout the person’s life. Treatment can help to control the condition. Treatment is based on relief of symptoms and preventing future symptoms and attacks from developing. Successful prevention can be achieved through a combination of medicines, lifestyle changes, identification and avoiding asthma triggers. RELIEVER INHALERS A short-acting beta 2-agonist opens up the airways. These work quickly to relieve asthma. They work by relaxing the muscles surrounding the narrowed airways. Examples of beta 2-agonists include salbutamol (Ventolin®, Salamol®) and terbutaline (Bricanyl®). They are usually blue in colour. They are generally safe medicines with few side effects, unless they are over used. It is important for every asthmatic to have a beta-2 agonist inhaler. If an asthmatic needs to use their beta agonist inhaler too regularly (three or more times per week) they should have their therapy reviewed. The main side effects include a mild shaking of the hands, headache and muscle cramps. These usually only occur with high doses of relievers and usually only last for a few minutes. Excessive use of short acting relievers have been associated with asthma deaths.5, 6 This is not the fault of the reliever medication, but down to the fact that the patient failed to

• wakes up once a week due to asthma • has to use a reliever inhaler more than twice a week.

Regular, inhaled corticosteroids have been shown to reduce symptoms, exacerbations, hospital readmissions and asthma deaths.5, 7, 8-11 The majority of patients require a dose of less than 400mcg per day to achieve maximum or near maximum benefit. Side effects are minimal at this dose. Smoking can reduce the effects of preventer inhalers. Preventers are very safe at usual doses, although they can cause some side effects at high doses, especially over long-term use. The main side effect of preventer inhalers is a fungal infection (oral candidiasis) of the mouth or throat. This can be prevented by rinsing the mouth with water after inhaling a dose. The patient may also develop a hoarse voice. Using a spacer can help prevent these side effects. LONG-ACTING RELIEVER INHALER If short acting beta 2-agonist inhalers and preventer inhalers are not providing sufficient symptom relief, a long-acting reliever (long acting beta 2-agonist) may be tried. Inhalers combining an inhaled steroid and a long-acting bronchodilator (combination inhaler) are more commonly prescribed than long acting beta 2-agonists on their own. Long acting beta 2-agonists work in the same way as shortacting relievers but they take longer to work and can last up to 12 hours.

asthma, although increased risk of death is small.17 In November 2005, the Food and Drug Administration in the United States issued an alert indicating the potential increase risk of worsening symptoms and sometimes death associated with the use of long acting beta 2-agonists.18 COMBINATION INHALERS Examples of combination inhalers containing long acting beta 2-agonist and steroids include Seretide® and Symbicort®. Combination inhalers containing beta 2-agonists and corticosteroids can be very effective in attaining asthma control. They have been shown to have better outcomes compared to leukotriene receptor antagonists, such as montelukast.19 Both treatment options lead to improved asthma control; however compared to leukotriene receptor antagonists, the addition of longacting beta 2-agonist to inhaled corticosteroids is associated with significantly improved lung function, symptom-free days, need for short term beta 2-agonists, night awakenings, and quality of life, 19 even though the magnitude of some of these differences is small.19 OTHER PREVENTER MEDICATION If treatment of asthma is still not successful, additional preventer medicines can be tried. Two possible alternatives include:

• leukotriene receptor antagonists (montelukast

– brand name Singulair®): act by blocking part of the chemical reaction involved in inflammation of the airways

• theophyllines: help to widen the airways by relaxing the muscles around them

If asthma is still not under control, regular oral corticosteroids may be prescribed. This treatment is usually monitored by a respiratory specialist. Long-term use of oral corticosteroids has possible serious side effects, so they are only used once other treatment options have been tried. Theophylline is known to cause potential side effects, including headaches, nausea, insomnia, vomiting, irritability and stomach upsets. These can usually be avoided by adjusting the dose. Leukotriene receptor agonists do not usually cause side effects, although there have been reports of stomach upsets, feeling thirsty and headache. OCCASIONAL USE OF ORAL CORTICOSTEROIDS Most people only need to take a course of oral corticosteroids for one or two weeks. Once the asthma symptoms are under control, the dose can be reduced slowly over a few days. Oral corticosteroids can cause side effects if they

A salmeterol (Serevent®) inhaler is an example of a long-acting reliever inhaler used in Ireland. Long-acting relievers may cause similar side effects to short-acting relievers, including a mild shaking of the hands, headache and muscle cramps. Long-acting reliever inhalers should only be used in combination with a preventer inhaler. Studies have shown that using a longacting reliever on its own (without a combination corticosteroid) can increase asthma attack and can even increase the risk of death from

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CPD 23: ASTHMA are taken for more than three months or if they are taken frequently (three or four courses of corticosteroids a year). Side effects can include:

• weight gain • thinning of the skin • osteoporosis • hypertension • diabetes • cataracts and glaucoma • easy bruising • muscle weakness To minimise the risk of taking oral corticosteroids:

• Eat a healthy, balanced diet with plenty of calcium.

• Maintain a healthy body weight. • Stop smoking • Only drink alcohol in moderation • Do regular exercise WHEN CAN THERAPY BE REDUCED? Once control is achieved and sustained, gradual stepping down of therapy is recommended.5 Good control is reflected by the absence of night time symptoms, no symptoms on exercise and the use of relievers less than three times a week. Patients should be maintained on the lowest effective dose of inhaled steroids, with reductions of 25-50% being considered every three months. SPACER DEVICES Spacers are large plastic or metal containers with a mouthpiece at one end and a hole for the inhaler at the other. The medicine is puffed into the spacer by the inhaler and it is then breathed in through the spacer mouthpiece. Spacer devices, in combination with metered dose inhalers (MDI) have a number of advantages: a) no need to co-ordinate inhaler activation with inspiration, b) improvement in lung deposition and c) reduction in oropharyngeal deposition (resulting in fewer local side effects and lower systemic absorption).2 Some inhalers emit an aerosol jet when pressed. These work better if given through a spacer, which increases the amount of medication that reaches the lungs and reduce side effects.6 Some patients, especially children and elderly patients find using inhalers difficult and spacers can help. However, spacers are often advised even for patients who use inhalers well because they improve the distribution of medication in the lungs. Spacers are also good for reducing the risk of thrush in the mouth or throat with corticosteroid inhalers. When a spacer device is being used, only one puff of the inhaler must occur at a time. ASTHMA DEATHS Underestimating the severity of a fatal attack by the doctor, patient or relatives is considered to be the biggest cause of death in asthmatics.5,12, 13 There were 92 asthma-related deaths in Ireland in 1999.1 The risk of dying from asthma increases with age and asthma-related deaths is extremely rare in children. Patients at risk of death are those who have

severe asthma, are obese, have a history of non-compliance with therapy and have one or more adverse psychological factors such as: alcohol or drug use, employment or income problems, social isolation or current or recent tranquilliser use. ASTHMA AND PREGNANCY Medication used for asthma will not cause any problems for the developing baby in the womb. Due to the changes that take place in the body during pregnancy, asthma symptoms may change. For some women asthma improves, for others asthma worsens and, for others asthma stays the same. The most severe asthma symptoms experienced by pregnant women tend to occur between the 24th and 36th week of pregnancy. Symptoms then decrease significantly during the last month of pregnancy. Only 10% of women experience asthma symptoms during labour and delivery, and these symptoms can normally be controlled through the use of a reliever medicine. Asthmatics who are pregnant should manage their asthma in the same way as before pregnancy. The medicines used for asthma have been proven to be safe to take during pregnancy and when breastfeeding. The one exception is leukotriene receptor antagonists (Singulair®). There is no evidence that it can harm babies during pregnancy and breastfeeding. However there is insufficient evidence regarding its safety compared with other asthma medications. If leukotriene receptor antagonists are needed to control asthma during pregnancy, the GP or asthma clinic may recommend that they be continued. This is because the risks to the patient and child from uncontrolled asthma are far higher than any potential risk from this medicine. Theophyline is often avoided during pregnancy and breastfeeding because of reports of neonatal irritability and apnoea. REFERENCES 1. Brennan N, O’Connor T. Ireland needs healthier airways and lungs – the evidence (INHALE). June 2003 2. Stenius-Aaniala B, Pousa T, Kvarnstrom J, Gronlund EL et al. Immediate and long-term effects of weight reduction in obese people with asthma: randomised controlled study. BMJ 2000; 320: 827 3. Cochrane Review on House dust mite control. BMJ 1998; 317: 1105-10, Cochrane Database of Systemic Reviews. 2004 Oct 18; 4 4. Woodcock A, Forster L, Matthews E et al. Control of exposure to mite allergen and allergen-impermeable bed covers for adults with asthma NEJM 2003 Jul 17; 349 (3): 225-36 5. British Guideline on the Management of Asthma BTS, SIGN, Revised edition April 2004 www.sign.ac.uk (Guideline 63) 6. Spelman R Guidelines for the diagnosis and management of asthma in general practice ICGP 2003 (Jan) 7. Cates C Chronic Asthma – Extracts from “Clinical Evidence”. BMJ 2000; 323: 976-9 8. Hatoum HT, Schumock GT, Kendzierski DL. Metaanalysis of controlled trials of drug therapy in mild chronic asthma: the role of inhaled corticosteroids. Ann Pharmacotherapy 1994; 28: 1285-1289 9. O’Byrne PM, Barnes PJ, Rodriquez-Roisin R et al Low dose inhaled budesonide and formoterol in mild persistent asthma. American Journal Respiratory and Critical Care Medicine 2001; 164: 1392-97 10. Blais L, Ernst P, Boivin J-F, Suissa S. Inhaled

corticosteroids and the prevention of readmission to hospital for asthma. American Journal Respiratory and Critical Care Medicine 1998; 158: 126-32 11. Suissa S, Ernsst P, Benayoun S, Baltzan M et al. Low dose inhaled corticosteroids and the prevention of death from asthma. NEJM 2000; 343: 332-36 12. Bucknall CE, Slack R, Godley CC et al on behalf of SCIAD collaborators. Scottish Confidential Inquiry into Asthma Deaths (SCIAD), 1994-6. Thorax (BMJ) 1999; 54: 978-84. 13. Burr ML, Davies BH, Hoare A et al. A confidential inquiry into asthma deaths in Wales. Thorax (BMJ) 1999; 54: 985-89 14. www.asthmasociety.ie/all-about-asthma/AsthmaStatistics (accessed by E Brady in 2012) 15. Strachan DP (November 1989). Hay fever, hygiene, and household size. BMJ 299 (6710): 1259–60 16. Gibson PG, Henry RL, Shah S, Powell H, Wang H (September 2003). “Migration to a western country increases asthma symptoms but not eosinophilic airway inflammation”. Pediatric Pulmonology. 36 (3): 209–15 17. Shelley R. Salpeter; Nicholas S. Buckley; Thomas M. Ormiston; Edwin E. Salpeter. Meta-Analysis: Effect of Long-Acting Beta-Agonists on Severe Asthma; Exacerbations and Asthma-Related Deaths. Annals of Internal Medicine. Volume 144, No. 12. June 2006: 904-912 18. Advair Diskus, Advair HFA, Brovana, Foradil, Perforomist, Serevent Diskus, and Symbicort Information (Long Acting Beta Agonists). Post Market Drug Safety information for patients and providers. www.fda.gov. November 2005 19. Ducharme FM, Lasserson TJ, Cates CJ. Longacting beta2-agonists versus anti-leukotrienes as add-on therapy to inhaled corticosteroids for chronic asthma (Review). Cochrane Review. 2009 (Issue 3):1-107

Pfizer Healthcare Ireland are committed to supporting the continuous professional development of pharmacists in Ireland. We are delighted to be partnering with Irish Pharmacy News in order to succeed with this. Throughout the year, Irish Pharmacy News will deliver 12 separate modules of continuous professional development, across a wide range of therapy areas. These topics are chosen to support the more common interactions with pharmacy patients, and to optimise the patient experience with retail pharmacy. We began the 2011 programme with a section on the Gastrointestinal System. Other topics include Diabetes (Types I and II), the Cardiovascular System, Smoking Cessation, Infections, Parkinson’s Disease, Alzheimer’s Disease, Depression and others. We hope you will find value in all topics. Pfizer’s support of this programme is the latest element in a range of activities designed to benefit retail pharmacy. Other initiatives include the Multilingual Pharmacy Tool, a tailored Medical Communications Programme, Educational Meetings and Grants, our Patient Information Pack, new pharmacy Consultation Room brochures and other patient-assist programmes including the Quit with Help programme and www.mysterypain.ie. If you would like additional information on any of these pharmacy programmes, please contact Pfizer Healthcare Ireland on 01-4676500 and ask for the Established Products Business Unit. EPBU/2012/092/1

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Learning, Evaluation, Accredited, Readers, Network | www.learninpharmacy.ie


IPN • November 2012 37

News

DocMorris sale has no effect news brief on Irish pharmacies Retail sales continue to German pharmaceutical wholesaler Celesio has sold the DocMorris mailorder division to Swiss rival Zur Rose for ¤25 million – just 10% of the price that it paid for the unit in 2007. However, the managing director of DocMorris Ireland, Cormac Tobin, said that the sale of the mail-order division will not affect the DocMorris retail pharmacy chain in Ireland.

In 2009, Europe's highest court upheld a German law that only allows certified dispensing pharmacists to operate pharmacies within Germany. Currently, German pharmacists are permitted to own no more than four pharmacies and all of these must be located within a certain distance of each other. In addition, the government limits the profit margin pharmacists may earn.

“When Celesio announced its intention to sell the mail-order unit some months ago, the company said it wanted to concentrate on the wholesale side of the business, its wholesale customers and on retail pharmacy,” said Tobin. “We have known for quite a while that this sale was on the cards, but it makes no difference to us.”

Since the ruling, Celesio only used the DocMorris brand for its online mail-order business and to sell brand licences to individual pharmacists using a franchise marketing model. Its mail-order facility competed directly with traditional pharmacists, but offered products at lower prices. This business model did little to repair the relationship between the company and its German pharmacy customers.

Celesio said that the acquisition of DocMorris in 2007 created a constant state of conflict with the company's German pharmacy customers. “By selling (this division of) DocMorris, Celesio solves this conflict, thus paving the way for new partnership models for pharmacy customers,” said a company spokesman. The strained relations came about because Celesio bought DocMorris in the hope of developing a chain of drug outlets in Germany. However, pharmacists in that country were unhappy with the emergence of a new competitor and retaliated by cutting orders to Celesio’s wholesale arm.

Celesio said that the sale of the DocMorris mail-order division would trigger an impairment loss of about ¤30 million. However, the company said it still expected adjusted earnings before interest, tax, depreciation and amortisation for this year of at least ¤550 million. “It is business as usual for us in Ireland," said Tobin. "We are seeing continued growth and we now have 60 pharmacies, which have been re-branded under the DocMorris umbrella. Hopefully, there will be six more before Christmas. The latest pharmacy to be re-branded is in the Ballyfermot area of Dublin.”

experience aggressive declines

Retail sales continued to disappoint during the third quarter of 2012 according to Retail Excellence Ireland’s (REI) Irish Retail Industry Performance Review Q3 2012. According to recent statistics, Q3 has turned out to be the 14th consecutive quarter of sales decline in Ireland. In better news for the profession, pharmacy has been shown to have traded 'robustly' throughout the quarter. Speaking at the publication of the Q3 2012 retail figures, REI Chief Executive Officer, David Fitzsimons, said: “There were mixed fortunes experienced by different sectors in quarter three 2012. It is no surprise that non-discretionary sectors including Pharmacy, Grocery and Hot Beverage enjoyed a reasonable trading period, while the inclement summer weather negatively impacted on Ladies Fashion sales and Garden Centre activity. “Consumer electronics enjoyed a buoyant period helped for the most part by the digital switchover, while computing sales were hit with price deflation and purchase postponement. It is disappointing that the quarter gradually disimproved, primarily due to Budget 2013 speculation, indicating that a return to growth is less likely than first thought. Home dependent sectors including Furniture & Flooring and Home & Giftware continue to suffer due to the lack of a functioning residential property market. If matters do not significantly improve in the run-up to Christmas 2012, further failure is assured”. The worst performing sectors for Q3 included IT / Computing (down -19.90% on Q3 in 2011), Garden Centre (down -8.54% on Q3 in 2011) and Photo (Camera) (down -7.10% on Q3 in 2011). The best performing retail industry sectors included Consumer Electronics (Brown Goods) and Home Appliances (Small), both increasing sales levels in Q3 2012 compared with Q3 2011. September proved to be the most challenging month of the quarter, with sales falling by -1.48% year-on-year. Pre-budget speculation in September, which caused a decrease in consumer sentiment, is the main reason for this. The month of July saw an improvement, with Irish retailers reporting a decrease of only -0.07%.


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40 November 2012 • IPN

Diabetes

Diabetes diagnosis and management in the pharmacy diabetes) is an indicator that patients will develop full-blown type II diabetes if such lifestyles are not altered. The VHI Healthcare Screening Project tested 19,000 people aged from between 45-75 years for type II diabetes between 2009 and 2011 and found that 2,400 were either suffering from undiagnosed type II diabetes or prediabetes. Based on these figures, 1.38 million people within Ireland between the ages of 45 and 47 could have undetected type II diabetes and over 146,000 people could have undetected impaired glucose tolerance. GLUCOSE SCREENING Undoubtedly, pharmacy screening could play an important role in detecting diabetes, with many pharmacists already offering blood-glucose testing. Risk factors for developing type II diabetes include: • A body mass index of greater than 30 (this is the single greatest risk factor) James Cassidy, director, Healthwise Pharmacies: 'screening promotes community goodwill'

Diabetes is a chronic disease that occurs as type I or type II diabetes. Type I is an autoimmune disease characterised by the lack of insulin – the hormone that regulates blood glucose concentrations – production by the pancreas. Type II diabetes is a metabolic disorder in which there are two main biological defects: a deficient production of insulin and the reduced ability of the body to respond to the insulin being produced. Type I and type II diabetes are characterised by an increase in blood glucose concentrations (hyperglycemia). The incidence of type II diabetes is growing at an alarming rate, with nearly 348 million people worldwide living with the condition today. Over time, uncontrolled hyperglycaemia leads to macrovascular and microvascular complications. Macrovascular complications, which affect the large blood

vessels, include heart attack, stroke and peripheral vascular disease. Microvascular complications affect the small blood vessels of the eyes, kidney and nerves.

• Caucasian ethnicity (if aged over 40 years) or of South Asian, African Caribbean, Black African or Chinese descent (if aged over 25) • A waist measurement of over 37 inches for men and 31.5 inches for women

The current International Diabetes Federation report, ‘Diabetes: The Policy Puzzle – Is Europe Making Progress?’ estimates that there are 191,380 people with diabetes in Ireland – some 6.1 per cent of the population – and that by 2030, this will rise to well over quarter of a million people, some 7.5 per cent of the population.

• A family history of diabetes

Type I diabetes, which is generally diagnosed in childhood, accounts for approximately 14,000 of those suffering from diabetes in Ireland.

• Giving birth to a large baby (over 9lb)

Type II diabetes, which tends to develop later in life, as a result of largely controllable lifestyle factors is much more prevalent and is of particular concern to the health experts. Impaired glucose tolerance (pre-

• High blood pressure, heart disease or a previous heart attack or stroke • High cholesterol • High blood glucose in the past • Lack of exercise

• Lack of fruit and vegetables in the diet. Before screening for blood-glucose, it is advisable to ask the patient a few questions, based on the points above and it is also advisable to take the patient's blood pressure. Depending on the results, the patient


42 November 2012 • IPN

Diabetes may be asked to return to the pharmacy for a fasting blood-glucose test, which involves taking a sample of blood on an empty stomach. If the glucose levels are only slightly raised, the pharmacist can recommend ways to reduce the possibility of diabetes developing in the patient. If the test indicates that the patient already has diabetes, they should be referred to their doctor. OTHER PRODUCTS AND SERVICES Patients who are diagnosed with diabetes will find it particularly useful to receive ongoing diet and lifestyle advice from their pharmacist, as well as advice regarding their medications. As type II diabetes generally affects people the older they become, it is common for patients to have concomitant health conditions. A private consultation with the pharmacist can help them to manage their different conditions and medications. Patients could also be tested for cholesterol testing at the same time. Weight management programmes can also be discussed, where applicable. There is a plethora of products and vitamins that can be recommended in order to maintain the day-to-day well-being of GROUP SCREENING PROGRAMMES The Healthwise Pharmacy Group offers diabetes testing to its patients in its thirteen pharmacies in counties Donegal, Galway and Sligo. James Cassidy, director said, “We started screening five years ago in response to the growing number of people with diabetes – more specifically, because of those who were not aware that they were at risk. “Initially, we ran the programmes in conjunction with the Diabetes Federation of Ireland. Anna Clarke, the Federation’s

INDEPENDENT PHARMACY Independent pharmacies have also spotted the potential benefits of offering diabetes-related services to their patients. Pharmacist Michael Collins is set to introduce blood-glucose testing in his pharmacy in Wicklow town. “Many of our existing customers have diabetes and a member within my family has recently been diagnosed, so it has really emphasised how prevalent the

sufferers. Vitamins B1, B6 and C are known to help stabilise glucose metabolism. Sufferers should also be encouraged to check their condition at home, using bloodglucose monitors and test strips. Medical alert bracelets should be worn in the case of an accident or hypoglycaemic episode and insulated wallets can help to keep insulin pens cool. One side-effect of uncontrolled diabetes is circulation problems, so foot-care accessories and creams should be part of patients’ foot-care regime. Blood-pressure monitors, scales, body-fat monitors and weight-loss aids can all help to keep hypertension and body weight under control and could be offered to patients to carry out checks at home. Where applicable, sufferers should also be encouraged to stop smoking and keep their weight down. EVIDENCE FOR PHARMACIST INTERVENTION A study published last year in the Journal of Diabetology showed that pharmacist intervention in type II diabetes patients was successful in leading to reductions in mortality, morbidity and treatment costs.

Cork identified 23 published studies that demonstrated the effect of pharmacist intervention on HbA1c, which measures a patient’s glucose readings over the longer term. In all cases, it was reported that pharmacist intervention was successful in reducing HbA1c in patients with type II diabetes. The minimum reduction obtained was 0.5 per cent, with a maximum reduction of 3.4 per cent. Pharmacist intervention also proved successful in improving patients’ lipid profiles, cardiovascular outcomes, body mass index and other complications associated with type II diabetes. The researchers also reported that there were economic advantages associated with pharmacist management. Pharmacists can play an important role in diagnosing diabetes, as well as providing ongoing support and advice for patients because GPs are under growing pressure, due to the HSE policy of transferring chronic disease management from secondary to primary care. Pharmacy diagnosis and management of diabetes can free up GPs’ time at the same time as offering the community a valuable added service.

Researchers from University College health promotion and research manager, visited our pharmacies during our screening days so that existing patients were able to talk to her about their diabetes management. In addition, we offered blood-glucose testing for anyone who wanted the test. We created a lot of community goodwill, with many people popping in to take advantage of what we had on offer. “We will test anyone on any day, on demand if they want a glucose test but we host the specific Diabetes Days to encourage more people to take the initiative to be tested. The Donegal

condition is – and how many people are walking around without knowing that they have diabetes,” said Collins. “Many of the pharmacy chains offer glucose testing as part of their point-of-care screening, so we feel that, as an independent pharmacy we can offer the same service with an extra, personalised touch.” He said that his pharmacy already hosts ‘dietitian days’ and iron-deficiency testing, which generates extra footfall and he

Diabetes Association also refers some of its members to us and, consequently, we become part of the patient's health management team." Healthwise Pharmacies also offer diabetes screening to patients with hypertension or those who are taking part in their weightmanagement programmes. “We regularly pick up the condition in these patients," said Cassidy. "Of course, we also offer ongoing advice to patients, who have already been diagnosed. Helping patients to manage their own health not only benefits the person, it also helps to engender customer loyalty.”

anticipated that diabetes awareness days would prove even more successful. “We recently re-vamped the pharmacy and now have bigger consultation rooms, so we want to make the most of this,” Collins continued. “We are currently talking to the suppliers of diabetes equipment to obtain the various testing equipment that we will need and we intend to speak to local healthcare professionals as well to invite them to take part in our screening service.”


IPN • November 2012 43

News

Bantry Hospice benefits from local fundraising drive Gurtycloona Community Alert recently presented a cheque of ¤500 to Pat Morrissey of the Bantry Hospice Group, which was greatly appreciated. Sean Kelly of Gurtycloona Community Alert, which celebrates its 20th birthday this year, explained that the group wanted to give something back to its local community in West Cork. “We recently had a church-gate collection to raise money for our Community Alert group, which works to improve safety and crime prevention in the community of Gurtycloona,” he said. “The response was so generous that we decided to also make a contribution to the Bantry Hospice Group.” He said that the Rowa Group were very involved with fundraising efforts for the hospice, which comes under the aegis of Bantry General Hospital.

Pictured at the presentation of the cheque are (from left to right): Mary Hegarty, Bantry Hospice Group; Denis Minehane, Gurtycloona Community Alert; Bill Cashmen, Gurtycloona Community Alert; Joe Keane, Bantry Hospice Group; Sean Kelly, Gurtycloona Community Alert; and Pat Morrissey, Brigitte Wagner-Halswick, Eugene Cronin and Kevin O’Donovan from the Bantry Hospice Project.


44 November 2012 • IPN

News news brief Bayer welcomes Liam Condon Ireland's Liam Condon has been appointed Chairman of the Executive Committee of the Bayer CropScience subgroup and Chairman of the Board of Management of Bayer CropScience effective December 1, 2012. The decision was made by the Supervisory Board of Bayer CropScience. He succeeds Sandra E. Peterson, who is leaving the company on November 30. Condon has been Managing Director of Bayer Vital GmbH, Leverkusen, and head of Bayer Pharma's business in Germany since January 2010. Bayer Vital is the business operations company for the Bayer HealthCare subgroup in Germany.

Charity launches in memory of pharmacist Brain Tumour Ireland (The Ronnie Fehily Foundation) is a new Irish charity launching during International Brain Tumour Awareness Week (28th Oct-3rd Nov), in memory of Ronnie Fehily, an otherwise healthy and active pharmacist and mum of four, who died of a brain tumour in January 2012. Speaking at the launch, Ronnie’s son and spokesperson for Brain Tumour Ireland, Simon Roche said: “Brain Tumour Ireland (The Ronnie Fehily Foundation) is a new Irish charity being launched this week in memory of my mother, Ronnie Fehily who sadly passed away in January of this year as

"Liam Condon is a highly successful and experienced manager with proven expertise in marketing and sales, who has demonstrated his leadership skills internationally over a 20-year period. We are convinced of his ability to continue the dynamic development of Bayer CropScience," said Bayer Group CEO Dr. Marijn Dekkers. Liam Condon was born in Dublin and studied International Business in Dublin and - as a scholarship holder of the German Academic Exchange Service (DAAD) - at the Technical University of Berlin. He holds a B.A. degree in International Marketing & Languages from Dublin City University and an MBA from the Japan Management Association.

a result of a brain tumour. During her short illness, we found that aside from the excellent medical care she received, there was very little information or support available in Ireland for brain tumour patients and their loved ones.

The late Ronnie Fehily

“Brain Tumour Ireland aims to raise awareness of brain tumours in Ireland, a subject not often talked about. There is a perception that it is a rare disease but unfortunately the most recent figures from the National Cancer Registry show a yearly average of 372 brain tumour cases. Putting their heads together for brain tumour awareness- Ryan Tubridy with Sandra Doyle and Simon Roche of Brain Tumour Ireland. Sandra is the sister and Simon the son of Ronnie Fehily in whose memory the charity has been set up.

“With our accompanying website www. braintumourireland.com we also aim to provide information and support to brain tumour patients and families, and in the long term, we will fundraise for medical research on brain tumours.”

CEO opens Clonmel pharmacy

Patrick McCormack, CEO of Sam McCauley Pharmacies (fifth from left) and Ireland/Leinster rugby player Rob Kearney (centre) opened a new Sam McCauley pharmacy recently. Also pictured are the staff of the new pharmacy, which is located in Clonmel's Showgrounds Shopping Centre.


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46 November 2012 • IPN

News news brief A time of great challenge “This is a time of great challenge for all stakeholders involved in healthcare delivery, not least the research-based pharmaceutical industry,” said Francis Lynch. “As an industry, we fully recognise that we have a central role to play in assisting the State in containing the cost of medicines while, at the same time our commitment to meeting the needs of patients is unequivocal.” These are the words of Francis Lynch, newly appointed President of The Irish Pharmaceutical Healthcare Association. Francis Lynch, general manager of A. Menarini Pharmaceuticals Ireland Ltd, has been elected as president for a term of two years. He succeeds David Gallagher of Pfizer Healthcare Ireland. Lynch joined Menarini Pharmaceuticals in 1999 after working for Abbott Laboratories Ireland Ltd, first as pharmaceutical products division manager and latterly as sales manager of the hospital product division/pharmaceutical product division. He is a graduate of Trinity College Dublin, from where he earned a BSc Management Degree and a Diploma in Law. Dr Leisha Daly, country director of Janssen, has been appointed as IPHA vice president. Dr Daly has been a member of the Association’s Board of Directors since June of this year and was reappointed to the Prescription Medicines Division Strategy Board in August.

Drontal Window Display competition attracts almost 70 entries Almost 70 pharmacists from across the country entered this year’s Drontal Pharmacy Window Display competition, which was sponsored by Bayer Ltd. “We never expected to receive such a huge amount of entries,” said Philip Bergin of Bayer’s Animal Health Division. “Pharmacists had to design and implement a window display featuring Drontal products, along with photographs of local pet owners who had submitted photos of themselves with their pets to the pharmacy. The photos had to sow how owners and pets hjelp to keep each other happy and healthy." Bayer provided 1,500 in prize money for the best individual photo. For the second competition, which was for the best pharmacy window display, Uniphar sponsored the prize of 250. From the many entries received, an independent judge selected a picture of Valerie Claxton from Portlaoise and her dog Lucy as the Drontal Photo Competition winner.

Window Display competition was Brendan Loftus Pharmacy in Bunclody, Co. Wexford. “The displays have also been a great way of attracting business into pharmacies," Bergin continued. "They have made people aware that they can buy many pet-health supplies, such as worming tablets, from pharmacies and that pharmacists are an excellent source of information about pet health. “Devoting a few square feet of a pharmacy to pet health can generate significant extra income, because the pharmacy is not competing with supermarkets and grocery stores for this business – unlike with toiletries and cosmetics.” Bergin concluded that the Drontal Window Display competition had been such a success that Bayer Ltd hopes to expand it next year. Bayer Animal Health is committed to supporting pharmacies that are interested in developing an Animal Health section. Please contact Sinead Boyle at (01) 299 9313 or sinead.boyle@bayer.com for further information and/or promotional material.

The winner of the best Drontal Pharmacy

Diary date The ‘RCSI Innovations' expo will run from 2pm to 5pm on Monday, 12th November, in the Exam Hall, RCSI and will feature demonstrations from leading experts from our Schools of Pharmacy and Physiotherapy; as well as from the Departments of Surgery, Anatomy and Physiology & Medical Physics. There will also be an opportunity to simulate surgical procedures, and discover more about health research. This exhibition will be educational for students that are interested in science, health, medicine and research. The RCSI Innovations exhibition is part of the Dublin City of Science 2012. Valerie Claxton from Portlaoise and her dog Lucy were the Drontal Photo Competition winners.


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48 November 2012 • IPN

News news brief Locums and pharmacist recruitment agency opens Clare branch

Boots Ireland offers faster payment options

Pharmaconex, the first employment agency in Ireland for locums and pharmacists, has opened a new centre in Westpark Business Campus, Shannon, Co Clare. Nicola Ryan heads up the new branch and is responsible for placing locums and full-time pharmacists. “We decided to establish an operations centre in Shannon to cater for pharmacists in the Munster and Connaught regions,” said Paolo Iacovelli, Pharmaconex managing director. “We had a busy summer and then September broke all records for us. We now have approximately 1,200 live locum pharmacists registered on our database.” Ryan has worked in recruitment since 2010 and has extensive experience as a pharmacist locum co-ordinator and as a recruiter for full-time roles. She comes from the locality and knows the Munster/ Connaught region well. “Locums or employers can arrange to meet Nicola in Shannon to discuss their requirements or they can contact her by phone or email," said Iacovelli. “We are extremely happy with the progress that the company has made so far and we anticipate further expansion in other parts of Ireland in the near future,” he added. Pharmaconex’s Shannon division can be contacted at (061) 530202 or email: nicola@pharmaconex.com

Nicola Ryan heads Pharmaconex's Shannon operations.

Debbie Smith, managing director of Boots Ireland. Boots customers in Ireland can now pay for any purchases costing under ¤15 by touching their Visa Debit card under their point-of-sale terminal, without using their PIN number. This contactless payment option has been launched in partnership with Streamline, a provider of merchant accounts for credit card services, and Visa Europe and will reduce the waiting times at the point-of-sale terminals and cash points. In April, Visa Europe reported that Irish customers spend 11.2 million minutes queuing daily to pay for lowvalue purchases.

Boots Ireland also claims that it offers customers a convenient and more secure way to pay by reducing the need to go to ATMs or carry cash.

Jentadueto now available for type II diabetes

and either 850mg or 1,000mg of metformin hydrochloride and it is taken twice daily.

Jentadueto, a tablet that combines two antihyperglycaemic medicinal products with complementary mechanisms of action to improve glycaemic control in type II diabetes, is now available in Ireland.

It is also licensed for those already being treated with the combination of linagliptin and metformin – and in triple therapy in combination with a sulphonylurea – as an adjunct to diet and exercise in adult patients inadequately controlled on their maximal tolerated dose of metformin and a sulphonylurea.

Jentadueto contains 2.5mg of linagliptin

“Our aim is to offer customers a great shopping experience with quick, easy ways to pay and we believe that contactless payment is one way to deliver this,” said Boots Ireland managing director, Debbie Smith. “We know that our customers want us to offer an unrivalled choice of services and products and we hope they will enjoy the benefits of using contactless technology in our store.”

Jentadueto is indicated in the treatment of adult patients with type II diabetes. It is licensed for use in dual therapy as an adjunct to diet and exercise to improve glycaemic control in adult patients whose diabetes is inadequately controlled on their maximal tolerated dose of metformin alone.


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OF GORD Choose NEPRAMEL to help heal and soothe the symptoms of GORD ABBREVIATED PRESCRIBING INFORMATION Nepramel 20 and 40 mg gastro-resistant capsules, hard Nepramel 20 mg Capsules: Each capsule contains 20 mg of esomeprazole (as magnesium dihydrate). Nepramel 40 mg Capsules: Each capsule contains 40 mg of esomeprazole (as magnesium dihydrate). Presentation: Nepramel 20 mg Capsules: Capsule with an opaque yellow cap and an opaque white body imprinted in black with “20 mg”. Nepramel 40 mg Capsules: Capsule with an opaque yellow cap and an opaque yellow body imprinted in black with “40 mg”. Indications: Gastro-oesophageal Reflux Disease (GORD): treatment of erosive reflux oesophagitis, long-term management of patients with healed oesophagitis to prevent relapse, symptomatic treatment of GORD. In combination with appropriate antibacterial therapeutic regimens for the eradication of Helicobacter pylori, healing of H. pylori associated duodenal ulcer and prevention of relapse of peptic ulcers in patients with H. pylori associated ulcers. Patients requiring continued NSAID therapy: healing of gastric ulcers associated with NSAID therapy, prevention of gastric and duodenal ulcers associated with NSAID therapy, in patients at risk. Prolonged treatment after i.v. induced prevention of rebleeding of peptic ulcers. Treatment of Zollinger Ellison Syndrome. Dosage: The capsules should be swallowed whole with liquid. The capsules should not be chewed or crushed. Adults and adolescents from the age of 12 years: Gastro-oesophageal Reflux Disease (GORD): Treatment of erosive reflux oesophagitis: 40 mg once daily for 4 weeks. An additional 4 weeks treatment is recommended for patients in whom oesophagitis has not healed or who have persistent symptoms. Long-term management of patients with healed oesophagitis to prevent relapse: 20 mg once daily. Symptomatic treatment of gastro-oesophageal reflux disease (GORD): 20 mg once daily in patients without oesophagitis. If symptom control has not been achieved after 4 weeks, the patient should be further investigated. Once symptoms have resolved, subsequent symptom control can be achieved using 20 mg once daily. Please refer to Summary of Product Characteristics. Children below the age of 12 years: Not recommended. Impaired renal function: Dose adjustment is not required in patients with impaired renal function. Treat patients with severe renal insufficiency with caution. Impaired hepatic function: Dose adjustment is not required in patients with mild to moderate liver impairment. For patients with severe liver impairment, a maximum dose of 20 mg should not be exceeded. Elderly: Dose adjustment is not required. Contraindications: Known hypersensitivity to esomeprazole, substituted benzimidazoles or any other constituents of the formulation. Esomeprazole should not be used concomitantly with nelfinavir. Warnings and precautions: In the presence of any alarm symptom (e.g. significant unintentional weight loss, recurrent vomiting, dysphagia, haematemesis or melaena) and when gastric ulcer is suspected or present, malignancy should be excluded. Patients on longterm treatment should be kept under regular surveillance. Patients on on-demand treatment should be instructed to contact their physician if their symptoms change in character. When prescribing esomeprazole for eradication of Helicobacter pylori possible drug interactions for all components in the triple therapy should be considered. Contains sucrose. Patients with rare hereditary problems of fructose intolerance, glucose-galactose malabsorption or sucrase-isomaltase insufficiency should not take this medicine. Contains parahydroxybenzoates, which may cause allergic reactions (possibly delayed). Treatment with proton pump inhibitors may lead to slightly increased risk of gastrointestinal infections. Esomeprazole is a CYPRC19 inhibitor; the potential for interactions with drugs metabolised through CYP2C19 should be considered concomitant use of esomeprazole and clopidogrel should be discouraged. Esomeprazole should be stopped for at least 5 days before CgA measurements. Esomeprazole may reduce absorption of vitamin B12. Interactions: Esomeprazole is metabolised by CYP2C19 and CYP3A4 and inhibits CYP2C19. Ketoconazole, itraconazole, atazanavir, nelfinavir, saquinavir, diazepam, citalopram, imipramine, clomipramine, phenytoin, voriconazole, cisapride, warfarin, clarithromycin, St. John’s Wort, rifampicin. Pregnancy and lactation: For esomeprazole clinical data on exposed pregnancies are insufficient. Caution should be exercised when prescribing to pregnant women. Nepramel should not be used during breast-feeding. Undesirable effects: Headache, abdominal pain, constipation, diarrhoea, flatulence, nausea/vomiting, peripheral oedema, insomnia, dizziness, paraesthesia, somnolence, vertigo, dry mouth, increased liver enzymes, dermatitis, pruritis, rash, urticaria. Refer to Summary of Product Characteristics for other adverse effects. Pack size: 28 capsules. Marketing authorisation holder: Clonmel Healthcare Ltd., Clonmel, Co. Tipperary. Marketing authorisation number: PA 126/208/1-2. Full prescribing information is available on request, or go to www.clonmel-health.ie. Medicinal product subject to medical prescription. Date last revised: March 2012. Ref 1: Nepramel Summary of Product Characteristics 2012/ADV/ESO/077

Nepramel is indicated for Gastro-oesophageal Reflux Disease (GORD) Nepramel is indicated in combination with appropriate antibacterial therapeutic regimens for the eradication of Helicobacter pylori. Nepramel is also indicated for patients requiring continued NSAID therapy1

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50 November 2012 • IPN

Gastroenterology

Over-the-counter digestive remedies The Christmas party season is about to kick off again, which means late nights, over-indulgence and rich food, all washed down by plenty of alcohol. It is little wonder that some normal digestive rhythms become disrupted, with some patients experiencing uncomfortable symptoms, such as bloating, indigestion and stomach cramps. The good news for patients and for pharmacy businesses, however is that a wide range of products are available to help address these problems and that many of these can be bought over the counter. INDIGESTION Indigestion is a common problem among patients presenting to the pharmacy, especially at this time of the year. Symptoms include stomach ache,

heartburn, nausea, belching and bloating. Antacids can be used to reduce acid in the stomach because they work by neutralising the acid, with the result that it no longer irritates the mucosa of the digestive system. Antacids are available in tablet and liquid form. Acid suppressants can stop the stomach from forming too much acid in the first place, while alginate gum builds a protective barrier on top of the stomach, stopping stomach acid from flowing back up the oesophagus. Preparations with calcium and magnesium help to relieve trapped wind and ease discomfort. Patients can help to prevent this type of indigestion by avoiding too much rich and spicy food, drinking too much alcohol and eating late at night. Peppermint-oil capsules can also be helpful but should never be taken at the same time of day as indigestion remedies, as the peppermint can prevent the indigestion treatments from working properly. If the patient has severe or recurring indigestion, treatment with antacids and alginates may not be sufficiently effective to control symptoms. If this is the case, proton pump inhibitors (PPIs) may be the answer. Like antacids, PPIs affect the acid in the stomach. However, rather than neutralising the acid, they inhibit the acid production in the stomach. Some types of PPIs can be bought over the counter by patients over the age of 18 years, such as pantoprazole. CONSTIPATION Constipation – infrequent bowel movements or hard, dry stools – can be treated with a fibre substitute to bulk up the diet. If the patient is still having problems after increasing their fibre

intake, drinking more water and taking exercise is to be recommended. If this does not work, laxatives can also be taken to move things along. These work in three ways. Bulk-forming laxatives are the first line of treatment. They help to make stools denser and softer, which means that they should be easier to pass. Commonly used bulk-forming laxatives include ispaghula husk, methylcellulose and sterculia. Osmotic laxatives increase the amount of fluid in the patient’s bowels. This helps to stimulate the body to pass and soften stools. Osmotic laxatives include lactulose and macrogols. Stimulant laxatives stimulate the muscles that line the digestive tract, helping them to move stools and waste products along. These laxatives include senna, bisacodyl and sodium picosulphate. They are usually only used on a shortterm basis and will normally start to work within six to 12 hours. No matter which type of laxative is used, the pharmacist should encourage patients to increase the amount of fibre in their diet, drink more fluid and take regular exercise. DIARRHOEA Diarrhoea is characterised by loose or watery bowel movements, which occur more than three times a day and which are usually accompanied by stomach cramps. A common cause in both children and adults is gastroenteritis, an infection of the bowel. Bouts of diarrhoea in adults may also be brought on by anxiety or drinking too much coffee or alcohol. Diarrhoea may also be a side effect of medications such as antibiotics, antacid medicines that contain magnesium, non-steroidal antiinflammatory drugs, selective serotonin reuptake inhibitors or statins.


IPN • November 2012 51

Gastroenterology In adults, diarrhoea usually clears up within two-to-four days. It can be managed with loperamide tablets to stop the diarrhoea, hyoscine butylbromide for the intestinal cramps and oral rehydration powders (mixed with water and taken as a drink) to replace lost fluids and minerals. Pharmacists should advise patients to drink a lot of fluids. If diarrhoea continues for more than a few weeks or if stools are bloody, the patient should be advised to see their doctor. IRRITABLE BOWEL SYNDROME Irritable bowel syndrome (IBS) is quite common, with as many as one in five people thought to be affected. It is twice as common in women as it is in men and it usually occurs in people in their 20s and 30s. IBS is an upset in the natural rhythm of the bowel. Symptoms can vary from person to person but the most common are alternating constipation and diarrhoea, abdominal pain or discomfort, bloating and wind. Other bowel symptoms include passing mucus, urgency, feeling relief from abdominal discomfort after going to the lavatory, a change in the frequency of bowel motions (either more or less often than usual) and a change in stool appearance. Symptoms are usually worse after eating. IBS can be difficult to treat and patients may need the pharmacist's advice to tackle alternating symptoms. The good news is that a number of different medications are available to help treat IBS. These are: 1) antispasmodic medicines, which help to reduce abdominal pain and cramping 2) laxatives, which help to treat the symptoms of constipation 3) antimotility medicines, which help to treat the symptoms of diarrhoea 4) antidepressants, which were originally designed to treat depression but can also reduce abdominal pain and cramping 5) capsules containing peppermint oil to help soothe the lining of the bowel Some people find that taking probiotics regularly can help to relieve the symptoms of IBS and other stomach upsets. Probiotics are dietary supplements that contain ‘friendly bacteria’ and may need to be taken for several weeks before they

have any beneficial effect. They can also help after a patient has taken a course of antibiotics, during which important gut flora can be lost.

consumer spending, meaning less frequent visits to the doctor. However, it is also due to a general increased awareness in health and wellness.

According to Euromonitor International, specialists in strategy research for consumer markets, the digestive remedies sector in Ireland is expected to achieve a compound annual growth rate of 1 per cent over its forecast period to 2016. Selfmedication is expected to continue to increase over the forecast period. This is due to the ongoing recession and reduced

Meeting the needs of patients with digestive problems, particularly in the run-up to the Christmas season and into the New Year offers pharmacists the opportunity to alleviate their customers’ ‘tummy troubles’, while also potentially saving them from an expensive visit to the doctor.


52 November 2012 • IPN

News

IPU issues pre-budget submission A much greater range of medicines should be available without prescription from pharmacists, a move that would reduce cost burdens on primary and secondary healthcare systems while bringing health, social and economic benefits to all, the Irish Pharmacy Union (IPU) has stated. In its pre-budget submission 2013, the IPU once again called on the Government to expand their role in the delivery of a reformed primary healthcare system resulting in improved outcomes for patients and significant savings to the Exchequer. Encouraging responsible self-care and appropriate self-medication and further expanding the professional role of the pharmacist should be explicit objectives of public health policy going forward, pharmacists say. “More should be done to empower patients to take care of their own health in a safe, convenient and cost-effective manner. This would entail making a much greater range of medicines available without prescription from pharmacists – particularly those medicines with long-established safety profiles, many of which are available without prescription in other jurisdictions”, IPU President Rory O’Donnell stated. Mr O’Donnell said Ireland should be looking at the partnership model in the UK, which has shown the possibilities for expanding self-medication through a change in the method of supply of some medicines from prescription-only to pharmacy-only. “A study in the UK has shown that GPtreated ailments that could have been

self-treated cost the NHS £2 billion every year. This shows the type of savings that could be generated in Ireland if we moved more towards a pharmacy-based system rather than an over-reliance on a GP-based system”, he stated. In its pre-budget submission the IPU emphasised that significant savings could also be made if pharmacists were to become more active in chronic disease management and health screening. The introduction of structured Medicine Use Reviews, particularly for patients on complex medicine regimes would enhance patients’ health outcomes and generate savings in the long term. “These are specific next steps for community pharmacy”, Mr O’Donnell said. In a recent IPU survey 91% of pharmacists said that the levels of general healthcare reliance on their service has

grown as a result of the recession. The IPU also highlighted the urgent need for the Government to address the costs on business that come under its direct control. In addition to draconian rents, Mr O’Donnell said that pharmacists are particularly concerned about exorbitant local charges, commercial rates and excessive energy costs, which are having a devastating effect on the viability of pharmacies throughout the country. “In the past ten years rates have increased by a massive 47%, well in excess of inflation. Despite the substantial drop in retail sales for pharmacies, a 6% decrease last year, this has not been reflected in a corresponding reduction in rates which are strangling pharmacists. We are calling on the Government to implement a fairer system based on the ability of a small business to pay.” The regulatory environment and in particular the excessive fees paid to the Pharmacy Regulator, was also highlighted as an area that needed immediate attention. The cost of registering a pharmacy with the Pharmaceutical Society of Ireland (PSI) is eight times higher than the registration fee in the UK. “This year’s Budget needs to recognise the significant role that pharmacists have to play in contributing to an effective and efficient healthcare system that can bring significant savings to the State, during these turbulent economic times. The costs and other burdens that are imposed on retail pharmacy businesses together with the burdensome regulatory environment are key issues that need to be urgently addressed to secure the future of this highly important sector”, concluded O’Donnell.


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54 November 2012 • IPN

Report

Helping Patients to Help Themselves learn to delegate and as a result, it is to be hoped that GPs will learn to delegate to other primary care professionals, such as pharmacists or nurses,” Prof Bradley continued. “Primary care professionals, in turn, will have to learn to delegate to patients. Everybody needs to learn the art of safe delegation.” Although many modern medicines have wide safety margins, all medicines carry risks if not used properly. The key to safe use is adequate, accessible and accurate information. Patients need to be educated about balancing the benefits and the side effects and must be made aware of any side effects and how to respond to them. But, it would seem that many patients in Ireland are ready to take on this greater responsibility. ATTITUDES TO SELF CARE

Prof Colin Bradley Healthcare in Ireland is changing. There is an ageing population yet medical advances are such that people are living longer, with the result that they often need more care. The current health model, which focuses on secondary care, is struggling with this demographic change and the associated economic consequences. The country needs to foster self-care and pharmacy should be in the forefront, helping and advising patients. “Patients who are empowered to manage their own illnesses are less reliant on health professionals,” said Prof Colin Bradley, Professor of General Practice in University College Cork, at the recent launch of SelfCare First, a national framework policy document for patient self-management (see October issue of IPN). Diabetes was formerly a hospital-only disease but its prevalence is now beyond the capacity of the traditional hospital model. Type II diabetes can usually be managed through the GP surgery or through the patient's local pharmacist. Patients with diabetes will need to do more for themselves, such as monitoring their own blood glucose levels and making dietary and insulin adjustments. "Healthcare specialists will also have to

A survey called Self-Medication & Self-Care: A Multi-Country Study Exploring Consumer Attitudes & Behaviours revealed that 90% of those surveyed had experienced a minor ailment of some kind every month. Well over half of those surveyed also said that more medicines should be available OTC (compared to a European average of 31%) and eight out of ten were open to learning more about their own healthcare from doctors, pharmacists and health campaigns. The results showed that Irish consumers are open to improved availability of medicines and that healthcare engagement initiatives would be well received. However, better collaboration between industry, healthcare professional (HCP) bodies and Government agencies is required to unlock self-care opportunities. Of course, HCPs play a vital role in the process. The study revealed that HCPs are the most trusted sources of information – in fact, 44% of respondents wanted more advice from their pharmacist, compared to 31% of respondents across Western Europe. Ireland was one of only three countries (the others being Switzerland and France) where the pharmacist was seen as an equal or preferred source of information to doctors. Industry has a complementary role to play through brand campaigns, patient information leaflets and disease-awareness campaigns. Technology will also continue to affect healthcare provision, with Irish patients expecting similar services and medications to those available in other countries. To drive self-care initiatives, consistent

messages must be delivered by all stakeholders, such as Government bodies, industry, patient organisations and professional bodies. Major campaigns should target important healthcare issues, such as smoking cessation and obesity but education can only go so far towards helping patients to help themselves. Access to appropriate medicines should also be improved through switching prescription drugs to OTC. MORE OTC MEDICINES? Increasing the range of availability of prescription only medicines available to patients would help to improve access to the health and social benefits of selfmedication. Switching some POMs to Ps would help patients to feel better quickly, safely and inexpensively. There are also significant economic benefits to switching. The Association of the European Self-Medication Industry, in a study entitled Economic and Public Health Value of Self-Medication, identified that a shift of 5% of prescribed items to self-medication would result in annual total savings to the public funds and to the national economies of Europe of over ¤16.5 billion. This is equivalent to ¤75 million for Ireland every year. The savings would arise, for example, from reducing absenteeism and its attendant costs and by reducing the unnecessary utilisation of doctors’ time dealing with minor ailments. Another study called The Value of OTC Medicines in the United States found that each dollar spent on OTC medicines saves $6-7 for the US healthcare system. The non-profit Swedish Institute for Health Economics also estimated that switching prescription medicines to non-prescription could result in a 15-24% decrease in medical visits and a potential drop in prescriptions of between 6% and 70% (depending on the scale of the switch). Recent successful switches in Ireland include Curanail, Pantoprazole and Norlevo but there is scope for a greater range of medicines to be switched and dispensed under pharmacist supervision. Ireland still lags behind some other European countries in the number of medicines that have been switched but, so far, the onus on switching brands from POM to P has been on the pharmaceutical industry to propose which products should be considered. In countries such as the UK, Governments have taken a more pro-active approach


One-third of French Pharmacies offer lab services Many people visit their local pharmacy to gauge if their symptoms can be helped without medical care. As a PrePrimary-Care Centre the pharmacy boasts free entry, motivated personnel and low to no waiting times. Google but interactive. Peter Conry MPSI of Nutricentric Healthcare spent two decades in mainland Europe and the Far East. He witnessed how regional differences in diet led to different health complaints. And how the spread of the Western diet soon leads to Western complaints like prostate cancer or myocardial infarction. Back in Ireland, the Western Diet itself has not stood still. Our people are showing the accelerated effects of convenience-food lifestyles, creeping sweetening of foods and misleading labelling (‘0% Fat!’). Despite an unprecedented rise in associated illnesses, the medical and pharmaceutical colleges still largely ignore nutrition and exercise. Nutritional and exercise therapists exist, but finding the right people at the right time is often a matter of luck. Based on his work with patients on diet and lifestyle, Peter began using diagnostic tests to guide the patients’ efforts, also working closely with nutritional therapists. Over time, this developed into Nutricentric Healthcare. The aim is to provide proper diagnostic testing with minimal or no hardware investment and reasonable prices. In France, the provision of laboratory services does not cause a turf war with the medical system. In Ireland, there is an unmet need for more pre-primary care. ‘I don’t see diagnosis as an end in itself’ says Conry. ‘Where possible, the patient should be given a result and something to work with”. There are many proven interventions involving nutritional supplements, improved diet and exercise. Where appropriate, the pharmacy can also refer patients to qualified nutritional therapists, physical therapists, diet and exercise coaches and other appropriately qualified health providers for specific, tailored care. “The patient’s willingness to work hard to maintain health is often underestimated”. Nutricentric has a range of easy-to-learn diagnostic tools. They cover fields as diverse as food intolerance, inhaled allergy, coeliac and lactose intolerance testing, screening for hypothyroidism or Prostate Specific Antigen as well as more accurate bone density scanning. In many cases, there are protocols that patients with mild symptoms can try before recourse to prescription medication – for example the combination of Vitamin D and weight-bearing exercise in milder osteopoenia.

‘Many pharmacies have dabbled in blood glucose, cholesterol testing, or vaccination, so fingerprick blood sampling is not a problem. There is a chance to help patients and there is great satisfaction in helping steer them onto the right path’. Nutricentric Healthcare can be contacted by e-mailing Peter on peter@nutricentric.com or by sending a query to info@nutricentric.com

Nutricentric Healthcare, Enniskerry, Co. Wicklow

Nutricentric has developed a non-electronic simple Pop-Up Lab system for blood-testing.

FOOD INTOLERANCE 40-minute ELISA test for elevated IgG antibodies against over 50 Food Detective Professional foods. COELIAC DISEASE 5-minute screening test to detect the anti-tissue transglutaminase Xeliac Pro (tTG) antibodies (IgA & IgG) LACTOSE INTOLERANCE Saliva DNA test (post to lab) testing for European gene governing FOOD 40-minute ELISA test for elevated IgG antibodies against over Lactose Intolerance DNA testINTOLERANCE lactose tolerance Food Detective Professional foods. RESPIRATORY ALLERGY 30-minute test to detect IgE antibodies against the top 10 inhaled COELIAC DISEASE 5-minute screening test to detect the anti-tissue transglutam ImmunoCAP rapid (adult/child) allergens in Europe (incl dust mite, pets, pollens) Xeliac Pro High-sensitivity C-Reactive (tTG)Protein antibodies (IgA &sensitive IgG) INFLAMMATION is a more marker for LACTOSE INTOLERANCE Saliva DNA test to lab) testing HsCRP TECO inflammation. High predictive value for(post cardiovascular & for European gene gover Lactose Intolerance DNA test lactose tolerance metabolic disease RESPIRATORY 30-minute test toofdetect IgEDantibodies against the top 10 inh VITAMIN D TheALLERGY internationally preferred measure Vitamin status. Many rapidpeople (adult/child) allergens in Europe (incl dust mite, pets, pollens) 25-hydroxy Vitamin D ImmunoCAPIrish are deficient. High-sensitivity C-Reactive is a more sensitive marker HYPOTHYROIDISM INFLAMMATION 10-minute screening test to detect raised levels ofProtein TSH hormone HsCRP TECO(≥5 ɥIU/ml) – a markerinflammation. High predictive value for cardiovascular & THyroScreen for hypothyroidism metabolic disease IRON DEFICIENCY ANAEMIA 10-minute blood screening test for low ferritin levels (<20 ng/ml) VITAMIN D – a marker for iron deficiency The internationally AnaemiaScreen anaemia preferred measure of Vitamin D status. M D screening showing Irish people deficient. PROSTATE SCREENING25-hydroxy Vitamin 15-minute if PSAare is mildly (4 ng/ml) or strongly HYPOTHYROIDISM ProstaQUICK (10ng/ml) elevated. 10-minute screening test to detect raised levels of TSH hormo THyroScreen (≥5 ɥIU/ml) – a marker for hypothyroidism IRON DEFICIENCY ANAEMIA 10-minute blood screening test for low ferritin levels (<20 ng Nutricentric OTC tests AnaemiaScreen – a marker for iron deficiency anaemia Personal Breathalyzer PROSTATE SCREENING RRP ~ €5. Tests Irish 0.05% BAC limit. 15-minute screening showing if PSA is mildly (4 ng/ml) or stro st Nov 1elevated. , 2012, (10ng/ml) TEST AND DRIVEProstaQUICKFrench NF-approved. Since mandatory fines apply in France if cars don’t carry at least one NF-approved, inNutricentricdate, OTCfunctional tests breathalyzer test. Family Fertility PlanningPersonal Breathalyzer RRPare ~ €5. Tests Irish 0.05% BAC limit. RRP €79.95. Male factors partly FrenchPack NF-approved. includes Since Nov 1st, 2012, DRIVEin 50% of infertility. FertilityTRIO TEST ANDinvolved mandatory finessperm apply in France if cars 5 ovulation tests, pregnancy test and don’t carry at least one NF-approved, incount. date, functional breathalyzer test. Family Fertility Planning RRP €79.95. Male factors are partly involved in 50% of infertility. Pack includes FertilityTRIO 5 ovulation tests, pregnancy test and sperm count.

November sees the launch of Nutricentric’s TEST AND DRIVE, personal breathalyzer.


56 November 2012 • IPN

Report news brief

Continued from 54

Self-Eating Cells May Hold key to New Inflammatory Therapies

to the switch process, working with key stakeholders to identify suitable products and the type of education and information campaigns that would be required to facilitate such switches.

Research just carried out in the Immunology Research Centre, led by Dr James Harris, based in the School of Biochemistry and Immunology, Trinity College Dublin, shows that the process of autophagy regulates the production of inflammatory molecules and may therefore represent an effective target for the development of new antiinflammatory therapeutics. Inflammation is a key component of immune responses to infection, but when uncontrolled can lead to autoimmune diseases like Crohn’s disease, rheumatoid arthritis, type I diabetes, ankylosing spondylitis, lupus, psoriasis and multiple sclerosis. In these diseases inflammation is mediated by molecules of the immune system called cytokines and cells that respond to these cytokines called T cells. The work by Dr Harris and colleagues showed that autophagy also control release of the inflammatory cytokines and cells that have been implicated in the pathology of autoimmune diseases. The findings suggest that autophagy represents a potent target for new antiinflammatory therapies, which could be beneficial in a range of autoimmune disorders. The group, in combination with Professor Kingston Mills, now hopes to apply these findings to specific models of autoimmune disease. The work is funded by Science Foundation Ireland as part of a Strategic Research Cluster (SRC) award based in The Trinity Biomedical Sciences Institute. “Autophagy is a common cellular process that is important for the maintenance of normal cell functions. Our work has shown that this process is important in the control of inflammation and, as such, could represent a particularly efficacious target for new drugs against inflammatory conditions. There are over 80 different autoimmune diseases, most of which are chronic and debilitating and can be difficult and expensive to treat. Any research which helps us to better understand the underlying mechanisms behind the control of inflammation will ultimately lead to better treatments,” explained Dr James Harris.

Switching more medications would ease the pressure on the already over-burdened health system and enable doctors to spend more time with those who suffer from more complicated illnesses. It would also allow pharmacists to use their clinical knowledge to help patients choose which medicine would be the most appropriate for selfmedication. PATIENTS ENDORSE PHARMACY PRESCRIBING Pharmacists have one of the most important roles to play in self-care. As highly trained professionals, they are at the heart of healthcare and are often the first port of call for the patient. Pharmacists can ensure the safe and effective use of non-prescription medicines and are the primary source of advice on medicines available off prescription. They offer a wide range of services to help patients to tackle obesity, smoking and other ailments and are ideally placed to initiate

discussions about sensitive topics, such as sexual health and family planning. The pharmacy network is extensive, allowing for convenient access to when it suits the patient, especially during out-of-surgery hours. In fact, some 85 million visits were paid to pharmacies in 2011. Research published by the IPU found that 92% of the public are in favour of pharmacists being able to prescribe for minor ailments. The IPU also says that pharmacists are in an ideal position to treat routine ailments promptly, as well as managing areas such pain management, gastro-intestinal complaints, cold sores, allergies and rhinitis. They also believe that the pharmacist has an important role to play in wider health promotion. Increased self-care in Ireland can ease the pressures on the health system but patients need easy access to more effective, regulated medicines through appropriate switching. They also need easy access to trustworthy information on the correct use of these medicines – and this is where their local pharmacist can play an essential role. The road to better, self-medicated health should also cost the patient less money that it currently does.


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58 November 2012 • IPN

Out and About Awards for excellence at RCSI The Royal College of Surgeons in Ireland Awards Ceremony for RCSI students who achieved excellence to date took place on Tuesday, 2nd October. Pictured are the winners in the Pharmacy categories.

Mr Yann Mazeman, General Manager Servier Laboratories (Ireland) Ltd; Professor Hannah McGee, Dean of the Faculty of Medicine and Health Sciences, RCSI; William Whyte and Mary Hopkins, recipients of the Servier Medals for Novice Research; and Amy Whelan, recipient of the Servier Medal for Experienced Research.

Above: Professor Hannah McGee, Dean of the Faculty of Medicine and Health Sciences, RCSI; Patricia Halliday, recipient of Pharmacy Union Prize for Community Pharmacy Practice/Internship; and Bernard Duggan, Chairman of the Community Pharmacy Committee, Irish Pharmacy Union. Below: Dr Judith Strawbridge, Programme Director for BSc in Pharmacy, RCS (pictured centre) with Mary Hopkins and William Whyte, recipients of the Servier Medals for Novice Research.

Amy Whelan, recipient of the Servier Medal for Experienced Research; Yvonne Boland, joint winner of Leo Medal for Excellence in Pharmaceutics; Dr Judith Strawbridge, Programme Director for BSc in Pharmacy, RCSI; Karen Jordan, joint winner of Leo Medal for Excellence in Pharmaceutics and recipient of the Boots Medal for Excellence in Pharmacy Practice.

Research reveals people living with psoriasis avoid social situations Half of people living with psoriasis believe the social stigma associated with the frequently visible skin condition causes them greater distress than the actual medical symptoms of the illness, according to a survey of psoriasis patients supported by Abbott. The multicultural population-based survey was conducted to obtain information on the psychological, social and economic impacts of living with psoriasis and designed to give insight into the lifetime impact of the disease. Launched ahead of World Psoriasis Day on 29th October, the research established that half (48%) of people living with psoriasis say that their “fear of what others might think” affects them more than the physical challenge of having the condition. Pictured at the launch are Prof. Brian Kirby, Consultant Dermatologist, Theresa Bugler, Caroline Irwin, Chairperson of the Psoriasis Association of Ireland, Lisa O’Connor and Ollie Kinlough,Business Unit Manager, Dermatology, Abbott.


IPN â&#x20AC;˘ November 2012 59

Out and About Doors open at DocMorris Donnybrook Pictures from the recent opening of DocMorris Pharmacy in Donnybrook, Dublin 4.

Sarah Jane Allen (area manager) and Sinead Magner (operations project manager).

Dominika Augustyn (Manager), Shane Jennings (Leinster rugby player) and Ann Marie Walsh (supervising pharmacist).

Martina Doyle (commercial director), Kate Stewart, Hannagh McCauley, Kate Feighan (OTC and cosmetics), Elana Otallarruchi (pharmacist), Laura Nyhan (pharmacist), Monika Safroni (OTC and cosmetics), Shane Jennings (Leinster rugby player), Dominika Augustyn (store manager), Ann Marie Walsh (supervising pharmacist) and Grainne Farrell-Cooper.


60 November 2012 • IPN

October Product News leader in Titanium Alloy Earrings , we Safetec Ear Piercing System - As the market of Most the systems in use are cumbersome , as old fashioned are often asked to

recommend an ear piercing system suitable for Pharmacy. stud , and finally the clasp , making it difficult to ensure that piercing guns needs to be loaded first with an adaptor , then the both remain sterile. The Safetec piercing instrument is simplicity itself to use , as the disposable capsule is pre-loaded , and so safe to use , that gloves are not required. Eastpark House, Marina Commercial Park, Cork, Ireland. Ph: 00353 21 4320337 Fax 00353 21 4318727 e: info@earsense.ie www.earsense.ie

Aveeno® DERMEXA

Do you have an itch for the perfect product to relieve dry skin? Many adults, children and babies in Ireland suffer from the unpleasant side effects of dry skin. However, Aveeno® DERME XA is on hand to soothe and hydrate skin as well as provide relief from itching, flaking and redness. People of all shapes, sizes and ages* can reap the benefits of Aveeno® DERME XA; using the Aveeno® DERMEXA Soothing Emollient Wash and Aveeno® DERMEXA Soothing Emollient Cream daily as part of a skincare routine, can maintain a healthy skin barrier and relieve symptom s of dry skin and help prevent nasty flare ups. *Suitable for adults and babies as young as three months.

Confidante®

Confidante® is a revolutionary new sexual health test from Randox Laboratories. It is the only OTC product that can simultaneously detect 10 of the most common STIs from a single self-collected sample, including Chlamydia, gonorrhoea and syphilis. Confidante provides simple, accurate and confidential access to laboratory STI testing from home. Pinora Sky Ltd T/A Earsense Registered Number 455615

bBold

Why be naughty this Christmas, when you can bBold? bBold self tanning products provide instant colour, dry in minutes and last on the skin for up to five days. Enriched with Aloe Vera and Vitamin E this range helps to tone, protect and moisturise the skin while antioxidants assist in improving skin texture and reduce signs of premature ageing. The bBold range includes; liquid 150ml (RRP €18.95), lotion 250ml (RRP €18.95) both available in Light/Medium or Medium/Dark and the bBold applicat or mitt (RRP €3.99). For further information on becoming a bBold stockist please contact Pharmacy Supplies on 048 796 27889.


HAVE YOU THOUGHT ABOUT JOINING

RETAIL EXCELLENCE IRELAND?

Here are a few reasons to become part of Ireland’s largest retail industry group: • Join the REI Pharmacy Network and benefit from peer to peer case studies, pharmacy member networking, pharmacy specific learning interventions, bespoke pharmacy market intelligence et al. • Receive complimentary over the phone human resource management advice • Receive a quarterly pharmacy sector productivity review investigating dispensary, OTC and retail sales trends. The report also insights payroll cost, rent cost, average transaction values and retail space productivity • Receive complimentary over the phone legal and financial advice • Benefit from REI’s representation of Ireland’s largest industry including our plans to revive Ireland’s towns and cities • Enjoy a wide range of leading retail industry learning interventions • Receive Retail Times Magazine every two months • Enjoy regular member e-mail updates highlighting pertinent retail industry issues • Join a vibrant community of more than 400 progressive and professional pharmacy stores who are REI members

For further details please contact Susan Meade at: 065 6846927 or susan@retailexcellence.ie.


62 November 2012 • IPN

CPL HEALTHCARE IS IRELAND’S LARGEST HEALTHCARE RECRUITMENT AGENCY We have been helping Pharmacists, Pharmacy Technicians, OTC Assistants & Pharmacy Store Managers to progress their career at every level for over 13 years Job Seekers

We are the Supplier of choice to the retail Pharmacy sector. We are the exclusive supplier of Pharmacy staff to the HSE in the South, East & Midlands. We are the preferred supplier to Private Hospitals nationally.

Employers

We offer: highly experienced & thoroughly vetted staff – Permanent & Locum. We provide: advice on salaries & new employment legislation, market information and a payroll service.

DUBLIN | CORK GALWAY | LIMERICK LONDON

www.cplhealthcare.com

Cpl Healthcare, 2nd Floor, 49 St. Stephen’s Green East, Dublin 2 T: 061 208 647 E: jo.oconnell@cplhealthcare.com

Cholesterol Lowering Product Exclusive to Pharmacy Non-Prescription

Natural Plant Sterols Clinically Proven to Reduce Cholesterol Suitable for Lactose Intolerance Pharmacy Exclusive Product €12m sales p.a in Irish Grocery for Plant Sterol Foods RSP €24.95 24.95 for a months supply - Zero VAT Produced in Ireland - FSAI Registered

Pemberton International Ltd.

Tel: 01-4632424


IPN • November 2012 63

Simple, accurate & confidential STI testing

Confidante® is a revolutionary new sexual health test. It is the only OTC product that can simultaneously detect 10 of the most common sexually transmitted infections (STIs) in a single test.

“for peace of mind” For more information and to find out how to stock Confidante® call +44 (0) 28 9445 1004, visit www.confidantetest.com or email info@confidantetest.com

NO0912654 Date of Preparation: September 2012

AV AI

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a Novartis company

Introducing Biosimilars: New horizons in affordable healthcare

Pioneering the future

For further information contact Alison Henderson on Alison.henderson@novartis.com or 087 6858069 5065 - Novartis Biosimiliars IP Ad.indd 1

Novartis Ireland Ltd., Beech House, Beech Hill Office Campus, Clonskeagh, Dublin 4 Tel: 01 260 1255 Fax: 01 260 1263 12/10/2012 16:31


64 November 2012 • IPN

Clinical Profiles XALUPRINE (MERCAPTOPURINE) 2 0MG/ML Oral Suspension Xaluprine ( Mercaptopurine) 20mg/ml Oral Suspension has been granted a European license , EU/1/11/272/001, and is indicated for the treatment of acute lymphoblastic leukaemia (ALL) in adults, adolescents and children. Xaluprine is available as a 100ml bottle at a list price of ¤252.97 and is GMS reimbursable from September 2012. Dosing can be accurately and consistently achieved using the 1ml & 5ml oral syringes supplied with the product. Xaluprine is distributed in Ireland by all the major wholesalers. Full prescribing information is available on request. This product is subject to medical prescription.

Bonasol Once Weekly Bonasol Once Weekly, a sugar-free orangeflavoured medicine, is a 70mg alendronic acid liquid approved for the treatment of postmenopausal osteoporosis and reduces the risk of vertebral and hip fractures. Bonasol acts selectively on bone tissue without directly affecting bone formation, and the reduction of elevated bone turnover leads to continuous net gains in bone mass and decreased occurrences of vertebral and hip fractures. The issue is ensuring adequate absorption of alendronic acid. Patient compliance while taking alendronic acid medication in tablet form is difficult to achieve due to complicated method of administration. Bonasol overcomes issues presented by the tablet-form, predominantly damage to the oesophagus, poor absorption rates and patient compliance. Take Tablets: � hour before breakfast or first food of the day, with 200ml of water in either a sitting or standing position (no going back to bed) 4 hours before other medication. Take Bonasol Once Weekly: � hour before breakfast or first food of the day with at least 30ml of water and wait at least 30minutes before lying down again. The product was developed and registered by a new Irish company, Xeolas Pharmaceuticals. It is a prescription only medicine. Full prescribing information and references available from Fannin Ltd. Email: medinfo@fannin.ie.


SAFETEC Own-Label Vitamins, Minerals Own-Label Vitamins, Minerals and and Supplements Since 1989 Safetecone is anpiece easy to use ear-piercing system, ideal for use in The fully enclosed disposable your consultation room. Certified staff your capsule is Supplements safe and sterile, and easy to for training is availablepharmacy if required.

your consultation room. Certified staff training is available if Ear Piercing System required. SAFETEC Piercing Safetec is an easyEar to use ear-piercingSystem system, ideal for use in ™

EARRINGS FOR SENSITIVE EARS

your consultation room. Certified staff training is available if required.

The fully enclosed disposable one piece capsule is safe and sterile, and easy to The fullypiercing enclosed disposable use. The instrument is hand one pressured and virtually piece capsule is safesilent. and sterile, and

use. The piercing instrument is hand pressured and virtually silent.

LIFETIME GUARANTEE AGAINST SENSITIVITY

CLASSIC TIMELESS DESIGNS

Ear piercing studs are available in 9ct Gold, Titanium, 24ct Gold Plate and in SUITABLE FOR ALL AGES White Stainless. AFFORDABLE PRICING

easy to use. The piercing instrument Ear piercing studs are available in 9ct isGold, hand pressured and virtually silent. Titanium, 24ct Gold Plate and in

White Stainless. Ear piercing studs are available in 9ct Gold, Titanium, 24ct Gold Plate and in Ear Sense recommend Safetec, as it is White Stainless. easy to use, safe and sterile.

NEW SPACE EFFICIENT MINI DISPLAYS

Ear Sense recommend Safetec, as it is Ear Sense recommend Safetec, as it is easier to use, easy to use, safe and sterile.

safe and sterile.Ear Sense, East Park House, Marina Commercial Park, Cork, Irela

T: 00353 21 4320337 F: 00353 21 4318727 E: info@earsense.ie W: www

SAFETEC Ear Piercing System Ear Sense, East Park House, Marina Commercial Park, Cork, Ireland T: 00353 21 4320337 F: 00353 21 4318727 E: info@earsense.ie W: www.earsense.ie

Safetec is an easy to use ear-piercing system, ideal for use in your consultation room. Certified staff training is available if required. The fully enclosed disposable one piece capsule is safe and sterile, and easy to use. The piercing instrument is hand pressured and virtually silent.

Own-Label Vitamins, Minerals Own-Label Vitamins, Minerals and No contract, and Supplements Since 1989 No contract, Supplements for your pharmacy No set up costs, No set up costs, Ear piercing studs are available in 9ct Gold, Titanium, 24ct Gold Plate and in White Stainless.

Ear Sense recommend Safetec, as it is easy to use, safe and sterile.

Ear Sense, East Park House, Marina Commercial Park, Cork, Ireland T: 00353 21 4320337 F: 00353 21 4318727 E: info@earsense.ie W: www.earsense.ie

No commitment No stock commitment About Premier Health

1.Providers of Own-Label since 1989 Lower retail prices and higher profit margins • than other brands. • Sold in over 1,000 Pharmacies 2. Sold in over 100 pharmacies across Ireland. • The highest quality at a price that’s right 3. The highest quality at a price that’s right. • A unique range not found in supermarkets or Pharmacy only. Not found in supermarkets. 4.national chains 5. Point of sale package includes shelf talkers Free branding for your range and optional posters from A4 to A1 at no charge to you. Don’t have a usable logo?

Free branding for your range Don’tsimple a usable logo?started So to get Nohave contract, We provide free logo templates...

For the best in quality and value, our own-brand vitamins and supplements Testimonials “Selling really well, offering the customer a top quality Pharmacy own branded product at affordable prices.” Mike Walsh, Walsh’s Pharmacy, Fermoy, Co. Cork. “The range has been a huge success. Its eye catching, prices are good, and orders are delivered quickly.” Eamonn Brady, Whelehans Pharmacy, 38 Pearse St, Mullingar.

We provide free logo templates. No No set up costs, No commitment Nocontract, contract, Three simple steps that give you a great range...

How do I get get started? No set upstarted costs, How 1. Lowerdo retaili prices and higher profit margins than other brands.

FRE

lo go

No set up costs, It’s easy. Supply us with your store logo, which we 2. Sold incommitment over 100 pharmacies across Ireland. No It’s easy. Supply us with your store logo, which we No stock commitment incorporate into our label template. You sign it off, About Premier Health

E

s

“Customer’s trust our name, and have a great loyalty to our Pharmacy. We are te m plate delighted to offer an own brand range 3. The highest quality at a price that's right. incorporate into our label template. You sign it off, that brings real savings in these difficult times.” and then we supply your goods. Simple! for more 4. Pharmacy only. Not found in supermarkets. Sean Foley, Meath Street Pharmacy and Foley’s and then we supply your goods. Simple! For more information, log on to website. Pharmacy, ThomastoSt, Dublin 8. 5. Point of sale package includes shelf talkers and optional posters from A4 to A1 at no charge you. information, log on to website.

About Premier Health

1.Providers of Own-Label since 1989 Lower retail prices and higher profit margins • than other brands. • Sold in over 1,000 Pharmacies 2. Sold in over 100 pharmacies across Ireland. • The highest quality at a price that’s right 3. The highest quality at a price that’s right. • A unique range not found in supermarkets or

For the best in quality Tel. 021 4318875 Fax. 021 4318727 and value, our own-brand

Email. info@premierhealth.ie www.premierhealth.ie vitamins and supplements


66 November 2012 • IPN

Appointments Taoiseach Enda Kenny has formally told the Dáil that Alex White has been appointed by Government as minister of state in the Department of Health. Mr White replaces Roisin Shortall, who resigned over what she described as a "lack of support for the reforms in the Programme for Government". Mr White was the chairman of the Joint Oireachtas Committee on Finance, Public Expenditure and Reform and a former member of South Dublin County Council. He was elected to the Seanad in 2007.

Biosensia Ltd, a point of care diagnostics Company, has announced the appointment of James D. Merselis as Non-Executive Director. Jim is currently a non-executive director at Trinity Biotech (NASDAQ: TRIB) and a consultant to healthcare diagnostics companies. He was formerly President and CEO of ITC Nexus Dx, Inc, a privately held diagnostics company working to improve patient care by providing rapid and reliable Point-of-Care medical test information. Prior to this, he served as President and CEO of Alverix, Inc, a privately held company developing portable medical diagnostic instruments.

Bristol Myers Squibb has announced that Frances Heller will join the company as senior vice president, Business Development, on October 1, 2012. She will report to Lamberto Andreotti, chief executive officer, and will be a member of the company’s Senior Management Team.

Dr Leisha Daly, country director of Janssen, has been appointed as IPHA vice president. Dr Daly has been a member of the Association’s Board of Directors since June of this year and was reappointed to the Prescription Medicines Division Strategy Board in August. Dr Daly holds a PhD in Clinical Medicine from Trinity. Following some years in clinical research, she joined the pharmaceutical industry as technical advisor for Hoechst Ireland. She joined Janssen as Head of Technical Affairs in 1998, and since then served in a variety of senior positions in medical, sales and marketing.

Francis Lynch, general manager of A. Menarini Pharmaceuticals Ireland Ltd has been elected as president of the Irish Pharmaceutical Healthcare Association (IPHA). He succeeds David Gallagher of Pfizer Healthcare Ireland. Lynch joined Menarini Pharmaceuticals in 1999 after working for Abbott Laboratories Ireland Ltd, first as pharmaceutical products division manager and latterly as sales manager of the hospital product division/pharmaceutical product division.

The Department of Health, Social Services and Public Safety has announced the appointment of the President, Vice-President, and Members to the Council of the Pharmaceutical Society of Northern Ireland. Ms Jacqui Dougan has been appointed as President of the Council for a two year period. Mr Garry McKenna has been appointed as a Lay Member for a four year period, and during the first two years of his term, he has been appointed as Vice-President of the Council.


gift wrap and packaging centre

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Fox & Geese House, Naas Road, Dublin 22.

ORDERLINE: 01-4504121 | FAXLINE: 01-4569217

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BabyVitD3 Pump

To help build Strong & healthy bones

BabyVitD3 Pump is easy to use. is designed to support accurate dosing. just 1 press provides 5ug of Vitamin D3 in line with national recommendations & guidelines. is odourless and tasteless. is produced in the EU to the highest pharmaceutical standards. is available in all pharmacies.

w w w. s h i e l d h e a l t h . i e


HELP SHIFT THE PHLEGM

BEHIND YOUR CUSTOMERS’ COUGHS AND COLDS

NEW COUGH & COLD SEASON IS ON IT’S WAY, SO DON’T FORGET TO STOCK UP. Benylin Phlegm Cough & Cold Multi-Relief Tablets. Composition: Paracetamol 250mg, Guaifenesin100mg, Phenylepherine hydrochloride 5mg. Pharmaceutical form: Film-coated tablet. Therapeutic indications: For the relief of symptoms associated with colds and flu, including aches and pains, headache, blocked nose and sore throat, chills and chesty cough. Posology and method of administration: For oral use. Take tablets with water. Swallow whole, do not chew. Adults, the Elderly and children aged 12 years and over: Two tablets. Repeat every four hours as required. Do not take more than 8 tablets (4 doses) in any 24 hour period. Do not give to children under 12 years, except on medical advice. Do not exceed the stated dose. Contraindications: Hypersensitivity to paracetamol or any of the other ingredients. Hypertension, hyperthyroidism, diabetes, serious heart disease or those patients receiving or within two weeks of stopping therapy with monoamine oxidase inhibitors. Use in patients with glaucoma or urinary retention. Use in patients who are currently receiving other sympathomimetic drugs. Special warnings and precautions for use: The physician or pharmacist should check that sympathomimetic containing preparations are not simultaneously administered by several routes i.e. orally and topically (nasal, aural and eye preparations). Care is advised in the administration of paracetamol to patients with severe renal or hepatic impairment. The hazards of overdose are greater in those with non-cirrhotic alcoholic liver disease. Use with caution in patients with circulatory disorders such as Raynaud’s Phenomenon. Patients with prostatic hypertrophy may have increased difficulty with micturition. Sympathomimetic-containing products may act as cerebral stimulants giving rise to insomnia, nervousness, hyperpyrexia, tremor and epileptiform convulsions. Long term use of the product is not recommended. Do not exceed the recommended dose. If symptoms persist consult your doctor. Keep all medicines out of the reach and sight of children. Undesirable effects: The active ingredients are usually well tolerated in normal use. Paracetamol: Adverse effects of paracetamol are rare but hypersensitivity including skin rashes may occur. There have been reports of blood dyscrasias including thrombocytopenia and agranulocytosis, but these were not necessarily causally related to paracetamol. The active ingredients are usually well tolerated in normal use. Guaifenesin: Gastrointestinal discomfort has occasionally been reported with guaifenesin. Phenylepherine hydrochloride: Phenylephrine Hydrochloride may elevate blood pressure with headache, vomiting and rarely palpitations, tachycardia or reflex bradycardia, tingling and coolness of the skin. There have been rare reports of allergic reactions. PA number: PA 1120/1/1. Marketing Authorisation Holder: Wrafton Laboratories Ltd., Braunton, Devon, EX33 2DL, United Kingdom Date of last revision: June 2012. Products not subject to medical prescription. Further information available upon request from Johnson & Johnson (Ireland) Ltd BEN/055/00

IRISH PHARMACY NEWS - ISSUE 11 - 2012  

In this issue: NEWS: New proposals from IACPT on technician registration - PROFILE: New IPU President Rory O'Donnell speaks exclusively to I...

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