THE INDEPENDENT VOICE OF PHARMACY

March 2013Volume 5 Issue 3

In this issue:

NEWS:Re-vamped website launched byIrwin's Pharmacy Page 7

PROFILE: Pharmacists' role going unrecognised, according to former ICCPE chief Tom McGuinnPage 11

REPORT:Is work-related stressa growing problem? Page 27

AWARDS: Make sure you get your application form in and book those tables! Page 28

CPD:Asthma management in the community pharmacy Page 29

FEATURE:Ensuring you offer thebest in baby care Page 43

REPORT:Importance ofCategory Management Page 58

Instant release spray.So fast, it’s breathtaking.

· NICORETTE® QuickMist is clinically proven to relieve cravings in just 60 seconds with 2x1mg/sprays1

· NICORETTE® QuickMist is 46% more effective at helping smokers quit compared with placebo at 4 weeks2

NICORETTE® QuickMist mouthspraynicotine

Product Name:Nicorette QuickMist 1 mg/spray, Oromucosal Spray. Composition: 0,07 ml contains 1 mg nicotine, corresponding to 1 mg nicotine/spray dose. Form: Oromucosal spray. A clear to weakly opalescent, colourless to light yellow solution. Therapeutic indications: For the treatment of tobacco dependence by relieving nicotine craving and withdrawal symptoms, thereby facilitating smoking cessation in smokers motivated to quit. Advice and support normally improve the success rate. Dosage: After priming, point the spray nozzle as close to the open mouth as possible. Press the top of the dispenser and release one spray into the mouth, avoiding the lips. Subjects should not inhale while spraying to avoid getting spray into the respiratory tract. For best results, do not swallow for a few seconds after spraying. Subjects should not eat or drink when administering the oromucosal spray. Subjects should stop smoking completely during the course of treatment with Nicorette QuickMist. Step I: Weeks 1-6: Use 1 or 2 sprays when cigarettes normally would have been smoked or if cravings emerge. If after a single spray cravings are not controlled within a few minutes, a second spray should be used. If 2 sprays are required, future doses may be delivered as 2 consecutive sprays. Most smokers will require 1-2 sprays every 30 minutes to 1 hour. Step II: Weeks 7-9: Start reducing the number of sprays per day. By the end of week 9 subjects should be using half the average number of sprays per day that was used in Step I. Step III: Weeks 10-12: Continue reducing the number of sprays per day so that subjects are not using more than 4 sprays per day during week 12. When subjects have reduced to 2-4 sprays per day, the oromucosal spray use should be discontinued. To help stay smoke free after Step III, subjects may continue to use the oromucosal spray in situations when they are strongly tempted to smoke. One spray may be used in situations where there is an urge to smoke, with a second spray if one spray does not help within a few minutes. No more than four sprays per day should be used during this period. Regular use of the oromucosal spray beyond 6 months is generally not recommended. Some ex-smokers may need treatment with the oromucosal spray longer to

avoid returning to smoking. Any remaining oromucosal spray should be retained to be used in the event of sudden cravings. Do not administer Nicorette QuickMist to persons under 18 years of age without recommendation from a physician. There is no experience of treating adolescents under the age of 18 with Nicorette QuickMist. Contraindications: Hypersensitivity to nicotine or to any of the excipients of the oromucosal spray. Special warnings and precautions: Nicorette QuickMist should not be used by non-smokers. Dependent smokers with a recent myocardial infarction, unstable or worsening angina including Prinzmetal’s angina, severe cardiac arrhythmias, uncontrolled hypertensions or recent cerebrovascular accident should be encouraged to stop smoking with non-pharmacological interventions (such as counselling). If this fails, the oromucosal spray may be considered but as data on safety in this patient group are limited, initiation should only be under close medical supervision. Diabetes Mellitus. Patients with diabetes mellitus should be advised to monitor their blood sugar levels more closely than usual when smoking is stopped and NRT is initiated as reduction in nicotine induced catecholamine release can affect carbohydrate metabolism. Allergic reactions: Susceptibility to angioedema and urticaria. A risk-benefit assessment should be made by an appropriate healthcare professional for patients with the following conditions: Renal and hepatic impairment: Use with caution in patients with moderate to severe hepatic impairment and/or severe renal impairment as the clearance of nicotine or its metabolites may be decreased with the potential for increased adverse effects. Phaeochromocytoma and uncontrolled hyperthyroidism: Use with caution in patients with uncontrolled hyperthyroidism or phaeochromocytoma as nicotine causes release of catecholamines. Gastrointestinal Disease: Swallowed nicotine may exacerbate symptoms in patients suffering from oesophagitis, gastric or peptic ulcers and oral NRT preparations should be used with caution in these conditions. Danger in small children: Doses of nicotine tolerated by adult and adolescent smokers can produce severe toxicity in small children that may be fatal. Products containing nicotine should not be

left where they may be misused, handled or ingested by children. Transferred dependence: Transferred dependence can occur but is both less harmful and easier to break than smoking dependence. Stopping smoking: Polycyclic aromatic hydrocarbons in tobacco smoke induce the metabolism of drugs metabolised by CYP 1A2 (and possibly by CYP 1A1). When a smoker stops smoking, this may result in slower metabolism and a consequent rise in blood levels of such drugs. This is of potential clinical importance for products with a narrow therapeutic window, e.g. theophylline, tacrine, clozapine and ropinirole. Excipients: The oromucosal spray contains small amounts of ethanol (alcohol), less than 100 mg per spray. Care should be taken not to spray the eyes whilst administering the oromucosal spray. Undesirable effects: Subjects quitting habitual tobacco use by any means could expect to suffer from an associated nicotine withdrawal syndrome that includes four or more of the following: dysphoria or depressed mood; insomnia; irritability, frustration or anger; anxiety; difficulty concentrating, restlessness or impatience; decreased heart rate; and increased appetite or weight gain. These have been observed in those using the oromucosal spray. Nicotine craving with urge to smoke is also recognised as a clinically relevant symptom, and an important additional element in nicotine withdrawal after smoking cessation. In addition to this, other cessation-associated symptoms were seen in those using the oromucosal spray: dizziness, presyncopal symptoms, cough, constipation, mouth ulceration, gingival bleeding and nasopharyngitis. Nicorette QuickMist may cause adverse reactions similar to those associated with nicotine given by other means and these are mainly dose-dependent. Allergic reactions such as angioedema, urticaria or anaphylaxis may occur in susceptible individuals. Local adverse effects of administration are similar to those seen with other orally delivered forms. During the first few days of treatment irritation in the mouth and throat may be experienced, and hiccups are particularly common. Tolerance is normal with continued use. Daily collection of data from trial subjects demonstrated that very commonly occurring adverse events were

reported with onset in the first 2-3 weeks of use of the oromucosal spray, and declined thereafter. Adverse reactions reported in clinical trials of the oromucosal spray include: Nervous system disorders: Very common: Headache, dysgeusia Uncommon: Paraesthesia Eye disorders: Uncommon: Lacrimation increase Not known: Vision blurred Cardiac disorders: Uncommon: Palpitations Not known: Atrial fibrillation Vascular disorders: Uncommon: Flushing Respiratory, thoracic and mediastinal disorders: Very common: Hiccups Uncommon: Dyspnoea, rhinorrhoea, bronchospasm, sneezing, nasal congestion Gastrointestinal disorders: Very common: Nausea, dyspepsia Common: Vomiting, flatulence, abdominal pain, diarrhoea Uncommon: Gingivitis, glossitis Skin and subcutaneous tissue disorders: Uncommon: Hyperhydrosis, pruritus, rash, urticaria Immune system disorders: Uncommon: Hypersensitivity. General disorders and administration site conditions Very common: Oral soft tissue pain and paraesthesia, stomatitis, salivary hypersecretion, burning lips, dry mouth and/or throat Common: Throat tightness, fatigue, chest pain and discomfort Uncommon: Oral mucosal exfoliation, dysphonia Not known:Allergic reactions including angioedema and anaphylaxis. MA Holder: McNeil Healthcare (Ireland) Limited, Airton Road, Tallaght, Dublin 24 Ireland. MA Number: PA 823/49/29. Revision of text: August 2012. Legal Category: Not subject to medical prescription. Further information available upon request from Johnson & Johnson (Ireland) Ltd.References: 1. Hansson A et al. Craving Relief With A Novel Nicotine Mouth Spray Form Of Nicotine Replacement Therapy. Poster POS3-45 Presented at SRNT, Feb 16–19th, 2011, Toronto, Canada. 2. Tønnesen P, et al. Efficacy And Safety Of A Novel Nicotine Mouth Spray In Smoking Cessation. A Randomized, Placebo-Controlled, Double-Blind, Multi-Center Study With A 52-Week Follow-Up. Poster POS2-38 Presented at SRNT, Feb 16-19th, 2011, Toronto, Canada.

IRE/NI/12-0230

NEW

For every cigarette, there’s a nicorette®

www.nicorette.ie

Shortlisted BUSINESS TO BUSINESS MAGAZINE OF THE YEAR

2

Does the baby have any special nutritional needs or feeding problems?

2

This chart is intended as guide only and is not a diagnostic tool. For Healthcare Professional Use Only.

The complete guide to SMA

IMPORTANT NOTICE: Breastfeeding is best for babies. You should always seek the advice of a doctor, midwife, health visitor, public health nurse, dietitian or pharmacist on the need for and proper method of use of infant milks and on all matters of infant feeding. SMA Follow-on Milk is for babies over 6 months, as part of a varied weaning diet. Not intended to replace breastfeeding. • These products must be used under medical supervision: SMA Staydown, SMA LF Lactose Free, SMA High Energy, SMA Breast Milk Fortifier, SMA Gold Prem 1 and SMA Gold Prem 2. For more product information read the label or visit www.smahcp.ie

1800 931 832

For Healthcare Professional

advice and support FREEPHONE

For more information visitZRI 042

Is the baby being given breast milk?

The complete guide to SMAStart Here Is the bottle-fed baby full term?

Yes

No

YesNo

Yes No

SMAGold Prem 2Post discharge formula Available in 250ml RTU/ 400g

SMABreast Milk FortifierFrom birth+Available in 50x2g sachets

SMA Follow-on Milk From 6 months +Available in 250ml/ 1 litre RTUSMA RTU Spouts available for use with SMA Follow-on Easy feed 250ml bottles

SMAFirst Infant MilkFrom birth +Available in 450g / 900g

From birth

SMAFollow-on MilkFrom 6 months +Available in 450g / 900g

From 6 months+

SMAToddler MilkFrom 1 year +Available in 450g / 900g

For babies from 1 yr + as part of a balanced diet

SMAExtra Hungry Infant Milk From birth +Available in 450g/ 900g

For hungrier babies

The SMA Easy Feed SystemNEWSYSTEM

Is the baby still in hospital? No

Available in 450g/

Extra Hungry

Available in 450g/

SMA Comfort Easy to Digest Infant MilkFrom birth +Available in 800g

Easy to digest

SMA StaydownFrom birth+Available in 900g

For babies with significant reflux

For babies intolerant to lactose

SMA LFFrom birth +PrescribableGMS No. 82511Available in 430g OTC

For babies with cow’s milk intolerance

SMA WysoyFrom birth +PrescribableGMS No.83083Available in 430g / 860g OTC

For babies with high energy needs

SMA High EnergyFrom birth +PrescribableGMS No. 81479Available in 250ml/ 100ml RTU (hospital only)

Yes No

Yes

The SMA Core Range

SMA Formulas for Special Purposes

To join the SMA professional know-how programme for healthcare professionals:

Go online: or

FREEPHONE: 1800 931 832

SMA First Infant Milk Starter PackFrom birth +The starter pack includes 12 x 100ml bottles and 12 individually wrapped SMA teats

SMA First Infant MilkFrom birth +Available in 100ml (hospital only)

Catch up formula for low birthweight and preterm babies

For low birthweight and preterm babies

Catch up formula for low birthweight and preterm babies

SMA Gold Prem 1From birth+Available in 100ml (hospital only)

SMA Gold Prem 2Available in 100ml (hospital only)

SMA Extra-hungry Milk From birth +Available in 250ml/ 1 litre RTUSMA RTU Teats available for use with SMA Easy feed bottles

SMA Toddler Milk RTU From 1 year+Available in 200ml (with straw)

SMA First Infant Milk From birth +Available in 250ml/ 1 litre RTUSMA RTU Teats available for use with SMA Easy feed bottles

For Healthcare Professional Use Only.

MADE IN IRELAND

MADE IN IRELAND

Is the baby still in hospital?

3

Does the baby have any special nutritional needs or feeding problems?

This chart is intended as guide only and is not a diagnostic tool. For Healthcare Professional Use Only.

The complete guide to SMA

IMPORTANT NOTICE: Breastfeeding is best for babies. You should always seek the advice of a doctor, midwife, health visitor, public health nurse, dietitian or pharmacist on the need for and proper method of use of infant milks and on all matters of infant feeding. SMA Follow-on Milk is for babies over 6 months, as part of a varied weaning diet. Not intended to replace breastfeeding. • These products must be used under medical supervision: SMA Staydown, SMA LF Lactose Free, SMA High Energy, SMA Breast Milk Fortifier, SMA Gold Prem 1 and SMA Gold Prem 2. For more product information read the label or visit www.smahcp.ie

1800 931 832

For Healthcare Professional

advice and support FREEPHONE

For more information visitZRI 042

Is the baby being given breast milk?

Start Here Is the bottle-fed baby full term?

Yes

No

YesNo

Yes No

SMAGold Prem 2Post discharge formula Available in 250ml RTU/ 400g

SMABreast Milk FortifierFrom birth+Available in 50x2g sachets

SMA Follow-on Milk From 6 months +Available in 250ml/ 1 litre RTUSMA RTU Spouts available for use with SMA Follow-on Easy feed 250ml bottles

SMAFirst Infant MilkFrom birth +Available in 450g / 900g

From birth

SMAFollow-on MilkFrom 6 months +Available in 450g / 900g

From 6 months+

SMAToddler MilkFrom 1 year +Available in 450g / 900g

For babies from 1 yr + as part of a balanced diet

SMAExtra Hungry Infant Milk From birth +Available in 450g/ 900g

For hungrier babies

The SMA Easy Feed SystemNEWSYSTEM

Is the baby still in hospital? No

SMA Comfort Easy to Digest Infant MilkFrom birth +Available in 800g

Easy to digest

SMA StaydownFrom birth+Available in 900g

For babies with significant reflux

For babies intolerant to lactose

SMA LFFrom birth +PrescribableGMS No. 82511Available in 430g OTC

For babies with cow’s milk intolerance

SMA WysoyFrom birth +PrescribableGMS No.83083Available in 430g / 860g OTC

For babies with high energy needs

SMA High EnergyFrom birth +PrescribableGMS No. 81479Available in 250ml/ 100ml RTU (hospital only)

Yes No

Yes

The SMA Core Range

SMA Formulas for Special Purposes

To join the SMA professional know-how programme for healthcare professionals:

Go online: or

FREEPHONE: 1800 931 832

Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online: Go online:

SMA First Infant Milk Starter PackFrom birth +The starter pack includes 12 x 100ml bottles and 12 individually wrapped SMA teats

SMA First Infant MilkFrom birth +Available in 100ml (hospital only)

Catch up formula for low birthweight and preterm babies

For low birthweight and preterm babies

Catch up formula for low birthweight and preterm babies

SMA Gold Prem 1From birth+Available in 100ml (hospital only)

SMA Gold Prem 2Available in 100ml (hospital only)

SMA Extra-hungry Milk From birth +Available in 250ml/ 1 litre RTUSMA RTU Teats available for use with SMA Easy feed bottles

SMA Toddler Milk RTU From 1 year+Available in 200ml (with straw)

SMA First Infant Milk From birth +Available in 250ml/ 1 litre RTUSMA RTU Teats available for use with SMA Easy feed bottles

For Healthcare Professional Use Only.

MADE IN IRELAND

MADE IN IRELAND

Is the baby still in hospital?

Irish Pharmacy News is circulated to all independent, multiple and hospital pharmacist, pre reg pharmacists, students pharmacy student’s offi cial bodies, government offi cials and departments, pharmacy managers, manufactures, wholesalers. Buyers of pharmacy groups and healthcare outlets. Circulation is free to all pharmacists subscription rate for Irish Pharmacy News ¤60 plus vat per year.

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

IRISH PHARMACY NEWS

ForewordContentsPage 8Cavan pharmacist launches salt therapy to the UK

Page 14Increased generic use could lead to savings

Page 20Pharmacy researchers say conscience clauses should be scrapped

Page 24Is work-related stress a growing problem within community pharmacy, asks Michael Doody?

Page 48Meagher's Pharmacy trials new product for irritable bowel syndrome

Page 54Pharmacists are urged to upskill in diabetes care

CUT TO THE BONE ALTERNATIVE

To Err is Human

The difference between this magazine and a national newspaper is that IPN reports Pharmacy news, as well as offering features, such as CPD and category features for the benefit and education of its readers but the main raison d’etre of the newspapers is to make money by raising their circulation figures. And, the more sensational a piece of news is, the more copies will be sold. Pharmacy errors, particularly if a death is involved, is a case in point.

IPN’s debate (see page 18) is on the same subject and each contributor makes a lot of sense. Indeed, one pharmacist points out that the PINCER trial in the UK – but it would be expensive.

Of course, anything that can be done to help eliminate errors is worth every cent but, to be honest, unfortunately the Government/HSE is not in a position to pursue any such technology at the moment. In a recent errors’ incident, Daktarin Mouth Gel was given to a patient on warfarin, with tragic results. However, this does beg the question of whether or not patients should also take some responsibility for their own health.

The full facts surrounding the court case for compensation are unknown to this publication at this juncture so the following observations are made completely independently and do not allude to it whatsoever, or the subsequent judgement that was made.

Irrespective of the premise that, when a patient presents a prescription he or she could be a total stranger to the pharmacist; or they might have become confused or forgetful if asked whether they were taking any other medicines; or whether they were known to the doctor; or if either the doctor or the pharmacist forgot to ask whether the patient was taking any other medication, one fact is patently clear. Had a patient, who is on warfarin and is given and uses Daktarin Mouth Gel - and subsequently dies - read the pack instructions beforehand, perhaps they would not have taken it until such time as they had been able to check with the pharmacist.

A pharmacist’s and/or a doctor’s sole aim is to help patients stay healthy but patients must help themselves as well and they must read the literature regarding any drug that is given to them, particularly the sections about side effects and the warnings about any other drug interactions.

Unfortunately, hardly anyone does this. And, thereby lies the crux of a myriad of potential problems. Ultimately, each one of us adults is responsible for our own health – and even the pharmacy we choose to dispense our prescription.

EDITOR Bridget Casey

Regulars

14

48

CPD: Asthma 31

Feature - Smoking Cessation 36

Feature - Baby Care 40

Clinical Profi les 61

Product Profi les 62

Appointments 63

PUBLISHERIPN Communications Ireland Ltd. Carmichael House, Lower Baggot Street, Dublin 2 00353 (01) 6024715

MANAGING DIRECTORNatalie Maginnis n-maginnis@btconnect.com

GROUP SALES MANAGERDebbie Graham debbie.hpn@btconnect.com0044 7450274112

EDITOR - Bridget Casey bcasey.ipn@btconnect.com

SUB EDITOR - Kelly Jo Eastwoodkelly@hospitalpharmacy.ie

SENIOR JOURNALISTMary Anne Kenny

EDITORIAL DEPARTMENTeditorial@ipnirishpharmacynews.ie

ACCOUNTS - Lorraine Moore cs.ipn@btconnect.com

ADVERTISING MANAGERNicola McGarveynicola@ipnirishpharmacynews.ie

CONTRIBUTORS - Eamonn Brady

ART DIRECTOR - Smart Page Design

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6

NewsIMED Healthcare Ltd takes over Profind

UNITED DRUG SEES 60% RISE IN SHARE PRICEIrish healthcare outsourcing group United Drug has reported a 60% rise in its share price since February 2012. The company issued a positive trading statement last month for the first quarter of its financial year. Its recently published annual report indicated a revenue increase of 5% to ¤1.8 billion in 2012.

Earnings per share are expected to rise by between 5% and 8% for the year to the end of September 2013. Some of this appreciation can be put down to the fact that United Drug is now listed on the FTSE 250 in London, having moved from the Irish Stock Exchange last December.

Group revenues for the three months to December 31 were ahead of the same period in the previous year and underlined the fact that most of United Drug’s growth continued to come from outside of Ireland, with overseas now accounting for 70% of profits.

Strong performances in Q1 sales were outlined, with revenues strong in its marketing and medical division and its healthcare supply chain division. Profits were ahead of expectation in wholesale for both the Republic and Northern Ireland, thanks to market-share breakthroughs which have helped to offset the effects of austerity.

"The European business is in the process of being rebranded to maximise cross-selling opportunities between the US and Europe and leverage the strong equity of our existing brand,” said the statement. “We are reviewing the optimal infrastructure configuration required to support the long-term growth of the European business."

news brief

“The move had been in the pipeline for a little while. We wanted to expand our operations and the opportunity to buy Profind came at the right time for us,” said Paul Murphy, Managing Director of IMED.

“Under the original name of IMED Healthcare Ltd, our ‘new’ company will provide additional benefits to our pharmacy customers in Ireland,” he added. “We will offer more competitive discounts, an expanded sales team and a larger product range, as well as

IMED Healthcare Ltd has bought the trading business and all associated licenses of Profind, with the aim of offering a bigger and better proposition for pharmacists in Ireland. The sale took place in January and IMED Healthcare Ltd will see staff numbers increase to 40.

IPU Academy Spring Programme

The IPU Academy’s first six topics include Parkinson’s disease, gastroenterology, women’s health, men’s health, type 2 diabetes and hypertension. According to Liz Hoctor, the IPU’s CPD & IT manager, the programme will be delivered countrywide across a number of venues and many experienced ICCPE tutors are

collaborating in the development and delivery of this programme.

“We have also recruited some additional experienced tutors to assist in facilitating the nationwide delivery of the IPU Academy Spring Programme,” said Hoctor. “The experience of these committed tutors is now being

shared with IPU Academy in its mission to support pharmacists’ engagement with CPD.”

The Union is inviting feedback on this inaugural programme and suggestions for future topics to be developed by the IPU Academy. Email: ipuacademy@ipu.ie.

The Irish Pharmacy Union has launched its inaugural IPU Academy Spring Programme, which runs until the end of April. The educational initiative has been developed by the IPU to support pharmacist engagement with Continuing Professional Development (CPD), since the Irish Centre for Continuing Pharmaceutical Education (ICCPE) closed its doors at the end of 2012 (see this month’s profile on page 11).

IPU's CPD & IT Manager Liz Hoctor

enhanced service levels.”

With the acquisition of Profind’s headquarters in Dublin, IMED Healthcare’s main sales office is moving from Buncrana, Co Donegal to the capital. For more

information, please contact the IMED sales team. Freefone: 1800 864 864 or email: sales@imed.ie. The company also offers an online ordering service at www.imed.ie.

Pharmacy students gain experience

Doireann’s project was to determine the implications of the new EU Falsified Medicines Directive while David’s project involved reviewing the new guidelines from the US Food and Drug Administration (FDA) and the European Medicines Agency (EMA) relating to process validation.

This initiative is in its third year and involves two students gaining direct experience in a pharmaceutical company which operates in a highly regulated environment.

Julie O’Neill, a pharmacist and currently Vice President Operations & General Manager

of Gilead, highlights ‘the benefit of enhanced collaboration with the research teams in the university’ and she welcomes ‘the opportunity to raise the awareness of career opportunities within the pharmaceutical industry for Pharmacy graduates.’

UCC Pharmacy students Doireann Ní Nuanáin and David Walsh recently spent four weeks in the QA department at Gilead Sciences undertaking their final year projects.

7

The PSI discussed with the Minister the future roles for pharmacy in the health service and also the plans for the International Pharmaceutical Federation (FIP) World Congress, which is coming to Dublin later this year.

The event will take place from 31 August until 5 September at the Convention Centre Dublin. It will be the first time the FIP Congress has taken place in Ireland since 1975 and is set to attract 3,000 international delegates.

News

Pictured at a recent Pharmaceutical Society of Ireland (PSI) Council meeting are PSI President Paul Fahey (l) and Minister for Primary Care at the Department of Health & Children, Alex White TD.

PSI Spring Meetings

PSI president gears up for FIP Congress

RAMONA JOINS THE DRAGONS

Ramona Nicholas, the name and face behind the 12-strong chain of Cara Pharmacies has been recruited as the newest Dragon on the popular RTE programme, Dragon's Den.

Nicholas, who lives in Bundoran with her husband Canice, cut her television teeth with an episode of The Secret Millionaire where she helped people with alcohol and drug addiction in Galway.

Originally from Dungannon, Co Tyrone, she is the daughter of a plumber and a schoolteacher and after studying pharmacy in Queen's University she worked in the Dublin chemist shop, learning a lot about business and life.

"I had a very negative attitude to certain problems like alcoholism and drug addiction – when I was 21 I worked as a pharmacist in Coolock (Dublin) and put myself in some situations I probably shouldn't have, becoming the confidante of a drug addict," she told the Sunday Independent.

news brief

The PSI will be organising a series of information meetings about its pharmacy education and training reform programme, which all pharmacist are invited to attend.

These meetings will offer an overview of the key developments

• the five-year integrated

Masters qualification for practice

• the core competency framework for pharmacists and

• the CPD model which will be introduced via the new Irish Institute of Pharmacy

The meetings also aim to facilitate

discussion with pharmacists about how these developments will impact on them and their professional practice in the near future, and the opportunities for the future development of the profession. Further details can be found at www.thepsi.ie

Meaghers’ pharmacist heads REI’s new Women in Retail CommitteeRetail Excellence Ireland (REI) has established a Women in Retail Committee to work towards greater female participation at Board level in Irish retail companies.

Oonagh O’Hagan, managing director of Meagher’s Pharmacy Group, chairs the new Committee. Other pharmacist participants include: Debbie Smith from Boots Ireland; Ramona Nicholas from Cara Pharmacy and Goretti Brady from DocMorris. Fine Gael TD Áine Collins and Labour’s Ann Phelan are also members in order that the Committee’s interests can be represented in the Dáil.

“We carried out a survey at the REI Retail Retreat last September, which revealed that women represented fewer than 10% of Board/senior management members in Irish retail organisations,” said O’Hagan.

“Research from the Institute of Directors revealed similar results – it found that just 7% of directors were women. Some 78% of retail staff in Ireland are female and,

as women are usually the end consumer, this is a terribly low level of representation.

O’Hagan said that after the Retail Retreat, the REI Board (of which she is a member) decided that it needed to address the issue and established the Women in Retail Committee. Its first meeting will take place on the 13th of May.

“We have gathered together a group of high-achieving women who have many years of expertise between them,” O’Hagan told Irish Pharmacy News. “We wanted representatives from both large and small businesses. The Committee also includes women from Irish companies, such as the Kilkenny Shop and O’Brien’s Wines, as well as international retail organisations Benetton/Sisley and McDonalds.”

“We will officially launch the Group at the next Retail Retreat, which will take place in May in Kildare’s Carton House Hotel, and invite women to become involved. We are hoping to recruit around 100 women into the Group so that they can have the opportunity to network, discuss current challenges and exchange ideas.”

Oonagh O’Hagan, managing director of Meagher’s Pharmacy Group

8

NewsIrish pharmacist launches salt therapy to the UK marketSUCCESSFUL

PHARMACY TECHNICIAN DAYIT Carlow recently hosted a continuous professional development day for pharmacy technicians. Attendees included technicians working in hospitals and communities nationwide.

Students from third level colleges as far away as Limerick, Galway and Dublin also attended. President of the IACPT, Claire Ward was present as were Gerri Hughes, IACPT, Jennifer Mackey and Rebekah Corrigan of NAHPT.

Topics in focus included first aid in pharmacy, and understanding dressings. The NCSS discussed the role of the pharmacy technician in providing accurate information about the cancer screening services in Ireland, with particular focus on the new scheme for screening of bowel cancer. CPL Healthcare gave information about job applications, CVs and interview skills.

IT Carlow announced its new suite of Lifelong Learning modules which are open to technicinas from IPU, AIT, DIT, ITC and LYIT.

Information on the full range of modules, which include subjects such as Mental Health Awareness, Pharmacy Business Skills and Diabetes, can be obtained by contacting Dr. David Ryan, Department of Science and Health, IT College Carlow, david.ryan@itcarlow.ie or Nicola Cantwell nicola.cantwell@itcarlow.ie. Based on the success of this CPD day, a future event is planned for October. Register interest on facebook at Pharmacy Technician IT Carlow or email David or Nicola.

news brief

O’Donoghue, managing director of Virginia Medical Supplies is also a community pharmacist and owner of O’Donoghue’s Pharmacy

in Virginia, Cavan. Two years ago, he introduced Salin Plus Air Purifier to Irish pharmacies. The product is distributed by Pinewood

Healthcare to almost 600 pharmacies in Ireland and is also available online. The treatment uses dry sodium chloride to help relieve respiratory problems.

“When we launched in Ireland we targeted proactive pharmacies that we felt would suit our product and I am overwhelmed with the response from community pharmacists all over the country,” said O’Donoghue.

O’Donoghue launched the product in the UK in January this year. “We are very excited about the potential in the UK, where more than five million people have asthma. Furthermore our launch comes a year after the UK Government announced a fresh strategy to improve treatment for people with asthma and chronic obstructive pulmonary disease. Targeting GPs and clinicians across the country, we have contracted a high-profile public relations company to communicate the benefits of the product to target audiences. They have developed a comprehensive promotional programme, which will be delivered using traditional media as well as an online education programme social media campaign.”

The Salin Plus Air Purifier was launched to the UK media on January 16 at London’s Sanderson Hotel to a group of twelve health journalists as well as ‘media medics’ – well-known doctors that appear in the UK media/TV.

O’Donoghue said the company are was close to making a significant announcement about where UK consumers would be able purchase Salin Plus Air Purifier, but could not comment further until details were finalised.

Brian O’Donoghue, a pharmacist from Co Cavan, has just launched an innovative ‘salt therapy’ in the UK market, building on the success of the product in Ireland.

Diploma for RoryIPU President Rory O’Donnell recently graduated from the Irish Management Institute with a Diploma in Strategy and Innovation.

The course, which ran for seven months from November 2011 to

May 2012 involved formal face-to face-lectures as well as project work. The diploma is part of the IMI/UCC Masters of Business programme, which candidates can elect to pursue by completing two diplomas followed by a Business-Related Project. Rory is likely to

return to the IMI in a year or so to complete the MoB.

He commented that he found the course stimulating and very relevant to todays’ challenging business environment.

Brian O’Donoghue, Virginia Medical Supplies (left), at the UK Launch of the Salin Plus Air Purifier with UK TV doctor, Dr Bob Hicks

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Prescribing Information (Please refer to full Summary of Product Characteristics [SmPC])Exputex 250mg/5ml Oral SolutionPresentation: Carbocisteine provided as 250mg/5ml oral solution. Uses: As a mucolyticadjunct for respiratory tract disorders characterised by excessive or viscous mucous.Dosage and administration: Oral. Adults/Elderly: Three 5ml spoonfuls three timesdaily initially. Reduce to two 5ml spoonfuls three times daily when a satisfactory responsehas been obtained. Children: 6-12 years: 5ml spoonful (250mg) two to three times daily.2-5 years: Half a 5ml spoonful (125mg) two to three times daily. Under 2 years: Notrecommended. Contraindications: Hypersensitivity, patients with known active pepticulceration. Special Warnings and Precautions: Patients with a history of pepticulceration, avoid in patients with active ulceration, patients on a controlled sodium diet.Contains parahydroxybenzoates (E215, E217 and E219), sunset yellow FCF (E110) andethanol. Interactions: None listed. Pregnancy and Lactation: Not recommended.Undesirable Effects: Nausea, headache, gastrointestinal upset and skin rash.Overdose: No experience. Serious effects not expected. Legal category: S1B(E)Product Authorisation number: PA 488/14/1. Product Authorisation holder:Monmouth Pharmaceuticals Limited, Hampshire International Business Park, Chineham,

Basingstoke, Hampshire, RG24 8EP, UK. Distributed by: Cahill May Roberts,Pharmapark, Chapelizod, Dublin 20. Further information is available from: ShirePharmaceuticals Limited, Hampshire International Business Park, Chineham,Basingstoke, Hampshire, RG24 8EP, UK. Tel: +44 1256 894000. Date of revision: June2008. Exputex is a registered trademark of Shire US Inc. in Ireland.Adverse events should be reported to the Pharmacovigilance Unit at the IrishMedicines Board (IMB) (imbpharmacovigilance@imb.ie). Information aboutadverse event reporting can be found on the IMB website (www.imb.ie).Adverse events should also be reported to Shire Pharmaceuticals Ltd on+44 1256 894000.

Monmouth Pharmaceuticals Ltd, HampshireInternational Business Park, Chineham,Basingstoke, Hants RG24 8EP

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11

Importance of pharmacist’s role often goes unrecognised, says former chief pharmacist

As the former chief pharmacist at the Department of Health from 1977 to 2005, Tom McGuinn has been instrumental in initiating many changes in Irish Pharmacy, not least of which was laying the groundwork for the Pharmacy Act 2007.

“International standards of pharmacy practice at the time were moving towards extending more responsibility to the profession but the absence of an effective ‘fitness to practice’ system presented a major obstacle to the introduction of these developments,” said McGuinn.

“Pharmacists did not have the right to regulate themselves until 2007, when the Pharmaceutical Society of Ireland (PSI) was set up as an independent statutory body with a lay majority and with responsibility for the supervision of pharmacists and pharmacies, and the services that they provide,” continued McGuinn. “The 2007 Act replaced a number of Acts and regulations dating all the way back to 1875 and it is reasonable to say that, until then, the profession was effectively unregulated.”

“The concept of requiring pharmacies to be registered was new, so too was the extension of the principles of good manufacturing and wholesaling practice, in the

context of standards of good pharmacy practice. This presented a significant challenge to the profession.

“Compliance with those principles by manufacturers, wholesalers and those conducting clinical trials had been in place for over 30 years and it certainly was not before its time that similar principles would be required of pharmacies. This meant that there was much work to be done by all.”

The Pharmacy Act 2007 also introduced a requirement for continuing professional development for pharmacists in Ireland. In order for their registrations to be continued annually, pharmacists must confirm that they ‘maintained appropriate experience in the practice of pharmacy, keep abreast of continuing education and professional developments in the Pharmacy and to undertake appropriate continuing professional development relevant to the practice of pharmacy’.

Since its foundation in 1998, the Irish Centre for Continuing Pharmaceutical Education (ICCPE) was responsible for co-ordinating and delivering continuing pharmacy education and training for community pharmacists and pharmacy assistants in Ireland. McGuinn was involved with

Profile

Tom McGuinn, former chief pharmacist at the Department of Health & Children and former chair of the ICCPE Management Committee, has seen a number of changes since he has been in the profession. McGuinn spoke to IPN about the current state of the sector.

12

the ICCPE at its inception and became chair of the organisation in 2005, shortly after he left the Department.

CONTINUING PROFESSIONAL DEVELOPMENT

In February 2012, the PSI launched the Irish Institute of Pharmacy (IIoP) to oversee the delivery of CPD for pharmacy and the PSI awarded a contract to the Royal College of Surgeons of Ireland to facilitate the establishment and operation of this on behalf of the Irish Institute of Pharmacy.

“It was decided by the HSE, in consultation with the Institute, that it would be more appropriate that all the funding available for continuing pharmaceutical education should be invested in that Institute,” said McGuinn. “As a result, the office of the ICCPE closed on December 31, 2012, with all the activities that had previously been undertaken by the ICCPE ceasing from that date. All pharmacists and pharmaceutical

assistants were informed about this closure by letter dated 4th December

“To a degree, we saw the closure coming but we did not know the exact details of how this would happen. We found out for certain at the end of October, when the Management Committee was informally advised that the ICCPE funding was to be diverted to the new Institute,” he continued. “It had been expected that there would be some form of a transition and that some functions of the ICCPE would be folded into the IIoP and that the Institute management body would lead the profession, in meeting their CPD obligations.”

Instead, the Institute is charged with the overall development, management and overseeing the delivery of CPD for pharmacists in Ireland. It will identify the needs of pharmacists, service providers and the wider healthcare system and, subsequently, commission relevant learning activities from appropriate

providers. These accredited third parties will then roll out the training to be availed of by the individual pharmacists.

“We will, of course, have to wait and see how this will work out but we are moving in the right direction,” said McGuinn. “The PSI is making a very big effort to make progress with this new statutory role. The Institute will have to make certain that the necessary CPD opportunities are available and that compliance is being achieved. This will be a major task.

“CPD is recognised as an important area and it is now getting the attention that it deserves. It cannot be done overnight – it requires time and planning. Pharmacists will have to work hard on their CPD and put their learning into practice. In the end, it will be well worth the effort, as participation in CPD will not just contribute to the betterment of the profession, it will also contribute greatly to improved patient care. To date, all CPD has been voluntary

“To a degree, we saw the closure coming but we did not know the exact details of how this would happen. We found out for certain at the end of October”

13

PHARMACY BACKGROUNDMcGuinn graduated with a degree in Pharmacy from University College Dublin in 1964.

“Even though there were no pharmacists in my family, I was always very interested in science and chemistry, so it seemed the obvious choice for me. I moved into industry in 1965 and joined Antigen Pharmaceuticals. I have also done a lot of locum work over the years and, of course I did my apprenticeship in community pharmacy.”

McGuinn rose through the ranks of Pharmacy and served as an elected member of the Council of the Pharmaceutical Society of Ireland from 1971 to 1977. He is also a former member of the National Drugs Advisory Board (the predecessor of the Irish Medicines Board), the GMS Payments Board and was the last chair of the Poisons Council.

McGuinn took a step back from his PSI work after he was appointed chief pharmacist with the Department of Health in 1977, where he was mostly concerned with regulatory affairs relating to drugs, medicines and poisons. The health services had undergone a major overhaul just a few years earlier when the current General Medical Services (GMS) Scheme was introduced, replacing the previous outdated Dispensary System that had been in place under the Poor Law Act 1838.

“The introduction of the General Medical Services’ scheme was one of the biggest developments ever undertaken within the Irish healthcare system and it also changed the face of pharmacy,” said McGuinn. “The contracts for services under the GMS Scheme entered into by Health Boards with individual GPs and pharmacists were on the basis of a ‘fee per item’ and made available to card holders the freedom of choice of their doctor and pharmacy. In 1989, after a major review by the Department, the basis of payment for doctors was switched mainly to a capitation system. It was a period of great change.

“I also worked very closely with the National Drugs Advisory Board, which was eventually replaced by the Irish Medicines Board in 1995.”

but, in future pharmacists will be regularly assessed to make sure they are keeping up with their CPD activities and thus ensure that they continue to be fit to practice.”

McGuinn said that the details of how this will be monitored have yet to be announced but the PSI has recently notified all registered pharmacists of a series of information meetings to advise pharmacists on the PSI’s overall pharmacy education and training reform programme, including the new CPD model.

“I anticipate that the new system will work in a somewhat similar way to that required of medical practitioners,” McGuin added. “There is no sense in clocking up CPD points and, perhaps learning nothing. In Canada, for example, the pharmacist register is divided into five sections and sample groups from each section are called up for their CPD assessment. The Irish model might work in this way, where a representative sample will be evaluated annually.”

INCREASED RESPONSIBILITIES

McGuinn said he was hopeful that increased responsibilities would be extended to pharmacists in the future.

“With the flu vaccination and emergency contraception being made available in pharmacies, we are going in the right direction. It was also positive that the profession agreed to exercise restraint on the sales of codeine products. There is not always an appreciation of the pharmacist’s important professional role and initiatives like these are to be welcomed as they also raise the profile of the pharmacy.”

McGuinn said that pharmacists could possibly do more in this regard but he understood that they work under severe time constraints and with reduced resources in recent years.

“Under the 1996 community pharmacy agreement, pharmacists were required to review medications when a patient presented a prescription and to counsel the patient. In some instances, pharmacists are not getting the time to do this, which is very unfortunate,” McGuinn continued. “According to the pharmacy structure currently in operation, each pharmacy must have not less than one whole-time equivalent pharmacist, but this is obviously

not enough when you consider the range of responsibilities that this one pharmacist is required to discharge, including the obligatory medication reviews, the supervision of dispensing, front-of-shop sales and the counselling of patients. It is too great a responsibility for one pharmacist to deliver all these responsibilities.

“When I started in the profession back in the 1960s, it was common to have five or six pharmacists dispensing in a pharmacy. But back then, then there was much extemporaneous compounding being carried out. That compounding aspect has now largely disappeared and pharmacist manpower is being reduced to the absolute legal minimum. That presents a real difficulty for pharmacy if it expects further professional responsibilities to be given to the profession.”

McGuinn pointed out that current payment systems, based mainly on margins rather than on fees for services, poses a problem as it does not provide the type of incentive that will deliver a high-quality, professional pharmacy service, where the interests of patients are paramount. He would favour a move to fee-based payments but acknowledges that the country’s finances might not be healthy enough to support this. With a degree of ingenuity supported by a degree of flexibility on all sides, he considers that this should be possible. While this type of change would require some negotiation with the representative interests, the attitude of the Competition Authority to such discussions has not been helpful.

“Admittedly, it is probable that there are too many pharmacies in this country. There is also a strong case to be made for pharmacies to

employ more pharmacists in their existing pharmacies, instead of forcing the younger pharmacists to consider opening their own pharmacies. This will effectively dilute the available professional pharmacy services to such an extent that the provision of those services will be rendered so uneconomical that the quality of those services overall will be reduced to the lowest possible level.

“In general, I think that pharmacy is definitely going in the right direction but, like everything else in Ireland at the moment, how it plays out depends greatly on the resources available. Notwithstanding this, we should not underestimate the ingenuity of the various interests involved, particularly if the necessary degree of flexibility and goodwill were to be available,” McGuinn concluded.

“The Institute will have to make certain that the necessary CPD opportunities are available and that compliance is being achieved. This will be a major task”

14

NewsIncreased generic usage could achieve major savings for State drugs bill

REQUEST FOR NOMINATIONSThe acting PSI Registrar, Ciara McGoldrick, in her capacity as Returning Officer, has requested nominations from pharmacists on the Register of Pharmacists held by the PSI who may wish to stand for election for appointment to the PSI Council.

Nomination papers are available by request from the Acting Registrar and are also available to download on the PSI website. The closing date for receipt of nominations papers is Wednesday 20th March 2013 at 12 noon. Nomination papers should be returned to the PSI offices at PSI House, Fenian Street, Dublin 2.

The 2013 election for appointment to the PSI Council is being conducted in accordance with the PSI (Council) Rules 2008.

news briefThe ‘Cost of Medicines Index’ survey of 1,000 consumers, which was commissioned by Teva Pharmaceuticals Ireland, also found that the introduction of medicine use reviews (MURs) in the community pharmacy setting could significantly improve patient outcomes and lead to safer and more cost-effective use of both medication and healthcare resources.

The results were announced at a recent conference organised by Teva, which featured presentations from the London

School of Economics and the National Health Service experts. The seminar examined Ireland’s current medicines policy, made comparisons between EU countries, and proposed how Ireland can enhance the affordability of medicines.

Sandra Gannon, Teva’s general manager, said a sustained reduction in the costs of Ireland’s annual drugs bill would involve a wider programme of reforms, rather than just a sole reliance on the blunt tool of medicine price reductions.

“Medicine price cuts are not an infinite well for the generation of savings,” she said. “They can only deliver so much, particularly in a market which has a high cost of entry.

‘The UK, which has an 80% usage of generics versus a 20% usage in Ireland, has been very proactive in introducing measures to transform both dispensing and prescribing patterns. Technology that informs better prescribing at source, can achieve savings while protecting health outcomes.

“We must move now to replicate these advances, if we are to achieve better value for taxpayers, and make budget headroom for new medicines, measures such as these are required,” added Gannon.

The Department of Health

should also introduce and fund a comprehensive MUR programme in community pharmacy, delegates at the conference heard. Experience and outcomes from the UK suggests that MURs can demonstrate major improvements in patient compliance, less medicine wastage and better patient outcomes. A recent report from the South of England suggests that following MURs carried out for asthma and COPD patients, over 40% of those asthmatics involved in the MUR showed better asthma control following the intervention.

Speaking at the conference, Dr Sotiris Vandoros, London School of Economics, said: “Patent expiry of medicines alone will not generate savings. There must be a swift shift to generics. Generics will also allow resources to be used to fund new medicines.”

Other speakers at the conference included Dr Paul Cornes, NHS Consultant at the Bristol Oncology Centre who outlined actions which can be taken to meet the demand for new medicines, and Senator John Crown, Consultant Oncologist, St Vincent’s Hospital, who discussed the Health Pricing and Supply of Medicine Goods Bill currently before the Oireachtas, and how policy makers can influence more effective medicine use and better patient outcomes.

A new survey has found that 96% of the public would accept generic medicine if offered by doctor or pharmacist, while pharmacists are three times more likely to recommend generics than doctors.

Pharmacy group losses fall by 75%

According to the directors’ report from Behey Ltd, which is the pharmacy group’s parent company, net margins in its pharmacy business were down, relative to the results in previous years.

“These (pharmacy) reductions are directly attributable to the significant reduction in reimbursement levels by the Health

Service Executive for medicines dispensed to patients on their behalf and reduced dispensing fees from the Health Service Executive,'' said the report.

"There have been further reductions in these areas in 2012 and the outlook for 2013 is also expected to be challenging. The directors have succeeded

in clawing back some of the reductions through better purchasing and through savings in overheads," it said.

Behey Ltd also runs the Radisson Blu Farnham Estate Hotel in Co Cavan. The company’s operating profits declined by 11% to ¤5.4 million, according to the Irish Examiner.

Sandra Gannon, General Manager of Teva, pictured (left to right) with fellow speakers Larry Ryan of Behaviour and Attitudes, Prof John Crown and Dr Sotiris Vandoros of the London School of Economics.

The company that operates the McCabe’s Pharmacy Group has seen its pre-tax losses fall by 75% last year to €3.4 million, despite losses in its pharmacy division.

Easofen 200mg �lm-coated tablets. Easofen Max Strength 400mg �lm-coated tablets. Ibuprofen.Clonmel Healthcare Ltd., Waterford Road, Clonmel, Co. Tipperary.A copy of the summary of product characteristics is available on request.Medicinal product available for retail sale through pharmacy only. 2012/ADV/IBU/113. Date prepared: January 2013

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16

NewsLess optimism in pharmacy sector aslike-for-like sales dropNEW

PHARMACY BREATHES 'LIFE' INTO BRAY

“Life” is the country’s only pharmacy network where all of the pharmacies are franchise owned and operated. Currently the franchise network is growing with a new franchisee opening in Bray, and a further franchisee opening in Leixlip, Co. Kildare in March.

The new Life Pharmacy in Bray is the newest pharmacy in the Dargle Pharmacy family business. The well known name above the door of this new life pharmacy is Patrick Geoghegan MPSI, a respected professional in the industry, who among many other notable achievements, was a former president of the IPU.

"When we were looking to open our next pharmacy, it made perfect sense for us to look at joining up with a brand. The support that we have received from the life pharmacy team has been excellent and I have been very impressed with professionalism of the shop fi t team. Certainly we have no regrets in choosing to partner with life for the latest Dargle Pharmacy and look forward to developing a successful business together," he said.

The new pharmacy is a fi rst for the Life network, as it is a development of a vacant unit to open as an entirely new pharmacy – not a conversion of an existing business as with all previous Life pharmacies. The pharmacy features a robotic dispensary system which has been carefully planned to fi t into the relatively small square footage pharmacy.

news brief

Pharmacy like-for-like sales are down by 1.29% in the last quarter of 2012 compared to the last quarter of 2011, according to Retail Excellence Ireland’s (REI’s) ‘Irish Retail Industry Productivity Review: Q4 2012’.

“Q4 of 2012 proved to be very challenging in the retail pharmacy sector. Having seen some slight positive signs in Q3, November 2012 saw further cuts in drug prices which helped to push the sector into negative growth again,” said Patrick McCormack, MD of the Sam McCauley Chemist Group. “General consumer demand was not helped by the late Budget announcements. November alone saw a drop in pharmacy sales of 3.01% (see diagram).

“In the front-of-shop area, there were some positive signs but these were very much driven by heavy discounting in many areas to maintain market share. This year promises to be another challenging year, with further decreases in drug prices and a review under way of pharmacist professional fees under the FEMPI legislation.”

A breakdown of the quarter reveals the full effect of the drop in sales in November. In October, total sales were up .16%, with dispensary up 2.91%. However, OTC dropped by .51% and retail sales fell by 4.49%. The situation worsened in November, with dispensary down by .41%, OTC down by 1.22% ad retail down by 3.62%. The ‘Christmas factor’ meant that total sales rose again in December, but only by .09% (dispensary fell by 1.76%, but OTC sales rose by 1.31% and retail was up by .11%.

The gloomy outlook in the REI report is echoed by the latest Irish Pharmacy Union (IPU) research. According to the

Union’s Q4 2012 pharmacy ‘Business Trends Survey’, more than half of pharmacies (54%) are anticipating diffi cult times ahead and are less optimistic about their business prospects than they were last October. Just under half (49%) believe that the overall environment for their business is worsening. The number of Irish pharmacies expecting to suffer a fall in sales in the next three months has increased sharply, from 46% to 58%.

Other fi ndings from the survey confi rm:

• There has been no change in employment numbers in the three months prior to the survey, with employment levels anticipated to remain relatively stable;

• Stock levels were below normal for the time of the year for 26% of respondents, with 12% reporting stocks above normal;

• Business costs – in particular energy, employment, waste charges and commercial rates – remained a concern, with 43% reporting an increase in costs in the previous three months. Only 6% reported a reduction in business costs;

• Further cuts to pharmacy payments under the FEMPI legislation were the main business concern for 53% of respondents.

"The latest survey shows that while the majority of Irish pharmacies expect a signifi cant drop in sales in the next three months, most are managing to maintain employment levels,” said Rory O’Donnell, IPU president. “We have serious concerns, however, that if business costs, particularly State-infl uenced business costs, continue to increase, this will represent a clear danger to employment.”

2012 PHARMACY SALES LIKE-FOR-LIKE SALES Q4 2012 (INDUSTRY AVERAGE)

Oct +0.16% +1.26%

Nov -3.01% -0.17%

Dec +0.09% +0.31%

Q4 2012 -1.29% +0.21%

Patrick McCormack, MD of the Sam McCauley Chemist Group

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18

Debate

Dispensing errors - is too much being asked of pharmacists?Patient safety and providing the best patient care is every pharmacist’s first priority and the sector’s professional practice is built around this responsibility. Hand in hand with responsibility goes accountability but, are dispensing errors punished too harshly and is too much being asked of pharmacists in this regard?

A number of cases of dispensing errors have featured in the media in recent months, not least of which was the case of pharmacist Joseph Kelly of Castlemartyr, Co Cork. Kelly was sued for dispensing Daktarin mouth gel to a patient, who was on warfarin treatment and who died as a result of drug-drug interaction. The patient’s widow received ¤520,000 as a result of her High Court action.

The Pharmaceutical Society of Ireland (PSI) confirmed that any complaint regarding a pharmacist's misconduct or error would have to be considered on its own merits. The context and mitigating circumstances would all be taken into account because each case is potentially different.

“Overall, the superintendent and supervising pharmacist have responsibility for the safe management of medicines and patients,” said Kate O’Flaherty, PSI head of communications. “All medicines must be supplied by or under the personal supervision of a pharmacist.”

She said that, as with prescription medicines, checking a person's medical history and current medicine use was an important part of that safe supply, to ensure that a person did not take a non-prescription medicine that would, for example, interact with something else they took or which was not suitable for them because they had a particular medical condition.

“Where pharmacists involve other members of staff in the sale and supply of non-prescription medicines, they must ensure that, through appropriate policies, procedures and staff training, they have the requisite knowledge and skills for the work for which they are responsible,” she continued.

“This is what we sign up for when we become pharmacists,” agreed Mary-Rose Burke, Boots’ chief pharmacist. “Medications are poisons; this is why their sale is restricted through pharmacies – we are the safeguard for the patient when it comes to these powerful chemicals and we accept that responsibility wholeheartedly.

“Unfortunately, there are occasional shortcomings in the care given to patients. As we saw in the Castlemartyr case, these can have catastrophic consequences for the patient. But these are very rare occurrences and I would hate for the public to lose any degree of confidence in pharmacy as a result. We have to stress the value that pharmacists provide to the health service and to thousands of patients annually.”

Burke said that the vast majority of pharmacists had no problem with the current regulatory system. However, despite legislation and regulation, mistakes still happened in pharmacy. “It is impossible for any industry to report a zero error-rate. Human error cannot be legislated for. The important thing is to learn from any errors that occur.”

She said that although pharmacists are not covered by the State’s Clinical Indemnity Scheme, they must insure for mandatory professional indemnity. “Professional indemnity is absolutely vital in the event of a pharmacist making an ‘act or omission of action that causes harm to a patient'. This insurance means that the patient can have redress," she continued.

“The Pharmacy Act 2007 has a strong focus on risk management and gives us up-to-date, modern legislation. The PSI, in its sanctions, acts in the public’s best interest and not necessarily the pharmacist’s – and this is as

it should be. In this regard, it is great that we have mandatory CPD coming down the line because it is vital that we keep our skills up to date.

“If a doctor makes a mistake on a prescription or the pharmacist cannot read the handwriting, then it is part of the job to address this. The separation of the prescription and the dispensing process is itself a risk-management procedure. In cases of dispensing errors, a judge would take each case on its own merits. Ultimately, the judge may decide that the pharmacist is at fault, that it is the doctor’s fault or that both are responsible as independent, autonomous professionals. I think that is the fairest way to approach such cases.”

RESPONSIBILITY

“I think pharmacists are stuck between a rock and a hard place,” said an independent pharmacist from Clonmel, Co Tipperary. “On one hand, we bear so much responsibility for patient safety but, on the other, our position in the health service is not valued as much as it should be – certainly not by the public. We are an important link in the health service because if a patient does not take the medication properly, then

all the tests, doctor visits and diagnoses that have gone before are wasted.

“Having said that, I think it would be unfair if a pharmacist was to be punished for a doctor’s prescribing mistake. We are under so many time pressures in the past few years that it would be unreasonable to expect pharmacists to keep calling the local GPs to check what they have written on the script – it is just not practical in real life. I am not using that as an excuse for a dispensing error; I am just saying that if the mistake originates with the doctor, that should be taken into account strongly if the patient was to suffer harm as a result.

“We just do not have the resources at the moment to meet all of our requirements properly,” he said. “Obviously, patient care and safety is paramount and that always comes first but I am running to stand still when it comes to keeping up with paperwork, PSI requirements, medication reviews, supervising everything that is dispensed and front-of-shop – and all while trying to make a profit and pay the rent. I am afraid that there will be more instances of dispensing errors coming down the line because we just have too much on our plates.”

Joanne Kissane

19

COMPLAINTS AND ENQUIRIES

Joanne Kissane, superintendent pharmacist with DocMorris said that the PSI must act to protect the health and safety of the public and also has an important role in improving the pharmacy profession.

“Unfortunately dispensing errors happen and, regrettable as they are, they can be made by any pharmacist, no matter how proficient or professional,” she added.

“Even if a complaint is proven against a pharmacist, neither the holding of an inquiry nor a finding against the pharmacist concerned contributes to improving the provision by pharmacists in general of pharmacy services to the public any more than could be achieved by other means – such as the issuing of guidance to the profession or through the PSI newsletter or, more constructively, by the pharmacist agreeing to undergo additional training.”

She said that the holding of an inquiry, in many cases, served no purpose other than punishing the pharmacist concerned in the event of the complaint being proven.

“Pharmacists are dedicated to maintaining the health and wellbeing of patients and form a barrier between safety and harm on a daily basis for patients. This important role is overshadowed in situations where a dispensing error occurs and a complaint is made, and is often forgotten in the protracted and stressful complaints procedure.

“However, in cases where a pharmacist is complacent about his or her responsibilities to the public and where there is continuing non-compliance with legislation; guidance and principles of good professional practice, then the role of the regulator in ensuring that standards of professional competence and ethical conduct are upheld is immensely important. I would see it as of paramount importance that the regulator conducts inquiries into these situations and that sanctions are imposed as appropriate.”

MEDIA SPOTLIGHT

Aaron Carlyle, pharmacist with Brennan’s Pharmacy in Buncrana, Co Donegal said the profession needed processes to ensure accountability but that he felt sorry for anyone, who found themselves in the media spotlight because of a dispensing error.

“No mistake is intentional and

there will always be ‘human error’. Even if someone makes a minor mistake that could not cause any harm, it becomes public knowledge and appears in the national and industry press. Under the Pharmacy Act 2007, the media are entitled to report on the PSI’s investigations, on the basis of transparency, patient safety and public interest.

“The PSI has to follow due process but I think the publicising of minor errors, where safety was not compromised is perhaps unhelpful,” Carlyle continued. “It can undermine public confidence in the profession and encourages a culture of blame instead of a safety culture. We need an open forum, where pharmacists voluntarily report ‘near misses’ – so we can all learn from these. If a pharmacist who makes a mistake, even if no harm was caused, is afraid to speak up for fear of it becoming public knowledge, that is not good for the profession."

In the UK, some 961 million items were dispensed in 2012 but it is difficult to get dispensing data for Ireland because of the data collection method and the divide

between State-funded and private prescriptions. However, studies show that pharmacists intercept many prescribing mistakes. Carlyle referred to a 2010 study in the Irish Journal of Medical Science, which found that 27% of individual prescriptions in an Irish hospital had potential to cause prescription error because of illegibility or omission of medication

administration details.

Another study in the European Journal of General Practice from 2009, documented errors in prescriptions from 28 GPs, over a three-day period in 12 community pharmacies. Some 12.4% of scripts contained one or more errors. The majority were minor (72.9%) but 24.7% were major nuisance errors and there were 2.4% potentially serious errors.

“This is what we deal with every day, and all the while under a lot of time pressures,” Carlyle commented. “It is a shame that the number of mistakes we pick up is not in the public domain.”

TACKLING THE PROBLEM

Carlyle said that one way to reduce dispensing errors was to work more closely with GPs. The PINCER trial found that pharmacist reviews in UK GP practices cut prescribing errors by 30%. “We are seeing more pharmacists under the same roof as GPs in primary care centres but it would be great if they actually worked in the same practice – not two separate business areas,” he said.

“We would see fewer prescription/dispensing errors if we had more pharmacists carrying out medication reviews, producing formularies and tackling difficult prescriptions in the GP practice. After all, GPs are under a lot of pressure, too.

“Better use of technology would also reduce dispensing errors. A 2007 study in the International Journal of Pharmacy Practice estimated that a stand-alone system would prevent about one in five content errors and would greatly reduce labelling errors. A Patient Medication Record-linked system would prevent one-quarter of content errors and one-third of labelling errors and an Electronic Transfer of Prescription-linked system would prevent nearly half of content and labelling errors. The researchers estimated that 22% to 60% of moderate errors could be prevented, depending on the system used.

“There will always be human error and I agree with Mary-Rose that it is very unlikely that we could ever see a zero error-rate. Our

Pharmacy Act is still in its infancy and it will be interesting to see whether pharmacists will agree that its disciplinary procedures are truly fair and appropriate for both patients and pharmacists,” Carlyle said.

"Unfortunately many of our patients have no understanding or appreciation of how many errors pharmacists detect and how much time we spend liaising with prescribers to ensure these issues are resolved. This area of quality assurance and clinical governance is an area where pharmacists across the country offer substantial value in the healthcare system. This is particularly significant when we consider the sizeable costs associated with drug related hospital admissions, readmissions and the negative health outcomes that occur as a result of adverse drug reactions and unnecessary 'polypharmacy'.

“I feel that this is an area where pharmacists should, ultimately be paid for by the Government, as part of the pharmacy contract. This could be achieved with a drive for quality and a structured agenda and framework for recording and reviewing the relevant data from pharmacists. One which embraces a pro-active and generative safety culture, rather than one of blame, where risk management is an integral part of pharmacy processes.

"Unfortunately, the current system fails to deliver this on a number of levels,” Carlyle concluded.

Mary-Rose Burke

“Unfortunately there are occasional shortcomings in the care given to patients. These can have catastrophic consequences...but are very rare”

20

News‘Conscience clauses’ should be scrapped, say RCSI researchers

IMB STATES THAT DIANETTE IS SAFE TO USEThe Irish Medicines Board (IMB) has reassured patients prescribed the contraceptive pill Dianette that they should continue to take their medication, even though French authorities have raised concerns about the drug.

France has asked the European Medicines Agency (EMA) to review the third and fourth generation combined oral contraceptive, to determine if there was a need to restrict the use of these medicines in women who cannot take other combined oral contraceptives.

France has suspended the marketing authorisation of Diane 35 — marketed in Ireland as Dianette — following a recent report which found a high risk of thromboembolism and limited benefi t in treating acne.

“Last month, the EMA issued its intention to conduct the review [that has been requested by France] and the IMB will be actively involved in that review in the coming months,” said an IMB spokesperson. “There is no reason for any woman to stop taking her contraceptive. If a woman has concerns, she should discuss this with her doctor.”

Dianette is approved for use in Ireland since 1988 and is indicated for use in the management of severe acne vulgaris, especially those forms which are accompanied by seborrhoea or by infl ammation or formation of nodes in women. It is also indicated as an oral contraception for the woman suffering from the above.

The product information also states: “Although Dianette also acts as an oral contraceptive, it should not be used in women solely for contraception, but should be reserved for women requiring treatment for the androgen-dependent acne described.”

It is long been established that combined contraceptives carry a very small risk of venous thromboembolism (VTE). Pharmacists can advise patients about the risks of VTE, or refer them to the approved product information for prescribers and patients, which is included in the product packaging.

news briefAll pharmacists in Ireland and in the UK should be required to dispense emergency contraception regardless of their moral or religious objections, according to a new report published in the Journal of Medical Ethics.

The researchers – from the University of Hertfordshire’s Pharmacy Department and the Royal College of Surgeons in Ireland’s School of Pharmacy – argue against the Pharmaceutical Society of Ireland and the UK’s General Pharmaceutical Council’s ‘conscience clause’. This allows pharmacists to refuse to dispense emergency contraception on religious or moral grounds, as long as they refer patients to other facilities where they could access the service. The morning-after pill has been available without prescription in Ireland since 2011.

The researchers reported that there have been a growing number of cases of women being refused the medication — even when prescribed by a doctor — on the grounds of the pharmacists supposed religious conscience. They said that this situation was “not satisfactory" to either conscientious objectors or to those

who must regulate them.

They added that pharmacists who objected to supplying the pill "have allowed themselves to be convinced that referral to another willing supplier is ethically any different from supply" and that regulators have created a "pass the buck system".

The researchers said that the situation was morally no different from refusing to supply 200 paracetamol tablets to depressed customers for the purpose of committing suicide, but explaining to the patients that they could purchase tablets in local newsagents, grocers and supermarkets. “If they do not believe that paracetamol should be put to this purpose, then they must remove themselves entirely from the chain of supply," according to the report.

They warned of the "inevitable incidence" of a pharmacist refusing

to supply the morning-after pill to a patient who could not be referred elsewhere — for example, in a rural area where the nearest alternative supplier might not be accessible within the 72-hour time window.

"Either the General Pharmaceutical Council's and Pharmaceutical Society of Ireland must compel all pharmacists to dispense emergency contraception to all patients meeting the clinical criteria who request it regardless of their own moral or religious objections, or the pharmacist must refuse both to supply EHC and to refer the patient to an alternative supplier and confront the possible consequence of a complaint against them for poor professional performance or professional misconduct,” said the authors.

"The alternative is to remain locked in the current cycles of mutual cognitive dissonance wherein the objectors convince themselves that referral does not constitute supply and the regulators do not place themselves in the position of having to deal with a vocal religious minority of whom they are terrifi ed,” the report concluded.

Allegro to distribute new treatment for irritable bowel syndrome

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A new product for the treatment of irritable bowel syndrome (IBS) has been launched in Ireland and is being distributed by Allegro, one of the largest and longest-established sales, marketing and distribution companies in Ireland.

David Fox, Ivan Ryan and Tony Pacitti, all from Allegro, at the launch of Symprove in Ireland

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Headache Awareness Week in association with

Nurofen will be investing half a million euros behind awareness raising activities, which will include a national radio campaign, outdoor, public relations, in-store materials and the provision of a free to download Nurofen Headache Soother app.

Make Nurofen the first choice for headacheOver two thirds of people (69%) will take a pain reliever to manage headache symptoms(1). Ibuprofen, which is the main active ingredient in Nurofen, provides superior headache relief compared to paracetamol(3,4,5) with almost twice as many people experiencing complete headache relief in one of the studies*(3).

The reality and severity of headaches in Ireland

3.2 million people in Ireland suffer from headaches(1). According to the World Health Organisation headache is under-recognised, under-diagnosed and under-treated(2). As the first ever Headache Awareness Week in association with Nurofen takes places from 16th to 23rd of March 2013, the campaign is intended to make people more aware of the types and causes of headaches, as well as highlighting the important role of the pharmacist in managing headache.

New research carried out by Nurofen shows that headaches are widespread and something that people have to frequently deal with(1).Almost one in five people (17%) get headaches once a week or more, with 7% of people experiencing them two to three times a week(1). The levels of pain can be significant with a fifth of people surveyed describing their pain as ‘bad,’ ‘very bad,’ or at a level where they feel they ‘cannot cope’(1)

References.(1)Headache Awareness Week, Headaches in Ireland research, Conducted January 2013, this survey was nationally representative of the population of the Republic of Ireland aged 18+. A total of 963 people participated in this survey. (2) Atlas of headache disorders and resources in the world 2011. A collaborative project of World Health Organization and lifting the burden. 2011. (3) Schachtel BP, Sandy A, Furey MD et al. Non prescription ibuprofen and acetaminophen in the treatment of tension-type headache. J Clin Pharmacol 1996; 36: 1120-5. (4) Fogelman F. A study to compare the analgesic efficacy of oral doses of ibuprofen 400mg, paracetamol 1000mg and placebo under

Abbreviated Prescribing Information. (1) Nurofen Express 200mg Tablets. (2) Nurofen Express Maximum Strength 400mg Tablets. (3) Nurofen 200mg Coated Tablets

Presentation: (1) Nurofen Express 200mg Tablets; tablets containing Ibuprofen 200mg (as sodium dihydrate). (2) Nurofen Express Maximum Strength 400mg Tablets; tablets containing Ibuprofen 400mg (as sodium dihydrate), (3) Nurofen 200mg Coated Tablets; tablet containing 200mg Ibuprofen.Indications: (1, 2, & 3) anti-inflammatory, analgesic and antipyretic for short-term management of mild to moderate pain such as is associated with headache, dental pain, fever, period pain, muscular strain, backache, and for the management of the symptoms of head colds and influenza, (3) For the symptomatic treatment of osteoarthritis. Dosage & Administration: For oral administration. Short term use only. Adults and children over 12 years: (1) Nurofen Express 200mg Tablets: 1-2 tablets every four hours with a maximum of 6 tablets in a 24 hours, i.e. maximum dose of 1200mg in a 24 hour period. (2) Nurofen Express Maximum Strength 400mg Tablets; ONLY 1 TABLET PER DOSE. 1 tablet every four hours with a maximum of 3 tablets in a 24 hours, i.e. maximum dose of 1200mg in a 24 hour period. Max duration of treatment 3 days. (3) Nurofen 200mg Coated Tablets: Adults and children over 12 years: Initial dose is 400mg and subsequently if necessary 200mg to 400mg every four hours with a maximum of 1200mg in a 24 hour period. (1, 2, & 3) If the symptoms worsen you should consult a doctor. Not suitable for children under 12

years of age without medical advice. Use NSAIDs with caution in the elderly and at the lowest dose of shortest period due to higher risk of adverse drug reactions (ADRs). Discontinue if no benefit is seen or intolerance occurs. Contraindications: (1, 2 & 3) Patients with: History of GI bleeding or perforation related to previous NSAIDs therapy. Active or history of recurrent peptic ulcer/haemorrhage other gastrointestinal disorder. Hypersensitivity to ibuprofen or if any of the excipients, aspirin or other NSAIDs. Severe hepatic failure, severe renal failure or severe heart failure. Rare hereditary problems of fructose intolerance, glucose-galactose malabsorption or sucrase-isomaltase insufficiency. Do not use in children under 12 years of age (1& 2) or during the last trimester of pregnancy. Special Warnings and Special Precautions for Use: (1, 2 & 3) Elderly: increased frequency of ADRs to NSAIDs especially GI bleeding and perforation which may be fatal & prolonged use not recommended. Avoid concomitant use with NSAIDs, including cyclooxygenase-2 selective inhibitors. GI bleeding, ulceration or perforation, can be fatal and occur any time during treatment, with or without any warning symptoms not only in the elderly or those with a previous history of serious GI events. Risk is increased with duration of use/dose/patients age/previous history/concomitant medications (e.g. oral corticosteroids, anticoagulants such as warfarin, SSRI’s or anti-platelet agents such as aspirin). If GI bleeding or ulceration occurs withdraw treatment immediately. NSAIDs should be given with care to patients with a history of gastrointestinal disease (ulcerative colitis, Crohn’s Disease) as their condition may be exacerbated. Caution (discussion with doctor or pharmacist)

Headachesin Ireland:How pharmacists can help customers manage head pain

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*Study compared 400mg Ibuprofen tablets vs 1,000mg Paracetamol tablets. ** Refers to absorption compared to standard Ibuprofen 200mg tablets.

Headache Awareness Week is sponsored by Reckitt Benckiser, makers of Nurofen.

Nurofen Express targets

pain twice as fast as standard

Ibuprofen(9)**

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Jean McAleenan, a pharmacist, notes that when a customer asks for a pain reliever for a headache, she uses the opportunity to explore more about their health. “The pharmacist is best placed to provide a full consultation to a headache sufferer about their pain. I will ask the customer if this is a once off, or if they have been having a number of headaches recently. I also ask what kind of pain they have and how long they have had it. Asking a few quick questions often leads to a lot of information and means that you can better understand their individual symptoms and recommend the best course of action for pain relief.”

“

“

In professional headache guidelines,

Nurofen is recommended as a first line treatment for headaches in adults

and children on the basis of it’s efficacy and

safety(6,7,8)

1st

3.2 million people in Ireland suffer from

headaches(1). According to the World Health

Organisation headache is under-recognised, under-

diagnosed and under-treated(2).

3.2m

Trade advert single pages 210mmx297mm+5m bleed.indd 2 19/02/2013 14:41

is required prior to starting treatment in patients with a history of controlled or uncontrolled hypertension and/or heart failure as fluid retention and oedema have been reported in association with NSAID therapy. Please refer to SmPC section 4.4 for full detail. Caution in patients with uncontrolled hypertension, congestive heart failure, established ischaemic heart disease, peripheral arterial disease, and/or cerebrovascular disease and those with risk factors for cardiovascular events (e.g. hypertension, hyperlipidaemia, diabetes mellitus, smoking). Increased risk of arterial thrombotic events & myocardial infarction with long term use. Serious skin reactions, some of them fatal have been reported very rarely, see SmPC for full detail. In patients with renal, cardiac or hepatic impairment, intracranial haemorrhage and bleeding diathesis caution is required. If pregnant, elderly, suffer asthma, bronchospasm, (1 & 2) SLE or are on any other medication, consult a doctor before taking this medicine. Patients with rare, hereditary problems of fructose intolerance, glucose-galactose malabsorption or sucrase-isomaltase insufficiency should not take this medicine. This medicine may cause impairment of female fertility by an effect on ovulation. This is reversible on withdrawal of treatment. (1) Each 200mg tablet contains an average of 24.6mg (1.07mmol) of sodium ,(2) and each 400mg tablet contains an average of 49.2mg (2.14 mmol) of sodium this needs to to be taken into consideration for those on low salt diet.Interactions: (1, 2 & 3) This medicine is known to interact with the following, please see SmPC for full detail: Corticosteroids, Anti-coagulants, Anti-platelet agents and SSRIs, Anti-hypertensive, Diuretics, Cardiac glycosides, Lithium, Methotrexate, Ciclosporin,

Other NSAIDs, Aminoglycosides, Probenecid, Oral hypoglycaemic agents, Zidovudine, Mifepristone, Tacrolimus, Quinolone antibiotics and low dose aspirin.Pregnancy and Lactation: (1, 2 & 3) Ibuprofen is not recommended during the first six months of pregnancy and is contraindicated in the last trimester of pregnancy. Ibuprofen and its metabolites can pass in very small concentrations into the breast milk. No harmful effects to infants are known, so it is not necessary to interrupt breast-feeding for short-term treatment with the recommended dose for mild to moderate pain and fever. Undesirable Effects: (1, 2 & 3) The most likely side effects are dyspepsia, nausea, gastrointestinal intolerance and bleeding. Skin rashes, including pruritus, erythema, urticaria, maculopapular rash and other allergic reactions have been reported. Very rarely erythema multiforme has been reported (3) Thrombocytopenia has also been reported. Haematopoietic disorders have also been reported very rarely. Please refer to SmPC (section 4.8) for full detail.Legal Category: Retail Sales through Pharmacy only.PA Holder: Reckitt Benckiser Ireland Ltd, Citywest Business campus, Dublin 24, Ireland. PA Number: (1) PA 979/32/10, (2) PA 979/32/11, (3) PA 979/32/06. Date of preparation or last review of abbreviated prescribing information: January 2013For full prescribing information, please consult the SmPC which is available on www.medicines.ie. For product queries please call (01) 630 5429 or contact Reckitt Benckiser Ireland Ltd., Citywest Business Campus, Dublin 24.Item No; IRL/N/0113/0001n. Date of Preparation; January 2013*The views expressed by the healthcare professional are their own.

March 16th – 23rd

double-blind conditions in non specific headaches. 1985 Study no. M85099. (5) Noyelle RM, Crossland DM and Pickvance NJ. Ibuprofen, asprin and paracetamol in a community study. The pharmaceutical Journal, 1987 May; 238(561-564) (6)Evers S, et al. Eur J Neurol 2009; 1(9):968-81. (7) Bendsten L, et al. Eur J Neurol. 2010; 17(11):1318-25. (8) Steiner TJ, et al. Practitioner 1983; 227(1377):465-7. (9) Dewland, et al. Bioavailability of Ibuprofen following oral administrationof standard Ibuprofen, sodium Ibuprofenor Ibuprofen acid incorporating poloxamer in healthy volunteers. Clin Pharmacol 2009 Dec 5;9:19.doi: 10.1186/14 72-6904-9-19

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24

NewsWork-related stress - a growing problem?

The community pharmacy profession in Ireland has undergone dramatic changes in recent years. Research on stress among community pharmacists in some jurisdictions, notably Northern Ireland and New Zealand, has pointed to a rise in occupational stress due to increased bureaucracy, a culture of long working hours, increased patient care demands and the need to balance clinical expertise with management skills.

Given the recent changes in legislation and the author’s experience of community pharmacy to date, it was timely to examine the issue of work-related stress among community pharmacists in Ireland. This research was conducted for a Master’s thesis, which formed part of an MSc in Management that was completed in September 2012.

The research for this study was carried out among a sample of 73 community pharmacists working in the Republic of Ireland, using questionnaires and semi-structured interviews. Participants were asked to rate the frequency of stress experienced in different situations (35 in total) by selecting one of the following options:

• Never

• Rarely

• Sometimes

• Often

• Frequently.

The questionnaire and interviews covered fi ve key areas:

• Patient care responsibility

• Workload

• Work confl icts

• Professional recognition

• Professional uncertainty.

The results demonstrated that work-related stress is experienced by the community pharmacists who participated in this study. Stress was experienced by participants across each of the fi ve areas examined by the questionnaire and the four interviewees were found to experience work-related stress also. Table 1 lists the top six factors which questionnaire participants said caused them stress ‘frequently’.

Table 1: Top 6 situations which participants said caused them ‘frequent’ stress

• Interruption by phone calls or other staff when performing work duties: 33%

• On-going uncertainty over HSE drug prices and fees paid to pharmacists: 29%

• Excessive or increased workloads: 25%

• Not being able to fulfi l one's abilities to the fullest: 22%

• Having so much work to do that everything cannot be performed well: 21%

• Not having enough staff to provide necessary services adequately: 21%

PATIENT CARE RESPONSIBILITY

Some 92% of pharmacists surveyed were found to experience some level of stress because they are responsible for patient outcomes. As the number of items dispensed per day increased, the frequency of stress was also seen to rise.

This may be linked to the increased likelihood of an error occurring, as data from other studies indicate that the rate at which pharmacists identify prescribing problems is

related negatively to the number of prescriptions they dispense per hour. In this study, 75% of pharmacists were found to experience stress due to a fear of making a mistake.

PROFESSIONAL-BUSINESS ROLE DICHOTOMY

The combination of clinical and managerial roles is known as 'professional-business role dichotomy'. The issue of managerial duties causing stress was a recurring theme throughout the questionnaire and interview data. A large proportion of pharmacists (67%) indicated they were stressed as a result of having to entrust work to others. While stress due to clinical responsibilities was evident, issues surrounding pharmacy management also contributed to stress levels.

The interviews allowed participants to be more open about this apparent professional-business dichotomy. Once their responses were combined with the evidence from the questionnaire data, it was clear that non-clinical duties, such as stock, human resource and fi nancial management are taking up an increasing amount of time and leading to increased pressure on many pharmacists. One striking quote from an interviewee stated: “A degree in pharmacy doesn’t teach you anything about the day-to-day running of a pharmacy.”

This evidence implies that the role of a pharmacist now involves increasing managerial responsibilities which must be carried out in addition to clinical duties. Research from the UK and Europe also indicates that management skills can be as important as medical skills in a community pharmacy.

PROFESSIONAL RECOGNITION

Not being able to use one’s abilities to the fullest proved to be an important issue for many pharmacists. Just under half (49%) of questionnaire respondents were found to be ‘frequently’ or ‘often’ stressed by this. There appears to be a frustration among pharmacists that current work practices mean they cannot interact with patients as much as they would like, leading to lack of self-fulfi lment. This was a particular cause of worry for pharmacists.

Pharmacist Michael Doody outlines the results of his recent research into work-related stress among community pharmacists. He found that community pharmacists are particularly prone to work-related stress and that administrative and managerial tasks are assuming much greater importance for many pharmacists.

One participant reported: “Increased workload regarding paperwork, mainly in trying to adhere to all the new PSI regulations, leaves little time for what you’re qualifi ed to do.” Another said: “Time to speak with patients has reduced dramatically.”

While dispensing and administration duties are, to some extent, preventing pharmacists from taking a more active role in patient care, business management duties are becoming more important and taking up more time, to the detriment of patients. This is having a knock-on effect on the perceived quality of patient care, which is adding to the stress levels of pharmacists.

MANAGING WORKLOAD

The majority of respondents (81%) experienced some level of stress due to work overload, as shown in Diagram 1.

Diagram 1: Pie chart of frequency of stress experienced due to excessive or increased workloads

Interestingly, in 50% of cases, those working in single independent pharmacies experienced stress ‘often’ and ‘frequently’. However, for those working in small multiples (2-5 pharmacy chain), this fi gure was 36%.

In addition to this, 42% of those in single pharmacies experienced stress due to lack of control over workload ‘often’ or ‘frequently’. This compares to the lower fi gure of 28% for those working in small multiples. In 50% of cases, those working in single pharmacies experienced stress ‘often’ and ‘frequently’, due to having so much work to do that everything could not be performed well. However, for those working in small

Michael Doody

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26

SCHOOL OF PHARMACY MOVES TO INSTITUTEThe Trinity College School of Pharmacy & Pharmaceutical Sciences recently moved to Trinity Biomedical Sciences Institute (TBSI), a state-of-the-art research facility supported by HEA’s PRTLI Cycle 5.

"This is an exciting development for our School which allows us to excel in pharmaceutical research and development. This new facility will provide us with high-tech technology and interdisciplinary collaborations to support our research," says Professor Marek Radomski. Radomski, Head of this School and Director of the Centre for Cancer Drug Discovery in TBSI, is a highly-cited pharmacologist interested in nanomedical research.

To mark the opening, the School also held a Research Symposium. The Symposium started with presentations honouring and celebrating the research achievements of Professor Owen Corrigan. Corrigan is the founder of modern pharmaceutical technology research in Ireland. Following these presentations, a keynote lecture was delivered by Professor Patrick Vallance. Vallance is the President of Pharmaceuticals R&D at Glaxo Smith Kline (GSK). He discussed how the process of discovery advances drug development. Following the lecture, Principal Investigators from the School of Pharmacy & Pharmaceutical Sciences went on to highlight their innovative and groundbreaking research.

news brief

Newsmultiples, this fi gure was 36%.

Pharmacists working in single pharmacies are experiencing more stress than those working in small multiples, large multiples or pharmacy chains and may be more at risk from the negative outcomes of stress than those working for larger chains.

When asked to describe how busy the pharmacist is in a normal day, one interviewee remarked that “whether or not he managed to eat lunch” was an indication of how busy he was, and his duties consisted of “doing everything and anything”. He went on to explain: “Complex prescriptions from hospitals increase workload; having a few of these prescriptions will have a signifi cant impact. You get stretched and stress levels go up.”

As shown in Table 1, 33% of respondents reported interruption by phone calls or other staff when performing work duties to be a ‘frequent’ cause of stress. This was the highest ‘frequently’ response obtained from all the questionnaire questions, indicating that this is a very important issue. These fi ndings mirrored the results of a recent similar study in Northern Ireland.

LACK OF CHALLENGE

Over half of respondents reported experiencing stress because they did not consider their work to be challenging enough. It appears that it is at the clinical end, rather than on the managerial side, that pharmacists fi nd themselves ‘unchallenged’. Both the questionnaires and the interviews indicated that the majority (77%) of pharmacists experienced signifi cant stress when dealing with managerial issues, such as delegating work.

UNDERSTAFFING

Understaffi ng in pharmacies was found to be a major cause of pressure and anxiety for community pharmacists, with some 21% of respondents reporting that they experienced stress ‘frequently’ regarding this.

“If there are not enough other staff, you can be distracted easily. You can be more stressed in terms of getting everything done inside (in the dispensary), while having to deal with customers at the same time. Mistakes happen more frequently,” one interviewee stated.

Some 8% and 12% of those working in single pharmacies experienced stress ‘frequently’ and ‘often’ in this regard, compared to 6% and 3% respectively for small multiples. A possible reason for this is that independent pharmacies may be under more fi nancial pressure and thus have

fewer staff, or perhaps they do not have the same level of managerial expertise and support available to ensure staff are organised more effectively.

PROFESSIONAL UNCERTAINTY

The issue which appeared to cause most stress to pharmacists in relation to professional uncertainty was the lack of clarity regarding HSE reimbursement prices and professional fees paid to pharmacies. Some 48% were stressed either ‘often’ or ‘frequently’ by this.

Stress due to fi nancial issues and increased competition was highest among superintendent and supervising pharmacists. The interviews were quite revealing in that one pharmacist described how he worried about the future of community pharmacy, describing the industry at present as a ‘race to the bottom’ in terms of drug prices and salaries. He questioned whether he was right to choose community pharmacy as a career.

The interviews also revealed evidence of a shift in emphasis for some pharmacists away from the clinical aspect of their job towards a more fi nancially orientated role, with issues such as cost savings through closer stock control central to this.

“Paperwork, stock control and human resources take from the function of the pharmacist; unfortunately, these are now part and parcel of the job,” was one comment.

CONCLUSIONS

Work-related stress has a negative impact on many pharmacists in Ireland because their daily workload is increasing. Clinical responsibilities have not diminished but managerial tasks have assumed greater importance for many pharmacists, including personnel management and stock control. The marriage of these two roles is proving diffi cult, due to a lack of management skills.

Education in the area of business management may allow pharmacists to assume more control over their workload. It may also assist in addressing the issue of understaffi ng, because a more thorough understanding of personnel management may mean more effective use of human resources available.

While the limitations of this research must be acknowledged, the fi ndings present strong evidence for the presence of work-related stress among community pharmacists in Ireland. Further research is required in order to better understand this phenomenon.

RECOMMENDATIONS

• The introduction of management modules to the curriculum for pharmacy students and also to continuing professional development courses would help to bridge the apparent knowledge gap regarding business management.

• Education of all pharmacists in the area of stress management should be encouraged.

• Evaluating dispensing processes and reviewing the work environment may help to identify and reduce 'stress causing' practices. Simple practical solutions to some issues may involve screening phone calls or moving telephones away from the dispensing area to minimise interruptions whilst the pharmacist is dispensing.

• Pharmacy owners/managers must examine ways to allow pharmacists to take breaks during the day. Simply encouraging pharmacists to take regular breaks during less busy times may help this situation as evidence indicates that many pharmacists choose not to take breaks, even when the opportunity arises.

• Increased recognition by the HSE of the clinical skills that pharmacists possess could lead to the introduction of more clinical responsibilities for pharmacists. This would enable community pharmacists to move away from dispensing and administrative roles towards a more active role in patient care.

Michael Doody works inRathmines Pharmacy, Dublin 6 and in Drug Addiction Services in Dublin and the Midlands. He studied Pharmacy in University College Cork and completed a Masters in Management in the National College of Ireland. He completed his thesis under the guidance of Dr Colette Darcy and received a Distinction Award for Best Thesis in NCI School of Business 2012. For further information on this study, contact: thomasmichaeldoody@gmail.com.

EsomeprazoleGASTRO-RESISTANT

CAPSULES20mg 40mg

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

ESOMEPRAZOLE20mg & 40mg GASTRO-RESISTANT CAPSULES

Choose NEPRAMEL to help heal and soothe the symptoms of GORD

TAKE THE HEAT OUT 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 long-term 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 Characteristics2012/ADV/ESO/077

Irish Pharmacy Awards 2013

The deadline to submit your entry for the Irish Pharmacy Awards is Thursday, April 11th, 2013. Do not miss out on the opportunity to showcase your service and have it viewed by our prestigious panel of judges.

The winners will be announced at a gala dinner attended by the industry’s most infl uential players on May 28th at the Burlington Hotel, Dublin.

The process of securing one of these coveted awards begins with your application/nomination form which allows us to collect and compare award candidates so that the right winner can be chosen. Therefore there are some key points to remember before fi lling in your application/nomination form:

Before you start - Read the guidance notes for your chosen award category carefully and make sure you are fully informed as to the details of the award. Go through the criteria carefully to make sure you are eligible to enter;

Meeting the criteria - Check on your application form if there are any conditions that the candidate must fi ll in. Some award application/nomination forms will require a cover letter and will state the minimum word count for these. Make sure you have this completed and attached with each award entry form.

Before setting pen to paper - Make sure you have read through the form fully before starting to fi ll in in to ensure you are confi dent in answering the questions detailed within each section.

For full details of the award categories, application/nominationforms and the awards evening itselfplease visit our website at: www.pharmacynewsireland.comor contact Kelly Eastwood at0044787 6548989Email: kjeastwood@hotmail.com

Don’t miss out on the chance to be recognised as a pharmacy, pharmacist or pharmacy team that sets the bar within Ireland in all issues community pharmacy. Now in their 2nd year, the Irish Pharmacy Awards - the Irish awards for community pharmacy are the industry’s most coveted awards.

Don't miss out on your chance!

Read the guidance

before starting to fi ll in in to ensure you

Innovation and service development(Independent)Sponsored by McLernon Computers Limited

Innovation and service development (Chain) Sponsored by Clonmel Healthcare

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Business development (Chain) Sponsored by KRKA Pharma Ltd

Young Pharmacist of the year Sponsored by Teva Pharmaceuticals Ireland

Community Pharmacist of the year Sponsored by Pinewood Healthcare

Pharmacy team of the year Sponsored by McNeil Healthcare (Ireland) Ltd

OTC Retailer of the year (Chain) NEW Sponsored by Reckitt Benckiser Ireland Limited

Counter Assistant of the year Sponsored by Sanofi Ireland Ltd

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Pharmacy Manager of the year NEW Sponsored by IPN Communications Ltd

Award Categories

Ireland’s No. 1 Generic Healthcare Specialists

20 mg & 40 mg gastro-resistant capsules, hard

Esomeprazole

Nexazole

Nexazole: for the treatment of erosive reflux oesophagitisPrescribing Information for Nexazole 20 mg & 40 mg gastro – resistant capsules, hard. Qualitative and Quantitative Composition: Each capsule contains 20 mg or 40 mg of esomeprazole (as esomeprazole magnesium dihydrate). Pharmaceutical Form: Hard, gastro-resistant capsule: Slightly pink body and cap, containing white to almost white pellets. Therapeutic Indications: Treatment of erosive reflux oesophagitis. Prevention of relapse of healed oesophagitis in long-term management of patients. Symptomatic treatment of gastroesophageal reflux disease (GERD). Eradication of H. pylori concurrently given with appropriate antibiotic therapy for treatment of H.pylori-associated ulcers. Treatment of NSAID-associated gastric and duodenal ulcers in patients requiring continued NSAID-treatment. Prophylaxis of NSAID-associated gastric ulcers and duodenal ulcers in patients at risk requiring continued therapy. Prolonged treatment after i.v. induced prevention of rebleeding of peptic ulcers. Treatment of Zollinger Ellison Syndrome. Dosage and Method of Administration: Capsules should be swallowed whole with liquid. The capsules can be opened and the pellets mixed in half a glass of non-carbonated water or if desired this solution administered through a gastric – tube in patients with swallowing difficulties. The capsules and / or contents should not be chewed or crushed. Treatment of erosive reflux oesophagitis: 40 mg once daily for 4 weeks. Long-term management of patients with healed oesophagitis to prevent relapse: 20 mg once daily. Symptomatic treatment of gastroesophageal reflux disease: 20 mg once daily. Eradication of H. pylori for treatment of H.pylori-associated ulcers: 20 mg with 1 g amoxicillin + 500 mg clarithromycin, all twice daily for 7 days. NSAID associated gastric & duodenal ulcers: 20 mg once daily for 4 – 8 weeks. Prophylaxis treatment: 20 mg once daily. Prolonged treatment after i.v induced prevention of rebleeding of peptic ulcers: 40 mg once daily for 4 weeks. Zollinger Ellison Syndrome: Initial dose is 40 mg once daily. Dosage should be individually adjusted. Daily doses up to 160 mg have been used. If the required daily dose exceeds 80 mg, it should be divided and given twice daily. Severe liver impairment: Patients should not exceed a max. dose of 20 mg. Contraindications: Hypersensitivity to esomeprazole or to any of the excipients. Esomeprazole should not be administered with atazanavir. Pregnancy and breast-feeding due to insufficient data. Children under 12 years. Special warnings and precautions for use: The possibility of a malignant gastric tumour should be excluded as Nexazole may alleviate symptoms and delay diagnosis. Regularly monitor patients on long-term treatment. Patients on on-demand treatment should contact their physician if symptoms change in character. If esomeprazole is used in combination with antibiotics, then the instructions for the use of these antibiotics should also be followed. Treatment with esomeprazole may lead to slightly increased risk of gastrointestinal infections such as Salmonella and Campylobacter. Contains sucrose – Patients with rare hereditary problems of fructose intolerance, glucose – galactose malabsorption or sucrase-isomaltase insufficiency should not take this medicine. Drug Interactions: Esomeprazole can affect the absorption of ketoconazole and itracanazole. Dose reduction may be required when administered with drugs metabolised by CYP2C19 as esomeprazole may increase their plasma concentration. Monitor patients when given in combination with warfarin or other coumarine derivatives. Undesirable effects: Common: Headache, abdominal pain, constipation, diarrhoea, flatulence, nausea/vomiting. Shelf Life: 2 years. Marketing Authorisation Holder: Pinewood Laboratories Ltd., Ballymacarbry, Clonmel, Co. Tipperary. Marketing Authorisation Holder Number(s): PA 281/146/1-2. This medicine is a prescription only product. Further prescribing information is available on request. Date of revision of text: July 2010.

Nexazole_IPN_A4.indd 1 27/07/2010 11:40:05

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4 Kurtz ES & Wallo W.J Drugs Dermatol 2007;6(2): 167-170 5 Fowler J & Silverberg N. Semin Med Surg 2008;27(2 Suppl):8-10

Module 1 June 2012

Chronic Pain – assessment and management in primary care

For use by Healthcare Professionals in the Republic of Ireland only© Copyright 2012 Pfizer Healthcare IrelandDate of Preparation: Module 1 June 2012 EPBU/2012/XXX

Established Products

Educational distance learning content for healthcare professionals in Ireland

Introduction

Pain is one of the commonest reasons for patients to seek medical attention.1 A recent survey has shown that as many as 8.3 visits per year to primary care physicians in Ireland were due to symptoms of pain.2 A large scale survey carried out in 15 European countries and Israel in 2006, screening 46,394 respondents reported that the prevalence of chronic pain of moderate to severe intensity in adult Europeans was 19%.3

More recent survey data from another study, carried out in 2,019 people with chronic pain and 1,472 primary care physicians across 15 European countries, have demonstrated that chronic pain affects 12-54% of adult Europeans, and its prevalence in Ireland is up to 13%.2 The PRIME (Prevalence, Impact and Cost of Chronic Pain) study, on the other hand, determined the prevalence of chronic pain to be as high as 35.5% in Ireland.4 The PRIME study was designed to investigate the prevalence of chronic pain in Ireland; compare the psychological and physical health profiles of those with and without chronic pain; and explore pain-related disability.4 Responses to survey questions were obtained from 1,204 people.

Despite the magnitude of the problem, chronic pain is both under-recognised and undertreated in primary care.2,5 Indeed, up to 38% of patients reported being inadequately managed in primary care for their pain symptoms.2 In addition, people with chronic pain reported waiting up to 2.2 years between seeking help and diagnosis, and 1.9 years before their pain was adequately managed.2

Sheehan et al reported in 1996 that the estimated cost of pain for 95 patients to the Irish Health Services when added to the amount of Social Welfare payments received and the lost earnings of each patient amounted to 1.9 million pounds at the time of referral.6 The recent data from PRIME survey show that the mean cost per chronic pain patient is estimated at €5,665 per year across all grades of pain, which was extrapolated to €5.34 billion or 2.86% of Irish GDP per year.7 This demonstrates an urgent need for cost effective strategies to manage chronic pain effectively.

Understanding chronic pain

Chronic pain is defined as pain that outlasts normal healing time (usually three to six months), and is most frequently associated with musculoskeletal disorders such as low back pain and arthritis. However, it can also be associated with other disorders such as depression or metabolic disorders or neurologic conditions such as multiple sclerosis.

Pain (acute or chronic) can be categorised as nociceptive or neuropathic. Nociceptive pain is caused by an active illness, injury and/or inflammatory process associated with actual or potential tissue damage i.e. Nociceptive pain results from activity in neural pathways secondary to actual or potential tissue damage. Nociceptive pain is mediated by pain receptors located in skin, musculoskeletal system, bone, and joints.8 Neuropathic pain, on the other hand, results from direct injury to a peripheral or central sensory nerve; the affected nerves do not produce transduction at nociceptors.8 Pain characteristics and associated conditions for both types of pain are shown in Table 1.

CPD 27: ASTHMA

Asthma

Supported by

60SecondSummaryAsthma is a long-term condition that can cause coughing, wheezing and breathlessness. With asthma, the airways become over-sensitive to things that would normally not cause a problem, such as cold air, exercise, animal fur, pollen or dust. Asthma in children is more common in boys than in girls.

Diagnosis includes the use of spirometry, peak expiratory flow rate and an exercise test. There is no cure and treatment is based on relief of symptoms and preventing future attacks. Successful prevention is through a combination of medicines, lifestyle changes and identification and avoiding asthma triggers.

Short-acting beta 2-agonists work quickly to relieve asthma. If an asthmatic needs to use their beta agonist inhaler too regularly, they should have their therapy reviewed. Excessive use of short-acting relievers has been associated with asthma deaths.

Corticosteroid inhalers reduce inflammation in the airways and must be used daily for some time before full benefit is achieved. The majority of patients require a corticosteroid dose of less than 400mcg per day to achieve maximum benefit.

If short acting beta 2-agonist inhalers and corticosteroid inhalers do not provide sufficient symptom relief, a long acting beta 2-agonist inhaler may be tried. Studies have shown that using a long-acting reliever on its own can increase asthma attack and can even increase the risk of death from asthma. A combination inhaler of a corticosteroid and a long acting beta 2-agonist provides better control.

If asthma control is not successful through use of inhalers alone, options include the addition of oral leukotriene receptor antagonists and oral theophyllines. If asthma is still not under control, regular oral corticosteroids may be prescribed.

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

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 this is why the chest has to work so hard.

Tightening of muscle around the airways can happen quickly and is the most common cause of mild asthma. The tightening of muscle can be relieved with a reliever inhaler. However, the swelling and build-up of mucus that occurs happens more slowly and needs a different treatment. This takes longer to clear up and is a serious problem in moderate to severe asthma.

Symptoms of asthma include:

• 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, perhaps brought on by colds or chest infections, exercise, change of temperature, dust or other irritants in the air, or by an allergy (such as a reaction to pollen or animals). Episodes at night are common, often affecting sleep.

CAUSE AND INCIDENCE

The exact cause of asthma is not known. According to the Asthma Insights and Realities in Ireland (AIRI) report in 2002, some 470,000 people have asthma in Ireland – meaning that approximately one in eight of the population suffers 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 to asthma. If a parent has the condition, the risk of their child getting it doubles. If both parents have it, it doubles again. In addition, if one member of a family has asthma, the risk of the other children getting it increases, but it is not known by how much. In adults, it is more common in women than in men.

Asthma can start at any age but, most commonly 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, who also suffer from hayfever find that their symptoms become worse during their hayfever symptoms. In fact, research by Allergy UK found that 69% of asthmatics who also had hayfever found their symptoms worsened during the hayfever season.

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.

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.

Asthma is a long-term condition that can cause coughing, wheezing and/or 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. Asthma itself is the second most common single condition reported.1

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.

Module 1 June 2012

Chronic Pain – assessment and management in primary care

For use by Healthcare Professionals in the Republic of Ireland only© Copyright 2012 Pfizer Healthcare IrelandDate of Preparation: Module 1 June 2012 EPBU/2012/XXX

Established Products

Educational distance learning content for healthcare professionals in Ireland

Introduction

Pain is one of the commonest reasons for patients to seek medical attention.1 A recent survey has shown that as many as 8.3 visits per year to primary care physicians in Ireland were due to symptoms of pain.2 A large scale survey carried out in 15 European countries and Israel in 2006, screening 46,394 respondents reported that the prevalence of chronic pain of moderate to severe intensity in adult Europeans was 19%.3

More recent survey data from another study, carried out in 2,019 people with chronic pain and 1,472 primary care physicians across 15 European countries, have demonstrated that chronic pain affects 12-54% of adult Europeans, and its prevalence in Ireland is up to 13%.2 The PRIME (Prevalence, Impact and Cost of Chronic Pain) study, on the other hand, determined the prevalence of chronic pain to be as high as 35.5% in Ireland.4 The PRIME study was designed to investigate the prevalence of chronic pain in Ireland; compare the psychological and physical health profiles of those with and without chronic pain; and explore pain-related disability.4 Responses to survey questions were obtained from 1,204 people.

Despite the magnitude of the problem, chronic pain is both under-recognised and undertreated in primary care.2,5 Indeed, up to 38% of patients reported being inadequately managed in primary care for their pain symptoms.2 In addition, people with chronic pain reported waiting up to 2.2 years between seeking help and diagnosis, and 1.9 years before their pain was adequately managed.2

Sheehan et al reported in 1996 that the estimated cost of pain for 95 patients to the Irish Health Services when added to the amount of Social Welfare payments received and the lost earnings of each patient amounted to 1.9 million pounds at the time of referral.6 The recent data from PRIME survey show that the mean cost per chronic pain patient is estimated at €5,665 per year across all grades of pain, which was extrapolated to €5.34 billion or 2.86% of Irish GDP per year.7 This demonstrates an urgent need for cost effective strategies to manage chronic pain effectively.

Understanding chronic pain

Chronic pain is defined as pain that outlasts normal healing time (usually three to six months), and is most frequently associated with musculoskeletal disorders such as low back pain and arthritis. However, it can also be associated with other disorders such as depression or metabolic disorders or neurologic conditions such as multiple sclerosis.

Pain (acute or chronic) can be categorised as nociceptive or neuropathic. Nociceptive pain is caused by an active illness, injury and/or inflammatory process associated with actual or potential tissue damage i.e. Nociceptive pain results from activity in neural pathways secondary to actual or potential tissue damage. Nociceptive pain is mediated by pain receptors located in skin, musculoskeletal system, bone, and joints.8 Neuropathic pain, on the other hand, results from direct injury to a peripheral or central sensory nerve; the affected nerves do not produce transduction at nociceptors.8 Pain characteristics and associated conditions for both types of pain are shown in Table 1.

CPD 27: ASTHMA

Asthma has become more common in recent years. The incidence of asthma among 13 and 14 year olds has 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 with the condition.

Known risk factors for the development of asthma in children include:

• A family history of asthma, or other related allergic conditions (known as atopic 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 those children who are given fewer antibiotics and those 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 a theory that lack of exposure in early childhood to infectious agents means 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 hypothesizes that because the immune system is ‘not activated’ during childhood; this leads to the immune system becoming over sensitive to common substances, such as pollen, dust-mite, animal fur leading to the higher incidence of auto-immune conditions, such as asthma, hayfever and eczema in recent years.

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 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 less exposure to germs and infections. Over the same period, health authorities have seen an explosion in auto-immune conditions such as asthma. 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 living environments are more sterile these immigrants suffer from increased levels of auto-immune conditions like asthma. 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 when 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 is to ensure children are administered important vaccines but ‘allow kids be kids’. Let children play outside with friends and try not to worry about them coming in contact with dirt and germs but always be cautious with children with life-threatening food allergies.

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, such as nut allergy.

WHAT HAPPENS DURING AN ASTHMA ATTACK?

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 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. A spirometer is the device that is used to make the measurements. It is common to measure lung function with a spirometer before and after a dose of reliever to see if lung function has improved

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

• 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 finger nails look blue.

NON-PHARMACOLOGICAL MANAGEMENT

Asthmatics should be advised strongly not to

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Module 1 June 2012

Chronic Pain – assessment and management in primary care

For use by Healthcare Professionals in the Republic of Ireland only© Copyright 2012 Pfizer Healthcare IrelandDate of Preparation: Module 1 June 2012 EPBU/2012/XXX

Established Products

Educational distance learning content for healthcare professionals in Ireland

Introduction

Pain is one of the commonest reasons for patients to seek medical attention.1 A recent survey has shown that as many as 8.3 visits per year to primary care physicians in Ireland were due to symptoms of pain.2 A large scale survey carried out in 15 European countries and Israel in 2006, screening 46,394 respondents reported that the prevalence of chronic pain of moderate to severe intensity in adult Europeans was 19%.3

More recent survey data from another study, carried out in 2,019 people with chronic pain and 1,472 primary care physicians across 15 European countries, have demonstrated that chronic pain affects 12-54% of adult Europeans, and its prevalence in Ireland is up to 13%.2 The PRIME (Prevalence, Impact and Cost of Chronic Pain) study, on the other hand, determined the prevalence of chronic pain to be as high as 35.5% in Ireland.4 The PRIME study was designed to investigate the prevalence of chronic pain in Ireland; compare the psychological and physical health profiles of those with and without chronic pain; and explore pain-related disability.4 Responses to survey questions were obtained from 1,204 people.

Despite the magnitude of the problem, chronic pain is both under-recognised and undertreated in primary care.2,5 Indeed, up to 38% of patients reported being inadequately managed in primary care for their pain symptoms.2 In addition, people with chronic pain reported waiting up to 2.2 years between seeking help and diagnosis, and 1.9 years before their pain was adequately managed.2

Sheehan et al reported in 1996 that the estimated cost of pain for 95 patients to the Irish Health Services when added to the amount of Social Welfare payments received and the lost earnings of each patient amounted to 1.9 million pounds at the time of referral.6 The recent data from PRIME survey show that the mean cost per chronic pain patient is estimated at €5,665 per year across all grades of pain, which was extrapolated to €5.34 billion or 2.86% of Irish GDP per year.7 This demonstrates an urgent need for cost effective strategies to manage chronic pain effectively.

Understanding chronic pain

Chronic pain is defined as pain that outlasts normal healing time (usually three to six months), and is most frequently associated with musculoskeletal disorders such as low back pain and arthritis. However, it can also be associated with other disorders such as depression or metabolic disorders or neurologic conditions such as multiple sclerosis.

Pain (acute or chronic) can be categorised as nociceptive or neuropathic. Nociceptive pain is caused by an active illness, injury and/or inflammatory process associated with actual or potential tissue damage i.e. Nociceptive pain results from activity in neural pathways secondary to actual or potential tissue damage. Nociceptive pain is mediated by pain receptors located in skin, musculoskeletal system, bone, and joints.8 Neuropathic pain, on the other hand, results from direct injury to a peripheral or central sensory nerve; the affected nerves do not produce transduction at nociceptors.8 Pain characteristics and associated conditions for both types of pain are shown in Table 1.

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

CPD 27: ASTHMA

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 and 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 and terbutaline. 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 has been associated with asthma deaths. 5, 6 This is not the fault of the reliever medication, but is down to the fact that the patient failed to 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, budesonide and fluticasone. 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 not sufficient improvement in the symptoms. Preventer treatment is normally recommended if the patient:

• has asthma symptoms more than twice a week;

• wakes up once a week due to asthma symptoms;

• 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 short-acting relievers but they take longer to work, and can last up to 12 hours. A salmeterol 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 long-acting reliever on its own (without a combination corticosteroid) can increase asthma attack and can even increase the risk of death from asthma, though the 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

Combination inhalers contain long acting beta 2-agonist and steroids. Combination inhalers 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 long-acting beta 2-agonist to inhaled corticosteroids is associated with significantly improved lung function, symptom-free days, the need for short term beta 2-agonists, night awakenings, and quality of life – although 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: these act by blocking part of the chemical reaction involved in inflammation of the airways;

• theophyllines: these 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 after 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 headaches.

• 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 down slowly over a few days. Oral corticosteroids can cause side effects if they are taken for more than three months or if theyare 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.

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CPD 27: ASTHMA

Pfi zer 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 fi nd value in all topics.

Pfi zer’s support of this programme is the latest element in a range of activities designed to benefi t 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 Pfi zer Healthcare Ireland on 01-4676500 and ask for the Established Products Business Unit.

EPBU/2013/019/1

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 the 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 during pregnancy. 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 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. There is no evidence that it can harm babies during pregnancy and breastfeeding. However, there is not enough

evidence about its safety compared with other asthma medications.

However, if leukotriene receptor antagonists are needed to control asthma during pregnancy, the GP or asthma clinic may recommend that they are 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. Meta-analysis 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/Asthma-Statistics (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. Long-acting beta2-agonists versus anti-leukotrienes as add-on therapy to inhaled corticosteroids for chronic asthma (Review). Cochrane Review. 2009 (Issue 3): 1-107

Module 1 June 2012

Chronic Pain – assessment and management in primary care

For use by Healthcare Professionals in the Republic of Ireland only© Copyright 2012 Pfizer Healthcare IrelandDate of Preparation: Module 1 June 2012 EPBU/2012/XXX

Established Products

Educational distance learning content for healthcare professionals in Ireland

Introduction

Pain is one of the commonest reasons for patients to seek medical attention.1 A recent survey has shown that as many as 8.3 visits per year to primary care physicians in Ireland were due to symptoms of pain.2 A large scale survey carried out in 15 European countries and Israel in 2006, screening 46,394 respondents reported that the prevalence of chronic pain of moderate to severe intensity in adult Europeans was 19%.3

More recent survey data from another study, carried out in 2,019 people with chronic pain and 1,472 primary care physicians across 15 European countries, have demonstrated that chronic pain affects 12-54% of adult Europeans, and its prevalence in Ireland is up to 13%.2 The PRIME (Prevalence, Impact and Cost of Chronic Pain) study, on the other hand, determined the prevalence of chronic pain to be as high as 35.5% in Ireland.4 The PRIME study was designed to investigate the prevalence of chronic pain in Ireland; compare the psychological and physical health profiles of those with and without chronic pain; and explore pain-related disability.4 Responses to survey questions were obtained from 1,204 people.

Despite the magnitude of the problem, chronic pain is both under-recognised and undertreated in primary care.2,5 Indeed, up to 38% of patients reported being inadequately managed in primary care for their pain symptoms.2 In addition, people with chronic pain reported waiting up to 2.2 years between seeking help and diagnosis, and 1.9 years before their pain was adequately managed.2

Sheehan et al reported in 1996 that the estimated cost of pain for 95 patients to the Irish Health Services when added to the amount of Social Welfare payments received and the lost earnings of each patient amounted to 1.9 million pounds at the time of referral.6 The recent data from PRIME survey show that the mean cost per chronic pain patient is estimated at €5,665 per year across all grades of pain, which was extrapolated to €5.34 billion or 2.86% of Irish GDP per year.7 This demonstrates an urgent need for cost effective strategies to manage chronic pain effectively.

Understanding chronic pain

Chronic pain is defined as pain that outlasts normal healing time (usually three to six months), and is most frequently associated with musculoskeletal disorders such as low back pain and arthritis. However, it can also be associated with other disorders such as depression or metabolic disorders or neurologic conditions such as multiple sclerosis.

Pain (acute or chronic) can be categorised as nociceptive or neuropathic. Nociceptive pain is caused by an active illness, injury and/or inflammatory process associated with actual or potential tissue damage i.e. Nociceptive pain results from activity in neural pathways secondary to actual or potential tissue damage. Nociceptive pain is mediated by pain receptors located in skin, musculoskeletal system, bone, and joints.8 Neuropathic pain, on the other hand, results from direct injury to a peripheral or central sensory nerve; the affected nerves do not produce transduction at nociceptors.8 Pain characteristics and associated conditions for both types of pain are shown in Table 1.

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35695 Bonjela Teething A4+5.indd 1 26/02/2013 09:52

Smoking Cessation

Should NRT products be sold outside pharmacies?

ASH Ireland has called on the Government to change the situation in Ireland and allow widespread sales of nicotine replacement products in supermarkets and other outlets.

According to Action on Smoking and Health (ASH) Ireland, between 70%-80% of Irish smokers would like to quit smoking and about 40% of smokers try to give up the habit every year. Many of those who succeed in quitting find the support which is available in the community helpful, such as the

HSE’s National Smokers’ Quitline and the smoking cessation services and/or medications provided by their pharmacists or GPs.

ASH Ireland is now calling for the Government to encourage more widespread use of nicotine replacement therapies (NRTs), to help more people in their efforts to give up the weed.

“We recently met with the Minister for Health James Reilly and we stressed the vital need to reduce the cost of NRT available to Irish smokers,” said Dr Ross Morgan, consultant respiratory physician and chair of ASH Ireland. “We believe that this can be done in two ways: the first is by removing the VAT on nicotine replacement patches and the second is for the Irish Medicines Board to allow the products to be more widely available through retail outlets. This competition would help to reduce prices.”

As far as reducing the price of nicotine replacement products is concerned, because of the stricter guidelines on the sale of medicines in the Republic, own-brand products, which are normally cheaper than the branded products, are not available.

“NRT patches can cost three times more in the Republic than they do in Britain, for example,” said Dr Morgan. “They are not considered to be an oral medicine, which would mean zero per cent VAT. Instead, the Irish Government puts 23% VAT on nicotine patches,

36

Minister for Health Dr James Reilly (right), Chief Medical Officer Dr Tony Holohan and Minister for Children Frances Fitzgerald pictured at the launch of the Government's latest smoking-cessation initiative. Since 1 February, cigarette packages on the Irish market have to display graphic photographs with a strong health warning. (Pic: Robbie Reynolds/CPR)

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whereas in the UK the VAT rate on these products is only 5%.”

Ann Phelan, TD for Carlow-Kilkenny raised these VAT issues in the Dáil on December 13 last. Minister of State at the Department of Jobs, Enterprise and Innovation, John Perry, replied on behalf of Finance Minister Michael Noonan. Perry mentioned the possibility of the VAT rate being decreased to of 9% or 13.5% on nicotine replacement patches and agreed with Deputy Phelan that these products should be more widely available. He also said it might be possible to place nicotine patches on open display to make them more available to the consumer.

“After the Dáil debate, and with considerable support from a number of TDs, we are now waiting to see what the next step will be,” said Dr Morgan.

INDUSTRY VIEW

Joanne O’Hagan is the sales, customer and employee manager at Meagher’s Pharmacy Group. She said she agreed that the wider the availability of NRTs, the more likely they were to be used.

“However, there is a big difference between using a smoking-cessation aid and using it properly,” she said. “There is no doubt that offering counselling to potential quitters is vital. Without the right information and advice, they may well pick a product that does not suit them, or they might not use the NRT properly – they

might take the wrong dose or they may not use the product for the right length of time. They also need to be counselled about potential side effects.

“It can even be hard for pharmacists to keep up to date on all of the latest products and how they should be used, so I do not know how other shop staff would know all of this without the proper training. While it may seem to make sense to make NRTs more readily available, I think that they should stay within pharmacies so that we can ensure that they are used properly.”

Linda Cooney, a pharmacist with Cooney’s Pharmacy in Athlone, Co Westmeath, agreed with O’Hagan. She said that in her opinion, NRTs should only be sold in pharmacies.

“I do not think that they should be sold elsewhere,” she told Irish Pharmacy News. “People will not get the proper advice and counselling that they need with regard to these products, if they can buy them in any shop or supermarket. Pharmacy staff have undergone the proper training needed to advise on NRT use and I can see for myself how much these consultations help people when it comes to giving up.”

Edward McReynolds, UK & Ireland training manager with McNeil Healthcare Ltd, said that the issue of NRT availability was “a hoary old chestnut”.

“On one side of the debate,

there is a strong argument that anywhere cigarettes are available, NRTs should also be available. The theory is that the more freely you can buy NRTs, the more likely people are to use them. The counter argument goes that without the advice, motivation and tips that you receive from a pharmacy consultation, the more difficult it is to quit.

“When a customer buys a NRT in a pharmacy, it is a golden opportunity for intervention, to see whether the person has tried to quit before and what made them start smoking again. Then the pharmacy staff can discuss what event caused the lapse, how

39

The NRT market in Ireland

The Public Health (Tobacco) (Amendment) Act 2011 enabled the Minister for Health to make regulations to introduce combined text and photo warnings on tobacco products. This was a further bid to raise and maintain awareness of the associated risks of smoking and, hence to reduce the numbers of smokers in Ireland and those taking up the habit in the first place. Currently, 29% of the Irish population smokes.

As from February 1, 2013 tobacco companies have to print photographic health warnings on cigarette packets. The photographs include a photo of a tumour growing from a man’s throat and a picture showing how smoking ages the skin. With initiatives such as these and with the high price of cigarettes as significant impetus to quit, it is likely that the number of NRT products sold will rise in the short-to-medium term.

According to Euromonitor, NRT smoking cessation aids are expected to see a compound annual growth rate (CAGR) of 1% to reach an impressive ¤23 million over three years. NRT inhalators will continue to return good positive growth with a CAGR of 3% to 2016 while patches are expected to remain popular as the most unobtrusive and easy-to-manage aid. It is thought that the CAGR for these type of products will be around 2%.

Edward McReynolds

Delivering Consistency in Quality,Value and Supply

63-2013_KRKA_POSTER_IE(ie).indd 1 2/4/2013 3:14:26 PM

the quitter might deal with such an event in the future and review the options to find out the most suitable product for the would-be quitter. It should be much more than a purely transactional exchange – knowledge and professional experience should be passed on too. Motivated and helpful pharmacy staff can make it much easier for the patient to actually give up for good.”

UK PERSPECTIVE

McReynolds works mainly in the UK, where NRTs are widely available. “Even though it would seem logical that NRT products should be available in shops and supermarkets, studies show that interventions by healthcare professionals can really increase the person’s chance of quitting,” he said. Crucially, McReynolds added, he was not aware of studies to indicate that increased availability of NRTs actually reduced smoking rates.

“My view is that although supermarkets in the UK have gone to great lengths to promote their NRT products, their efforts have had varied success rates. The attitude of staff is crucial to making stop smoking attempts successful and pharmacy staff better placed to help someone in their quit attempt. Someone working on the supermarket checkout will not pick up the NRT product when the customer is about to pay for it and start counselling them about smoking cessation.”

40

National smoking cessation guidelines recommend that all healthcare professionals, including pharmacists, should check on the smoking status of their patients at least once a year and those who smoke should be advised to quit. Pharmacists can offer this advice even when smokers are not directly seeking help with regard to smoking cessation.

ASH Ireland research has shown that the vast majority of smokers want to quit and would likely be happy for the topic to be brought up by a health professional if it is done in a supportive and non-judgmental manner. Studies show that patients, even those who intend to continue smoking, prefer intervention and advice from health professionals.

According to the Irish Pharmacy Union, the average person visits a community pharmacy 19 times a year. In most instances, this will be the first port of call within the healthcare system for the patient because pharmacists are easily accessible and trusted. Most pharmacists also enjoy long-term, established relationships with many of their patients. When a patient makes a purchase or asks for advice, particularly for a cough/cold item, the pharmacist and/or

PHARMACIST ROLE IN KICKING THE HABITWith the advent of National No Smoking Day taking place last month, the Irish Pharmacy Union (IPU) is encouraging people to ask their pharmacist about support and advice on how to stop smoking. 7,000 people die from smoking-related diseases in Ireland each year.

Pharmacists say these deaths are preventable and anyone who decides to give up smoking will see immediate benefi ts.

Kathy Maher, Vice-President of the IPU, said: "Research shows that 70% of people who do smoke wish to give up and pharmacists are available to support people who do want to stop. A successful outcome for a patient depends on a number of different things including the smoker's temperament, the severity of their addiction, how many times they've tried to quit before and their motivation for quitting. Pharmacists can help patients fi nd what works best for them and offer advice on other appropriate supports such as nicotine replacement therapy to help manage cravings."

news brief

the pharmacy staff can easily ask if the person is a smoker and advise accordingly.

Dispensing prescription medications also presents an opportunity to make a smoking cessation intervention – especially when dispensing treatments for respiratory or cardiovascular diseases or issuing oral contraceptives (particularly to women over the age of 35 years).

Studies have shown that smokers who receive assistance from a non-physician clinician (such as a pharmacist) are 1.7 times more likely to quit successfully for five or more months than smokers who do not receive such support.

The three-point plan for pharmacists consists of:

• Asking if the patient smokes

• Advising them of the importance of quitting

• Helping them if they want to quit by providing them with appropriate information and advice on cessation products and programmes.

Encouraging patients to quit

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XLS Ireland Trade Ad (IPN March).pdf 1 20/02/2013 14:58

On Wednesday she gets a bottle and I get to go to my best friend‘s birthday.

To To T switch between bottle and breastfeeeding without any problems: NUK FIRST CHOICE.

No matter how much you love your child, you also need some time for yourself. NUK FIRST CHOICE teats are naturally asymmetrically shaped. So your baby hardly notices any difference from breast-feeding and takes to the bottle smoothly.

FFiinnd d out morre aatt nnuukk.c.coomm

Range of products available in your localpharmacy through Intrapharma Consumer Health

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07797 NUK Advert_07797 NUK Advert 18/07/2012 09:29 Page 1

43

Baby Care

Baby business booming

parents are more likely to visit their pharmacist for free advice when their child has a minor ailment, rather than paying up to ¤65 for a GP visit. Admittedly, pharmacies do not generally have the floor

space to offer as many products as supermarkets, but they must recognise the need to offer a wide range of baby-care products. Securing the trust of parents at this early stage in their children’s

With Ireland’s birth rate continuing to boom, the baby care market could potentially benefit pharmacy businesses. Pharmacies have significant advantages over supermarkets, mainly because pharmacy staff can offer advice and expertise that the supermarkets do not offer.

Along with Ireland’s birth rate, the baby-care product market in this country is booming – in fact, according to Euromonitor, the international market research company, it was worth almost ¤23 million in 2011. Within the overall baby-care market, baby skincare products performed the strongest, with value sales of ¤5.7 million. Baby toiletries – such as bath washes, cleaners and moisturisers – accounted for value sales of ¤5.3 million. This was closely followed by sales of baby haircare products, which came in at ¤5.2 million.

Other categories within this sector, according to Euromonitor, are nappy-rash treatments (¤1.1 million), baby sun care (¤3.7 million) and medicated baby care (¤1.6 million). The latter represented value growth of 26% over five years, however, with baby sun care also performing strongly at 25.7% value growth over the same period.

With women in Ireland bearing an average of 2.1 children each, baby care represents a growing market. In general, product price is not as important within baby care and child-specific products as in other beauty and personal care categories because mothers are prepared to spend more on their babies – they want products that are of the highest quality.

Although supermarkets may account for a large proportion of baby care product sales, pharmacy has a significant advantage in this

regard, as pharmacy staff have the time and expertise to advise parents about what is best for their baby.

In the current economic climate,

On Wednesday she gets a bottle and I get to go to my best friend‘s birthday.

To To T switch between bottle and breastfeeeding without any problems: NUK FIRST CHOICE.

No matter how much you love your child, you also need some time for yourself. NUK FIRST CHOICE teats are naturally asymmetrically shaped. So your baby hardly notices any difference from breast-feeding and takes to the bottle smoothly.

FFiinnd d out morre aatt nnuukk.c.coomm

Range of products available in your localpharmacy through Intrapharma Consumer Health

NU

K is

a r

egis

tere

d tr

adem

ark

of M

APA

Gm

bH/G

erm

any

07797 NUK Advert_07797 NUK Advert 18/07/2012 09:29 Page 1

lives by offering sound advice can secure their repeat business for years to come.

SKINCARE AND NAPPY RASH

Medicated baby products in general achieved value growth of 5% in 2011. Within the nappy-rash treatment category, the top two brands are also medicated. Most babies experience nappy rash at some stage of their infancy – in fact, it is thought that up to one-third of babies are affected at any given time. When the baby soils itself and the nappy is not changed soon enough, the urine can encourage the production of ammonia, which irritates the baby’s skin.

Pharmacy staff can advise that barrier creams can help treat and prevent nappy rash. They should be used every time that baby’s nappy is changed. Zinc oxide creams, dexpanthenol creams and

petroleum jelly are suitable barrier creams, and zinc oxide free-creams that contain pro-vitamin B5 are also available. Parents may find that recently developed products that contain the cream embedded into a wipe are handy when out and about, and some preparations are also available in a mousse formula.

If nappy rash is severe, medications such as topical corticosteroids can be prescribed to help reduce inflammation and relieve itching and redness. They should be used once daily for no more than seven days. Anticandidials, such as topical imidazoles, are also effective in the treatment of nappy rash.

Many midwives recommend that only water should be used to clean the baby’s bottom, but this might not always be practical – in any case, a very gentle cleanser specially formulated for infant

skin should be used. Parents should use a barrier cream after each nappy change, as previously mentioned, but not talcum powder or any other powder. Finally, tight-fitting plastic pants should not be used over nappies, as these may encourage fungal growth.

Other baby skincare products include baby oils, moisturisers, wet wipes, bath washes, shampoo, cotton buds and nappies. Although pharmacy must compete with supermarkets sales of these products – where they are usually sold at a lower price – pharmacy staff should suggest linkage sales when parents are buying other baby products. They can offer advice on the different ingredients in these products and whether an ingredient is suitable for an individual child. This tailored advice can rarely be gleaned from supermarket staff, if ever.

MINOR AILMENTS

In September 2011, the Irish Medicines Board (IMB) reviewed the safety and efficacy of over-the-counter cough and cold medicines authorised for use in children between 2-6 years of age. In a letter issued to pharmacists, the IMB said: “The risk-benefit balance in this age group has not been shown to be favourable.” There was also some evidence of links between these products and allergic reactions and drowsiness in children. Advice for children aged 6 to 12 years remained unchanged.

Figures for the paediatric analgesic market are not yet available for 2012, so it is still unclear as to the effect of the IMB’s guidance

44

on sales of these products. However, in 2011, the market was worth ¤4.2 million and, according to Euromonitor, pharmacy-led sales dominate these channels. Parents may also welcome natural remedies containing ingredients such as glycerol, as they can help ease cough and cold symptoms in under-sixes.

Sales of paediatric analgesics experienced considerable growth in 2011, reaching sales worth ¤3.3 million. In light of the IMB’s recommendations on cough and cold products, Euromonitor anticipated further growth, as parents turn to these products to treat their children’s ailments. In 2011, paediatric paracetamol alone experienced 8% value growth, to reach sales of ¤1.5 million. IMS data showed that sales of paediatric ibuprofen grew by 21% from ¤5.8 million in 2010 to over ¤7 million in 2011. Such products are exclusively available in pharmacies.

Last September, the Self-Care Working Group launched its proposals for a framework for self-care in Ireland (see October 2012 issue of IPN). The Group comprised representatives from the Irish Pharmacy Union, Trinity College School of Pharmacy and Pharmaceutical Sciences, the Department of General Practice at University College Cork, representatives of the pharmaceutical industry and the Health Service Executive (HSE).

The framework promotes patient self-treatment whenever possible, in accordance with the Department of Health’s self-care policies. With such a concerted effort being

Not everyone has a licence to heal.Unlike some nappy rash creams, Sudocrem Antiseptic Healing Cream is a licensed medicine, which actually treats nappy rash and doesn’t just soothe the symptoms.

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Available from supermarkets & pharmacies nationwide

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

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

FAST-ACTINGStarts to relieve fever in just 15 minutes.1

8 HOURS RELIEFProvides fever relief for up to 8 hours.2

1,2

COMES WITH SYRINGE FOR ACCURATE DOSING.

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

NFC ad A4.indd 1 26/02/2013 10:08

made to encourage people to look after their own health, it is likely that parents may also be more likely to seek a pharmacist’s advice and treat their child’s pain before visiting a GP.

Parents may be cautious regarding the correct dosage for their child, and indeed the best product to treat a specific type of pain, so pharmacy staff should never miss an opportunity to advise customers when they buy these products. This reinforces the message that pharmacists are experts in medications and know what is best for a child.

DIETARY SUPPLEMENTS

Increasing numbers of people in Ireland appear to believe that ‘one’s health is one’s wealth’, and sales of vitamin and mineral supplements are strong in this country. According to Euromonitor, paediatric dietary supplements are a strong performer in Ireland, reaching sales of ¤5.2 million in 2011. Some 95% of these were represented by sales of vitamin products specifically.

Supplements, which were once viewed as a means of recuperation after illness or when in need of a tonic, are now accepted as being beneficial to health on an ongoing basis. This trend is expected to continue, helping to maintain

growth in vitamins and dietary supplements in general, through increased penetration and higher frequency of use.

There were numerous product launches in recent years, including ‘chewy vitamins’ for children (a pharmacy-specific product comprising vitamins A to E) and other ‘softies’ products. All new products performed to market expectations, gaining some small share, but did not present a significant threat to the top-performing brands.

Pharmacy staff should make parents aware that the HSE recommends that from birth to one year, all babies in Ireland should be given 5µg of vitamin D3 daily, whether or not they are breastfed. Cholecalciferol is the preferred form of vitamin D for infants. The Executive’s guidance states that only liquid vitamin D should be given to babies and that the vitamin preparation chosen should contain vitamin D on its own (not in combination with other vitamins, such as in a multivitamin preparation).

“Pharmacists advising parents about vitamin D3 supplements should ensure that they are familiar with the different products and different doses required by each product to provide 5µg of vitamin D3 per day,” the guidance states.

47

Category management

Brand heritage and trust in particular products is an important factor within the baby-care market. Brand loyalty is strong and the power of these brands should be harnessed in the pharmacy – popular brands should have a presence on pharmacy shelves. They can be used as ‘markers’, positioned to the left-hand side to reflect the way the customer shops the fixture, and blocked by brand.

It is a given that customers seeking baby-care products will often be accompanied by small children – they may not have a lot of time to make their purchase. Ensuring that the merchandising makes it as simple as possible for customers to select products should help to drive sales.

Products for babies and children should be displayed together in one section, alongside typical impulse purchases such as babywipes and bubble bath. These products should ideally be located close to the door, so that parents with prams and buggies can make their purchases more easily. Providing leaflets designed to support parents and update them on new products adds value to the pharmacy service.

On a related note, pharmacy staff should also advise new mothers that they should take supplements containing 10mcg of vitamin D each day, to help protect their bones from thinning later in life and to provide some vitamin D to their baby.

Figures from 2011 have shown that the average dietary intake of vitamin D among pregnant women in Ireland ranges from 1.9µg to 2.1µg daily – some 80% below current recommended levels of 10µg daily for the average adult.

Other dietary supplements may be useful for breastfeeding mothers who may not eat a balanced diet. Once again, a pharmacy consultation with these women can reveal if they need supplementation while breastfeeding, for the benefit of their own health and their baby’s.

Euromonitor expects baby and child products to hold its own over the next few years and to even achieve a compound annual growth rate (CAGR) of 1%. The best performance is expected in medicated products, which is predicted to achieve a 2% CAGR within three years. Stocking quality brands, and offering expert advice on infant conditions and products, will help a pharmacy to be the ‘best for baby’ in their locality.

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

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

FAST-ACTINGStarts to relieve fever in just 15 minutes.1

8 HOURS RELIEFProvides fever relief for up to 8 hours.2

1,2

COMES WITH SYRINGE FOR ACCURATE DOSING.

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

NFC ad A4.indd 1 26/02/2013 10:08

48

News

Take a leaf out of this pharmacy’s book

Repeated cuts by the HSE have forced pharmacies to look again at the retail side of their business, in order to make up some of the losses to the dispensary profitability. There has been a noticeable shift in consumer spending away from cosmetics and luxury products to more value-related items and healthcare products, to reflect these recessionary times.

Meagher’s Pharmacy Group has a diverse customer base, with six locations in South Dublin: one in Baggot Street, Dublin 4; one in Barrow Street, Dublin 4; two in Ranelagh, Dublin 6; and two in Tallaght, Dublin 24. Oonagh O’Hagan, owner and managing director of Meagher’s, said it required a lot of ‘buy one, get one

free’ toiletry offers to generate the same profit as just one quality, pharmacy-only product.

“We wanted to leverage our position as trusted health experts to help the consumer,” she said. “I was on the look-out for a product that was not available in grocery and had a significant point of difference, so that people would return to buy it again. It was also crucial that we could stand over the product – it had to work, so that our customers got value for the money they spent.”

O’Hagan got in touch with the founders of Symprove, Barry and Anne Smith, through a mutual business interest for whom she often reviewed products. Symprove is a multi-strain formula,

designed to lessen the symptoms of irritable bowel syndrome (see panel). “He approached me and detailed the product, after which I agreed to meet up with the Smiths,” explained the Meagher’s MD. “Following this meeting, I offered to trial the product. We were the first pharmacies in Ireland to stock Symprove – the trial began in September 2012 and ran until January of this year.”

O’Hagan saw that Symprove brought with it great opportunities, but also some considerable challenges.

“I was genuinely excited about this next generation of live ‘good’ bacteria,” she said. “It was backed up by clinical research into its benefits, especially for patients

Meagher’s Pharmacy Group recently completed a trial of a new product for irritable bowel syndrome in its six Dublin pharmacies. Oonagh O’Hagan, the group’s owner and MD, outlines why and how her pharmacies got involved in such an innovative trial.

with irritable bowel syndrome (IBS). I really wanted patients of our pharmacies to get the chance to try Symprove and improve their quality of life. On the other hand, Symprove is on the more expensive side in comparison to competitor multi-strain formulae. At its recommended retail price of ¤26, we thought that it was outside of the ‘impulse buy’ price range. We knew we would have to work to convince people that it merits its price-tag.”

She was particularly keen to trial Symprove because a high percentage of Meagher’s customers suffer from IBS. “We had identified this through our food intolerance testing service and our questioning techniques when selling over-the-counter medication,” she added.

STAFF TRAINING

O’Hagan arranged for Barry and Anne Smith to visit the Meagher’s pharmacies, for initial training in the Symprove product. They showed them customer testimonials, along with videos and clinical trial results.

“A Symprove training brief was created,” explained Samantha Bakir, shopfloor supervisor and sales trainer with Meagher’s Pharmacy Group. “The brief contained Symprove information, key points to remember, selling points and potential link sales. The selling tips, in particular, proved to be invaluable. Our pharmacy staff had three main selling points to pass on to potential customers:

• For the price of a daily cup of coffee, patients could treat their IBS with Symprove;

• The product was dairy-, lactose- and gluten-free; and

• Symprove conducted the largest study of ‘good’ bacteria in the world for IBS.

In order to generate sales, store visits were arranged during the

Oonagh O'Hagan and Samantha Bakir of Meaghers Pharmacy

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Newsfi rst week of the introduction of Symprove to Meagher’s Pharmacy. On these visits, product revision exercises were carried out with all members of staff. Revision exercises followed this initial training, including ‘question and answer’ sessions and role-play exercises.

Bakir carried out the training throughout Meagher’s Pharmacy Group. “Our EPOS manager relayed each of the six pharmacies’ sales fi gures to me, on a weekly basis, so that we could monitor sales,” she said. “Quantity and value sales increased straight after the training provided during the fi rst week. An incentive of ¤150 was offered for the pharmacy that had the highest quantity of retail sales over a four-week period. Initial monthly sales reached approximately ¤2,000, with increased growth to ¤3,000 in month two.”

In-store profi ling also played an important role in achieving these sales fi gures. Staff placed Symprove in a prominent position within each of the Meagher’s pharmacies. They also maximised the point of sale material provided by the manufacturer at the OTC counters and in eye-catching window displays. Despite the ¤26 price, Meagher’s staff sold the product as an impulse buy, placing the product beside the sales tills and also in the vitamins/natural remedies sector.

They stripped off shelves and blocked them with Symprove, to

maximise impact. The in-store pharmacy TV channel also showed Symprove advertisements, every 15 minutes. “We had ‘sampling days’, where people were invited to try the product and we also featured Symprove on our website,” said O’Hagan. “Digital marketing also worked well. We have a loyalty card, which enables us to communicate directly with our customers, so we could notify people who had previously bought gastro-intestinal products. We also link-sold it to people who took a food-intolerance test with us. It is all about communicating with customers through the most appropriate channels.”

STAFF AND CUSTOMER FEEDBACK

“We soon started to hear great feedback regarding Symprove,” said O’Hagan. “Our staff reported that once a customer started to purchase Symprove, they continued to purchase it regularly thereafter. We found that once the fi rst purchase was made, it sold itself after that. Symprove was just as easy to sell as any other ‘good’ bacteria, if not easier in certain circumstances because of its effectiveness.”

“We also heard wonderful feedback from our patients,” added Bakir. “Customers would come back and tell us that their IBS symptoms had improved, if not completely vanished. We found that people travelled from all over, just to buy it – one customer came all the way from Mayo to

SYMPROVE PRODUCT PROFILE

Symprove is a multi-strain formula, containing live and activated bacteria protected by a unique delivery system. This ensures that these ‘friendly’ bacteria are delivered to the right part of the bowel and populate effectively. Symprove contains high concentrations of naturally occurring bacteria grown on extract of barley. The four species in the product are: L. rhamnosus, L. acidophilus, L. plantarum and E. faecium.

Professor Ingvar Bjaranason, of London’s Kings College Hospital, agreed to research the product and set up a double-blind, investigator-led, placebo-controlled clinical trial into the effects of Symprove on IBS sufferers – arguably the largest study of IBS patients in the world to date. The results showed statistically signifi cant improvement in many of the key indicators of the trial: symptom severity score, pain and habit.

Symprove is designed to be taken each morning on an empty stomach, fi ve minutes before eating breakfast (1ml per kilo of bodyweight). It is recommended that patients drink a course of Symprove for 12 weeks, to restore and maintain the balance of fl ora in the gut. See Symprove.com for more details.

one of our Tallaght stores, to buy six bottles. In addition, they also said that Symprove was easy to take that it had a pleasant taste, so that was a bonus. People are more likely to stick with a treatment if compliance is easy.”

She also stressed that when dealing with digestive issues, it was important for pharmacy staff to ask the right questions, understand the patient’s inherent embarrassment, bring them into the consultation room and have the conviction to recommend the right product. “Of course, we always had a bottle in the fridge, ready for them to sample,” added Bakir.

O’Hagan is soon to meet with gastroenterologists in local hospitals, to discuss the potential benefi ts that Symprove could bring to its outpatients. Leaving bottles of the product with local GPs was the next step, she said.

O’Hagan offered her fi nal thoughts on Symprove. “Yes, it is on the more expensive side when compared to other multi-strain products. However, it truly does represent great value for money,” she said. “My advice, when introducing Symprove to retail staff, is that it is essential that all pharmacy staff understand and have the knowledge about how Symprove works. Staff have to believe in the product and get the message across to customers that it really does work and that it is worth the investment. The fi rst sale is the ‘clincher’.”

Barry Packaging raises €4,500 for Action Breast Cancer

Barry Packaging issued a cheque for ¤4,500 to Action Breast Cancer last month, on behalf of its customers who got behind the company’s ‘Pink Ribbon’ carrier-bag campaign (see October 2012 issue of IPN). Action Breast Cancer is part of the Irish Cancer Society.

This was the second year that the Tralee-based packaging company ran the fundraising campaign. It produced pink carrier bags for pharmacies and other retailers to mark Breast Cancer Awareness Month, which takes place each October. The full cost of ¤35 from every box of bags sold was donated to Action Breast Cancer. In total, over 20,000 ‘Pink Ribbon’ carrier bags have been sold since the initiative began in September 2011.

“Action Breast Cancer is a charity

close to everybody’s heart and we are delighted with the response we received from our customers,” said Eamonn Barry, managing director of Barry Packaging. “We wanted to do something different for charity and being in the carrier-bag business, this was a great way for us to get directly involved.”

Chris Griffi n, from the Kerry branch of the Irish Cancer Society, said the organisation was delighted to receive the cheque.

“I would like to thank all the retailers and pharmacies who participated in the campaign,” he said. “The much-valued funds will help fund research to fi nd new therapies to prevent breast cancer, better techniques to diagnose it accurately and new treatments to ultimately cure it.”

Left-right: Brenda Griffin, Kerry branch of Irish Cancer Society; Breda Barry, Barry Packaging; Chris Griffin, Kerry branch of Irish Cancer Society; Ashley Casey, Barry Packaging; and Eamonn Barry, Barry Packaging.

Protect the skinthat protectsthe baby.With new Bepanthen® Stretch Mark Cream.

Bepanthen® Stretch Mark Cream has been developed to care for the needs of

skin that has been stretched both during and after pregnancy and helps to minimise the development of stretch marks.

Bepanthen® Stretch Mark Cream contains:

� A high quality extract of Centella Asiatica, known to help minimise the development of stretch marks

� Provitamin B5 and glycerin, proven ingredients to nourish and moisturise, in order to make the skin soft, supple and elastic

� Pure olive oil and skin lipids to support the skin barrier, key in protecting against external influences.

Bepanthen® Stretch Mark Cream is:

Hypoallergenic

Preservative free

Colour free

Dermatologically tested

Recommend Bepanthen® Stretch Mark Cream as part of their maternity routine to help take the worry out of stretch marks.

www.bepanthen.ie

For further information please contact: Bayer Consumer Care, The Atrium, Blackthorn Road, Sandyford Industrial Estate, Dublin 18. Tel: 00 353 (0)1 2999313.*Bepanthen is a registered trademark.

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NewsIrwin’s Pharmacy Group re-vamps website for mobile devicesINCREASE IN

PAEDIATRIC DISPENSING ERRORS

The Pharmaceutical Society of Ireland (PSI) has said that in recent months, it has seen an increase in the number of complaints relating to paediatric dispensing errors in Ireland.

The Society explained that the most common issues reported involved dosing faults (including errors in dose calculation or in labelling), dispensing ‘high-tech’ medicines for children, and mistakes being repeated as a result of not reviewing the original prescription every time a medication was dispensed.

“While many of these types of errors can also occur in dispensing prescriptions for adults, it is widely acknowledged that children are generally at greater risk of suffering harm from medication errors than adults. Therefore it is important that pharmacists are especially vigilant when dispensing or supplying medicines for use in children and that measures to minimise the risk of errors are constantly reviewed and improved,” said the PSI.

The pharmacy regulatory body said that observations such as the rise in complaints regarding paediatric dispensing errors were disseminated to pharmacists around the country. As a result, the complaints received by the Society, its resulting inquiries and its disciplinary processes provided a learning opportunity for the pharmacy profession.

“Therefore, the Pharmaceutical Society of Ireland would like to make pharmacists aware of [the] issue, which has arisen through our complaints system,” the PSI said, without indicating the extent of the increase.

news brief

The Cork-based Irwin's Pharmacy Group has re-launched its website, to accommodate mobile users and make its site more user-friendly. Irwins has three pharmacies in the Cork area, in Mayfield, Shandon Street and Togher.

The new site is easy to access and navigate, making it very accessible to all users and showing clear menu navigation in regard to the pharmacy group’s service offerings, locations and providing the latest news and advice.

“The site is also easy to access by mobile and tablet,” said Eddie Irwin, pharmacist and owner of Irwin’s. “That was the main reason for the revamp. The old site was not compatible with smaller screens such as iPads and mobile phones.”

The website clearly shows contact details via phone or email of each of the Irwin’s pharmacies,

along with opening hours. The pharmacy’s logo is clearly reflected on each of the pages, which reinforces the strong brand

presence throughout the site. It is powered by WordPress, which allows the pharmacies to update content regularly themselves.

Smaller pack-sizes reduce deaths

Smaller packs has led to a 43% reduction in the number of poisoning deaths in the UK, according to the new study, which was published on BMJ.com. In 1998, packs were restricted to a maximum of 32 tablets through pharmacy sales and 16 for non-

pharmacy. This legislation came into Ireland in 2001, but with smaller maximum pack sizes (24 and 12 tablets).

Researchers examined data concerning poisoning deaths in England and Wales between 1993 and 2009. Their findings suggest

a significant decrease in deaths involving paracetamol.

In contrast, a study from 2011 found that “the difference in paracetamol pack-size legislation does not appear to have resulted in a major difference in sizes of overdoses” in Ireland.

A new UK study suggests that smaller-sized packets of paracetamol have led to fewer poisoning deaths in the UK – contradicting 2011 research, which found that the smaller packs made no difference to the situation in Ireland.

2nd Summit on research and innovation

Organised by Atomium Culture, in partnership with Trinity College Dublin and the Irish Times, the Summit will focus on the role that media plays in the relationship between science and society.

Speakers include: Prof. Carlo Rubbia, (former Director of CERN, Nobel Laureate), Prof. Anne Glover (Chief Scientific Adviser to the President of the European Commission) and Mr. Alexander

von Gabain (Chairman of the Governing Board of the EIT). For full programme visit http://eisri-summit.eu/programme-2/

On Monday 25th of February Minister Sean Sherlock and Trinity College Dublin Provost Patrick Prendergast opened the second edition of the European Intersectoral Summit on Research and Innovation at Trinity College Dublin.

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News

Diabetes Ireland urges pharmacists to upskill in diabetes care

Currently, it is estimated that 8.9% of adults over 45 years have either diagnosed or undiagnosed diabetes. Within this age group, 30% of all diabetes is undiagnosed and undiagnosed diabetes is more common among men than women.

All healthcare professionals need to have up-to-date knowledge on how best to prevent diabetes and also provide support, information and motivation for people with diabetes. For many people, the pharmacist is their interface with the healthcare system. To maintain continued professional development, healthcare professionals including pharmacists should avail of study days that provide a format to upskill in the area of diabetes care.

The Minister for Health, Dr James Reilly will formally open the Diabetes Ireland/Irish Endocrine Society study day, ‘Promoting Wellbeing and Health by Prevention and Management of Diabetes to Best International Standards’ on Friday the 8th of March in the Hogan Mezzanine Suite, Croke Park. All pharmacists are invited to register for attendance at this prestigious event.

This study day aims to provide an interesting and topical programme, including information on best practice care and research. The overall aim of the day is that health professionals attending get the latest, evidenced-based information from a selection of speakers in areas which are topical and relevant to their everyday work. The study day provides an opportunity to network with other diabetes professionals. There are also various exhibitors who help to update participants with the latest diabetes products.

The study day is broken up into two sessions. The morning session focuses on the management of type 2 diabetes through structured group education, integrated care pathways and reviews the usefulness of HbA1c in the diagnosis of diabetes. The afternoon session is learning about setting up a diabetes clinic in practice and reviewing the planning and implementing of a national diabetes retinal screening programme.

Professor T.J. McKenna starts the day by looking back at where diabetes care has come from and the many advances he has seen as

a consultant working in diabetes care for the last few decades. Dr Francis Finucane, Consultant Endocrinologist, Galway University Hospital, will discuss the ‘The Challenge of Diabetes Prevention’ so that health professionals including pharmacists gain an understanding of how to assess diabetes risk in and how to support clients who are at high risk using proven intervention strategies.

Rita Forde, Advanced Nurse Practitioner, Dublin presents ‘Towards excellence in diabetes education – is structured group education feasible for all?‘ outlining the importance of group education and the benefit it has for self-management of diabetes. Pharmacists will receive first-hand information on who is suitable for these programmes, gain an understanding of how group education works and how it empowers clients but most importantly how their clients can access them locally.

Dr Diarmuid Smith, the HSE Clinical Lead for the National Diabetes Programme will discuss ‘An Integrated Model of Care for the person with Type 2 Diabetes’ and outline how the model of

Nearly 10% of people in Ireland aged over 45 years could have diabetes by 2020, according to new research. The Institute of Public Health reports these findings and anticipates a 62% increase in the prevalence of diabetes by 2020 to over 232,000 people in Ireland.

care for diabetes is currently being implemented and the future developments planned. It is well known that level of diabetes care differs in relation to your geographical postal code – this is pharmacist’s opportunity to highlight their area and specifically help identify deficits.

Professor John Wilding, Professor of Medicine, University of Liverpool will cover ‘Current and future perspectives in diabetes treatment - the medicines challenge’ so that participants can be enlightened to new medical options in the management of diabetes coming in the future alongside better understanding of current medicines used.

By virtue of having a condition such as diabetes, individuals not only carry ultimate responsibility for their own well-being, but also directly experience its consequences throughout their lives. Only during the brief consultations with their doctor, nurse or pharmacist do they have the opportunity to share this responsibility with an informed clinician. Pharmacists can play an important role in supporting their clients with diabetes by having up to date knowledge on the model of care for diabetes, lifestyle choices and diabetes treatments.

Health professionals who attend the study day receive automatic membership on the Diabetes Ireland’s database ensuring they receive updates on public meetings and events running in their area and regularly receive their copy of both Diabetes Ireland’s magazine Diabetes Professional and Diabetes Ireland.

For more details on the study day, contact Elaine Newell, Diabetes Development Officer with Diabetes Ireland. Lo-call: (1850) 909 909. Phone: (01) 836 3022. Web: www.diabetes.ie.

fl utiform® (FLUTICASONE PROPIONATE AND FORMOTEROL FUMARATE) PRESSURISED INHALATION SUSPENSION. Prescribing Information Ireland. Please read the Summary of Product Characteristics before prescribing.Presentation: Pressurised inhalation suspension, in a pressurised metered dose inhaler (pMDI), containing fl uticasone propionate and formoterol fumarate dihydrate at strengths of 50 µg/5 µg, 125 µg/5 µg or 250 µg/10 µg per actuation. Indications: Regular treatment of asthma where the use of a combination product (inhaled corticosteroid and long-acting ß2-agonist) is appropriate: For patients not adequately controlled with inhaled corticosteroids and ‘as required’ inhaled short-acting ß2-agonist (SABA), or for patients already adequately controlled on both an inhaled corticosteroid and a long-acting ß2-agonist (LABA). fl utiform 50 µg/5 µg and 125 µg/5 µg per actuation are indicated for use in adults and adolescents 12 years and above. fl utiform 250 µg/10 µg per actuation is only indicated for use in adults. Dosage and administration: For inhalation use. The patient should be shown how to use the inhaler correctly by a physician or other healthcare professional. Patients should be given the strength of fl utiform containing the appropriate fl uticasone propionate dose for their disease severity (note that fl utiform 50 µg/5 µg per actuation is not appropriate in patients with severe asthma). The appropriate strength should be taken as two inhalations, twice-daily (normally in the morning and evening) and used every day, even when asymptomatic. fl utiform should not be used in children under 12 years. Prescribers should be aware that in asthmatics, fl uticasone propionate is as effective as some other inhaled steroids when administered at approximately half the total daily microgram dose. Total daily dose can be increased if asthma remains poorly controlled by administering a higher strength inhaler. Appropriate doses of the ß2-agonist and inhaled corticosteroid (ICS) in separate inhalers, or the ICS alone, should be prescribed if a patient requires doses outside the recommended dose regimens. Patients should be assessed regularly and once asthma is controlled, treatment should be reviewed and stepped down to the lowest effective dose, or an ICS alone. It is extremely important to regularly review patients as their treatment is stepped down. ICSs alone are fi rst line treatment for most patients. fl utiform is not intended for initial treatment of mild asthma. For patients with severe asthma the ICS therapy should be established before prescribing a fi xed-dose combination product. Patients on fl utiform must not use an additional LABA. An inhaled SABA should be taken for immediate relief of asthma symptoms arising between doses. The AeroChamber Plus® spacer device is recommended in patients who fi nd it diffi cult to use inhalers; re-titration should always follow the introduction of a spacer device. Patients should be advised to contact their prescriber when the fl utiform dose indicator is getting near zero.Contra-indications: Hypersensitivity to any of the active substances or excipients. Precautions and warnings: fl utiform should not be used for the fi rst treatment of asthma, to treat acute asthma symptoms or for prophylaxis of exercise-induced asthma. It should not be initiated during an exacerbation, during signifi cantly worsening or acutely deteriorating asthma, and should not be stopped abruptly. Patients should use their fl utiform maintenance treatment as prescribed, even when asymptomatic. If a patient experiences serious asthma-related adverse events or exacerbations, they should continue treatment but also seek medical advice. Patients should be reviewed as soon as possible if there is any indication of deteriorating asthma control. In the case of sudden and progressive deterioration, which is potentially life-threatening, an urgent medical assessment should be carried out. Use with caution in patients with: pulmonary tuberculosis; quiescent tuberculosis; fungal, viral or other infections of the airway; thyrotoxicosis; pheochromocytoma; diabetes mellitus (consider additional blood sugar controls); uncorrected hypokalaemia; predisposition to low levels of serum potassium; impaired adrenal function (monitor HPA axis function regularly) ; hypertrophic obstructive cardiomyopathy; idiopathic subvalvular aortic stenosis; severe hypertension; aneurysm or other severe cardiovascular disorders. There is risk of potentially serious hypokalaemia with high doses of ß2-agonists or concomitant treatment with ß2-agonists and drugs that can induce or potentiate a hypokalaemic effect. Particular caution is recommended in unstable or acute severe asthma and other conditions when the likelihood for hypokalemia adverse effects is increased. Monitoring of serum potassium levels is recommended during these circumstances. Formoterol may induce prolongation of the QTc interval. Caution must be observed when treating patients with existing prolongation of QTc interval. fl utiform should be discontinued immediately if there is evidence of paradoxical bronchospasm. Systemic effects with an ICS may occur, particularly at high doses for prolonged periods or when combined with potent CYP3A4 inhibitors, but are less likely than with oral corticosteroids. Use of a spacer device may also cause an increased systemic exposure. Increased exposure can be expected in patients with severe hepatic impairment. Prolonged

treatment with high doses of corticosteroids may result in adrenal suppression and acute adrenal crisis, particularly in adolescents and children or potentially as a result of trauma, surgery, infection or rapid dose reduction. Patients should be advised that fl utiform contains a small amount of ethanol; however this negligible amount does not pose a risk to patients. fl utiform is not recommended in children under 12 years of age. Interactions: Caution is advised in long-term co-administration with strong CYP3A4 inhibitors (e.g. ritonavir, atazanavir, clarithromycin, indinavir, itraconazole, nelfi navir, saquinavir, ketoconazole and telithromycin); co-administration should be avoided if possible. Ritonavir in particular should be avoided, unless the benefi ts outweigh the risks of systemic side-effects. Caution is advised with use of non-potassium sparing diuretics (e.g. loop or thiazide), xanthine derivatives, glucocorticosteroids, L-Dopa, L-thyroxine, oxytocin, alcohol or other adrenergic drugs. There is an increased risk of arrhythmias in patients receiving concomitant anaesthesia with halogenated hydrocarbons. Hypokalaemia may increase the risk of arrhythmias in patients being treated with digitalis glycosides. Concomitant use of ß-adrenergic drugs can have a potentially additive effect. Extreme caution should be taken when using formoterol fumarate with drugs known to prolong the QTc interval, such as tricyclic antidepressants or MAOIs (and for two weeks following their discontinuation), as well as antipsychotics (including phenothiazines), quinidine, disopyramide, procainamide and antihistamines. Concomitant use of an MAOI or a similar agent, such as furazolidone or procarbazine, may precipitate hypertensive reactions. ß-blockers and formoterol fumarate may inhibit the effect of each other. ß-blockers may produce severe bronchospasm in asthma patients, and they should not normally be treated with ß-blockers including those that are used as eye drops to treat glaucoma. Under certain circumstances, e.g. as prophylaxis after myocardial infarction, cardioselective ß blockers could be considered with caution Pregnancy and lactation: fl utiform is not recommended during pregnancy. It should only be considered if benefi ts to the mother outweigh risks to the foetus. It is not known whether fl uticasone propionate or formoterol are excreted in breast milk; a risk to the breast feeding infant cannot be excluded. A decision should be made on whether to discontinue breastfeeding or discontinue/abstain from fl utiform. Side-effects: Potentially serious side-effects: hyperglycaemia; depression; aggression; behavioural changes (predominantly in children); paradoxical bronchospasm; agitation; vertigo; palpitations; ventricular extrasystoles; angina pectoris; tachycardia; hypertension; dyspnoea; peripheral oedema; Cushings Syndrome; adrenal suppression; growth retardation; cataract and glaucoma; hypersensitivity reactions and QTc interval prolongation. Please consult the SPC for details of non-serious side-effects and those reported for the individual molecules. Legal category: POM Package quantities: One inhaler containing 120 actuations 50 µg/5 µg, 125 µg/5 µg, 250 µg/10 µg Marketing Authorisation numbers: PA 1688/13/1-3 Marketing Authorisation holder: Mundipharma Pharmaceuticals Limited, Millbank House, Arkle Road, Sandyford, Dublin 18, Ireland. Member of the Mundipharma Pharmaceutical Group. For medical information enquiries, please contact info@mundipharma.ieDate of preparation: January 2013

Reference:1. fl utiform Summary of Product Characteristics

® FLUTIFORM is a registered trademark of Jagotec AG, and is used under licence.® AEROCHAMBER and AEROCHAMBER PLUS are registered trade marks of Trudell Medical International. © 2012 Mundipharma Pharmaceuticals Limited.

Adverse events should be reported. Reporting forms and information can be found at http://www.imb.ie/EN/Safety--Quality/Online-Forms/Human- Medicine-Adverse-Drug-Reaction.aspx Adverse events should also be reported to Mundipharma Pharmaceuticals Limited on 01 206 3800.

IRE/FL-12042

A P O W E R F U L P A R T N E R S H I P

NEW

fluticasone propionate/formoterolfl utiform is indicated for the regular treatment of asthma in adults and adolescents (12 years and over),where use of a combination product (inhaled corticosteroid [ICS] and long-acting ß2-agonist [LABA]) is appropriate. fl utiform 250/10µg indicated in adults only.

Rapid onset* andlong lasting effi cacy**

COMBINATION

Modern aerosol device with a patient-facing dose counter1

INNOVATION

Modern aerosol device with a patient-facing dose counter

INNOVATION

* Open label study, signifi cant increase in FEV1 5 mins after dosing (p=o.oo1) (Aalbers et al: Onset of Bronchodilationwith fl uticasone/formoterol combination versus fl uticasone/salmeterol in an open-label, randomised study; Adv Ther 2012)** 6-12 month open label study, signifi cant improvement in spirometric secondary endpoints vs baseline (Mansur et al,Long Term Safety and Effi cacy of fl uticasone/formoterol combination therapy in Asthma; JAMP -Vol 25, No0, 2012 p1-10)

NEW

50/5 µg 125/5 µg 250/10 µg

The NEW asthma maintenance treatment

Flutiform_product ad IPN FP.indd 1 22/02/2013 13:59

Out & AboutTeva hold Dublin medicines meeting

Teva Pharmaceuticals Ireland recently hosted a conference in Dublin featuring presentations from the London School of Economics and the National Health Service experts. The seminar examined Ireland’s current medicines policy, made comparisons between EU countries, and proposed how Ireland can enhance the affordability of medicines.

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1. Sandra Gannon, General Manager of Teva. 2. (Left to right) - Pamela Logan, Irish Pharmacy Union; Sandra Gannon, General Manager of Teva; Michael Tierney, Tierney Pharmacy, Rathdrum, Co. Wicklow; and Avril Ryan, Teva. 3. Paul Brennan, Brennan Pharmacy, Ballyboden, Dublin; Jason Doherty, Doherty Pharmacy, Beaumont; and Adrian Dunne, Adrian Dunne Pharmacies. 4. Ruth Kelly, Sam McCauley Chemists; and Declan Boyle, United Drug. 5. Rachel Foley, Irish Cancer Society and Paul Harmon, hospital business manager, Teva. 6. Gary Collins, Cahill May Roberts; and Cormac Tobin, Doc Morris.

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Technicians CPD day IT Carlow recently hosted a continuous professional development day for pharmacy technicians. Attendees included technicians working in hospitals and communities nationwide.

1. Jacinta Farrell, Healy's Pharmacy, Bagnalstown; Ashling Hutton, Morgan's Medical Hall, Tullow. 2. Laura South, Lorilee Ryan, both from O'Malley's Pharmacy, Limerick. 3. Gayane Adibeaova, Coombe Women's Hospital; Nisso Kurbanova, Boots Pharmacy, Naas.

RCSI welcomes new pharmacy graduates

The Royal College of Surgeons in Ireland (RCSI) welcomed 22 new students to the College as the MSc in Industrial Pharmaceutical Science (MIPS) group.

This course meets the educational requirements for ‘Qualified Person' status, a role specified in European Union legislation and unique to European Pharmaceutical Manufacture.

The MSc in Industrial Pharmaceutical Science course is run over two years, primarily online, and is suitable for candidates wishing to undergo further training and improve their knowledge

of and gain further skills in the pharmaceutical sciences. The course, jointly offered between RCSI and the School of Science at the Institute of Technology Sligo, was launched in

response to the needs of the pharmaceutical healthcare sector in Ireland. In recent years, the course has attracted students from outside Ireland including UK, Europe, Africa and Australia.

1. Deirdre McCormack who graduated with a Masters in Pharmacy with her Mother Mary at the Royal College of Surgeons in Ireland (RCSI) 2. Maria Murphy and Aoife Corrigan who both graduated with degrees in BSc in Pharmacy at the Royal College of Surgeons in Ireland (RCSI) 3. Elaine Hanley and Ella Doherty who both graduated with a Master's in Pharmacy at the Royal College of Surgeons in Ireland (RCSI) 4. Caitriona McCarrick and Neasa Chambers who both graduated with a Masters in Pharmacy in the Royal College of Surgeons in Ireland (RCSI) 5. Anna Moynihan, Helen Naddy, Stephanie Donohue and Naomi Hodgins Pictures: Ray Lohan/RCSI

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Category Management SERIES ONE

Strategic Importance of Category ManagementIn these challenging economic times, Irish pharmacies are looking for means to ensure that their front of shop is working hard and delivering to the bottom line of their businesses. Whereas many have now heard of category management and believe that it could improve the shopper experience in their pharmacy and contribute to the performance of their front of shop business, there remains some uncertainty around what category management actually involves and how best to harness it’s potential. The Category Management Department in United Drug have outlined below what category management is, how its techniques are applied and what that can mean for the front of shop business. In addition to this, included are some quick, easy and affordable tips to improve the front of shop shopping experience for your customers. Remember, the strategic significance of the front of shop should not be underestimated, this area is responsible for the look and feel of the pharmacy and attracts and most importantly retains customers…

Category management is a practice which has been used extensively in grocery retail since it was first conceived in the 1980s by Dr Brian Harris. In its essence, category management is about optimising retail performance and in simple terms is often described as a tool which can help to get the right product, to the right customers, at the right time. Key global retailers and suppliers alike use its principles to drive improved results. When correctly applied, category management techniques may result in improved sales performance, greater profitability, reduced stock holding and greater customer satisfaction. Below we will explain category management techniques from a micro and macro perspective and outline how United Drug can work with you to apply category management expertise to your pharmacy.

Category management involves combining similar or related products together into a group or ‘category’ and then managing that category as a distinct business unit in order to optimise its performance. The implications on the total category must be considered when any action is taken on a specific brand or SKU. Managing the category so as to improve performance should involve;

• Defining the category, determining what its sub-categories are and deciding what products fall into each sub-category

• Developing an understanding of the role of a category within the pharmacy. For example, baby might be a core strategic destination category for a pharmacy located in an area populated by young families.

This is due to the fact that the pharmacy’s baby category will be key to attracting young parents into the pharmacy and retaining them as loyal customers as their families grow

• Analysis of store EPOS data to determine; the share of total sales that a category accounts for, what share each sub-category holds of the total category, top selling SKUs and non-performing SKUs

• Comparison of store EPOS data to the market to identify any opportunities for your business

• Ensuring that the correct amount of space on the category fixture is allocated to each sub-category based on its share of total category sales and its potential for growth/decline

• Ensuring that the ‘flow’ or order of products on the fixture correctly reflects how the category is shopped and how shopper decisions are made (the shopper decision tree)

• Using key brands strategically placed at eye level to sign post the category to the shopper

• Determining the correct category range to drive category performance and best meet shopper needs

• Allocating the correct amount of facings to each individual product, based on that products sales performance

All of the above actions are then reflected visually in a map of the category or a ‘planogram’ as it should appear on shelf. This planogram should then be used as a tool to implement and maintain the ideal category layout in store. The above actions

are categorised as practices of category management at a micro level as they are performed on each individual category within the store.

Category management at a macro level/macro store planning has become more widely practiced in Ireland in recent years as retailers seek to maximise each square centimetre of their shop floor. Applying a macro planning view to the shop floor should involve;

• Ensuring that each category has the correct share of total front of shop space based on its contribution to overall sales and its potential for growth/decline

• Ensuring that ‘linked’ categories are located close to each other so as to maximise the relationships that exist between them

• Developing an understanding of the natural shopper flow around the pharmacy through shopper observation and exploiting opportunities that arise from this understanding. For example, at Christmas it is effective to place seasonal gift sets in a hot-spot along the natural path that the shopper takes through the pharmacy as this will increase the chance of an impulse purchase

• Ensuring that shopper demographics are taken into account when considering the overall store layout

• Taking account of key shopper missions when determining optimum store layout. This involves taking a broader view of the shopper’s true need. For example, taking a narrow view we might consider the need of the shopper entering

a pharmacy in July to be 'purchase a bottle of sunscreen'. Taking a more expansive view we might consider their broader mission to be ‘getting ready for my summer holiday’. Thinking about the shopper’s mission in this broad sense could lead to placing insect repellent or travel sized toiletries adjacent to sunscreen. Considering shopper missions and tailoring your store layout to meet these greatly increases the chances of the shopper picking up additional items which tie into their broader shopper mission.

Below we have outlined some simple, quick and affordable steps which you can take to improve your front of shop offering from the moment the shopper enters the pharmacy until they leave, a satisfied customer…

• First impressions do count so make your pharmacy appealing from the outside; ensure that your shop front is clean, well maintained, has a functioning green cross, clean windows and your hours of business clearly displayed

• Ensure that there are ample shopping baskets available just inside the door, you want to ensure that you make it as easy as possible for shoppers to pick up several items in your pharmacy

• Ensure that the store is bright and well lit, make it a pleasure for the shopper to shop in your store

• Signpost key categories so that they are easily located by the shopper, strong brand blocking can also be effective in sign posting the category

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• Ensure that the floor is kept clear at all times. Totes abandoned on the floor are a health and safety hazard, they also make it more difficult for shoppers with impaired mobility or parents with buggies to navigate aisles which may result in them choosing a different pharmacy over yours in the future

• Reduce the clutter – less is more as an overabundance of posters, POS etc. can just confuse and frustrate the shopper

• Keep fixtures and fittings clean and dust free

• Consider the impact of price points, a ¤2.99 price point may sound more clear and appealing to the shopper than ¤3.04

• Ensure that all products are priced. Many shoppers are more likely to leave a product on the shelf than go to the bother of asking, resulting in a lost sale

• Merchandise related categories close together. A shopper who enters your pharmacy to buy fake tan for a big night out may easily pick up an item from your cosmetic stand if they are

situated close together

• Maximise the impact of promotions. Use POS such as a price card or shelf talker to highlight the promo price/discount. If the offer is not clearly visible the shopper is unlikely to take the time to investigate the detail themselves

• Recognise the opportunity that lies in the couple of minutes while the customer waits for their prescription to be filled. Ensure that attractive, promo ends with clearly marked promo price points are close to the dispensary waiting area, this will increase the chance of a shopper making an impulse purchase. Use the Pharmacy Channel to promote products and services available in your pharmacy to waiting customers

• Tailor impulse items around the till area to the season e.g. individual packets of tissues and chap sticks are good impulse items during winter

Our Category Management team here in United Drug can provide you with category management expertise to help to optimise the performance of your front of

shop categories, to free up cash by reducing stock holding and ultimately improve margin and also advise on how to best implement category practices using a simple approach based on 3 core steps; plan, do and review. For an annual fee we will provide you with category management support on a micro level including;

• Access to our Category Management website where you can find category planograms and market analysis on key front of shop categories

• Detailed analysis of EPOS data to help you to make better decisions on the correct range for your pharmacy

• Identification of potential growth areas for your business based on a comparison of your sales data vs. the market

And on a macro level;

• Provision of detailed recommendations on overall layout and category positioning within your pharmacy following a consultation in store

• Advice on correct space allocation for front of shop categories based on an analysis

of your sales data, to ensure that categories which are driving your business are getting sufficient space

• Delivery of recommendations on the overall look and feel of the pharmacy so as to improve the shopper experience within your store

The Category Management team in United Drug invite you to contact us to see how we can help you to apply category management principles to your pharmacy. Additional information can be found on our website http://udretailinitiatives.ie/

Sources

- www.igd.com

- www.thepartneringgroup.com

- The Missing Metric Missing Shelf-Space Profitability Booz & Co 2007

Mary Magner, Category Manager 01 4632538/087 3777035

Kim D’Arcy, Category Management Associate 01 4632514

Kim D’Arcy and Mary Magner, Category Management Department, United Drug

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To become a Confidante stockist, please call+44 (0) 28 9445 1004 or email info@confidantetest.com

Confidante is the only OTC product which can detect 10 STIs in a single test, including chlamydia,

gonorrhoea and syphilis.

Confidante provides customers with simple, accurate and confidential laboratory testing from home,

without visiting a GUM clinic.

Improve your current sexual health range and make your pharmacy

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HOME STI TESTING KIT

When the biological clock starts to tick, couples want fast results. This pressure may end in IVF treatment, but the starting point is to work out where problems may lie and act on them without delay.

Either partner may be affected.

FertilityTRIO is an affordable (RRP ¤74.95), fast and tactful starting point. It includes 3 home test kits - an ovulation test 5-pack, a pregnancy test and, importantly, a rapid sperm-count test*.

To order, please contact Nutricentric Healthcare by e-mail (peter@nutricentric.com) or text/call Peter Conry on(086) 348 3592

Nutricentric Healthcare (Nutricentric.com) specializes in establishing pharmacy in-store diagnostic services related to respiratory allergy (dust mite, pollens etc; 30 minute test), food intolerance (50+ foods, under an hour), thyroid or iron deficiency, or low Vitamin D. We can also help link you with a local nutritional therapist for when specialist expertise is needed. *The component tests are produced by NanoRepro AG a specialized reproductive health test producer based in Marburg, Germany. When issues are found, lifestyle and nutritional improvement alone may suffice.

Clinical Profiles

Cymalon, the over-the-counter cystitis treatment from Actavis Ireland, has been re-launched with a new look for 2013.

The new, eye-catching packaging refreshes the look of this well-established product, which offers fast, effective relief from a range of condition-related symptoms including: a burning sensation when passing water; the need to pass water frequently and a general discomfort in the lower abdomen area.

A familiar sight on Irish pharmacy shelves and a popular choice among Irish cystitis sufferers1, Cymalon offers a complete 48-hour course of treatment, with six lemon flavour sachets of granules, mixed to take as an oral solution.

Cymalon contains citric acid which helps increase the secretion of urine and render it less acidic and sodium citrate which aids the treatment of the urinary tract infection.

Cymalon (x six sachets) is available at a trade price of ¤4.51.

For further information on the Actavis OTC Product portfolio please contact the Actavis OTC Account Manager Barry Doyle on (086) 0242 131.

Cymalon gets new look for 2013

Actavis Ireland is pleased to announce the introduction of Montelukast Paediatric (4 mg and 5 mg) and Montelukast Actavis (10 mg) on the first day of patent expiry.

Delivering key products on Day One continues to be an important focus for Actavis Ireland and this latest launch - on 25th February - continues to underline Actavis’ position as the fastest growing pharmaceutical company on the Irish market1.

Indicated for the treatment of asthma, Montelukast Paediatric is available in 4 mg and 5 mg x 28 chewable tablets and Montelukast Actavis 10mg, for adolescents and adults from 15 years of age, is available in packs of 28 film coated tablets. Subject to medical prescription, Montelukast is GMS reimbursable and available from all wholesalers from February 25th.

Montelukast Paediatric 4 mg is available at a trade price of ¤18.27 and the 5 mg at ¤18.71. Montelukast Actavis 10 mg has a trade price of ¤18.38.

For further information on the Actavis portfolio please contact Actavis on 1890 33 32 31 or email on contact@actavis.ie

Montelukast is day one launch for Actavis

Montelair (Montelukast) 10mg Film-coated Tablets are indicated for: 1

• The treatment of asthma as add-on therapy in those patients, 15 years and older, with mild to moderate persistent asthma who are inadequately controlled on inhaled corticosteroids and in whom 'as-needed' short-acting beta-agonists provide inadequate clinical control of asthma

• Adult asthmatic patients (15 years and over) in whom Montelair is indicated in asthma, Montelair can also provide symptomatic relief of seasonal allergic rhinitis.

• The prophylaxis of asthma in patients in which the predominant component is exercise-induced bronchoconstriction.

Also available, Montelair 4mg Chewable tablets for patients aged 2 to 5 years and Montelair 5mg Chewable tablets for patients aged 6 to 14 years.

Please refer to the summary of product characteristics for full details of indications.

Montelair Chewable and Film-coated tablets are available in a 28 pack.

Full prescribing information for Montelair is available on request or go to www.clonmel-health.ie . This Product is subject to medical prescription. Montelair is GMS reimbursable from 1st March 2013.

Please contact Clonmel Healthcare on 01-6204000 if you require any additional information on Montelair

Montelair (Montelukast) 4mg, 5mg chewable tablets and 10mg film-coated tablets launched

Fortisip Compact is an energy dense (2.4kcal/ml), nutritionally complete oral nutritional supplement (ONS) that equates to 40% less volume compared with the traditional 200ml bottle. Fortisip Compact (and Fortisip Compact Fibre) is now GMS listed. It offers a number of benefits:

Small volume, leading to greater compliance and less wastage Low volume, energy dense ONS have been shown to result in greater compliance in comparison to the standard 200ml. Consumption of a product such as Fortisip Compact has been shown to significantly increase weight and also result in greater total energy and protein intake than standard 200ml ONS, without compromising food intake.

Cost savings Nutricia Medical is delighted to be able to provide this innovative product at a price of ¤1.38 per 125ml bottle. This represents a 19% cost saving versus standard 200ml supplements and provides healthcare professionals with the option of prescribing the highest compliance product at the lowest price for their patients.

Improved packaging, reduced storage space and weight As Fortisip Compact has 40% less volume, this also equates to an advantageous 33% less storage than standard 200ml ONS. This is a benefit for both shelf space in a pharmacy, but also for the patient in their own home.

Fortisip Compact is suitable for a wide range of patients In addition to being ideal for patients with poor appetites, patients on fluid restrictions and elderly patients who may not be able to consume large meals/drinks, Fortisip Compact is very useful for patients with cancer. Due to the symptoms associated with many cancers – odynophagia, dysphagia, taste changes and early satiety – it is often very difficult for patients to manage their prescribed dose.

Optimising compliance to and intake from ONS is of vital importance. By choosing Fortisip Compact, patients get more energy, protein and micronutrients, all in a lower-volume 125ml supplement.

Fortisip Compact oral nutritional supplement improves compliance

Rowex Ltd is pleased to announce the launch of Montelukast Paediatric 4mg, 5mg Chewable Tablets and Montelukast 10mg Film-Coated Tablets x 28’s (Montelukast)

The details of the launch are as follows;

• Treatment of mild to moderate asthma as add-on therapy in patients inadequately controlled on inhaled corticosteroids.

• Prophylaxis of exercise induced asthma.

• Treatment of mild to moderate persistent asthma with Montelukast Paediatric in paediatric patients incapable of using inhaled corticosteroids and with no recent history of acute asthma attacks that would require an oral corticosteroid.

• Symptomatic relief of seasonal allergic rhinitis with Montelukast 10mg film coated tablets in patients where Montelukast in indicated in asthma.

For further information contact Rowex Ltd., Bantry, Co. Cork. Freephone 1800 304 400, email rowex@rowa-pharma.ie

Montelukast Paediatric 4mg, 5mg Chewable Tablets and Montelukast 10mg Film-Coated Tablets

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Product Profiles

Revolutionary Hand Care from Cuticura enters Boots Ireland

Cuticura are delighted to announce that their new trio of deep cleansing antibacterial hand washes are now available at Boots stores in Ireland. The new range is available in three different varieties Ginger and Manuka Honey, Lime and Bamboo and

Black Pepper and Pomegranate. The new Cuticura Hand Wash Anti Bacterial Technology gently cleanses hands killing 99.9% of bacteria and unlike hand wash, prevents reinfection for up to 3 hours.

As well as revolutionising the category, the new Cuticura range answers consumer demand for products that not only kill bacteria, but also offer protection and care for skin. This new offering is set to drive incremental sales through its market leading technology, credentials as hand hygiene experts and enhanced offering for consumers.

Cuticura is part of the Keyline Brand Ltd portfolio; Keyline is dedicated to delivering high quality, affordable beauty and personal care products, constantly innovating and quickly responding to consumer needs and market trends.

www.cuticura.co.uk

Actavis Ireland launches vibrant new marketing campaign for CYMEX CREAM

Actavis Ireland launches a new, eye-catching marketing campaign for its cold sore cream CYMEX. Developed for rollout across a range of media platforms, the campaign introduces ‘BLIPPY’ the new - and rather nasty – character, a visual depiction the cold sore virus.

Over the coming weeks, ‘BLIPPY’ will appear on Irish cinema screens, introduce himself on national and local radio and is set to make his mark across a range of media locations including buses, trains and shopping centres. His fate (naturally) will in all instances be sealed by CYMEX CREAM with the campaign messaging highlighting the product’s unique triple action formula for soothing tingling, relieving cracked lips and controlling infection following a cold sore outbreak.

Pharmacies wishing to avail of in-store materials and window kitting may arrange this with their local Actavis Ireland representative or by making contact directly with the OTC Manager Barry Doyle on (086) 0242 131.

New diarrhoea treatment launched for the whole family

Ocean Healthcare is pleased to announce the launch of Tasectan on the

Irish market. Tasectan - Gelatin Tannate, is indicated for the treatment of diarrhoea.

Tasectan has a unique mode of action that targets the source of diarrhoea. It is the only product suitable for use in infants, children and adults. Tasectan is available in capsules for adults and sachets for paediatric use. More information is available on www.diarrhoea.ie

The launch of Tasectan will be supported by a heavyweight marketing campaign targeting consumers and healthcare professionals. The campaign will include Radio, Print and online advertising.

Tasectan is available from Ocean Healthcare and all wholesalers. For more information contact Ocean Healthcare 01 2968080

Tasectan Capsules 8s RRP ¤7.95 Tasectan Sachets Paediatric 10s ¤8.95

SNORING A PROBLEM for your customers? Are they tired of dealing with it? 60% of the population is effected by snoring.

Here is something worth trying - the Good Night Anti-snoring Ring. It comes with a Money Back Guarantee.

The Good Night Anti-snoring Ring utilises proven ancient Chinese acupressure therapy.

Simply place the Good Night Anti-snoring Ring on the little finger at night just before going to sleep.

The ring works on two acu-pressure points located on the little finger. The ring’s two acu-activators work to free up ones breathing passages and natural bio rhythms to give a snore-free restful night’s sleep.

The Good Night Ring retails for ¤39.99, is available from Pharmaher Healthcare Ltd – call 041-988-2255 to order now. Ask for a free display unit to boost your sales. Let the Ring put a “ring” on your till.

Massive continuous National Media support that includes, RTE, TV3 and Setanta.

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Send your appointments announcements to Irish Pharmacy NewsOur appointments page offers you a chance to offi cially welcome your new colleague to your pharmacy and to let your peers know about positive happenings within your business. Simply send in 100-200 words providing some background career details on the person and a separatehigh-resolution headshot (preferably a JPEG) to accompany the piece.

Send your details and photograph to editorial@ipnirishpharmacynews.ie or call (01) 602 4715 for more details.

Appointments

Lifes2good has announced the appointment of Kevin Barry as business manager for the Irish market. Barry has an extensive commercial business and management background, having studied human resource management at undergraduate level and information technology at postgraduate level, at Dublin City University.

Mary Dickens, Country Manager of Sanofi Ireland Ltd, has been elected as Vice President of the Irish Pharmaceutical Healthcare Association (IPHA). She has been a member of the IPHA Strategy Board since September 2011 and was appointed to the Board of Directors in November 2012. She joined the Sanofi Group in 1984 as a Medical Representative in the UK.

Eamonn Gargan has joined United Drug as HSC ROI Facilities and Maintenance Manager. A building services engineer with an electrical background, Gargan has 17 years’ experience working in various engineering environments, both in Ireland and overseas. Hailing from Swords, Co Dublin, he previously worked for six years in the pharmaceutical industry with Cahill May Roberts/Celesio and before that, he was a Project Manager at Dublin Airport.

Gary Joyce has been appointed as an independent non-executive director at Sam McCauley Chemists Limited. Joyce is managing partner of Genesis, the leading strategic marketing consultancy. She is a director of Dublin Bus and is a Fellow of the Marketing Institute of Ireland and the Institute of Management Consultants and Advisers in Ireland.

Mary Magner joined United Drug on 28 January as Category Manager. Hailing originally from Cork, she previously worked in McCain Foods in Account Management and spent over five years in Heineken, where she ended up specialising in Category Management in the off trade. Magner holds a BComm (European) degree with French from University College Cork.

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

Martin Small has taken up the position of Account Manager, Healthcare Supply Chain Republic of Ireland, at United Drug. Small previously worked with Movianto Ireland and the Pre-Wholesale Division of Cahill May Roberts. He was born in Newry, Co Down but now lives in Castleknock, Dublin 15 and he started in his new position last November.

Breathe easily!Nature’s way to wash away allergens and congestion

Use the power of sea water to help clear and unblock noses naturally

Available in your local pharmacy through Intrapharma Consumer Health