Issue 1 Volume 7 January/February 2014

IPNA CoNFereNCe rePort ANd

PICture gAllery

AN overvIew oF gyNAeCologICAl CANCers

Debra McKnight and Dr Waseem Kamran

MANAgINg Cholesterol IN PrIMAry heAlthCAreDarina Lane

dIAbetes: eNgAgINg PAtIeNts IN selF MANAgeMeNtClair Naughton

uPdAte oN resPIrAtory drugsRuth Morrow

INtervIew: KAreN CANNINg PrACtICe Nurse

oF the yeAr

IrelANd’s eheAlth strAtegy: whAt It MeANs For PNs

Lisa Nolan

the Journal of the Irish Practice Nurses Association

Enhancing dopamine, enhancing lives of patients with Parkinson’s disease 1,2

A balance of efficacy, tolerability and convenience 4

Abbreviated Prescribing Information. For full prescribing information refer to the Summary of Product Characteristics. Name: Azilect® 1mg tablets. Active Substance: Rasagiline mesilate. Indication: Treatmentof idiopathic Parkinson’s disease (PD) as monotherapy (without levodopa) or as adjunct therapy (with levodopa) in patients with end of dose fluctuations. Dosage: 1 mg tablet orally once-daily with orwithout levodopa. It may be taken with or without food. Elderly: No change in dose is required for elderly patients. Children and adolescents(< 18yrs): Not recommended due to lack of data on safety andefficacy. Contraindications: Hypersensitivity to the active substance or to any of the excipients. Concomitant treatment with other monoamine oxidase (MAO) inhibitors, including medicinal and naturalproducts without prescription (e.g. St. John’s Wort) or pethidine. At least 14 days must elapse between discontinuation of rasagiline and initiation of treatment with MAO inhibitors or pethidine. Rasagilineis contraindicated in patients with severe hepatic impairment. Special warnings and precautions: The concomitant use of rasagiline and fluoxetine or fluvoxamine should be avoided. At least five weeksshould elapse between discontinuation of fluoxetine and initiation of treatment with rasagiline. At least 14 days should elapse between discontinuation of rasagiline and initiation of treatment with fluoxetineor fluvoxamine. The concomitant use of rasagiline and dextromethorphan or sympathomimetics such as those present in nasal and oral decongestants or cold medications containing ephedrine orpseudoephedrine is not recommended. Caution should be used when initiating treatment with rasagiline in patients with mild hepatic impairment. Rasagiline use in patients with moderate hepatic impairmentshould be avoided. Parkinson’s disease is associated with a higher risk of skin cancer, any suspicious skin lesion should be evaluated by a specialist. Interactions: In view of the MAO inhibitory activity ofrasagiline, antidepressants should be administered with caution. Co-administration of rasagiline and ciprofloxacin (or other potent inhibitors of CYP1A2) is cautioned. There is a risk that the plasma levels ofrasagiline in smoking patients could be decreased. See also interactions listed in the contraindications and special warning sections. Pregnancy and lactation: Caution should be exercised when prescribingto pregnant women. Caution should be exercised when rasagiline is administered to a breast-feeding mother. Driving: Patients should be cautioned about operating hazardous machines, including motorvehicles until reasonably certain Azilect does not affect them adversely. Adverse reactions: Monotherapy: Very common (≥1/10): headache. Common (≥1/100 to <1/10): Influenza, skin carcinoma, leucopenia,allergy, depression, hallucinations, vertigo, conjunctivitis, angina pectoris, rhinitis, flatulence, dermatitis, musculoskeletal pain, neck pain, arthritis, urinary urgency, fever, malaise. Uncommon (≥1/1000 to<1/100): Decreased appetite, cerebrovascular accident, myocardial infarction, vesiculobullous rash. Adjunctive therapy: Very common (≥1/10): Dyskinesia. Common (≥1/100 to <1/10): Decreased appetite,hallucinations, abnormal dreams, dystonia, carpal tunnel syndrome, balance disorder, orthostatic hypotension, constipation, abdominal pain, nausea, vomiting, dry mouth, rash, arthralgia, neck pain, decreasedweight, fall. Uncommon (≥1/1000 to <1/100): Skin melanoma, confusion, cerebrovascular accident, angina pectoris. Post-marketing- serotonin syndrome was reported with use of antidepressants andrasagiline. Elevated blood pressure and rarely hypertensive crisis have been reported with concomitant ingestion of rasagiline and tyramine rich foods. Overdose: Symptoms reported with Azilect dosesranging from 3mg to 100mg included dysphoria, hypomania, hypertensive crisis and serotonin syndrome. There is nospecific antidote. Patients should be monitored and the appropriate symptomatic and supportive therapy instituted.Legal Category: POM. Marketing Authorisation Holder: Teva Pharma GmbH, Germany. Marketing Authorisation Numbers:EU/1/04/304/003 Tablets 1mg 28 pack. Further information may be obtained from Lundbeck (Ireland) Ltd., 7 Riverwalk,Citywest Business Campus, Citywest, Dublin 24, Ph: 01-4689800. Date of Preparation: November 2010. References: 1.Azilect SPC 2. Biglan et al, Mov.Dis. Vol.21, No.5, 2006 pp.616-623 3. J.P.M Finberg, M.B.H Youdim / Neuropharmacology43(2002) 1110-1118 4. Hoy & Keating, Drugs 2012;72(5):643-669.

AZ2/1/13

HOLD ON TOWHAT YOU’VE GOT 3

08494 Azilect Man Community Nursing_A4 20/06/2013 14:51 Page 1

1

Issue 5 Volume 2 September / October2009

ContentsThe Journal of the Irish Practice Nurses Association

Issue 1 Volume 7 January / February 2014

Nursing in General Practice is published by GreenCross Publishing Ltd., 7 Upper Leeson Street, Dublin 4. Tel: 01 4410024 Fax: 01 5472388Email: maura@greenx.ie

DisclaimerThe views expressed in Nursing in General Practice are not necessarily those of the publishers, editor or editorial advisory board. While the publishers, editor and editorial advisory board have taken every care with regard to accuracy of editorial and advertisement contributions, they cannot be held responsible for any errors or omissions contained.

*GreenCross Publishing was established in 2007 and is jointly owned by Graham Cooke and Maura Henderson.

© Copyright GreenCross Publishing Ltd. 2014The contents of Nursing in General Practice are protected by copyright. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form by any means – electronic, mechanical or photocopy recording or otherwise – whole or in part, in any form whatsoever for advertising or promotional purposes without the prior written permission of the editor or publishers

EDITorMaura Henderson

CoNSULTING EDITorSDarina Lane and ruth Morrow

DESIGNErBarbara Vasic

PUBLISHErSGraham CookeMaura Henderson

2 edItorIAl

4 brANCh News

revIews

7 dIAbetes MANAgeMeNt IN PrIMAry CAre: eNgAgINg PAtIeNts IN selF MANAgeMeNt Clair Naughton

13 uPdAte oN resPIrAtory drugs ruth Morrow

20 MANAgINg Cholesterol IN PrIMAry heAlthCAre darina lane

22 AN overvIew oF gyNAeCologICAl CANCers debra McKnight and dr waseem Kamran

INtervIew

26 KAreN CANNINg PrACtICe Nurse oF the yeAr

CoNFereNCe 2013

28 IPNA CoNFereNCe rePort ANd PICture gAllery

teChNology

32 IrelANd’s eheAlth strAtegy: whAt It MeANs For PNs lisa Nolan

34 AbstrACts

IrrItAble bowel syNdroMe

35 ProduCts

37 Crossword

2

editorial

CPd – one of the many benefits of IPNA membership

There is an onus on every practice nurse to maintain his/her continuing professional development (CPD). The Nursing & Midwifery Board of Ireland (NMBI) is currently exploring how this is going to be monitored in the future so that we can maintain our registration. It is imperative that nurses continue to provide care that is safe, effective, evidence-based and of a good standard.

There are a number of avenues available to us to assist us with our continuing professional development. The Professional Development Co-ordinators for Practice Nursing (PDCs) continue to work tirelessly on our behalf to assist us with CPD in what is a challenging time. However, for many of us getting protected time to attend study days is difficult.

On-line or e-learning seems to the buzz word at the moment. There is a plethora of e-learning opportunities available to us through registration with pharmaceutical companies eg Univadis™ (MSD), Simply4Nurses™ (AstraZeneca). HSEland (www.hseland.ie) also offers online learning opportunities which practice nurses can avail of free of charge eg e-learning module for Asthma, Diabetes Footcare programme. COPDexchange launched at the end of 2013 provides education on COPD for health professionals (further information in this issue….see meeting report).The IPNA, will soon have a link from their website to e-learning modules which will be available to all members. These modules have been developed with the ICGP and a lot of work by Roisin Doogue (past IPNA National Chairperson). This development will greatly enhance the benefits of IPNA membership.

As a member of the IPNA, the nurse has access to frequent branch educational meetings, an annual conference, and bi-monthly nursing publication specific to practice nursing along with frequent emails about educational opportunities. A practice nurse could solely maintain her professional development by being a member of the IPNA. Attendance at meetings is not mandatory and many nurses are unable to attend for a number of reasons so the new e-learning modules will offer the practice nurse ongoing education which he/she can access 24/7. As regular readers of this publication I know I am speaking to the converted. However, we need to encourage our colleagues who are not members to join our vibrant association and have access to ongoing CPD, peer support and friendship. In the future, every nurse will have to demonstrate evidence of CPD, whatever format this will take, we have to wait and see.

The number of practice nurses in Ireland has increased dramatically over the past 10 years and many are not members of the IPNA. If we all make a belated New Year’s Resolution to recruit a new member, we could double our membership in 2014!! We need to continue increasing awareness of the IPNA and no better way to do that is by increasing our membership.

Ruth Taylor

ASK

ABO

UT ALCOHOL

TO GET THE FULL PATIE

NT

PIC

TU

RE

* Aged 30+. 10g alcohol = 1 standard drink. Irish standard drink approximations are one ½ pint of beer; one small glass of wine (12.5% volume); or one pub measure of spirits (35.5 ml). One bottle of wine contains 8 standard drinks.3

References: 1. Empathy Research 2013. 2. Adapted from acute problems EMA/CHMP/EWP/20097/2008.

3. Accessed August 2013 www.hse.ie/eng/health/az/A/Alcohol-misuse SEL1/8/13

Daily risk levels of drinking2 Women Men

Very High Risk Over 6 standard drinks

Over 10 standard drinks

High Risk4-6 standard drinks 6-10 standard drinks

HOW MUCH IS TOO MUCH?• 43% of mature* drinkers consume alcohol two or more times a week1

• During any single drinking occasion 51% of female and 30% of male mature* drinkers consumed at a high risk level1

Why not discuss drinking habits with your patients today?

8564_AlcAware_SEL1/8/13_HowMuchAd_OCT13_MI_10X4.indd 1 30/10/2013 17:27

4

News for IPNA br ANches couNtry wIderegional news

CAvAN/MoNAghAN

MARGARET GEOGHEGAN

The Cavan/Monaghan branch held our November meeting in Errigal Hotel, Cootehill. This meeting was sponsored by La Roche Posay, A very good presentation was given by Orla O’Keefe, CNS Dermatology, in Cavan General Hospital. She spoke about the management and treatment of atopic eczema, emollient therapy, and management of dry skin, She also gave us very good patient information leaflets on the application of topical steroid creams and ointments.

Our December meeting was sponsored by Abina O’Flynn from MSD. Dr Kiernan Hannon gave an excellent interactive presentation on Hypertension and Vitamin D deficiency. Many thanks to Abina for sponsoring a beautiful Christmas dinner. We are very sad that Abina is moving from our area as she has

always been there to sponsor meetings and provide endless educational resources for us. We wish her the very best in her new role.

Our first meeting for 2014 was held on January 15th. Eimear Donnolly eating disorder therapist with Cavan/Monaghan HSE gave a very interesting presentation on eating disorders, recognizing early signs and symptoms and the services available.

We hope you have all renewed your IPNA membership for 2014 and perhaps you could encourage other practice nurses to join also. If all current members could get one new member to join it would boost our numbers and ensure our organization grows and develops.

North dublIN brANCh

ANNE MARIE ELLWOOD

Following the success of our National Conference it was back to business for all the North Dublin Branch. Our AGM in November saw us elect a new chairperson and treasurer. Our speaker that evening was Mary McDonald, ANP Paediatric Respiratory, who gave us an excellent talk on asthma and allergies. We had our December meeting at Clontarf Castle and

a wonderful talk from Catherine Diskin, Paediatric Registrar from the Coombe on infant feeding problems. Our meeting in January was a Cervical Check update from the amazing Carrie Powles who is a mine of information! We will be having our next meeting in February. Just a reminder to all to renew their IPNA annual membership.

south dublIN

ANNE O’CONNOR AND KAREN CANNING

Happy New Year to all our members. Now that the new year has begun it’s time to motivate members to attend our branch meetings. And what a great line-up we have this year. The details of all our meetings until the summer have now been posted on www.ipna.ie. Why not take a look?

In December our meeting was held in Bewley’s Hotel, Leopardstown and was kindly sponsored by Fran Cahalane of Abbott’s Diabetes Division. Karen Canning, Practice Nurse, gave a very practical presentation on Setting up a Diabetes Register. We also used this night to let our hair down and enjoy ourselves. See picture attached, lots of fun was had!

Our first meeting of 2014 was held on Jan 14th in the Plaza Hotel, Tallaght. Anthony Carroll of SMA Nutrition kindly sponsored this meeting.

Our guest speaker was Deirdre Madden, Perinatal Mental Health Nurse, who gave a fantastic presentation on perinatal mental health. Very thought provoking indeed.

Our next meeting is on Wednesday 12th February at Bewley’s Hotel, Leopardstown and will address the area of Child Protection. It is kindly sponsored by Aisling McCormack of Aptamil Infant Nutrition.

Looking forward to seeing you all there in February.

5

News for IPNA br ANches couNtry wIde regional news

NEC NEWS

dAte For dIAryThe 2014 IPNA Annual Educational Conference / AGM will be held on Friday 17th and Saturday 18th October 2014 in the Limerick Strand Hotel, hosted by the IPNA Kerry Branch.

NeC MeetINgs 2014 Wednesday 5th February 2014, Ashling Hotel, D.8, 11am-3pmWednesday 7th May 2014, Ashling Hotel, D.8, 11am-3pmWednesday 3rd September 2014, Ashling Hotel, D.8, 11am-3pmFriday 17th October 2014, Limerick Strand Hotel, time tbc

IPNA websIteThe IPNA website, www.irishpracticenurses.ie is updated constantly, so please log in regularly to get the latest news on study days, education, new comments in the Discussion boards and more. You will also find IPNA Policies, Articles of Association and Minutes of all NEC meetings to date in the Members Area.

IPNA oN twItterIf you have a Twitter account you can follow the handle @PracticeNurses to receive IPNA news, reminders & useful information that is retweeted from other groups – directly to your timeline.

Lisa Nolan, IPNA Administrator: Tel: 042 9692403 e-mail: admin@irishpracticenurses.ie

KIlKeNNy

HELEN FOGARTY

Firstly, we would like to wish everyone a very happy and healthy New Year. We hope you enjoyed your Christmas break and are now back to business as usual.

Our December meeting took place in Lyrath Hotel kindly spon-sored by Aptamil Nutrition. Michelle Gray gave a very interesting and informative presentation on Aptamil products including the

new anti reflux formula. She also gave us some useful websites for breastfeeding, infant weaning and nutrition and told us about mumslikeus.ie and aptaclub.ie

We look forward to kicking off 2014 with our meeting on 22nd January – the topic is coronary artery disease.

wexFord

DORA MULLIGAN

Hello and a very Happy New Year to all from the Wexford branch. Here’s hoping 2014 will bring us all good health and happiness and lots of enthusiasm in every aspect of our lives.

To catch up from our November AGM meeting, our current committee members Suzanne Dundon, Treasurer, Dora Mulligan, Secretary were re-elected. Roisin Cooney agreed to continue until a new Chairperson volunteers. The delegates who attended the Conference gave very positive feedback on a great weekend with interesting speakers – especially, Donal O’Shea on obesity and the drug talk from the Yoda group. So well done to the North Dublin branch. All members agreed that the proposed definition of a Practice Nurse was clear and concise and needs no changes. Our speakers for the night were Sam MCabe, CNS and Rosaleen Macuistin, CNS who gave an informative talk on the new COPD guidelines and Outreach care provided by Wexford General Hos-pital. The night was sponsored by GSK.

For the rest of this year, we hope to have talks on Diabetes (February), Cardiovascular and IHD (March), Asthma (April) and Women’s Health (May). Again, each meeting will be kindly spon-sored and we do appreciate the support we get from the various drug reps/companies. We are all well aware how tough and chal-lenging these times are, for all of us.

In total we have 22 members in the Wexford branch with a good turnout at our meetings. They provide a great opportunity to connect with each other especially for those working alone in practice. Both the website and journal are great resources if people are unable to attend meetings. Hopefully the IPNA can continue to provide these services and we, as practice nurses, can provide our support.

Many thanks to Actimel who sponsored our Christmas night out in the Monart Spa and Retreat.

...coming soon

7

clinical review

Diabetes management in primary care: engaging patients in self management ClAIr NAughtoN, REGIONAL DEVELOPMENT OFFICER NORTH WEST

diabetes IrelandIn 2010 the National Clinical Programme for Diabetes was one of the first clinical care programmes initiated under Dr Barry White, then National Director of Clinical Strategy and Programmes. This programme was established to improve the quality of care provided to people with diabetes and improve clinical outcomes.1 The implementation of the programme has brought about wel-come changes in the organisation and management of diabetes care in Ireland: roll-out of the national multi-disciplinary footcare package, publication of guidelines for diabetes in pregnancy, roll-out of the integrated care programme, to name but a few.1 2013 saw the National Diabetes Retinopathy Screening programme known as Diabetic Retina Eye screen (www.diabeticretinascreen.ie) begin its phased roll-out following years of professional bodies and Diabetes Ireland canvassing for its implementation.2

The roll-out of the National Clinical Programme for Diabetes means that the management of diabetes nationally is continuously evolving; with an emphasis on integrated care. Under the proposed integrated care model in Ireland the aim is that uncomplicated patients with type 2 diabetes will be managed in primary care (approximately 100,000 patients in Ireland). A further aim is that the care of complicated patients with type 2 diabetes (60,000) will be managed between primary and secondary care settings. These proposed changes will create challenges for all health care professionals in primary care.3 Despite frustrating time lags with the roll-out of the National Programme since its initiation in 2010, some positive strides have been made. Diabetes Ireland will continue to monitor and advocate for the full implementation of the National Programme in 2014.

8

clinical review

Multidisciplinary Diabetes Study DayFriday, March 21, 2014

Hogan Mezzanine Suite, Croke Park, Dublin 3

‘Promoting patient and professional engagement in diabetes management’

Morning session

8.30am Registration

9amWelcome and opening remarks Chairperson: Prof Seamus Sreenan, Consultant in Diabetes and Endocrinology, Connolly Hospital, Blanchardstown, Dublin

9.15amDiabetes Service update Dr Ronan Canavan, Consultant Endocrinologist, HSE Clinical Lead for the National Diabetes Programme

9.45amEngaging the patient in their own self-care through motivational interviewing Rev Eugene Curran CM, DMin, Lecturer, All Hallows College, Dublin

10.15amBarriers to effective diabetes self-management Lyndi Wiltshire, Dietitian and Head of Diabetes Care, Birmingham and Solihull Mental Health Foundation Trust, UK

10.45am Coffee

11.15amGlucose self-monitoring and how technology can help? Dr Tommy Tun, Consultant Endocrinologist, Connolly Hospital, Blanchardstown

11.45amIncreasing exercise levels in type 2 diabetes – the how and why Dr Rob Andrews, Consultant Senior Lecturer in Diabetes and Endocrinology, School of Clinical Sciences, University of Bristol

12.15pmUpdate on the Diabetic Retinopathy Screening programme – one year on? Margaret Morgan, The National Diabetic Retinal Screening Programme

1pm Lunch

Afternoon session

2pmDiagnosis and management of renal complications of diabetes? Dr Yvonne O’Meara, Consultant Nephrologist, Mater Misericordiae University Hospital, Dublin

2.30pmDietary considerations for renal impairment Teresa Loughnane, Senior Dietitian, Mater Misericordiae University Hospital, Dublin

2.45pmThe fructose versus sucrose debate Dr Trudi Deakin, X-Pert Health, Birmingham, UK

3.15pmIncreasing complexity of medication choice – what to use when? Dr Diarmuid Smith, Consultant Endocrinologist, Beaumont Hospital, Dublin

3.30pm Closing remarks

For further details or to reserve a place, please contact Diabetes Ireland on 1850 909 909

MultiDiscStudyDay.indd 1 16/12/2013 11:36

9

clinical review

Multidisciplinary Diabetes Study DayFriday, March 21, 2014

Hogan Mezzanine Suite, Croke Park, Dublin 3

‘Promoting patient and professional engagement in diabetes management’

Morning session

8.30am Registration

9amWelcome and opening remarks Chairperson: Prof Seamus Sreenan, Consultant in Diabetes and Endocrinology, Connolly Hospital, Blanchardstown, Dublin

9.15amDiabetes Service update Dr Ronan Canavan, Consultant Endocrinologist, HSE Clinical Lead for the National Diabetes Programme

9.45amEngaging the patient in their own self-care through motivational interviewing Rev Eugene Curran CM, DMin, Lecturer, All Hallows College, Dublin

10.15amBarriers to effective diabetes self-management Lyndi Wiltshire, Dietitian and Head of Diabetes Care, Birmingham and Solihull Mental Health Foundation Trust, UK

10.45am Coffee

11.15amGlucose self-monitoring and how technology can help? Dr Tommy Tun, Consultant Endocrinologist, Connolly Hospital, Blanchardstown

11.45amIncreasing exercise levels in type 2 diabetes – the how and why Dr Rob Andrews, Consultant Senior Lecturer in Diabetes and Endocrinology, School of Clinical Sciences, University of Bristol

12.15pmUpdate on the Diabetic Retinopathy Screening programme – one year on? Margaret Morgan, The National Diabetic Retinal Screening Programme

1pm Lunch

Afternoon session

2pmDiagnosis and management of renal complications of diabetes? Dr Yvonne O’Meara, Consultant Nephrologist, Mater Misericordiae University Hospital, Dublin

2.30pmDietary considerations for renal impairment Teresa Loughnane, Senior Dietitian, Mater Misericordiae University Hospital, Dublin

2.45pmThe fructose versus sucrose debate Dr Trudi Deakin, X-Pert Health, Birmingham, UK

3.15pmIncreasing complexity of medication choice – what to use when? Dr Diarmuid Smith, Consultant Endocrinologist, Beaumont Hospital, Dublin

3.30pm Closing remarks

For further details or to reserve a place, please contact Diabetes Ireland on 1850 909 909

MultiDiscStudyDay.indd 1 16/12/2013 11:36

the complexity of diabetes managementThe management of diabetes is particularly difficult due to the many issues involved, requiring a multi-factorial risk reduction framework. The chronic, non-curable and complex nature of diabetes means that patients have to engage in a number of tasks on a daily basis in order to effectively self manage their diabetes. 4 Healthcare professionals have to try and motivate patients to engage in self management that involves them adopting behaviour changes and having to adhere to an often complex medication regimen. An increase in the number of pharmacological agents for glycaemic control licensed in recent years is another factor adding to the complexity of the management of type 2 diabetes. With such a wide variety of drugs to choose from it can lead to confusion among health care staff when choosing the best treatment options for the patient. With the incidence of type 2 diabetes increasing and the consequent economic burden it is essential that effective strategies are employed to manage the condition.5

Patient choices and the effect on outcomes The choices patients make regarding how they manage their diabetes in between clinic appointments has a greater impact than those choices made by health professionals on their diabetes related outcomes. Improving our communication skills with our patients will improve the quality of care we provide and the clinical outcomes. In the management of diabetes, techniques such as persuasion and offering advice have proven to have limited value and also causes resistance among

patients which in turn leads to frustration among clinicians and patients. 6 As early as the 1600s, it was recognised that ‘we are usually convinced more easily by reasons we have found ourselves than by those that have occurred to others’.7 A patient being expected to adhere to a pre-determined care plan is not an acceptable way for them to manage the condition. Patients are only weakly motivated by what others say to them; they may respond with ambivalence or resistance and do not follow through with the plan given to them by the health professional. Therefore health professionals need to adopt more interactive methods to motivate their patients to make good choices by ensuring that they are involved in identifying their barriers to change and in the negotiation of realistic goals.8

self management: collaborative approachHealth professionals are comfortable in their role providing education and information to their patients but many struggle, particularly in a busy clinical setting, to provide the type of support that helps facilitate the behavioural change that is necessary for diabetes self-management. Although it is essential that the patient acquires knowledge about diabetes, knowledge alone is not sufficient to engage patients in effective diabetes self-management. Frequently, health professionals fail to engage patients in effective diabetes self-management and find it frustrating when their advice is not followed.4 When examining the barriers to effective diabetes self-management one of the problems identified by Wiltshire (2013) may be that health professionals and patients have conflicting agendas. Health professionals see the patients’ world through their own eyes. The health professionals feel responsible but they are not in control as the majority of diabetes care is provided by the patient. Although health professionals have the medical experience, the professional qualifications and are familiar with the evidence and research, patients understand their priorities and are aware of how diabetes self-management tasks will fit into their lives. Patients know what might work and what will not work, as they are aware of their own lifestyle and priorities. In fact both health professionals and patients are experts and therefore they should work together.9

The benefits of using a collaborative approach are echoed by other diabetes educators. Robert Anderson, a well-known diabetes educator, also identified one of the reasons for non-compliance as when health professionals and patients pursue different goals.10 He suggests that, knowledge between the health care professional and the patient should be exchanged and the responsibility shared. Collaborative communication between patient and health care professionals results in greater adherence to treatment plans and enhanced patient satisfaction. If patients and health professionals agree on goals it leads to more effective diabetes self-management.6

Patient centred careA joint position statement issued in 2012 by the American Diabetes Association (ADA) and the European Association for the study of Diabetes (EASD) providing recommendations for the management of type 2 diabetes also emphasised the importance of patient centred care.11 Patient centred care is defined as “providing care that is respectful of and responsive to individual patient preferences, needs and values and ensuring that all patient values guide all clinical decisions”.12 The ADA/EASD in these recommendations recognise that

Although health professionals have the medical experience, the professional qualifications and are familiar with the evidence and research, patients understand their priorities and are aware of how diabetes self-management tasks will fit into their lives.

10

clinical review

when patients are engaged in their health care decisions it may improve their adherence to therapy. Glycaemic targets and glucose lowering therapies must be individualised for each patient taking into consideration the needs, preferences and tolerances of each patient. In this shared decision making approach health care professionals and patients act as partners in reaching a consensus on which course of action to be taken.11

diabetes Ireland Multi-disciplinary diabetes study day“Promoting patient and professional engagement in Diabetes Management” is the theme of this year’s annual Diabetes Ireland multi-disciplinary study day will take place in the Hogan Mezzanine Suite, Croke Park on Friday 21st of March 2014, Dr Ronan Kavanagh, Consultant Endocrinologist and the HSE clinical lead for the National Diabetes Programme, will give an update on diabetes services in Ireland. Margaret Moran from the National Diabetic Retinopathy Screening Programme will give an update on diabetic retinopathy screening, one year from its initiation. Ms Lyndi Wiltshire who is currently the head of diabetes care at Birmingham and Solihull Mental Health Foundation Trust will speak on ‘The barriers to effective Diabetes Self-management’. Also, Reverend Eugene Curran, a lecturer from All Hallows College in Dublin, will discuss how motivational interviewing can help to engage patients in their own self-care. There will also be lectures on glucose self monitoring and technology, renal impairment and it’s management, exercise, and finally the increasing complexity of medication choice with guidelines of what to use and when.

references1. National Clinical Programme for Diabetes available at www.

hse.ie/diabetesprogrammes assessed 6th January 20142. Diabetic Retina Screen – The National Diabetic Retinal

Screening programme www.diabeticretinascreen.ie assessed 6th Jan 2014.

3. HSE website 17 new integrated care diabetes nurse specialists to support patients with diabetes 6th March 2013 available at www.hse.ie/eng/services/news/newsarchive assessed 6th Jan 2014

4. Funnell M, Anderson R. Empowerment and self-management of Diabetes. Clinical Diabetes 2004; 22(3): 123-127

5. Harkins V. A practical guide to integrated type 2 diabetes care. In: Irish College of General Practitioners, Health Service Executive, Irish Endocrine Society, eds. Dublin: Health Service Executive, 2008.

6. Heisler M, Bouknight RR, Hayward RA, et al. The relative importance of physician communication, participatory decision-making, and patient understanding in diabetes self-management. J Gen Intern Medicine 1002; 17: 234-252

7. Pascal B, Genet C. Pensees. Paris, Hatier, 16708. Welsh G. Motivational interviewing and diabetes: What is it,

how is it used and does it work. Diabetes Spectrum 2006; 19(1): 5-11

9. Wiltshite L. Barriers to effective self-management. The Diabetes Education Network. Available from: www.diabetes-education.net/pdf/annual.../self_mgm_workshop.pdf accessed 24/10/2013

10. Anderson RM, Funnell MM. Compliance and adherence are dysfunctional concepts in diabetes care. Diabetes Educator 2000; 26: 597-604

11. Inzucchi S and Associates Management of hyperglycaemia in type 2 diabetes: A patient centred approach. Position statement of American Diabetes Association (ADA) and European Association of the Study of Diabetes (EASD) 2012. Diabetes Care

12. Committee on Quality of healthcare in America: Institute of medicine, crossing the quality chasm: A new health system for the 21st century. Washington DC, the national academics press 2001

If patients and health professionals agree on goals it leads to more effective diabetes self-management.

SPIRIVA® Respimat® 5 µg is indicated as a maintenance bronchodilator treatment to relieve symptoms of patients with chronic obstructive pulmonary disease (COPD).2

Date of preparation: January 2014. IRE/SPI – 131004

References:1. Bateman ED et al. A one-year trial of tiotropium Respimat® plus usual therapy in COPD patients. Respir Med 2010;104:1460–1472.2. SPIRIVA® Respimat® 2.5 µg Summary of Product Characteristics.3. Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2013.

Available from: http://www.goldcopd.org/. Accessed January 2014.

*Patients were permitted to continue all usual therapy excluding other anticholinergics.

LAMA: Long-acting muscarinic antagonist

Make an impact on COPD exacerbations

• SPIRIVA® Respimat® 5 µg

– Demonstrated a 31% reduction in relative risk of having at least one COPD exacerbation (p<0.0001) vs control in one year*1,2

– Showed a 27% reduction in relative risk of hospitalisation due to COPD exacerbation (p<0.005) vs control in one year*1,2

– Is the only non-dry powder LAMA inhaler for the treatment of COPD symptoms2,3

Prescribing Information (Ireland) SPIRIVA® RESPIMAT® (tiotropium)Solution for inhalation containing 2.5 microgram tiotropium (as bromide monohydrate) per puff. Indication: Tiotropium is indicated as a maintenance bronchodilator treatment to relieve symptoms of patients with chronic obstructive pulmonary disease (COPD). Dose and Administration: Adults only aged 18 years or over: 5 microgram tiotropium given as two puffs from the Respimat inhaler once daily, at the same time of the day. Contraindications: Hypersensitivity to tiotropium bromide, atropine or its derivatives, e.g ipratropium or oxitropium or to any of the excipients; benzalkonium chloride, disodium edetate, purified water, hydrochloric acid 3.6% (for pH adjustment). Warnings and Precautions: Not for the initial treatment of acute episodes of bronchospasm, i.e. rescue therapy. Immediate hypersensitivity reactions may occur after administration of tiotropium bromide solution for inhalation. Caution in patients with narrow-angle glaucoma, prostatic hyperplasia or bladder-neck obstruction. Inhaled medicines may cause inhalation-induced bronchospasm. Caution in patients with known cardiac rhythm disorders. In patients with moderate to severe renal impairment (creatinine clearance ≤50 ml/min) tiotropium bromide should be used only if the expected benefit outweighs the potential risk. Patients should be cautioned to avoid getting the spray into their eyes. They should be advised that this may result in precipitation or worsening of narrow-angle glaucoma,

eye pain or discomfort, temporary blurring of vision, visual halos or coloured images in association with red eyes from conjunctival congestion and corneal oedema. Should any combination of these eye symptoms develop, patients should stop using tiotropium bromide and consult a specialist immediately. Tiotropium bromide should not be used more frequently than once a day. Interactions: Although no formal drug interaction studies have been performed, tiotropium bromide has been used concomitantly with other drugs commonly used in the treatment of COPD, including sympathomimetic bronchodilators, methylxanthines, oral and inhaled steroids without clinical evidence of drug interactions. The co-administration of tiotropium bromide with other anticholinergic-containing drugs has not been studied and is therefore not recommended. Fertility, Pregnancy and Lactation: No clinical data on exposed pregnancies are available. The potential risk for humans is unknown. Spiriva Respimat should therefore only be used during pregnancy when clearly indicated. It is unknown whether tiotropium bromide is excreted in human breast milk. Use of Spiriva Respimat during breast feeding is not recommended. A decision on whether to continue/discontinue breast feeding or therapy with Spiriva Respimat should be made taking into account the benefit of breast feeding to the child and the benefit of Spiriva Respimat therapy to the woman. Clinical data on fertility are

not available for tiotropium. Effects on ability to drive and use machines: No studies have been performed. The occurrence of dizziness or blurred vision may influence the ability to drive and use machinery. Undesirable effects: Common (≥1/100 to <1/10): Dry mouth. Uncommon (≥1/1000 to <1/100): Dizziness, headache, atrial fibrillation, palpitations, supraventricular tachycardia, tachycardia, cough, epistaxis, pharyngitis, dysphonia, constipation, oropharyngeal candidiasis, dysphagia, rash, pruritus, urinary retention, dysuria. Serious undesirable effects include anaphylactic reaction and consistent with anticholinergic effects: glaucoma, constipation, intestinal obstruction including ileus paralytic and urinary retention. An increase in anticholinergic effects may occur with increasing age. Prescribers should consult the Summary of Product Characteristics for further information on undesirable effects. Pack sizes: Single pack: 1 Respimat inhaler and 1 cartridge, providing 60 puffs (30 medicinal doses). Legal category: POM. MA number: PA 775/2/2. Marketing Authorisation Holder: Boehringer Ingelheim International GmbH, D-55216 Ingelheim am Rhein, Germany. Prescribers should consult the Summary of Product Characteristics for full prescribing information. Additional information is available on request from Boehringer Ingelheim Ireland Ltd, The Hyde Building, The Park, Carrickmines, Dublin 18. Prepared in November 2013.

6462 Respimat Ad_297x210_IRE Update.indd 1 08/01/2014 11:24

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

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

Reference:1. fl utiform Summary of Product Characteristics

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

Adverse events should be reported. Reporting forms and information can be found at http://www.imb.ie/EN/Safety--Quality/Online-Forms/Human- Medicine-Adverse-Drug-Reaction.aspx Adverse events should also be reported to Mundipharma Pharmaceuticals Limited on 01 206 3800/1800 991830 (outside offi ce hours).

IRE/FL-12042

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

NEW

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

Rapid onset* andlong lasting effi cacy**

COMBINATION

Modern aerosol device with a patient-facing dose counter1

INNOVATION

Modern aerosol device with a patient-facing dose counter

INNOVATION

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

NEW

50/5 µg 125/5 µg 250/10 µg

The NEW asthma maintenance treatment

13

clinical review

Update on respiratory drugsruth Morrow, ADVANCED NURSE PRACTITIONER (PRIMARY CARE) AND REGISTERED NURSE PRESCRIBER

This article focuses on respiratory drugs which the practice nurse may encounter on a daily basis through caring for patients with COPD, asthma and other chronic respiratory conditions. It will also address the newer drugs on the market that may be

prescribed in secondary care, which may require the practice nurse to provide ongoing support monitoring for the patient. Keeping in mind, the one airway concept, the article will also focus drugs used to treat upper airway conditions such as chronic and seasonal allergic rhinitis.

It is important when considering prescribing any drug that the benefits outweigh the risks and patients should be counselled on potential side effects and management of these. Where at all possible, medication should be administered via inhalation to reduce the risk of systemic absorption and side effects. For the majority of respiratory medications, inhaled medication is the route of administration of choice as it targets the airways and minimises the risk of systemic side effects. All patients should be educated in inhaler technique and re-assessed at every visit thereafter.

Respiratory drugs can be basically classified into:

1. Bronchodilators which may be short-acting or long-acting2. Anti-cholinergics which may be short-acting or long-acting3. Corticosteroids which may be inhaled, oral or intravenous4. Leukotriene receptor antagonists5. Theophyllines which have both bronchodilator and anti-

inflammatory benefits6. Monoclonal antibodies7. PDE4s.

1. bronchodilatorsIn 1969, Ventolin, the first selective short-acting Beta2 agonist for asthma was launched (www.health.gsk.ie accessed 31st December 2013). Bronchoconstriction occurs when the Beta 2 receptors become hyper-responsive in response to a stimulus such as an allergen, smoking or occupational exposure causing wheezing, coughing and shortness of breath. Bronchodilators are drugs which act on the Beta 2 receptors in the airways and cause bronchodilation and increase airflow of the airway. These can be classified into short-acting (SABA) and long-acting (LABA) bronchodilators. Salbutamol (SABA), Terbutaline (SABA), Salmeterol (LABA, Formoterol (LABA) and Indacterol

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

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

Reference:1. fl utiform Summary of Product Characteristics

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

Adverse events should be reported. Reporting forms and information can be found at http://www.imb.ie/EN/Safety--Quality/Online-Forms/Human- Medicine-Adverse-Drug-Reaction.aspx Adverse events should also be reported to Mundipharma Pharmaceuticals Limited on 01 206 3800/1800 991830 (outside offi ce hours).

IRE/FL-12042

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

NEW

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

Rapid onset* andlong lasting effi cacy**

COMBINATION

Modern aerosol device with a patient-facing dose counter1

INNOVATION

Modern aerosol device with a patient-facing dose counter

INNOVATION

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

NEW

50/5 µg 125/5 µg 250/10 µg

The NEW asthma maintenance treatment

14

clinical review

drug NAMe ForMulAtIoN dose FreQueNCy sIde eFFeCts AvAIlAbIlIty As CoMbINAtIoN therAPy

Salbutamol (SABA)Ventolin™Gerivent™Novolizer Salbutamol™Salamol™Salbul™

Inhaler, syrup, nebule, intravenous infusion/injection

Up to 4 times per dayTachycardia, skeletal muscle tremor, headache and irritability. At very high doses, hyperglycaemia, hypokalemia.

systemic administration with syrup or intravenous increases the risk of side effects.

Yes – with Ipratropium bromide (Combivent™)(available only as UDU’s)

Terbutaline (SABA)Bricanyl™

Inhaler, injection Up to 4 times per day No

Salmeterol (LABA)Serevent™

Inhaler Twice daily Yes – with Fluticasone (Seretide™)

Formoterol (LABA)Oxis™

Inhaler Twice daily Yes – with Fluticasone (Flutiform™) and with Budesonide (Symbicort™)

Indacterol (LABA)Onbrez™

Inhaler Once daily Yes – combined with Glycopyrronium (Ultibro™)

Ipratropium bromideAtrovent™

Inhaler, nebule Up to four times per day

Mouth dryness, bad taste in mouth

Yes – with Salbutamol(Combivent™)(available only as UDU’s)

Tiotropium bromideSpiriva™

Inhaler Once daily No

GlycopyrroniumSeebri™

Inhaler Once daily Yes – combined with Indacterol (Ultibro™)

table 1: bronchodilator and anti-cholinergic drugs

all work on the Beta 2 receptors. Indacterol is the only bronchodilator licensed for once daily use for COPD. All the others are twice daily or on as needed basis up to a maximum of four times per day. These drugs are commonly called ‘relievers’ and are recommended as first line treatment for asthma (GINA, 2012) and for COPD (GOLD, 2013). However, in asthma it is recommended that should the patient be using the bronchodilator therapy more than twice a week, they should be commenced on Step 2 of the GINA guidelines (GINA, 2012). Table 1 illustrates the onset of action, side effects and method of administration of these drugs.

2. Anti-cholinergic drugsAnti-cholinergic drugs, also known as muscarinic antagonists, work by inhibiting the production of acetylcholine by the M1, M2 and M3 receptors. They are slower acting than bronchodilators. Again, these drugs may be categorised into short-acting (SAMA) and long-acting (LAMA) anti-cholinergics. Ipratropium bromide (SAMA), Tiotropium bromide (LAMA) and Glycopyrronium (LAMA) are currently available in Ireland. Glycopyrronium and Tiotropium bromide are both licensed for one daily use in COPD.

Many of these bronchodilator and anti-cholinergic drugs are available in combination preparations either with inhaled corticosteroids or with other bronchodilator/anti-cholinergic drugs. Table 1 illustrates the wide range of combination therapies available. In COPD, research has illustrated that combined therapies of bronchodilators and anti-cholinergic drugs are more effective at preserving lung function than single agents alone and are therefore recommended as first line in COPD management (GOLD, 2013). Combination therapies aid adherence to medication regimes and should be considered by the prescriber in collaboration with the patient as a treatment option. (table 1)

3. CorticosteroidsInhaled corticosteroids (ICS) have been long used for the treatment of respiratory conditions. They are the cornerstone of asthma management (GOLD, 2012) and are used in combination preparations for the management of severe COPD (GOLD, 2013). Oral preparations (OCS) also have a role to play in severe asthma, very severe COPD and acute exacerbations of both asthma and COPD (GINA, 2012, GOLD 2013). It is thought that corticosteroids have an important effect on T-cell

where at all possible, medication should be administered via inhalation to reduce the risk of systemic absorption and side effects.

NO1113673

THE FIRST ONCE-DAILY DUAL BRONCHODILATOR1

START A NEW CHAPTER IN COPD2-4

ULTIBRO® BREEZHALER®

Once-daily ULTIBRO BREEZHALER is indicated as maintenance bronchodilator treatment to relievesymptoms in adult patients with chronic obstructive pulmonary disease (COPD).1

ABBREVIATED PRESCRIBING INFORMATIONPlease refer to Summary of Product Characteristics (SmPC) before prescribing.Presentation: Ultibro Breezhaler 85mcg / 43mcg inhalation powder hard capsules containing indacaterol maleate and glycopyronium bromide respectively and separate Ultibro Breezhaler inhaler. Indications: A maintenance bronchodilator treatment to relieve symptoms in adult patients with chronic obstructive pulmonary disease (COPD). Dosage and administration: Recommended dose is the inhalation of the content of one capsule once daily, administered at the same time of the day each day, using the Ultibro Breezhaler inhaler. Capsules must not be swallowed. No dose adjustment required in elderly patients, for patients with mild and moderate hepatic impairment or for patients with mild to moderate renal impairment. No data available for use in patients with severe hepatic impairment and should only be in patients with severe renal impairment or end-stage renal disease requiring dialysis if the expected benefi t outweighs the potential risk. No relevant use in the paediatric population. Contraindications: Hypersensitivity to the active substances or to any of the excipients.Warnings/Precautions: Not to be administered concomitantly with medicinal products containing other LABA’s or LAMA’s. Asthma: ♦ULTIBRO BREEZHALER SHOULD NOT BE USED FOR TREATMENT OF ASTHMA. Acute use: ♦Not indicated for treatment of acute episodes of bronchospasm. Hypersensitivity related to indacaterol: ♦Immediate hypersensitivity reactions have been reported after administration of indacaterol. If signs suggesting allergic reactions (in particular, diffi culties in breathing or swallowing, swelling of tongue, lips and face, urticaria, skin rash) occur, treatment should be discontinued immediately and alternative therapy instituted. Paradoxical bronchospasm: ♦If paradoxical bronchospasm occurs, Ultibro Breezhaler should be discontinued immediately and alternative therapy instituted. Anticholinergic e� ects related to glycopyrronium: ♦To be used with caution in patients with narrow-angle glaucoma and in patients with urinary retention. Patients with severe renal impairment: ♦Should only be used in patients with severe renal impairment, including those with end-stage renal disease requiring dialysis, if the expected benefi t outweighs

the potential risk. These patients should be monitored closely for potential adverse reactions. Cardiovascular e� ects: ♦To be used with caution in patients with cardiovascular disorders (coronary artery disease, acute myocardial infarction, cardiac arrhythmias, hypertension), in patients with known or suspected prolongation of the QT interval or patients treated with medicinal products affecting the QT interval and in patients with unstable ischaemic heart disease, left ventricular failure, history of myocardial infarction, arrhythmia (excluding chronic stable atrial fi brillation), a history of long QT syndrome or whose QTc (Fridericia method) was prolonged. ♦LABA’s may produce a clinically signifi cant cardiovascular effect in some patients as measured by increases in pulse rate, blood pressure, and/or symptoms, ECG changes. In case such effects occur, treatment may need to be discontinued. Hypokalaemia: ♦LABA’s may produce signifi cant hypokalaemia in some patients, which has the potential to produce cardiovascular effects. In patients with severe COPD, hypokalaemia may be potentiated by hypoxia and concomitant treatment which may increase the susceptibility to cardiac arrhythmias. Hyperglycaemia: ♦Inhalation of high doses of LABA’s may produce increases in plasma glucose. Upon initiation of treatment with Ultibro Breezhaler plasma glucose should be monitored more closely in diabetic patients. ♦Ultibro Breezhaler has not been investigated in patients for whom diabetes mellitus is not well controlled. General disorders: ♦To be used with caution in patients with convulsive disorders or thyrotoxicosis, and in patients who are unusually responsive to LABA’s. Excipients: ♦Patients with rare hereditary problems of galactose intolerance, the Lapp lactase defi ciency or glucose-galactose malabsorption should not take this medicine. Pregnancy and Lactation: ♦Ultibro Breezhaler should only be used during pregnancy if the expected benefi t to the patient justifi es the potential risk to the foetus. ♦Not known whether indacaterol, glycopyrronium and their metabolites are excreted in human milk. Use of Ultibro Breezhaler by breast-feeding women should only be considered if the expected benefi t to the woman is greater than any possible risk to the infant. Interactions: ♦Concomitant use is not recommended with beta-adrenergic blockers, anticholinergics or sympathomimetic agents. ♦Concomitant hypokalaemic treatment with methylxanthine derivatives, steroids, or non-potassium-sparing diuretics may potentiate

the possible hypokalaemic effect of beta2-adrenergic agonists, therefore use with caution. ♦Inhibition of the key contributors of indacaterol clearance, CYP3A4 and P-gp, does not raise any safety concerns given the safety experience of treatment with indacaterol. ♦No clinically relevant drug interaction is expected when glycopyrronium is co-administered with cimetidine or other inhibitors of the organic cation transport. Adverse reactions: ♦Very common: upper respiratory tract infection. ♦Common: nasopharyngitis, urinary tract infection, sinusitis, rhinitis, dizziness, headache, cough, oropharyngeal pain including throat irritation, dyspepsia, dental caries, gastroenteritis, musculoskeletal pain, pyrexia, chest pain. ♦Uncommon: hypersensitivity, diabetes mellitus and hyperglycaemia, insomnia, paraesthesia, glaucoma, ischaemic heart disease, atrial fi brillation, tachycardia, palpitations, paradoxical bronchospasm, epistaxis, dry mouth, pruritus / rash, muscle spasm, myalgia, pain in extremity, bladder obstruction and urinary retention, peripheral oedema and fatigue. ♦Please refer to SmPC for a full list of adverse events for Ultibro Breezhaler. Legal Category: POM Pack sizes: Cartons containing 6 capsules (1x6 capsule blister strips) and one Ultibro Breezhaler inhaler or 30 capsules (5x6 capsule blister strips) and one Ultibro Breezhaler inhaler. Marketing Authorisation Holder: Novartis Europharm Limited, Wimblehurst Road, Horsham, West Sussex, RH12 5AB, United Kingdom. Marketing Authorisation Numbers: EU/1/13/862/001 & 003. Full prescribing information is available on request from Novartis Ireland Ltd, Beech Hill Offi ce Campus, Clonskeagh, Dublin 4. Tel: 01 2601255 or at www.medicines.ieDate of Creation of API Text: Sept 2013 Date of Preparation: November 2013

1. Ultibro Breezhaler SmPC. www.medicines.ie , accessed on Nov 2013.2. Vogelmeier CF, Bateman ED, Pallante J, et al. Effi cacy and safety of once-daily QVA149 compared with twice-daily salmeterol/ fl uticasone in patients with COPD (ILLUMINATE): a randomised, double-blind, prallel group study. Lancet Respir Med. 2013;1:51-60.3. Bateman ED, Ferguson GT, Barnes et al. Dual bronchodilation with QVA149 vs single bronchodilatot therapy: the SHINE study. EUR Respir J. Published online May 2013 as doi: 10.1183/0931936.00200212.4. Wedzicha JA, Decramer M, Ficker JH, et al. Analysis of chronic obstructive pulnmonary disease exacerbations with the dual bronchodilator therapy QVA149 compared with glycopyrronium and tiotropium (SPARK): a randomised, double-blind, parallel group study. Lancet Respir Med. 2013;1:199-209.

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clinical review

functioning preventing cytokine synthesis and release which prevents immune cell recruitment and cell activation and indirectly, prevents mediator release. Tables 2 and 3 illustrate the range of corticosteroids available for conditions affecting the upper and lower respiratory tract. (table 2)(table 3)

4. leukotriene receptor antagonistsLeukotriene receptor antagonists (LRTAs) block the production of leukotrienes. Leukotrienes are chemical medical mediators produced by cells as a result of an inflammatory response. LRTAs block the action of this inflammatory response and

can contribute to preventing allergic symptoms both in the upper and lower airway. They are licensed for use both in asthma and allergic rhinitis and can be introduced at Step 2 of the GINA guidelines (GINA, 2012). LRTAs are only effective in approximately 50% of patients. It is recommended that a trial is performed for 6 weeks and if no improvement, then they should be discontinued. (see Table 4).

5. xanthinesXanthines directly relax bronchial smooth muscle and also have an anti-inflammatory effect. These drugs are metabolised

drug NAMe drug ClAssIFICAtIoN dose FreQueNCy

sIde eFFeCts AvAIlAbIlIty As CoMbINAtIoN therAPy

Fluticasone fuorateAvamys™

Corticosteroid Once daily Epistaxis, nasal ulceration No

Fluticasone propionateDymista™

Corticosteroid with antihistamine

Twice daily Epistaxis, nasal irritation, unpleasant taste/smell

Yes – combined with Azelastine HCl

Beclomethasone dipropionateBeconase™Nasobec™

Corticosteroid Twice daily Epistaxis, nasal irritation, unpleasant taste/smell, throat dryness/irritation

No

Mometasone furoateNasonex™

Corticosteroid Once daily Headache, epistaxis, nasal irritation/ulceration

No

Azelastine HClRhinolast™

Antihistamine Twice daily Nasal irritation, taste disturbance

Yes – with Fluticasone propionate

BudesonideRhinocort™

Corticosteroid Daily or twice daily

Epistaxis, sneezing, stinging, dryness

No

table 3: Nasal preparations

drug NAMe ForMulAtIoN dose FreQueNCy

sIde eFFeCts AvAIlAbIlIty As CoMbINAtIoN therAPy

BeclomethaoneBecotide™Beclazone™Qvar™

Inhaler Twice daily But can be used up to four times daily Oral candidiasis, dysphonia,

pharyngitis

No

BudesonidePulmicort™Novolizer budesonide™

Inhaler, respules Twice daily but can be used up to four times daily

Yes – with Formoterol (Symbicort™)

Fluticasone ProprionateFlixotide™

Inhaler, nasal preparation

Twice daily Yes – with Salmeterol™

MometasoneAsmanex™

Inhaler Once daily No

ClicesoniseAlvesco™

Inhaler Once daily No

PrednisilonePrednesol™Deltacortril Enteric™

Tablet, intravenous/intramuscular preparation, soluble preparation

Once daily Prolonged use can cause:Weight gain, hypertension, diabetes, changes in mood, moon face, hirsuitism, depression, adrenal suppression

No

table 2: Corticosteroids

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clinical review

through the liver and their action is increased in patients with liver failure and heart failure and are decreased by smoking and heavy drinking. They interact with a number of drugs such as Erythromycin and Cimetidine as Xanthines act on the same P450 enzyme. Xanthines have a narrow therapeutic range (27-80 µmol/L) and blood monitoring is required for patients on these drugs to ensure patients do not become toxic and therefore increase the likelihood of side effects. Table 4 illustrates the range of Xanthines available. (see Table 5).

6. Monoclonal antibodiesOmalizumab is a monoclonal antibody which forms complexes with Immunoglobulin E (IgE) circulating in the blood. It blocks the action of IgE by preventing it from attaching to mast cells. This prevents the mast cell from degranulating and limits the release of inflammatory mediators (Oba and Salzman, 2004, Walker et al, 2004). Omalizumab is a treatment option for patients with severe allergic asthma who remain uncontrolled despite being on maximum inhaled therapy.(see Table 6)

7. Pde4sPhosphodiesterases 4 (PDE4s) are the new kids on the block in COPD and are yet to become available in Ireland. Cilomilast and Roflumilast are currently in development. PDE4 is expressed in airway smooth muscle and, in vitro, PDE4 inhibitors relax lung smooth muscle. They also address the inflammatory process which is associated with COPD which is quite different to the inflammatory process in asthma. Selective PDE4 inhibitors are being developed for treating COPD (Brown, 2007) and will become available in Ireland in the near future.

drug NAMe ForMulAtIoN dose FreQueNCy sIde eFFeCts

MontekulastSingulairMontelair™

Tablet, granules Daily Insomnia, disturbed sleep, headache, abdominal pain, thirst

ZarfukulastAccolate™

Tablet Daily

table 4: leukotriene receptor antagonists

drug NAMe Method oF AdMINIstrAtIoN dose FreQueNCy sIde eFFeCts

TheophyllineUniphyllin™

Oral Twice daily GI upset, arrythmias, tremors, transient increased urination

AminophyllinePhyllocontin™

Oral Twice daily Nausea, gastric irritation, CNS stimulation, headache

table 5: xanthines

drug NAMe ForMulAtIoN dose FreQueNCy sIde eFFeCts

OmalizumabXolair™

Pre-filled syringe 1 to 4 sc injections depending on baseline IgE and body weight. Max 600mgs every 2 weeks. Assess at 16 weeks and continue if marked imrpovent (MIMS, January 2014)

Headache, injection site reactions, upper abdominal pain, pyrexia in children 6 – 12 years

table 6: Monoclonal antibodies

CoNClusIoNThis article has addressed respiratory drugs which the practice nurse may encounter on a daily basis. It is important that patients are actively involved in their treatment options and in particular their device selection. This will aid adherence and concordance with medication regime. Finally, the article very briefly introduced the reader to a new class of drugs which will become available in the near future for COPD management. Education and informing patients about their drugs including mode of action, onset of action and side effects remain paramount in caring for and managing patients with chronic respiratory disease.

reFereNCesBrown W., 2007, Treating COPD with PDE4 inhibitors, International Journal Chronic Obstructive Pulmonary Disease, 2(4): 517–533. Published online 2007 December.Global Initiative for Asthma, 2012, Global Strategy for Asthma Management and Prevention.Global Initiative for Chronic Lung Disease, 2013, Global Strategy for the Diagnosis, Management and Prevention of COPD.MIMS Ireland, January 2014Oba Y., Salzman GA., 2004, Cost-effectiveness analysis of Omalizumab in adults and children with moderate to severe allergic asthma. Journal of Allergy and Clinical Immunology, 114, 2, 265-269Walker S., Monteil M., Phelan K., et al, 2004, Anti-IgE for chronic asthma in adults and children. The Cochrane Database of Systematic Reviews, Issue 2. Art. No.: CD003559. DOI: 19.1002/14651858. CD 003559.pub2

Practice nurse requiredCo westmeath

Practice nurse required 1.5 days per week to cover maternity leave March - September 2014.

Please contact dr gerard Fallon, Moate, Co westmeath, 090 6481685 / drgerardfallon@gmail.com

Practice nurse requiredCo wicklow

Part-time Practice Nurse or part-time Phlebotomist required (six month contract for maternity leave cover) to join our team of 3 practice nurses in our pleasant, modern, fully computerised practice. Competence in the areas of cervical screening, childhood immunisations, midwifery, ECGs, 24 hour BP monitoring, cryotherapy, spirometry would be advantageous.

For enquiries, or to apply, please contact Mary toomey, Practice Manager, Carlton Clinic, Novara Avenue, bray, Co wicklow. tel. 01 2021070 or email Cv to mtoomey@carlton-clinic.ie

Practice nurse requiredsouth Co dublin

Part-time Practice Nurse required for South Co Dublin practice. Experience in Health Screening and Promotion, Childhood Immunisations, Travel Vaccinations, etc. an advantage.

Please reply to Colette roche, Practice Manager, beechlawn Medical Centre, Carrickbrennan road, Monkstown, Co dublin or email Cv to beechlawn@gmail.com.

Practice Nurse recruitment

To advertise here contact Graham: graham@greenx.ie or Louis: louis@mindo.ie Tel: 01 4410024

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clinical review

Cholesterol and cardiovascular disease in primary healthcaredArINA lANe

Cardiovascular disease is the primary cause of death in Ireland and the UK. There is a relative lack of research data in Ireland whilst the UK has provided data within the recommendations presented in the Nice Clinical Guidelines 67-Lipid modification.

For the purpose of this article the evidence based research from the NICE Report is used from England. Reference is also made to one of the most recent Irish cardiovascular studies – Heartwatch. Heartwatch was initiated in 2002. The first group of patients were seen in 2003 and the study completed in 2006.

Heartwatch, a secondary prevention programme in primary healthcare was based on the second European Joint Task Force Recommendations for Secondary Prevention of Cardiovascular Disease.

The aim of the study was to examine the effect of the first two years of the Heartwatch programme on cardiovascular risk factors and treatment.

risk factorsThe study concluded that there was significant improvement in the main risk factors and treatments of CHD. However, it stated that more effective interventions were required to reduce body mass index (BMI), waist circumference, and physical activity in this particular group. (European Journal of CVD.)

Risk factor modifications have been unequivocally shown to reduce mortality and morbidity, especially in people with either recognised or unrecognised CHD. (Leahy. J, 2006)

It was also suggested that the programme be used as a template for future management of chronic illnesses in PHC.

Apart from age and gender there are three main risk factors:• Smoking• Hypertension• Raised lipids

These factors make a major contribution to CVD, especially in combination. Indeed they account for 80% of all premature CHD. (Emberson, 2003)

The high risk population can be identified for future CVD events by using these three main factors.

social factorsCVD is strongly associated with low income groups and social deprivation. Family history of premature CHD identifies an important group that contains those with a genetic predisposition.

The practice nurse plays an impotant role when it comes to modifiable risk factors such as cholesterol. The common aim within the multidisciplinary team is towards the reduction and modification of possible risk factors.

21

clinical review

The primary care setting is an ideal arena to address and identify those at risk.

The aim of practice nurses, along with their colleagues, is to work towards the modification of lipids and other modifiable factors (lifestyle factors) in the at risk groups and those with established CHD.

treatmentTreatment is aimed at reducing overall risks in collaboration with the patient.

Both the knowledge and wealth of experience between the multidisciplinary team members allows for a multifactorial approach highlighting all risk factors yields most benefit.

The NICE guidelines offer best practice on the care of adults at risk of developing CHD and those with established CHD. It is important to remember that whilst it is always a partnership in care, the client is also encouraged to take responsibility for their health. Ideally, the treatment and care is tailored to the individual using a holistic approach taking into account their needs and preferences.

The role of the practice nurse is pivotal to the success of implementing key priorities of care within the team.

Within the scope of implementation the practice nurse may take on agreed responsibility for:• Identification of those who are likely to be high risk• Use of computerised records to enter valuable data and

chronic illnesses• Coding of medical records• Use of risk equations• Patient information, health promotion, benefits of treatment

and side effects of treatment• Recording baseline blood pressure, weight, pulse BMI,• Lifestyle habits such as smoking and alcohol intake, exercise

habits• Serum analysis: fasting glucose, liver function test, renal

function test, full cholesterol profile including total cholesterol, HDL, LDL and triglycerides. If the lipids are abnormal a TFT is carried out.It is important to remember that the team also need to

monitor and manage other chronic diseases whilst considering optimising the modification of the CHD risks.

The GP may prescribe a statin pending on the CHD risk and the lipid profile results.

Statins are prescribed with the aim of reducing the

cholesterol to less than 4mmol/l and an LDL of less than 2mmol/l .

The practice nurse is advised that, when creating a register of risk groups opportunistic assessment should not be used as the main strategy.

It is important to be mindful that those already taking medication for hypertension and raised lipids are at risk of being underestimated for cardiovascular risk.

Also those with a BMI greater than 40 also affects cardiovascular risk.

The communication between the patient and the health care professional, usually the practice nurse, is paramount in order to promote patient participation in reducing CVD risk. Exploration of patient beliefs, existing knowledge, and general understanding of their condition is important in order to correct any misinformation.

Assessment of their readiness to make lifestyle changes regarding smoking, alcohol consumption, diet and exercise should always be confirmed.

A review of the patient’s liver function prior to statin treatment and again 3 months following initiation of treatment is advised.

It seems that an enormous amount of work is needed to invest in good cardiac health for patient populations at risk. Who better to carry out the work than the practice nurse?

The work profile of the practice nurse continues to increase as time goes on. The payoff is a positive one when we look at results from the Heartwatch programme.

Croi Ireland is advancing to the forefront of cardiac health care. The Croi programme which was set up in the West of Ireland in 2009, is Ireland’s first purpose built centre dedicated to cardiovascular disease prevention and rehabilitation.

Croi backs initiatives across all areas of cardiac care, including in-hospital patient care, interventional cardiology, heart failure and other sub-specialities, cardiac surgery, patient care in the community, family support, disease prevention, cardiovascular research and community and professional education. Croi’s current focus is very much community based: it supports innovative approaches to education, heart health promotion, lifestyle and behaviour changes.

Practices nurses are in a prime position to continue the goral of Heartwatch in striving to improve our heart health.

referencesNICE Clinical Guidelines 67 – Lipid Modification, 2010 National Institute for Health and Clinical Excellence.Emberson, J.R.et al (2003) Reassessing the contribution of serum total cholesterol, blood pressure and cigarette smoking to aetiology of CHD: European Heart Journal 24: 1719-26.WWW.nice.org.uk/cg67/full guidelines.Obesity, NICE Guidelines 43WWW.stats.gov.uk/downloads/theme-health/hsq33web.pdf1. ICGP. (July 2006) Second Report on Heartwatch Programme Publication.Heartwatch – (2006) The National Programme in General Practice for the Secondary Prevention of CHD in Ireland.Culliton, G. (2013) Preventive Medicine. Irish Medical Times

bibliographywww.eatwell.gov.uk/healthydietwww.5aday.nhs.uk

A review of the patient’s liver function prior to statin treatment and again 3 months following initiation of treatment is advised.

22

clinical review

Cancer of the cervixGlobally cervix cancer accounted for an estimated 530,000 new cancer cases worldwide and 275,000 deaths in 2008. In Ireland there are appropriately 320 new cases diagnosed annually. Unfortunately in countries that do not have access to cervical cancer screening, cervical cancer remains the second most com-mon type of cancer. Global incidence and mortality rates depend upon the presence of screening programmes for cervical pre-cancer and cancer and of human papillomavirus vaccination. These interventions have seen a 75 % decrease in the incidence and mortality of cervical cancer over the past 50 years in devel-oped countries. (BMJ 1999)

Pathogenesis Human papillomavirus (HPV) is central to the development of cervical cancer and can be detected in 99.7% of cases. There are four major steps in the development of cervical cancer.1. Oncogenic HPV infection of the metaplastic epithelium at

the cervical transformation zone.2. Persistence of the HPV infection.3. Progression of a clone of epithelial cells from persistent viral

infection to pre-cancer.4. And finally the development of carcinoma and invasion

through the basement membrane.

It can take anywhere from 5-15 years for a pre-cancer lesion to develop into a cancerous lesion.

Genital tract HPV infection is extremely common but results in cervical cancer in only a small proportion of infected women. Appropriately 75-80% of sexually active adults will acquire HPV before the age of 50. There are over 40 genital mucosal HPV types identified, subtype 16 and 18 are found in over 70% of all cervical cancers.

The main histological subtypes of cervical cancer are squa-mous cell carcinoma which accounts for around 80% of cervical cancers and adenocarcinomas which account for 20%. The development of adenocarcinoma is associated with exposure to oestrogens both endogenous e.g. obesity and exogenous e.g. contraceptive pill and hormone replacement therapy. Adeno-carcinoma is associated with poorer outcome than squamous cell cancers.

risk factorsEarly onset of sexual activity and multiple sexual partners increases the risk of exposure to HPV.

Women who smoke are more likely to develop pre-cancerous lesions and or squamous cell cervical cancer. Having a weak-ened immune system may allow pre cancer lesions to develop into cancer. The immune system can be weakened by smoking,

An overview of gynaecological cancersdebrA MCKNIght, CANCER NURSE CO-ORDINATOR, ST JAMES’S HOSPITAL, DUBLIN. wAseeM KAMrAN, CONSULTANT SURGICAL GYNAECOLOGICAL ONCOLOGIST, ST JAMES’S HOSPITAL, DUBLIN.

23

clinical review

a poor diet and infections such as such HIV/AIDS. Long term use of the contraceptive pill (more than 10 years)

can slightly increase the risk of developing cervical cancer, but for most women the benefits outweigh the risks.

PresentationEarly cervical cancers are frequently asymptomatic underscor-ing the importance of screening. The most common symptoms are irregular or heavy bleeding, postcoital bleeding, and post-menopausal bleeding. In late stage disease lower back pain may be problematic and may radiate along the posterior side of the lower limbs.

diagnosisThis is made based upon histologic evaluation of a cervical biopsy. Once a diagnosis is made the patient’s cancer is staged by evaluating the disease radiologically. MRI imaging will assess the nodal status and parametrial involvement. The use of PET/CT now allows more accurate evaluation of distant disease. However clinical examination is still the primary tool used to stage the cervical cancer. This involves examination under an-aesthetic of the cervical canal, parametria, rectum and bladder. Cervical cancer is staged using the Federation of Gynaecology & Obstetrics (Figo).

treatmentEarly stage cervical cancer (1A-1B1) is treated surgically; options include cone biopsy, trachelectomy simple hysterectomy or radical hysterectomy. A cone biopsy, involves removing a small cone-shaped section of the cervix which is large enough to contain the abnormal area.

Trachelectomy involves removal of the entire cervix up to within 1 cm of the isthmus, dissection of the top 2cms of vaginal cuff, removal of the parametria and pelvic node dissection. Both procedures allow young women of childbearing years the opportunity to preserve fertility. There is a higher chance of early or late miscarriage and premature delivery. Delivery is by caesarean section only.

By contrast a radical hysterectomy involves removal of the uterus, fallopian tubes and in the case of adenocarcinoma the ovaries and pelvic and para aortic lymph nodes. This procedure is commonly performed by laparoscopic surgery, minimizing post-operative recovery. Lymph node dissection carries its own morbidities with some women developing lymphoedema as a consequence which can have a profound effect on body image.

Cervical cancers greater than 4cms (1B2-IV) are treated with radiotherapy and chemotherapy. The objective is curative; however cure rates decrease rapidly with each advancing stage. Potential side effects of this treatment include vaginal stenosis,

which can have a devastating impact on sexuality and sexual function. Ovarian failure can occur within one week of treat-ment, inducing menopause, where symptoms are often more pronounced than would be experienced naturally, particularly with young women in their 20s 30s and 40s. Hormone replace-ment therapy is contra-indicated in women with an adenocarci-noma of the cervix.

Other side effects include bladder irritation and altered bowel habit where in some cases a colostomy formation is required to relieve symptoms. However, the majority of patients experience minimal side effects.

Cancer of the ovaryOvarian cancer, commonly referred to as a ‘silent killer’, is the fourth most common cancer among women in Ireland account-ing for an average of 500 new cases per year. The life time risk of developing ovarian cancer is approximately 1 in 80 and the majority of these cancers are epithelial in origin. Ovarian epithe-lial cancer has the highest mortality of all the gynaecological cancers and the poor prognosis is largely due to the fact that it presents late in the course of the disease.

PathogenesisEpithelial ovarian carcinoma refers to a large group of pelvic cancers which present as a congealed mass involving ovary, fallopian tube and peritoneum. These epithelial tumours can broadly be divided into two main categories in terms of prob-able site of origin. The first group, with possible origin in the ovary, include mucinous, clear cell, borderline, endometroid and low grade serous tumours. The clear cell and endometroid carcinomas carry the worst prognosis and can be a continuum from endometriosis to advanced ovarian malignancy. The sec-ond categories of pelvic serous tumours, particularly the high grade ones, were traditionally considered to have arisen from the ovarian surface epithelium. Now, the distal fallopian tube is emerging as a potential site of origin for these tumours in the general population.

PresentationUp to 75% patients of ovarian malignancies present with advanced stage disease (stage III/IV). Most women may have vague or no symptoms at the early stage disease. Early symp-toms include abdominal discomfort/distension, vague aches and pains, anorexia, bowel or bladder symptoms and weight loss. Late presentation could be back pain and shortness of breath due to pleural effusion or significant ascites.

risk factorsNulliparity, early menarche, late menopause, hormone replace-ment therapy especially oestrogen only preparation for over 5 years, use of fertility drugs e.g. clomiphene citrate, endome-triosis, high fat diet, and family history of ovarian cancer are considered to be the risk factors for developing ovarian cancer. Women with personal or family history of breast cancer and, in particular, those carrying BRCAI/BRCAII germ line mutation are at increased risk of ovarian cancer.

InvestigationsIn primary careWomen, especially over the age of 50, with persistent abdominal pain/bloating, weight loss, unexplained fatigue, altered bowel habit or bladder symptoms should be considered for CA125 and pelvic ultrasound to assess adnexa. Women with abdomino-pelvic mass and or ascites on ultrasound should urgently be re-ferred to hospital for further investigation. Women with normal or raised CA125 should be investigated for other causes.

genital tract hPv infection is extremely common but results in cervical cancer in only a small proportion of infected women.

24

clinical review

In secondary careCT thorax, abdomen and pelvis and CA125 if not already done should be performed in cases of suspected ovarian cancer to establish the stage of the disease. There is no need for a routine MRI. In younger women under 40, other tumour markers – alpha fetoprotein (AFP), beta human chorionic gonadotrophin (beta-hCG) – should also be performed prior to referral to a tertiary regional gynaecological oncology centre. In cases of advanced malignancy involving abdomen and pelvis, percutaneous image-guided biopsy is arranged to determine the histological type of cancer prior to the treatment.

screeningDespite all the recent advances in the field of radiology and molecular biology, there is no reliable method of screening for ovarian cancer. Failure to detect early ovarian cancer reliably with a combination of trans-vaginal ultrasound and CA-125 has left at risk women, with no option but to have surgery following genetic risk assessment.

risk reducing surgeryUntil recently, salpingo-oophorectomy was considered the only option in surgical prophylaxis in ovarian cancer. With emerg-ing evidence that the fallopian tube may be the origin of some ovarian cancers, salpingectomy alone may offer some protec-tion; however, the extent of that protection remains to be deter-mined. Women from high risk families, and those known to carry BRCA mutations, form a separate group for whom there is a current recommendation that bilateral salpingo-oophorectomy should be considered after the age 35 years or when childbear-ing is complete (NIH consensus 1995).

treatmentTreatment of ovarian cancer should be provided in the desig-nated specialised centres. The debulking procedures for ovarian cancers are often highly complex due to widespread carcinama-tosis and require extensive abdomino-pelvic resections, which can be best undertaken in a tertiary gynaecological oncology centres with particular expertise.

In early stage ovarian cancer, primary surgery remains the mainstay of treatment. Surgery alone may prove curative in early stage ovarian cancer without the need for chemotherapy. However, in certain early stage ovarian cancers such as poorly differentiated tumours chemotherapy can be considered.

In the advanced stage ovarian cancer (stage II-IV), the main aim of treatment is to achieve the complete cytoreduction which is an important independent prognostic factor in terms of survival and progression free interval. The treatment of advanced ovarian cancer could be either neo-adjuvant chemo-therapy followed by interval debulking surgery or primary surgery based on radiological appearance, the stage of the dis-ease, histological type and the performance status of a patient. The UK’s National Institute of Health and Care Excellence (NICE) recommends paclitaxel in combination with platinum based compound or platinum based therapy alone (cisplatin/carbopl-atin) as first line chemotherapy.

PrognosisSurvival rates in women with ovarian cancers have improved in the last three decades due to centralised cancer care, advances in surgery and better chemotherapy agents. Patients under the age of 50 with good performance status have better 5 years survival rate. Overall, 5 year survival in women with advanced epithelial cancers is still poor; 15-20% and 5% in stage III and IV respectively.

the role of the nurse The role of the nurse in caring for these women cannot be un-derestimated. They are often the greatest source of information and support for women both from a practical and psychological point of view. It is paramount that they have a good under-standing of the disease process, its treatment and potential complications/side effects. They should assess and examine the patients view regarding treatment and the impact of a cancer diagnosis. A good working knowledge of local and national support services i.e. Irish Cancer Society, MLD Ireland and local cancer support groups (which may be a cancer site specific) are invaluable to some patients. Ultimately communication between primary and secondary healthcare should be seamless in order to deliver optimum patient care.

useful reading1. Quinn M et el. Effect of screening on incidence of and mor-

tality from cancer of the cervix in England. BMJ 1999 2. CG122 Ovarian cancer, NICE, http://guidance.nice.org.uk3. TA284 Bevacizumab in combination with paclitaxel and car-

boplatin for first-line treatment of advanced ovarian cancer: guidance, NICE guidelines

4. Centralisation of care may prolong survival in women with ovarian cancer, and possibly more generally, gynaecologi-cal cancer – See more at: http://summaries.cochrane.org/CD007945/centralisation-of-care-may-prolong-survival-in-women-with-ovarian-cancer-and-possibly-more-generally-gynaecological-cancer#sthash.sofuogGV.dpuf

5. Cancer Trends No 14. Cancers of the cervix, National cancer registry, Ireland

6. NIH consensus conference. Ovarian cancer. Screening, treat-ment, and follow-up. NIH Consensus Development Panel on Ovarian Cancer. JAMA. 1995 Feb 8;273(6):491-7.

7. Cancer Trends No 14. Cancers of the ovary, May 2012, Na-tional Cancer Registry, Ireland

8. Cervical cancer, NICE http;//guidance.nice.org.uk

women, especially over the age of 50, with persistent abdominal pain/bloating, weight loss, unexplained fatigue, altered bowel habit or bladder symptoms should be considered for CA125 and pelvic ultrasound to assess adnexa.

What about them?

She’s offered protection from HPV types 6, 11, 16 and 18 through the national HPV vaccination programme in second level

Gardasil® – paves the way for cervical cancer and other HPV genital disease prevention1

• Most women under 45 years can gain some benefit from Gardasil® regardless of past or current infection1,2

• Gardasil is effective in preventing genital warts causally related to HPV 6, 11, 16 and 18 in males1

• Gardasil is indicated from 9-45 years of age in women and 9-26 years of age in men1

11/13 IR00132(1)

Information about adverse event reporting can be found at www.imb.ie. Adverse events and inadvertent vaccination during pregnancy should also be reported to Sanofi Pasteur MSD by calling 00 44 1628 785291. Further information available upon request.

ABRIDGED PRESCRIBING INFORMATION GARDASIL® (Human Papillomavirus Vaccine [Types 6, 11, 16, 18] (Recombinant, adsorbed)). Refer to Summary of Product Characteristics for full product information before prescribing. Additional information is available on request. Presentation: Gardasil is supplied as a single dose pre-filled syringe containing 0.5 millilitre of suspension. Each dose of the quadrivalent vaccine contains highly purified virus-like particles (VLPs) of the major capsid L1 protein of Human Papillomavirus (HPV). These are type 6 (20 μg), type 11 (40 μg), type 16 (40 μg) and type 18 (20 μg). Indications: Gardasil is a vaccine for use from the age of 9 years for the prevention of premalignant genital lesions (cervical, vulvar and vaginal) and cervical cancer causally related to certain oncogenic Human Papillomavirus (HPV) types and genital warts (condyloma acuminata) causally related to specific HPV types. The indication is based on the demonstration of efficacy of Gardasil in females 16 to 45 years of age and in males 16 to 26 years of age and on the demonstration of immunogenicity of Gardasil in 9- to 15-year old children and adolescents. Dosage and administration: The primary vaccination series consists of 3 separate 0.5 millilitre doses administered according to the following schedule: 0, 2, 6 months. If an alternate schedule is necessary the second dose should be administered at least one month after the first and the third dose at least three months after the second. All three doses should be given within a 1 year period. The need for a booster dose has not been established. The vaccine should be administered by intramuscular injection. Contraindications: Hypersensitivity to any component of the vaccine. Hypersensitivity after previous administration of Gardasil. Acute severe febrile illness. Warnings and precautions: The decision to vaccinate an individual should take into account the risk for previous HPV exposure and potential benefit from vaccination. As with all vaccines, appropriate medical treatment should always be available in case of rare anaphylactic reactions. The vaccine should be given with caution to individuals with thrombocytopaenia or any coagulation disorder because bleeding may occur following an intramuscular administration in these individuals. Syncope, sometimes associated with falling, can occur before or after vaccination with Gardasil

as a psychogenic response to the needle injection. Vaccinees should be observed for approximately 15 minutes after vaccination; procedures should be in place to avoid injury from faints. There is insufficient data to recommend use of Gardasil during pregnancy therefore the vaccination should be postponed until after completion of the pregnancy. The vaccine can be given to breastfeeding women. Gardasil will only protect against diseases that are caused by HPV types 6, 11, 16 and 18 and to some limited extent against diseases caused by certain related HPV types. Vaccination is not a substitute for routine cervical screening. Individuals with impaired immune responsiveness, due to either the use of potent immunosuppressive therapy, a genetic defect, or other causes, may not respond to the vaccine. As with any vaccine, vaccination with Gardasil may not result in protection in all vaccine recipients. There are no safety, immunogenicity or efficacy data to support interchangeability of Gardasil with other HPV vaccines. Undesirable effects: Very common side effects include: headache and at the injection site, erythema, pain and swelling. Common side effects include bruising and pruritus at the injection site, pyrexia, nausea, and pain in the extremity. Rarely urticaria and very rarely bronchospasm has been reported. Idiopathic thrombocytopenic purpura, Guillain-Barré Syndrome and hypersensitivity reactions including, anaphylactic/anaphylactoid reactions have also been reported. For a complete list of undesirable effects please refer to the Summary of Product Characteristics. Package quantities: Single pack containing one 0.5 millilitre dose pre-filled syringe with two separate needles. Marketing authorisation holder: Sanofi Pasteur MSD SNC, 8 rue Jonas Salk, F-69007, Lyon, France Marketing authorisation number: EU/1/06/357/007 (pre-filled syringe with two separate needles). Legal category: POM. ®Registered trademark. Date of last review: Nov 2012.

References: 1. Gardasil® Summary of Product Characteristics. 2. Castellsague X, Munoz N, Pitisuttithum P et al. End-of-study safety, immunogenicity, and efficacy of quadrivalent HPV (types 6, 11, 16, 18) recombinant vaccine in adult women 24–45 years of age. Br J Cancer 2011; 105:28-37.

GARDASIL_she’s protected_A4_SEPT13_02.indd 1 08/11/2013 13:57

26

interview

Karen Canning – Practice Nurse of the yearJAMes FogArty

‘For as long as I can remember, I always wanted to be a nurse’ Karen Canning, winner of the 2013 Practice Nurse of the Year award tells Nursing in General Practice.

‘Thirty three years later, I can’t imagine doing anything else or enjoying any other type of nursing more than Practice Nursing. It fits in very well with family life and facilitates study opportunities. Every working day is different.’

In October 2013, Ms Canning was honoured by her colleagues at the Irish Practice Nurse Association (IPNA) who awarded her the coveted prize at the association’s annual conference in Athlone.

It was Karen’s first time to be nominated for the award, an award which aims to recognize the contribution made by the individual Practice Nurse in any area within Practice Nursing, i.e. patient care, education, support of colleagues.

Nomination process“Anne O’Connor, of the IPNA South Dublin branch, suggested my nomination for the award,” Ms Canning explained. As part of the application a GP, a patient and a lecturer at NUI Galway very kindly wrote a piece, all of which were submitted to the judging panel.”

“I am delighted and honoured to receive this award and I would really like to thank Anne O’Connor for all her hard work, all members of the IPNA South Dublin branch, and everyone who was involved in my nomination.”

Karen also thanked all her colleagues both at the Kilmacud Medical Centre (KMC) and Beechwood Medical, Ranelagh for their support and encouragement. On the KMC’s website they describe her as “pivotal in the development” of continuing professional development by setting up the IPNA South Dublin branch.

Karen is the Chairperson of the relatively newly formed IPNA South Dublin branch, the formation of which was her idea and she has put in an immense amount of work into getting it established.

educationMs Canning’s career in nursing began in the 1980s, training as an RGN in St Lawrence’s (Richmond) Hospital, Dublin 7.

“I originally trained as a registered general nurse qualifying back in 1983 before going on to train as a midwife in the Rotunda Hospital,” she explained.

“Training at St Lawrence’s Hospital, which was the neurological centre of Ireland at the time, gave me a love of neurology and neurosurgical nursing. When I finished my midwifery at the Rotunda Hospital in 1987, there were no jobs in Ireland. I had just gotten engaged to Adrian, but had to go to the UK to work. I worked at the Atkinson Morley Hospital in Wimbledon, which was a neurological hospital, so I could continue my love of nursing and neurosurgical patients,” she explained. “I missed midwifery so much. But luckily I secured a job in the Rotunda while home for Christmas holidays and I was able to move back to Ireland within six months.”

From 1987 to 1999 she worked as a Midwife in one of the busiest hospitals in the country before moving on to Clinical Research/Practice Nursing. Karen also completed the first ‘Introduction to Practice Nursing Course’ in 1991.

While working as a Practice Nurse she became increasingly interested in the management of type II diabetes.

“I’m particularly interested in type II diabetes which has the potential to be looked after in primary care,” she said. “We see a certain amount of diabetes patients where I work at the moment but most of the patients I see get referred onto St Vincent’s Hospital. Currently many of the hospitals are trying to transfer the care of their patients with T2DM back into primary care, but unfortunately there has been very little communication between the HSE and the GPs about this.”

In 2007 Karen was introduced to academic writing while studying the Nursing Management of the Individual with Diabetes (stand alone module) DCU. This was a daunting but positive experience for her which lead to her completing a Post Graduate Diploma in Clinical Primary Care in NUIG in 2010 with Honours. Karen subsequently (2011) completed a research

27

interview

Masters of Health Sciences (Primary Care) in NUIG entitled ‘A Feasibility Study on Insulin Initiation for patients with Type 2 Diabetes in General Practice and Current Diabetes Care in General Practice – Practice Nurses’ Perspective.’

“I see how effective three monthly diabetes visits can be for patients with T2DM by supporting them to make significant lifestyle changes and educating them about their condition.

Future While Ms Canning believes in nursing and applauds anyone who goes into the profession, she is concerned for people just starting off on their careers, particularly during this difficult time.

“I would recommend nursing as a career and I think that there is a lot to be said for the conventional way in which I was trained” she said. “I think it is very difficult for hospital nurses now. The wards are a lot more short-staffed than when I was hospital based.”

While nursing in Ireland is facing an uncertain future, Karen Canning is looking forward to the challenges ahead.

Karen is the Chairperson of the relatively newly formed IPNA south dublin branch, the formation of which was her idea and she has put in an immense amount of work into getting it established.

Ireland’s first National homecare Conference The World Health Organisation are one of many speakers to attend Irelands First National Homecare Conference at the Ballsbridge Dublin on Friday March 28th & Saturday March 29th.

The National Homecare Ireland Conference 2014 takes place on Friday March 28th & Saturday 29th 2014 at Ballsbridge Hotel Dublin from 9:00am -5:00pm. This inaugural event will provide policy makers, care professionals, service providers, patients, carers and all stakeholders with a clear picture of the current state of home care in Ireland as well as the international and national issues which are likely to influence the sector in the future.

The first Friday morning session has been designed specifically for policy makers and service providers, and will examine the sector in Ireland, Europe and the US to develop a plan for the evolution of home care in this country. The second session will address issues relevant to care professionals and will focus on the practical, evidence-based management of clinical scenarios which are common to this patient population.

Current speakers include Dr Aegis Tsouros of the World Health Organisation on Homecare in Europe, Stephan McMahon CEO of the Irish Patients Association on Keeping the patient’s needs at the centre of home care services and Andrew McFarlane of the Netwell Centre on IT and chronic disease management – the impact for home care.

myhomecare.ie is the platinum sponsor of the National Homecare Ireland Conference 2014 and the event is been organised by Mernagh Communications and Medical Conference Management

delegate bookings are now been accepted online at www.nationalhomecareirelandconference.com

and exhibitors booking can made by calling Andrew Mernagh on 01-4440536

28

IPNA Conference 2013

IPNA Conference report 2013ruth Morrow, IPNA NATIONAL PRO

The North Dublin Branch welcomed over 140 delegates to Athlone for the 2013 IPNA Conference and AGM. An earlier than usual start on Friday afternoon saw del-egates hear presentations from Dr Catherine Conlon, Philip James and Deirdre Carmody. Dr Conlon from

the HSE Crisis Pregnancy Programme, presented research on mi-grant women’s sexual and reproductive health. Philip James, CNS in Adolescence Substance Abuse in Tallaght provided delegates with a presentation on substance abuse in adolescence and his challenging role. Deirdre Carmody, Drug Liaison Midwife at the Coombe Hospital spoke about the complexities of looking after women with drug addiction during pregnancy.

The keynote speech on Friday night was Mary Scott’s Good Sexual History which gave us an enlightening history lesson on women’s health throughout the middle-ages. The Dublin Branch provided us with even more enlightenment on the role of the practice nurse…it can be safely said that practice nursing is alive and well in the North Dublin Branch!!

The evening concluded with the presentation of two awards – the Clinical Award and the Irish Practice Nurse of the Year Award. Cardiovascular disease was the subject for this year’s award. The winner was Christine Doherty from the Donegal Branch. The Irish Practice Nurse of the Year Award went to Karen Canning of the newly formed South Dublin Branch. Congratulations to both award winners! Thank you to MSD (Clinical Award) and SMA (Practice Nurse of the Year Award) for their support of these awards.

Saturday morning kicked off with a presentation from Prof Donal O’Shea on the obesity problem which challenges us on a

daily basis. This was followed by Dr Jay Sharma who spoke on hy-pertension. The final speaker was Dr Patrick Ormond, Dermatolo-gist from St James’ Hospital, who gave an excellent, if not alarm-ing, presentation on the recognition and diagnosis of malignant melanoma. Saturday morning concluded with the presentation of the Valerie Mangan Award which went to Pauline McLoughlin from the Sligo/Leitrim Branch.

The AGM on Saturday afternoon was well attended. The new committee elected for the incoming year were: Siobhan Jordan (National Chairperson), Cora Gould (National Vice-Chairperson), Mary O’Sullivan (National Honorary Treasurer) and Ruth Morrow (National PRO). Many thanks to Roisin Doogue and Brid Buckley who worked tirelessly for the IPNA and stepped down from the National Executive.

The IPNA would like to thank all our sponsors who supported our conference and our local branch meetings in 2013. We greatly appreciate your ongoing support for our association and we look forward to welcoming you in Limerick on the 17th and 18th October 2014. Thank you also to the Radisson Hotel in Athlone for a great weekend.

Well done to the North Dublin branch for hosting a superb conference and we hope you enjoyed the experience. You made us feel very welcome in Athlone and the hard work you put in throughout the year paid off in the smooth running of the con-ference. Best of luck to the Kerry branch who will be hosting the 2014 conference in Limerick so make sure you have the 17th and 18th October 2014 in your diaries.

deirdre Carmodydr Catherine Conlon

roisin doogue, dr Jay sharma, and siobhan Jordan

bríd buckley

dr Patrick ormond

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IPNA Conference 2013

siobhan Moore and brid buckley, North dublinMaura Costello, Anthony Carroll and roisin doogue

brid buckley, Anthony Carroll and roisin doogueClinical Award winner Christine doherty, with Msd sponsor sarah hardwicke, and outgoing National Chairperson roisin doogue

Christine doherty

and Patricia gallagher

Prof donal o’shea and siobhan Jordan

30

IPNA Conference 2013

dublin North Members, brid buckley, Jennifer Jones, elaine scanlon, liz healy, elaine burtenshaw, rachel Quinn, and siobhan Moore

Irish Practice Nurse of the year 2013 Award winner Karen Canning, with roisin doogue and Anthony Carroll, sMA

bríd buckley, laura street, Philip James, CNs, dr Catherine Conlon, róisín doogue, and deirdre Carmody

Karen Canning and roisin doogue

Register for your digital copy today!

www.mindo.ie

Nurses now have access to the award winning medical

newspaper

32

technology

eheAlthThe World Health Organisation defines eHealth as “… the transfer of health resources and health care by electronic means.”2 Ireland’s eHealth Strategy aims to harness advances in technology and use it to improve population health, promote health literacy, increase efficiency at the point of care and reduce costs. It is widely acknowledged that the health sector worldwide has been slow to embrace technology, for a variety of reasons including mistrust, lack of time and cuts in long-term investments in healthcare services since the recession. Ireland’s investment in healthcare ICT is 0.85% of total health budget, below the EU range of 2-3%.

However, in countries where investment has been made and then managed under sound governance structures, the Return on Investment has been remarkable. For example:• In Canada, the savings after complete roll out of ePrescribing

is expected to be almost $1 billion. Telehealth is estimated to have saved $55 million (and about 47 million miles of travelling for patients). The total savings from eHealth over the past 10 years is estimated at $7.7 billion.

• In Australia, the development of Personally Controlled Electronic Health Records (PCEHR) is expected to yield net annual benefits to the economy of around €5.5 billion. Ireland’s eHealth Strategy was developed on the back of

extensive research across eight countries that shows clear evidence of the benefits of eHealth to patients individually and populations in general. It is also expected to be of significant benefit to the Irish economy. An economic impact assessment

estimated that, if rolled out successfully, it could add 2-2.9% to Ireland’s GDP via increased activity and exports in the medical devices and pharmaceutical industries. It is expected that by 2020 there will be 50 billion internet connected devices, equating to 6.5 per person on the planet. As Ireland is currently “home to 15 of the top 20 medical technology companies in the world, 9 of the top 10 global pharmaceutical companies and 9 out of 10 global ICT companies”, it is believed that we are in an ideal position to make the most of the increasing demand worldwide for healthcare technology.

The Strategy outlines services that patients themselves are now demanding, such as telehealth for chronic conditions, ePrescribing, online referrals and appointments, up-to-date patient summaries and patient access to their health records. Funding is to be provided through “a re-alignment of the national healthcare budget” and through EU funding programmes. The EU views eHealth as vital to health and social care and has therefore allocated over €8 billion to healthcare system innovation through its Horizon 2020 programme, due to commence in January 20143.

The proposed timeframe for full implementation of the Strategy is 7 years. A new entity called ‘eHealth Ireland’ will be established to coordinate the Strategy and recruitment for a Chief Information Officer has already begun.

health Identifiers billThe Health Identifiers Bill, when enacted into law, aims to improve patient safety and reduce errors by assigning each

On 13th December 2013, Minister for Health and Children James Reilly

TD, published the eHealth Strategy for Ireland along with the Health

Identifiers Bill 2013.1 This fulfilled a commitment made to the Troika in

June to establish a legal basis for Health Identifiers for all patients. It

also complies with the Irish Presidency Declaration at the EU eHealth

Conference held in Dublin in May 2013, which committed member states to

developing eHealth Ecosystems.

Ireland’s eHealth Strategy: what it means

for Practice NurseslIsA NolAN, HEALTHCARE VIRTUAL ADMINISTRATOR AT

ASLAN VIRTUAL ADMIN

33

technology

it easier to assess and monitor compliance to medication and treatment plans.

• Patient hospital discharge summaries will be available instantly, in real time.

• Patients will be able to book and rearrange appointments online.

• Patients will have access to some or all of their health records online.

• Patients will be able to request repeat prescriptions online and GPs/RNPs will be able to issue prescriptions to dispensaries electronically, i.e. no more errors caused by illegible handwritten prescriptions.

• Patients will be able to access your expert advice on the management of their chronic conditions online (where clinical examination is not necessary) without the hassle, time and expense of having to attend the surgery, which also helps avoid unnecessary exposure to influenza, norovirus, etc.

• It is hoped that improved efficiency of the healthcare system will translate directly into more face to face time with your patients.

• It should be easier to conduct audits.• Immunisations and vaccinations are not mentioned in the

report, but presumably the Health Identifiers will make it easier to track the vaccination history of children who move home frequently.Throughout the 80 page eHealth Strategy document, the

importance of involving all stakeholders is emphasised as being vital for the success of the plan. In fact, the advice from other countries whose eHealth initiatives were not successful (due to failure to allocate sufficient resources) was taken on board by the architects of the Irish eHealth Strategy. Training, up-skilling and continued professional development of healthcare professionals will be a feature of the investment and are expected to be in place by year 4 of the plan. One of the key roles of the eHealth Ireland entity will be to work proactively with healthcare providers to minimise disruption to services during implementation of eHealth programmes.

No doubt there will be teething problems and it won’t all be plain sailing, but in the not too distant future a Practice Nurse’s working day could revolve around patients who are informed, engaged and empowered. It could involve much less admin and paperwork, and much more of what you are so highly trained for – providing focussed expert nursing care to the people who need it.

AcronymsEU European UnionGDP Gross Domestic ProductICT Information and Communication TechnologiesIT Information TechnologyNMBI Nursing and Midwifery Board of Ireland (formerly An Bord Altranais)

references1. “eHealth Strategy for Ireland”, Department of Health and

Children. http://www.dohc.ie/publications/pdf/HSE_eHealth_Strategy.pdf?direct=1

2. World Health Organisation. http://www.who.int/trade/glossary/story021/en/

3. Horizon 2020 http://ec.europa.eu/programmes/horizon2020/en

4. “Future Health – A Strategic Framework for Reform of the Irish Health Service 2012-2015” http://www.dohc.ie/publications/pdf/Future_Health.pdf?direct=1

health service user with a unique identification number to ensure that the right information is associated with the right patient, whether the setting is primary or secondary care, public or private. Healthcare professionals will also have unique identifiers, most likely their professional registration PINs, which will be used when recording patient care.

The Department of Health intends to use Individual Health Identifiers (IHIs) as a vehicle for the planned ‘Money follows the patient’ system outlined in Future Health.4 In an attempt to address concerns about patient privacy, the Department

has stated that no personal or clinical data will be held on the IHI Register and that access to such data will be restricted to approved personnel, with penalties for any breach of privacy.

Healthcare providers will be required to identify patients by using their IHI, but cannot refuse treatment if the patient is unable or refuses to give that information.

So how might the eHealth Strategy and Health Identifiers Bill 2013 affect the work of Practice Nurses in the future? Below are some practical examples, presuming the strategy is rolled out as planned and the Bill as proposed becomes law:• Your NMBI PIN is likely to be used as your unique identifier as

a healthcare professional.• The NMBI will be compelled by the new law to provide

information about all nurses on the register to the Minister for the purposes of implementing the system.

• All healthcare providers will need to comply with the HIQA National Standards for Safer Better Healthcare in order to maintain their licence.

• You will be required to identify each patient’s IHI before providing care.

• You will have to include the patient’s IHI along with your unique identifier as a healthcare professional in the patient’s records.

• You will be able to evaluate your patient’s ongoing health via medical devices such as body-worn sensors measuring glucose levels, or via Ambient Assisted Living (AAL) devices such as sensors to detect the number of falls suffered by patients with, for example, epilepsy. These devices also make

No doubt there will be teething problems and it won’t all be plain sailing, but in the not too distant future a Practice Nurse’s working day could revolve around patients who are informed, engaged and empowered.

34

abstracts

The impact of physical complaints, social environment, and psychological functioning on IBS patients’ health perceptions: looking beyond GI symptom severity.

lackner JM et al.

In the absence of a reliable biomarker, clinical decisions for a functional gastrointestinal (GI) disorder like irritable bowel syndrome (IBS) depend on asking patients to appraise and communicate their health status. Self-ratings of health (SRH) have proven a powerful and consistent predictor of health outcomes, but little is known about how they relate to those relevant to IBS (e.g., quality of life (QOL), IBS symptom severity). This study examined what psychosocial factors, if any, predict SRH among a cohort of more severe IBS patients.

Subjects included 234 Rome III-positive IBS patients (mean age=41 years, female=78%) without comorbid organic GI disease. Subjects were administered a test battery that included the IBS Symptom Severity Scale, Screening for Somatoform Symptoms, IBS Medical Comorbidity Inventory, SF-12 Vitality Scale, Perceived Stress Scale, Beck Depression Inventory, Trait Anxiety Inventory, and Negative Interactions Scale.

Partial correlations identified somatization, depression, fatigue, stress, anxiety, and medical comorbidities as variables with the strongest correlations with SRH (r values=0.36-0.41, P values <0.05). IBS symptom severity was weakly associated with SRH (r=0.18, P<0.05). The final regression model explained 41.3% of the variance in SRH scores (F=8.49, P<0.001) with significant predictors including fatigue, medical comorbidities, somatization, and negative social interactions.

SRH are associated with psychological (anxiety, stress, depression), social (negative interactions), and extraintestinal somatic factors (fatigue, somatization, medical comorbidities). The severity of IBS symptoms appears to have a relatively modest role in how IBS patients describe their health in general.

Am J Gastroenterol advance online publication, 14 January 2014; doi:10.1038/ajg.2013.410.

The overlap between IBS and IBD – what is it and what does it mean?

stanisic v, Quigley eM.

The nature and clinical implications of irritable bowel syndrome (IBS) type symptoms in patients with inflammatory bowel disease (IBD) who are in apparent remission have generated considerable debate. While, on the one hand, these symptoms satisfy Rome III criteria for IBS and their occurrence correlates highly with anxiety, a known trigger for IBS, on the other hand, recent studies have shown that many of these patients exhibit subtle inflammatory changes. Are these symptoms ‘true’ IBS superimposed on IBD, or an active but sub-clinical form of IBD? The authors propose a unifying model to explain and reconcile current knowledge on this topic, a model that could provide a conceptual framework for understanding the nature of these symptoms and point towards effective management strategies. They propose that IBS symptoms in IBD patients who are in remission be termed irritable inflammatory bowel syndrome in order to emphasize their unique presentation and etiology and to distinguish them from both IBS and IBD.

FocuS on: IrrITaBle Bowel SynDrome

35

product news

Poor rates of VTE prophylaxis in acute hospitalsAdherence to the guidelines on venous thromboembolism prophylaxis is poor according to a recent study which appeared in The Irish Medical Journal.

The study examined the thromboprophylaxis rate for VTE in at risk medical patients in acute hospitals. The hospitals looked at included: the Mater Hospital, Beaumont Hospital, Connolly Hospital, St John’s Hospital Limerick, Kerry General Hospital, Midland’s Regional Hospital, Sligo General Hospital, Mid-Western Regional Hospital, Co Limerick, Letterkenny General Hospital and Waterford Regional Hospital.

The study sought to ascertain if the use of stickers to alert physicians about thromboprophylaxis would increase the rate of prophylaxis in a follow-up audit.

Some 651 acute hospital admission patients were recruited in the first audit: 524 were recruited in the second re-audit.

Roughly the same number of men and women were recruited. The patients had a mean age of 66.5. The first audit identified 549 of patients at risk for VTE. The second audit identified 487 of patients at risk. Of the at risk patients in the first audit, a mere 163 patients received low molecular weight heparin (LMWH). In the second audit, just 132 received LMWH. Mechanical thromboprophylaxis was instigated in 75 patients in the first audit and in 86 patients in the second audit.

According to the study, the placement of stickers on patient charts failed to produce a noticeable increase in treatment of at risk patients in the second audit.

The authors concluded that there is an unacceptably low adherence to the ACCP guidelines across acute hospitals and that a more effective intervention than chart reminders is needed if compliance is to be improved.

Boehringer Ingelheim Ireland has been awarded Best in Pharma Company by InBusiness magazine and Chambers Ireland.

Boehringer Ingelheim received this award in recognition of the company’s ongoing commitment to the research and development of medical products in Ireland while helping the medical profession deliver world class healthcare to pa-tients. Boehringer Ingelheim was selected from 28 pharma-ceutical companies in Ireland.

The InBusiness editorial team considered a number of factors including, research and development, profile of the business, commitment to Ireland, with particular emphasis on the contribution made to the healthcare sector as a result of additional initiatives.

The team considered the number and quality of initiatives each company delivered, relative to the size of the company, as well as how effective each company was in communicating their initiatives to key stakeholders in the healthcare community. The editorial team felt that Boehringer had demonstrated a very high standard of excellence in terms of the number and potential impact of initiatives, as well as the

Boehringer Ingelheim – Best Pharma Company

proactive way they are communicated to the wider healthcare community.

These national awards, now in their second year, aim to recognise and reward exceptional business achievement and innovation, and celebrating the resilience of Irish business.

Ian talbot, Chief executive of Chambers Ireland, Joseph o’Connor, Inbusiness magazine editor presenting the award for best in Pharma to dr Colin edwards from boehringer Ingelheim, at the Inbusiness 2013 Awards held at the st stephen’s green Club.

36

product news

Distaclor – now distributed by Fannin

Data presented at EASD support safety profile of Trajenta (linagliptin) in type 2 diabetes• Boehringer Ingelheim and Eli Lilly and Company announced

that results from two different pooled analyses of clinical studies support previous observations that the dipeptidyl peptidase-4 (DPP-4) inhibitor linagliptin was shown to be well tolerated in a broad range of adults with type 2 diabetes (T2D). These data were presented at the 49th European Association of Diabetes (EASD) Annual Meeting. Findings from a pooled comprehensive analysis of safety data in 22 linagliptin clinical trials with 7,400 people with T2D (4,810 received linagliptin, 2,590 received placebo) included the following:1

• Linagliptin was well tolerated overall and across all age groups studied, with a low incidence of hypoglycemic events

• Overall incidence of adverse events (AE) or serious adverse events (SAE) with linagliptin was similar to placebo (AE 56.5 percent versus 61.2 percent, and SAE 4.8 percent versus 6.3 percent, respectively)

• The incidence of AEs with linagliptin compared to placebo remained similar irrespective of the age category (≤65 years, 65-74 years, ≥75 years) “Drug tolerability is an important consideration in the selection of appropriate treatments for people with type 2 diabetes, as often different populations will have drug contraindications and require dose adjustments to manage their disease,” said Prof. Nikolaus Marx, Professor of Medicine and Cardiology, University Hospital of Aachen, Germany. “The results presented today support the safety profile of linagliptin.” Renal safety in the elderly. Results from a post-hoc analysis of pooled data from

seven clinical trials including 1,293 people with T2D aged 65 years or older showed: 2

• Linagliptin was well tolerated providing clinical efficacy in an elderly population with renal function ranging from normal to severe renal impairment

• Overall renal function was not significantly altered by treatment with linagliptin from baseline to week 24, versus placebo

• Patients taking linagliptin achieved a HbA1c reduction of – 0.6 percent from baseline and −0.8 mmol/L for fasting plasma glucose (both values placebo-corrected)

• The overall incidence of AEs with linagliptin was similar to placebo (71.3 percent versus 72.8 percent, respectively)

• Incidence of investigator-defined hypoglycaemia was not higher in patients who received linagliptin compared to those receiving placebo (21.3 percent versus 24.7 percent), with most events occurring in the trials that included a sulphonylurea or basal insulin as background therapy

• Renal and urinary AEs were experienced by 5.5 percent and 4.3 percent of linagliptin and placebo patients, respectively. “The data presented from these analyses supplement the already established evidence demonstrating that linagliptin is a well-tolerated treatment for a broad range of people with type 2 diabetes,” said Professor Klaus Dugi, Corporate Senior Vice President Medicine, Boehringer Ingelheim. “This should provide physicians further assurance when treating different patient types with linagliptin.”

Fannin Ltd has become the sole distributor for Distaclor within the Republic of Ireland.

Distaclor is a broad spectrum antibiotic which aids in fighting secondary bacterial respiratory infections.

Distaclor is available in the following formats:• Distaclor LA 500mg tabs• Distaclor LA 375mg tabs• 125mg/5ml Distaclor Suspension• 250mg/5ml Distaclor Suspension

Distaclor is available in pharmacies nationwide.For further information on Distaclor please see www.

fannin.eu/Distaclor

37

crossword

Name:

Address:

Email:

Congratulations to the winner of last month’s crossword,

Anne Halkett, c/o Dr John Halkett’s Surgery, 71 Church Street, Listowel, Co Kerry.

Please send your answers to the Editor, Nursing in General Practice, GreenCross Publishing, 7 Leeson Street, Dublin 4. Closing date for entries: 14 March 2014.Winner will receive v50. Please note: the winners’ cheques will be sent out within 45 days.

Caltrate is a trademark. PA 172/38/1. Full prescribing information available from Pfizer Consumer Healthcare Ltd., 9 Riverwalk, National Digital Park, Citywest Business Campus, Dublin 24 or from www.medicines.ie

ACross6 Perform in a theatre! (7)7 Pertaining to the city – in both directions! (5)9 Jumper on dog can be irritating! (4)10 One gets it in the lip from Herpes! (4,4)11 No silt crumbled in ones throat (6)13 Water vessel! (4)15 Burden placed upon ourselves? (4)16 My deer panicking for a cure (6)18 Christmas paper could cause one to grip pawn

awkwardly (8)21 Gallery discovered in aorta tests (4)22 A cob for him and a pen for her? – That’s for the birds!

(5)23 Ivan ran askew but it was paradise for Kurt Cobain (7)

dowN1 One taken daily keeps the doctor away (5)2 Makers of exploding reactors (8)3 It’s found in root icterus of the ear! (4)4 A snaky sound! (4)5 I forbid mutation of benign tumour (7)8 As a race, it’s downhill all the way! (6)12 Rips an injured ligament (6)13 Deviates deviating for tranquillizer (8)14 Ring now for a painful toenail (7)17 Tents disassembled into small surgical tube (5)19 A small boat – in old money? (4)20 Sand that was true for John Wayne and Jeff Bridges! (4)

ANswers to lAst Issue’s CrosswordAcross: 6 Osmosis, 7 Croup, 9 Lady, 10 Saucepan, 11 Gung-ho, 13 Dart, 15 Onus, 16 Died of, 18 Hay fever, 21 Eire, 22 Hives, 23 Amputee. down: 1 Essay, 2 Toby jugs, 3 Aids, 4 Tree, 5 Au pairs, 8 Furore, 12 Godiva, 13 Duodenum, 14 Antacid, 17 Green, 19 Feet, 20 Ramp.

1 2 3 4 5

6 7

8

9 10

11 12 13

14

15 16

17

18 19 21

22 23

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Over 350 million patients treated with Clexane worldwide2

NOT ACTUAL SIZE

Clear visibility of expiry date

Colour-coded labelling and clear identification of CLEXANE® syringes by dose

Needle completely covered by the protection cap immediately after the injection

Automatic release of the safety mechanism when the plunger is fully depressed

Clear product identification

Designed to

protect against

needle stick

injuries1

References:1. CLEXANE® Summary of Product Characteristics. sanofi 2. Sanofi IMS data on file April 2012

CLEXANE® CONFIDENCE AT YOUR FINGERTIPS

New Clexane® and Clexane® Fortesafety lock syringes

CLEXANE® SYRINGES AND CLEXANE® FORTE SYRINGES PRESCRIBING INFORMATIONPresentation: Clear, colourless to pale yellow solution of either 100mg enoxaparin per 1ml (anti-factor Xa activity of 10,000IU/ml with reference to the WHO First International LMW Heparin Reference Standard) or 150mg enoxaparin per 1ml (anti-factor Xa activity of 15,000IU/ml). Clexane® Syringes: single dose pre-filled syringes containing either: 20mg enoxaparin in 0.2ml (2,000IU), 40mg enoxaparin in 0.4ml (4,000IU), 60mg enoxaparin in 0.6ml (6,000IU), 80mg in 0.8ml (8,000IU) or 100mg in 1ml (10,000IU). Clexane® Forte Syringes: single dose pre-filled syringes containing either: 120mg enoxaparin in 0.8ml (12,000IU) or 150mg in 1ml (15,000IU). Indications: Prophylaxis of thromboembolic disorders of venous origin, in particular those associated with orthopaedic or general surgery and in medical patients bedridden due to acute illness. Treatment of venous thromboembolic disease presenting with deep vein thrombosis, pulmonary embolism or both. Treatment of unstable angina and non-Q-wave myocardial infarction, administered concurrently with aspirin. Prevention of thrombus formation in the extracorporeal circulation during haemodialysis. Clexane 100mg/ml syringes only: Treatment of acute ST-segment Elevation Myocardial Infarction (STEMI) including patients to be managed medically or with subsequent Percutaneous Coronary Intervention (PCI) in conjunction with thrombolytic drugs (fibrin or non-fibrin specific). Dosage & Administration: Prophylaxis: Patients with low to moderate risk of thromboembolism, e.g. general surgery, recommended dose of Clexane® is 20mg (2,000IU) once daily subcutaneously. Clexane® should be continued for 7 to 10 days or until risk of thromboembolism has diminished. Longer durations may be appropriate in some patients following hip replacement. Patients undergoing surgery, initial dose approximately 2 hours preoperatively. Patients with high risk of venous thromboembolism, e.g. orthopaedic surgery, the recommended dose is 40mg (4,000IU) once daily subcutaneously, initial dose being given approximately 12 hours preoperatively. Medical patients bedridden due to acute illness, the recommended dose is 40mg (4,000IU) once daily for a minimum of 6 days until return to full ambulation, for a maximum of 14 days. Longer durations may necessary if it is there is an ongoing significant risk of thromboembolic events beyond 14 days. Treatment: Subcutaneous administration either as a single injection of 1.5mg/kg (150 IU/kg) or as a twice daily injection of 1 mg /kg (100 IU/kg) usually for 5 days and until adequate oral anticoagulation is established. Unstable angina and non-Q-wave myocardial infarction recommended dose is 1mg/kg (100IU/kg) every 12 hours subcutaneously, administered concurrently with oral aspirin 100 to 325mg once daily. Treatment should be for minimum of 2 days and continued until clinical stabilisation, usual duration 2 to 8 days. Clexane 100mg/ml syringes only: Treatment of STEMI, the recommended dose is a single IV bolus of 30mg, plus a 1mg/kg SC dose followed by 1mg/kg administered SC every 12 hours (max 100mg for the first two doses only, followed by 1mg/kg dosing for the remaining doses) for 8 days or until hospital discharge, whichever comes first. For dosage in patients ≥75 years of age, see elderly section. When used with a thrombolytic (fibrin specific or non-fibrin specific) Clexane® should be given between 15 minutes before and 30 minutes after the start of fibrinolytic therapy. All patients should receive aspirin 75 to 325mg once daily unless contraindicated. For patients managed with PCI: If the last Clexane® SC administration was given less than 8 hours before balloon inflation, no additional dosing is needed. If the last SC administration was given more than 8 hours before balloon inflation, an IV bolus of 0.3mg/kg of Clexane® should be administered. During haemodialysis: 1mg/kg (100IU/kg) Clexane® introduced into arterial line of the circuit at beginning of dialysis. This dose is usually sufficient for a 4 hour session. If fibrin rings are found, e.g. after a longer session, a further 0.5 to 1mg/kg (50 to 100IU/kg) may be given. In patients with high risk of haemorrhage reduce the dose to 0.5mg/kg (50IU/kg) (double vascular access) or 0.75mg/kg (75IU/kg) (single vascular access). Elderly: Clexane 100mg/ml syringes only: For treatment of STEMI in patients ≥75 years of age, do not use an initial IV bolus. Initiate dosing with 0.75mg/kg SC every 12 hours (maximum 75mg for the first two doses only, followed by 0.75mg/kg dosing for the remaining doses). For other indications, no dosage adjustment necessary unless kidney function is impaired. Children: Not recommended. Renal impairment: Dosage adjustment required for patients with severe renal impairment. Contraindications: Acute bacterial endocarditis; active major bleeding and conditions with a high risk of uncontrolled haemorrhage, including recent haemorrhagic stroke or subdural haematoma; thrombocytopenia in patients with positive in vitro aggregation test in presence of Clexane®; in jaundice; active gastric/duodenal ulcer; hiatal ulceration; threatened abortion or retinopathy; hypersensitivity to enoxaparin, heparin or other LMWH. Warnings and Precautions: Clexane® must not be administered by the intramuscular route. Different low

molecular weight heparins may not be equivalent; alternative products should not be substituted during therapy. Neuraxial haematomas may occur when Clexane® is used concomitantly with spinal/epidural anaesthesia. Haemodynamically unstable patients with pulmonary embolism may require alternative treatment. Use in patients with prosthetic heart valves has not been adequately studied and is not recommended. Clexane® should be used with care in hepatic insufficiency, history of thrombocytopenia, and conditions or patients with increased bleeding potential (such as those with peptic ulcers, recent ischaemic stroke, uncontrolled severe arterial hypertension, diabetic retinopathy, renal impairment, elderly and extremes of weight). Platelet counts should be measured prior to initiation of Clexane® and regularly during treatment. Heparins can suppress adrenal secretion of aldosterone leading to hyperkalaemia. Following vascular instrumentation adhere precisely to recommended dose intervals. If a closure device is used, the sheath can be removed immediately. If a manual compression method is used, sheath should be removed 6 hours after the last IV/SC enoxaparin sodium injection. If treatment is to be continued, the next scheduled dose should be given no sooner than 6 to 8 hours after sheath removal. The site of the procedure should be observed for signs of bleeding or haematoma formation. Pregnancy: Clexane® should be used during pregnancy only if the physician has established a clear need. Lactation: Advise avoidance of breast-feeding. Interactions: Discontinue unless essential agents affecting haemostasis, e.g. oral anticoagulants, thrombolytics, systemic glucocorticoids, NSAIDs, aspirin, clopidogrel. If the combination cannot be avoided, careful clinical and laboratory monitoring is recommended. Adverse Reactions: Bleeding, including retroperitoneal and intracranial, with or without the presence of associated risk factors, such as invasive procedures or use of medications affecting haemostasis. Thrombocytopenia, including rare cases of immuno-allergic thrombocytopenia with thrombosis. Elevation of liver enzyme levels and platelet count, and cutaneous or systemic allergic reactions (including anaphylactic/anaphylactoid reactions, and very rarely cutaneous vasculitis) have been reported. At site of injection: pain, haematoma, irritation, rarely hard inflammatory nodules and skin necrosis. Heparins can cause hypoaldsteronism which can increase in plasma potassium, and rarely, clinically significant hyperkalaemia. Rare reports of neuraxial haematoma when using spinal/epidural anaesthesia and post-operative indwelling catheter. Please consult SPC for full details of the recognised side effects with Clexane. Pharmaceutical Precautions: Do not mix with other injections or infusions. Do not store above 25°C. Do not refrigerate or freeze. PI revision: November 2012Product Licence numbers: PA 540/97/1: Clexane® Syringes; PA 540/97/2: Clexane® Forte Syringes.Legal category: POMMarketing Authorisation Holder: Sanofi-Aventis Ireland Ltd., Citywest Business Campus, Dublin 24, Ireland.Further information is available from: Sanofi 18 Riverwalk, Citywest Business Campus, Dublin 24 or contact IEmedinfo@sanofi.com Tel.: (01) 4035600.

References:1. CLEXANE® Summary of Product Characteristics. sanofi 2. sanofi Data on file April 2012

Please refer to the Summary of Product Characteristics which can be found on IPHA @ http://www.medicines.ie/ before prescribing.

Information about adverse event reporting can be found at www.imb.ie Adverse events should be reported to the Sanofi Drug Safety Department

GBIE.ENO.13.06.01 Date of preparation July 2013

RRD01246 Clexane Sanofi A4 Ad_V6 (Resized).indd 1 8/8/13 3:00 PM