The Journal of the Irish Practice Nurses AssociationIssues 3 and 4 Volume 6 May/June and July/August 2013

INflAMMATory JoINT dIseAseTrish Bewley and Dr Mark J I Phelan

IBs – dIAgNosIs ANd MANAgeMeNTThomas Broe

osTeoPorosIs: The sIleNT kIllerProfessor Moira O’Brien

INJecTIoN TechNIque – ProMoTINg BesT PrAcTIceForum for Injection Technique Ireland

four eAsy sTePs To helP you eNTer The IPNA

clINIcAl AwArdLisa Nolan

edITorIAl: chAlleNges or oPPorTuNITIes

Roisin Doogue

Designed to help your smokers quit for good

90% more effective at helping smokers quit compared with placebo at 12 weeks1

(34% quit on NICORETTE® INVISIPATCH™ vs 17.5% on placebo; p<0.001).

Well tolerated with a good safety profile2

www.nicorette.ie For every cigarette, there’s a nicorette®

“ I used to be stuck on smoking. With NICORETTE® INVISIPATCH™, I’m sticking with quitting”

nicotine

Nicorette Invisi Patch Product Information:Product Name: Nicorette Invisi 10mg/16 hours Transdermal Patch. Nicorette Invisi 15mg/16 hours Transdermal Patch. Nicorette Invisi Extra Strength 25mg/16 hours Transdermal Patch Composition: 10mg Patch - Nicotine, 10mg released over 16 hours use. 15mg Patch - Nicotine, 15mg released over 16 hours use. 25mg Patch - Nicotine, 25mg released over 16 hours use. Pharmaceutical Form: Beige semi-transparent patch consisting of pre coated backing layer, nicotine source layer, a skin contact adhesive layer on a pre-coated, aluminized and siliconised release layer with “nicorette” printed on the top face of the patch. Indications: For the treatment of tobacco dependence by relieving nicotine craving and withdrawal symptoms, thereby facilitating smoking cessation in smokers motivated to quit. Dosage: Adults and the Elderly: Nicorette Invisi Patch should not be used concurrently with any other nicotine products and patients must stop smoking completely when starting treatment. The patch should be applied to an intact area of the skin upon waking up in the morning and removed at bedtime. Patch treatment mimics the fluctuations of nicotine over the day in smokers, with no nicotine administration during sleep. Daytime nicotine patch treatment does not give the nicotine induced sleep disturbances seen with nicotine administration during sleep.Heavy smokers are recommended to start at Step 1 with the 25 mg/ 16 hours patch and use one patch daily for 8 weeks. Gradual weaning to the 15 mg/16 hours patch for 2 weeks followed by the 10 mg/16 hours patch daily for 2 weeks. Light smokers are recommended to start at Step 2 (15 mg) for 8 weeks and decrease the dose to Step 3 (10 mg) for the final 4 weeks. Use of the patch beyond 6 months is generally not recommended. Special Warnings and Precautions: Nicotine in any dose form is capable of inducing a dependence syndrome after chronic use and is highly toxic after acute use. However, dependence with Nicorette Invisi Patch is a rare side-effect and is both less harmful

and easier to break than smoking dependence. Particular cardiovascular patient groups should only use Nicorette Invisi Patch after consulting a physician. These patients include those who have experienced a serious cardiovascular event, or hospitalisation for a cardiovascular complaint, in the previous 4 weeks (e.g. stroke, myocardial infarction, unstable angina, cardiac arrhythmia, coronary artery bypass graft and angioplasty) or those who suffer from uncontrolled hypertension.Nicorette Invisi Patch should be used with caution in patients with severe/moderate hepatic impairment, severe renal impairment, active duodenal and gastric ulcers. The risk of using nicotine replacement therapy should be weighed against the risk of continued smoking. Nicotine, both from nicotine replacement products and smoking, causes the release of catecholamines from the adrenal medulla. Therefore Nicorette Invisi Patch should also be used with caution in patients with uncontrolled hyperthyroidism or phaeochromocytoma. Patients with diabetes mellitus may require lower doses of insulin as a result of smoking cessation. Patients with chronic dermatological disorders such as psoriasis, chronic dermatitis or urticaria should not apply Nicorette Invisi Patch to the affected areas. Erythema may occur. If it is severe or persistent, treatment should be discontinued. Interactions: Smoking (but not nicotine) is associated with an increase in CYP1A2 activity. After cessation of smoking, reduced clearance of substrates for this enzyme may occur. This may lead to an increase in plasma levels for some medicinal products of potential clinical importance and for products with a narrow therapeutic window, e.g. theophylline, tacrine, clozapine and ropinirole. The plasma concentration of other drugs metabolised in part by CYP1A2 e.g. imipramine, olanzapine, clonipramine and fluvoxamine may also increase on cessation of smoking, although data to support this are lacking and the possible clinical significance of this effect is unknown. Limited data indicate the metabolism of flecainide and pentazocine may also be induced by smoking.

Undesirable Effects: Nicorette Invisi Patch may cause adverse reactions similar to those associated with nicotine administered by other means and are mainly dose dependent. About 20% of users experienced mild local skin reactions, during the first weeks of treatment. Some symptoms, such as dizziness, headache and sleeplessness may be related to withdrawal symptoms associated with abstinence from smoking. Increased frequency of aphthous ulcer may occur after abstinence from smoking. The causality is unclear. Nervous system disorders: Common:Dizziness, headache.Cardiac disorders: Uncommon:Palpitations. Very rare: Reversible atrial fibrillation. Gastrointestinal disorders: Common: Gastro-intestinal discomfort, nausea, vomiting. Skin and subcutaneous. Uncommon: Urticaria tissue disorders: General disorders and Very common: Itching administration site, Common: Erythema disorders. Marketing Authorisation Holder: McNeil Healthcare (Ireland) Limited, Airton Road, Tallaght, Dublin 24, Ireland. Marketing Authorisation Number: 10mg Patch - PA 823/49/21, 15mg Patch PA 823/49/22, 25mg Patch – PA 823/49/23. Date of (Partial) Revision of the Text: March 2011. Legal Category: Supply through pharmacies only. Product not subject to medical prescription.Further information available upon request from Johnson & Johnson (Ireland) Ltd.

References: 1. Data on file – CEASE 4. 2. Tønnesen P et al. Eur Resp J 1999; 13: 238–246.

IRE/NI/12-0218

InvisiPatch NursingGenPract Ad.indd 1 21/01/2013 16:33

1

editorial

Primary care: challenges

or opportunities?

There has never been a more challenging time to work in Primary Care. However, challenges can also bring change and opportunity. Primary health care is changing at a significant rate in Ireland. It has been identified as a priority area for service development in all strategy documents and development plans since the turn of the millennium. In 2001, a strategy for the development of primary care services was published by the Department of Health. The aim of this strategy was to improve quality and access,

reduce the burden on secondary care and provide a more cohesive service to patients in the community. The development of primary care teams to provide integrated care is envisioned as the cornerstone of service delivery in the community. Although only a handful of primary care centres are in operation to date, primary care teams have been developing throughout the country. Health service providers, including GPs, Practice Nurses, Public Health Nurses, Physiotherapists, Occupational Therapists, Community Dietitians and Social Workers have been meeting, planning and coordinating care with the aim of delivering a service that reflects the community’s needs. The aim is to deliver not only standardised, but individualised care.

Practice nursing is pivotal in primary care. We make a difference to patients’ lives every day. Practice nursing is a specialised area of nursing that is truly committed to nursing values and holistic patient, family and community care. Practice nurses provide services that are patient focused, accessible and quality driven. The services provided are constantly changing and are based on the needs of the communities we serve. Practice nurses are uniquely placed to offer advice and support in the management and prevention of long-term conditions. We build up trust, and this enables us to form relationships and work in partnership to improve the quality and effectiveness of holistic care.

Our economic climate is in turmoil. Resources are limited, putting pressure on decision makers to allocate resources to areas of greatest need. Chronic disease management accounts for a major proportion of the health care budget. Currently this could be better utilised. Funding the education of practice nurses to deliver the clinical programmes of care can improve the level of care patients receive, reduce hospitalisations and in turn significantly reduce the cost of health care to the exchequer.

It is well documented that practice nurses who are educated, and have acquired the appropriate skills and qualifications, have demonstrated improved access to care, improved patient outcomes and reduced hospital waiting lists. Conversely, lack of educational funding has been identified as a barrier.

Recent public discussion has not painted nursing and healthcare in a good light, highlighting many problems and deficits in the current system. I urge all of you dedicated practice nurses to not only hear your patient’s stories but to act as an advocate for them. If care has not been to an appropriate standard, assist patients and their families in making a formal complaint. This is the only way we can help weed out sub standard care and optimise the top class care everyone deserves.

Practice nurses are an enthusiastic, motivated and progressive group of nurses. Members of the IPNA have always shown determination and commitment to continued professional development. Since its establishment in 1993, the IPNA has grown into an organisation that not only facilitates and encourages education but also provides continued professional development for practice nurses. The recent co-operation with other disciplines e.g. ICGP, HSE and other groups has facilitated the IPNA with the capability of offering online learning modules which will be another way to gather our Continuing Education Units (CEUs). The plan is to develop a suite of online learning modules which will be available to members through the member’s area of our website. Diversity in the educational opportunities provided by the IPNA is pivotal to facilitate the changing needs of our practice nurse members. The IPNA plans to support members in attaining CEUs through branch meetings, the national annual conference and elearning modules.

Continue to embrace the challenges and opportunities in primary care. After all, the communities we serve deserve the best healthcare we can provide.

Róisín DoogueNational Chairperson IPNA

2

Issue 5 Volume 2 September / October2009

ContentsThe Journal of the Irish Practice Nurses Association

Issue 3 Volume 6 May / June 2013

Nursing in General Practice is published by GreenCross Publishing Ltd., 7 Leeson Street, Dublin 4. Tel: 01 4410024 Fax: 01 547 2388Email: 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. 2013The 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

1 edITorIAl

4 News

8 BrANch News

revIews

10 IrrITABle Bowel syNdroMe – dIAgNosIs ANd MANAgeMeNT IBS diagnosis rarely needs to be revised and no evidence exists that it leads to more serious GI diseases

Thomas Broe

13 INflAMMATory JoINT dIseAse Management and progress of inflammatory joint disease with biological agents and the development of a seamless service Trish Bewley Bsc, srN, rheumatology Nurse specialist, galway clinic and dr Mark J I Phelan,

23 osTeoPorosIs: The sIleNT kIller Osteoporosis is a preventable disease and treatable in the majority of cases. Professor Moira o’Brien

IN PrAcTIce

18 INJecTIoN TechNIque – ProMoTINg BesT PrAcTIce FIT’s mission is to support people with diabetes using injectable therapies forum for Injection Technique Ireland

TechNology

27 four eAsy sTePs To helP you eNTer The IPNA clINIcAl AwArd lisa Nolan

ABsTrAcTs

29 focus oN: Allergy

30 focus oN: PAIN

31 ProducTs

33 crossword

EDITORMaura Henderson

CONSUlTING EDITORSDarina lane and Ruth Morrow

DESIGNERBarbara Vasic

PUBlISHERSGraham CookeMaura Henderson

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

4

newsNEC NEWS

IPNA AwArds 2013The following awards are being offered to members this year. Please see IPNA website (Grants and Awards page) and recent eNewsletter for more details.• Practice Nurse of the Year 2013.• Valerie Mangan IPNA loyalty Award 2013.• IPNA Clinical Award 2013 (ESC CVD Prevention Guidelines

2012).

IPNA ANNuAl educATIoNAl coNfereNce & AgM 2013Friday 11th/Saturday 12th October in the Radisson Blu Hotel, Athlone; hosted by the IPNA North Dublin Branch. Theme: Old Issues – New Ideas.

Registration forms and programme will be emailed and posted on the IPNA website as soon as they are available. Exhibitor queries can be e-mailed to ipnaconference@irishpracticenurses.ie

IPNA MeMBers IN florA woMeN’s MINI-MArAThoNCora Goold (National PRO) is coordinating a group of members to walk or run the Flora Women’s Mini-Marathon on behalf of the IPNA and in support of the Marie Keating Foundation.

This charity was chosen by the NEC in honour of the two NEC Officers who have successfully beaten breast cancer over the past year. Anyone interested should register themselves for the Mini-Marathon first and then contact Cora at pro@irishpracticenurses.ie

Nec MeeTINgs 2013 Wednesday 4th September 2013, Ashling Hotel, D.8, 11am-3pm.Friday 11th October 2013. 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 and useful information that is retweeted from other groups – directly to your timeline.

lisa Nolan, IPNA Administrator Tel: 042-9692403 email: admin@irishpracticenurses.ie

Every vaccine is little victory in the fight against serious childhood diseaseA major new immunisation campaign was launched last month. The public health campaign highlights the importance of childhood immunisation in preventing serious disease and was developed by Pfizer Healthcare Ireland and is supported by the HSE. The campaign includes a TV, radio and bus shelter ad which goes live today – further information is available on the HSE National Immunisation website, www.immunisation.ie.

Dr James Reilly, Minister for Health officially launched the campaign: Vaccination is now recognised as one of the most successful and effective public health interventions for saving lives and promoting good health. Prevention is a key goal in healthcare and the ability of vaccines to prevent illness and death associated with many serious diseases is one of the success stories of scientific innovation.”

“Immunisation is a simple, and effective way of protecting children against certain diseases. Parents and carers need to remember that children need to complete the full immunisation schedule to ensure they are adequately protected,” said Dr. Brenda Corcoran, Consultant in Public Health Medicine, HSE National Immunisation Office. “Getting these diseases presents a much greater risk than the minor side effects from immunisation. We often forget how serious these are – thanks largely to vaccines – because we don t see them nearly as much as we used to. However, they can cause serious illness and death,” she added.

Measles used to kill thousands of people in Europe and the United States every year. In the 1940s and 1950s, tens of thousands of children were crippled or killed by polio. As recently as the mid 1980s, over 100 children a year in Ireland suffered from meningitis and other serious complications as a result of routine childhood diseases. These diseases have not changed. They can still cause pneumonia, choking, meningitis,

brain damage and heart problems in children who are not protected. These diseases continue today, to present a significant risk to Irish children and the importance of vaccination cannot be underestimated.

“Immunisation is one of the most important things you can do for your child. By vaccinating, you help protect your child from getting diseases that can cause both minor and major illness,” said Professor Denis Gill, Chairman, National Immunisation Advisory Committee. “Immunisation rates in Ireland are relatively high but we need to achieve a 95% vaccination rate to ensure the public is effectively protected against disease.”

Speaking about the campaign, Paul Reid, Specialty Care Director, Pfizer, said: “In Ireland, effective implementation of a comprehensive childhood immunisation schedule has resulted in very significant reductions in the incidence of serious, vaccine preventable, childhood diseases. This new campaign aims to highlight the positive impact and health benefits of vaccines, and how they are an effective and economical way to prevent infectious disease.”

For more information on vaccines and immunisation visit www.immunisation.ie

in the ongoing battle against serious childhood diseases.

www.immunisation.ie

PZF002 V for Vac 6S.indd 1 16/04/2013 14:40

5

news

99 & Me – bipolar disorder campaignWith approximately 1 in every 100 people in Ireland affected by bipolar I disorder the 99 & Me campaign, launched recently by lundbeck, tackles the misunderstanding that surrounds the condition.

One of the key aims of 99 & Me is to remove the stigma and negativity surrounding bipolar disor-der and provide information and support both to people with the condition and their loved ones.

Speaking at the launch of the campaign, Dr Paul Scully, Consultant Psychiatrist, St James’s Hospital said: “It’s essential that we continue to address the stigma surrounding bipolar disorder. From the public’s view there are various myths and a general lack of understanding surround-ing the condition and often this can hinder those who would benefit from support accessing the services they need.

“Appropriate, accessible resources and sup-ports can address this and are much-needed. 99 & Me fills this gap and is a useful tool for patients, families and healthcare professionals who may be interacting with these patients in primary care.”

Dr Scully added “Not infrequently bipolar disorder may be misdiagnosed as depression so a greater understanding of the condition, both from a medical perspective and that of patients and families, is vital. This new campaign seeks to ad-dress this issue and provides user-friendly information on the condition.”

A new website, www.99&me.ie, aims to empower those in the process of getting a diagnosis to seek treatment and support.

To inform the development of this campaign, research was undertaken by lundbeck in partnership with Empathy Re-search, to better understand people’s experiences of bipolar disorder.

Almost a third of people with the condition had experi-enced symptoms for 2-3 years before diagnosis with the most common symptoms that prompted people to seek help being unexplained mood swings (55%), risk-taking, poor judgment, reckless behaviour (46%) and an episode of mania (45%).

Eleven percent of those included in the survey were themselves diagnosed with bipolar disorder while 46% had a family member (parent, partner, sibling) with a diagnosis of the condition. Key findings indicated that a quarter of people were diagnosed between the ages of 31-40.

And, of the people with a diagnosis, only a third were diagnosed by a GP, while more than 78% of family members were diagnosed by a psychiatrist which clearly indicates the need for accurate understanding of the condition in primary care settings.

The majority (62%) sought treatment through the public health system, however more than a third of these had to wait three months or more to get an appointment with a psychia-trist.

More than a third of people with a diagnosis of bipolar disorder (37%) had problems taking medication as required and 1 in 3 people reported being unable to work due to the impact the condition has on their lives.

Association of Lactation Consultants in Ireland www.alcireland.ie

October 4th and

5th, 2013

Save the dates

Guest Speaker: Linda Smith IBCLC, author, birth educator, sports coach and more

Mind your language - creating expectations Coaching mums towards realistic expectations

Impact of birth practices on breastfeeding Assessing feeding and sucking difficulties

Plus

Community initiatives for breastfeeding Recent Irish research Small group discussions on: Choosing and using breast pumps, Is it time

for BYOB in hospitals, Achieving change in practice, and more.

Two full conference days and a social evening! Make sure you are there.

ALCI Annual Conference Creating Realistic

Breastfeeding Expectations Green Isle Hotel, Clondalkin, Dublin

6

news

The Irish Association for Nurses in oncology – recent affiliation The Irish Association for Nurses in Oncology (IANO) has announced that a number of other cancer nursing associations have recently come under the umbrella of the IANO.

The sub-specialty associations in question include the Irish Breast Care Nurses Association (IBCNA), the Irish Gynaecology Oncology Nurses Association (IGONA), the Irish lung Cancer Nurses Group (IlCNG), the Oncology Research Nursing Group (ORNG) and the Colorectal Cancer Nurses Association (CRCNA).

These different cancer nursing specialties have now become Special Interest Groups (SIGs) within the IANO and each SIG will be represented on the IANO national executive committee (NEC) by a co-ordinator of their association.

This is a very important development for cancer nursing in Ireland as it will facilitate greater sharing of expertise among our members which we feel will ultimately benefit patient care. In addition, it will allow for greater opportunities for cancer nurses to meet and network with colleagues at our annual conference and to communicate through our website http://www.iano.ie .

We would like to thank the Irish Cancer Society for their financial support in helping to fund this initiative.

Founded in 1982, the IANO is a non-profit organisation which promotes continuing nurse education and provides a forum for exchange of knowledge among cancer nurses in Ireland.

International Nursing and Midwifery conference NuIg

At the recent international Nursing and Midwifery conference, Building and Promoting excellence in Practice, at NuI galway were, Professor declan devane, conference chair and Professor of Midwifery at NuI galway; dr Mary quinn griffin cape western university usA; NuI galway President, dr Jim Browne; Professor Joyce fitzpatrick cape western university usA; Professor kathy Murphy, school of Nursing and Midwifery, NuI galway; and Adeline cooney, head of school of Nursing and Midwifery, NuI galway.

Attending the IMPAcT meeting sponsored by Pfizer healthcare were, rheumatology clinical Nurse specialists, geraldine Mannion, Trish Bewley and Ann-Maria curran.

collette cowan, group director of Nursing and Midwifery, galway and roscommon university hospitals group; Professor kathy Murphy, school of Nursing and Midwifery, NuI galway; Adeline cooney, head of school of Nursing and Midwifery, NuI galway; Jean kelly, director of Nursing and Midwifery, university hospital galway; NuI galway President, dr Jim Browne; Mary francis o’reilly, directory of the NMPdu; and Professor declan devane, conference chair and Professor of Midwifery at NuI galway.

IMmunology Pathways And innovative Clinical Therapeutics

Attending the IMPAcT meeting sponsored by Pfizer healthcare were, rheumatology clinical Nurse specialists, clara Bannon and una Martin.

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-000

0

NASONEX 50 micrograms/actuation Nasal Spray, Suspension mometasone furoate ABBREVIATED PRESCRIBING INFORMATION [Phenylethyl alcohol-free formulation] Refer to Summary of Product Characteristics before prescribing. PRESENTATION: Nasal spray suspension containing mometasone furoate (as monohydrate) 50 micrograms per actuation. USES: Adults and children aged 18 and over: Treatment of nasal polyps. Adults and children over the age of 12 years: For the treatment of the symptoms of seasonal allergic rhinitis or perennial rhinitis. Children 6 to 11 years of age: For the treatment of the symptoms of seasonal allergic rhinitis or perennial allergic rhinitis. In patients who have a history of moderate to severe symptoms of seasonal allergic rhinitis, prophylactic treatment with Nasonex may be initiated up to four weeks prior to the anticipated start of the pollen season. DOSAGE: Nasal Polyposis: Adults and children aged 18 and over: The usual recommended starting dose for polyposis is two actuations (50 micrograms/actuation) in each nostril once daily (total daily dose of 200 micrograms). If after 5 to 6 weeks symptoms are inadequately controlled, the dose may be increased to a daily dose of two sprays in each nostril twice daily (total daily dose of 400 micrograms). The dose should be reduced following control of symptoms. If no improvement in symptoms is seen after 5 to 6 weeks of twice daily administration, alternative therapies should be considered. Ef� cacy and safety studies of Nasonex Nasal Spray for the treatment of nasal polyposis were four months in duration. Seasonal or Perennial Allergic Rhinitis: Adults and children over the age of 12 years: Two sprays (50 micrograms/spray) in each nostril once daily (total dose 200 micrograms). Once symptoms are controlled, dose reduction to one spray in each nostril (total dose 100 micrograms) may be effective for maintenance. If symptoms are inadequately controlled, the dose may be increased to a maximum daily dose of four sprays in each nostril (total dose 400 micrograms). Dose reduction is recommended following control of symptoms. Children 6 to 11 years of age: One spray (50 micrograms/spray) in each nostril once daily (total dose 100 micrograms). Clinically signi� cant onset of action occurs in some patients within 12 hours after the � rst dose. Full bene� t of treatment may not be achieved in the � rst 48 hours. Regular use is recommended to achieve full therapeutic bene� t. CONTRAINDICATIONS: Hypersensitivity to any of the ingredients. Do not use in the presence of untreated localised infection involving the nasal mucosa. Patients who have experienced recent nasal surgery or trauma should not use a nasal corticosteroid until healing has occurred. PRECAUTIONS AND WARNINGS: Use with caution, if at all, in patients with active or quiescent tuberculous infections of the respiratory tract, or in untreated fungal, bacterial, systemic viral infections or ocular herpes simplex. There was no evidence of atrophy of the nasal mucosa following 12 months of treatment. Patients using Nasonex over several months or longer should be examined periodically for changes in the nasal mucosa. If localised fungal infection of the nose or pharynx develops, discontinuance of Nasonex therapy or appropriate treatment may be required. Persistence of nasopharyngeal irritation may be an indication for discontinuing Nasonex. The concomitant use of additional therapy may provide additional relief particularly of ocular symptoms. There is no evidence of HPA axis suppression following prolonged treatment with Nasonex. Patients who are transferred from long-term administration of systemically active corticosteroids to Nasonex require careful attention. The safety and ef� cacy of Nasonex has not been studied for use in the treatment of unilateral polyps, polyps associated with cystic � brosis, or polyps that completely obstruct the nasal cavities. Unilateral polyps that are unusual or irregular in appearance, especially if ulcerating or bleeding, should be further evaluated. Patients who are potentially immunosuppressed should be warned of the risk of exposure to certain infections. Rare cases of nasal septum perforation, increased intraocular pressure and/or cataracts have been reported following the use of intranasal corticosteroids. Nasonex should only be used in pregnant women, nursing mothers or women of child-bearing age if the potential bene� t justi� es the potential risk to the mother, foetus or infant. Systemic effects of nasal corticosteroids may occur, particularly at high doses prescribed for prolonged periods. These effects are much less likely to occur than with oral corticosteroids and may vary in individual patients and between different corticosteroid preparations. Potential systemic effects may include Cushing’s syndrome, Cushingoid features, adrenal suppression, growth retardation in children and adolescents, cataract, glaucoma and more rarely, a range of psychological or behavioural effects including psychomotor hyperactivity, sleep disorders, anxiety, depression or aggression (particularly in children). It is recommended that the height of children receiving prolonged treatment with nasal corticosteroids is regularly monitored. If growth is slowed, therapy should be reviewed with the aim of reducing the dose of nasal corticosteroid, if possible, to the lowest dose at which effective control of symptoms is maintained. In addition, consideration should be given to referring patient to a paediatric specialist. Safety and ef� cacy of Nasonex Nasal Spray for the treatment of nasal polyposis in children and adolescents under 18 years of age have not been studied. Treatment with higher than recommended doses may result in clinically signi� cant adrenal suppression. If there is evidence for higher than recommended doses being used, then additional systemic corticosteroid cover should be considered during periods of stress or elective surgery. In a placebo-controlled clinical trial in which paediatric patients (n=49/group) were administered Nasonex 100 micrograms daily for one year, no reduction in growth velocity was observed. INTERACTIONS: A clinical interaction study was conducted with loratadine. No interactions were observed. SIDE EFFECTS: Adverse effects commonly reported in clinical trials in adult and adolescent patients include headache, epistaxis, pharyngitis, nasal burning, nasal irritation and nasal ulceration. Other less common and rarely reported side effects are listed in the SPC. PACKAGE QUANTITIES: 18g per bottle, supplied with a metered-dose manual spray pump actuator which delivers 50 micrograms per actuation. Legal Category: Prescription Only Medicine. Marketing Authorisation Number: PA 1286/38/1 Marketing Authorisation Holder: Merck Sharp & Dohme Ireland (Human Health) Limited, Pelham House, South County Business Park, Leopardstown, Dublin 18, Ireland. Date of Revision of Text: June 2012 Further information is available on request from: MSD, Red Oak North, South County Business Park, Leopardstown, Dublin 18 or from www.medicines.ie. © Merck Sharp & Dohme Ireland (Human Health) Limited, 2012. All rights reserved. Date of preparation: August 2012.

Reference: 1. Shedden A. Impact of nasal congestion on quality of life and work productivity in allergic rhinitis: � ndings from a large online survey. Treat Respir Med. 2005;4(6):438-445.

Red Oak North, South County Business Park, Leopardstown, Dublin 18, Ireland

8

News for IPNA br ANches couNtry wIderegional news

cArlow

KATE ATTRIDE

The Carlow Branch of the IPNA held its last meeting before the summer break on Wednesday 8 May at 7.30pm in Teach Dolmen, Carlow. The meeting was very kindly sponsored by Catherine O’Donnell of Thermo Fisher who has organised our guest speaker on the night. Dearbhla Hunt is a dietitian with special interest in food allergies. She gave a very interesting presentation on the night. Thanks to Patricia McQuillan for organising the recent BlS study day in St Dympna’s Hospita; on Thursday 11 April and also for the up and coming training session on the new Growth Charts organised for HSE on Thursday 16th May in HSE lacken. We would like to thank all our members and sponsors for their on going support throughout the year.

cAvAN/MoNAghAN

MARGARET GEOGHEGAN

The Cavan/Monaghan branch held their first meeting for 2013 on 15 January in the Errigal Hotel, Cootehill. This meeting was sponsored by Ultan Kenny from GSK and the presentation was on allergic rhinitis. Ultan also introduced us to the GSK online learning webinar platform and encouraged us all to register with it. This will be a very useful elearning device for us and hopefully will be beneficial in attaining CEUs in the future.

Our next meeting was held on 21 February. This was an unusually well attended meeting. It was sponsored by Eddie Mitchell from Janssen Pharmaceutical Company of Johnson & Johnson in Ireland. The speaker was Una Forde Clinical Co-coordinator Monaghan Community Mental Health team. Una gave an excellent presentation outlining the mental health services for adolescents in our area. It was very informative and there was great interaction from the members.

The minutes from the National Executive meeting were discussed and Ruth brought us up to speed on developments at national level. Teresa Shortt clarified some issues from CervicalCheck re inappropriate smears, ineligible smears and labeling of specimens.

Our April meeting was sponsored by Michelle Doherty from Bayer Medical. The presentation was given by Suzanne Walsh, CNS in Stroke Management, St James’s Hospital. Suzanne gave a very excellent presentation on the acute management of stroke.

As the branch financial status is quite good we have decided to help our members with funding for study days or courses. There is criteria for same and members can apply to the branch committee. An email has been sent to members outlining the criteria. Dates for future branch meetings were confirmed.

Asthma and COPD training is ongoing in this region. This course is facilitated by Ruth Morrow ANP in General Practice and is well worth attending.

Our branch members would like to wish our colleague Jenni Wilson a speedy recovery.Hope you will soon be back fighting fit again,The branch would like to welcome the new members who have joined. We can assure you it is very worthwhile joining the IPNA.

We look forward to meeting you all at our next meeting and hope you will become an integral part of our branch.

doNegAl

BRIDGET BREEN

Our first meeting of the year was on 26 February in the Radisson, letterkenny. The evening was sponsored by Kevin O’Donnell from Astra Zeneca. Dr Michael Sugrue from letterkenny Hospital gave a very informative and engaging presentation on breast cancer, from diagnosis, to treatment and recovery. The meeting was well attended and feedback was positive. Ursula Molloy, our colleague who is currently doing the post graduate diploma in primary care, gave a brief overview on the diabetic module.

John Downes the Novartis rep sponsored the March meeting. He introduced us to Regina Walsh the COPD nurse adviser with his company. She will be visiting the practices with a view to assisting in running COPD clinics. Deirdre O’Neill from Aptamil sponsored the April meeting. Niamh Brannelly, a specialist dietitian spoke on childhood allergies. She answered questions from the floor and we all came away with plenty knowledge on the subject.

Nicky Walsh from Meda is looking after our next meeting on 26 May in the Yellow Pepper restaurant. As this is the last meeting before the summer break, we are hoping for a good turn out.

Registration is slightly up on last year; there are over 70 practice nurses in Donegal but just 33 are DPNA members. Overall the attendances at meetings are up, which is good.

9

News for IPNA br ANches couNtry wIde regional news

NorTh duBlIN

ANNE MARIE EllWOOD

We are a very busy branch at the present preparing to host the National Conference in October so we have been alternating branch meetings with conference meetings. Plans are in full swing for an educational and fun filled conference.

Our last meeting was 13 March at the Hilton Hotel and our speaker was Dr Eddie Murphy, Psychologist (of Operation Transformation fame) who gave a really interesting, funny and interactive talk on motivational interviewing. Many thanks to lucy Miley from Novo Nordisk for sponsoring the meeting.

The 9 May meeting on COPD was held at the Hilton Hotel, Malahide Road.We wish our colleagues in the newly formed South Dublin Branch all the very best and look forward to working closely with them.

Hopefully we will have new members of the IPNA to swell our ranks, as well the usual stalwart members!

souTh duBlIN

KAREN CANNING AND ANNE O’CONNOR

We’ve had two meetings since our submission in the last issue of Nursing in General Practice. We would like to thank the Wicklow branch for their good wishes.

Our April branch meeting was very well attended at Bewley’s Hotel, leopardstown. Jane Smyth, MSD, very kindly sponsored the night and brought Sophie Charles, Cardiac Rehabilitation Coordinator at St Columcille’s Hospital, loughlinstown, who gave us an insight into their rehabilitation programme.

The guest speaker on the night was Maura McCrudden, Senior Case Worker Area 1, who delivered a thought provoking presenta-tion on Elder Abuse.

Anne O’Connor (Sec) informed us of the topics and sponsors for all meetings until the end of the year and that all are listed on the IPNA website.

We advised those present that the National Conference, being hosted by IPNA North Dublin branch in Oct 2013, would be a great event and urged our members to attend.

Our May meeting was on the topic of Anaphylaxis in Primary Care. Our guest speaker was Johanna O’Callaghan, Respiratory CNS from AMNCH, who gave a very informative and practical presentation relevant to primary care. This meeting was kindly sponsored by Vista Pharmaceuticals, the makers of Jext, Adrenaline Auto Injector Pens. On this occasion we were at the Plaza Hotel, Tallaght and once again had great attendance.

We will now break for the summer during which time we are calling all members to make suggestions of topics of interest for next year’s meetings. We are also asking all members to avail of the early bird rate and book their place at the National Conference in October. We’ll have great craic there, not to mention enjoy updating our skills and knowledge!

Our next meeting will take place on Tuesday 10th September at Bewley’s Hotel, leopardstown. Our guest speaker will be Imelda Noone, Stroke CNS, St. Vincent’s Hospital. Imelda will present on the changing topic of Afib and it’s management.

Thanks again, to all who have helped support our new branch and who continue to do so by showing such enthusiasm. Enjoy the summer.

kIlkeNNy

lEONIE FINNEGAN, CHAIRPERSON

Hello to all from the Kilkenny branch. With summer coming, we have gained some valuable education updates to be considering during our break! Our March meeting was sponsored by MSD, though local rep Frank Tynan. The Management of Heart Failure, was excellently covered by CNS from St luke’s Hospital, Roseanne Coghlan and the educational presentation received Category 1 Approval and 2 CEUs. This update proved very relevant with interactive discussion ongoing throughout. We were also reminded of the service from MSD of a helpful, informative, educational website at Univadis.ie and the upcoming IPNA Clinical Award 2013 also supported by MSD.

Our April education update was sponsored by Nova Nordisk. Following a very practical synopsis on diabetes education and man-agement by Novo Nordisk Diabetic Nurse Educator, lisa Hennessy. Following this Olive O’Grady from the Diabetic Nurse Specialist team in St luke’s Hospital Kilkenny, undertook case study reviews and put some of this theory into practice. It was an enjoyable session and reinforced current treatment options and choices.

A lengthy and intense interest was again voiced by members on the current situation with Medication Protocols. We are hop-ing that the situation will continue to progress as these would greatly assist us to ensure standardised, quality and effective care in delivery of vaccination medications.

We again wish to remind all our members that we plan a change of Officers in the autumn – of chairperson and secretary and would urge everyone to consider these opportunities over the summer months. We welcome louise Hogan a new member to the Kilkenny branch and wish her many hours of happy networking and education at the branch meetings. We look forward to Carol Mc Namara, Cervical Check National Training Coordinator, who will attend branch meeting on 15 May to give an update on current smear-taking guidelines in the Pembroke Hotel @ 19.00 sharp.

Thanks again to all our members who supported each other and attended so well over the last year and hoping our summer is sun filled and relaxing. See you all in September.

10

clinical review

Irritable bowel syndrome – diagnosis and management ThoMAs Broe, COMMUNITY PHARMACIST

Irritable bowel syndrome (IBS) is a chronic relapsing and remitting functional disorder of the gastrointestinal (GI) tract.1 It is characterised by symptoms of recurrent abdominal pain or discomfort directly associated with disturbances in defecation which are not explained by

structural abnormalities.2 While the symptoms are frequent the GI tract does not become damaged.3 Spiller notes that IBS diagnosis rarely needs to be revised and no evidence exists that it leads to more serious GI diseases.4 It has recognised links with absenteeism and can be very disruptive to a patient’s well being and quality of life.5

PrevAleNceIBS has a prevalence of between 10-20%.6 Prevalence is higher among younger people, females and those with coexisting functional GI diseases, particularly dyspepsia.1 A recent meta-analysis highlighted that patients with dyspepsia had an eightfold increase in the prevalence of IBS.7 Women are more likely to suffer from constipation predominant IBS while men

are more likely to suffer from diarrhoea predominant IBS. Symptoms in women are typically more pronounced around the menses. Women are also more likely to seek healthcare for their condition.8 less than one-third of people with IBS have accessed healthcare to have it diagnosed.3 Diagnosis is made based on a broad range of symptoms which are reported by the patient, with the result that numerous theories have been put forward to explain the causes of IBS. To date, rather unsurprisingly the search for a unifying hypothesis has failed.9

cAusesSuggested causes include hypermobility, irregular intestinal secretion, visceral sensitivity, past infection of the gut and an imbalance in the gut flora.10 Patients who have had gastroenteritis are six times more likely to develop IBS and the chances are increased with the following risk factors: prolonged fever, young age, anxiety and depression.11 Patients with IBS have higher rates of depression and anxiety than controls without IBS, however, despite this longitudinal studies

11

clinical review

have shown survival rates in the community are unaffected by IBS.12 Three per cent of all general practice consultations are due to IBS13 and it is the most common condition encountered by gastroenterologists.5

syMPToMsThe main symptoms of IBS reported by patients are recurrent abdominal pain and/or discomfort, which are simultaneously experienced with changes in stool frequency or form and are usually alleviated by defecation. Altered stool frequency can mean diarrhoea, constipation or a mixture of both. As Spiller also points out, it is the relationship of the pain/discomfort with the bowel function which distinguishes this condition from gynaecological, urinary or musculoskeletal disorders.4 Bloating is also a common symptom.14 As well as the GI symptoms, patients often experience lassitude, headache, backache, dysmenorrhoea and dyspareunia.4 People sometimes wrongly assume they have a food allergy as their symptoms often coincide with the consumption of a particular food.9 Often this is the body’s physiological response to food – induction of colonic contractions – and is related to the underlying cause of IBS and not the food type consumed.13 As mentioned earlier IBS often coexists with other functional GI diseases so heartburn can also be present.

dIAgNosIsAs no biological marker exists, a diagnosis of IBS is made on symptoms-based criteria. In the past IBS was considered by a process of exclusion by carrying out tests and when these had been exhausted and proved inconclusive, a diagnosis of IBS was made. Guidelines advocate a move away from unnecessary testing and encourage diagnosis through symptoms based criteria.14 In patients exhibiting signs of IBS testing for coeliac disease is advised as the symptoms overlap and studies have found that if 5% of those tested are coeliac then the testing is cost effective.12 If certain red flag symptoms are present then a referral for further tests is required.14 These red flag symptoms include:

•unintentionalandunexplainedweightloss•rectalbleeding•afamilyhistoryofbowelorovariancancer•andinpeopleagedover60,achangeinbowelhabitlasting

more than 6 weeks with looser and/or more frequent stools.

Table 1. criteria for diagnosis14

Abdominal pain or discomfort lasting longer than three months that is relieved by defecation or is associated with a change in stool frequency or appearance.

And a minimum of two of the following apply:

abdominal bloating, distension, tension or hardness,

straining, urgency or incomplete evacuation on passing stools,

symptoms attenuated by eating,

the passing of mucus

The symptoms must also have first presented at least six months beforehand.

clAssIfIcATIoNIBS can be classified according to the predominant bowel habit15 as shown in Table 2 and this in turn can affect treatment. For around a third of patients their bowel habit changes from one sub-type to another over months or years.4

Table 2. Predominant stool type

IBS-constipation≥ 25% hard or lumpy<25% loose or watery

IBS-diarrhoea≥ 25% loose or watery< 25% hard or lumpy

IBS-mixed pattern≥ 25% hard or lumpy≥ 25% loose or watery

IBS-unspecified<25% hard or lumpy<25% loose or watery

TreATMeNTAs no gold standard exists for the treatment of IBS, treatments tend to focus on lessening symptoms and not actually curing the conditions (Sainsbury).1 IBS is well cited as being particularly susceptible to placebo and this presents difficulties when conducting trials.5 A meta-analysis showed a pooled placebo response rate of almost 40%.10

lIfesTyle ANd dIeTThere are many simple steps patients can take surrounding their own diet and lifestyle which may improve their condition and lessen the extent of symptoms. National Institute for Health and Clinical Excellence (NICE) guidelines recommend the following:14

• Drink at least eight cups of fluid (preferably non-caffeinated)• Make time for leisure and relaxation• Assess the patient’s fibre intake with a view to regulating

it depending on the predominant stool type. For instance in diarrhoea predominant IBS (D-IBS) the consumption of insoluble fibre such as bran should be reduced. If constipation is a problem soluble fibres need to be increased and these include oats and supplements such as ispaghula powder.

• limit to three per day the number of cups of caffeinated products like tea or coffee

• Cut down on alcohol and carbonated drinks• limit the amount of resistant starch (found in processed

meals) eaten as it is reaches the colon undigested• Eat no more than three portions of fruit each day • Wind and bloating can be alleviated by increasing intake of

oats, by having an oats-based breakfast cereal, and taking up to one tablespoon of linseeds per day.

fIrsT-lINe TherAPIes14

As well as the dietary and lifestyle options mentioned above, available pharmacological therapies include:• antispasmodics (including peppermint oil) have been found

to reduce abdominal pain• loperamide should be used to reduce stool frequency but

may not improve other symptoms • laxatives should be offered to patients with the exception

of lactulose. Depending on the frequency and form of the stools, the patient should be advised how to tailor their doses of laxatives and the anti-diarrhoeal drug loperamide, to achieve soft well-formed stools.

secoNd-lINe TherAPIes14

Anti-depressants can be prescribed to help alleviate the abdominal pain. Tricyclic anti-depressants should be tried first and if proven ineffective then selective serotonin reuptake inhibitors (SSRIs) should be considered.

ProBIoTIcsAs the intestinal fauna of IBS patients is often altered, it is thought that this bacterium in the gut may have a role in the cause of the disease16 and that probiotics may be of clinical use

12

clinical review

but how they exert benefit is still unknown.17

The World Health Organization defines probiotics as ‘live organisms which when administered in adequate amounts confer a health benefit on the host’.17

A recent meta-analysis found that probiotics seem to be effective with a number needed to treat of four to improve or cure one patient’s IBS symptoms. They have a very good safety profile.16 They were found to lessen abdominal pain, bloating and flatulence. Uncertainty still remains with regard to the most efficacious species and strain. NICE guidelines recommend that probiotics be stopped after four weeks if no improvement is seen.14

In patients with gastro-oesophageal reflux disease (GORD) demonstrating IBS like symptoms it has been found that proton pump inhibitors (PPIs) can improve these.18

develoPMeNTs ANd lATesT reseArchThe European Medicines Agency (EMA) recently granted approval to Constella, which contains linaclotide and is indicated for the symptomatic treatment of moderate to severe IBS-C in adults.19 It reduces visceral pain and constipation with diarrhoea being the most common side effect.

The Cork longitudinal IBS Study (Colonist) is a five year longitudinal study aimed at charting the phenotype, immune profile, dietary intake and composition of the human intestinal micro biota of over 500 IBS sufferers and compare this to the micro biota in healthy subjects.20

A further study also conducted by researchers at University College Cork found that IBS increases the risk of miscarriage and ectopic pregnancy.21

coNclusIoNDiagnosis can often be difficult, and despite symptoms based criteria existing, may only happen after the patient has gone through an extensive list of unnecessary tests. Treatment of IBS is aimed solely at the relief of symptoms and while treatment algorithms exist, it is very much up to the patient how they choose to manage their condition as dietary advice can be observed and many of the first-line pharmacological treatments are available over the counter.

Aside from pharmacological treatments dietary supplements such as linseed, which can help with the bloating experienced with IBS, can be bought in most pharmacies today.

As highlighted earlier in the article, not everyone with the condition seeks medical treatment and are as such self-diagnosed or unaware that their symptoms have a medical diagnosis. The practice nurse potentially has access to this patient group, and can continue to support self-care; and when red flag symptoms present suggest the patient seeks the GP’s advice. For those patients with a clinical diagnosis of IBS, it is important as with any new medical information, to be supportive following diagnosis. It is more likely that this group will be better educated as to how to manage their condition.

references1. Sainsbury A, Ford AC. Treatment of irritable bowel

syndrome: beyond fiber and antispasmodic agents. Therap Adv Gastroenterol. 2011 Mar;4(2):115-27.

2. Drossman DA, Camilleri M, Mayer EA, et al. AGA technical review on irritable bowel syndrome. Gastroenterology 2002; 123:2108–2131.

3. National Digestive Diseases Information Clearinghouse. Irritable bowel syndrome. National Institute of Health Publication No. 12-693. Page last updated July 2, 2012. Accessed at http://digestive.niddk.nih.gov/ddiseases/pubs/

ibs/ on 15 Oct 2012.4. Spiller R. Clinical update: Irritable bowel syndrome. Lancet.

2007;369(9573):1586-15885. Clarke G, Cryan JF, Dinan TG, Quigley EM. Review article:

probiotics for the treatment of irritable bowel syndrome--focus on lactic acid bacteria. Aliment Pharmacol Ther. 2012 Feb;35(4):403-13. doi: 10.1111/j.1365-2036.2011.04965.x. Epub 2012 Jan 8.

6. Kennedy TM, Jones RH. Epidemiology of cholecystectomy and irritable bowel syndrome in a UK population. Br J Surg. 2000;87:1658–1663.

7. Monnikes H, Schwan T, Van Rensburg C, Straszak A, Theek C, Sander P, luhmann R. Randomised clinical trial: sustained response to PPI treatment of symptoms resembling functional dyspepsia and irritable bowel syndrome in patients suffering from an overlap with erosive gastro-oesophageal reflux disease. Aliment Pharmacol Ther. 2012 Jun;35(11):1279-89. doi: 10.1111/j.1365-2036.2012.05085.x. Epub 2012 Apr 8.

8. Adeyemo MA, Spiegel BM, Chang l. Meta-analysis: do irritable bowel syndrome symptoms vary between men and women? Aliment Pharmacol Ther. 2010 Sep;32(6):738-55. doi: 10.1111/j.1365-2036.2010.04409.x. Epub 2010 Jul 22.

9. Morcos A. Dinan T. Quigley EM. Irritable bowel syndrome: Role of food pathogenesis and management. Journal of Digestive Diseases. 2009;10:237-246

10. Ford AC, Vandvik PO. Irritable bowel syndrome. Clin Evid. 2012;01:410

11. Thabane M, Kottachchi DT, Marshall JK. Systematic review and meta-analysis: the incidence and prognosis of post-infectious irritable bowel syndrome. Aliment Pharmacol Ther. 2007;26:535–44.

12. Ford AC, Talley NJ. Clinical Review: Irritable Bowel Syndrome. BMJ. 2012;345:e5836

13. Spiller RC. Irritable Bowel Syndrome. British Medical Bulletin. 2004;72:15-29

14. National Institute for Health and Clinical Excellence (NICE). Irritable bowel syndrome in adults: Diagnosis and management of irritable bowel syndrome in primary care . CG61. london, NICE. 2008

15. longstreth GF, Thompson WG, Chey WD, Houghton lA, Mearin F, Spiller RC. Functional bowel disorders. Gastroenterology. 2006;130:1480–91.

16. Moayyedi P, Ford AC, Brandt lJ, Foxx-Orenstein AE, Cremonini F, Talley NJ, et al. The efficacy of probiotics in the treatment of irritable bowel syndrome: a systematic review. Gut. 2010;59:325-32

17. Verna, EC, lucak S. Use of probiotics in gastrointestinal disorders. Ther Adv Gastroenterol. 2010;3(5):307-319

18. Mönnikes H, Heading RC, Schmitt H, Doerfler. H Influence of irritable bowel syndrome on treatment outcome in gastroesophageal reflux disease. World J Gastroenterol. 2011 July 21; 17(27): 3235-3241

19. Committee for Medicinal Products for Human Use. Summary of positive opinion for Constella. European Medicines Agency. 20 Sep 2012 . EMA/CHMP/604998/2012

20. Alimentary Pharmabiotic Centre. COlONIST – the COrk lONgitudinal IBS STudy. Biosciences Institute, University College Cork. 2012. Accessed at: http://www.ucc.ie/research/apc/content/research/clinical_trials.html on 15 Oct 2012.

21. Khashan AS, Quigley EM, McNamee R, McCarthy FP, Shanahan F, & Kenny lC. Increased Risk of Miscarriage and Ectopic Pregnancy Among Women With Irritable Bowel Syndrome. Clin Gastroenerol Hepatol 2012 Aug;10(8):902-9. Epub 2012 Feb 25.

13

clinical review

Management and progress of inflammatory joint disease with biological agents and the development of a seamless serviceTrIsh Bewley Bsc, SRN, RHEUMATOlOGY NURSE SPECIAlIST, GAlWAY ClINIC AND

dr MArk J I PhelAN, CONSUlTANT RHEUMATOlOGIST, SOUTH INFIRMARY VICTORIA UNIVERSITY HOSPITAl, CORK

The World Health Organisation and the United Nations designated the first decade of this century as the Decade of Bone and Joint Disease.1 This heralded dramatic and unprecedented changes in the management of inflammatory joint diseases such as rheumatoid arthritis (RA), psoriatic arthritis (PsA), ankylosing spondylitis (AS) and other disorders.

These diseases used to follow an almost invariably destructive pathway, albeit retarded by traditional disease modifying anti-rheumatic drugs (DMARDs). Patients were eventually left with gross deformities and became profoundly disabled (Figure.1).

The introduction of methotrexate (MTX) and later

the ‘biologic’ drugs currently used in the treatment of inflammatory joint disease has changed this completely, resulting in sustained suppression of disease in most patients, and the now achievable goal of disease remission.

As a clinical nurse manager in rheumatology one of our main roles is in the education regarding these drugs, initiation of

14

clinical review

There are currently nine such drugs licensed in this country to treat RA (Table 1) and some of them are also used to treat some of the other inflammatory diseases in other specialities such as gastroenterology. One of these, anakinra, is rarely used because of its disappointing therapeutic response.

MedIcAl chAlleNgeSuch treatments present society, the medical profession and the nursing profession with considerable challenges. These treatments are very expensive, have some significant potential side effects and require a good deal of support and monitoring from nurses over the longer term.

The practice nurse is in a particularly pivotal position in this regard. Patients on these treatments require regular blood test monitoring and often need help in initiating and administration of these drugs.

An understanding of the mechanism of action, modes of administration and possible adverse events is therefore extremely important to help the practice nurse in helping to support these patients.

them and support of the patient while they are on them. This extends from the clinical nurse manager in the rheumatology department to the general practice nurse.

As the understanding of rheumatic disease and its treatment evolved over the last few decades, so did the involvement of the nurse in the care of such patients. From an initial two dozen Rheumatology Nurse Specialists in the entire UK in the early 1990s2 to the clinical nurse manager now having a pivotal role in most rheumatology departments throughout Europe,3 to the natural progression of the general practice nurse in a shared care model, the nurse is a vital link in the care and support of rheumatic patients on complex medical treatment.

Patients who develop diseases such as RA can now look forward to a full life with good disease control, no significant joint deformities and normal family, social and working lives with the help of these treatments.

Inflammation involves a cascade of cells and proteins that are usually invoked by the body in response to injury and usually have a protective and healing effect. In inflammatory arthritis the inflammatory response becomes uncontrolled and eventually causes damage to the body itself – so called autoimmune damage. B cells are immune cells, which create antibodies, and T cells are other immune cells, which coordinate the immune and inflammatory response particularly within cells (Figure 2). It is when these cells become unregulated and damage the body’s own tissue that inflammatory arthritis occurs.

These immune cells communicate with each other by releasing proteins that activate other cells. Biological therapies are molecules that are designed to target specific proteins involved in inflammation and to halt and control this process. They can be monoclonal antibodies to the molecules themselves such as adalimumab, which is an antibody to tumour necrosis factor (anti TNF) or receptor antagonists themselves such aseEtanercept (TNF receptors antagonists used to mop up the excess amount of TNF). They can also be directed against specific cells in the inflammatory process such as rituximab, which is used to block B cells or tocilizumab binds to receptors for interleukin 6 (Il6), a cytokine, and thus prevents effects of Il6. Abatacept, which are used to block T cells .

An understanding of the mechanism of action, modes of administration and possible adverse events is therefore extremely important to help the practice nurse in helping to support these patients.figure 1. A picture from the past – untreated rheumatoid

arthritis

figure 2. cells involved in auto-immunity which can be inhibited by biological agents

16

clinical review

There are international guidelines which provide a common pathway which rheumatologists will usually follow providing a sequence of drugs and supports, either singly or in combination until these diseases are controlled. These recommendations for RA,4 AS5 and PsA,6 are not only aimed at rheumatologists but also GPs and allied professionals in primary care.

There are a number of aspects of care that all of these drugs have in common. They are as follows:

1. Prescribing: Most biologic drugs are co-prescribed with traditional DMARDs such as Methotrexate (MTX). Biologics are usually only initiated when there has been an inadequate response to MTX. Their efficacy is usually better when co-prescribed with DMARDs.

2. Infections: Biologics can be associated with an increased incidence of infections such as respiratory tract infections. If a patient has an infection requiring antibiotic treatments it is usual practice to stop the biological treatment until the infection has resolved and the antibiotic course has been completed.

Rheumatology departments usually recommend that patients on biologics avail of the annual influenza vaccine and the pneumovax every five years.

3. Pre-screening: There is an increased incidence of tuberculosis in patients taking biologics. This is especially the case if the patient has had previous TB infections. Therefore pre-screening is standard practice. A chest x ray and, either a Mantoux test, or Quantiferon blood test, are performed by the treating rheumatology department prior to commencing treatment.

4. Anti-TB treatment: If screening indicates previous TB infection the patient is usually commenced on anti-TB treatment (usually isoniazid and pyridoxine). TB prophylaxis treatment is usually continued for nine months and biologic treatment is normally started four weeks after this has been commenced.

It should be noted that isoniazid may cause abnormalities in liver function tests (lFTs). As the lFTs

Table 1. comparison of biologic drugs in rheumatic disease (frequency of administration may vary with initiation and from patient to patient)

Inhibits what? Type of biologic how given given how often

Abatacept T cells Receptor antagonist Intravenous infusion Every 4 weeks

Adalimumab TNF Antibody Subcutaneous injection Every 2 weeks

Anakinra Il-1 Receptor antagonist Subcutaneous injection Daily

certolizumab TNF Antibody Subcutaneous injection Every 2 weeks

etanercept TNF Receptor Subcutaneous injection Weekly

golimumab TNF Antibody Subcutaneous injection Every 4 weeks

Infliximab TNF Antibody Intravenous infusion Every 8 weeks

rituximab B cells Receptor Antagonist Intravenous infusion Every 6 months

Tocilizumab Il-6 Receptor antagonist Intravenous infusion Every 4 weeks

are part of the monitoring required for MTX therapy confusion can occur as to which drug is implicated in any abnormalities of the lFTs and if necessary these tests should be communicated to the treating rheumatology department who will be in a position to decide the best way to manage things.

5. Monitoring: Patients on DMARDs and biological agents require regular blood test monitoring which are usually performed as part of a shared-care protocol. The prescribing rheumatology department provide guidelines as to which bloods are required, the frequency of such tests and the parameters to follow.

6. Administration: The routes of administration of biologics vary. Some are given by sub-cutaneous injections and the rest are administered by infusions, which are organised by the prescribing rheumatology units.

Although most biological agents commonly prescribed are self administered by subcutaneous injection, the delivery systems of these drugs vary from simple prefilled syringes to prefilled pens.

If patients are having difficulties with the various delivery techniques the general practice nurse should liaise with the prescribing rheumatology department who are likely to have support systems in place to assist.

The practice nurse in a shared care model is a vital link in the care and support of rheumatic patients on complex medical treatment.

17

clinical review

Pre-conception and pregnancy advice: There is a female predominance in RA, and many of them are of childbearing age.7 There is a requirement that women taking a biologic agent will need to discontinue any biologic drugs they are taking before conception. The length of time to abstain is indi-vidual depending on the biologic agent. They will require care from a multidisciplinary team including the rheumatologist, obstetrician, GP, midwife and practice nurse. Fortunately a large percentage of women with RA improve during pregnancy.8

Postpartum: Postpartum flare can occur in as many as 90% of these women within three months9 at a time when they are trying to cope with all the stress and pressures of becoming a mother. It is important to make these women aware of this sudden change in disease activity and to have a plan of reinitiating treatment quickly. This can also affect the decision of the women breastfeeding.

In summary the treatment and support services for inflammatory joint disease has evolved such that with proper treatment and support, patients can look forward to a normal working, leisure and family life.

Because of the complexities of the different treatment options, which are likely to be life long, patients require the support and care of the clinical nurse manager in rheumatology and the general practice nurse now more than ever.

references1. Woolf A. The Bone and Joint Decade 2000-2010 Ann Rheum

Dis 2000; 59:81–82.

2. Phelan MJI, Byrne J, Campbell A. et al. A Profile of the Rheumatology Nurse Specialist in the United Kingdom Rheumatology. B J Rheumatol (1992) 31(12): 858-859.

3. Heijstek, MW, Ott de Bruin lM, Bijl M, et al. EUlAR recommendations for the role of the nurse in the management of chronic inflammatory arthritis. Ann Rheum Dis doi:10.1136/annrheumdis-2011-200185

4. Smolen J, landewé R, Breedveld, F et al.. EUlAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying anti-rheumatic drugs. Ann Rheum Dis: 5 May 2010 doi:10.1136/ard.2009.126532

5. Braun J, van den Berg R, Baraliakos X et al. 2010 update of the ASAS/EUlAR recommendations for the management of ankylosing spondylitis. Ann Rheum Dis 2011; 70: 896-904 doi:10.1136/ard.2011.

6. Gossec l, Smolen J S, Gaujoux-Viala C. et al. European league Against Rheumatism recommendations for the management of psoriatic arthritis with pharmacological therapies. Ann Rheum Dis 2012; 71:4-12 doi:10.1136/annrheumdis-2011-200350

7. Dugowson CE, Koepsell TD, Voigt lF. et al. Rheumatoid arthritis in women. Incidence rates in group health cooperative, Seattle, Washington, 1987-1989, Arthritis Rheum 1991; 34:1502

8. Hench PS. The ameliorating effect of pregnancy on chronic atrophic (infectious rheumatoid) arthritis, fibrosis and intermittent hydrarthrosis. Mayo Clin Proc 1938; 13:161

9. Persellin RH. The effect of pregnancy on rheumatoid arthritis. Bull Rheum Dis. 1976 1977; 27(9): 922.

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For all that matters in medicine

18

in practice

Injection technique – promoting best practiceheleN TwAMley, ClINICAl NURSE MANAGER, BEAUMONT HOSPITAl soNyA BrowNe, ClINICAl NURSE SPECIAlIST, BEAUMONT HOSPITAl heleN Burke, ADVANCED NURSE PRACTITIONER, UNIVERSITY COllEGE HOSPITAl GAlWAYPATrIcIA coAdy, ClINICAl NURSE SPECIAlIST, CORK UNIVERSITY HOSPITAl, yvoNNe MoloNey, ClINICAl MIDWIFE SPECIAlIST, MID-WESTERN REGIONAl MATERNITY HOSPITAl ALL ArE MEMBErS of THE foruM for INJECTIoN TECHNIquE (fIT) IrELAND

19

in practice

Diabetes is a major chronic illness, with type 2 diabetes affecting 1 in 20 people in Ireland.1 It is estimated that 180,000 people, of all age groups, have either type 1 or type 2 diabetes, and this is ex-pected to rise to 233,000 by 2020.2 Recent research

conducted by Diabetes Ireland shows that 1 in 3 people has a family member with diabetes.3

It is estimated that almost 30% of people with diabetes use injectable therapies,4 which, based on current figures, can be calculated as approximately 54,000 Irish people.5 For injectable therapies to work optimally, correct injection technique is es-sential.

support for primary care teams Recently launched in Ireland, the Forum for Injection Technique (FIT) is an initiative which aims to raise awareness of emerging and existing research relating to diabetes injection technique and the impact this may have on health outcomes. FIT is an international endeavour which originated in the UK and now also has boards in Canada, India and Ireland.

FIT’s mission is to support people with diabetes using inject-able therapies, through evidence based practice in order to achieve the best possible health outcomes that are influenced by correct injection technique. This will be done through professional and patient education, accessible support and research. For the last three years a dedicated group of injec-tion technique experts have analysed the literature and have helped to bring together new recommendations.

One of FIT Ireland’s first actions has been the publication of the First Irish Injection Technique Recommendations, which have been adapted from the First UK Injection Technique Recommendations 2nd Edition, published by FIT UK. The recom-mendations provide up-to-date guidance for diabetes practi-

tioners and equip them with a clear and concise educational resource to share with their diabetes patients.

Supporting self-care is a crucial aspect of any high-quality diabetes service, and structured patient education is an impor-tant part of this.6 High-quality, structured education can have a profound effect on biomedical outcomes, and can significantly improve a patient’s quality of life and satisfaction.7 Once a patient is imbued with knowledge, skills and confidence, they are better able to control of their own condition and integrate effective self-management into their daily lives.

The recommendations support them in this and include the latest advice on injection sites and care, insulin storage and sus-pension, the correct use of pen devices and syringes, absorption rates, skin folds, lipohypertrophy, needle length, and rotation of injection sites. Areas such as the psychological challenges of in-jections, therapeutic education and the safe disposal of injecting material are also covered. A scale is included throughout to show the weight a recommendation should have in daily practice and the degree of support in the currently available medical litera-ture. The document will be regularly updated to ensure that the best guidance is always available.

Supporting practitioners and patients with educational tools will not only increase self-management but, importantly, this knowledge will help to ensure that the dose is delivered to the right injection site, using the right technique every time. Injection technique is one of the keystones of diabetes injec-tion therapy, and it is vital that patients are educated on best practice. When injectable therapies are not absorbed properly, immediate problems such as hypoglycaemia (a sudden drop in blood sugar because of accelerated insulin absorption) and/or hyperglycaemia (a rise in blood sugar because of slow insulin absorption) can occur.

Hypoglycaemia is a serious side-effect of insulin therapy and sulphonylurea therapy and can cause both autonomic symp-toms (nervousness, sweating, and hunger) and neuroglycopen-ic symptoms (confusion, weakness, and less frequently seizure or coma), and can ultimately lead to death if treatment is not given.6 longer-term problems can also include lipohypertrophy (accumulation of fat under the skin which can be caused by injecting too frequently in the same area). Where lipohypertro-phy occurs, the effectiveness of absorption from subcutaneous tissue may be affected.

In addition to health benefits, establishing a culture of good injection technique could contribute to managing the cost of

fIT’s mission is to support people with diabetes using injectable therapies, through evidence based practice in order to achieve the best possible health outcomes.

4mmPN1

20

in practice

diabetes care. The cost of diabetes care is becoming an increas-ing burden for the Irish Health Service Executive as diabetes treatment and complications contribute to up to 5% of Irish national health expenditure.7 Recent research shows that the cost of treating diabetes complications greatly outweighs the cost of maintaining good blood glucose control.8 Achieving optimal glycaemic control can help reduce immediate problems such as hypoglycaemia and longer term complications such as lipohypertrophy.

conclusionDiabetes care management is a process that supports an on-go-ing partnership between healthcare professionals and people with diabetes. It is important that the resources are available to support both parties. Establishing FIT in Ireland will help to im-prove diabetes care by providing relevant and fully-researched guidance to promote best practice in injection technique for all those involved in diabetes care. It is our belief that by establish-ing a culture of good injection technique in Ireland, the chronic situation that diabetes presents may be greatly improved.

FIT Ireland will be holding Diabetes Educational Meetings in Dublin and Cork in conjunction with the Irish Nurses and Mid-wives Organisation (INMO) from April-June 2013.

The First Irish Injection Technique Recommendations can be found at: www.fit4diabetes.com/ireland

longer-term problems can also include lipohypertrophy (accumulation of fat under the skin which can be caused by injecting too frequently in the same area).

safety-engineered Pen Needle

references1. Health Service Executive, Review of Diabetes Structured

Education, Republic of Ireland 2009 http://www.hse.ie/eng/services/Publications/topics/Diabetes/diabetesstructureded.pdf

2. Irish Times, Diabetes at crisis level in Ireland, new figures confirm (October 4th 2011) http://www.irishtimes.com/newspaper/health/2011/1004/1224305196665.html

3. Diabetes Federation of Ireland, One in three families affected by diabeteshttp://www.diabetes.ie/2011/10/03/know-your-numbers/

4. Diabetes inhaler rejected for NHS, BBC News, 19 April 2006 5 Based on the current 180,000 figure for the number of people with diabetes in Ireland

5. DoH, Improving Diabetes Services, p.10 7 Ibid.6. Ritzholz MD, Jacobson AM. living with Hypoglycemia,

Journal of General Internal Medicine; 1998, December; 13. (12): p. 799

7. Strauss K. Injectable therapy injection techniques: Report from the 1st International Injectable Therapy Injection Technique Workshop, Strasbourg, France – June 1997. Practical Diabetes International; 1998. 1: 16-20

8. http://www.diabetes.co.uk/news/2012/Feb/diabetic-complications-the-greatest-health-cost-for – diabetes-93725210.html

ASTHMA ADVICELINE NURSEThe Asthma Society of Ireland (ASI) is the national charity representing the more than 470,000 people in Ireland with asthma, and the leading provider of information on all aspects of asthma. We provide support to patients, carers, the general public and healthcare professionals. The Asthma Society of Ireland runs Ireland’s only National Asthma Adviceline, which is a non-judgemental and completely confidential telephone service. We are seeking an Asthma Adviceline Nurse to join our team.

JOB TITLE: Asthma Adviceline NurseREPORTS TO: Director of Nursing ServicesLOCATION OF WORK: 42-43 Amiens Street, Dublin 1HOURS OF WORK: 10am – 1pm (3 mornings per week)

Practice nurse requiredclonmel, co. Tipperary

Practice Nurse required for busy, modern GP practice. Duties to include child vaccinations, management of chronic illness, antenatal care, cervical smears and phlebotomy. This is a permanent part-time position with an immediate start.

Please forward cv to manager@westwell.ie or phone 0872504313 for further information

Middleton, corkconsulting rooms available

Middleton, Cork consulting rooms available to rent in a building that has busy dental and physio practices. Dental practice has a patient base of 10,000 patients. Good footfall and referrals available from these businesses. Each room is approx 110 square feet. located, just off Midleton’s main street, close to good restaurants and boutiques, in a public car park with free parking. State of the art building and rooms will be altered to clients specifications.

Rent 210/week per room, utilities included. Reception staff can be provided but will incur additional charge.

Available from October 1st 2013.

contact carmel@corabbeydentalclinic.ie or phone 0866026786

To advertise here contact

QUALIFICATIONSThe successful candidate must:• Be on a current register of An Bord Altranais• Have at least three years experience in asthma/respiratory nursing• Have Asthma Nursing Qualification e.g. Higher Diploma In

Respiratory Nursing/Asthma Diploma• Be computer literate

KEY RESPONSIBILITIES• Respond to queries in a supportive timely manner ensuring

caller dignity.• Answer calls in accordance with the operational policies of the ASI.• Respond to queries received via email.• Make every effort to ensure that information given to callers,

both verbal and written, is from reliable sources.• Forward information to callers (e.g. leaflets, etc.) or forward

them to relevant areas of the Asthma Society of Ireland.• Write and contribute to ASI literature and publications as

requested, which includes patient information booklets, fact-sheets and articles for the website.

• Maintain confidentiality and anonymity as appropriate.• Maintain a knowledge base on developments in asthma care.• Keep informed regarding ASI campaigns and events, which may

result in an increased number of calls on a specific issue.• Participate in managing ASI exhibition stands as required at vari-

ous workshops /conferences for both patients and healthcare professionals.

• Keep informed of activities and co-operate with other sections within the ASI (e.g. Research, Fundraising and Communications)

You will be required to be flexible in this position as other responsi-bilities within your abilities, which may be in addition to or outside your normal duties, might be assigned to you.

FURTHER INFORMATIONFor further information please visit our website www.asthma.ie. You can also contact our Director of Nursing Services, Frances Guiney, with informal queries at 01-8178886 or by emailing frances.guiney@asthmasociety.ie.

HOW TO APPLYIf you are interested in applying for the role, please send a cover letter and an up-to date CV, by email to hr@asthmasociety.ie.

Closing Date: 21st June.

recruitment / classifieds

graham graham@greenx.ie

louis louis@mindo.ie

01 4410024

or

1200 mg/800 I.U. powder for oral suspensionCalcium phosphate/ Vitamin D3

Before prescribing a calcium & vitamin D supplement, think twice and consider

the supplement that patientsdrink once daily.

Osteofos D3 1200 mg/ 800 I.U. powder for oral suspension (colecalciferol and calcium phosphate) Abbreviated Prescribing Information Please consult the Summary of Product Characteristics (SPC) for full prescribing information. Presentation: Powder for oral suspension. Each sachet contains colecalciferol (Vitamin D3)20 micrograms (equivalent to 800 I.U.) and calcium phosphate 3100 mg (equivalent to 1200 mg or 30 mmol of elemental calcium per sachet). Also contains Sunset yellow FCF (E110) and sucrose. Use: Correction of calcium and Vitamin D deficiency in the elderly. May be used as an adjunct to specific therapy for osteoporosis, in patients with either established vitamin D and calcium combined deficiencies, or in those patients at high risk of needing such therapeutic supplements. Dosage: Adults and elderly: 1 sachet/day for oral use. Not recommended for use in children or patients with severe renal dysfunction. Contraindications: Hypersensitivity to active substances or to excipients. Hypercalcaemia (>10.5 mg/dl), hypercalciuria (300 mg or 7.5 mmol/24 hours), severe renal insufficiency, kidney stones, calcium lithiasis, calcification of tissues,

prolonged immobilization accompanied by hypercalciurea and/or hypercalcaemia, hypervitaminosis D. Do not use in children, pregnancy or lactation. Warnings and precautions for use: Use with caution in patients with renal insufficiency or when there is a known tendency for the formation of urinary calculi. Monitor calcaemia and calciuria adequately in these patients to prevent the onset of hypercalcaemia. If calciuria levels exceed 7.5 mmol/24hours (300 mg/24 hours), treatment should be temporarily interrupted. Special caution also required in patients with cardiovascular disease. The effect of cardiac glycosides may be accentuated with the oral administration of calcium combined with Vitamin D. Strict medical supervision, and if necessary, monitoring ECG and calcaemia are necessary. All other Vitamin D compounds and their derivatives, including food-stuffs which may be fortified with Vitamin D, should be withheld during treatment. Prescribe with caution to patients with sarcoidosis because of possible increased metabolism of Vitamin D to its active form. These patients should be monitored for serum and urinary calcium. Contains the colouring agent E110 which can cause

allergic-type reactions including asthma. Do not use in patients with rare hereditary problems of fructose intolerance, glucose-galactose malabsorption or sucrase- isomaltase insufficiency. Interactions: Absorption of orally administered tetracyclines can be reduced by the simultaneous oral administration of calcium. Take at least 3 hours apart. Diuretics (furosemide, ethacrynic acid), antacids containing aluminium salts and thyroid hormones, thiazide diuretics, some antibiotics such as penicillin, neomycin and chloramphenicol. Monitoring of the serum calcium levels during prolonged treatment is recommended. Colestyramine, corticosteroids and mineral oils, phenytoin and barbiturates. Calcium/digitalis synergism on the heart may cause severe disorders of cardiac function. Concomitant treatment with bisphosphonate or with sodium fluoride - allow a minimum period of two hours before taking Osteofos D3. Please consult the SPC for a full list of interactions. Side-effects: Frequency not known: anaphylactic reaction, allergic dermatitis, hypercalcaemia, hypercalciuria, nausea, constipation, diarrhoea, epigastric pain and urticaria. Pack size: 30 sachets. Legal category: POM. Marketing

Authorisation Number: PA 865/7/1. Marketing Authorisation holder: Menarini International Operations Luxembourg S.A. 1, Avenue de la Gare, L-1611Luxembourg. Marketed by: A. Menarini Pharmaceuticals Ireland Ltd. Further information is available on request from A. Menarini Pharmaceuticals Ireland Ltd., 2nd Floor, Castlecourt, Monkstown Farm, Monkstown, Co. Dublin or may be found in the SPC. Date of preparation: June 2010.

Reference: 1. MIMS, November 2012. Date of item: November 2012. 12Ost004.

23

clinical review

osteoporosis: the silent killerProfessor MoIrA o’BrIeN, PROFESSOR EMERITUS, FRCPI, FFSEM, FFSEM (UK) FTCD

Osteoporosis is a preventable disease and treatable in the majority of cases.

Osteoporosis is a silent disease that is usually not diagnosed until a fracture (broken bone) occurs. Osteoporosis results in bones becoming very brittle; therefore a minor bump or fall can result in bone/s being broken.

Osteoporosis is not just an old person’s disease; it affects all age groups including children. 25% of men and 50% of women over 50 have osteoporosis. It is estimated that 300,000 people in Ireland are affected and the government spent €402 million just on falls and fractures in senior citizens in 2010.

Osteoporosis is a systemic skeletal disease characterized by low bone mass and micro architectural deterioration of bone tissue. This compromises bone strength, which increases bone fragility and susceptibility to fracture, particularly of the wrist, hip and spine.3 These three areas consist mainly of trabecular or spongy bone, which is why they tend to fracture first, however any bone can be affected. The clinical significance of osteoporosis is in the fractures that occur. Risk of fractures is increased in patients with low bone density and with each additional risk factor. One low trauma fracture increases the risk of another fracture.

soMe rIsk fAcTors• low levels of sex hormones, oestrogen in women and

testosterone in men.• late first period (after 15 years of age) or irregular

menstruation.• Amenorrhea (no period) for more than six months in a year

not due to pregnancy.• Women who have had an early menopause (before 45 years

of age), natural or surgical (particularly if one or both ovaries have been removed or a total hysterectomy).

• Men with low testosterone levels.• Eating disorders (e.g. anorexia nervosa, bulimia).• Genetics; a family history of osteoporosis is a very strong risk

factor, as 80% of a person’s bone is due to genetics, particu-larly if it includes a history of hip fracture/s or if their parents had lost height or developed a hump on their upper back.

• Senior citizens are more at risk: senior citizens are more likely to have low oestrogen and testosterone levels, low vitamin D levels, poor nutrition, take less exercise and have other medical conditions or be on a medication that can increase bone loss.

24

clinical review

Note: There are many medications that cause bone loss. • Inadequate intake of calcium, vitamin D3 and calories.• Excessive exercise with inadequate nutrition.• Excessive psychological or physiological stress.• Excessive alcohol, fibre or caffeine intake.• Smoking: it is very important for those diagnosed to seek

help to quit.• Malabsorption problems; coeliac or gluten sensitivity, lactose

intolerance or cystic fibrosis.• Inflammatory bowel disease; Crohn’s disease, irritable bowel,

ulcerative colitis.• Gastrectomy or small bowel resection.• Severe liver disease.• Chronic obstructive jaundice.• Hyperadrenocorticism: endogenous or exogenous, e.g.

Cushing’s syndrome.• Hyperthyroidism.• Hyperparathyroidism (primary or secondary due to low

vitamin D or poor renal function).• Hyperprolactinaemia.• Insulin dependent diabetes.• Haemochromatosis.Drug induced• long-term use of corticosteroids (e.g. cortisone,

prednisolone, Delta Cortril, dexamethasone etc). Corticosteroids are used for the treatment of many conditions, and are the most common cause of secondary osteoporosis. Main bone loss occurs in the first six months of treatment. Corticosteroids 7.5 mg a day for more than 3 months in a year. Bone loss may occur at lower doses in some people, particularly if the person has other risk factors or if they already have undiagnosed low bone density.

• Thyroxine, if serum levels are high.• Chemotherapy.• Radiation.• GnRh analogues.• lHRH analogues; testosterone suppression; leuprorelin.• Aromatase inhibitors for the treatment of prostatic and

breast cancers: arimidex for breast cancer• Post organ transplant patients.• Anticonvulsant therapy, anti-epileptic medications

(phenytoin, phenobarbitone) can interfere with calcium absorption and the production of vitamin D.

• Chronic heparin or warfarin therapy.• long term lithium therapy. • Depot-provera, particularly in adolescents.• Prolactin raising drugs, antipsychotic medication, e.g. some

SSRIs.• Diuretics such as Burinex and lasix. • Proton pump inhibitors.• Tranquillizers and sedatives may increase the risk of a fall.

since the disease is silent, a person can look perfectly healthy and have severe bone loss.

who should hAve A dXA scANAny patient who has one or more risk factors or a fragility fracture should have a DXA scan. Since the disease is silent, a person can look perfectly healthy and have severe bone loss. It is essential that those at risk are identified as early as possible, due to the devastating affects of undiagnosed osteoporosis, which occurs in 85% of those undiagnosed. A DXA scan is a simple, painless test that is not claustrophobic.

AddITIoNAl red flAgs for referrINg for A dXA scAN:• Any adult who breaks a bone from a trip and fall or less, even

if on cement or ice. • Any adult who has lost height.• Any patient who has undiagnosed back pain.• Any patient who has developed a hump on their upper back.• Any patient who has unexplained fractures.

fINdINg cAuse Is esseNTIAlIt is essential that all cause/s are found and addressed. Many people assume that the menopause and steroids are the only cause/s. Malabsorption is a major cause of bone loss in Ireland, along with low vitamin D levels. There is a worldwide epidemic of low vitamin D levels which affects calcium absorption.

Example: If a patient is diagnosed with osteoporosis, put on an osteoporosis medication but has very low levels of vitamin D, they will not absorb calcium, which is an essential part of prevention and treatment of osteoporosis. This patient will not get the full benefit from the treatment, as one of the causes of bone loss has not been addressed.

role of PN• Prevent fractures – educate your patients in prevention of

this silent killer. Explain to them that unlike most diseases there are no signs or symptoms.

• compliance is very poor, 70% of osteoporosis patients worldwide stop taking their treatment within one year: Explain to them how important it is for them to take their treat-ment, that they did not feel their bones getting weaker and that they will not feel their bones getting stronger. (except PTH and strontium ranelate which can decrease pain from fractures)

• Prevent falls – most falls occur in the home and most can be prevented. A fall prevention leaflet is available from the Irish Osteoporosis Society Charity. Refer the patient to a fall prevention programme by a chartered physiotherapist, for those with a prior fall or at risk to fall. It is essential to ask patients if they have had a fall or are they apprehensive of falling, as many, due to pride and fear of nursing home placement, will not openly admit a past fall or fear of falling.

• History of low trauma fractures: prevent further fractures, if in doubt it is cheaper and less painful for the patient to DXA scan them.

• Costs 40% less thannearest competitor1*

• No.1 in Ireland*

• Available in 100 tablet and 60 tablet packs

CALCICHEW-D3 FORTE CHEWABLE TABLETS PRESCRIBING INFORMATION.(Please refer to full Summary of Product Characteristics whenprescribing). Presentation: Chewable tablet containing 1250mg calciumcarbonate (equivalent to 500mg of elemental calcium) plus 400IU colecalciferol(equivalent to 10 micrograms vitamin D3). Uses: Prevention and treatment ofvitamin D/calcium deficiency. Supplementation of vitamin D and calcium as anadjunct to specific therapy for osteoporosis, in pregnancy, in established vitaminD dependent osteomalacia and in other situations requiring therapeuticsupplementation of malnutrition. Dosage and administration: Oral (suck orchew). Adults and elderly: Two tablets daily. Children: Not intended for use inchildren. Hepatic impairment: No dose adjustment required. Renal impairment:Should not be used in patients with severe renal impairment.Contraindications: Diseases and/or conditions resulting in hypercalcaemiaand/or hypercalciuria, severe renal impairment, renal stones, hypervitaminosisD, hypersensitivity to ingredient(s) Precautions: Monitor serum calcium andcreatinine levels, particularly in patients on cardiac glycosides or diuretics andin patients with high tendency to calculus formation. Use with caution inpatients with impaired renal function. Take into account risk of soft tissuecalcification. Avoid in patients with phenylketonuria or sugar intolerance.

Prescribe with caution in patients with sarcoidosis. Use with caution inimmobilised patients. Additional doses of calcium or vitamin D should only betaken under close medical supervision. Interactions: Tetracyclines (take 2hours before, or 4 to 6 hours after Calcichew-D3 Forte), bisphosphonates orsodium fluoride (take 3 hours before Calcichew-D3 Forte), Quinolone antibiotics(take two hours before or after), levothyroxine (take four hours before or after),thiazide diuretics, corticosteroids, cardiac glycosides, ion exchange resins(cholestyramine), laxatives (paraffin oil). Calcichew-D3 Forte should not betaken within 2 hours of eating foods high in oxalic acid (e.g. spinach andrhubarb) or phytic acid (e.g. whole cereals). Side effects: Hypercalcaemia,hypercalciuria, constipation, dyspepsia, flatulence, nausea, abdominal pain,diarrhoea, pruritus, rash, urticaria. Very rarely (usually only seen on overdose)milk-alkali syndrome. Use in pregnancy and lactation: Can be used in case ofcalcium and vitamin D deficiency. Daily intake in pregnancy should not exceed1500mg calcium and 600IU colecalciferol (15 micrograms vitamin D3). Avoidoverdose as permanent hypercalcaemia affects developing foetus. Calcium andvitamin D3 pass into breast milk so consider this when giving additional vitaminD to the child. Pharmaceutical precautions: Do not store above 30°C. Keepcontainer tightly closed to protect from moisture. Legal category: Pharmacy

product. Product Authorisation No: 535/1/3. Product Authorisation holder:Shire Pharmaceuticals Ltd., Hampshire International Business Park, Chineham,Basingstoke, Hampshire RG24 8EP UK. Distributed in Republic of Ireland by:Cahill May Roberts, P.O. Box 1090, Chapelizod, Dublin 20, Republic of Ireland.Further information is available on request. Date of revision: May 2011.CALCICHEW is a registered trademark of Shire Pharmaceuticals Ltd in theRepublic of Ireland.

Adverse events should be reported to the Pharmacovigilance Unit atthe Irish Medicines Board (IMB) (imbpharmacovigilance@imb.ie).Information about adverse event reporting can be found on the IMBwebsite (www.imb.ie). Adverse events may also be reported to ShirePharmaceuticals Ltd on +44 1256 894000.

Reference: 1. MIMS May 2012.

Date of preparation: June 2012.Item Code: IRE/BU/CDF/12/0007.*According to IMS unit sales data April 2012.

Their strength is our forte

HELP PROTECT THEFRAGILE ELDERLY

NEW60 TABLETPACK

Calcichew New Pack A4_Layout 1 03/07/2012 15:30 Page 1

26

clinical review

PreveNTABle ANd TreATABle The best prevention against osteoporosis is to have a healthy lifestyle and to encourage bone health during each stage of the lifecycle. To function properly, bones require normal levels of hormones particularly sex hormones, calcium, protein, vitamin D3, adequate calories and daily weight bearing exercise. The best preventive measures should occur in childhood and adolescence, but senior citizens can improve their bone strength. Between the ages of eight and 20 years (60% of bone is laid down. Therefore encouraging children to do weight bearing exercise during this time, can significantly help to decrease their risk of developing osteoporosis in later life.

People with osteoporosis can get a fracture when only a light pressure is applied to the bone, causing pain and a significant deterioration in their quality of life. Osteoporosis is considered to be a ‘silent’ epidemic as there are no signs or symptoms until the first fracture occurs. In fact, 30% of the skeleton may have already been lost before the first fracture occurs, usually of the wrist, spine or hip.

Examples: a person with severe undiagnosed osteoporosis can sneeze or cough and fracture ribs. Patients have stood up from a chair or turned over in bed and fractured vertebrae. 50% of women with vertebral fractures go undiagnosed.

eArly deTecTIoN Is vITAl• 20% of Irish people aged 60+ who fracture a hip will die

within 6-12 months• 50% of Irish people aged 60+ who fracture a hip will not

be able to wash, dress or walk across a room unaided. Patients could have been 100% independent prior to the fracture.

• Only 30% of Irish people aged 60+ who fracture a hip, regain their independence. Unfortunately once a person has fractured their hip, it can significantly increase their risk of a second hip fracture.

• There is a hip fracture every 30 seconds in the EU.• 90% of hip fractures are due to osteoporosis.• One hip fracture costs in total €55,000.• A DXA scan for osteoporosis costs approximately €100.• A detailed questionnaire can be downloaded free of charge

from the Irish Osteoporosis Society website.

MeN ANd osTeoPorosIs Men are at a disadvantage, as it is often not considered as a diagnosis in men. Up to 20% of symptomatic vertebral fractures and 30% of hip fractures occur in men, where they are associated with excess mortality, substantial morbidity, possibly due to co-existing conditions associated with osteoporosis rather than the fracture itself. All low trauma fractures in both sexes should be considered osteoporosis, unless proven otherwise. There is an increased morbidity and mortality after all major osteoporotic fractures, but it is higher in men than women. If a man is positive for osteopenia or osteoporosis, their testosterone levels should be checked.

youNg PeoPle ANd osTeoPorosIs Causes in young people are often due to treatments/medications they have undergone for other medical problems, that unfortunately cause osteoporosis. low hormone levels due to eating disorders are another cause.

More frAcTures occur IN The osTeoPeNIA rANgeResearch shows that the majority of people who fracture have moderate to marked osteopenia. The risk of a subsequent fracture is much higher in postmenopausal women who already have had a fracture. It is the result of the negative balance between bone formation and bone resorption, i.e. more bone is lost than is formed. The rate of bone turnover is determined by hormonal and local factors.

TreATINg osTeoPeNIA or osTeoPorosIsIf a person has osteopenia which is the earlier stage of osteoporosis, it is essential that you find out if it is mild, moderate or marked osteopenia. It is essential to try and determine the cause/s. Some people who have moderate or marked osteopenia may need to be placed on an osteoporosis medication as well as calcium, vitamin D and daily weight bearing exercises. If a patient has osteoporosis, the above combined with an osteoporosis medication is usually the recommended treatment to prevent further bone loss and the risk of a low trauma fracture. A list of the investigations to assist finding the cause/s is available from the Osteoporosis Society.

dIAgNosINg osTeoPorosIsA DXA scan of the spine and hips is highly recommended and is the gold standard for diagnosing osteoporosis. The Irish Osteoporosis Society Charity does not recommend any type of heel scan for the diagnosis of osteoporosis. A list of all DXA clinics can be found on the charity’s website.

A person’s treatment should be based on:• Their risk of fracture or re-fracture. • The cause/s of their osteoporosis.• Their age.• Medical history.• Difficulty swallowing tablets.• Not able to sit upright for 60 minutes• lifestyle: frequency of medication, e.g. daily, monthly, etc.

references: The Irish Osteoporosis SocietyNOS (UK)IOF

It is essential that those at risk are identified as early as possible, due to the devastating affects of undiagnosed osteoporosis, which occurs in 85% of those undiagnosed.

27

technology

Four easy technologically-savvy steps to help yor with your entry to this year’s IPNA Clinical AwardThe secret of getting ahead is getting started. The secret of getting started is breaking your complex overwhelming tasks into small manageable tasks, and then starting on the first one – Mark Twain

lIsA NolAN

When you have a large project of any kind, it’s all too easy to put it aside until you have ‘a few hours to tackle it properly’, but in today’s busy world the chance of having several consecutive free hours is slim – or nil. If you have been put-

ting off starting your entry for this year’s IPNA Clinical Award, make this the day that you do. Here are four simple steps to getting a head start on it. Even if you just do the first step today, which will literally take about 20 seconds, you will have made a start – which is a world away from “I’ll get to it tomorrow”!

creATe The docuMeNT for your eNTry To The AwArd (TAkes 20 secoNds)It sounds obvious, but it’s what gets you out of the starting blocks. Whether you intend to work on your entry on a day off or break in down into bite-sized chunks throughout the week, this is a step you will have to take anyway – so why not do it right now?

Open a new document in Word and immediately go to ‘Save As’ and name it Clinical Award 2013 Draft. If you save it onto your Desktop it will be even easier to find and open when you do get a few minutes to work on it. It’s a good idea to save a working document with draft in the name of the file so that when it’s finished you can save the finished version as ‘final’ – that way you won’t send the wrong document by mistake when you are entering the Award.

creATe A folder where you cAN quIckly sAve INTeresTINg weBsITes, ArTIcles or refereNces As you coMe Across TheMThere are numerous tools available now for collating notes and references. The important thing is to create a folder – somewhere – for you to throw in useful articles as you come across them so that they are readily available when you sit down to work on your answers to the Case Study. Even if you like to do your background reading and research offline, buy a cheap manila folder or plastic envelope to store articles from journals and handwritten notes.

Here are two online tools for organising your notes. Create a bookmarks folder on your browser (takes 20

seconds)All browsers have a bookmarks tool and if you have a

smartphone you can sync them so you can save work on the go. Obviously the ESC website is the first site you should bookmark so I have used that as an example for these instructions.

Google Chrome: Click on star icon and select ‘Choose another folder’ from the drop-down list (Figure 1), then select ‘Bookmarks Bar’ and then ‘New Folder’. Name the new folder, e.g. IPNA Clinical Award, and click ‘Save’ (Figure 2). The bookmarks folder is now easily visible on your browser window. When you come across a relevant webpage during your internet research, just click the star icon at the top and select ‘IPNA Clinical Award’ folder from the dropdown menu. The star will turn yellow to indicate that the webpage has

figure 2. chrome

figure 1. chrome

28

technology

go directly to the Chrome Web Store, search for it and install directly.

Whenever you find a website that you want to keep, just click this button and decide if you want to keep the web address, full page, PDF, etc. Figure 4 shows an IPNA Clinical Award notebook in Evernote, the 2 website clips and a personal reminder that are in that notebook and a preview of the clip that has been selected.

creATe google AlerTs (less ThAN A MINuTe)What could be better than the internet doing some of the work for you?! Google alerts are a valuable tool to save time trawling through the internet for specific search terms. If you set up a Google alert for ESC CVD guidelines, Google will e-mail you each time they are mentioned anywhere on the web, as picked up by Google Search Engines. This way you can keep on top of any up-to-the-minute news about the guidelines as you prepare your entry to the Award.

Go to www.google.com/alerts and click ‘Create a New Alert. Type your preferred keywords into the box beside ‘Search query’ and select your preferred options from the drop down lists. You will see examples of the search results appear on the right side of the screen (see Figure 5). If you are happy that your search terms are going to be productive, click the red Create Alert button. You can manage or delete your alerts from this URl or from links that will appear at the end of each e-mailed alert you receive.

seT reMINders IN google cAleNder (ABouT 30 secoNds for eAch reMINder)And finally, going back to the famous – and spot-on – advice by Mark Twain, why not plan out the project, break it down into small manageable parts and then set up regular reminders for yourself using Google Calendar. The link is at the top of your Gmail account, or just go directly to www.google.com/calender Click on any date and time to type in a reminder and Google will email you with your own note on that date, at that time. Tip: mark it as unread after you have opened that email and don’t delete it until you have carried out your own instructions in the reminder. It would be especially useful to set a reminder a week before the closing date to finalise your entry and send it in, so that you don’t waste all that time you spent doing it.

Best of luck!

been bookmarked. When you hover over the IPNA Clinical Award folder, all websites that you have bookmarked into it will appear (Figure 3).

Mozilla Firefox and Internet Explorer have similar star icons and options for bookmarking sites.

everNoTe (ABouT A MINuTe – dePeNdINg oN how fAsT your INTerNeT Is)Evernote is currently one of the most popular web clipping tools and whether you are writing a research thesis or collecting recipes, it’s well worth setting up an account and syncing it with your smartphone and other mobile devices. Then you can save webpages, articles, your own notes, images and audio clips as you come across them. They can be organised into notebooks and easily managed.

Go to www.evernote.com and sign up. Create a New Notebook called IPNA Clinical Award.

The Evernote Web Clipper is a really useful little button to have on your Google Chrome Browser. To install it, click the wrench or settings symbol in your browser, select Extensions from the menu on the left and search for it there. Alternatively

figure 3. chrome

figure 4. evernote clips figure 5. google alerts

29

abstracts

Asthma management in pregnancy

charlton rA, hutchison A,

davis kJ, de vries cs.Department

of Pharmacy and Pharmacology,

University of Bath, Bath, UK.

Asthma is common during pregnancy, however research is limited regarding the extent and timing of changes in asthma management associated with pregnancy.

The authors sought to determine the prevalence of asthma during pregnancy and identify changes in treatment and asthma exacerbation rates associated with pregnancy, while controlling for seasonal influences.

Pregnant women with asthma were identified from the UK General Practice Research Database between 2000 and 2008. For each woman asthma medication prescribed during the study period was identified; for each product combination the British Thoracic Society medication-defined asthma treatment step was identified. Asthma exacerbations were identified during pregnancy and in the corresponding 12 months prior. Analyses of changes in asthma treatment and exacerbation rates during pregnancy relative to the corresponding period 12 months prior, to control for seasonality, were stratified by trimester and asthma treatment intensity level.

The prevalence of treated asthma in pregnancies resulting in a delivery was 8.3%. From 14,141 pregnancies, in 12,828 women with asthma, 68.4% received prescriptions for a short-acting β2-agonist and 41.2% for inhaled corticosteroids; 76.5% were managed with asthma treatment Step 1 or 2. Poor persistence to inhaled corticosteroids, defined as a gap of up to 60 days between prescriptions, was common. In 45.0% of pregnancies, an increase in average treatment step was observed whereas in 25.6% the treatment step decreased. Treatment intensity remained the same in 29.5% of pregnancies. Exacerbations occurred in 4.8% of pregnancies compared to 5.9% in the same season the year before (p<0.001).

Exacerbation rates during pregnancy were slightly lower than in the year before. However, treatment patterns and exacerbation rates in this study suggest asthma control during pregnancy is variable, and women may require close monitoring especially in those with evidence of poor control before pregnancy.

Use of spirometry in the diagnosis of COPD: a qualitative study in primary care

Joo MJ, sharp lk, Au dh,

et al. Section of

Pulmonary, Critical Care, Sleep and

Allergy, Department of Medicine,

University of Illinois Hospital and Health

Sciences System, Chicago.

Guidelines that recommend spirometry to confirm airflow obstruction among patients with suspected COPD are not routinely followed. The authors conducted a qualitative study to identify attitudes and barriers of primary care physicians to performing spirometry for patients with possible COPD. They conducted four focus groups, each with three primary care physicians (PCPs) who practice in an urban, academic medical centre. In general, PCPs believed that spirometry was not necessary to confirm the diagnosis of COPD. Compared to other co-morbid conditions, in a patient with a diagnosis of COPD without self-reported symptoms, COPD was not a priority during a clinic visit. This was in part due to the belief that there was lack of evidence that medication used in COPD lead to improved outcomes and that there was no point of care measure for COPD compared to other co-morbid conditions such as diabetes mellitus or hypertension. Health system barriers specific to spirometry use was not identified. In conclusion, among this sample of PCPs, there was scepticism that spirometry is warranted to diagnose and manage COPD. Availability of spirometry was not a perceived barrier. The results explain, in part, why previous interventions to improve access to spirometry and diagnosis of COPD in primary care settings has been difficult to conduct and/or have had marginal success. The findings strongly suggest that a first step toward increasing the use of spirometry among primary care physicians is to have them believe in its utility in the diagnosis of COPD.

FOCUs On: ALLERGY

30

abstracts

FOCUs On: PAIn

Dizziness and headache: a common association in children and adolescents

weisleder P, fife Td.

Division of Pediatric Neurology,

Duke University Medical Center,

Durham, NC, 27710, US

Vertigo has long been recognized by the clinician as a frequent accompanying symptom of the adult migraine syndrome. This association has not been so readily identified in the paediatric population, and, as a consequence, children undergo unnecessary evaluations. The authors reviewed the charts of all children and adolescents referred for vestibular function testing to the Balance Center at the Barrow Neurological Institute between July 1994 and July 2000 (N = 31). Items analyzed included age, gender, symptoms that prompted the referral, test outcomes, family medical history, and final diagnosis. The most common justi-fication for vestibular testing referral was the combination of dizziness and headache. Other less common reasons were “passing out” episodes, poor balance, and blurred vision. Normal test results were obtained from 70% of patients (n = 22). The most common abnormal test outcome was unilateral vestibular dys-function (n = 5). Bilateral peripheral vestibular dysfunction was present in three patients. One patient had central vestibular dysfunction. The final diagnoses were vestibular migraine (n = 11), benign paroxysmal vertigo of childhood (n = 6), anxiety attacks (n = 3), Meniere’s disease (n = 2), idiopathic sudden-onset sensorineural hearing loss (n = 1), vertigo not otherwise specified (n = 1), familial vertigo/ataxia syndrome (n = 1), and malingering (n = 1); in five patients, no definitive diagnosis was established. The stereotypical patient with vestibular migraine was a teenage female with repeated episodes of headache and dizziness, a past history of carsickness, a family history of migraine, and a normal neurologic examination. Patients who fit this profile are likely to have migrainous vertigo. Consequently, a trial of prophylactic migraine medica-tion should be considered for both diagnostic and therapeutic purposes. Brain imaging and other tests are appropriate for patients whose symptoms deviate from this profile.

Association between overweight and low back pain: a population-based prospective cohort study of adolescents

Mikkonen P, et al

Institute of Clinical Sciences,

Department of Physical and Rehabilitation

Medicine, University of Oulu, Oulu,

Finland.

Study: a prospective cohort study in adolescents aged 7 to 19 years. Objective: to evaluate whether persis-tent overweight increases the risk of low back pain (lBP) among adolescents. Summary of background data: overweight and lBP are common health problems in adolescents. Their relationship is still controversial among adolescents, as well as among adults.

The study population, the Oulu Back Study, was drawn from the Northern Finland Birth Cohort 1986. The final study sample included 1,660 adolescents (56% females). The subcohort of 786 subjects (57% females) was used in the analysis of waist circumference (WC). The association between the area under the curve (AUC) of BMI from 7 to 16 years, and from 16 to 18 years, and AUC of WC from 16 to 19 years, and lBP during the past 6 months was evaluated separately for incident (reporting lBP at 18 or 19 but not at 16 years) and persistent lBP (reporting lBP at 16 and 18 or 19 years). Relative risks (RR) and their 95% confidence intervals (95% CI) were adjusted for smoking, leisure time physical activity and family socioeconomic status at 16 years and stratified by gender.

BMI from 16 to 18 years among girls and BMI from 7 to 16 years among boys predicted incident lBP at 18 years (girls: RR 1.09; 95% CI 1.01-1.18; boys: RR 1.15; 95% CI 1.00-1.32). Among boys, WC from 16 to 19 years was also associated with incident lBP (RR 1.16; 95% CI 1.02-1.32). Overweight was not associated with persistent lBP.

In this population-based cohort study, persistent overweight slightly increased the risk of incident lBP, but the time period during which overweight was related to incident lBP differed between genders.

31

product news

Toviaz shown to be effective in reducing most OAB symptoms in patients with suboptimal response to tolterodine extended releaseResults from the Assessment of Fesoterodine after Tolterodine ER (AFTER) study showed that Toviaz (fesoterodine) 8mg was effective on most endpoints and well-tolerated in patients with overactive bladder (OAB) with suboptimal response to tolterodine extended release (ER) 4mg. The study met its primary endpoint: Toviaz significantly reduced urgency urinary incontinence (UUI) episodes per 24 hours compared with placebo from baseline to week 12 in patients with OAB who had a suboptimal response (equal to or less than 50% reduction in UUI) to tolterodine ER. Dry mouth and constipation were the most frequently reported adverse events. The study results were announced at the 28th Annual European Association of Urology (EAU) Congress held in Milan recently.

“The AFTER study shows that fesoterodine at its higher dose can be an effective, well-tolerated option for patients with overactive bladder who have had a suboptimal response to tolterodine ER,” said lead investigator Professor linda Cardozo, Professor of Urogynaecology and Consultant Gynaecologist, King’s College Hospital, london. “These results provide additional evidence that may reassure physicians regarding the role of fesoterodine within the range of medications available for overactive bladder and may help to guide treatment decisions for those individuals who suffer from OAB at varying levels of symptom control.”

Significant differences were also observed between the Toviaz and placebo groups at week 12 for most secondary endpoints including urgency episodes per 24 hours and

patient-reported outcome measures described by the Patient Perception of Bladder Control (PPBC) questionnaire, Urgency Perception Scale (UPS) and Overactive Bladder Questionnaire (OAB-q). The responder rates (>50% and >70% reduction in UUI episodes) for Toviaz was also significantly greater versus placebo at week 12. The differences in two secondary endpoints, a reduction in micturitions per 24 hours and an increase in diary-dry rate, were however not significant versus placebo.

The AFTER study was a 14-week, randomised, parallel-group, placebo-controlled, double-blind, multi-centre trial, designed to assess the efficacy and tolerability of Toviaz 8mg, its highest approved dose, in patients with OAB who had a suboptimal response to tolterodine ER 4 mg in its highest approved dose. The study comprised a 2-week, open-label run-in with tolterodine ER 4mg. Suboptimal responders were then randomised to either Toviaz (n=308) (4mg for week 1; 8mg for week 2-12) or placebo (n=320) once daily. They also completed 3-day bladder diaries and the PPBC questionnaire, UPS and the OAB-q at baseline and week 12.

Participants were adults aged 18 years and older with self-reported OAB symptoms for at least 6 months, 8 or more micturitions, ≥2 and <15 UUI episodes per 24 hours on a 3-day diary, and at least ‘some moderate problems’ on the PPBC questionnaire.

The safety and tolerability profiles of Toviaz and tolterodine were consistent with previous studies.

Free arthritis information pack available

A major public awareness campaign, developed in partnership by Arthritis Ireland and Pfizer Healthcare Ireland has just been launched. The multi-channel campaign aims to increase symptom awareness of rheumatoid arthritis among the general public and educate consumers on the benefits of early intervention. The direct response TV/radio/online advert highlights how difficult simple daily tasks (such as using a knife, peeling an orange, opening a jar or toothpaste, tying shoelaces) can become if suffering from painful, stiff and swollen joints and encourages consumers to take action by calling Arthritis Ireland on 1850 911 995 or visiting arthritisireland.ie to receive their free information pack.

The creative concept was developed in response to patient feedback, with a survey finding that 98% of people found simple everyday tasks, like opening a jar, tying shoelaces or chopping with a knife, difficult to do. Of six tasks identified as being particularly challenging, 74% said they found opening a jar most difficult.

Painful, stiff and swollen joints can make even the simplest of daily tasks a struggle and could be the early signs of rheumatoid arthritis. Arthritis Ireland is launching this campaign in an effort to raise awareness among the general public of these symptoms and urges people experiencing these types of difficulties to call free phone 1850 911 995 to receive their free arthritis information pack.

Paul Reid, Country Manager, Pfizer Healthcare Ireland said: “We are delighted to support this public awareness campaign

which recognises that with early diagnosis and proper treatment rheumatoid arthritis can be managed.”

Consultant Rheumatologist, Prof. David Kane said: “If a person is experiencing painful stiff and swollen joints, it could be an early sign of arthritis and I would urge them to visit their doctor and get in touch with Arthritis Ireland to receive their free information pack.”

Anyone who is experiencing painful, stiff or swollen joints or having difficulty with basic, everyday tasks can contact Arthritis Ireland on 1850 911 995 or visit www.arthritisireland.ie to receive their free information pack.

32

product news

Actavis adds 1g and 2g vials to its Floxapen rangeActavis Ireland has announced a line extension to its Floxapen IV range, with the launch of Floxapen IV 1g and 2g vials for injection. These latest launches add to the existing Actavis 250mg and 500mg strengths and extend the Actavis offering to a full range, which now includes 250mg, 500mg, 1000mg and 2000mg.

The introduction of the Floxapen 2g presentation to the market is another first for Actavis, as this is the first and only 2g presentation available in Ireland. This further underlines Actavis’ commitment to providing the market with the right products.

Indicated for the treatment of infections due to penicillinase-producing staphylococci and other gram-positive organisms susceptible to this anti-infective, Floxapen IV is also indicated for use as a prophylactic agent during major surgical procedures.

Floxapen IV 1g has been available since mid-March and 2g x 10 vials are available from early May, 2013.

For further information on the Actavis hospital portfolio please contact Actavis Ireland on 1890 33 32 31 or email con-tact@actavis.ie.

Clonmel Healthcare launchClonmel Healthcare is delighted to announce the launch of Prosentio (Modafinil) 100mg and 200mg tablets.

Prosentio (Modafinil) 100mg and 200mg Tablets are indicated for the treatment of excessive sleepiness associated with narcolepsy in adults with or without cataplexy.

Prosentio tablets are available in a 30 pack.Full prescribing information for Prosentio is available on

request or go to www.clonmel-health.ie. This product is subject to medical prescription. Prosentio is GMS reimbursable from June 1, 2013.

Please contact Clonmel Healthcare on 01-620 4000 if you require any additional information on Prosentio.

Selincro significantly reduces alcohol consumption in alcohol-dependent patients with a high-risk drinking levellundbeck Ireland has announced the presentation (poster) of long-term efficacy data for Selincro (nalmefene) at the 21st European Congress of Psychiatry (EPA)in Nice, France.

In the SENSE study, patients with a high-risk drinking level drank on average 100/g of alcohol per day. Selincro-treated pa-tients showed a significant reduction in total alcohol consump-tion from month two, and this reduction continued during the 12 months of the study with total alcohol consumption decreasing to 33/g of alcohol per day.

A decrease of total alcohol consumption of 67 per cent, or one and a half pints per day, moves Selincro-treated patients out of the high-risk categories of drinking.

Selincro offers a new approach for the treatment of adults with alcohol dependence who have a high drinking risk level (DRl) without physical withdrawal symptoms and who do not require immediate detoxification.

Dosing for Selincro is as needed; that is, to be taken on each day the patient perceives a risk of drinking alcohol, and one tablet should be taken preferably one to two hours prior to the anticipated time of drinking. Selincro is an opioid system modulator that works on the brain’s motivational system, which is dysregulated in patients with alcohol dependence.

for further information please contact Aimee Casey, Lundbeck Ireland: 01 468 9823.

Actavis launches Buplex Rx 200mg and 600mg to marketActavis Ireland has added to its BUPlEX Rx Ibuprofen product range (prescription) with the launch of 200mg and 600mg packs to the Irish market. The launch adds to the existing 400mg pack and extends the Actavis offering to 200mg, 400mg and 600mg.

Available across the range in packs of 100 film-coated tablets, BUPlEX Rx is indicated for the treatment of rheumatic conditions such as arthritic diseases (e.g. rheumatoid arthritis including juvenile rheumatoid arthritis), degenerative arthritic conditions (e.g. osteoarthritis), non-articular rheumatic conditions and soft tissue injuries.

BUPlEX Rx is subject to medical prescription and is GMS reimbursable.

BUPlEX Rx trade pricing:BUPlEX Rx 200 mg x 100 film-coated tablets: €3.95BUPlEX Rx 400 mg x 100 film-coated tablets: €3.05BUPlEX Rx 600 mg x 100 film-coated tablets: €4.85

33

crossword

Name:

Address:

Email:

Congratulations to the winner of last month’s crossword, Dolores Toner, letterkenny Road, Convoy, Co Donegal

Please send your answers to the Editor, Nursing in General Practice, GreenCross Publishing, 7 leeson Street, Dublin 4. Closing date for entries: 4 July 2013.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 Old T.V. doctor found west of Dublin! (7)7 Arterial passage in Iona or Tara (5)9 Incline to be thin? (4)10 Every colour of the rainbow (8)11 Itsy-bitsy swimwear (6)13 Rooster known to crow at dawn (4)15 Shut clumsily in this way (4)16 Tousled cot mat for a mouser (3,3)18 Resistance to mutiny I’m reorganising (8)21 Fe, in periodic table, for golf club (4)22 A sacred song for Sam, we hear (5)23 Aerial on insect’s head! (7)

dowN1 They’re ten to a Dollar! (5)2 Nasopharyngeal tissue strangely anodised (8)3 She surrounds a pupil with colour! (4)4 An owl wouldn’t give one if it cared! (4)5 Demolished huts can reveal loyalty! (7)8 Average communicator with the spirits! (6)12 Fit as a fiddle in Co. Meath? (2,4)13 Stormy liner act for a wind instrument (8)14 He needs drugs to keep him going! (7)17 Etna, Carmel or Everest (5)19 Debug lyceum. What it contains is unsightly! (4)20 An American jerk? (4)

Across: 6 Antacid, 7 Block, 9 Bloc, 10 Aardvark, 11 Gemini, 13 Obey, 15 Bass, 16 Tremor, 18 Idolater, 21 Corn, 22 Essay, 23 Complex. down: 1 Ankle, 2 Pancreas, 3 Diva, 4 Slav, 5 Scarlet, 8 Cruise, 12 In toto, 13 Otoscope, 14 Hardest, 17 Green, 19 lead, 20 Rook.

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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ONCEDAILY

O

Xarelto 15mg and 20mg film-coated tablets (Rivaroxaban).Please refer to full SmPC before prescribing. Presentation: Film-coated tablet containing 15mg or 20mg of rivaroxaban.Indication: Prevention of stroke and systemic embolism in adult patients with non-valvular atrial fibrillation with oneor more risk factors, such as congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, prior stroke ortransient ischaemic attack. Treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE) and prevention ofrecurrent DVT and PE in adults. Dosage and Administration: Prevention of stroke and systemic embolism: Therecommended dose is 20 mg once daily, which is also the recommended maximum dose. Treatment of DVT, treatment ofPE and prevention of recurrent DVT and PE: The recommended dose for the initial treatment of acute DVT or PE is 15 mgtwice daily for the first three weeks followed by 20 mg once daily for the continued treatment and prevention of recurrentDVT and PE. Renal impairment: No dose adjustment is necessary in patients with mild renal impairment. Patients withmoderate or severe renal impairment, for the prevention of stroke and systemic embolism in patients with non-valvularatrial fibrillation, the recommended dose is 15mg once daily. For the treatment of DVT, treatment of PE and preventionof recurrent DVT and PE no dose adjustment is required, although a reduction of the dose from 20 mg once daily to 15mg once daily should be considered if the patient’s assessed risk for bleeding outweighs the risk for recurrent DVT andPE. Hepatic impairment: Contraindicated in patients with hepatic disease associated with coagulopathy and clinicallyrelevant bleeding risk including cirrhotic patients with Child Pugh B and C. Contraindications: Hypersensitivity to theactive substance or any of the excipients; clinically significant active bleeding; lesion or condition at significant risk ofmajor bleeding; concomitant treatment with any other anticoagulant agent except under the circumstances of switchingtherapy to or from rivaroxaban or when unfractionated heparin is given at doses necessary to maintain a patent centralvenous or arterial catheter; hepatic disease associated with coagulopathy and clinically relevant bleeding risk includingcirrhotic patients with Child Pugh B and C; pregnancy and breast feeding. Warnings and Precautions: Clinicalsurveillance in line with anticoagulation practice is recommended throughout treatment. Xarelto should be discontinuedif severe haemorrhage occurs. Not recommended: in patients with severe renal impairment (creatinine clearance <15ml/min); in patients receiving concomitant systemic treatment with strong concurrent CYP3A4- and P-gp-inhibitors, i.e.

azole-antimycotics or HIV protease inhibitors; in patients with increased bleeding risk; due to lack of data: in patientsbelow 18 years of age, in patients with prosthetic heart valves, in patients with PE who are haemodynamically unstableor may receive thrombolysis or pulmonary embolectomy; in patients concomitantly treated with dronedarone. Use withcaution: in conditions with increased risk of haemorrhage; in patients with severe renal impairment (creatinine clearance15 - 29 ml/min) or with renal impairment concomitantly receiving other medicinal products which increase rivaroxabanplasma concentrations; in patients treated concomitantly with medicinal products affecting haemostasis or with strongCYP3A4 inducers. In patients at risk of ulcerative gastrointestinal disease prophylactic treatment may be considered.Although treatment with rivaroxaban does not require routine monitoring of exposure, rivaroxaban levels measured witha calibrated quantitative anti-Factor Xa assay may be useful in exceptional situations. Specific dose recommendationsapply for patients with moderate to severe renal impairment. Xarelto contains lactose. Undesirable effects: Common:anaemia, dizziness, headache, eye haemorrhage, hypotension, haematoma, epistaxis, haemoptysis, gingival bleeding,gastrointestinal tract haemorrhage, gastrointestinal and abdominal pains, dyspepsia, nausea, constipation, diarrhoea,vomiting, pruritus, rash, ecchymosis, cutaneous and subcutaneous haemorrhage, pain in extremity, urogenital tracthaemorrhage, renal impairment, fever, peripheral oedema, decreased general strength and energy, increase intransaminases, post-procedural haemorrhage, contusion, wound secretion. Uncommon: thrombocythemia, allergicreaction, dermatitis allergic, cerebral and intracranial haemorrhage, syncope, tachycardia, dry mouth, hepatic functionabnormal, urticaria, haemarthrosis, feeling unwell, increases in: bilirubin, blood alkaline phosphatase, LDH, lipase, amylase,GGT. Rare: jaundice, muscle haemorrhage, localised oedema, bilirubin conjugated increased, vascular pseudoaneurysm(uncommon: in prevention therapy in ACS following percutaneous intervention). Frequency not known: compartmentsyndrome or (acute) renal failure secondary to a bleeding. Prescription only. Marketing Authorisation Holder:Bayer Pharma AG, D-13342 Berlin, Germany. MA numbers: EU/1/08/472/011-21. Further information availablefrom: Bayer Ltd., The Atrium, Blackthorn Road, Dublin 18. Tel: 01 2999313. Date of Preparation: 11/2012.

L.IE.GM.12.2012.0092 Date of Preparation: 12/2012.

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AF=atrial fibrillation.

References: 1. Xarelto [summary of product characteristics].2. Patel MR, Mahaffey KW, Garg J, et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med. 2011;365(10):883-891.

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