Men's Health Week 2021

Home , Cormac Devlin, Jerry Buttimer, John Lahart, Lenny Abrahamson, Maria Byrne, Robert Troy

IRELAND’S OFFICIAL PHARMACY PUBLICATION

JUNE 2021 Men's Health Week 2021 COVID-19 vaccines and new variants Veterinary medicine: the view from both sides COVID-19 vaccination Minister Donnelly: “Pharmacies to be involved in June”

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Beconase Hayfever nasal spray 50 micrograms per spray contains beclometasone dipropionate. For the prevention and relief of symptoms of Hayfever and other seasonal allergic conditions. Adults aged 18 and over: 2 sprays into each nostril twice a day. Max 8 applications per day (400 mcg). Seek medical advice if symptoms do not improve after 2 weeks. Do not use continuously for longer than 3 months without consulting a doctor. Do not give to persons under 18 years. Pregnant and breastfeeding mothers should not use without consulting a healthcare professional. Caution: Recent nasal injury or surgery. Side effects: Rare cases of hypersensitivity reactions. Unpleasant taste/smell, dryness/irritation of the nose and throat, raised intra-ocular pressure, nasal septal perforation. PA 1186/8/1. P. MAH: Chefaro Ireland Limited, The Sharp Building, Hogan Place, Dublin 2, Ireland. SPC: http://www.medicines.ie/medicine/7169/SPC/Beconase+Hayfever/. Date of preparation March 2021. Always read the leaflet. Becodefence is a medical device. Contraindications: known hypersensitivity to ingredients or those with a Sesame Oil allergy. Always read the leaflet. IRE BEC 2021 02

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7 A Note from the Editor 8 Message to IPU members from TOTAL Stephen Donnelly TD, Minister for Health IPU News The latest news and events HAY FEVER from Butterfield House 10 Statement of Strategy 10 Pharmacy in the Media The IPU Review is published monthly and circulated to Irish 11 Message to Oireachtas Members pharmacists. The views expressed on role of pharmacies in COVID-19 by contributors are not those vaccination rollout CONTROL of the IPU nor is responsibility accepted for claims in articles 12 New IPU website or advertisements. 12 Updated IPU logo 25 GETS Subscription: €100 (Ireland North & South) and TO WORK €150 (including postage overseas). in mins in Publisher: 6 1 Irish Pharmacy Union 3 RELIEF (IPU Services Ltd), Butterfield House, Butterfield Avenue, Rathfarnham, Dublin 14, D14 E126 Tel: (01) 493 6401 Fax: (01) 493 6626 Email: [email protected] Website: www.ipu.ie Features Editor: Jack Shanahan MPSI Editorial Associates: 13 Unveiling the new ipu.ie Daniel Rowan, Ciara Browne and Jim Curran Advertising: Daniel Rowan 17 COVID-19 Vaccines: Email: [email protected] Tel: (01) 493 6401 How well will they work against new variants? ©2021 Copyright: All Rights Reserved, Irish Pharmacy Union. 20 CPD: Constipation Printed by Rymar Print. IPU Review is a Registered Trademark of the Irish Pharmacy Union. 25 Men’s Health Week 13 DEFENCE RELIEF

For more detail and for any training requirements please contact your Perrigo Pharmacy Business Manager ALAN HARNETT RUTH GRANT CHARLIE RICKARD ANNE MARIE O’NEILL BRENDAN O’KEEFFE PAUL FLYNN OLLIE HIGGINS 17 Waterford/Tipperary/ Nth Leinster Midlands Greater Dublin South Leinster Cork and Kerry Limerick/Clare West 086-8189846 086-4679113 086-6011643 086-1749626 086-8189843 086-1427717 087-9533161

Beconase Hayfever nasal spray 50 micrograms per spray contains beclometasone dipropionate. For the prevention and relief of symptoms of Hayfever and other seasonal allergic conditions. Adults aged 18 and over: 2 sprays into each nostril twice a day. Max 8 applications per day (400 mcg). Seek medical advice if symptoms do not improve 20 after 2 weeks. Do not use continuously for longer than 3 months without consulting a doctor. Do not give to persons under 18 years. Pregnant and breastfeeding mothers should not use without consulting a healthcare professional. Caution: Recent nasal injury or surgery. Side effects: Rare cases of hypersensitivity reactions. Unpleasant taste/smell, dryness/irritation of the nose and throat, raised intra-ocular pressure, nasal septal perforation. PA 1186/8/1. P. MAH: Chefaro Ireland Limited, The Sharp Building, Hogan Place, Dublin 2, Ireland. SPC: http://www.medicines.ie/medicine/7169/SPC/Beconase+Hayfever/. Date of preparation March 2021. Always read the leaflet. Becodefence is a medical device. Contraindications: known hypersensitivity to ingredients or those with a Sesame Oil allergy. Always read the leaflet. IRE BEC 2021 02 IPUREVIEW JUNE 2021 3

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Clonfolic is contraindicated in cases of Vitamin B12 deficiency. Caution is advised for patients under therapy for folate-dependent tumours when taking folic acid. Women with pre-existing diabetes, obesity, family history of neural tube defects, or previous pregnancy affected by neural tube defect have an increased risk of having a pregnancy affected by a neural tube defect and higher doses should be considered. For women taking anti-seizure medication the requirement for folic acid may be different and they should be under the supervision of a physician while taking folic acid supplements. The tablet also includes lactose monohydrate. A copy of the summary of product characteristics is available on request. Clonfolic 0.4mg tablets. PA 126/95/1. PA Holder: Clonmel Healthcare Ltd, Waterford Road, Clonmel, Co Tipperary, Ireland. www.clonmel-health.ie Medicinal product not subject to medical prescription. Supply through general sales. References: 1. NTDs (neural tube defects). 2. Leading sales brand in pharmacy – IQVIA, IRLP audit, units, MAT Jan 20. Date prepared July 2020. 2020/ADV/CLO/048H It’s that simple... 30 What will new veterinary medicine regulations mean for pharmacists? 33 New veterinary medicine regulations: The perspective ... for all women from the HPRA 36 Political report 30 39 Letter to the Editor capable of conceiving. 40 Oral Health: The role of pharmacists Other News 43 Studies 44 Sunscreen survey 46 Clinical Tip: Changes 45 MSc in Clinical Pharmacy 52 Folic Acid - helps prevent Spina Bifida and other NTDs1. to Madopar dosing in UCC 45 New PGEU President Clonfolic is the market-leading brand2. Take one tablet daily. 48 High Tech: Praulent pre-filled pens 40 50 Summer wines 52 The Village Bookshelf Key Facts 54 Crossword • Studies have shown over 70% of first time NTDs1, such as Spina Bifida can be prevented by taking 0.4mg of folic acid daily.

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IPUREVIEW JUNE 2021 5 Essential medicines information to support pharmacists make informed treatment choices

95% of people are in favour of pharmacists being able to Accessed at the point of need, MedicinesComplete prescribe some medicines for minor ailments according supports your ability to: to a 2020 survey by the Irish Pharmacy Union (IPU).* ● Find medicines information that is most relevant to With some community pharmacists now trained to the patient’s needs administer certain prescription only medicines in ● Make decisions with conﬁdence on the best emergencies (e.g epinephrine)**, the need to have treatment for patients quick access to trusted, evidence-based information ● Make safe and eective decisions about dosage to support their decision-making has never been queries so important. ● Quickly interpret information to manage adverse drug reactions MedicinesComplete makes it easy for healthcare professionals to access essential medicines information With the support of MedicinesComplete, you can be at the point of care. Providing trusted evidence-based safe in the knowledge that your pharmacy team will knowledge for conﬁdent decision-making and eective have increased ability to make eective decisions at the patient care. point of care.

“The IPU is delighted to add yet another beneﬁt to what we o er our members. MedicinesComplete is a great service, and we are very pleased to be working with the Pharmaceutical Press to o er this service at a substantially discounted rate for our members”. — Darragh O’Loughlin, IPU Secretary General

Special oer for members of the IPU MedicinesComplete are pleased to support members with a 92% reduced rate subscription to essential information through MedicinesComplete. This special oer includes easy-to-use and trusted resources:

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Prices start at €452 for one site/premises and €395.50 per site for members who own between 2 and 10 sites/premises. For more information about this special rate subscription visit: about.medicinescomplete.com/sector/pharmacy/Ireland

*ipu.ie/home/pharmacy-in-ireland/ ** https://www.thepsi.ie/gns/Pharmacy_Practice/pharmacy_practice_reports/Future_Pharmacy_Practice_Report A NOTE FROM THE EDITOR Jack Shanahan MPSI The basic truth is more important than ever in this age of alternative facts

It has often been pointed out that one of the great problems of democracy is that people can vote. Essential medicines information to support he convulsions of accepted as over enthusiasm, clear that there are checks are not going to please pharmacists make informed treatment choices partisanship are unfortunate or just simply, and balances to ensure a everyone. Those that are not representative of ‘there must be a good reason steady, solid service. We all pleased can get upset. They another global why they did that’. Some benefit. Whether it is as an can be vocal, which, in today’s 95% of people are in favour of pharmacists being able to Accessed at the point of need, MedicinesComplete pandemic. While critical faculties are turned advocate, answering a query internet-based social media hackneyed phrases like ‘post off. Just as important, you authoritatively, some CPD, or can make quite a storm. prescribe some medicines for minor ailments according supports your ability to: Ttruth’ and ’echo chambers’ start to depersonalise the more serious support, the IPU That is their prerogative. Yet, to a 2020 survey by the Irish Pharmacy Union (IPU).* have largely lost the interest other tribe. This is a leaf from is there. Obviously there are it is important to be able to ● Find medicines information that is most relevant to of the public, their legacies the training manual of the caveats. Miracles are in short disagree without resorting to With some community pharmacists now trained to the patient’s needs continue to escalate. I am military. It is hard to shoot a supply. It isn’t always possible scorched earth policies. Cancel administer certain prescription only medicines in ● Make decisions with confidence on the best of the generation that was person, but relatively easy to to unconditionally support culture is a phenomenon that brought up to believe that take out a subject. members. For instance, if a nobody gains from. I am a emergencies (e.g epinephrine)**, the need to have treatment for patients there was always a basic Why am I going over this member finds themselves proud member of the IPU for quick access to trusted, evidence-based information ● Make safe and eective decisions about dosage truth, a set of undisputable relatively well-ploughed in a spot of bother with over thirty years, as was my to support their decision-making has never been queries facts. There was always ground? I am of the belief the authorities because of father before me. I trust the so important. ● Quickly interpret information to manage adverse ‘your side, my side and the that there is a risk of a similar fraudulent misbehaviour, structure, the processes and drug reactions truth’. Not any more. When partisanship developing in support is, by necessity, the people, many volunteers, we had the jaw-dropping Irish community pharmacy. limited. Equally, the Union that give their time and energy MedicinesComplete makes it easy for healthcare ‘alternative facts’, from the The last decade has seen some cannot be expected to spend to the profession. It would professionals to access essential medicines information With the support of MedicinesComplete, you can be great spinmeister, Kellyanne fundamental changes in the its resources on what would be a sad day if partisanship, at the point of care. Providing trusted evidence-based safe in the knowledge that your pharmacy team will Conway, there was an direction of pharmacy. At a be perceived as fool’s errands. bitterness, targeting and knowledge for confident decision-making and eective have increased ability to make eective decisions at the underlying feeling that her macro level, we have seen the There are enough issues that general nastiness created a patient care. point of care. tongue was firmly planted in rapid adoption of co-operatives have attainable objectives structure that most people her cheek. We re-learned the and branding groups in the without squandering capital would actively avoid. As I Abraham Lincoln maxim that community. We have seen by tilting at windmills. For started, I will finish. The IPU is “The IPU is delighted to add yet another benefit to what we o er our members. MedicinesComplete is a “You can fool all of the people an acceleration in the direct instance, FMD. Suddenly, when a democratic organisation. It is the letters started to come our Union. It is our actions, our great service, and we are very pleased to be working with the Pharmaceutical Press to o er this service at a some of the time, some of ownership of pharmacies by the people all of the time but drug wholesalers. At one level, from the regulator, people decisions that will determine substantially discounted rate for our members”. — Darragh O’Loughlin, IPU Secretary General you can’t fool all the people we see pharmacists agreeing finally realised that this is its future. all the time”. The evolution that working together is actually a legal requirement. of the partisan playbook has important. The most obvious Immediately it became ‘what been a true revolution. It aspect of this is the Irish is the Union doing about has shown us that there are Pharmacy Union. The beauty it?’. The previous decade of Special oer for members of the IPU circumstances where normal of this Union is that it has opposition, progressing to people can become utterly one, simple, clear objective. amelioration of the effects of MedicinesComplete are pleased to support members with a 92% reduced rate subscription to essential polarised. While this is not It is to advocate for, and act FMD are forgotten or ignored. information through MedicinesComplete. This special oer includes easy-to-use and trusted resources: news to any of us, the fallout on, initiatives to improve the We are stuck with an EU is something that is changing lot of pharmacists in Ireland. solution to a global problem. our nature and our futures. It is democratic, in that It may not be good, but you Partisanship is much more positions on all committees get used to it. There are more than simple opposition. It is an are electable. These important issues. all-in tribalism. It is the very committees decide policy One salient aspect is the antithesis of democracy, as that is then implemented right of the Union to do what British National BNF Stockley’s Drug Stockley’s Martindale: The Martindale’s ADR Formulary (BNF) for Children Interactions Interactions Complete Drug Checker it denies that your opponent by an executive team, led it feels is right for its members, Checker Reference can have a legitimate view. by the Secretary General. within the parameters of its If anyone in your tribe says There is no doubt that rules and what is considered Prices start at €452 for one site/premises and €395.50 per site for members who own or does anything, it’s OK. the IPU hasn’t always got legal. This can mean difficult between 2 and 10 sites/premises. Doesn’t matter what it is, it is everything right. But it is also choices, which, by definition, For more information about this special rate subscription visit: If you have any comments, queries or issues to raise, send about.medicinescomplete.com/sector/pharmacy/Ireland your “Letters to the Editor” by email to [email protected].

*ipu.ie/home/pharmacy-in-ireland/ ** https://www.thepsi.ie/gns/Pharmacy_Practice/pharmacy_practice_reports/Future_Pharmacy_Practice_Report IPUREVIEW JUNE 2021 7 MESSAGE FROM MINISTER Message from the Minister for Health, Stephen Donnelly TD to the members of the Irish Pharmacy Union

he past year has impacts on the business been a period of model of many community unprecedented pharmacies over the course difficulty for the of the pandemic. I fully country, and you appreciate that you, as with have been at many other sectors, have the forefront of experienced added financial the response to the COVID-19 pressures during the crisis. crisis and have played a I gratefully acknowledge Tpivotal role in responding that, notwithstanding this, to the health needs of the you have played a vital role public. You have ensured in protecting the essential the continued availability medicine supply to the public. of a professional, accessible I wish to thank service and have successfully community pharmacists managed to alleviate concerns for embracing the use of around continuity of medicine Healthmail during Covid-19. supply in the face of great I understand that work is uncertainty. ongoing on introducing a I do, however, acknowledge, full E-prescribing system that there have been and I welcome the IPU’s

8 IPUREVIEW JUNE 2021 “ I appreciate that community pharmacists are eager to be involved in the administration of the COVID-19 vaccine programme. I understand that work is ongoing within the HSE in this regard and anticipate that you will be involved in June.”

involvement in advancing this vaccination campaign. I am the continuity of supply care. I am committed to important innovation further aware that there has never of medicines and medical further developing that role in in 2021. been a greater demand for the devices. Safeguarding the context of health service I am pleased that the adult vaccination and that that supply and ensuring reform. I have listened to Community Pharmacy the rates of uptake have been continuity of care and and met with the IPU, both Contingency Forum, which unprecedented. treatment to Irish patients in Opposition and since I was formed in April 2020, is still I appreciate that community was and continues to be of appointed Minister for Health, ongoing. I believe that this pharmacists are eager to be the utmost importance to and firmly believe that there is forum has been important involved in the administration this Government. As key much merit in initiatives you in responding to clinical of the COVID-19 vaccine stakeholders in the supply are seeking progress such as a and operational challenges programme. I understand of medical products to Irish Minor Ailment Scheme. that have faced community that work is ongoing within patients, your continued I believe that we pharmacists over the past the HSE in this regard and support in relaying clear and cannot reform our health year. It is my hope that this anticipate that you will be accurate information to the system unless we work forum will continue to meet in involved in June. public has been crucial. collaboratively, and with the long term. As we are all aware, Brexit I also wish to emphasise the other healthcare providers, to I wish to express my sincere posed an unprecedented important role community make a significant difference appreciation to all community risk to many aspects of pharmacists play in the wider to patient outcomes. The full pharmacists for their life in Ireland, not least to Irish Health Service in the potential of your profession participation in the recent flu the healthcare system and delivery of holistic patient should be maximised.

IPUREVIEW JUNE 2021 9 Pharmacy in the Media The Irish Times carried an article regarding the number of vaccinators in Ireland and the delays in the COVID vaccination roll out in pharmacies. This was also highlighted on Newstalk’s Down to Business with Bobby Kerr. IPU PCC Committee member Tom Murray was interviewed for an RTE SixOne piece where he discussed the roll-out of the vaccination service and the role for pharmacies. This also appeared on the 9 o’clock news. Tom also gave an Statement interview to Radio Foyle. On the same subject, IPU member, Jack Shanahan also gave an interview to Radio Kerry. The Secretary General was interviewed on RTÉ Radio 1 Today with Claire Byrne advocating for of Strategy the immediate roll-out of COVID-19 vaccination through local pharmacies instead of only focusing on mass vaccination centres. This interview gained extensive national coverage and was picked up on RTÉ 2FM, RTÉ.ie, Irish Examiner, Irish Daily Mail and 2021-2024 Irish Mirror. Fergal Bowers also addressed this in his weekend report. IPU member Ultan Molloy was also interviewed for an Irish Independent article on the topic. The IPU Statement of Strategy 2021-2024 was recently Past President, Daragh Connolly and the published. The Statement will build on the progress of Secretary General were quoted in an article in the the previous Strategy and will inform our work as an Sunday Independent discussing pharmacy services organisation over the next three years. The Statement and the pharmacy contract. of Strategy has evolved and been updated to respond to IPU Employee Pharmacy Committee Chair, the current legislative and economic context and to take Rebecca Barry was interviewed on Limerick account of the ever changing professional and business 95FM where she discussed, among other issues, environment over the next number of years. You can read the IPU’s call for access to contraception to be further information on the new Strategy and download a made available directly from a pharmacy without copy from the IPU website www.ipu.ie under the About tab. prescription and without charge. RTÉ.ie and RTÉ Radio 1 reported on the HSE cyber-attack and carried comments from the IPU regarding the effect the attack could have on certain patients getting their medications. The Secretary General was interviewed on Newstalk Breakfast and this was picked up on multiple regional radio stations. There was also coverage in the Irish Examiner and Irish Daily Star, as well as online media on Buzz.ie. To stay up to date with all of our coverage, check out our Pharmacy in the Media section, which you can access under News & Publications on the IPU website.

10 IPUREVIEW JUNE 2021 IPU NEWS Roll-out of COVID vaccinations in Pharmacies – why are we waiting?

Email sent from the IPU to all TDs and Senators on 7th May

I’m writing to you in relation to the continued exclusion of pharmacists from the COVID-19 National Vaccination Programme and to seek your support in enabling people to get vaccinated by their local pharmacist. Pharmacists have vast experience as vaccinators and are ready and willing to help the Government reach its ambitious vaccination targets. There are 1,200 pharmacy locations available throughout the country with 2,000 fully trained vaccinators ready and available to vaccinate. The reopening of Ireland’s economy and society depends on the pace of the vaccine roll-out. Why leave 2,000 experienced vaccinators on the side-lines? We estimate that pharmacists have the capacity to vaccinate over 50,000 people per week. However, pharmacists have, so far, not been allowed to vaccinate their patients against COVID-19 by the HSE. This is despite having been allocated a central role in the in the Government’s National COVID-19 Vaccination Strategy and Implementation Plan last December alongside GPs and vaccination centres. No clinical or operational rationale has been given for this ongoing exclusion. Members of the public are used to being vaccinated by their local pharmacist. Last flu season, pharmacists vaccinated over 300,000 people. Many of these people want to get their COVID-19 vaccination from their pharmacist too. We know this because our pharmacists are constantly getting calls and queries in relation to it from people in their communities. Furthermore, for people in remote rural areas, it makes little sense for them to make long journeys to, and face long waits in, vaccination centres when they can get vaccinated in their local pharmacy. For example, there is only one vaccination centre in Co. Galway, so, for someone from Ballyconneely, it is a 3.5-hour We have seen the pivotal role that pharmacists are playing round trip to the vaccination centre in Ballybrit. Why make in Northern Ireland and in countries such as the United people go to such lengths when they can get vaccinated in States, Canada and Germany in getting large numbers of their own communities by someone they know? people vaccinated. Pharmacy vaccination is easy, convenient and it’s local. It We hope you agree that it is very much in the public interest is also a key, but as yet unrealised, part of the Government’s for people here to be able to be vaccinated locally by their COVID-19 Vaccination Strategy. pharmacist. In January of this year, the Irish Pharmacy Union, along I would greatly appreciate if you could use your platform with the IMO, reached agreement with the Government on the as a public representative and Member of the Oireachtas fees to be paid for administering the vaccine. GPs have been to call on the Minister for Health, Stephen Donnelly TD to vaccinating since February. So far, all pharmacists have gotten enable pharmacists to vaccinate without any further delay. from the Minister and the HSE is vague assurances of a non- We would greatly appreciate if you could lend your support specific future role. to this matter in the Oireachtas, on local and national media It is simply not sustainable to place the full burden of and on social media. community vaccination onto over-stretched GPs who have I have attached some concise information in relation to this been vaccinating since early this year, often at the expense of issue which may be of use to you. I would be very happy to normal GP services. talk to you at any stage in relation to this matter.

IPUREVIEW JUNE 2021 11 IPU NEWS

Dates for your Diary JUNE 2021 14 June World Blood Donor Day, www.giveblood.ie 14-20 June Men's Health Week, www.mhfi.org

New IPU website Updated We recently launched our new website. The purpose of the new design is to make the website easy for members to navigate and to find information, therefore improving the user’s experience. IPU logo Turn to pages 13-16 for an overview of the new designs and layout. We have freshened up the IPU logo and colours to modernise our branding. The symbol shape remains the same, but the colours have been enhanced to make them more vibrant for digital use and printed publications. The font has also been updated and changed to title case, which is visually more pleasing while keeping the logo symmetrical.

12 IPUREVIEW JUNE 2021 COMMUNICATIONS Ciara Browne, Communications and Events Executive, IPU Unveiling the new ipu.ie

We have officially launched our new website. Ipu.ie is a tool for IPU members to source up-to-date information on a wide range of issues relevant to their profession and their business. The purpose of the new design is to make the website easier for members to navigate and to find important information. In this article, Ciara Browne, the IPU’s Communications and Events Executive, takes you through the new designs and layout and explains how the new ipu.ie will improve the user’s experience.

IPUREVIEW JUNE 2021 13 Background top of the page and displays all the website sections Earlier this year, work at once, giving you a clear commenced on this project, picture of the content within with Refill Assistant each section at a glance. commissioned as the website Taking the member’s section developer. Refill Assistant as an example, the main previously developed the headers in the menu are: website for National Health Products Catalogue (NHPC), n News & Publications launched by the IPU last – News, GMs, the IPU year. They also worked with Review, the Annual a number of IPU member Report and Reports & pharmacies to build their Submissions all have individual pharmacy websites their own homes; and offer a Pharmacy Services n Resources Booking Engine to their – Most content is in customers. this part of the mega To help get the most out of menu and laid out as Search function this function, we want to the design process, we also individual sections, such commissioned a creative know so that we can continue as Professional, HSE The Search function appears improving it. Please send any agency named Language, Contract etc, with their on all pages of the website who we have used for IPU suggestions or feedback to sub-sections clearly in the top right-hand corner. [email protected]. advertising campaigns, placed underneath. It has been designed to work as our design consultants We have made these similar to a Google search; if and to facilitate a series of changes to the menu in your search consists of just Homepages workshops. These workshops order to group content one word, type that word into were completed with IPU staff together more efficiently. the bar and click the button, The homepage of the website and IPU committee members Employee Pharmacists, but if you are searching a is the user’s landing page providing useful feedback Recruitment, Human phrase, such as “medicines and should display content and suggestions. Through the Resources and Lobbying authentication” or “high tech that you want to find as combined input of feedback are now housed in their hub”, then you need to include quickly as possible. To help from our staff and members, own sections; the double quotation marks distinguish between the public and the expertise of the for accuracy. The Search and member’s homepages, n Training & CPD designers and developers, we function reads all of the text we made the public site blue – IPU Training courses produced the new IPU website. in documents, posts and and the member’s site purple. and access to IPU titles, as well as tags given Below is an overview of the two Academy; homepages and their content. Mega menu to items by the IPU website n IPU Bookmarks administrators. The results Public: A significant difference – Easy access to IPUnet, that come back are displayed From our workshops, we between the last website and IPU Pharmacist Link, in a list, similar to Google, and identified that the purpose this one is the menu structure. the IPU Product File are displayed in chronological of the public-facing website Previously, the menu was download site and order so that you see the is to be resourceful and positioned vertically to the left more; and newest item first. The results of the screen and you could will also be a mix of posts and informative. We want to n see pages as you hovered About documents but it will be easy display information on over them with the mouse or – Information about IPU to differentiate the two. current health issues that clicked for drop-down menus staff, IPU committees, Improving the Search impact Irish patients and on your phone. the Statement of function was a key priority community pharmacies. For We have now introduced a Strategy and in this development. If users example, the top of this page “Mega Menu” which sits at the member benefits. are still finding issues with currently highlights access

14 IPUREVIEW JUNE 2021 to our Coronavirus section releases issued and updates but over time we will use this sent by email to members. area to highlight other topics The Most Recent Posts section of concern, as well as IPU works automatically and is campaigns and initiatives. populated when a document We have introduced an or post is added to the site. eye catching “Pharmacy Can It is a snapshot look at the Help With” section, which latest content that has been emphasises the varied services uploaded so if we have provided by community produced a new guide, FAQ or pharmacy. SOP, it will appear here for a Our Latest News section period of time. will pinpoint the latest in The homepage also allows pharmacy news such as press for videos to be uploaded, releases, campaigns and items which we will use to present of interest to the public. The IPU campaigns, media homepage also has an area appearances and recorded for the IPU Review, displaying messages. the latest editions and Also on this page, similar information on advertising. to the public homepage, is a Also on this page is a Who Quick Access area to sections of We Are section, and a Quick the website that are important Access area to sections we to members, as per our want to highlight to the public, workshops. such as the NHPC website, training courses and how to become a member. Pages with tables We have introduced tables Members: that list all of the relevant As with the public homepage, content for that section which the top of this page highlight we feel is a big improvement issues of current importance. on the previous site. Items For example, it is currently in this list will be a mix of focused on the Coronavirus. downloadable items and Our Featured Items section posts, and they will be listed will display IPU news from the in chronological order so that previous week, such as items you always see the newest from the eNewsletter, press item at the top.

IPUREVIEW JUNE 2021 15 Some pages contain Book a training course 4. You can then scroll down Sidebar large amounts of content, to enter the student in particular, the SOPs and For information on our training details. For example, if On each page there is a Guidelines page, which you courses, click on the Training & you are intending on sidebar that displays Quick will find under “Resources CPD tab in the mega menu and booking one student on Access links to other pages, > Professional” in the mega click Training Courses; this will one course and then Featured Items from the menu. When you first access bring you to a list of all courses two students on to a homepage to display some the page the list on the which you can click on to view different course, you items from the news of the screen will display all items all the details. will see three student week, and a highlighted associated with this section. Booking the courses works fields appear in the item, in this case COVID-19 Similar to the previous differently to the last website. Checkout, since you are vaccination. The sidebar is website, use the drop-down On the previous website, booking three slots. Any just another feature applied menu above the table on you were only able to book course you clicked Add to improve access to key the left, labelled Categories, one student at a time per to Cart on will appear in information and areas on the to select the particular course meaning you had the drop-down menu website. subject you are looking for to keep inputting the same labelled Student Course We encourage all members the SOPs and guidelines for. information (if it was the so you can easily select to browse the new website and Alternatively you can use the same student on multiple the course and enter the search for items in order to get search box above the table on courses) and make multiple details of the student used to the new look and feel. the right to start searching transactions. enrolling on that course. Our website is maintained for the item you need. For the On the new website, it works You would then repeat every day and over time new search box on these tables, the more like a shop: the same for the next menu items and pages will search will start as you type. two student fields. appear to keep the content Click View on the item you 1. You can add courses updated and organised. want and you will be taken to a shopping cart by 5. After entering all the Our eNewsletter will still to a page to either download hovering over the course relevant information, be used to direct members the document or to read the you want and clicking enter your card details to relevant documents or information if it is a post. Add to Cart. You will and click Place Order sections on the website. If be able to increase the to pay for all of the you have any questions or quantity at the Checkout bookings in one go. feedback in relation to the IPU Posts point. You can continue website, please email us on adding other courses to [email protected]. Posts are pages that just Important: If you are logged the cart, or when you in to the website, you will have page content and an are done, click View Cart associated document to automatically be charged the on the last course you member’s fee for the course; download if applicable. Many added. people access websites these however, if you are viewing the days on their phones or course from the public site, 2. From here, you can then you will be charged the tablets, and downloading files increase the quantity is not always a suitable option non-member price unless you but make sure to click check the box to say you are a if you are conscious of your Update Cart if you do so. device’s memory storage. Our member. aim is to upload content as 3. Click Proceed to Checkout posts where possible so that and enter your billing you can read the information details and pharmacist on your device and download details. it as a file if you choose. On each post will be a PDF icon which will covert the post into a customised PDF file that you can then download. Also on posts will be a printer icon should you wish to print the page.

16 IPUREVIEW JUNE 2021 PROFESSIONAL Pamela Logan, Director of Pharmacy Services, IPU COVID-19 Vaccines: will they work against new variants?

There’s been much talk in the media about new variants of coronavirus and whether the COVID-19 vaccines will work against them. The good news is that studies to date show that they will. In this article, Pamela Logan, Director of Pharmacy Services at the IPU, gives an overview of the new Variants of Concern and how the current vaccines perform.

IPUREVIEW JUNE 2021 17 iruses constantly to preventing severe disease. change through Vaccines produce antibodies mutation, and against many regions in the variations in spike protein, so it is unlikely the SARS-CoV-2 that a single change would Vvirus due to evolution and make the current COVID-19 adaptation processes have vaccines less effective. been observed worldwide. If someone received a While most emerging COVID-19 vaccine for an older mutations will not have a generation of the virus, they significant impact on the would likely have protection spread of the virus, some against new ones. mutations or combinations Data from a number of of mutations may provide studies indicate that fully the virus with a selective vaccinated patients are able to advantage, such as increased stave off severe disease from transmissibility or the ability the B.1.1.7, B.1.351, and P.1 to evade the host immune variants. response. The increased n A study published transmissibility of SARS-CoV-2 in the New England variants first identified in the Journal of Medicine UK/Kent (B.1.1.7), South Africa showed that the Pfizer/ (B.1.351) and Brazil (P.1) have BioNTech vaccine led to them being designated was effective against as Variants of Concern (VOC). the frequency of detection and quarantine and testing infection and disease in The latest variants to cause of both lineages B.1.617.1 of incoming travellers from the population of Qatar, concern globally are a range and B.1.617.2 is increasing. states where there is a risk of despite the B.1.1.7 and of B.1.617 variants. First Currently described lineages importation of VOC, due either B.1.351 variants being reported in India in December B.1.617.1, B.1.617.2 and to high levels of the virus in predominant within the 2020, the variants B.1.617.1, B.1.617.3 have distinct the community and/or known country. B.1.617.2 and B.1.617.3 have mutation profiles and warrant circulation of VOC. been increasingly detected in individual assessment. Given An analysis of VOC from n A study published in other countries. Over the past the still very limited available seven EU/EEA countries, the Lancet showed that, few months, India and some data with respect to their including Ireland, published in Israel, the Pfizer/ surrounding countries have transmissibility, disease on eurosurveillance.org BioNTech vaccine was seen a sharp increase in the severity and immune escape on 22 April 2021, showed effective against B.1.1.7. number of reported COVID-19 potential relative to other an increased risk for Vaccine effectiveness cases and deaths. This has co-circulating SARS-CoV-2 hospitalisations and ICU against B.1.351, however, been associated with a rising variants in the EU/EEA, the admissions associated with could not be estimated proportion of sequenced full impact of these lineages B.1.1.7, B.1.351 and P1. The in the study because viruses belonging to lineages on public health is not yet increased risk was also of the small number B.1.617.1 and B.1.617.2. The possible to assess. observed in middle-aged of B.1.351 infections World Health Organisation In Ireland, latest data individuals, which underlines identified in Israel during (WHO) has designated B.1.617 indicates that B.1.1.7 (UK/ the necessity to rapidly reach the study period. as the fourth Variant of Kent) accounts for over 90% high levels of vaccine coverage. n Moderna released a Concern. of cases sequenced. It has COVID-19 vaccines are statement indicating The UK has seen a rapid been seen in all age groups indisputably effective. that early results from increase in detection of and in all areas of the country. Although they don’t prevent an ongoing study of lineage B.1.617.1 and, to a The aim of the Irish public infection, they protect most a booster shot are greater extent, B.1.617.2, health response is to delay people against severe illness encouraging with regard associated with travel to importation and spread of and death. to the B.1.351 and P.1 India and onward community VOC. This is achieved by Scientists believe existing variants. transmission. In the EU/EEA, a combination of testing vaccines will help control there are indications that before arrival in Ireland, the variants when it comes

“ Vaccines produce antibodies against many regions in the spike protein, so it is unlikely that a single change would make the current COVID-19 vaccines less effective.”

18 IPUREVIEW JUNE 2021 n A study published resulted in a reduction in vaccines against new variants The European Commission has in The Lancet showed the duration of shedding or mixtures of variants. This announced that it's in talks to that efficacy of the and viral load. is already underway, with buy another 1.8 billion vaccine AstraZeneca vaccine new vaccines expected to be doses from Pfizer/BioNTech against the B.1.1.7 Luckily, the modern manufactured and tested for distribution between 2021- variant was similar technologies for vaccine within a few months. Booster 23. The additional doses are to the efficacy of the production, especially for vaccines are being prepared expected to help in the event vaccine against other mRNA and viral vector for new variants that have that we need booster shots lineages. Furthermore, vaccines, can facilitate rapid emerged and some companies or retooled vaccines to fight vaccination with development and manufacture are looking for a vaccine that coronavirus variants. AstraZeneca vaccine of second generation COVID-19 will work against any variant.

IPUREVIEW JUNE 2021 19 CPD Grainne Doyle MPSI, Community Pharmacist

Self-appraisal

Evaluate Document your learning Personal plan

Action Constipation

Constipation affects many of us and can greatly impact on quality of life. Community pharmacist, Grainne Doyle looks at the symptoms, causes and treatment for constipation and outlines how simple lifestyle changes can help to prevent and alleviate it.

onstipation with faecal incontinence in describes the children is commonly seen infrequency and by GPs. It affects 4% of difficulty when preschool children and emptying the 2% of school children. bowels.C It can affect people of all ages, although it is twice as likely to affect women, Symptoms particularly those who are Typical symptoms of pregnant due to hormonal constipation include fluctuations. Approximately abdominal pain, cramping, 40% of pregnant women bloating, nausea, loss of experience constipation appetite and straining during during their pregnancy. bowel movements. In children, Older people, particularly as well as infrequent or those aged over 70 years, irregular bowel movements, are five times more likely a child with constipation than younger adults to may also have the following have constipation, usually signs and symptoms, such as because of several factors, lack of energy, being irritable, including a more sedentary foul-smelling wind, soiling lifestyle, level of fluid intake, clothes and generally feeling diet and delaying the urge to unwell. Stools associated with defecate because of mobility constipation tend to be dry, issues. Chronic constipation

20 IPUREVIEW JUNE 2021 Figure 1: The Bristol Stool Chart Medications 1. Antihypertensives (diuretics, clonidine, calcium channel blockers) If clinically appropriate, switch to less constipating medicines such as ACE inhibitors, beta-blockers or angiotensin-II receptor antagonists. Diuretics can cause constipation due to less available fluid. Laxatives, such as docusate, can act as a surfactant and softener or osmotic laxatives can be used to increase the amount of water in the large bowel.

2. Tricyclic antidepressants (eg amitriptyline) Serotonin and noradrenaline re-uptake inhibitors are alternatives less associated with constipation.

3. Antimuscarinics (procyclidine, oxybutynin) These agents decrease GI motility and therefore a stimulant laxative may be necessary.

4. Antiparkinsonian medicines (levodopa, dopamine agonists, amantadine)

5. Iron supplements Intravenous iron could be used or a laxative may be co-prescribed.

6. Aluminium-containing agents (sucralfate and antacids) Proton pump inhibitors could be used instead.

7. Analgesics (Opioids hard and lumpy and indicated physiological cause. A person that alter the functionality of and NSAIDs) as type 1 or 2 on the Bristol with functional constipation the GI tract, such as Crohn’s Opioids cause constipation stool chart (see Figure 1). The may be healthy, yet has disease and ulcerative colitis. by decreasing peristalsis pain and discomfort from difficulty defecating leading Conditions such as Parkinson’s and enhancing the chronic constipation and the to a belief that it may be disease and multiple sclerosis resorption of fluids and associated complications neurological, psychological can also have direct effects electrolytes. A stimulant can greatly impact a or psychosomatic. It is on the nerves that control laxative, eg senna, is person’s quality of life. diagnosed by the exclusion of bowel function resulting in recommended at the lowest a pharmacological or medical uncoordinated contraction effective dose. Osmotic cause. Secondary constipation of abdominal muscles and laxatives are also effective Causes is generally caused by a drug inhibiting the passage of for this type of constipation or medical condition. stools. Secondary constipation and are often better Chronic constipation can can occur in patients with tolerated than stimulant be classified as functional diabetes and hypothyroidism laxatives which can cause (or idiopathic) or secondary Medical conditions due to weight gain and abdominal cramping. constipation. Functional reduced mobility associated constipation occurs Conditions known to cause with such conditions. without an anatomical or constipation include disorders

IPUREVIEW JUNE 2021 21 Other causes of Figure 2: Rome III diagnostic criteria of functional constipation constipation Pregnancy: Constipation is mostly experienced during the 1. Two or more of the following: early stages of pregnancy as • Fewer than 3 defecations per week a result of hormonal changes. • Hard stools, straining During at During pregnancy, more • Sensation of anorectal obstruction least 25% of progesterone which acts as a • Sensation of incomplete evacuations defecations muscle relaxant is produced. • Manual manoeuvres to defecate As food moves through the gut, the gut wall muscles contract and relax in a rippling wave- 2. Loose stools are rarely present without laxatives like motion. The increased progesterone interferes with 3. Insufficient criteria for IBS* the contraction of the bowel muscles making it harder for waste products to move along. Criteria fulfilled for the last three months with onset at least six months prior diagnosis. In young children: About *IBS: Irritable Bowel Syndrome one in three parents report constipation at some time conditions have been n Increase fluid intake: are more likely to get in their child’s life. Poor diet, excluded. It is recommended for constipated. fear about using the toilet and Lifestyle advice can help adults to drink at least poor toilet training can all be n Toilet routines: As a rule, to prevent and alleviate two litres of water each responsible. it is best to try going to constipation. In many cases, day. Children aged 1 to the toilet first thing in constipation may be as a 3 years should drink the morning or about 30 result of poor diet and lack of 900mls per day, aged 4 Diagnosis minutes after a meal. exercise. Patients should be to 8 years should drink This is because the Doctors define constipation in encouraged to increase fibre 1,200mls per day, and movement (propulsion) a number of ways: in their diet and fluid intake aged 9 to 13 years should of stools in the lower before trying laxatives. drink 1,800mls per day n Opening the bowels less bowel is greatest in the for boys and 1,600mls than three times a week; n Fibre increases the mornings and after per day for girls. bulk and plasticity of meals. ‘Bowel training’ n Needing to strain to open stools which encourages n Exercise – Daily walk/ with kids can be useful. bowels on more than a movement through the run: There is little Ask your child to sit on quarter of occasions; or colon. It is advised to evidence that exercise the toilet four times a n Passing a hard or pellet- consume at least 18 can increase gut motility, day after meals for five like stool on more than a to 30g of fibre (fruit, however, one study minutes, even if nothing quarter of occasions. veg, pasta, rice) each found that women who happens. Maintaining day. Also adding some report physical activity a good toilet position When assessing a patient bulking agents such as of once a week or more using a footstool will for constipation, possible wheat bran to your diet were significantly also aid the passage of causes, such as medication will contribute to softer less likely to report stools (Figure 3). and comorbidities along with stools and allow to pass constipation. Individuals diet, level of exercise and through the bowel easier. who lead sedentary lives recent changes in routines, are taken into consideration. Figure 3: Toilet position A physical or internal rectal examination may sometimes be performed to confirm that faecal masses are palpable abdominally or perianally. Patients with any red flag symptoms (unexplained weight loss, rectal bleeding, family history of colon cancer or inflammatory bowel disease or signs of obstruction) should be referred to a specialist for further investigation. The Rome III diagnostic criteria (Figure 2) can be used to classify functional gastrointestinal disorders and may be useful when functional constipation is suspected and contributing medicines or medical

22 IPUREVIEW JUNE 2021 Pharmacological treatment n Stimulant laxatives may be required if lifestyle (eg senna, bisacodyl): changes do not fully alleviate They are used generally Your 5-minute symptoms of constipation. on a short-term basis. The NICE guidelines advises They improve intestinal assessment that prescribing of laxatives motility via muscle for adults are limited to the contractions and reduce short-term treatment of water loss from the Answer the following questions: constipation when dietary faeces keeping the and lifestyle measures proved stool soft. They usually unsuccessful or if there is an start to work within 6 1. True or false: approximately 25% of pregnant women immediate clinical need. to 12 hours. A potential experience constipation during their pregnancy. unpleasant side-effect of stimulant laxatives is 2. True or false: chronic constipation can be classified as Laxatives abdominal cramping due functional or secondary constipation. to the increased muscle n Bulk-forming laxatives contractions in the gut 3. Which ONE of the following medicines is not known to cause (eg ispaghula husk, wall. constipation? methylcellulose, a) Calcium channel blockers b) ACE Inhibitors n Faecal softeners (eg sterculia): They increase c) Amitriptyline d) Oxybutynin docusate): They act by faecal mass through lowering the surface water binding which 4. Which ONE of the following medical conditions does not tension of the stool stimulates peristalsis. affect the functionality of the gut? allowing water to This class of laxative a) Parkinson’s Disease b) Multiple Sclerosis penetrate the dry faeces usually takes two c) Asthma d) Hypothyroidism and increase faecal to three days to be mass size stimulating effective. Plenty of fluids 5. True or false: Docusate acts by lowering the surface tension peristalsis. must be consumed with of the stool allowing water to penetrate the dry faeces and Faecal compaction occurs this type of laxative and increase faecal mass size stimulating peristalsis. when hard dry stools collect

are not advised to take

in the rectum causing

True. 5. (c). 4. (b). 3. True. 2. False. before bedtime. 1. an obstruction. Faecal

n Osmotic laxatives (eg compaction may initially be Answers macrogols, lactulose): treated with a high dose of If stools remain hard osmotic laxative macrogol after taking a bulk- followed by a stimulant 2. Severe faecal impaction causes small tears through forming laxative, laxative days later. If this can lead to several other the lining of the anal canal. osmotic laxatives may combination is not successful, complications such as be advised instead. They a suppository (eg bisacodyl or swelling of the rectum, 5. Psychological effects: work by drawing fluid glycerol) or mini enema (e.g. loss of sensation in and Faecal incontinence in into the large bowel docusate or sodium citrate) around the anus, faecal children can affect children from elsewhere in the may be administered. incontinence and anal psychologically making body or retaining the bleeding. them feel embarrassed and fluid consumed with the upset. It is important that medicine. It is advised Complications of 3. Rectal prolapse is a parents and their support to drink plenty of fluids chronic constipation protrusion of the lower network are compassionate when taking this laxative intestine through the anus and understanding when to prevent dehydration. 1. Haemorrhoids: Excessive due to repeated straining dealing with this condition As like bulk-forming straining to pass stools during bowel movement. in children. laxatives, they take two can lead to developing to three days to become haemorrhoids. 4. Anal fissures: The forced effective. passage of hard stools References available upon request.

“ The NICE guidelines advises that prescribing of laxatives for adults are limited to the short- term treatment of constipation when dietary and lifestyle measures proved unsuccessful or if there is an immediate clinical need.”

IPUREVIEW JUNE 2021 23 CPD overview

Self-appraisal Action

What do you know about constipation? Activities chosen should be outcomes based to meet learning objectives. What causes constipation? Implement plan. What are the symptoms of constipation? Read this article on constipation. Do I see many cases presenting in pharmacy? Consider the treatment options you are currently What is the best advice to give patients with recommending and examine if you might be able these symptoms? to offer more effective advice. Review the OTC products you are currently Personal plan recommending.

Including a list of desired learning outcomes in a personal Consider identifying and reviewing patients learning plan is a helpful self-analytical tool. with constipation. Create a list of desired learning outcomes. How will I accomplish these learning outcomes? Evaluate Identify resources available to achieve Consider outcomes of learning and impact of learning. learning outcomes. Have I met my desired learning outcomes? Develop a realistic timeframe for the plan. Do I now feel confident to engage with and counsel patients (and carers) about constipation? Provide an example(s) of changes that I have implemented in my pharmacy practice. Have further learning needs been identified?

Document your learning

Create a record in my ePortfolio. As part of this record, complete an evaluation, noting whether learning outcomes were achieved and identifying any future learning needs.

24 IPUREVIEW JUNE 2021 PROFESSIONAL Colin Fowler, Men's Health Forum in Ireland

Men’s Health. Are you making the connections? Check in. Check up. Check it out.

Ahead of Men’s Health Week, which takes place from 14 – 21 June, Colin Fowler of Men's Health Forum in Ireland highlights some of the most important men’s health issues and the role that pharmacies can play in addressing them.

IPUREVIEW JUNE 2021 25 Why focus on men? Yet, although the health of men in Ireland is poor, it is Not too long ago, we were not a lost cause and it can be unaware of the full extent improved in many significant of men’s poor health status ways. More importantly, local and the specific health issues pharmacies can play a crucial that they are contending gatekeeper role in supporting with. However, this is no changes for the better. longer the case. In recent years, a broad range of research has highlighted Men’s Health Week 2021 the challenges which face males in Ireland and further Men’s Health Week (MHW) afield. Indeed, the key hard 2021 begins on the Monday facts were crystallised in before Father's Day and ends on Father's Day itself. This the Men’s Health in Numbers n If you notice anything year, it will take place from Exceptional times publications which were worrying or which needs Monday 14 June - Sunday launched in December 2020. In any normal year, men’s medical attention, 20 June. It is celebrated in But what does this situation health requires attention. Check It Out and seek many European countries, as look like on-the-ground? However, 2021 has, once again, information, help, well as in the USA, Australia, been an exceptional year in support or treatment as n Local men continue to New Zealand, Canada and many ways, and the island of soon as possible. die, on average, younger a number of other places Ireland continues to wrestle than women do; worldwide, and offers an ideal with the global COVID-19 opportunity for everyone to do n Poor lifestyles (including pandemic. Worldwide, this So, where do their bit to improve the health smoking, drinking, diet virus is having a major and pharmacies fit in? of men and boys. and lack of exercise) are disproportionate impact upon The core aims of MHW One of the major responsible for a high men's health and wellbeing, each year are to: consequences of the COVID-19 proportion of chronic as well as other aspects of pandemic has been the diseases; n Heighten awareness their lives (see: www.mhfi.org/ increasing disconnection of preventable health coronavirus.html). Even with n Males have higher death between health services and problems for males the hope of vaccination, these rates than women for local people. However, even of all ages; are still extremely challenging almost all of the leading times. before the current situation, causes of death, and at n Support men and boys MHW 2021 will take it was well known that some all ages; to engage in healthier place against a backdrop men are not, necessarily, lifestyle choices/ good at going to their GP to n Men’s mental health of the COVID-19 pandemic. activities; and have their health issues dealt needs are often not Individuals across the country are trying to re-build their with. At the same time, there recognised or met; and n Encourage the early lives, relationships, jobs, is also important evidence detection and treatment n Late presentation to finances, physical health, which shows that pharmacies of health difficulties health services leads emotional resilience, networks can play a critical gatekeeper in males. to a large number of and routines. Some people role in being the first point problems becoming are still living with trauma of contact for promoting untreatable and bereavement. Others and improving the health of are having to re-focus their men and boys. For example, priorities. Everyone's mental findings from research health has been impacted to (www.mhfi.org/menand some degree. pharmacies.pdf) highlight This is why the theme that: chosen for MHW 2021 n Although many men are in Ireland is Making the reluctant to visit their Connections and the call to GP to seek advice or action is: treatment, pharmacies n Check In with yourself to can act as a first point of see how you are coping/ contact between these feeling, and to identify men and the medical any health worries that world, especially as you might have; pharmacies also sell non-medical products n Check Up on your family, which men need; friends, neighbours and colleagues to see how n Pharmacies have they’re doing and to characteristics that men offer support; and look for in a service, such as accessibility, flexibility and informality;

26 IPUREVIEW JUNE 2021 n Pharmacies are local, Get involved and offer a non- threatening environment Every pharmacy in Ireland can Doing even one of the simple to men; do something to mark MHW suggestions will contribute 2021. It can be as simple or as hugely to improving the n Pharmacies offer ease complex as you would like it health of local men and boys. of access, with no to be. If you’re stuck for ideas, appointments necessary; download the Toolbox for Action and explore the resources To find out more, email Colin n Staff offer a friendly, for the week from www.mhfi. Fowler from Men’s Health Forum relaxed, approachable org > MHW > MHW 2021. in Ireland at [email protected]. service, and don’t rush men in and out; n Pharmacists are recognised as experts on medication Pharmacies can, therefore, offer an on-street showcase for information which may increase awareness of the health issues facing men and boys. However, pharmacy staff are also well positioned to talk to men about their health needs, explore possible options and, if necessary, suggest that they may need to seek further expert assistance. As such, they play a crucial sign-poster role which has often been under-valued. But this is not one-way traffic; building relationships with men and getting them to use local pharmacies more regularly is also a sound business strategy!

” At the same time, there is also important evidence which shows that pharmacies can play a critical gatekeeper role in being the first point of contact for promoting and improving the health of men and boys.”

IPUREVIEW JUNE 2021 27 Pharmacists: Advance your Business Capabilities

Are you a pharmacist, or would you like to own or manage a pharmacy? The new Executive Diploma in Strategic Pharmacy Business Management from DBS can help you to learn the skills required to succeed in this field, while dealing with the challenges and pressures that the sector is currently under.

Aims and objectives The primary objective of this programme is to build and enhance the retail business capability of pharmacists and business owners as part of both the IPU's and independent pharmacy strategic objectives for 2021 and into the future. Key objectives of the programme Learn to critically evaluate and review relevant theories, concepts, frameworks, models and key issues in the field of pharmacy retail strategy. Provide an overview of consumer's decision-making processes, the influences upon consumers' behaviour and their implications for marketing. Equip learners with an understanding of how market environments affect organisations marketing strategies. Provide a framework from which students can analyse Assist learners to understand the fundamentals the issues involved in applied management practice of organisational behaviour. through a retail business simulation. Develop skills to interpret retail data and express Explore how procurement and supply chain its value visually through the use of case studies management can add value, enhance organisational and datasets. performance and be a source of sustainable competitive Demonstrate an understanding of the obligations advantage to a retail organisation. and limitations imposed by the law on the operation Provide learners' with an understanding of the core of a retail business. objectives of financial management.

IRISH PHARMACY UNION

I 04579-DBS-IPU-Pharmacy-Proof#08-A4.indd 1 Pharmacists: Advance your With the Executive Diploma in Strategic Pharmacy Business Capabilities Business Management you will cover the following topics:

► Retail Pharmacy Business Strategy ► Category Management and Retail Purchasing Are you a pharmacist, or would you like to own ► Organisational Behaviour or manage a pharmacy? The new Executive in Retail Environment ► Retail Management Simulation Diploma in Strategic Pharmacy Business Pharmacy Retail Consumer Business Intelligence and Management from DBS can help you to learn ► ► Behaviour Data Visualisation the skills required to succeed in this field, while dealing with the challenges and pressures that ► Legal Issues and Regulation ► Finance for non Financial Managers the sector is currently under. in Retail ► Leadership and Communication ► Pharmacy Retail Marketing Aims and objectives ► Capstone Project Preparation The primary objective of this programme is to build and enhance the retail business capability of pharmacists and business owners as part of both the IPU's and independent pharmacy strategic objectives Assessment for 2021 and into the future. To be awarded the Executive Diploma in Strategic Pharmacy Business Key objectives of the programme Management, a Pharmacist will be required to complete continuous Learn to critically evaluate and review relevant theories, assessment for all subjects and a final project. concepts, frameworks, models and key issues in the field of pharmacy retail strategy. Is this course for you? Provide an overview of consumer's decision-making If you have a pharmacy qualification and a drive to succeed, processes, the influences upon consumers' behaviour with great interpersonal skills then this is the course for you! and their implications for marketing. This programme will benefit those involved in the pharmacy Equip learners with an understanding of how market business, or pharmaceutical industry. environments affect organisations marketing strategies. Provide a framework from which students can analyse It will help anyone who is keen to invest in multiple pharmacy Assist learners to understand the fundamentals the issues involved in applied management practice businesses, acquire existing pharmacies, open a new pharmacy, of organisational behaviour. through a retail business simulation. or advance into senior management with your pharmacy business. Develop skills to interpret retail data and express Explore how procurement and supply chain its value visually through the use of case studies management can add value, enhance organisational Fees and datasets. performance and be a source of sustainable competitive €2,500 for IPU members Demonstrate an understanding of the obligations advantage to a retail organisation. €3,000 for non-lPU members and limitations imposed by the law on the operation Provide learners' with an understanding of the core of a retail business. objectives of financial management.

For more information, or to apply, contact us below: P: (0 1) 4177 500 IRISH E: [email protected] PHARMACY W: www.dbs.ie/pharmacy �, DBSDublin Business �# UNION School

I 04579-DBS-IPU-Pharmacy-Proof#08-A4.indd 1 I 04579-DBS-IPU-Pharmacy-Proof#08-A4.indd 2 VETERINARY Pamela Logan, Director of Pharmacy Services, IPU Veterinary medicines: new regulations – what will this mean for pharmacists?

The IPU has spent the last year fighting to keep antiparasitics for food-producing animals available without prescription. We have written to the Minister for Agriculture, Food and the Marine, appeared before and engaged with the Joint Committee on Agriculture and the Marine, and had a series of meetings with the Department of Agriculture Food and the Marine. In this article, Pamela Logan, Director of Pharmacy Services, IPU, outlines our case.

any antiparasitic veterinary Medicines (ACVM) established that the available scientific community medicinal products intended a Task Force to review the evidence shows that pharmacists for food-producing species route of supply of antiparasitic antiparasitic veterinary are actively under the EU Veterinary veterinary medicinal products medicines that are intended involved Medicines Regulation 2019/6, that are intended for food- for use in food-producing inM the supply of veterinary which comes into force on 28 producing animals against the species do not comply with medicines to farmers January 2022. criteria set out in Directive the criteria for derogation throughout the country. The In February 2019, the 2006/130/EC. The Task Force from veterinary prescription IPU has serious concerns Health Products Regulatory Report was endorsed by the specified in Regulation about the proposed changes Authority’s (HPRA) Advisory HPRA on 5 December 2019. (EU) 2019/6. It also states to the route of supply of Committee for Veterinary The Report concludes that a consequence of this

30 IPUREVIEW JUNE 2021 determination is that any of present and emerging and interval treatments to rigid interpretation of the such products that are threats in animals submitted slow the development of derogation available in supplied without veterinary for autopsy. They have not anthelmintic resistance in Regulation (EU) 2019/6, prescription will need to be reported or warned of a sheep, were classified as POM ie Article 105(4), which upregulated to supply under significant problem with when licensed by the HPRA. states that a Member State veterinary prescription, ie anthelmintic resistance This has had the unintended may allow a veterinary reclassified as prescription in their reports, although consequences of adversely prescription to be issued by only medicine (POM). these laboratories would be restricting their use and they a professional, other than a While it is accepted expected to detect such a have not been appropriately veterinarian, who is qualified there is evidence of cases problem on a regional basis, if used in flock treatment plans to do so in accordance with of anthelmintic resistance it existed. at any appreciable level due applicable national law at and this has been reported It is not clear that there to the restricted status of the the time of entry into force in published literature, a is sufficient evidence at this products. The use of these and of this Regulation. Such national field trial has never time to warrant regulating other anthelmintics would prescriptions shall be valid been carried out or published antiparasitic medicines be better approached as part only in that Member State and which confirms a widespread using prescription control, of a comprehensive parasite shall exclude prescriptions problem due to the presence and there is no evidence to management plan developed of antimicrobial medicinal of anthelmintic resistance in suggest that such a change for specific farm use, with products and any other herds and flocks throughout will have any positive products accessible to the veterinary medicinal products Ireland. The regional impact or help to reduce the farmer from appropriately where a diagnosis by a veterinary laboratories, which development of anthelmintic trained professionals. veterinarian is necessary. assist in the diagnosis and resistance. In fact, two novel In our opinion, the HPRA The current position of the control of disease in food- anthelmintics, derquantel and the Department of Department is that no other producing animals, regularly and monepantel, which are Agriculture Food and the professional was in a position publish case reports to warn best used as quarantine Marine have adopted a to prescribe prescription only

“ Pharmacists are ideally placed to continue to advise farmers on the targeted strategic use of these valuable medicines and ensure their rational use as part of herd and flock treatment plans as appropriate.”

IPUREVIEW JUNE 2021 31 products prior to the coming medicinal products to benefit from access to quality This route is used for into force of Regulation (EU) safeguard the efficacy of the information and advice on the animal remedies which, by 2019/6; however, this is clearly products concerned for the safe and effective use of these therapeutic classification, not the case as pharmacists future and to implement products. Farmers would also would be expected to be POM have supplied what would any future strategies to benefit from price competition but, because they do not otherwise be prescription minimise the development of between suppliers in the require veterinary diagnosis, only medicines (POM) under anthelmintic resistance. market. can be otherwise supplied. the POM(E) route of supply Most antiparasitic veterinary There is a well-documented POM(E) confers a level of for many years. Indeed, both medicinal products are shortage of veterinary importance to a veterinary pharmacists and vets have currently supplied in Ireland services in many rural areas, medicine in that only a vet or equivalent prescribing rights as non-prescription medicines, including the Minister’s own a pharmacist can personally for POM(E) products. mainly under the Licensed constituency in Donegal. supply it to the end user. Like The IPU believes that a Merchant (LM) category; this In Mayo, there is only one all other POM(E) medicines, balance should be achieved has been the case for three or veterinarian in all of Erris, these medicines always between the availability of more decades. In our opinion, an area the size of Louth, require professional advice at safe and effective medicines we feel that upregulating and there is no veterinarian the point of supply, including for routine use in otherwise antiparasitics to POM(E) would in Achill, the nearest being details on administration, healthy animals on the one be sufficient to address the in Westport, 60km away. reconstitution, storage hand and the need to ensure concerns of the Task Force Contrast this to the extensive after a container is opened professional input and advice Report. The use of the POM(E) availability of pharmacy and, ultimately, disposal to safeguard animal and route of supply would allow services throughout the of used containers and public health and welfare on ready access to antiparasitic country. Lack of access to residual material. POM(E) the other. Pharmacists are veterinary medicinal veterinary services to obtain a ensures appropriate access ideally placed to continue to products through community prescription for antiparasitics to medicines, particularly advise farmers on the targeted pharmacies throughout the will impose undue hardship from pharmacists who, as a strategic use of these valuable country, most especially in and expense on animal matter of course, are available medicines and ensure their rural Ireland, where many owners and, ultimately, six or seven days a week. rational use as part of isolated areas do not have animal welfare will suffer. Upregulating antiparasitic herd and flock treatment local access to veterinary The POM(E) route of veterinary medicines to plans as appropriate. services. Antiparasitics supply is a vital part of the POM(E) utilises the potential Furthermore, we support would also continue to be supply chain of veterinary of pharmacists for the benefit the need for responsible use available through veterinary medicines to farmers from of farmers and the health of of antiparasitic veterinary practitioners. Farmers would a pharmacist’s perspective. their animals.

32 IPUREVIEW JUNE 2021 VETERINARY JG.Beechinor, Director of Veterinary Sciences, HPRA Changes ahead in regulation of veterinary medicine

The EU Veterinary Medicines Regulation 2019/6 comes into force next January. The Director of Veterinary Sciences at the Health Products Regulatory Authority (HPRA), JG.Beechinor, outlines the changes to the route of supply of antiparasitic veterinary medicinal products intended for food-producing species.

IPUREVIEW JUNE 2021 33 he EU Veterinary assist veterinarians and users Medicines to identify medicines that are Regulation 2019/6, appropriate for the needs of which applies ” One of the goals of animal patients. from 28 January The database, which will 2022,T signals a number of the legislation is to be fully searchable, will important changes to the contain the SPC and product regulation and monitoring improve availability; by information in respect of over of veterinary medicines 30,000 veterinary medicines throughout the EU. The reducing the amount in the EU. While the database fundamental regulatory is being developed and rolled processes for gaining a of text on the labelling, out by the European Medicines marketing authorisation Agency (EMA) currently, it will for a new medicine remain the expectation is that be up to each Member State to largely unchanged, and the populate it with legacy product authorisation standards this will facilitate the information. Subsequently, remain as they are currently. the data is expected to However, the new legislation development of multi- be updated/enriched by has been largely decoupled marketing authorisation from the human medicines lingual labels making holders. This database will one, allowing it to better fit the underpin other EMA databases specificities and budgets of it easier for industry to that are being developed to the animal health sector and improve the functioning of to streamline some regulatory develop multi-country regulatory processes and processes. veterinary pharmacovigilance There are a number of product batches.” monitoring. It is expected changes which are expected that basic functionality of to be of relevance for the UPD will be available pharmacists. from January 2022, but utility The summary of product after 28 January 2022, but continue to be permitted, will improve during the characteristics (SPC) and will be applied to all current indications for the course of 2022 with future labelling of veterinary veterinary medicines by 2027. preventative use of antibiotics updates. Notwithstanding medicinal products are Another goal of the (use in the absence of an the availability of such, data set to change. While the legislation is to mitigate infection in an individual or a consumer expectation may SPC changes are relatively the risk of development of group) will disappear. need to be managed. The fact minor, of particular note is antimicrobial resistance Enhanced warnings, with that a medicine is authorised that much of the current both for animal and human the primary intention of in another EU Member State information on the immediate health. While additional data promoting prudent use are does not necessarily mean labelling of veterinary protection is provided for new also expected. According that it is available here. medicines will be displaced to antibiotics, significant new to the regulation, a Moreover, the import of the package leaflet. Moreover, restrictions are foreseen in veterinary prescription for veterinary medicines that are the marketing authorisation respect of existing antibiotics. an antimicrobial veterinary not authorised and labelled for number will no longer appear Some of the new restrictions medicine will be valid for five the Irish market are subject to on the immediate label and have yet to be delineated days from the date of issue. licensing by the Department the method of sale/supply by means of secondary EU Further legislation requiring of Agriculture, Food and the will no longer appear on legislation (delegated and national monitoring of the use Marine (DAFM). Furthermore, either the immediate product implementing acts). This of veterinary antimicrobials information on adverse label or outer product label legislation, which is to be in a phased basis between reaction reports which will be (this information will be available over the coming 2023 and 2030 is also planned. readily accessible from the EU available from the package months and will apply from In addition, legislation is in pharmacovigilance database leaflet and SPC). January, will mean that certain development to enhance may be misunderstood by the One of the goals of the critically important antibiotics instructions on the use lay public. This is especially legislation is to improve will be reserved exclusively for of oral medication that is the case as the current legal availability; by reducing human use while other classes incorporated in drinking water requirement for product the amount of text on the of antibiotics will be controlled or for on-farm mixing in feed causality assessment of labelling, the expectation is according to their significance (eg top-dressing). suspected adverse reactions that this will facilitate the to human and animal health. A Union Product Database has not been carried forward development of multi-lingual While the administration (UPD) containing information into the new regulation. labels making it easier for of antimicrobials to a group on all veterinary medicines While significant change industry to develop multi- of animals, with the aim of that are authorised in the EU in the regulatory controls country product batches. treating the clinically sick is being created. This database for veterinary medicines will Some of the existing text will animals and controlling will include information apply from January 2022, be replaced by pictograms the spread of the disease in respect of medicines the regulation provides for and abbreviations (e.g. LOT to animals in close contact authorised centrally, as further changes over the for batch number). The and at high risk and which well as those authorised coming years. The precise changes will be apparent on may already be subclinically nationally. This level of changes will be customised new medicines authorised infected (metaphylaxis) will transparency is expected to by means of secondary EU

34 IPUREVIEW JUNE 2021 legislation. This mechanism provides that Member States with marketing authorisation using veterinary medicinal allows the EU Commission may impose conditions on holders which will see all products. Nonetheless, several to future proof the current such supply which are justified such medicines that are changes are expected to result legislation according to on grounds of public health currently authorised for in the simplification / re- new developments in and protection. It is expected supply without prescription engineering of the regulatory technologies or animal that DAFM will elaborate changed to prescription-only processes, with the goal husbandry. Complementary national rules on this matter supply by 28 January 2022. to reduce administrative national legislation on in due course. The regulation The period of validity of a burden and thereby improve veterinary medicines is also also allows Member States veterinary prescription as availability. These changes in development by DAFM to allow internet sales of well as the conditions under are augmented by new currently; this is needed as prescription medicines within which the prescription may be transparency tools, as some provisions of the current its own country, provided written are subject to ongoing well as new monitoring Animal Remedies legislation there is a secure national deliberations between DAFM tools. Although the new will need to be amended so system to control it. Readers and the Veterinary Council. legislation will apply from that they will not conflict should consult DAFM for more 28 January 2022, it may take with the regulation, as well information on this point. a number of years for the as to cater for provisions in While not directly linked Conclusion animal health industry to the regulation that are at to the application of the Regulation 2019/6 has been respond fully to the new the discretion of individual regulation, in 2019 the elaborated after a relatively incentives. Nonetheless, this Member States. HPRA reviewed compliance long period of discussion, represents an important The regulation provides that of antiparasitic veterinary which began in 2014. It was opportunity for the animal non-prescription veterinary medicines for food-producing published in 2019 and applies health industry, which medicines may be supplied animals against the criteria from 28 January 2022. While should enhance availability over the internet, but the specified in the regulation. A comprehensive, many of the of veterinary medicines system is to be regulated report on this topic is available changes apply to regulatory in due course. Further using an EU common logo on the HPRA website (www. processes of companies and information on progress in where the user can verify hpra.ie). Since the publication competent authorities and the implementation of the the authenticity/security of of that report the HPRA might not be visible to those regulation is available from the retailer. The regulation embarked on a change process prescribing, dispensing or the HPRA website.

IPUREVIEW JUNE 2021 35 PROFESSIONALPOLITICS Brian Harrison, MKC Communications Vaccine scrutiny continues unabated

A sense of optimism is beginning to surface in Leinster House that the worst of the COVID-19 pandemic is finally behind us. Despite this optimism the vaccination campaign, quite appropriately, continues to face intense scrutiny.

Politicians of all persuasion, stage when it should be rolled pharmacists right now.” pharmacists?… Honestly, from both inside government out as quickly as possible. During the same debate and pharmacists have a huge and the opposition benches Pharmacists obviously have a in relation to the same matter, reach into the communities. are continually pressing for key role as well.” the Minister was put under What is the plan? What is details. Among the questions She also pressed him pressure for details on the the timeline for including on the supply of vaccines for a timescale, to which timeline by Cormac Devlin TD pharmacists?” into the country and the Donnelly responded that (Dún Laoghaire, Fianna Fáil). Representatives of the HSE pace at which they can be “it will be in the coming Devlin pressed for clarity on faced similar questions when administered, many continue weeks.” He claimed to have “when will the vaccinations updating the Oireachtas to ask when community discussed this at length with in pharmacies start?” He Health Committee on pharmacies will become the HSE and acknowledged also highlighted how “many vaccinations. John Lahart TD involved. that pharmacists “are ready pharmacists have completed (Dublin South West, Fianna Minister for Health, to go and we have had an the documentation that was Fail) pressed HSE Chief Stephen Donnelly faced this agreement in place with them required and sent it back to Clinical Officer Dr. Colm question multiple times when for a very long time.” the HSE.” Henry for details about when updating the Dáil on the When the issue of running Minister Donnelly advised pharmacists will join the vaccine campaign. vaccination centres 24 hours that he has “taken this up programme. “I want to see pharmacists a day was suggested to with the HSE on numerous Damien McCallion, who is playing a more prominent Minister Donnelly he cited the occasions, including this national lead on the COVID role in this,” the Minister told additional capacity offered by week. I believe there is a 19 vaccination programme Róisín Shortall TD (Dublin pharmacies as one reason that role for pharmacists to play responded by outlining work North West, Social Democrats). this might not be required. in the vaccination roll-out. done to date. “We have been Deputy Shortall had asked But he did commit that “If it That is why we put a deal in working with pharmacists for about the role of the pharmacy is needed to run the vaccine place with the Irish Pharmacy some time, and with the Irish network particularly as centres 24-hours a day, we will Union, IPU, at the start of this Pharmacy Union.” “there is a very significant absolutely do that.” process.” McCallion explained how dip in the administration of The Minister also advised Devlin’s questions were there have been a number of vaccines every weekend… that “The IT systems and echoed by Labour leader steps to go through “First, we The number drops down to portals for the pharmacists Alan Kelly TD (Tipperary, had to reach an agreement. about 12,000, which is just are being piloted with a Labour) who asked “When Second, we needed to put not really acceptable at this number of community are we going to include the in place an operational framework as to how they would operate as vaccinators. Third, we needed to put in a technology solution that would allow them to function.” Ultimately, McCallion explained that there are two factors that will determine the timing. “One relates to when Stephen Donnelly Róisín Shortall Cormac Devlin Alan Kelly John Lahart we have supply of the vaccine, Fianna Fáil Social Democrats Fianna Fáil Labour Fianna Fáil the other is the vaccine mix.

36 IPUREVIEW JUNE 2021 Pharmacy vaccination will “extraordinary that one of the lend itself better to some most valuable assets we have vaccinations than others, so is the community pharmacists the decision around the use of but they are not being the Janssen vaccine and so on utilised at all in the ongoing will affect that.” vaccination programme.” Responding to a question “In the first iteration of the on the practicalities of the national Covid-19 vaccination Seán Kyne Jerry Buttimer Brendan Griffin pharmacies vaccinations strategy implementation Fine Gael Fine Gael Fine Gael from Senator Seán Kyne (Fine plan, community pharmacists Gael) McCallion admitted, “We were identified in the report are still working through the as having a central role. Since model of how people will be then, we have seen 27 changes assigned to pharmacists.” to the vaccination programme In the Seanad too the but there is no sign of the Government faced multiple involvement of community questions. Senator Maria pharmacists despite them Byrne (Fine Gael) addressing being trained vaccinators. I Maria Byrne Pádraig O'Sullivan Réada Cronin An Tánaiste, Leo Varadkar have to ask why.” Fine Gael Fianna Fáil Sinn Féin highlighted how “Some 1,200 There were also questions pharmacists have registered from Pádraig O'Sullivan TD to become vaccinators... It (Cork North Central, Fianna would certainly help increase Fáil), and Minister Robert the number of vaccinators Troy TD (Longford-Westmeath, available.” Fianna Fáil). The Tánaiste, responding The cost of involving of to this, acknowledged that pharmacies was also raised some pharmacists “are a little by Ruairi Ó Murchú TD annoyed that they have not (Louth, Sinn Fein) who was Leo Varadkar Robert Troy Michael Collins been asked to help yet. They advised that the fees payable Fine Gael Fianna Fáil Independent will be, almost certainly in to pharmacists were set June and through to July and following consultation with thereafter.” the Irish Pharmacy Union, but Senator Sharon Keogan no estimate was provided. (Independent) cited the IPU’s Finally, there were also estimate that pharmacies questions put to the Minister have capacity to administer on the vaccination of all more than 50,000 a week. “If pharmacy staff by Brendan the Government wants to hit Griffin TD (Kerry, Fine Gael), Sharon Keogan Ruairi Ó Murchú its vaccination target by the Réada Cronin TD (Kildare Independent Sinn Féin end of June, I urge it to delay North, Sinn Fein) and Michael no longer.” Collins TD (Cork South West, While Senator Jerry Independent). Buttimer (Fine Gael) said it is

TDs Focus on e-prescribing

As talk begins to move to post pandemic healthcare there has been renewed focused on e-health and in particular e-prescribing. Neasa Hourigan (Dublin Central, Green Party) asked Minister Donnelly to detail progress on the implementation of an e-prescribing system. The Minister advised that “implementation of ePrescribing is a significant programme of work and will take time to embed in acute and primary care settings.” But also explained that “to support access to prescriptions during the Covid-19 pandemic, a new service to facilitate the secure electronic transfer of prescriptions (ETP) between GPs and community pharmacy was deployed in response to Covid-19.” According to the Minister this service has proven to be successful with approximately 50,000 scripts now being transferred electronically between GPs and community pharmacies every day. “To build on this work, the HSE has established an ePharmacy Programme which will be responsible for the implementation of a national ePrescribing solution for the health service.” Labour leader Alan Kelly TD also raised the topic in the context of EU recovery funding. Kelly wanted to know how the funding, approximately €853 million in 2021, would be spent. Kelly said he would welcome if some of this funding was put towards ehealth, specifying the national need for “An ehealth project would allow for the secure electronic sharing of Neasa Hourigan patient information lab results and prescriptions between medical providers.” Green Party

IPUREVIEW JUNE 2021 37 POLITICS

Medicinal cannabis products Healthy Ireland Strategic David Cullinane TD (Waterford, Sinn Fein) received Action Plan Launched detailed updates from Minister Donnelly on the regulatory treatment of medicinal cannabis products. The Government has published a new five-year Action Cullinane, who is the Sinn Fein health spokesperson, Plan for the Healthy Ireland Strategy. asked first “if an application has been received to add A core component of the implementation of the PCBD110 product to the medical cannabis access Sláintecare, this Healthy Ireland Strategy will have a programme”. He also sought clarity on the criteria which particular emphasis on reducing inequalities. It will prospective products for the medical cannabis access involve a comprehensive cross-government approach, programme must meet in order to be recommended for use with a total of 14 Government departments responsible in the programme and specifically “if trace-THC products for implementing actions for the next five years. may be considered for inclusion.” An Taoiseach Micheál Martin said “Healthy Ireland Minister Donnelly confirmed that the HPRA had received gives us a vision of how we as no application from any prospective supplier looking to a society can work together to add PCBD110 to the Medical Cannabis Access Programme bring about a Healthier Ireland (MCAP). In relation to products containing THC at trace where everyone can enjoy levels he said these “are still subject to control under physical and mental health the Misuse of Drugs Act and are eligible for inclusion in and wellbeing to their the MCAP provided they meet the definition of “specified full potential.” controlled drugs” in the regulations.” The Plan contains 56 Cullinane then sought an explanation on why none actions across six themes of the four products currently recommended for use in which will be implemented MCAP meet the criteria of less than 2% THC for use in over the next five years. This the treatment of resistant epilepsy. To which the Minister includes a commitment to responded that, “It is open to any supplier or producer further develop partnerships to apply to the HPRA to have their products assessed for with pharmacies in the inclusion in the programme.” years ahead. Elsewhere Pádraig O'Sullivan TD (Cork North Central, Fianna Fail) asked for information on the reimbursement of medicinal cannabis oil products PCBD. The Minister explained that MCAP is restricted to prescribing of cannabis-based products by medical Bruton seeks unwinding of FEMPI consultants, for patients with multiple sclerosis, nausea and vomiting associated with chemotherapy and severe, Former Minister Richard Bruton TD (Dublin Bay North, Fine Gael) refractory (treatment-resistant) epilepsy. has become the latest TD to ask questions in relation to the To date, four products have been added to Schedule 1 of restoration of FEMPI cuts to the pharmacy sector. the Misuse of Drugs (Prescription and Control of Supply of Responding to this parliamentary question, Minister Donnelly Cannabis for Medical Use) stated that it was his intention to honour the commitment Regulations 2019. made by the previous Government to the IPU for a strategic However, he explained review of the role of community pharmacists and to develop that “for medical revised contractual terms. indications not included “The GMS pharmacy contract is substantially outdated,” in the MCAP, doctors acknowledged Donnelly. “It has not kept pace with may continue to utilise developments that have taken place over the course of recent the Ministerial licencing years including the increasing emphasis on maximising the route to prescribe medical proportion of people’s healthcare needs met in primary care, cannabis for their interdisciplinary collaboration and the skillset that pharmacists patients.” have by virtue of their education and training.” Detailing the proposed review, the Minister said, “The comprehensive review of the pharmacy contract will address the role to be played by community pharmacy in the context of Sláintecare. It will consider all aspects of pharmacy service provision including delivery of a multi-disciplinary model of service delivery for patients.” David Cullinane Sinn Féin

Richard Bruton Fine Gael

38 IPUREVIEW JUNE 2021 LETTER TO THE EDITOR HPRA address Veterinary Medicines When the IPU Review arrives the first page I look at is the Representatives from the HPRA editor's comments. There is no doubt that the editor spends attended a meeting of the Joint a lot of time and thought into setting this up. The May 2021 Oireachtas Committee on Agriculture, issue brings back lots of memories to me. In the early 1980s Food and the Marine. Chief among there was the big drive to use computers in pharmacies. the topics raised was the proposed Many pharmacists cut their teeth with the BBC and basic changes to the route of supply of programs. I still remember being hauled over the coals for antiparasitic veterinary medicinal maintaining that this approach was not powerful enough and products intended for food-producing Joe Flaherty would have to be replaced with the IBM system. species under the EU Veterinary Fianna Fáil One problem that arose was the diversity of programs used Medicines Regulation 2019/6, which by wholesalers who wanted to tie in retail pharmacies to comes into force on 28 January 2022. their databases. Addressing the committee But with the immense help of Michael Doherty and members Dr. David Murphy, said “It Teresa Doherty (RIP) we succeeded in getting some form is clear that anti-parasitic resistance of unification. At that time, there was a tendency of is an issue.” Explaining that “anti- wholesalers to use the PIP code which was the British parasitic compounds are a precious standard. It was through the help and forethought of commodity. The last new broad Teresa and Michael that we went down the road of the spectrum anti-parasitic wormer Tim Lombard European barcode. And with Michael's help we were allotted product for cattle and sheep was Fine Gael a section of the EU barcodes which was then called IPU code. authorised ten years ago.” Following many rather belligerent meetings with According to Dr. Murphy the situation “requires that wholesalers, software producers and the IPU committee these substances are subject to prescription control.” we reached agreement to use this code in ordering, Joe Flaherty TD (Longford-Westmeath, Fianna Fáil) standardising the reception of orders and the information described the insight provided into the anti-parasitic coming back to the pharmacist. resistance as “a real eye-opener.” While Senator Tim This time around, with the introduction of the 3D codes Lombard (Fine Gael) raised the concern that there are I believe it is possible to standardise the information that “major quantities of food or product moving from the is sent out by the manufacturers into readable information North to South which have different regimes regarding for the suppliers, doctors and pharmacists. This would allow anti-parasitic drugs.” the introduction of an official International Health products In response to the latter concern Dr JG Beechinor catalogue. advised the committee that this was “a live issue with the While the IPU National Health Products Catalogue is Department through the Northern Ireland protocol.” But already in existence, why not use it in the format that Jack outlined his understanding that only a suitably qualified has suggested? I am sure that there are many knowledgeable person can prescribe anti-parasitics in respect of herds in people out there to assist with its development. Northern Ireland. Wishing the best of luck to Jack and, of course, the hard working and efficient team in the IPU.

Paddy Geoghegan

What is in the File? ISO Certified The File contains information on over 63,000 products, In 2016, the IPU Product File achieved including: ISO Certification for 9001 (Quality) ISO 9001 ISO 27001 and 27001 (Information Security). Registered Registered Licensed medicinal products Quality Information Security The audit and certification process for Management Management Unlicensed medicinal products ISO Certification emphasises the robustness of the Medical devices and sundries (bandages, dressings, IPU Product File and underpins its position as the IPU PRODUCT FILE ostomy equipment etc.) definitive medicinal product catalogue in Ireland. Nutritional products, including foods for special diets Easy to Use The IPU Product File has been in existence Veterinary products The IPU Product File is an open system, so no matter what for more than 30 years and is an indispensable Photographic products vendor you choose, the file can be adapted for your needs. The IPU Product File is available by electronic download, Cosmetic products resource for community pharmacists. where you can log-in and download your monthly update. It was designed for pharmacists by pharmacists Front of Shop products (shampoos, vitamins etc.) Contact Us and is also used by doctors and hospital In addition to pricing information, barcodes etc., personnel. It is a vital support tool for the IPU Product File provides valuable professional The IPU Product File team are available to answer your queries, whether it’s on sourcing a product, pricing queries prescribing, dispensing, claiming with PCRS, information on health products. The professional information provided includes the Medicinal Product etc., the team will be able to assist you. stock ordering, stock taking, price checking Name, PA/EU number, Generic Name, Pharmaceutical For any queries relating to the IPU Product File, please and product sourcing. Form, Strength and Legal Status. contact a staff member on01 406 1550 or [email protected]

IPUREVIEW JUNE 2021 39 PROFESSIONAL Etain Kett, Dental Health Foundation Ireland The role of the Pharmacist in improving oral health

Tooth decay is our most common childhood disease, despite being entirely preventable. Etain Kett of Dental Health Foundation Ireland offers some basic advice on protecting our teeth and gums and outlines the role that pharmacists can play in supporting improved oral hygiene.

ental caries, people aged 65–74 years have more commonly no natural teeth. It is fair to known as tooth say that many of the public decay, is entirely are not aware of the links preventable. Yet between oral and general Dit is the most widespread non- health or that ignoring communicable disease and your oral health may the most common childhood affect wellbeing. disease – due to risks like poor Maintaining good oral oral hygiene and exposure health is not just about the to sugar. absence of disease such as In Ireland, almost half tooth decay or gum disease. of five year olds without The Dental Health Foundation community water fluoridation provides practical and useful (CWF) and one in three information to people about with CWF have at least one their oral health and all decayed, missing or filled person health. We ensure that primary/baby tooth or have its advice is underpinned by experienced dental caries. science. We take the holistic Almost 100% of adults in approach and emphasise that the world have dental caries the goal is to have good oral and globally, about 30% of health for your lifetime.

40 IPUREVIEW JUNE 2021 The Irish Pharmacy Union commissioned a study in 2019 How to look after your teeth which showed that 70% of the public are more likely to visit Oral health is not just about helps to reduce either manual or powered. the local pharmacist ahead of appearance, it impacts on bad breath. It is important to choose a the GP, making the pharmacist your overall health and 5. Most people don’t think toothbrush that effectively ideally placed in helping to quality of life. With the about tongue brushing, and gently cleans your teeth promote oral health messaging links between gum disease but it has also been and gums, soft/medium is and ensuring that the public and oral health such as proved to be an effective best. Modified toothbrushes has access to professional and diabetes and cardiovascular measure in reducing are available for carers trustworthy information. disease it has never bad breath. or people who may have Getting back to good oral been more important difficulty holding brushes. health (which is not just to look after your teeth. Children Powered toothbrushes Pharmacists can provide a are also beneficial for about appearance, it impacts 1. Parents and carers of wealth of information on people who do not have on your overall health), the children aged 0-2 are effective oral hygiene. the dexterity to brush basics are good oral hygiene encouraged to brush their Regular toothbrushing effectively with a manual and a healthy diet. The key child’s teeth twice a day removes plaque, which is toothbrush. messages around this are a as soon as the first tooth good for gum health. It daily routine of brushing your appears, using a soft is recommended to use a Mouthwash teeth twice a day and eating a toothbrush and water. balanced diet with lots of fruit toothpaste with 1450 ppm F While mouthwash may 2. It is not recommended and vegetables and sticking (parts per million fluoride), help fight tooth decay and to use toothpaste for with tooth friendly drinks like the fluoride can help to gum disease, it shouldn’t children aged 0-2 years, water and milk. prevent and even reverse be used as a replacement unless advised by the Eating and snacking has decay in its early stages. for toothbrushing or dentist. become more common during shouldn’t be used straight lockdown. A good diet reduces Effective Toothbrushing 3. From age 2-7 years use a after brushing the teeth the risk of tooth decay, and Routine small pea size amount as it only rinses away other health related issues. 1. A gentle scrub technique of fluoride toothpaste. the higher fluoride Sugar is the most important involving very short 4. Children under the concentration from the dietary cause of tooth decay in horizontal movements is age of seven should fluoride toothpaste. Using children and adults. Drinking recommended. be supervised by an a fluoride mouthwash between brushings is one can of a sugary drink 2. Spit out toothpaste adult when brushing very useful if you wear a day increases the risk of and do not rinse after to avoid swallowing braces. The Dental Health developing type 2 diabetes by brushing. toothpaste. Do not rinse 22%. A lesser-known fact is after brushing so that Foundation recommends 3. Brush twice a day – that the acid in diet drinks can the effects of fluoride the use of alcohol-free at bedtime and at damage the teeth by causing toothpaste are not mouthwash and your one other time tooth erosion. diluted. dentist will recommend the during the day. The Healthy Food for most suitable mouthwash. Life Toolkit for the new 4. Daily flossing reduces Research shows if a child It is not recommended for Food Pyramid contains the amount of has dental decay at a young under seven years of age. useful advice and tips periodontal disease- age, they are more likely to on following a healthy causing bacteria present have dental decay and gum Dental Visits diet, which can only be of in plaque between disease as an adult. It is recommended to visit benefit from an oral health the teeth – this is Pharmacists can the dentist at least once perspective: https://assets. particularly important recommend the most a year for a dental check- gov.ie/7650/f3249ad0c728 for diabetics. It also suitable types of toothbrush, up and mouth cancer 4211b3fa41c69b33c8e2.pdf examination, even if you have no teeth of your own or wear dentures. If you have diabetes a visit is recommended every six months, due to the increased risk of gum disease.

IPUREVIEW JUNE 2021 41 population. As a pharmacist you can suggest some of the following for ulcers: Avoid spicy and sour foods until the ulcers heal; drink plenty of fluids; regularly rinse the mouth out with warm, slightly salted water; keep the mouth clean; take pain- relieving medication, such as paracetamol; apply antiseptic gel to the ulcers. However, you should recommend that the person visits their dentist or GP if the mouth ulcers don't clear up within a few days, or if they get them frequently. It's important to seek the advice of a dentist who may refer more Gum disease to help with dry mouth. to their dentist or doctor severe cases to a specialist in Sucking on sweets or sipping as they may be able to take oral medicine for a thorough Gum disease is caused by a on soft drinks and juices is prescription pills to prevent investigation. build-up of plaque on the bad for the teeth. cold sore outbreaks. teeth and around the gums, Cold sores can be very causing red swollen gums serious for young babies as Mouth, head and which bleed when brushing. Cold sores their immune systems aren’t neck cancer If left untreated, gum disease developed enough to fight off Mouth Head and Neck Cancer (or gingivitis) will progress Cold sores are painful red the infection. Advise people is the sixth most common to periodontal disease which blisters that occur on or not to kiss their newborn and cancer in men worldwide. causes bad breath, receding around the mouth and are to wash their hands before Smoking and drinking alcohol gums, wobbly teeth and, caused by herpes simplex virus touching their baby. are the most important risk ultimately, loss of teeth. (HSV) types 1 and 2. HSV type factors, but the risk is even Smoking also increases the 1 is the most common cause of greater if you smoke and risk of periodontal disease, cold sores. HSV type 2 usually Mouth ulcers drink. Alcohol plays a role in smokers are more likely to causes genital herpes, but it up to half of all cancers of get periodontal disease and can also cause cold sores. Many people suffer from the mouth, head and neck in prematurely lose their teeth recurrent ulcers in the mouth. men in Ireland with over 700 than non-smokers. These can be extremely How to prevent cases diagnosed every year in Poorly controlled painful and may make Ireland. diabetes increases the cold sores speaking and eating difficult. Mouth ulcers can be triggered Early diagnosis means risk of periodontal disease Prevention is difficult and cold by a wide range of factors the chance of survival is development, which in turn sores are contagious, strict including: greatly improved, so if a can make it more difficult to hygiene measures should be Accidental biting of the person notices any changes control diabetes. People with adopted when a person is inside of your cheek; vigorous in their mouth and has them diabetes should be encouraged infected. Here are some things toothbrushing; constant for more than three weeks, to have a good oral hygiene that can be done to reduce rubbing against misaligned/ the pharmacist should routine and regular visits to the number of outbreaks and sharp teeth, an irregular recommend that they visit their dentist. prevent spreading the virus. filling, dentures or braces; their dentist or doctor straight It’s also worth noting that Avoiding triggers such as emotional stress; deficiencies away. Things to look out hormonal changes during stress, colds or the flu; too in Vitamin B12, iron and for include a lump in your pregnancy can make women’s much sunlight can cause folic acid; burns from eating mouth or neck, a sore or gums more vulnerable to cold sores to flare so always hot food or irritation from ulcer, a persistent sore throat pregnancy gingivitis. Advice to use sunscreen on the face strong antiseptics, such as a and hoarseness, problems pregnant women about their and lip balm with a factor mouthwash; mouth cancer. with your tongue (including oral health during pregnancy on the lips. Avoid sharing Usually, one to five small mobility or numbness). is important to both the toothbrushes, towels, razors, ulcers appear (less than mother and baby. Making cutlery, cups or other objects 1mm in diameter) on the For more information see healthy choices can positively that a person with a cold sore inside of lips or cheeks or www.mouthcancer.ie affect a baby's development may have used, good hand the floor of the mouth or including in relation to his hygiene is important. A well- tongue. The ulcers tend to Advice on quitting smoking is or her teeth. established product on the be concentrated towards the available at www.quit.ie market (containing 5% w/w front of the mouth. They can acyclovir), if applied during last from a few days to a little Visit www.askaboutalcohol.ie Dry mouth and the early burning phase of over two weeks, but usually for advice on alcohol. medication cold sores, has been shown to about 10 days. Aphthous be effective in reducing the Certain medications may ulcers are recurring ulcers For additional information and duration of the episode. cause dry mouth. To help with no known cause and free downloadable resources on If a person gets cold sores relieve it sip water, chew sugar- affect around 20-30% of the these topics and more, visit www. free gum or use oral lubricants often advise them to talk dentalhealth.ie

42 IPUREVIEW JUNE 2021 STUDIES

Lancet publishes results from Trinity College clinical trial for Atopic Dermatitis

The findings of a clinical trial by Trinity College Dublin researchers of treatment for atopic dermatitis have been published in The Lancet journal. Results of the clinical trial at the School of Medicine, Trinity College and St James’s Hospital, Dublin have shown the drug upadacitinib to be the most effective treatment to date for this chronic, relapsing inflammatory condition. The research is significant as there is an unmet need which exists for therapies that provide remission of symptoms in moderate-to-severe atopic dermatitis. The Lancet reports efficacy and safety results ofupadacitinib compared with placebo for the treatment of moderate-to- severe atopic dermatitis in adults and adolescents. This pivotal Global Phase 3 study involved 1,600 patients and took place over the last two years at The Wellcome Trust/Health Research Board Clinical Research Facility at St James’s Hospital. Atopic dermatitis is a chronic, relapsing inflammatory condition characterised by a cycle of intense itching and scratching leading to cracked, scaly, oozing skin. It affects up to an estimated 10 percent of adults and 25 percent of children. Between 20 and 46 percent of adults with atopic dermatitis have moderate to severe disease. The range of symptoms pose significant physical, psychological and economic burden on individuals impacted by the disease. Results show upadacitinib to so far be the most effective treatment for atopic dermatitis in clinical trials. The magnitude and breadth of the treatment effect versus placebo across multifaceted aspects of atopic dermatitis provides evidence that a targeted therapy blocking multiple inflammatory pathways could help to address the substantial unmet needs in the treatment of moderate-to-severe atopic dermatitis. These pivotal findings could potentially transform the treatment goals and standards of care for patients with moderate- to-severe atopic dermatitis. Professor Alan Irvine, School of Medicine, Trinity College and Principal Investigator said: “Atopic dermatitis is a common inflammatory skin disease which, when severe, has a very significant impact on quality of life. These results are hugely encouraging and will hopefully offer an additional treatment option for patients very soon. The success of this clinical trial also shows the value of investment in our Trinity research facility at St James’s Hospital, meaning Irish patients have access to advanced therapies and Irish medical and nursing trainees gain valuable research skills.” The St James’s/Trinity Clinical Research Centre is funded by the Wellcome Trust and the Health Research Board (HRB). Link to full transcript in The Lancet is available at: https://bit.ly/2QB31es

Positive CHMP Opinion Recommending Darzalex Subcutaneous Formulation for Patients with Light-chain (AL) Amyloidosis

Genmab A/S has announced that the Committee for Medicinal Products for Human Use (CHMP) of the European Medicines Agency (EMA) has adopted a positive opinion and recommended granting marketing authorisation for the daratumumab subcutaneous (SC) formulation (daratumumab and hyaluronidase-fihj), known as DARZALEX® SC in the European Union, in combination with bortezomib, cyclophosphamide, and dexamethasone (VCd) for the treatment of adult patients with newly diagnosed systemic light-chain (AL) amyloidosis. The CHMP also issued a positive opinion recommending DARZALEX SC in combination with pomalidomide and dexamethasone (Pd) for the treatment of adult patients with multiple myeloma who have received one prior therapy containing a proteasome inhibitor (PI) and lenalidomide and were lenalidomide refractory, or who have received at least two prior therapies that included lenalidomide and a PI and have demonstrated disease progression on or after the last therapy. Janssen Pharmaceutica NV submitted Type II variation applications to the EMA for these indications in November 2020. In August 2012, Genmab granted Janssen Biotech, Inc. (Janssen) an exclusive worldwide license to develop, manufacture and commercialize daratumumab. “We are extremely pleased about the positive CHMP opinions for DARZALEX SC and hopeful that the positive opinion in AL amyloidosis will lead to the first approved treatment option for European patients with this devastating disease,” said Jan van de Winkel, Ph.D., Chief Executive Officer of Genmab.

About the ANDROMEDA (AMY3001) study The Phase 3 study (NCT03201965) included 416 patients newly diagnosed with AL amyloidosis. Patients were randomised to receive treatment with either daratumumab and hyaluronidase-fihj in combination with bortezomib (a proteasome inhibitor), cyclophosphamide (a chemotherapy), and dexamethasone (a corticosteroid) or treatment with VCd alone. The primary endpoint of the study was the percentage of patients who achieve hematologic complete response.

About the APOLLO (MMY3013) study The Phase 3 (NCT03180736), randomised, open-label, multicentre study included 304 patients with multiple myeloma who have previously been treated with lenalidomide and a PI. Patients were randomised 1:1 to either receive daratumumab in combination with Pd or Pd alone. In the original design of the study, patients in the daratumumab plus Pd arm were treated with the intravenous (IV) formulation of daratumumab. As of Amendment 1 to the study protocol, all new subjects in the experimental arm were dosed with the SC formulation of daratumumab and patients who had already begun treatment with IV daratumumab had the option to switch to the SC formulation. The primary endpoint of the study was progression free survival (PFS). The study was conducted in Europe under an agreement between Janssen, the European Myeloma Network (EMN) and Stichting Hemato-Oncologie voor Volwassenen Nederland (HOVON).

IPUREVIEW JUNE 2021 43 NEWS

Survey reveals 66% of people don’t wear sunscreen in summer

Results of a new survey carried out on behalf of LloydsPharmacy show that barely a third (34%) of adults wear sunscreen during the summer months but only when it's a sunny day. Only 16% wear sunscreen every day. Over 12,000 cases of Non-melanoma skin cancer (NMSC)[1] are diagnosed in Ireland each year with sun exposure acting as the main risk factor. Even though ‘’sun holidays” have been off limits, over a quarter (27%) of adults admitted to having experienced sunburn in the last year, with men (33%) more likely than women (22%) to fall into that category. Denis O’Driscoll Superintendent Pharmacist with LloydsPharmacy says people should follow these basic principles in relation to sunscreen: (1) Use more than you think! It is advised that you should use approximately a shot glass of product to cover your body, so don’t use it too sparingly. (2) Apply sunscreen 30 minutes before leaving the house to make sure the product has had enough time to soak in. (3) I’m only popping out; do I really need it? In short, yes. It’s still exposure, and depending on the time of day, you can get sunburnt quite quickly. Also, 20 minutes can easily turn into 40. (4) Reapply every two hours – yes, that is right, every two hours at least. If you go swimming you should reapply every time you get out of the water. Reapply more frequently if you are sweating a lot as well. (5) Remember to protect your eyes too, make sure that the sunnies you are wearing have UV protection and aren’t just stylish!

LloydsPharmacy research conducted by Empathy Research (Base: All Adults 18+ n=1,018)

1. Irish Cancer Society: https://www.cancer.ie/cancer- information-and-support/cancer-types/skin-cancer/ non-melanoma-skin-cancer

44 IPUREVIEW JUNE 2021 NEWS MSc in Clinical Pharmacy in UCC Newly elected President

Applications are invited for the two-year (part-time) distance learning MSc in Clinical of PGEU highlights role Pharmacy, which is offered by the School of Pharmacy, University College Cork and which will commence in September 2021. played by community The course is structured to provide specialist training to enable pharmacists working in hospital and community pharmacies to extend pharmacists in pandemic their professional role within the clinical healthcare system. The course administrators say that the course will help its students to develop The Pharmaceutical Group of the European Union has elected a greater understanding of the major Mr. Roberto Tobia, from the Italian Pharmacy Owners Federation pharmacotherapeutic issues of various (Federfarma) as PGEU President for 2022 and Mr. Raimund disease states and a better understanding of Podroschko from the Austrian Chamber of Pharmacists as PGEU the particular needs of patients with these Vice-President for 2022. diseases. It will also provide graduates with In his acceptance speech at the PGEU General Assembly the skills needed to become leaders in clinical meeting, Mr. Tobia praised the work of community pharmacists pharmacy services, such as critical appraisal during the pandemic: "The pandemic has revealed all the of drug therapies, rational drug use (including strengths and the weaknesses of our health care systems and pharmacoeconomic evaluation), medication has clearly shown that community pharmacists, in the front line safety management, research project against Covid-19 since day one, are a strong and indispensable management, presentation skills and pillar, working with tireless commitment 24/7 at the services of report writing. patients. Next year will be crucial for the reshaping of the role of The distance learning format allows students the EU in public health. Many EU legislative initiatives will have a to remain in employment throughout the significant impact on pharmacy daily practices, from the revision course. Students will be able to communicate of the EU pharmaceutical legislation to the creation of an EU with each other and the teaching staff by health data space. means of regular teleconferences/webinars and “Within PGEU will work together to bring the voice of interactive internet systems. community pharmacists to policy makers and stakeholders Applicants must hold a primary pharmacy and we will also make sure that the important changes of the degree and, ideally, should have a minimum legislation many countries have implemented to expand the of one-year practical experience. Applicants scope of pharmacy practice in response to the emergency will be must be registered as a pharmacist with the further consolidated”. professional accreditation authority in the A practicing pharmacy owner in Palermo, Sicily, Roberto Tobia country in which they are practising. is Federfarma National Secretary, Federfarma Palermo’s President Closing date for applications is 30 June 2021. and Utifar (Technical Union of Italian Pharmacists) Vicepresident. Applicants can apply online at www.ucc.ie/ Federfarma represents more than 90 % of Italian private apply, and further information about this pharmacy owners. course is available at www.ucc.ie/en/ckx03/, or Mr. Podroschko works in a community pharmacy in Vienna. by contacting Dr Teresa Barbosa, Programme Currently he is president of the Austrian Association of Employed Director, at [email protected] or on 021 490 1792. Pharmacists as well as Vice-President of the Austrian Chamber of Pharmacists.

IPUREVIEW JUNE 2021 45 CLINICAL TIPS Tara Kelly MPSI, Medicines Information Pharmacist, IPU

Change to Madopar dosing with respect to food

n May, the HPRA n A delay between a meal The recommended initial six months before failure is issued a safety notice and Madopar dosing dose is one dispersible tablet concluded from absence of entitled Update in may be advisable to of Madopar 50mg/12.5mg clinical response. dosing information in avoid lower absorption of three or four times daily. If Patients requiring a more the Madopar product levodopa by food; and the disease is at an advanced rapid onset of action, e.g., information with respect to food. stage, the starting dose should patients suffering from I n Undesirable gastro- be one dispersible tablet of early morning or afternoon intestinal effects, which Madopar 100mg/25mg three akinesia, or who exhibit may occur mainly in HPRA safety notice times daily. delayed on or wearing off the early stages of the The daily dosage should phenomena, are more likely The HPRA safety notice states: treatment, can largely then be increased by to benefit from Madopar “It was noted that the dosing be controlled by taking one dispersible tablet of Dispersible. information (specifically Madopar with a low Madopar 100mg/25mg, or For patients previously the timing of dosing with protein snack or liquid the equivalent, once or twice treated with levodopa, respect to food) in the product or by increasing the weekly until a full therapeutic levodopa alone should be information for Madopar dose slowly. products was not optimal: effect is obtained, or side- discontinued and Madopar effects supervene. In some started on the following day. it did not make clear that There are three licensed elderly patients, it may suffice The patient should be initiated dosing without food is possible preparations of Madopar to initiate treatment with one on a total of one less Madopar and may be preferable for available in Ireland – Madopar dispersible tablet of Madopar 100mg/25mg dispersible tablet some patients. This update 200mg/50mg hard capsules, 50mg/12.5mg once or twice daily than the total number makes the Madopar dosing Madopar 100mg/25mg daily, increasing by one of 500mg levodopa tablets or information with respect to dispersible tablets, and dispersible tablet every third capsules previously taken. The food more consistent with Madopar 50mg/12.5mg or fourth day. patient should be observed other levodopa-containing dispersible tablets. The effective dose usually for one week and then, if medicines and with most Madopar contains two lies within the range of four necessary, the dose as outlined clinical guidance.” active ingredients – levodopa to eight dispersible tablets of for existing patients. SPC Section 4.2 Method of and bensarazide. The licensed Madopar 100mg/25mg (two For patients previously Administration – updated indication is for the treatment to four capsules of Madopar treated with other levodopa/ the dosing information with of Parkinsonism. respect to food to include the 200mg/50mg) daily in decarboxylase inhibitor below: divided doses; most patients combinations, the previous Posology require no more than six therapy should be withdrawn n Where possible, Madopar dispersible tablets of Madopar for 12 hours. In order to should be taken in- Madopar 200mg/50mg 100mg/25mg daily. It is rarely minimise the potential for between meals, so that capsules are only for necessary to give more than 10 any effects of levodopa the competitive effect maintenance therapy once dispersible tablets of Madopar withdrawal, it may be of dietary protein on the optimal dosage has been 100mg/25mg (five capsules beneficial to discontinue levodopa can be avoided determined using Madopar of Madopar 200mg/50mg) previous therapy at night and and to facilitate a more 100mg/25mg dispersible per day. Treatment should institute Madopar therapy the rapid onset of action; tablets. be continued for at least following morning. The initial

46 IPUREVIEW JUNE 2021 Madopar dose should be one improvement in disability is The transport of levodopa Madopar should be taken in- dispersible tablet of Madopar gradually lost as the disease into the brain is subject to between meals, to avoid the 50mg/12.5mg three or four progresses and fluctuations competition from chemically effect of dietary protein on times daily. in mobility emerge. related amino acids. A high- levodopa and facilitate a more Postencephalitic parkinsonism protein diet has been shown rapid onset of action. A delay responds to levodopa, but a to reduce the therapeutic between a meal and Madopar Mode of action higher incidence of adverse effect of levodopa. Such may be advisable to avoid Levodopa, a naturally effects has been reported alterations in the absorption delays in gastric emptying occurring amino acid, is the than in the idiopathic form and transport of levodopa may which may reduce the amount immediate precursor of the so smaller doses are contribute to the fluctuating of levopdopa available for neurotransmitter dopamine. generally used. responses seen in Parkinson's absorption. The actions of levodopa are disease, the so-called 'on-off' mainly those of dopamine. phenomenon. Absorption References Unlike dopamine, levodopa HPRA Safety Notice ‘Update in readily enters the CNS and Levodopa is rapidly absorbed Change to warning label dosing information in the Madopar is used in the treatment of from the gastrointestinal product information with respect to conditions such as Parkinson's tract by an active transport The previous version of the food’, located at http://www.hpra. disease that are associated system. Most absorption takes HPRA SPC for Madopar stated, ie/docs/default-source/3rd-party- with depletion of dopamine in place in the small intestine; ‘Take with, or immediately documents/product-information- update-(piu)/product-information- the brain. Levodopa is rapidly absorption is very limited after, meals’. update-madopar-10-may-2021. decarboxylated by peripheral from the stomach, and since The warning label that was pdf?sfvrsn=4 enzymes. Consequently, decarboxylation to dopamine applied to Madopar tablets levodopa is usually given may take place in the by us at the NHPC (National Madopar SPC access online 14 with a peripheral dopa- stomach wall, delays in gastric Health Products Catalogue), May 2021 at https://www.hpra.ie/ decarboxylase inhibitor, such emptying may reduce the was therefore ‘Take with or homepage/medicines/medicines- information/find-a-medicine/ as benserazide or carbidopa, amount of levodopa available just after food, or a meal’. results?query=madopar&field= to increase the proportion for absorption. We have now removed this of levodopa that can enter Peak plasma concentrations warning label from the NHPC Martindale: The Complete the brain. occur within 1-2 hours of oral and IPU Product File. Drug Reference, accessed at The majority of patients doses. Food intake reduces the It should be communicated MedicinesComplete 14 May 2021 at with Parkinson's disease rate and extent of levodopa to patients and their carers https://www.medicinescomplete.com benefit from levodopa therapy, absorption by approximately that, as per the new SPC and but after two years or more, 30% and 15% respectively. Package leaflet, where possible,

NEED HELP WITH THE HSE? THE IPU CONTRACT UNIT IS HERE TO HELP YOU CONTACT DEREK For advice on any part of the pharmacy contract; For advice on all aspects of processing claims; For assistance in responding to direct correspondence from the HSE PCRS; If you are called to a meeting with the HSE PCRS; If your pharmacy is inspected by the HSE PCRS; If you are subject to a claims investigation; and If you are being investigated under the pharmacy contract.

Telephone: 01 406 1557 / 01 493 6401 Derek Reilly, Contract Manager, [email protected]

IPUREVIEW JUNE 2021 47 HIGH TECH MEDICINES UPDATE Tara Kelly MPSI, Medicines Information Pharmacist, IPU Praluent Pre-filled Pens

raluent 75mg and • In combination with correction of other of atherosclerosis also appear 150mg Pre-filled a statin or statin with risk factors: linked to plasma LDL-C levels Pens were added other lipid-lowering • In combination such as cerebrovascular to the High Tech therapies in patients with the maximum disease (i.e., stroke) or Medicines Scheme unable to reach low tolerated dose of a peripheral vascular disease. Pin April. density lipoprotein statin with or without Epidemiologic data indicates Each single-use pre-filled cholesterol (LDL-C) other lipid-lowering a continuously increasing risk pen contains 75mg or 150mg goals with the therapies; or from very low to normal and alirocumab in 1ml of solution. maximum tolerated high levels of LDL-C. A number • Alone or in Alirocumab is a human dose of a statin; or of interventions to achieve combination with IgG1 monoclonal antibody LDL-C control in patients • Alone or in other lipid-lowering produced in Chinese Hamster with elevated LDL-C and with combination with therapies in patients Ovary cells by recombinant high cardiovascular risk are other lipid-lowering who are statin- DNA technology. available, such as statins and therapies in patients intolerant, or for other lipid-lowering therapies. who are statin- whom a statin is Often, however, these are intolerant, or for contraindicated. Indications whom a statin is not sufficiently effective, or their use is limited by toxicity. contraindicated. A large body of n Praluent is indicated Therefore, there is a medical epidemiological evidence in adults with primary n Praluent is indicated in need for new effective and exists demonstrating a strong hypercholesterolaemia adults with established well tolerated treatments of positive correlation and (heterozygous familial atherosclerotic lipid disorders. and non-familial) or cardiovascular disease causal relationship between mixed dyslipidaemia, as to reduce cardiovascular serum LDL-C, and the risk of an adjunct to diet: risk by lowering LDL-C coronary heart disease (CHD). Posology and levels, as an adjunct to Other clinical manifestations administration The usual starting dose of alirocumab is 75mg administered subcutaneously once every two weeks. Patients requiring larger LDL-C reduction (>60%) may be started on 150mg once every two weeks, or 300mg once every four weeks, administered subcutaneously. The dose of alirocumab can be individualised based on patient characteristics such as baseline LDL-C level, goal of therapy, and response. Lipid levels can be assessed four to eight weeks after treatment initiation or titration, and dose adjusted accordingly. Alirocumab is injected as a subcutaneous injection into the thigh, abdomen or upper arm. Each pre-filled pen is for single use only.

48 IPUREVIEW JUNE 2021 It is recommended to rotate the injection site with each injection. Alirocumab should not be injected into areas of active skin disease or injury such as sunburn, skin rashes, inflammation, or skin infections. It must not be co-administered with other injectable medicinal products at the same injection site. The patient may either self-inject alirocumab, or a caregiver may administer alirocumab, after guidance has been provided by a healthcare professional on proper subcutaneous injection technique. The solution should be allowed to warm to room temperature prior to use. In order to improve the traceability of biological medicinal products, the name and the batch number of the administered product should hypersensitivity, nummular concomitantly with statins, Storage and pack details be clearly recorded. eczema, urticaria, and ezetimibe, and fenofibrate, hypersensitivity vasculitis respectively. However, Praluent must be stored in the pharmacy in a refrigerator (2°C Mode of action have been reported in reduction of LDL-C is clinical studies. If signs or maintained during the dosing to 8°C). Praluent can be stored Alirocumab is a fully human symptoms of serious allergic interval when alirocumab is outside the refrigerator (below IgG1 monoclonal antibody reactions occur, treatment administered every two weeks. 25°C) protected from light for that binds with high affinity with alirocumab must be The use of Praluent is a single period not exceeding and specificity to proprotein discontinued and appropriate not recommended during 30 days. After removal from convertase subtilisin kexin symptomatic treatment pregnancy unless the clinical the refrigerator, the medicinal type 9 (PCSK9). PCSK9 binds initiated. condition of the woman product must be used within to the low-density lipoprotein Alirocumab should be requires treatment with 30 days or discarded. receptors (LDLR) on the used with caution in patients alirocumab. surface of hepatocytes to with severe renal or severe It is not known whether The pre-filled pens are marketed promote LDLR degradation impairment. alirocumab is excreted in packs of two pens: within the liver. LDLR is the Since alirocumab is a in human milk. Human • Praluent 75mg primary receptor that clears biological medicinal product, immunoglobulin G (IgG) is 2 x pre-filled pens, circulating LDL, therefore the no pharmacokinetic effects excreted in human milk, GMS number 89070 decrease in LDLR levels by of alirocumab on other in particular in colostrum. PCSK9 results in higher blood medicinal products and no The use of Praluent is not • Praluent 150mg levels of LDL-C. effect on cytochrome P450 recommended in breast- 2 x pre-filled pens, By inhibiting the binding of enzymes are anticipated. feeding women during this GMS number 89071 PCSK9 to LDLR, alirocumab Statins and other lipid- period. For the remaining increases the number of LDLR modifying therapy are known duration of breast-feeding, Praluent was first authorised by available to clear LDL, thereby to increase production of exposure is expected to the EMA in 2015 and was added lowering LDL-C levels. PCSK9, the protein targeted be low. Since the effects of to the IPU Product File with the by alirocumab. This leads alirocumab on the breast- April 2021 update, following to the increased target- fed infant are unknown, a addition to the High Tech Scheme. Adverse reactions mediated clearance and decision should be made and drug interactions reduced systemic exposure whether to discontinue breast- Further information on the of alirocumab. Compared to feeding or to discontinue assessment of Praluent can be General allergic reactions, alirocumab monotherapy, Praluent. found in the European Public including pruritus, as well as the exposure to alirocumab Praluent has no or negligible Assessment Report and SmPC on rare and sometimes serious is about 40%, 15%, and influence on the ability to the EMA website at https://www. allergic reactions such as 35% lower when used drive and use machines. ema.europa.eu/en/medicines/ human/EPAR/praluent.

IPUREVIEW JUNE 2021 49 LIFESTYLE Brigid O’Hora

Brigid O’Hora of 'Virtual First Vineyards' recommends some suitable wines to accompany the pandemic of the era outdoor Irish summer summer wine

o finally, it seems get carried away, we do have drowned cats into the church. have the accessible appeal the restrictions are the minor issue of an outdoor Not even ‘Ellnet’ could have to them. lifting, the clouds summer. Now this ordinarily tamed the Atlantic swept The veritable ‘bag of are parting, the sounds like bliss, but when gruaig on everyone that day. cans’ is the handiest form sun cream is flying, reality kicks in for us good We Irish though, are the of consuming your well- albeitS for a rainy start so far. hearted Irish, we know that absolute warriors of outdoor earned refreshments on But the gist is, summer is summer is a mixed bag of all activities and now outdoor your outdoor escapades. coming. Hurrah! sorts. Forty seasons in one socialising. When planning But Bulmers or Guinness Indeed, we have so much day. I was once at a wedding those long lazy picnics, or don’t really do it for me to to be thankful for. Gratitude in Achill island in August and glitzy summer garden parties, match my beautifully curated is in full swing. But before we we were literally swept like let’s look at a few wines that charcuterie. I prefer wine.

50 IPUREVIEW JUNE 2021 Thankfully now, wine If you are a traditionalist producers have broken the at heart and are still swayed mould of the traditional towards the bottle and glass bottle and we can grab glasses for your outdoor ourselves a ‘bag of cans’ of escapades, then I would highly a Pinot Grigio, or a Rosé or a recommend a compact picnic Prosecco. Truthfully though, table from the inventive guys many of these cans that at Flying Elephant. Here you are available in the larger can source a picnic table that supermarkets are a little will hold your bottle and four devoid of flavour or character. wine glasses also, out of the I recently tried ‘Liberator’ way of preying dogs or cats or in a can. This is a stunning your own busy wobbly hands Chenin Blanc from South that are destined to knock Africa that has been created things over. These flatpack and perfected by the Master tables come with a laminate of Wine, Richard Kelley. He Maybe a Chenin is too easy wipe top, bottle, and believes, like many others, that serious for you. So now the glass holders. They are small the future of sustainability innovative guys at Winelab enough to repack back into in the wine industry lies with Ireland have brought out your tote bag and leave no recyclable packaging. And Ramona in a can. This is a major lugging around. If this is why compromise on quality Sommelier-created spritz the case, a bottle of Cremant and taste for this aspect of made with the highest Rosé is a must. Cremant is innovation. He has managed quality organic ingredients, the affordable style bubbles to create smaller production sustainable production produced in regions all over wines with real zest and methods, no added sugar, no France minus the Champagne intrigue and ‘can’ them! We gluten, basically no artificial price tag. These styles of as consumers are now offered anything. It is considered wines are some of the most the experience to sip away on Ramona is one of the best food friendly in the world. The fine Chenin Blanc, that has a fine wine options in a can. tiny persistent bubbles slice touch oak ageing and bracing This gentle spritz make them right through any fatty meats notes of baked lemons and ideal with creamy cheeses and refreshen the palate. The green apples on the palate to or even a country terrine. abundant strawberries and slice perfectly through your And how handy they are in raspberries are perfect at cured salty meats. If it is a terms of resting all your little contrasting with salty cheese choice between the wines picnic bits on the blanket, and cured meats. Plus, the in a can from the larger and the chilled can stays rock addition of pink bubbles from supermarkets and this sleek steady in its position. Can you are produced in the Fruili a proper champagne glass in and succulent Chenin Blanc imagine trying to achieve the region of Northern Italy. This is the sun is a little bit special. that is available online from same result, with your wine one of the top-quality regions This Cremant from the Loire Boutique Wines, I think I know opener, propping the wine in Italy that consistently produced by the Bollinger where my choice would be. It glasses up against your picnic produces aromatic well- owned Langlois is a gorgeous is just the matter of being a box, squeezing the cork back balanced wines, that far exceed example of summer in a glass. little more organised, and pre- into the bottle, one eye on expectations of ‘wine in a bag’. And in truth I would probably ordering your cans before your the glasses and another on Again, giving us the option rather this is park date. the neighbouring dog that is to pop this pre-chilled bag in a flute glass sniffing around and generally into your cool box of goodies poured from making a nuisance of himself. and off we go to our picnic the bottle Eh . . . cans please! or garden party with serious itself. Horses In the interest of quality and accessibility for for courses sustainability, but primarily our wine pleasure. eh . . . our outdoor enjoyment also, Winelab has released a ‘Bagnum’ for the summer. This is a double bottle wine bag that sits ideally into your tote bag for any summer garden party or indeed an evening bbq. The Bagnum is available in Sauvignon Blanc, Pinot Grigio and Refresco (Red). These sleek 15-litre bags stay fresh once opened for six weeks. So perhaps you enjoy a glass on a Monday or early week, but just the one, this is the option that allows you to have your favourite wine in the fridge fresher for longer. These wines

IPUREVIEW JUNE 2021 51 BOOK REVIEW The Village Bookshelf

The Village Bookshop in Terenure, Dublin, picks out some new and interesting titles from their shelves. An independent, family-run bookstore since 2013, they carry new, used, rare and out-of-print books and offer special nationwide postal rates.

White City First Person Kevin Power Singular From the author of Bad Day in Haruki Murakami Blackrock (inspiration for award- Eight stories told in the first winning filmWhat Richard Did, person by a classic Murakami by Lenny Abrahamson), this is ‘magic-realist’ narrator. From a darkly funny, gripping novel nostalgic memories of youth, about a life spinning out of meditations on music and control. Abruptly cut off, at an ardent love of baseball the age of 27, from a life of to dreamlike scenarios, an heedless privilege, Ben (only encounter with a talking son of a rich South Dublin monkey and invented jazz banker) flounders through a albums, together these stories world of drugs and dead-end challenge the boundaries jobs, his self-esteem at rock between our minds and the bottom. Then he gets involved exterior world. Occasionally, with a shady property deal in a narrator who may or may the Balkans which can deliver not be Murakami himself him from all his troubles: is present. Is it memoir or his addictions, his father’s fiction? You can decide! very public disgrace, and his Philosophical and mysterious, own self-loathing and regret. the stories touch on love Problem solved. Except his and solitude, childhood and problems have only begun! memory. Murakami may not Very entertaining with story be to everybody’s taste, but twists that keep you turning certainly worth trying! the page.

52 IPUREVIEW JUNE 2021 The Best Catholics Lord Emsworth in the World and Others Derek Scally P.G Wodehouse On a visit home from Berlin, From our secondhand corner. Dublin journalist Derek Scally Wodehouse is renowned finds more memories than for his limitless powers of congregants in the church comic invention. In the title where he was once an altar story – one of his longest and boy. This book is his resulting best shorter fictions – Lord quest to unravel what Emsworth takes his revenge happened to the remarkable on his ghastly secretary, the hold the Catholic Church Efficient Baxter, setting off had on the Irish people. He a wave of similar reprisals spent three years travelling at Blandings Castle with Ireland and Europe, talking to amazing results. In other tales those who have abandoned we meet several members the Church and those who of the Drones Club, the have held on, to survivors ineffable Ukridge, and Clarice and campaigners, to writers, Fitch, ‘the girl who used to historians, psychologists and fly oceans and things’. A many more. A great work of delightful meeting with old reporting and a lively read. friends for some readers, a Colm Toibin called it ‘a great superb introduction to the achievement - brilliant, idyllic world of Wodehouse for engaging and essential’. others.

What White People Kindness Grows Can Do Next Britta Teckentrup Emma Dabiri A peek-through picture book Emma Dabiri, acclaimed for 2-5 year olds. Angry words author of Don’t Touch My Hair, can ruin friendships, but a grew up mixed-race in Dublin gesture as simple as a smile and is now a teaching fellow can cause kindness to bloom in the Africa department at and friendships to mend. Die- School of Oriental & African cut pages feature a sapling Studies in London. She’s a that grows into a flowering regular media contributer tree with each turn of the page with a distinct perspective and as kindness is spread. Friends in this short book she reviews are sad when they’re left out, current attitudes to race and and once a mean word is how they might be improved. spoken, it’s impossible to take When it comes to racial it back. But what if we were justice, how do we transform to spread kindness instead? A demonstrations of support sweet book, great for teaching into real and meaningful the importance and relevance change? With intellectual of being kind to others, rigour and razor-sharp wit, especially our new friends. she manages to cut through the haze of online discourse to offer clear advice. An incisive and practical book.

101 Terenure Road North, Dublin 6W www.thevillagebookshop.ie

IPUREVIEW JUNE 2021 53 CROSSWORD

1 2 3 4 5 6 7 The answers to the IPU Review crossword 8 will be published in next months’ edition. 9 10 Across 1. Inducing sleep (8) 5. Unravel (4) 9. Reproductive unit of fungi (5) 11 12 10. Makes certain of (7) 11. Large grocery stores (12) 14. Stimulus (3) 13 15. Danger (5) 16. Great distress (3) 17. Inflexible (12) 14 15 16 20. Vague understanding; hint (7) 22. Verify (5) 23. Church service (4) 24. Hairdressers (8)

17 18 Down 1. Sound of a snake (4) 2. Give rise to (7) 19 3. Excessive stress (12) 4. Anger (3) 20 21 22 6. The Norwegian language (5) 7. Completely preoccupied with (8) 8. Relating to horoscopes (12) 12. Scores an exam paper (5) 13. Policy of direct action (8) 16. Is curious about (7) 23 24 18. Gains possession of (5) 19. Seek (anag) (4) 21. Acquire; obtain (3) Across Down

1Last - Inducing month's sleep solution (8) (May 2021 issue) 1 - Sound of a snake (4) 5 - Unravel (4) 2 - Give rise to (7) 1 2 3 4 5 6 7 9 - Reproductive unit of fungi (5) 3 - Excessive stress (12) 8 10 - Makes certain of (7) 4 - Anger (3) 9 10 11 - Large grocery stores (12) 6 - The Norwegian language (5)

14 - Stimulus (3) 7 - Completely preoccupied with (8) 11 15 - Danger (5) 8 - Relating to horoscopes (12) 12 16 - Great distress (3) 12 - Scores an exam paper (5) 13 14 15 17 - Inflexible (12) 13 - Policy of direct action (8) 16 20 - Vague understanding; hint (7) 16 - Is curious about (7) 17 18 22 - Verify (5) 18 - Gains possession of (5) 19 23 - Church service (4) 19 - Seek (anag) (4) 20 21 24 - Hairdressers (8) 21 - Acquire; obtain (3)

22 23

Across Down 1 - Close by (4) 1 - Low-cost travel package (2-6)

3 - Is composed of (8) 2 - Loft (5)

9 - Most obese (7) 4 - Make a larger offer at auction (6)

10 - Respond to (5) 5 - Immediately (12) IPUREVIEW JUNE 2021 1154 - Incurably bad (12) 6 - Swift-flying songbird (7)

13 - Living room (6) 7 - Takes an exam (4)

15 - Plumbing fixture; brief fall of rain (6) 8 - Cooling device (12)

17 - Showing gratitude (12) 12 - Fervently (8)

20 - Upright (5) 14 - Indefinitely many (7)

21 - Pass across or through (7) 16 - Hay-cutting tool (6)

22 - Watchmen (8) 18 - One image within another (5)

23 - Remain in the same place (4) 19 - Gets married (4) CLASSIFIEDS

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