NIGP September - October 2022 by GreenX Publishing

ISSUE 5 VOLUME 15 SEPTEMBER-OCTOBER 2022 IRELAND’S INDEPENDENT JOURNAL FOR GENERAL PRACTICE NURSES CARDIOVASCULAR DISEASE Cholesterol  Hypertension  Atrial fibrillation Best practice for GPNs ASTHMA UPDATE Managing the ‘September Spike’ INFANT FEEDING CPD MODULE Delirium in the hospitalised older adult

APTAMIL TODDLER This information is for healthcare Aptamil Toddler Milk should be 1. Irish Universities Alliance (IUNA), National https://www.iuna.net/surveyreports Available at: https://www.fsai.ie/Dietary_Recommendations_1-5_Year_Olds/ Available at: https://www.lenus.ie/handle/10147/44808 Scan for more freephone on DO FSAI Dietary Fortified intakes Daily recommended Just 2 beakers milk provides Vitamin Along with fortified Available in 800g APTAMIL TODDLER MILK This information is for healthcare professional use only. Aptamil Toddler Milk should be used as part of a varied and balanced diet from 1 year. Recommended serving per day is 300ml. 1. Irish Universities Alliance (IUNA), National Pre-school Nutritional Survey. Further analysis for Danone Nutricia (data available on request). Main survey available at: https://www.iuna.net/surveyreports 2. Food Safety Authority of Ireland (FSAI), Scientific Recommendations for Food-Based Dietary Guidelines for 1 to 5 Year-Olds in Ireland. Available at: https://www.fsai.ie/Dietary_Recommendations_1-5_Year_Olds/ 3. Food Safety Authority of Ireland (FSAI), Recommended Dietary Allowances for Ireland 1999. Available at: https://www.lenus.ie/handle/10147/44808 January 2022 Recommended serving per day is 300ml. (data available on request). Main survey available at: Food-Based Dietary Guidelines for 1 to 5 Year-Olds in Ireland. (FSAI), Recommended Dietary Allowances for Ireland 1999. dedicated 90% IRELAND VITAMIN D1 the toddlers2 Day*2 Toddler for January 2022

AT THE HEART OF SCREENING

Welcome to this issue of Nursing in General Practice. I hope you all have had a nice summer, had a chance to recharge the batteries, and enjoyed the beautiful weather we have had. There have been some changes since the last edition, with our editor Priscilla Lynch leaving to concentrate on other projects. I would like to thank Priscilla for all her hard work with our journal and wish her well in her future endeavours. Welcome to our new editor, Denise Doherty, who has a nursing background, along with many other skills and attributes. I look forward to working with her over the coming months and years.

This edition focuses on cardiovascular health, which is timely, as World Heart Day occurs on 29 September annually. The day is commemorated to promote preventative steps and changes in lifestyle to avoid cardiovascular diseases, like heart attack, stroke, heart failure, and any other condition related to the same. On average, more than 17 million people die from heart-related illnesses every year, which is more than those who die from HIV, malaria, and cancer.

The three articles on cardiovascular health have been written by our regular and valued contributor, Theresa Lowry-Lehnen. One of these articles looks at hyperlipidaemia, a condition which GPNs are well versed in treating. Hyperlipidaemia is among the leading risk factors associated with cardiovascular disease and Theresa discusses the evidence underpinning its diagnosis, treatment, and management. She also

examines the current, best practice guidelines for hypertension, of which Ireland has one of the highest rates internationally, but among the lowest levels of diagnosis, treatment, and optimal control. For many patients, hypertension is picked up as a co-incidental finding, with many not displaying symptoms, and therefore, going undiagnosed and untreated, leading to severe and lifechanging consequences, such as stroke, ischaemic heart disease, and other cardiovascular diseases. The Global Burden of Disease study in 2015 identified that non-optimal blood pressure (BP) control continues to be the single greatest risk factor contributing to the global burden of disease and to ‘all-cause mortality’ worldwide. For patients involved in the Chronic Disease Management (CDM) programme, this provides opportunities for regular review and optimal management of their hypertension. However, for those patients who do not meet the criteria for CDM, it appears that

opportunistic screening and diagnosis is the only option. In an ideal world, would a national screening programme for hypertension be beneficial in reducing mortality and morbidity?

Our final article on cardiovascular health guides best practice in atrial fibrillation (AF) and atrial flutter. AF is the most common cardiac arrhythmia diagnosed in clinical practice and affects more than 33 million people worldwide. It increases with age, and with increased longevity, it is predicted that AF will affect 14-17 million people in Europe by 2030. In Ireland, approximately onethird of strokes are associated with AF. Theresa discusses its diagnosis, management, and treatment modalities, as well as examining the differences between AF and atrial flutter. Research has shown the benefits of screening for AF in the over 65 population, with general practice being well-placed to provide opportunistic screening for older patients. Opportunistic screening for an irregular pulse carried out by GPNs and GPs has significant potential in stroke prevention and a subsequent improvement on quality-of-life, reducing disease burden, and its impact on the health service.

NiGP is now a fully independent publication and is no longer the official journal of the IGPNEA. If you are interested in writing an article for NiGP, please email denise@greenx.ie

A message from Ruth Morrow, Consulting Editor Ms Ruth Morrow

C ONT ENTS

32 ASTHMA UPDATE

EDITOR

Denise Doherty denise@greenx.ie

CONSULTING EDITOR

Ruth Morrow

SUB-EDITOR

Emer Keogh emer@greenx.ie

CREATIVE DIRECTOR

Laura Kenny laura@greenx.ie

'HER HEART MATTERS' CAMPAIGN LAUNCHED BY THE IRISH HEART FOUNDATION

Irish females are six times more likely to die from cardiovascular disease (CVD) than breast cancer and it looks as though few women are actually aware of this and other cardiovascularrelated facts. The Irish Heart Foundation (IHF) is setting the record straight this September by launching its “Her Heart Matters” campaign, which is supported by the HSE, TV personality Glenda Gilson, and Marks and Spencer. The campaign aims to highlight very serious trends in relation to the current incidence of CVD in women, particularly during and after menopause.

One-in-four female deaths in Ireland are attributable to heart disease and stroke, with risks rising significantly for women over 40 as they progress towards and into menopause. Only 13 per cent of women are actually aware of their increased heart disease risk, while a mere four per cent have knowledge of an increased risk of stroke, according to an Ipsos poll carried out on behalf of the IHF. The poll also revealed that 30 per cent of women report not having enough time to focus on their own health each day. The campaign is targeting these women in particular, to encourage them towards lifestyle and behavioural changes that are sustainable and conducive to cardiovascular health. These small, but significant changes, could prevent 80 per cent of early heart disease and stroke, according to Janis Morrissey, Director of Health Promotion for the IHF. She says that heart health should be a priority for these women, but acknowledges that most already have busy lives and don’t always make time for themselves. The campaign is therefore, all about promoting awareness, selfcare, and making small, gradual changes towards a better future.

According to Dr Angie Brown, Medical Director of the IHF and consultant cardiologist, heart disease in women has

been under-researched, under-diagnosed, and under-treated for far too long. Speaking at the launch of the campaign, Dr Brown emphasised the importance of early detection and management of CVD among women, highlighting the associations between oestrogen depletion and elevated levels of low-density lipoproteins (LDL) in menopause. Dr Brown advocates for early detection and management of CVD risk factors to improve heart health and reduce early deaths in women. The Ipsos poll indicated that 68 per cent of the women over 35 surveyed said that the subject of menopause had never been brought up during a healthcare consultation. General practice nurses (GPNs) are ideally placed to make this patient group more menopause and heart-health aware. As part of the campaign, the IHF have developed a range of resources to promote heart health during and after menopause that GPNs

can inform their patients about. Women can easily access information about menopause, heart health, and lifestyle on the IHF website, or sign up to receive tips and information by email in future. They can also access a free online selfassessment tool to identify lifestyle goals and download a wellbeing journal to support them towards achieving them. The IHF is also holding a free webinar for women on Thursday 29 September, World Heart Day. GPNs can inform patients about the event and explain that they will receive practical advice, hear real women’s experiences, and get advice from a panel of experts during the “Her Heart Matters: Let’s Talk About Menopause” webinar.

The free online event runs from 12.30pm to 1.45pm and anyone can register to attend on www./irishheart.ie/campaigns/herheart-matters-heart-month-2022/.

Rotunda Hospital celebrates World Breastfeeding Week with increased initiation rates and breastfeeding supports

The Rotunda Hospital has released new figures that show an increase of three per cent in breastfeeding initiation between 2020 and 2021. In addition to the increase in initiation rates, breastfeeding exclusively on discharge and mixed feeding on discharge also increased, both by one per cent, when compared to the previous year. Geraldine Gordon, Clinical Midwife Specialist in Lactation at the Rotunda Hospital said: "We want to ensure that our patients feel supported on their breastfeeding journey, which can be challenging for many people in the early days. We have a team of dedicated midwives on hand to provide support and a team of lactation specialists dealing with more complex cases.”

To continue to support parents on their breastfeeding journey, the hospital

has implemented a number of service developments, including the addition of two full-time lactation specialists to the lactation team, education and training provision for midwifery staff in the area of breastfeeding, a breast-pump loan

scheme, and the purchase of reclining chairs and bedside cots for an easier breastfeeding experience. These measures are believed to have contributed to the increased breastfeeding trends, as well as a subsequent 39 per cent increase in capacity for consultations with patients and a 36 per cent increase in neo-natal ICU consultations in the same period.

Marina Cullen, Clinical Midwife Specialist in Lactation at the Rotunda Hospital added: "Where possible, we recommend that women engage with our online resources on the hospital website (www.rotunda.ie) and with community support groups before birth to help them prepare for infant feeding. This also helps to facilitate a valuable support network after discharge as they embark on their breastfeeding journey.”

Servier launch cardiovascular website to help patients improve their understanding and promote better outcomes

Servier are delighted to announce the launch of their unique patient website –MyHealthPartner.ie. This platform has been designed in response to the urgent need for a unique website for cardiovascular patients, with simple information on disease aetiology, aimed at improving understanding of their condition and better adherence to treatment. It is an all-in-one, comprehensive website, developed through collaboration with the Global Heart Hub patients’ association, clinical

experts, and nutritionists.

With MyHealthPartner.ie, patients will receive clear information about risk factors and symptoms. They might also find answers to questions they are reluctant to ask their healthcare provider. The website is designed to empower the patient in the management of their own chronic disease, by providing information about lifestyle management also. Patients will learn about daily activities, behaviours, and diet options that help to reduce the risk of cardiovascular events.

MyHealthPartner.ie includes personalised recipes that are adapted to each patient profile, with weekly diet plans to help patients cook new meals every day. It also offers articles that teach patients how to relax and details physical exercises to encourage mobility. New content is added to the website on a regular basis to promote the ongoing implementation of small lifestyle changes and subsequent improvements in health outcomes.

MyHealthPartner.ie is now live and available for patient use.

HSE launches new model of service to promote improvements in mental health outcomes for children and adolescents with intellectual disabilities

The HSE and Minister for Mental Health and Older People, Mary Butler, have launched a new national model to promote improved clinical outcomes for children and adolescents with intellectual disability.

The CAMHS-ID National Service Model anticipates achieving these improvements by standardising and integrating mental health provision nationally. The document acknowledges that families and carers of children with an intellectual disability have expressed difficulty in securing an appointment with a mental health service provider in the past, and in understanding the referral pathway. The model subsequently aims to eliminate these and other pressing issues.

The publication is aligned with recommendations from the Sláintecare TenYear Plan, and guides service development and the resourcing requirements of the new specialist Child and Adolescent Mental Health of Intellectual Disability (CAMHS-ID) teams. These teams are distinctly separate from the multidisciplinary Children’s Disability Network Teams (CDNT) and existing Child and Adolescent Mental Health Services (CAMHS), but will closely collaborate with and complement these services, as well as services in primary care.

CAMHS-ID services are currently only operational at 22 per cent of the required service levels outlined in Vision for Change. For the limited number of CAMHS-ID teams to provide specialist assessments and interventions within an acceptable timeframe, they need to support a small caseload of complex individuals. This has been shown to promote individualised care, appropriate to the young person’s levels of ability. The document advocates that specialist services are most appropriate for:

 Children with a mental health disorder who function in the moderate, severe and profound intellectual disability range.

 Children and adolescents with limited or no verbal communication due to their intellectual disability.

 Complex medical or psychiatric needs, which present challenges to diagnosis and assessment.

CAMHS-ID teams provide discrete, specialist intervention to treat the child’s mental disorder and optimise quality-oflife. As interventions take effect and the young person’s mental health improves, the CAMHS-ID team will discharge back to the joint management between primary care and the CDNT, with a recovery care plan for staying well and information on how to access the team again if needed. The model advises that multidisciplinary intervention should be provided initially by the Children’s Disability Network Team, prior to a referral to CAMHS-ID. Early detection of a potential mental disorder along with timely referral from primary care is needed, and if a child or adolescent with an intellectual disability is already attending a clinical service in a primary care or disability team setting, they should

not be discharged from that clinical service. The CAMHS-ID team will provide specialist mental health intervention only and will not provide for all the clinical needs of the child or adolescent with an intellectual disability.

Dr Louise Sharkey, HSE National Clinical Development Lead, Child and Adolescent Mental Health Intellectual Disability, welcomes “The establishment of geographically distinct, community-based multidisciplinary mental health services for children and adolescents with intellectual disability, provided by specialist teams.” She and Minister Butler, highlight that the model is a vital step towards equal opportunities for accessing services and in the implementation of Sharing the Vision and the Sláintecare Implementation and Action Plan.”

The CAMHS Intellectual Disability National Model of Service is available to view on the HSE website at www.hse.ie/ eng/services/list/4/mental-health-services/ camhs/camhs-id-model-of-service/camhsid-model-of-service.pdf.

IMPORTANCE OF GENERAL PRACTICE HIGHLIGHTED AT ENHANCED COMMUNITY CARE CONFERENCE 2022

The HSE and the Department of Health hosted the Enhanced Community Care (ECC) Conference on 1 September to evaluate the progress of the €240 million programme and to support the implementation of necessary changes as they arise. The ECC programme is anticipated to achieve a 20 per cent reduction in the number of people over the age of 75 that are admitted to the acute care setting by 2023, and general practice is already playing a critical role in achieving this target and others. Attendees on the day heard from a range of expert speakers and senior HSE members, as well as first-hand accounts from patients who have directly experienced the positive impacts of the integrated care programme already.

Celine Naughton, a patient under the care of the Community Healthcare East respiratory team, received timely respiratory input from the Integrated Care Hub in Bray after swift referral by her GP and described a hugely positive experience of the entire

programme, adding how she hopes everyone will be able to avail of it soon. 87 of the planned 96 Community Healthcare Networks (CHNs) are now functioning nationally and 21 of 30 planned Integrated Care Programmes for Older Persons (ICPOP) have been established. Almost half of the 30 Integrated Care Programmes for Chronic Disease Management (ICPCDM) and 21 Community Intervention Teams

INMO update on public sector pay proposals

The INMO Executive Council has considered the pay deal for public sector employees and recommends that members accept the proposal brokered between public sector unions and representatives from the Department of Public Expenditure. Alongside other terms, the proposed package includes an immediate three per cent increase on base salary, backdated to February this year, a further one per cent increase (or €500) in October; followed by a two per cent increase in March next year, and a final 1.5 per cent rise (or €750) next October. Balloting will commence on 12 September, in tandem with an information campaign, and end on 5 October.

are also functional as the programme continues to develop.

Also speaking at the event, Dr David Hanlon, GP and HSE National Clinical Advisor for Primary Care, acknowledged that the ECC programme is founded on the deepening partnerships between primary, community and acute care professionals, and that these ever-evolving close relationships are delivering real change for patients in general practice. He commended the fact that over 90 per cent of GP practices are now delivering dedicated chronic disease consultations with patients, who now also have hugely improved access to x-rays, MRIs and other scans. Health Minister Stephen Donnelly; Paul Reid, HSE CEO; and keynote speaker on the day Prof Sir Chris Ham, all acknowledged how the teams working in primary care, in community services, and in new specialist teams and hubs are already reducing dependence on hospital services, and that Ireland has made an impressive start towards moving in line with international best practice.

The INMO continues to press the Department of Health (DoH) about addressing the ongoing issue of the pandemic bonus for frontline nurses working in general practice and private hospitals. To date, the HSE has paid the bonus to the majority of HSE and Section 38 employees and is in the process of delivering the bonus to agency workers, section 39 employees and those who worked in private nursing homes. Despite their lead role in vaccinating huge volumes of the Irish population and tending to the needs of their patients throughout the pandemic, GPNs have still not been added to the list of those entitled.

DoH proposals still do not address pandemic bonus for GPNs

My Health Partner, your new partner in understanding your disease better and improving your everyday lifestyle. DEVELOPED

BY NUTRITIONISTS, THERAPEUTIC EXPERTS AND PATIENT ASSOCIATIONS Hypertension Diabetes Heart Failure Angina High Cholesterol w w w.myhealthpartner.ie 2223 C1 MHP Press Ad CBU. Date of Preparation August 2022.

ICGP CALLS FOR INNOVATIVE SOLUTIONS TO THE CURRENT DEFICITS IN WORK CONDITIONS AND DOCTORS IN IRELAND

The Irish College of General Practitioners (ICGP) is warning of a workforce crisis in its Pre-Budget Submission 2023 and calls for urgent action before the situation worsens even further. Currently, only one-in-five GP practices can take new GMS patients and one-infour can accept new private patients. Services have already grown significantly under the Chronic Disease Management Programme and the expansion of free GP care for the under 65s. The ICGP is warning that the population of GPs in Ireland is aging, the number due to retire is increasing, and there is a critical shortage of replacements. All of these issues will have a major impact on current and future GPNs in Ireland.

The Irish Medical Council’s (IMC) recent Medical Workforce Intelligence Report for 2021 found that the deficit of GPs in Ireland currently stands at

42 per cent. Chairman of the ICGP, Dr John Farrell, said: “Our statistics show that five per cent of our GPs are over 70 years of age, 14 per cent are over 65, and 25 per cent are over 60,” before proceeding to add that the majority of younger GPs generally prefer working in bigger, urban practices, as opposed to rural areas. President of the ICGP, Dr Paul Armstrong, added that despite the ICGP’s 70 per cent increase in GP training numbers since 2017 and planned 350 training places by 2026, supply will still not meet demand. Pre-Budget Submission 2023 reiterates urgent calls for a Ministerial Working Group on Future General Practice, to help plan for the deficit and find innovative and effective solutions, especially in rural areas.

The ICGP also wants to start a realistic conversation about the critical state of current working conditions for doctors in Ireland. More concerning findings from

the intelligence report indicate an acute shortage of doctors across all specialties and settings, excessive workloads for existing doctors, non-compliance with European working directives, reliance on international graduates, lack of training and career progression opportunities, and a general sense of dissatisfaction within the profession. Overall, the IMC report and ICGP Pre-Budget Submission paint a grim reflection of the current situation in Ireland.

President of the Medical Council, Dr. Suzanne Crowe, considers the current situation a matter of urgency and members of the ICGP agree. They will be producing a Discussion Document at their Autumn Conference in October and Dr Farrell hopes this will “act as a level to bring stakeholders together and start a realistic conversation about the critical issue of workforce deficits in the Irish healthcare system”.

New model to tackle workforce shortages in nursing

The Minister for Health, Stephen Donnelly, and the Minister for Public Expenditure and Reform, Michael McGrath, recently launched A System Dynamics Model of Nursing Workforce Supply as part of the 2022 Spending Review process. The paper estimates that in 2021, approximately 46 per cent of the national nursing workforce had been educated abroad. Based on a current intake of 2,000 undergraduate nurses per year and historical patterns of retention, the proportion of domestically educated nurses will further decrease to approximately 38 per cent in 2041. The aim of this work is to provide an evidence

base to help inform policymakers on the appropriate student intake for nurses in Irish higher education institutions to promote future self-sufficiency.

Minister Donnelly welcomed the publication, saying: “Strategic workforce planning in healthcare is a key priority for me and this Government. I am delighted to support the publication of A System Dynamics Model of Nursing Workforce Supply. The solutions identified in this paper will address workforce challenges, help to meet expected increases in demand for nurses and reduce Ireland’s reliance on the recruitment of foreign educated nurses.”

BREAKTHROUGH STUDY BETWEEN NUI

GALWAY AND MASSACHUSETTS INSTITUTE MIGHT MAKE ARTIFICIAL PANCREAS A REALITY FOR DIABETICS

Adynamic team of researchers from NUI Galway and Massachusetts Institute of Technology (MIT) has devised a new design that may assist in the development of an artificial pancreas to treat diabetes. An immune response, known as the foreign body response, results in a buildup of scar tissue around implantable devices and has hindered efforts in the past, as the fibrous matrix quickly blocks the implanted device’s ability to release insulin. The new device is engineered to facilitate small and regular movements every 12 hours; a feature that allowed the device to remain functional after eight weeks of implantation. The researchers evaluated the effectiveness of the insulin release by measuring changes in blood glucose levels and found that effective insulin delivery was maintained throughout the eight weeks of the study. They also documented a modulated immune cell response to the implanted device, which extended its lifetime and efficacy, and negated the need for immunosuppressant drugs.

The collaboration was led by Dr Eimear Dolan; Assistant Professor in Biomedical Engineering from NUI Galway; Prof

Garry Duffy, Professor of Anatomy and Regenerative Medicine from NUI Galway; and Prof Ellen Roche, an Irish biomedical engineer and Associate Professor at MIT in the Department of Mechanical Engineering and the Institute of Medical Engineering and Science. Dr Dolan said: “We are very excited about the results of this study. We believe our approach holds promise to improve the performance of a range of implantable drug delivery devicesfrom insulin to cancer therapy delivery.”

Prof Roche added, “You can imagine that we can apply this technology to anything that is hindered by a foreign body response or fibrous capsule and have a long-term effect. I think any sort of implantable drug delivery device could benefit.” Prof Duffy also commented, saying that: “Soft robotics allow us to make the implants active and to influence how the immune system perceives medical device implants. We will continue to translate this technology through to the clinic in the

coming years.” The trio have co-founded Fada Medical, which is developing fully implantable and partially implantable versions of this technology to improve insulin delivery for people with diabetes. This venture will be supported by the unique NUI Galway innovation ecosystem, drawing expertise from CÚRAM, the HRB Clinical Research Facility and leading clinicians. The full study is available in Nature Communications at www.nature.com/ articles/s41467-022-32147-w.

Assistant Professor in Biomedical Engineer Dr Eimear Dolan and Prof Garry Duffy, Professor of Anatomy and Regenerative Medicine, NUI Galway. Credit – NUI Galway

AUTHOR: Denise Doherty

THE DARK DAYS OF SIGHT LOSS AND HOW NURSES REALLY DO MAKE A DIFFERENCE

To celebrate World Sight Day on October 13th, Nursing in General Practice (NiGP) met with a young woman from Donegal who suffered acute complications of type 1 diabetes at only 25 years old, losing her kidney function, her precious sight, and almost her life. Since then, Mariosa, now 32 years old, went on to become the third female in Ireland to receive a double kidney and pancreas transplant and is rebuilding her life in complete darkness, without diabetes and dialysis. She wants to raise awareness of the importance of eye health in diabetes, emphasising that young people can be affected too. She would also like to thank the many nurses she met during her illness, particularly those that shone a little light on some of her darkest days, and remind all of them how they make a valuable impact on patient’s lives.

It is hard to imagine opening your eyes in the morning and not a shred of anything flooding in. That is exactly what Mariosa describes though, as she talks about the day her final fragments of sight disappeared forever. The vast team of healthcare providers she had accumulated still

had hope, but she knew in her heart that morning, that she would never see again. Unfortunately, her gut instinct was right. As well as fighting to stay alive, adjusting to life on dialysis, and frequent admissions to hospital over the months that followed, Mariosa underwent several surgical attempts at repairing her sight before receiving her transplant; the last of which ended in a cardiac arrest, ventilation in ICU, and the loss of all

hope of ever seeing anything again. Mariosa recounts being a wellmanaged diabetic from her diagnosis at 11 years old and she smiles as she remembers her first encounter with a nurse in childhood. She does not recall anything more than her name and the gentle, understanding, and supportive approach that enabled the young girl to self-administer her first insulin injection and every one after that, including the last.

“I didn’t meet many nurses for a long time after that,” she says, and talks about her younger years as a talented footballer, reaching the peak of her game by playing in school All-Ireland finals and soccer for her country. She had a job she loved, a family she loved, and a life she loved before her body waged war on itself. The sense of loss that accompanies these memories is palpable and devastation radiates when she describes driving her car for the last time, watching a film for the last time, choosing clothes for the last time, and seeing the familiar faces she loves, fading into an extensive nothingness.

“It was like a nightmare,” she says softly and the grief slowly turns to fear and anxiety.

“I was terrified every time I had to

A YOUNG WOMAN TALKS ABOUT THE DEVASTATION OF SIGHT LOSS, WHAT NURSES MEAN TO HER, AND THE IMPORTANCE OF EYE HEALTH FOR YOUNG DIABETICS

Mariosa Gildea, the third female double transplant recipient in Ireland

leave the house. I couldn’t see what the doctors and nurses were doing during appointments, or when my kidneys started to fail and I ended up in hospital. I started dialysis in virtual darkness, I couldn’t see the unit, the staff, other patients or the equipment. The machines and alarms were loud and I had to get two huge needles inserted into my arm, three times every week. It was really scary. I was swollen up with fluid, I was vomiting all the time with gastroparesis, my blood pressure was either too high or too low, I was really anaemic and felt awful all the time. Then I got called for transplant twice, but wasn’t suitable for the organs and had to come back. It was a really tough few years. When

“I always had and still have amazing support from my family and very close friends,” she says, “but no matter where I was or what procedure I had to have, there was always a nurse there. It wasn’t just the care, treatment or drugs they gave me that made the difference; it was how they listened, tried to understand or just sat with me and explained what was going on. All the staff were lovely, but in general, the nurses were always there to listen and help. I was in hospitals all over the country and nurses in all of them made a difference.”

The nature of attending dialysis three times every week leads to a unique nurse-patient rapport that is well documented in nephrology

unit that I still miss today.”

The young survivor can’t find enough ways to express her gratitude to those special faces she will never see. Her appreciation extends beyond the acute setting too and into general practice, as she describes the day she made the transition from acute to primary care.

I finally got the call and the surgery, I had more complications and ended up staying in St Vincent’s Hospital, Dublin, for seven weeks. At that stage, I was used to everything going wrong, but I eventually recovered and here I am.”

Mariosa’s story is filled with unimaginable pain, terror, and loss, yet she has so much gratitude for the family, friends, and healthcare staff that supported her throughout.

“I haven’t actually seen a lot of the faces that helped me through so much of my illness,” she smiles sincerely, and talks about how the rest of the world kept turning when it felt as though her own had stopped.

“That’s where the nurses became really special,” Mariosa oozes warmth and explains that some of her nurses have even gone on to become her friends.

literature. Mariosa’s account goes a long way towards validating this phenomenon, and she expresses a lot of positive emotions when she talks about the two years she spent there. She doesn’t mention much about the needles or technicalities of haemodialysis though; she instead remembers the kindness, empathy and laughter that made dialysis in the dark bearable. “If I was afraid, they would reassure me and take time to explain. They would sit at the bed for a chat, make sure I had everything close to hand and they were all so friendly. They even came with me if I had to have other procedures for support because they understood how daunted I was by the dark. They gave me a shoulder to cry on, information when I wanted it, and they made me a comfort zone in the renal

“After the transplant and recovery, I was just getting used to feeling human again when my hearing started to feel a little funny. I was petrified, because without my sight, my ears have become so, so important. I had to visit my practice nurse to get them irrigated and I was very nervous. I was so used to getting everything sorted out in dialysis, it was hard to get to know new people and places. A few of my dialysis nurses kept in touch after the transplant and one of them insisted on coming with me when I opened up about my nerves. Having that familiarity made such a difference, but when I got there, all my anxiety went away because the new nurse was just as gentle, patient, and understanding. Together, they made the whole transition so easy for me and Mum. Nurses don’t get enough credit for what they do and how they do it.”

Alongside the special nurses that provided care during those difficult years, and continue to do so in general practice, Mariosa also holds the deepest and most heart-felt appreciation for her organ doner and their family.

“I lost the precious gift of sight, but was given an even more precious gift from a complete stranger. This act of kindness and all the care, compassion, and support I received from strangers throughout my journey will be cherished forever. I hope that my story might bring enough awareness to prevent even just one other person from living a life in the dark.” 

IF I WAS AFRAID, THEY WOULD REASSURE ME AND TAKE TIME TO EXPLAIN. THEY WOULD SIT AT THE BED FOR A CHAT, MAKE SURE I HAD EVERYTHING CLOSE TO HAND AND THEY WERE ALL SO FRIENDLY

treatment exacerbation* exacerbation treated past 12 months with statistically health-related rate of moderate/ budesonide/formoterol***

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***Co-primary endpoints were change from baseline in trough FEV1 and SGRQ at week 24 (n=1810). A subset of patients (n=430) remained on blinded study treatment for 52 weeks. Trelegy showed an improvement in trough FEV1 of 171mL versus budesonide/formoterol (p < 0.001, 95% CI 148,194) at week 24. Trelegy showed an improvement in health-related quality of life (SGRQ) of 2.2 units (p <0.001, 95% CI 3.5, 1.0) at week 24. At week 52 in a subset of patients Trelegy showed a 44% reduction in annualised rate of moderate/severe exacerbations versus budesonide/formoterol (95% CI 15,63, p=0.006, Absolute difference 0.16).

TRELEGY Ellipta is generally well tolerated. Common adverse reactions include: pneumonia, upper respiratory tract infection, bronchitis, pharyngitis, rhinitis, sinusitis, influenza, nasopharyngitis, candidiasis of mouth and throat, urinary tract infection, headache, cough, oropharyngeal pain, constipation, arthralgia, back pain1

FF, fluticasone furoate; ICS, inhaled corticosteroid; LABA, long-acting ß2-agonist; LAMA, long-acting muscarinic antagonist; OD, once-daily; UMEC, umeclidinium, VI, vilanterol

References: 1. TRELEGY Ellipta SmPC 2019. 2. Lipson DA et al. Am J Respir Crit Care Med 2017; 196:438–446. 3. Lipson DA et al.N Engl J Med 2018; 378:1671–1680.

Trelegy▼ Ellipta (fluticasone furoate/umeclidinium/vilanterol [as trifenatate]) Prescribing information.

Find

www.trelegy.ie

or request a visit from a GSK representative

oropharyngeal pain, arthralgia, back pain. Uncommon (≥1/1,000 to <1/100): viral respiratory tract infection, supraventricular tachyarrhythmia, tachycardia, atrial fibrillation, dysphonia, dry mouth, fractures. Rare (≥1/10,000 to <1/1,000): Hypersensitivity reactions, including anaphylaxis, angioedema, urticaria, and rash. Not known (cannot be estimated from the available data): vision blurred. Marketing Authorisation (MA) Holder: GlaxoSmithKline Trading Services Limited, 12 Riverwalk, Citywest Business Campus, Dublin 24, Ireland. MA No. [EU/1/17/1236/002]. Legal category: POM B. Last date of revision: September 2020. Code: PI-6725. Further information available on request from GlaxoSmithKline, 12 Riverwalk, Citywest Business Campus, Dublin 24. Tel: 01-4955000.

FF, fluticasone furoate; ICS, inhaled corticosteroid; LABA, long-acting ß2-agonist; LAMA, long-acting muscarinic antagonist; OD, once-daily; UMEC, umeclidinium, VI, vilanterol

References: 1. TRELEGY Ellipta SmPC 2019. 2. Lipson DA et al. Am J Respir Crit Care Med 2017; 196:438–446. 3. Lipson DA et al.N Engl J Med 2018; 378:1671–1680.

Trelegy▼ Ellipta (fluticasone furoate/umeclidinium/vilanterol [as trifenatate]) Prescribing information.

Please consult the full Summary of Product Characteristics (SmPC) before prescribing Trelegy Ellipta (fluticasone furoate/umeclidinium/vilanterol [as trifenatate]) inhalation powder. Each single inhalation of fluticasone furoate (FF) 100 micrograms (mcg), umeclidinium bromide (UMEC) 62.5 micrograms and vilanterol as trifenatate (VI) 25 mcg provides a delivered dose of 92 mcg FF, 55 mcg UMEC and 22 mcg VI. Indications: Maintenance treatment in adult patients with moderate to severe COPD who are not adequately treated by a combination of an inhaled corticosteroid (ICS) and a long-acting ß -agonist (LABA) or a combination of a LABA and a long acting muscarinic antagonist. Dosage and administration: One inhalation once daily at the same time each day. Contraindications: Hypersensitivity to the active substances or to any of the excipients (lactose monohydrate & magnesium stearate). Precautions: Paradoxical bronchospasm, unstable or lifethreatening cardiovascular disease or heart rhythm abnormalities, convulsive disorders or thyrotoxicosis, pulmonary tuberculosis or patients with chronic or untreated infections, narrow-angle glaucoma, urinary retention, hypokalaemia, patients predisposed to low levels of serum potassium, diabetes mellitus. In patients with moderate to severe hepatic impairment patients should be monitored for systemic corticosteroid-related adverse reactions. Eye symptoms such as blurred vision may be due to underlying serious conditions such as cataract, glaucoma or central serous chorioretinopathy (CSCR); consider referral to ophthalmologist. Increased incidence of pneumonia has been observed in patients with COPD receiving inhaled corticosteroids. Risk factors for pneumonia include: current smokers, old age, patients with a history of prior pneumonia, patients with a low body mass index and severe COPD. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take Trelegy. Acute symptoms: Not for acute symptoms, use short-acting inhaled bronchodilator. Warn patients to seek medical advice if short-acting inhaled bronchodilator use increases. Therapy should not be abruptly stopped without physician supervision due to risk of symptom recurrence. Systemic effects: Systemic effects of ICSs may occur, particularly at high doses for long periods, but much less likely than with oral corticosteroids. Interactions with other medicinal products: Caution should be exercised with concurrent use of ß-blockers.

Adverse events should be reported to the Health Products Regulatory Authority (HPRA) using an Adverse Reaction Report Form obtained either from the HPRA or electronically via the website at www.hpra.ie. Adverse reactions can also be reported to the HPRA by calling: (01) 6764971. Adverse events should also be reported to GlaxoSmithKline on 1800 244 255.

tachyarrhythmia, tachycardia, atrial angioedema, urticaria, and rash. Not Trading Services Limited, 12 Riverwalk, September 2020. Code: PI-6725. Further

Indications: Maintenance treatment in adult patients with moderate to severe COPD who are not adequately treated by a combination of an inhaled corticosteroid (ICS) and a long-acting ß2-agonist (LABA) or a combination of a LABA and a long acting muscarinic antagonist. Dosage and administration: One inhalation once daily at the same time each day. Contraindications: Hypersensitivity to the active substances or to any of the excipients (lactose monohydrate & magnesium stearate). Precautions: Paradoxical bronchospasm, unstable or lifethreatening cardiovascular disease or heart rhythm abnormalities, convulsive disorders or thyrotoxicosis, pulmonary tuberculosis or patients with chronic or untreated infections, narrow-angle glaucoma, urinary retention, hypokalaemia, patients predisposed to low levels of serum potassium, diabetes mellitus. In patients with moderate to severe hepatic impairment patients should be monitored for systemic corticosteroid-related adverse reactions. Eye symptoms such as blurred vision may be due to underlying serious conditions such as cataract, glaucoma or central serous chorioretinopathy (CSCR); consider referral to ophthalmologist.

Caution is advised when co-administering with strong CYP3A4 inhibitors (e.g. ketoconazole, ritonavir, cobicistat-containing products), hypokalaemic treatments or non-potassium-sparing diuretics. Co-administration with other long-acting muscarinic antagonists or long acting ß2-adrenergic agonists is not recommended.

Pregnancy and breast-feeding: Experience limited. Balance risks against benefits. Side effects: Common (≥1/100 to <1/10): pneumonia, upper respiratory tract infection, bronchitis, pharyngitis, rhinitis, sinusitis, influenza, nasopharyngitis, candidiasis of mouth and throat, urinary tract infection, headache, cough,

obtained either from the HPRA or events should also be reported to

TRELEGY Ellipta was developed in collaboration with

LOC_IE_OCT20_PM-IE-FVU-ADVT-200014_395x273_3mm Bleed_D1.indd 1

representative Companies or its licensor

Increased incidence of pneumonia has been observed in patients with COPD receiving inhaled corticosteroids. Risk factors for pneumonia include: current smokers, old age, patients with a history of prior pneumonia, patients with a low body mass index and severe COPD. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take Trelegy. Acute symptoms: Not for acute symptoms, use short-acting inhaled bronchodilator. Warn patients to seek medical advice if short-acting inhaled bronchodilator use increases. Therapy should not be abruptly stopped without physician supervision due to risk of symptom recurrence. Systemic effects: Systemic effects of ICSs may occur, particularly at high doses for long periods, but much less likely than with oral corticosteroids. Interactions with other medicinal products: Caution should be exercised with concurrent use of ß-blockers. Caution is advised when co-administering with strong CYP3A4 inhibitors (e.g. ketoconazole, ritonavir, cobicistat-containing products), hypokalaemic treatments or non-potassium-sparing diuretics. Co-administration with other long-acting muscarinic antagonists or long acting ß2-adrenergic agonists is not recommended. Pregnancy and breast-feeding: Experience limited. Balance risks against benefits. Side effects: Common (≥1/100 to <1/10): pneumonia, upper respiratory tract infection, bronchitis, pharyngitis, rhinitis, sinusitis, influenza, nasopharyngitis, candidiasis of mouth and throat, urinary tract infection, headache, cough,

developed in collaboration with

of Companies

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Group

PM-IE-FVU-ADVT-200014 | October 2020

Today. Tomorrow. TRELEGY.

Find out more here: www.trelegy.ie or request a visit from a GSK representative ©2020 GSK Group of Companies or its licensor Trademarks are owned by or licensed to the GSK Group of Companies PM-IE-FVU-ADVT-200014 | October 2020

was developed in collaboration with

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TRELEGY Ellipta

It’s the things you do today that make a big difference to their tomorrows1-3

Fictional patient, for illustrative purposes only

out more here:

24-10-2020 01:28:30

HYPERLIPIDAEMIA

HYPERLIPIDAEMIA IS ONE OF THE MOST PREVALENT RISK FACTORS CONTRIBUTING TO ATHEROSCLEROSIS AND CONSEQUENT VASCULAR DISEASE

Hyperlipidaemia is characterised by an increase in one or more of the plasma lipids, including cholesterol, cholesterol esters, triglycerides, phospholipids, and/or plasma lipoproteins, including very low-density and low-density lipoprotein along with reduced high-density lipoprotein levels.1

Hyperlipidaemia, in particular elevated low-density lipoprotein (LDL) cholesterol, is one of the most prevalent risk factors contributing to atherosclerosis and consequent vascular disease. In contrast, high-density lipoprotein (HDL) cholesterol assists in regulating cholesterol levels to prevent imbalances. Atherosclerosis is a pathologic process characterised by the accumulation of lipids, cholesterol and calcium, and the development of fibrous plaques within the walls of large and medium arteries.

Hypercholesterolaemia and hypertriglyceridaemia are the main cause of atherosclerosis, which is strongly related to ischaemic heart disease (IHD).1,2 Atherosclerosis often remains asymptomatic until plaque stenosis reaches 70-to-80 per cent of the vessel’s diameter. It originates after underlying endothelial damage occurs, which stems from loss of nitric oxide within the endothelium. This process leads to increased inflammation directly around the dysfunctional site, permitting the accumulation of lipids within the innermost layer of the endothelial wall. The lipids are then engulfed by macrophages, leading to the establishment of ‘foam cells’ or debris.

Cholesterol build-up within the foam cells causes subsequent mitochondrial dysfunction, apoptosis, and necrosis of the underlying tissues. Smooth muscle cells encapsulate the pack of foam cells, which produces a fibrotic plaque that inhibits underlying lipids from being destroyed.2

Cholesterol is naturally produced within the body and can also be obtained from animal fats in food. Cholesterol is absent in plant-based foods, however, plant products, such as flax seeds, may contain cholesterollike compounds called phytosterols, which are beneficial in the body. Cholesterol is an

AUTHOR: Theresa Lowry-Lehnen, RGN, PG Dip Coronary Care, RNP, BSc, MSc, PG Dip ED (QTS), M Ed, PhD Clinical Nurse Practitioner, and Associate Lecturer, South East Technological University FIGURE 1: Risk categories for dyslipidaemia and patient groups in each of these categories (ESC/EAS, 2019)5

essential substance in the body necessary for the production of cell structures and plasma membranes, energy expenditure and bile formation and it is important for the synthesis of steroids, hormones, vitamin D, and other substances. 3 Adults typically synthesise about 1g of cholesterol per day and the total body content is approximately 35g. The liver is the primary organ that synthesises cholesterol. About 20-to-25 per cent of total daily cholesterol production occurs in the liver. It is also synthesised to a smaller extent in the adrenal glands, intestines, and reproductive organs. The predominant route of cholesterol elimination from the body is by excretion into the bile. Cholesterol from cells is transported from the plasma membranes of peripheral cells to the liver HDLmediated process termed reverse cholesterol transport.3

Major dietary sources of cholesterol include cheese, egg yolks, beef, pork, poultry, and shrimp. Saturated and trans saturated fats in food raise blood cholesterol. Saturated fats are present in full fat dairy products, animal fats, and several types of oil and chocolate. Trans saturated fats are present in hydrogenated oils, which are found in many fast and snack foods and fried or baked products.3

Hyperlipidaemia can be subdivided into two broad categories: Primary (familial) or secondary (acquired). Familial hypercholesterolaemia (FH) is an inherited genetic defect that may lead to early development of atherosclerosis and IHD. Homozygous FH is rare; affecting 1:160,000 people, while heterozygous FH is more common; affecting approximately 1:250 people.4 Familial combined hyperlipidaemia may occur as an interaction of multiple genes and the person’s environment, and occurs in 1:100 to 1:200 people. Secondary hyperlipidaemia accounts for up to 40 per cent of hyperlipidaemia cases and typically originates from an alternate aetiology, such as an unhealthy diet, medications including amiodarone, and glucocorticoids, hypothyroidism, uncontrolled diabetes, and/or a poor lifestyle.2,4

For most patients, hyperlipidaemia is polygenic and influenced by factors, such as obesity, saturated fat intake, and the cholesterol content within the person’s diet. Another mechanism involves elevated levels of ‘apo B-100’ lipoproteins within the plasma, which may lead to atherosclerotic disease, even when the patient has no other risk factors. There is often a combination of genetic and environmental factors involved that contribute to a person’s risk of developing hyperlipidaemia and cardiovascular disease. 2

A focused physical exam is very important, including accurate blood pressure measurements, observing the patient’s skin for xanthomas, listening for carotid and femoral bruits for evidence of stenosis, listening for an S4 heart sound, and palpating for intact peripheral pulses in all four extremities. Bloods including a lipid profile (fasting) will be carried out, which routinely includes LDL, HDL, triglycerides, and total cholesterol. Other blood tests may include LFTs, HbA1c and TFTs. Urinalysis can be collected to screen for albuminuria. 2

Treatment and management

The treatment of hyperlipidaemia involves both primary and secondary prevention. Primary prevention concerns people with high cholesterol at risk of cardiovascular disease (CVD) with comorbidities, such as high blood pressure, type 1 and 2 diabetes or kidney disease, who do not yet have established CVD. Secondary prevention involves treating individuals with established CVD.4

Diagnosis

The diagnosis of hyperlipidaemia is often an incidental finding following a routine screening by a patient’s GP or general practice nurse conducting a cardiovascular risk assessment. Regularly, patients presenting with underlying hyperlipidaemia remain asymptomatic, therefore obtaining a thorough history is essential. It is important to assess a patient’s family history of cardiovascular disease, hyperlipidaemia, and/or familial hypercholesterolaemia, the patient’s diet and exercise habits, tobacco, alcohol or drug use, the presence of coronary artery disease (CAD), risk factors or history of CAD; and/or symptoms of peripheral arterial disease or angina. 2

The European Society of Cardiology and European Atherosclerosis Society (ESC/EAS) 2019 guidelines for the management of dyslipidaemia outline the risk categories and patient groups in each of these categories (Figure 1), and intervention strategies for primary and secondary prevention as a function of total cardiovascular risk and untreated LDL cholesterol levels (Figure 2).5

Initial treatment modalities are focused on diet and lifestyle modification, with the addition of lipid-lowering medications if needed. Patients with mild hyperlipidaemia and low CVD risk should focus on a low fat, low carbohydrate diet, and moderate- to high-intensity physical activity. Heart health diets are low in saturated and trans fats, sodium, added sugars, and refined grains. Weight loss and regular exercise do not result in significant LDL reduction; however, they play an important part in good cardiovascular health and are associated with reduced triglyceride levels. Smoking

FOR MOST PATIENTS, HYPERLIPIDAEMIA IS POLYGENIC AND INFLUENCED BY FACTORS, SUCH AS OBESITY, SATURATED FAT INTAKE, AND THE CHOLESTEROL CONTENT WITHIN THE PERSON’S DIET

cessation, lowering blood pressure, and losing weight are beneficial to lowering vascular disease risk. For patients at moderate-to-high CVD risk, the above lifestyle modification applies and lipidlowering statin medications should be added. There is a clear and proven benefit to statin therapy for the vast majority of patients from low-risk to high-risk, therefore these drugs’ side-effects and costs should be weighed against the individual patient’s potential benefit from

taking the medication. 2,6

The ESC/EAS 2019 guidelines for the management of dyslipidaemia also outline target plasma LDL cholesterol levels according to the patient’s risk level ( Figure 3).4,5 Statins are associated with a 30-to-60 per cent reduction in LDL cholesterol; a reduction of 20-to-40 per cent in triglyceride levels; and an increase in HDL cholesterol levels of approximately 3-to-12 per cent.4 Statins are the first-

line pharmacological intervention for abnormal lipid profiles. They work by inhibition of the enzyme HMG-CoA reductase, which is involved in the production of mevalonic acid in the cholesterol biosynthesis pathway. By preventing the endogenous production of cholesterol, the expression of LDL receptors in liver cells is upregulated, enhancing the clearance of the circulating LDL-C particles from the blood.6 Five statins are marketed

FIGURE 2: Intervention strategies for dyslipidaemia (ESC/EAS 2019)5

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for use in Ireland: Atorvastatin, fluvastatin, pravastatin, rosuvastatin, and simvastatin. Atorvastatin is the preferred statin for the treatment of hypercholesterolaemia and prevention of cardiovascular events under the HSE’s Medicine Management Programme (MMP) guidance.6

The usual starting dose of atorvastatin is 10mg once daily, and the dose can be adjusted at intervals of four weeks or more to achieve the target LDL cholesterol level. In secondary prevention, 30mg daily should be initiated after diagnosis.4

Prior to commencing cholesterollowering therapy, baseline cholesterol, LDL and HDL, and triglycerides must be measured. TFTs should also be checked and hypothyroidism treated if present before commencing cholesterol-reducing

FIGURE 3: ESC/EAS (2019). Guidelines for the management of dyslipidaemia5 FIGURE 4: Pharmacokinetic properties of statins6 (HSE Medicines Management Programme)

COMBINING POWER AND CONFIDENCE

AGAINST LDL-C* IN THE TREATMENT OF HYPERCHOLESTEROLAEMIA

20 mg /10 mg

Suvezen is indicated for substitution therapy in adult patients who are adequately controlled with rosuvastatin and ezetimibe given concurrently at the same dose level as in the fixed combination, but as separate products, as adjunct to diet for treatment of primary hypercholesterolaemia (heterozygous familial and nonfamilial) or homozygous familial hypercholesterolaemia1

Prescribing Information: Suvezen (rosuvastatin/ ezetimibe) film-coated tablets

Please refer to the Summary of Product Characteristics (SmPC) for full prescribing details.

Presentations: Suvezen 10mg/10mg, 20mg/10mg and 40mg/10mg: Each film-coated tablet contains 10mg; 20mg or 40mg of rosuvastatin (as rosuvastatin calcium) respectively, and 10mg ezetimibe. Indication: Suvezen is indicated for substitution therapy in adult patients who are adequately controlled with rosuvastatin and ezetimibe given concurrently at the same dose level as in the fixed combination, but as separate products, as adjunct to diet for treatment of primary hypercholesterolaemia (heterozygous familial and non-familial) or homozygous familial hypercholesterolaemia. Dosage and Administration: The patient should be on and continue, an appropriate lipid-lowering diet, during treatment with Suvezen. Suvezen is not suitable for initial therapy. Treatment initiation or dose adjustment, if necessary, should only be done with the monocomponents and after setting the appropriate doses the switch to the fixed dose combination of the appropriate strength is possible. Patient should use the strength corresponding to their previous treatment. The recommended dose is one Suvezen tablet daily. To be administered at any time of the day, with or without food. The tablet should be swallowed whole with a drink of water. If co-administered with bile acid sequestrant (BAS), administration of Suvezen should occur either ≥2 hours before or ≥4 hours after administration of a BAS. Special populations: Paediatric (<18 years): Safety and efficacy has not been established. Elderly (>70 years): Starting dose of 5 mg rosuvastatin is recommended. The combination is not suitable for initial therapy. Hepatic impairment: Mild: No dosage adjustment is required. Moderate/Severe: Treatment with Suvezen is not recommended. Renal impairment: Mild: No dose adjustment is necessary. Moderate (creatinine clearance <60 ml/min): The recommended start dose is rosuvastatin 5mg. Race: The recommended start dose is rosuvastatin 5 mg for patients of Asian ancestry due to increased systemic exposure. The fixed dose combination is not suitable for initial therapy. Monocomponent preparations should be used to start the treatment or to modify the dose. Suvezen 40 mg/10 mg tablets are contraindicated in these patients. Genetic polymorphisms: In patients who are known to have specific types of genetic polymorphisms that can lead to increased rosuvastatin exposure, a lower daily dose of Suvezen is recommended.

Dosage in patients with pre-disposing factors to myopathy: The recommended start dose is rosuvastatin 5mg in patients with pre-disposing factors to myopathy. Suvezen 40 mg/10 mg tablets are contraindicated in some of these patients. Concomitant therapy: The risk of myopathy (including rhabdomyolysis) is increased when Suvezen is administered concomitantly with certain medicinal products that may increase the plasma concentration of rosuvastatin (e.g. ciclosporin and certain protease inhibitors including combinations of ritonavir with atazanavir, lopinavir, and/or tipranavir). Whenever possible, alternative medications should be considered, and, if necessary, consider temporarily discontinuing Suvezen therapy. In situations where co-administration of these medicinal products with Suvezen is unavoidable, the benefit and the risk of concurrent treatment and rosuvastatin dosing adjustments should be carefully considered. Contraindications: Hypersensitivity to the active substances or excipients. Pregnancy, breast-feeding and in women of childbearing potential not using appropriate contraceptive measures. Active liver disease or any serum transaminase elevations which are unexplained, persistent or exceeding 3x the upper limit of normal (ULN). Severe renal impairment (creatinine clearance <30ml/min); myopathy or receiving concomitant ciclosporin. 40mg/10mg dose contraindicated in patients with predisposing factors for myopathy/rhabdomyolysis; such factors include: Moderate renal impairment (creatinine clearance <60ml/min), hypothyroidism, personal or family history of hereditary muscular disorders, previous history of muscular toxicity with another HMG-CoA reductase inhibitor or fibrate, alcohol abuse, situations where an increase in plasma levels of rosuvastatin may occur, Asian patients, concomitant use of fibrates.

Precautions and Warnings: Skeletal muscle effects: have been reported in rosuvastatin-treated patients with all doses and in particular with doses >20mg. As with other HMG-CoA reductase inhibitors, reporting rate for rhabdomyolysis is associated with use at doses >40mg. Post-marketing experience with ezetimibe, cases of myopathy and rhabdomyolysis have been reported. If myopathy is suspected based on muscle symptoms or is confirmed by a creatine phosphokinase (CPK) level, Suvezen and any of these other agents that the patient is taking concomitantly should be immediately discontinued. All patients starting therapy with Suvezen should be advised of the risk of myopathy and told to report promptly any unexplained muscle pain, tenderness or weakness, particularly if associated with malaise or fever. Creatine kinase (CK) measurement: CK should not be measured following strenuous exercise or in the presence of a plausible alternative cause of CK increase. If CK levels are significantly elevated at baseline (>5x ULN) a confirmatory test should be carried out within 5 – 7 days. If the repeat test confirms a baseline CK >5x ULN, treatment should not be started. Patients with pre-disposing factors for myopathy/rhabdomyolysis: Caution should be exercised in these patients. Risk: benefit of treatment should be considered and clinical monitoring is recommended. CK levels should be measured in these patients. Therapy should be discontinued if CK levels are markedly elevated (>5x ULN) or if muscular symptoms are severe and cause daily discomfort. If symptoms resolve and CK levels return to normal, then consideration should be given to re-introducing treatment at the lowest dose. Immune-mediated necrotising myopathy (IMNM): Clinically characterised by proximal muscle weakness and elevated serum CK, has been reported very rarely during or after treatment with statins, including rosuvastatin, despite discontinuation of statin treatment. In clinical trials an increase in the incidence of myositis and myopathy has been seen in patients receiving other HMG-CoA reductase inhibitors together with fibric acid derivatives. Suvezen should not be used in any patient with an acute, serious condition suggestive of myopathy or predisposing to the development of renal failure secondary to rhabdomyolysis (e.g. sepsis, hypotension, major surgery, trauma, severe metabolic, endocrine and electrolyte disorders; or uncontrolled seizures). Liver effects: In controlled coadministration trials in patients receiving ezetimibe with statin, consecutive transaminase elevations ≥3x ULN have been observed. It is recommended that liver function tests be carried out prior to, and 3 months following, the initiation of treatment. Rosuvastatin should be discontinued or the dose reduced if the level of serum transaminases is >3x ULN. The reporting rate for serious events is higher at the 40mg dose. In patients with secondary hypercholesterolaemia caused by hypothyroidism or nephrotic syndrome, the underlying disease should be treated prior to initiating therapy with rosuvastatin. Liver disease and alcohol: As with other HMG-CoA reductase inhibitors, rosuvastatin should be used with caution in patients who consume excessive quantities of alcohol and/or have a history of liver disease. Renal effects: Proteinuria has been observed in patients treated with higher doses of rosuvastatin and was transient or intermittent in most cases. Proteinuria has not been shown to be predictive of acute

Reference: 1. Suvezen Summary of Product Characteristics

* LDL-C: Low-density lipoprotein Cholesterol

40 mg /10 mg

Single-pill combination of rosuvastatin and ezetimibe available in 3 doses**

or progressive renal disease. An assessment of renal function should be considered during routine follow-up of patients treated with a dose of 40mg. Diabetes mellitus: Some evidence suggests that statins raise blood glucose and in some patients, at high risk of future diabetes, may produce a level of hyperglycaemia where formal diabetes care is appropriate. This risk, however, is outweighed by the reduction in vascular risk with statins and therefore should not be a reason for stopping statin treatment. Patients at risk (fasting glucose 5.6 – 6.9mmol/l, BMI >30kg/m2, raised triglycerides, hypertension) should be monitored both clinically and biochemically according to national guidelines. Interstitial lung disease: Exceptional cases have been reported with some statins, especially with long term therapy. Presenting features can include dyspnoea, non-productive cough and deterioration in general health (fatigue, weight loss and fever). If it is suspected, statin therapy should be discontinued. Severe cutaneous adverse reactions: Stevens-Johnson syndrome (SJS) and drug reaction with eosinophilia and systemic symptoms (DRESS), which could be life-threatening or fatal, have been reported with rosuvastatin. If signs and symptoms suggestive of this reaction appears, Suvezen must be discontinued immediately and an alternative treatment should be considered. Treatment with Suvezen must not be restarted at any time. Protease inhibitors: Increased systemic exposure to rosuvastatin has been observed in subjects receiving rosuvastatin concomitantly with various protease inhibitors in combination with ritonavir. Consideration should be given both to the benefit of lipid lowering by use of Suvezen in HIV patients receiving protease inhibitors and the potential for increased rosuvastatin plasma concentrations when initiating and up titrating rosuvastatin doses in patients treated with protease inhibitors. The concomitant use with certain protease inhibitors is not recommended unless the dose of rosuvastatin is adjusted. Fibrates: The safety and efficacy of ezetimibe administered with fibrates have not been established. If cholelithiasis is suspected in a patient receiving Suvezen and fenofibrate, gallbladder investigations are indicated and therapy should be discontinued. Anticoagulants: If Suvezen is added to warfarin, another coumarin anticoagulant, or fluindione, the International Normalised Ratio (INR) should be appropriately monitored. Fusidic acid: Suvezen must not be co-administered with systemic formulations of fusidic acid or within 7 days of stopping fusidic acid treatment. In patients where the use of systemic fusidic acid is considered essential, statin treatment should be discontinued throughout the duration of fusidic acid treatment. There have been reports of rhabdomyolysis (including some fatalities) in patients receiving fusidic acid and statins in combination. The patient should be advised to seek medical advice immediately if they experience any symptoms of muscle weakness, pain or tenderness. Statin therapy may be reintroduced seven days after the last dose of fusidic acid. In exceptional circumstances, where prolonged systemic fusidic acid is needed, e.g., for the treatment of severe infections, the need for co-administration of Suvezen and fusidic acid should only be considered on a case by case basis and under close medical supervision. Suvezen contains lactose monohydrate and sodium: Patients with rare hereditary problems of galactose intolerance, total lactase deficiency or glucose-galactose malabsorption should not take this medicine. This medicinal product contains less than 1 mmol sodium (23 mg) per tablet, that is to say essentially ‘sodiumfree’. Interactions: Contraindicated combinations: Ciclosporin. Not-recommended combinations: Fibrates and other lipid-lowering products, protease inhibitors, transporter protein inhibitors and fusidic acid. Other possible interactions: Cytochrome P450 enzymes, antacids, colestyramine, anticoagulants, Vitamin K antagonists, erythromycin, oral contraceptive/hormone replacement therapy. When coadministering rosuvastatin with other medicinal products known to increase exposure to rosuvastatin, doses should be adjusted (see SmPC for full details). The maximum daily dose should be adjusted so that the expected rosuvastatin exposure would not likely exceed that of a 40mg daily dose of rosuvastatin taken without interacting medicinal products. Fertility, Pregnancy and Breastfeeding: No clinical data are available on the use of ezetimibe during pregnancy. Potential risk from inhibition of HMG-CoA reductase outweighs the advantage of treatment during pregnancy. If a patient becomes pregnant during use of Suvezen, treatment should be discontinued immediately. Animal studies have shown excretion of medicinal product through breast milk. However, there are no data in humans. No clinical trial data on the effects of fertility in humans. Adverse Reactions: Adverse drug reactions previously reported with one of the individual components (ezetimibe or rosuvastatin) may be potential undesirable effects with Suvezen. Common (≥1/100 to <1/10): diabetes mellitus, headache, dizziness, constipation, nausea, abdominal pain, diarrhoea, flatulence, myalgia, ALT and/or AST increased, asthenia and fatigue. Uncommon (≥1/1,000 to <1/100): decreased appetite, paraesthesia, hot flush, hypertension, cough, dyspepsia, gastroesophageal reflux disease, nausea, dry mouth, gastritis, pruritus, rash, urticaria, arthralgia, muscle spasms, neck pain, back pain, muscular weakness, pain in extremity, ALT and/or AST increased, blood CPK increased, gamma-glutamyltransferase increased, liver function test abnormal, chest pain, pain, asthenia, oedema peripheral. Rare (≥1/10,000 to <1/1,000): thrombocytopenia, hypersensitivity reactions including angioedema, pancreatitis, increased hepatic transaminases, myopathy (including myositis), rhabdomyolysis, lupus-like syndrome and muscle rupture. Very rare (<1/10,000): polyneuropathy, memory loss, jaundice, hepatitis, arthralgia, haematuria, gynaecomastia. Not known: thrombocytopenia, hypersensitivity (including rash, urticaria, anaphylaxis and angioedema), depression, peripheral neuropathy, sleep disturbances (including insomnia and nightmares), dizziness, paraesthesia, cough, dyspnoea, diarrhoea, pancreatitis, constipation, hepatitis, cholelithiasis, cholecystitis, Stevens Johnson syndrome, erythema multiforme, drug reaction with eosinophilia and systemic symptoms, immune-mediated necrotising myopathy, tendon disorders (sometimes complicated by rupture), myalgia, myopathy/ rhabdomyolysis,

** Suvezen is available in 3 doses in Ireland. Suvezen 10mg/10mg, 20mg/10mg and 40mg/10mg: Each film-coated tablet contains 10mg; 20mg or 40mg of rosuvastatin (as rosuvastatin calcium) respectively, and 10mg ezetimibe.

Rosuvastatin + Ezetimibe 10 mg /10 mg Rosuvastatin + Ezetimibe Rosuvastatin + Ezetimibe

MAT-IE-2101261 (v2.0) | April 2022

adverse

Legal Category: POM. Marketing Authorisation Numbers: 10mg/10mg: PA0540/193/001; 20mg/10mg: PA0540/193/002; 40mg/10mg: PA0540/193/003. Marketing Authorisation Holder: Sanofi-Aventis Ireland Ltd. T/A SANOFI, Citywest Business Campus, Dublin 24, Ireland. Further information is available from: Sanofi, 18 Riverwalk, Citywest Business Campus, Dublin 24 or contact IEmedinfo@sanofi.com Date of Preparation: February 2022 (MAT-IE-2200101 v1.0)

events should be reported. Reporting forms and information can be found at www.hpra.ie; email: medsafety@hpra.ie Adverse events should also be reported to Sanofi Ireland Ltd. Tel: 01 403 5600. Alternatively, send via email to IEPharmacovigilance@sanofi.com

oedema, asthenia. Prescribers should consult the SmPC in relation to other

reactions.

Adverse

medication. LFTs should be measured and statins should not be commenced if liver transaminases are ≥three times the upper normal limit.4

Ezetimibe, co-administered with an HMG-CoA reductase inhibitor (statin) is indicated as an adjunctive therapy to diet for use in patients with primary (heterozygous familial and non-familial) hypercholesterolaemia who are not appropriately controlled with a statin alone.8 PCSK9 inhibitors, evolocumab and alirocumab, are monoclonal antibodies administered subcutaneously, which have shown an LDL cholesterol-reducing effect of up to 60 per cent when used alone and up to 70 per cent when used in conjunction with a statin. They can lower triglycerides by over 25 per cent. PCSK9 inhibitors are associated with reductions in the risk of heart attack and stroke. Evolocumab and alirocumab are both indicated for use in adults over the age of 18 years and evolocumab is indicated for use in patients over the age of 12.4

Complications

Patient education and information regarding lifestyle modification and pharmacological therapy is the key to success for improved cholesterol control and to prevent complications. Weight management, proper diet, increased physical activity, and smoking cessation are important factors to address to decrease cardiovascular risk. If pharmacological therapy is required, discussion of the risks and benefits of each medication should be explained to the patient before initiation. Primary care clinicians and pharmacists have a duty to educate the patient on medication compliance, side-effects, interactions, and overall risks versus the benefits of the medications prescribed. The patient must also understand the potential risks related to not taking the medication and what alternatives they may have as treatment options.

Potential statin medication complications include myopathy, renal injury, arthralgia, extremity pains, nausea, myalgia, elevated liver enzymes/hepatotoxicity, diarrhoea, and rhabdomyolysis. Up to 5-to-20 per

cent of patients taking a statin medication report experiencing a muscle-related intolerance. A lower dose of the statin should be tried or a transition to another lipid-lowering medication, such as ezetimibe or a PCSK9 inhibitor, such as evolocumab or alirocumab attempted.2

Benefits and monitoring

Based on a 20-year follow-up of the West of Scotland Coronary Prevention Study,

patients who received statin therapy for five years demonstrated improved survival rates and a clinically significant reduction in CVD over the 20-year period. This data and numerous other studies and clinical trials have shown a significant cardiovascular risk reduction when statin therapy is used appropriately.7

Patients should be monitored regularly in practice to prevent hyperlipidaemia progression and improve patient outcomes. Patients receiving lipidlowering medications should be reviewed after three months of initiating treatment and then at least once-yearly. In those receiving statin therapy, liver function needs to be assessed three months after commencing therapy and again at 12 months.

Patients should be monitored for medication compliance, tolerance, adherence, and adverse effects. If hyperlipidaemia is left untreated or undertreated, the condition is progressive and can lead to severe CVD, which can be fatal.

REFERENCES

1. Shattat G. A review article on hyperlipidemia: Types, treatments, and new drug targets. Biomed Pharmacol J 2014; 7 (2)

2. Hill M, Bordoni B. (2021). Hyperlipidemia. StatPearls Publishing. Available at: www.ncbi.nlm.nih.gov/ books/NBK559182/

3. Mandal A. (2019). Cholesterol physiology. In News, Medical Life Sciences. Available at: www.newsmedical.net/health/CholesterolPhysiology.aspx

4. Bermingham M. (2022). Managing cholesterol in the community setting. Irish Pharmacy News. January 2022

5. ESC/EAS (2019). Guidelines for the management of dyslipidaemias: Lipid modification to reduce cardiovascular risk: The taskforce for the management of dyslipidaemias of the European Society of Cardiology (ESC) and European

Atherosclerosis Society (EAS). Euro Heart J, Vol 41, Issue 1, 1 Jan 2020, Pages 111188. doi: 10.1093/eurheartj/ehz455

6. HSE (2020). Medicines Management Programme Preferred Drugs. Statin monotherapy for the treatment of hypercholesterolemia and prevention of cardiovascular events in adults. Health Service Executive. Available at: www.hse. ie/eng/about/who/cspd/ncps/medicinesmanagement/latest-updates/statinpreferred-drug-report-july-2020.pdf

7. Ford I, Murray H, McCowan C, Packard C. Long-term safety and efficacy of lowering low-density lipoprotein cholesterol with statin therapy: 20-year follow-up of West of Scotland coronary prevention study. Circulation. 2016 Mar 15; 133(11):1073-80

8. EMC (2022). Ezetimibe 10mg tablets. Medicines.org.UK. Available at: www. medicines.org.uk/emc/product/8618/ smpc#gref



PATIENTS SHOULD BE MONITORED REGULARLY IN PRACTICE TO PREVENT HYPERLIPIDAEMIA PROGRESSION AND IMPROVE PATIENT OUTCOMES

HYPERTENSION

IRELAND HAS ONE OF THE HIGHEST RATES OF HIGH BLOOD PRESSURE INTERNATIONALLY, BUT AMONG THE LOWEST LEVELS OF DIAGNOSIS, TREATMENT AND CONTROL OF THE CONDITION

Hypertension is the most common cause of cardiovascular disease (CVD) and the leading risk factor for premature death worldwide. Approximately 55 per cent of ischaemic heart disease, 50 per cent of ischaemic stroke, 58 per cent of haemorrhagic stroke and 58 per cent of other cardiovascular diseases, including rheumatic and hypertensive heart disease, cardiomyopathy, rhythm disorders, aortic aneurysms, and peripheral vascular disease, have been attributed to hypertension.1

The Global Burden of Disease study (2015) identified that non-optimal blood pressure (BP) continues to be the single greatest risk factor contributing to the global burden of disease and to ‘allcause mortality’ worldwide; leading to 9.4 million deaths and 212 million healthy life years lost (8.5 per cent of the global total) each year. 2 More than one billion adults worldwide have hypertension with up to 45 per cent of the adult population affected. The high prevalence of hypertension is consistent across all socio-economic and income strata, and the prevalence rises with age; affecting up to 60 per cent of the population above 60 years of age. Recent estimates suggest the total number of patients with hypertension could increase by as much as 15-to-20 per cent and reach close to 1.5 billion by 2025. 4

Ireland has one of the highest rates of high blood pressure internationally,

condition, according to a study carried out at Imperial College London. The research looked at 123 national surveys conducted over 40 years, involving more than 525,000 people aged 40-to-80. In a study from 12 high-income countries, findings revealed that men and women from Ireland were among the least likely to have been diagnosed with high blood pressure, given medication to treat the condition or have it controlled. Irish men ranked second at 56 per cent and Irish women ranked fourth at 43 per cent, according to the study, which

published in the Journal of Public Health in 2016, reported that 64 per cent of the over-50s, equivalent to 797,000 people in Ireland, had high BP. 8

The aetiology of hypertension involves the complex interplay of environmental and pathophysiological factors that affect multiple systems, as well as genetic predisposition. 3 The pathogenesis of essential hypertension is multifactorial and complex. The kidneys are both the contributing and the target organ of the hypertensive processes, and the disease involves

| HYPERTENSION | SEPTEMBER-OCTOBER 2022 | 21

AUTHOR: Theresa Lowry-Lehnen, RGN, PG Dip Coronary Care, RNP, BSc, MSc, PG Dip ED (QTS), M Ed, PhD Clinical Nurse Practitioner, and Associate Lecturer, South East Technological University

the interaction of multiple organ systems and numerous mechanisms of independent or interdependent pathways. Factors that play an important role in the pathogenesis of hypertension include genetics, activation of neuro-hormonal systems, such as the sympathetic nervous system and renin-angiotensin-aldosterone system, obesity, and increased dietary salt intake. 5 Primary hypertension involves multiple types of genes. Some allelic variants of several genes are associated with an increased risk of developing primary hypertension and are linked in almost all cases, to a positive family history. Malfunction or disruption of factors involved in BP control can directly or indirectly lead to increases in mean BP, BP variability or both, over time; resulting in target organ damage and CVD outcomes.7

BP is commonly expressed as the ratio of the systolic and the diastolic BP. While normal values can vary geographically, blood pressure is measured in mmHG. The European Society of Cardiology/European Society of Hypertension (ESC/ESH) 2018 guidelines express the normal BP value as <120 systolic over <80 diastolic.11

In 2017, new guidelines from the American Heart Association, the American College of Cardiology, and nine other health organisations lowered the numbers for the diagnosis of hypertension to 130/80mm Hg and higher for all adults. The new guidelines stem from the 2017 results of the

Systolic Blood Pressure Intervention Trial (SPRINT), which studied more than 9,000 adults aged 50 and older who had systolic blood pressure of 130mm Hg or higher and at least one risk factor for cardiovascular disease. 9

In 2019, NICE published a new clinical guideline on the diagnosis and management of hypertension in adults. The threshold for diagnosing and treating hypertension remained unchanged, at 140/90mmHg for clinic readings or 135/85mmHg for daytime ambulatory blood pressure monitoring (ABPM), or for home blood pressure measurement (HBPM). The definition for stage 2 hypertension remained the same at 160/100mmHg, but stage 3 or severe hypertension changed to a new diastolic cut-off of 180/110mmHg. NICE continues to recommend that BP should be measured in both arms at the time of diagnosis, but suggests a difference of 15mmHg should now be considered significant, compared to the previous 20mmHg.10 Another notable change in the NICE guideline is to offer people <80 years of age with stage 1 hypertension treatment using a 10-year cardiovascular risk (QRISK2) threshold of 10 per cent instead of the previous 20 per cent.

The European Society of Cardiology/ European Society of Hypertension (ESC/ESH) classification guidelines were issued in 2018 for use in all individuals ≥6 years of age.11

 Normal: SBP <120mmHg and

DBP <80mmHg;

 Pre-Hypertension: SBP 120-to139mmHg and DBP 80 to 89mmHg;

 Stage 1 Hypertension: SBP 140 to 159mmHg and DBP 90-to-99mmHg;

 Stage 2 Hypertension: SBP ≥ 160mmHg and DBP ≥100mmHg. The ESC/ESH guidelines recommend that when blood pressure lowering medications are used, the first objective should be to lower BP to less than 140/90mmHg in all patients. Provided treatment is well tolerated, treated BP values should be targeted to 130/80mmHg or lower in most patients. In patients over 65 years of age, systolic BP should be targeted to between 130 and 140mmHg, and diastolic BP to less than 80mmHg. The European target for hypertension in special situations, such as diabetes, coronary artery disease (CAD) and transient ischaemic attack (TIA), is BP 120-130/70-79mmHg for 18to-65 year-olds, and 130-139/70-79 for 65 to >80 year-olds. In chronic kidney disease (CKD), the systolic target is <140 to 130mmHg, if tolerated.11

Symptoms, diagnosis, and evaluation

Essential or primary hypertension is usually asymptomatic, and hypertension is most commonly diagnosed based on repeated BP measurements in a clinical office setting. Investigation is based on clinical history, physical examination, and routine laboratory investigations. Medical history assesses current and past BP measurements and antihypertensive medications if relevant. A history of pregnancyrelated hypertension is an important factor in the assessment of women with hypertension. Physical examination aims to establish the diagnosis of hypertension and screen for target organ damage and secondary causes.

The patient should sit quietly for five minutes before a BP reading is taken and the BP cuff should be positioned at heart level. An average of three BP measurements obtained on two-to-

BLOOD PRESSURE CLASSIFICATION SBP mmHg DBP mmHg Normal <120 and <80 Prehypertension 120-139 or 80-89 Stage 1 Hypertension 140-159 or 90-99 Stage 2 Hypertension ≥160 or ≥100

= Systolic blood pressure, DBP = Diastolic blood pressure

SBP

three separate occasions provides an accurate basis for estimation of BP.7 BP should be measured on both arms and differences in SBP >20mmHg and/ or in DBP >10mmHg should initiate investigations of vascular abnormalities. Careful attention should be paid to choosing an appropriately sized cuff, particularly for patients with obesity. BP should be measured in both sitting and standing positions to rule out orthostatic hypotension, and this is particularly important in older patients.7

Investigation should include auscultation of the carotid arteries, heart and renal arteries. Detection of murmurs should lead to further investigations including carotid ultrasound, echocardiography, and renal ultrasound. An irregular pulse frequently indicates atrial fibrillation, which should be confirmed by an electrocardiogram. Laboratory investigations are used to detect additional risk factors, to confirm or exclude secondary hypertension, to detect clinical or subclinical target organ damage and to estimate CVD risk.7 Blood workup includes FBC, ESR, creatinine, eGFR, electrolytes, HbA1c, thyroid profile, blood cholesterol levels, and serum uric acid.4

Accurate measurement and recording of BP is essential to categorise the level of BP, ascertain BP-related CVD risk and guide management.7 HBPM is the measurement of BP at regular intervals by an individual at home or outside the clinical setting. Ambulatory blood pressure measurement is the most accurate method to diagnose hypertension and also aids in identifying individuals with masked hypertension as well as white coat effect.4 ABPM consists of an ambulatory device worn by the patient that measures and records the BP at regular intervals, usually every 20-to-30 minutes, typically for a 24-hour period, while the individual goes about their daily activities.7

Evaluation of a patient with hypertension requires more than the

diagnosis of elevated BP. It should also include assessment of the CVD risk, target organ damage, and concomitant clinical conditions that may affect the BP or related target organ damage as well as recognition of features suggestive of secondary hypertension. Secondary hypertension should be considered in cases of a sudden worsening of hypertension, poor BP response to medication or severe target organ damage, which is out of proportion to the duration and severity of hypertension.7

effective management and should include information regarding physical activity, weight management, salt restriction, alcohol reduction and smoking cessation if applicable. 4,7

Pharmacological therapy consists of angiotensin-converting enzyme inhibitors (ACEi), angiotensin receptor blockers (ARBs), diuretics - usually thiazides – calcium channel blockers and beta-blockers, taking into account age, race and comorbidities, such as the presence of renal dysfunction, left ventricular dysfunction, heart failure and cerebrovascular disease.4

Treatment and management

The treatment and management of hypertension can be divided into pharmacological and nonpharmacological interventions. Non-pharmacological and lifestyle management are recommended for all individuals with raised blood pressure regardless of age, gender, comorbidities or cardiovascular risk status. Lifestyle changes alone can account for up to 15 per cent reduction in all cardiovascularrelated events. Reducing blood pressure in adults with a high normal BP provides the potential to directly reduce CVD risk and to prevent or slow the age-related tendency for individuals to develop hypertension. Patient education is important for

NICE recommends starting with monotherapy treatment, however, high blood pressure cannot be controlled with monotherapy in many patients, particularly those with severe hypertension and polypharmacy is common. There are two main approaches to pharmacological therapy; initiating two or more drugs, such as an ACEi or an ARB with a thiazide diuretic and calcium channel blocker simultaneously, or a stepwise titration approach with single therapy being titrated up to maximum dosage before initiating a second drug. Both are successful in improving patient outcomes, provided there is adequate patient compliance and treatment adherence.4,7 Patients must be aware of the possibility and monitored closely for side-effects, especially in the early stage of therapy. Side-effects of anti-hypertensive medication include hypotension, electrolyte imbalances, pedal oedema, and renal dysfunction. Renal dysfunction and electrolyte imbalance, especially hyponatraemia and hyperkalaemia, are common with ACE inhibitors and ARBs, so electrolytes must be monitored closely. Angioedema is a lifelong contra-indication for ACEi or ARB usage. For patients with severe side-effects, such as symptomatic hyperkalaemia or hyponatraemia, syncope and acute kidney injury (AKI), treatment needs to be discontinued, nephrologist and cardiologist opinions sought and inpatient management

ACCURATE MEASUREMENT AND RECORDING OF BP IS ESSENTIAL TO CATEGORISE THE LEVEL OF BP, ASCERTAIN BPRELATED CVD RISK AND GUIDE MANAGEMENT

considered. Once settled, treatment needs to be reinitiated slowly and cautiously, with careful monitoring and frequent follow-up.4

Prognosis and outlook

Although there is regional variability in the outlook for hypertension over the next five-to-10 years, it is clear that the prevalence and associated global burden attributable to hypertension will increase, with 1.5 billion people expected to be affected by 2025. Global population growth and aging will largely contribute to this increase. However, adverse trends in disease burden may invariably be offset by improvements in prevention, awareness and treatment. Improving the efficacy of drug treatment holds promise for reducing the associated disease burden of hypertension, and the greatest effect could be achieved by the delivery and distribution of affordable, effective single-pill combinations of two or

three drugs to low-income and middleincome countries; where the burden of hypertension is considerable and where such therapies are currently either unavailable or unaffordable. Efforts to drive public health policy towards the promotion of more healthy lifestyles must be encouraged, as well as scientific research, to allow precision medicine to be developed, applied and continued.

Hypertension is a chronic disorder that requires long-term care and management and a multi-disciplinary approach. Patient education and information regarding lifestyle modification and pharmacological therapy is the key to success for improved control and to prevent complications. Weight management, increased physical activity, limiting alcohol and smoking cessation are important factors to address to decrease cardiovascular risk. All patients with hypertension should have an evidence-based care plan that ensures

the achievement of treatment and selfmanagement goals, effective management of comorbid conditions and timely follow-up with the healthcare team.

Inter-professional team communication is important in identifying cases of resistant, or difficult to treat hypertension. Inter-specialty approaches can benefit patients the most. Effective communication within a multi professional team, including nurses, primary care physicians, cardiologists, nephrologists, pharmacists, dieticians and other healthcare professionals is essential for improving blood pressure control. A patient centred, multi-professional team approach to treating and managing hypertension, which monitors and identifies patient compliance, progress, potential toxicities and adverse effects, can result in fewer complications, reduced healthcare costs and improved patient outcomes. 

REFERENCES

1. Van Kleef M, Spiering W. Hypertension: Overly important, but under-controlled. European Journal of Preventive Cardiology 2017 Jun 16; 24(3) doi. org/10.1177/2047487317709116

2. GBD 2015 Risk Factors Collaborators. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 19902015: A systematic analysis for the Global Burden of Disease Study 2015. Lancet . 2016 Oct 8; 388 (10053):1659-1724. doi: 10.1016/ S0140-6736(16)31679-8

3. Oparil S, Acelajado, MC, Bakris GL, Berlowitz DR, Cífková R, Dominiczak AF, et al. Hypertension. Nature reviews. Disease primers. 2018 Mar 22; 4(18014). doi.org/10.1038/ nrdp.2018.14

4. Iqbal A, Jamal S. Essential

hypertension. In StatPearls. 2021 Available at: www.ncbi.nlm.nih.gov/ books/ NBK539859/

5. Hamrahian S, Batuman V. Pathophysiology of Hypertension. Medscape. Drugs and Diseases; Nephrology. 2017 May 19. Available at: www.emedicine.medscape.com/ article/1937383-overview

6. Cullen P. Irish blood pressure problem revealed in international study. The Irish Times . 2019 Sept 11. Available at: www.irishtimes. com/ news/health/irish-bloodpressureproblem-revealed-ininternationalstudy-1.4013974

7. Acelajado M, Bakris G, Berlowitz D, Cífková R, Dominiczak A, Grassi G, et al. Hypertension. Nature reviews . 2018 Mar 22. 4: 18014. doi.org/10.1038/ nrdp.2018.14

8. Murphy C, Kearney P, Shelley E, Fahey T, Dooley C, Kenny R. Hypertension prevalence, awareness, treatment and control in the over-

50s in Ireland: Evidence from the Irish Longitudinal Study on Ageing. Journal of Public Health. 2015 Apr 8; 38(3):450-458. doi. org/10.1093/ pubmed/fdv057

9. Harvard Health Publishing. Reading the new blood pressure guidelines. 2021 Available at: www.health. harvard.edu/heart-health/readingthenew-blood-pressure-guidelines

10. National Institute for Health and Care Excellence. Hypertension in adults: Diagnosis and management. NICE guideline 136. London. National Institute for Health and Care Excellence, 2019. Available at: www. nice.org.uk/guidance/ng136

11. European Society of Cardiology. 2018 ESC/ESH Clinical Practice Guidelines for the Management of Arterial Hypertension. European Society of Cardiology. 2018 Aug 25. Available at: www. escardio.org/ Guidelines/ClinicalPracticeGuidelines/Arterial-Hy

AUTHOR: Rachele Ricci, BSc Nursing (General), PGDip Gerontological Nursing, RGN Geriatric Medical Ward, Beaumont Hospital, Dublin

DELIRIUM IN THE HOSPITALISED OLDER ADULT

THIS MODULE DISCUSSES THE CLINICAL PRESENTATION AND MAIN TYPES OF DELIRIUM IN HOSPITALISED OLDER ADULTS. FURTHERMORE, IT ADDRESSES THE RISK FACTORS, ASSESSMENT, DIAGNOSIS, PREVENTION AND MANAGEMENT STRATEGIES OF THIS COMMON, YET POORLY RECOGNISED CONDITION

Introduction

Delirium is a neuropsychiatric condition largely affecting hospitalised older adults. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), defines delirium as an acute disruption of concentration, awareness and cognition, lasting hours to days and possibly fluctuating throughout the day and night, with evidence indicating that such disruption is triggered by direct physiological effects of another medical condition, substance intoxication/ withdrawal or multiple aetiologies.

While the incidence and prevalence of delirium in medical inpatients have been stable in the last four decades across countries and clinical settings, it continues to be a matter of urgency. According to the UK’s National Institute for Health and Care Excellence, (NICE), at least two-outof-10 inpatients on medical wards have delirium, and more specifically, one-out-of-five in Ireland. However, although delirium has been long acknowledged, documented and researched throughout the centuries, it remains misunderstood and therefore seriously under-detected in clinical practice.

Nurses have a professional responsibility to protect the health of their patients and play a key role in the timely recognition of delirium, to prompt early management and prevent further complications. Delirium is associated with multiple adverse outcomes, including increased mortality, decreased cognitive function, a new dementia diagnosis, longer hospital stay, increased placement to a long-term care setting, increased falls, and considerable distress for patients and their families. While it is still unclear why nurses have difficulties in recognising delirium, it is widely accepted that a lack of knowledge of delirium and validated delirium tools is the leading cause. Since delirium is preventable in more than one-third of older patients, nurses should become more competent in managing it.

Therefore, this module will provide evidence-based information to increase the knowledge and skills of nurses caring for hospitalised older adults above 65 years of age and to improve the nursing recognition and management of delirium. This will be achieved by addressing the risk factors and pathophysiology of delirium and discussing the signs and symptoms of delirium subtypes, followed by clinical assessment.

Finally, this module will encompass the prevention and treatment strategies of

delirium in the hospitalised older adult. To consolidate the acquired information, five multiple choice questions will be provided at the end with an explanation of the correct answer.

Risk factors

Although delirium in older adults is the result of several factors, one could be enough to trigger it. There are predisposing risk factors that consist of the patient’s baseline weaknesses that facilitate the development of delirium. Precipitating risk factors consist of events or conditions that trigger the delirium. Complex interrelationships between several predisposing factors cause a patient to be more susceptible to precipitating factors, thus contributing to the development of delirium in older adults. The most prevalent risk factors in older inpatients are represented in Table 1 A comprehensive review of delirium1 included the results of 11 validated studies in various hospital settings (medical, surgical and intensive care) and indicated dominant risk factors for delirium in the hospitalised older adult. Accordingly, dominant predisposing risk factors included cognitive impairment (dementia), functional disabilities, sensory disability (vision), alcohol misuse and older age. Moreover,

| NURSING IN GENERAL PRACTICE | SEPTEMBER-OCTOBER 2022 | 25 | DELIRIUM UPDATE

PREDISPOSING FACTORS PRECIPITATING FACTORS

 Cognitive impairment (dementia)

 Functional disabilities

 Older age

 Sensory disability (vision)

 Depression

 Frailty

 Alcohol misuse

 Comorbidities

 Brain injuries (stroke)

 Electrolyte imbalance (hyponatraemia)

 Polypharmacy/medications (psychoactive/hypnotic drugs)

 Severe illness

 Infections (respiratory and urinary)

 Pain

 Falls

 Immobility

 Physical restraints

 Room/bed transfers

 Urinary catheterisation

 Bowel/bladder retention

 Dehydration

 Hip fracture

 Sleep deprivation

 Surgery

TABLE 1: Predisposing and precipitating risk factors in delirium

dominant precipitating factors included polypharmacy (psychoactive/hypnotic drugs), physical restraint, severe illness and electrolyte imbalance. Additional studies and reviews have confirmed these and other risk factors. Although the association between room/ bed transfers within the hospital environment and delirium is majorly based on empirical knowledge, studies by Goldberg et al and Otremba et al have provided evidence for it.

Therefore, to identify patients at risk, nurses must obtain a comprehensive picture, including past surgical and medical history, presenting complaints, medications, social status, current diagnosis, laboratory results, environmental stimuli and safety concerns.

Frailty: A significant risk factor

There exists a link between frailty and delirium, further sustained by a systematic review and meta-analysis by

Persico et al, including 20 articles with a total of 5,541 participants. Although the included studies had high methodological heterogeneity regarding frailty and delirium measurement, this reflects ordinary practice, likely derived from a lack of standardised guidelines for both conditions. The findings demonstrated that frail individuals are 2.2 times more likely to develop delirium. Moreover, the Geriatric Medicine Research Collaborative examined the said nexus and determined that older adults with severe frailty are nine times more likely to develop delirium and that the detection of delirium in frail older adults is more difficult because of its presentation, subsequently leading to increased mortality.

Pathophysiology

The intrinsic pathophysiological process underlying delirium remains unclear. Every patient, as discussed above, can present with a unique combination of individual predisposing and precipitating factors contributing

Ipratropium bromide (Atrovent)

Olanzapine (Zyprexa)

Tiotropium bromide (Spiriva)

Atropine

Benztropine (Cogentin)

Scopolamine

Amitriptyline

Prochlorperazine

Fesoterodine (Toviaz)

Baclofen

Oxybutynin (Ditropan)

Carbamazepine (Tegretol)

Solifenacin (Vesicare)

Cetirizine (Zyrtec)

Tolterodine (Detrol)

Loperamide (Imodium)

Trospium (Sanctura)

Methadone

Chlorpromazine

Quetiapine (Seroquel)

to the pathophysiology of delirium. Nevertheless, more evidence is now suggesting a combination of factors causes a disruption in the neuronal interconnections between neurotransmitters, potentially causing the distinctive acute confusion of delirium. Some of these factors include hypoxia, inflammation, oxidative stress, electrolyte imbalance and metabolic disorders, therefore leading to an increased hypocholinergic and hyperdopaminergic status. There are various hypotheses based on the aforementioned factors. For instance, hypoxia causes a drop in acetylcholine, the main neurotransmitter involved in the reticular activating system, which is responsible for regulating alertness. Meanwhile, increased dopamine release is associated with hallucinations and agitation. Additionally, both neuroinflammation and oxidative stress are considered responsible for the

| NURSING IN GENERAL PRACTICE | 26 | SEPTEMBER-OCTOBER 2022 DELIRIUM UPDATE |

TABLE 2: Medications with anticholinergic effects Source: www.drugs.com

release of proinflammatory cytokines. MacLullich et al proposed that one of the causes of delirium was a possible exaggerated cytokine response in the nervous system. Proinflammatory cytokines are proteins that stimulate the immune system and are released by microglia, white blood cells that activate the immune response and tissue repair in the nervous system. Neuroinflammation caused by proinflammatory cytokines during infection or sepsis can increase neuronal damage leading to cellular apoptosis (programmed death), increased permeability of the blood-brain-barrier and exposure to medication. In particular, anticholinergic medications (see Table 2) used to treat overactive bladder, urinary incontinence and chronic obstructive pulmonary disease (COPD) can cause a decrease in acetylcholine by preventing it from binding to its receptors and leading to hypocholinergia. High serum anticholinergic activity in patients with delirium provides evidence to support the cholinergic hypothesis.

Signs and symptoms

Delirium Depression Dementia

Sudden onset (acute)

Mostly reversible

Impaired attention

Impaired consciousness

Variable onset (weeks to months)

Reversible

Intact attention, but poor concentration

Intact consciousness

Insidious onset (gradual and progressive; chronic)

Progressive

Attention fairly intact, but can be decreased

Intact consciousness

 Agitation

 Restlessness

 Hallucinations

 Delusions

 Combativeness

 Verbal and physical aggression

 Confusion

 Agitation

 Restlessness

 Hallucinations

 Combativeness

 Verbal and physical aggression

 Confusion

 Fidgeting

 Pulling at medical equipment (catheters/ tubings/drains/etc)

 Wandering

 Feeling anxious

 Feeling fearful

 Disturbed sleep

 Fidgeting

 Pulling at medical equipment (catheters/ tubings/drains/etc)

 Wandering

 Feeling anxious

 Feeling fearful

 Feeling hopeless

 Delusions

 Feeling hopeless

 Disturbed sleep

 Functional decline

 Reduced mobility

 Loss of appetite

 Lethargy

 Stupor

 Somnolence

 Inattention

 Apathy

Older patients with delirium present with various signs and symptoms that determine the subtype of delirium. There are three subtypes of delirium based on their motor features, such as hypoactive, hyperactive and mixed delirium. There is also a no-motor subtype of delirium, which presents without motor symptoms and exclusively with cognitive symptoms, like confusion, impaired attention and awareness. Symptoms of delirium are divided between neuropsychiatric (related to sleep, motor function, and psychosis) and cognitive. Because of its signs and symptoms, delirium is often mistaken for depression and/or dementia. Table 3 delineates their differences to aid the distinction of these three conditions.

 Withdrawing from others/ environment

BOX 1: Hypoactive delirium signs and symptoms

Signs and Hypoactivesymptoms: delirium

Hypoactive delirium is the most common subtype in the hospitalised older adult

as well as the most unrecognised. Additionally, hypoactive delirium is associated with older age and dementia. As mentioned above, this subtype can be mistaken for depression. Hypoactive delirium is characterised by a low level of psychomotor activity expressed through the signs and symptoms outlined in Box 1.

Signs and Hyperactivesymptoms: delirium

Hyperactive delirium is more likely to be detected because of its presentation, but it is not the most prevalent subtype of delirium, comprising only 25 per cent of all cases. Its signs and symptoms relate to a high level of psychomotor activity and are listed in Box 2.

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TABLE 3: Differences between delirium, depression, and dementia BOX 2: Hyperactive delirium signs and symptoms

Signs and symptoms: Mixed form delirium

Some older patients with delirium exhibit a combination of signs and symptoms of both hyperactive and hypoactive subtypes, which fluctuate within hours. This constitutes a motor subtype called mixed form delirium. Hospitalised older adults with intravenous lines are more likely to develop mixed form delirium. For instance, a patient could display characteristics of hypoactive delirium during the daytime by sleeping all the time, declining meals and not interacting with other people or the environment. Then, the same patient could display features of hyperactive delirium at night, being agitated and pulling at intravenous lines and catheters, feeling anxious, shouting and having hallucinations. Understandably, patients experiencing this subtype carry the most symptomatological disease burden because it encompasses features of both motor subtypes.

Assessment and diagnosis

Assessing and recognising delirium is a key responsibility of nurses, however, this can be difficult. During handovers, nurses routinely communicate to each other if a patient is more confused or less engaging, but do not provide evidence for it through a score to trigger escalation. Therefore SQiD (single question to identify delirium), a simple prompt for nurses asking “Is my patient more confused than before?”was introduced. If the answer to the question is affirmative, then nurses are prompted to begin the escalation with a delirium assessment tool, like the 4AT,and report the results to the medical team.

Delirium assessment tools are fundamental in the accurate identification, diagnosis and escalation of this serious condition. There is a plethora of validated assessment tools for delirium for various hospital settings and patients. However, compared to the 4AT56 and the Confusion Assessment Method (CAM),the other tools have significant disadvantages.

They often lack validity, tend to be timeconsuming and reflect poor sensitivity and specificity. Moreover, other delirium assessment tools may not be sensitive to all subtypes of delirium, contributing to the under-recognition of this condition.

The CAM tool and its variants are commonly used, but have a broad variety of specificity and sensitivity scores, may not apply to all settings and take five-to-10 minutes to complete. The CAM tool has a specificity of 100 per cent, but a sensitivity of 40 per cent, while the 4AT tool has a specificity of 94-to-95 per cent and a sensitivity of 76 per cent.Therefore, the 4AT assessment tool is recommended by the HSE in Ireland because of its more accurate sensitivity and specificity scores.It can also assess patients with psychomotor changes and/or altered consciousness.

4AT is a quick and functional tool that does not require training and can be used for patients that are very drowsy

or have underlying dementia. Moreover, it can be performed at admission to determine a baseline and subsequently if indicated. A systematic review including 17 studies confirmed the 4AT is an accurate diagnostic test for detecting delirium in clinical practice.

When performing the 4AT, the nurse must first observe the patient’s level of alertness, ask quick questions to gauge their cognition and attention, consider acute changes and fluctuations and finally determine the score to identify delirium. A score of 0 indicates delirium is unlikely, but does not exclude it, warranting further tests if the information on acute changes cannot be obtained from the GP, family members, carers or other staff. A score of one-tothree indicates cognitive impairment and warrants more specific cognitive tests, ie, Montreal Cognitive Assessment. A score of four and above indicates possible delirium. Nurses must involve family members and carers to obtain a good collateral history if the patient is not able to report the information necessary.

Additionally, the National Delirium Algorithm suggests that if a patient is unlikely to have delirium, nurses must continue to monitor and assess daily. If a patient is likely to have delirium, nurses must escalate the case, document the findings, inform the doctor and consider potential causes that triggered it. They can do so following the PINCH ME mnemonic (see Box 3). It is also paramount to reassess patients with delirium after 24 hours to determine if the condition has resolved or needs further management, based on the identification and treatment of its causes. Once resolved, nurses must ensure a care plan for delirium prevention is in place.

Non-pharmacological prevention strategies

According to strong evidence, prevention and non-pharmacological interventions are the most effective strategies to reduce the negative impact delirium

| NURSING IN GENERAL PRACTICE | 28 | SEPTEMBER-OCTOBER 2022 DELIRIUM UPDATE |

BOX 3: PINCH ME: Assessing triggers for delirium (British Geriatric Society)

inflicts on affected individuals and global healthcare systems. Preventing delirium is not just about what nurses can do; it is also about how nurses can empower patients to avoid it. Hospitalised older adults understand the importance of participating in preventing delirium and nurses must educate them and support their interventions. A person-centred approach with tailored multicomponent interventions is the essence of delirium prevention.

Every hospitalised older adult should be assessed for delirium risk factors within 24 hours of admission. Since many risk factors are modifiable, evidence suggests nonpharmacological, multi-component strategies are effective at preventing delirium.Nurses must involve other members of the multidisciplinary team (dietitian, occupational therapist, physiotherapist, doctor, medical social worker, etc) to successfully address the components of delirium prevention.

Table 4 includes nurses’ interventions for each component, following evidence-based recommendations from NICE, the Scottish Intercollegiate Guidelines Network, the National Dementia Office and other studies.

Based on the above, nurses could develop a ‘dementia and delirium bundle’ for patients at risk, including fluid balance, stool chart, nutrition chart, pain assessment and repositioning chart. If this is already part of routine nursing care, a delirium prevention checklist encompassing the components in Table 4 could provide more specific guidance.

Pharmacological prevention strategies

Some studies looked at how medications can be used to prevent delirium. A systematic review and metaanalysis comprising 11 randomised control trials, with a total of 2,890 older patients, concluded that prophylactic use of dexmedetomidine (analgesic, anxiolytic and sedative) peri-operatively for the older adults

Optimal nutrition and hydration

 Encourage patients to drink and eat

 Offer what they like and monitor their intake

 Consider subcutaneous or intravenous fluids (caution in patients with cardiac failure or chronic kidney disease)

 Patients should wear dentures

 Refer patient to the dietitian

Orientation

 Provide familiar objects (clock, calendar, visual signage, television/radio, photos)

 Reorient patients to person, time and place (orientation board)

 Family visits (remotely if required)

 Refer patient to the occupational therapist

Normal bowel/ bladder functioning

Infection

Mobilisation

 Monitor bowel motions and urinary output

 Encourage fluid intake

 Avoid unnecessary urinary catheterisation

 Treat constipation

 Follow local infection control policies

 Identify, escalate, and treat infection

 Encourage patients to mobilise

 Encourage patients to complete active range-of-motion exercises

 Avoid physical restraints/restrictions (bed rails, catheters, etc)

 Re-refer the patient to the physiotherapist

Pain control

Medication optimisation

Sensory aids

Sleep hygiene

 Assess pain (address verbal and non-verbal cues)

 Administer appropriate analgesia

 Avoid under-treating/over-treating pain

 Review patient’s medication

 Involve pharmacist and geriatrician to perform a medication review

 Ensure patients wear hearing and visual aids

 Administer eye drops and eye care

 Reduce noise, light, and procedures at night

 Provide sunlight during daytime

 Encourage relaxation at bedtime

Optimal oxygen saturation

Healing environment

 Administer supplemental oxygen if indicated

 Avoid bed transfers

 Allocate a single room

 Involve families/carers

| NURSING IN GENERAL PRACTICE | SEPTEMBER-OCTOBER 2022 | 29 | DELIRIUM UPDATE

TABLE 4: Multicomponent nursing interventions for delirium prevention

reduces delirium, but is associated with bradycardia and hypotension. Moreover, dexmedetomidine is often used with other medications in clinical trials and is not clear if it reduces delirium or the need for medication that can be deliriogenic, therefore, it is not recommended.

Another systematic review and meta-analysis by Yang et al investigated the preventive efficacy of melatonin (a hormone with hypnotic effects), including six randomised control trials with a total of 913 older adults. Although recent guidelines do not recommend melatonin for delirium prevention because of lack of evidence, Yang et al provided evidence to suggest low-dose melatonergic agents are effective and could potentially be included in future guidelines.

Additionally, the use of antipsychotics in delirium prevention continues to be disputed due to the positive and negative effects and heterogeneous studies from various settings. Therefore, the principal pharmacological prevention strategy for delirium consists of a medication review to identify and safely deprescribe deliriogenic medications and avoid them unless necessary. Notable deliriogenic medications include benzodiazepines, opiates, anticholinergics, antihistamines and antidepressants. Medications to treat underlying causes like constipation, infection and pain should also be administered as part of pharmacological prevention strategies.

Non-pharmacological treatment strategies

León-Salas et al conducted a metaanalysis including 10 randomised control trials comparing multicomponent interventions with usual care among a total of 2,850 older patients. The results determined that multicomponent interventions reduce delirium incidence, duration and severity in the hospitalised older adult. Therefore, multicomponent interventions are not only effective at preventing delirium, but also at treating it by addressing its causes.

The treatment guidelines by NICE

are divided between initial treatment and treating distressed patients. Initial non-pharmacological management includes nursing interventions presented in Table 4, since they address the principal causes of delirium. Moreover, communication with the patient affected by delirium could help reduce anxiety and fears. This could be achieved by providing visual cues, paced clear communication, and involving family members.

The following discusses the non-pharmacological treatment of distressed older patients with delirium. Care companions, also referred to as ‘one-to-one’, ‘specials’ or ‘sitters’, are healthcare assistants trained in the management of difficult behaviours and assigned to care for delirious patients. The National Dementia Office guidelines suggest their utilisation in delirious patients. A scoping review by Wood et al including 44 studies explored the role of care companions in managing distress in confused patients. They concluded that although one-to-one carers are commonly utilised globally, they are costly and there is not enough evidence to determine their effectiveness. Therefore, their utilisation must be considered cautiously. Their utilisation should not be to solely observe the delirious patient, but to support the implementation of care plans instead. Moreover, nurses looking after distressed delirious patients should undertake training in the management of difficult behaviours to safely and successfully de-escalate situations. Promoting an ongoing therapeutic relationship with the patient is essential to minimise distress. Family members can also be included to manage distress. To achieve this, nurses must educate the relatives by providing information on delirium in a way that respects their cognitive, cultural and language requirements.

Recently, many older adults have been affected by social isolation because

of the pandemic caused by the SARSCoV-2 virus (Covid-19). Visiting has been restricted and even stopped in many hospitals. Nevertheless, involving families, either remotely through video calls or in person, is another paramount intervention to comfort the older adults with delirium in the hospital and to aid communication.

Pharmacological treatment strategies

Pharmacological treatment strategies focus principally on managing distress in delirious patients to maintain safety and comfort once non-pharmacological strategies have failed. Therefore, it would be advisable to administer antipsychotic medication starting at the lowest dose and for no longer than a week, but avoiding them in older adults with Parkinson’s disease or Lewy Bodies dementia. Nevertheless, this is not well supported by current evidence. A Cochrane review by Burry et al, including nine randomised and non-randomised trials, compared antipsychotics to a placebo or other medication across various hospital settings.

The authors concluded antipsychotics do not curtail delirium severity or duration. More evidence identified inappropriate continuation of antipsychotics post-discharge in patients who started receiving them in the hospital due to delirium. If the continuation of antipsychotics postdischarge is appropriate, there should be a clear plan for a medication review and follow-up in the community. Therefore, the use of antipsychotics like haloperidol is not fully supported by current best available evidence and recent guidelines unless deemed necessary to maintain the safety of the patient and others. If, despite all interventions, delirium perseveres, nurses should re-evaluate underlying causes and refer the patient for a dementia assessment.

References available on request

| NURSING IN GENERAL PRACTICE | 30 | SEPTEMBER-OCTOBER 2022 DELIRIUM UPDATE |

Q1. The most common subtype of delirium is the hyperactive one, where the patient is agitated and anxious, disrupting the environment.

True or false?

TRUE/FALSE QUESTIONS

Q5. Anticholinergic medication used for urinary incontinence and chronic obstructive pulmonary disease can cause delirium.

True or false?

the multidisciplinary team are the best way to prevent delirium.

True or false?

Q2. Delirium can be mistaken for depression.

True or false?

Q3. Pain is a risk factor for delirium in older patients.

True or false?

Q4. Frail patients are less likely to develop delirium than non-frail patients.

True or false?

Q2. All assessment tools for delirium can detect both the hypoactive and the hyperactive subtypes.

True or false?

Q7. Patients with mixed form delirium are subject to the highest disease burden in this condition.

True or false?

Q8. Multicomponent interventions addressing risk factors and involving

Q9. One-to-one specials are healthcare assistants that provide continuous observation and management of difficult behaviours. Local guidelines recommend their utilisation because evidence suggests they are clearly effective.

True or false?

Q10. If a patient is restless and is pacing in the corridor, haloperidol is the recommended medication to manage this symptom of delirium.

True or false?

Check

| NURSING IN GENERAL PRACTICE | SEPTEMBER-OCTOBER 2022 | 31 | DELIRIUM UPDATE

your answers against the latest module on nursecpd.ie Successful completion of this module will earn you 2 CPD credits COMPLETE THIS MODULE ONLINE

BACK TO SCHOOL CHECKLIST FOR CHILDREN WITH ASTHMA

ASTHMA AFFECTS ONE-IN-10 CHILDREN AND ADOLESCENTS UNDER 18 IN IRELAND. IT IS THE MOST COMMON CHRONIC CONDITION AMONG THIS AGE GROUP AND IS A LEADING CAUSE OF ABSENTEEISM FROM SCHOOL

This article addresses asthma management as we enter back to school season. It is a time of year when the condition can become increasingly problematic for children and adolescents. Ruth Morrow, from the Asthma Society of Ireland provides useful resources, facts and guidance to help GPNs, teachers, parents and young people prevent adverse events during “the September spike”.

Back to school checklist for children with asthma

Asthma affects one-in-10 children and adolescents under 18 in Ireland. It is the most common chronic condition among this age group and is a leading cause of absenteeism from school. Children with asthma are unable to attend an average of five days every school year, which can negatively impact learning and educational development. September signals a return to school, but can also see a dramatic rise in the number of children admitted to hospital with exacerbations of asthma, known as the “September spike.” This

spike correlates to triggers which are commonly found in schools and include:

 Chemical fumes

 Perfumes

 Aerosols

 Chalk dust

In addition, changes in weather, an increase in fungal spores, moulds and an increase in circulating viruses, such as respiratory syncytial virus (RSV), all contribute to an increase in asthma symptoms at this time of year.

Advice for parents

This checklist should help you control your child’s asthma during September and into the winter months.

 Have your child’s asthma reviewed by your GP in August/September.

 Ensure your child has an Asthma Action Plan and that it is up to date.

 Use the inhaler technique videos on asthma.ie to help your child take their inhaler properly.

 Make sure your child carries their reliever inhaler (usually blue) at all times.

 Check that they take their medication every day with a fridge planner.

 Leave a spare reliever inhaler and spacer in the school, with the child’s

name clearly labelled.

 If your child is participating in PE or other activities, place a reliever inhaler and spacer in their bag.

 Never send a sick child to school.

 Show them how to wash their hands correctly and explain why this is important.

 An older child/teenager often requires extra supervision and cannot be relied on to selfmedicate independently - put systems in place as they may avoid taking their medication.

 Visit the school and make sure your child’s teacher is aware that they have asthma.

 Explain what their triggers are and what to do if your child has an asthma attack.

 Check if there is a school asthma policy in place.

 If your child is starting a new school, speak to teachers about your child’s asthma, even if they are well right now.

Asthma policy for schools

The Asthma Society of Ireland recommends that all schools have an asthma policy in place that is

AUTHOR: Ruth Morrow, Registered Advanced Nurse Practitioner (Primary Care); Respiratory Nurse Specialist (WhatsApp Messaging Service, Asthma Society of Ireland); and Nurse Educator and Consultant.

Asthma*

KEEP ASTHMA TAMED

Proactive asthma control that lasts1,2

RELVAR ELLIPTA (fluticasone furoate/vilanterol)

* Relvar Ellipta is indicated for the regular treatment of asthma in adults and adolescents aged 12 years and older where use of a combination medicinal product (long-acting β 2-agonist and inhaled corticosteroid) is appropriate: patients not adequately controlled with inhaled corticosteroids and ‘as needed’ inhaled short acting β 2-agonists or patients already adequately controlled on both inhaled corticosteroid and long-acting β 2 - agonist 2

For Healthcare Professionals only. Images used are for illustrative purposes only. Relvar is well tolerated. Most common adverse events are nasopharyngitis and headache2 PM-IE-FFV-ADVT-210002 September 2021

Relvar Ellipta was developed in collaboration with

available on www.medicines.ie

Relvar® Ellipta® (fluticasone furoate/ vilanterol [as trifenatate]) Prescribing information

2. Relvar Ellipta SmPC, 2021, available on www.medicines.ie

(Please consult the full Summary of Product Characteristics (SmPC) before prescribing)

Relvar® Ellipta® (fluticasone furoate/ vilanterol [as trifenatate]) Prescribing information

& magnesium stearate). Precautions: Pulmonary tuberculosis, cardiovascular disorders, heart rhythm abnormalities, thyrotoxicosis, hypokalaemia or patients predisposed to low levels of serum chronic or untreated infections, diabetes mellitus. Paradoxical – substitute alternative therapy if necessary. In patients with moderate to severe impairment 92/22mcg dose should be symptoms: Not for acute symptoms, use short-acting inhaled Warn patients to seek medical advice if short-acting inhaled use increases. Therapy should not be abruptly stopped without supervision due to risk of symptom recurrence. Asthma-related adverse exacerbations may occur during treatment. Patients should continue seek medical advice if asthma symptoms remain uncontrolled or initiation of Relvar. Systemic effects: Systemic effects of inhaled may occur, particularly at high doses for long periods, but much than with oral corticosteroids. Possible Systemic effects include: syndrome, Cushingoid features, adrenal suppression, decrease in density, growth retardation in children and adolescents, cataract, More rarely, a range of psychological or behavioural effects including hyperactivity, sleep disorders, anxiety, depression or aggression children). Increased incidence of pneumonia, including pneumonia hospitalisation, has been observed in patients with COPD receiving corticosteroids. If a patient presents with visual disturbance they should for referral to an ophthalmologist for evaluation of possible causes include cataract, glaucoma, or rare diseases such as central serous chorioretinopathy. Physicians should remain vigilant for the possible development in patients with COPD as the clinical features of such infections the symptoms of COPD exacerbations. Risk factors for pneumonia current smoking, older age, low body mass index and severe COPD. of pneumonia in patients with asthma was common at the higher (184/22mcg). Patients with rare hereditary problems of galactose the total lactase deficiency or glucose-galactose malabsorption

Relvar® Ellipta® (fluticasone furoate/vilanterol [as trifenatate]) inhalation powder. Each single inhalation of fluticasone furoate (FF) 100 micrograms (mcg) and vilanterol (VI) 25mcg provides a delivered dose of 92mcg FF and 22mcg VI. Each single inhalation of FF 200mcg and VI 25mcg provides a delivered dose of 184mcg of FF and 22mcg of VI. Indications: Asthma: Regular treatment of asthma in patients ≥12 years and older where a long-acting β2-agonist and inhaled corticosteroid combination is appropriate and where patients are not adequately controlled on inhaled corticosteroids and “as needed” short-acting inhaled β2-agonists, or where patients are already controlled on both inhaled corticosteroid and long-acting β2-agonist. COPD (Relvar 92/22mcg only): Symptomatic treatment of adults with COPD with a FEV1<70% predicted normal (post-bronchodilator) and an exacerbation history despite regular bronchodilator therapy). Dosage and administration: Inhalation only. Asthma: Patients with asthma should be given the strength of Relvar Ellipta containing the appropriate fluticasone furoate (FF) dosage for the severity of their disease. Prescribers should be aware that in patients with asthma, FF 100 mcg once daily is approximately equivalent to fluticasone propionate (FP) 250 mcg twice daily, while FF 200 mcg once daily is approximately equivalent to FP 500 mcg twice daily. Adults and adolescents ≥12 years: one inhalation once daily of: Relvar 92/22mcg for patients who require a low to mid dose of inhaled corticosteroid in combination with a long-acting β2-agonist. If patients are inadequately controlled then the dose can be increased to one inhalation once daily Relvar 184/22mcg. Relvar 184/22mcg can also be considered for patients who require a higher dose of inhaled corticosteroid in combination with a long-acting β2-agonist. Regularly review patients and reduce dose to lowest that maintains effective symptom control. COPD: one inhalation once daily of Relvar 92/22mcg. Contraindications: Hypersensitivity to the active substances or to any of the excipients (lactose

(Please consult the full Summary of Product Characteristics (SmPC) before prescribing) Relvar® Ellipta® (fluticasone furoate/vilanterol [as trifenatate]) inhalation powder. Each single inhalation of fluticasone furoate (FF) 100 micrograms (mcg) and vilanterol (VI) 25mcg provides a delivered dose of 92mcg FF and 22mcg VI. Each single inhalation of FF 200mcg and VI 25mcg provides a delivered dose of 184mcg of FF and 22mcg of VI. Indications: Asthma: Regular treatment of asthma in patients ≥12 years and older where a long-acting β2-agonist and inhaled corticosteroid combination is appropriate and where patients are not adequately controlled on inhaled corticosteroids and “as needed” short-acting inhaled β2-agonists, or where patients are already controlled on both inhaled corticosteroid and long-acting β2-agonist. COPD (Relvar 92/22mcg only): Symptomatic treatment of adults with COPD with a FEV1<70% predicted normal (post-bronchodilator) and an exacerbation history despite regular bronchodilator therapy). Dosage and administration: Inhalation only. Asthma: Patients with asthma should be given the strength of Relvar Ellipta containing the appropriate fluticasone furoate (FF) dosage for the severity of their disease. Prescribers should be aware that in patients with asthma, FF 100 mcg once daily is approximately equivalent to fluticasone propionate (FP) 250 mcg twice daily, while FF 200 mcg once daily is approximately equivalent to FP 500 mcg twice daily. Adults and adolescents ≥12 years: one inhalation once daily of: Relvar 92/22mcg for patients who require a low to mid dose of inhaled corticosteroid in combination with a long-acting β2-agonist. If patients are inadequately controlled then the dose can be increased to one inhalation once daily Relvar 184/22mcg. Relvar 184/22mcg can also be considered for patients who require a higher dose of inhaled corticosteroid in combination with a long-acting β2-agonist. Regularly review patients and reduce dose to lowest that maintains effective symptom control. COPD: one inhalation once daily of Relvar 92/22mcg. Contraindications: Hypersensitivity to the active substances or to any of the excipients (lactose

monohydrate & magnesium stearate). Precautions: Pulmonary tuberculosis, severe cardiovascular disorders, heart rhythm abnormalities, thyrotoxicosis, uncorrected hypokalaemia or patients predisposed to low levels of serum potassium. chronic or untreated infections, diabetes mellitus. Paradoxical bronchospasm – substitute alternative therapy if necessary. In patients with hepatic with moderate to severe impairment 92/22mcg dose should be used. Acute symptoms: Not for acute symptoms, use short-acting inhaled bronchodilator. Warn patients to seek medical advice if short-acting inhaled bronchodilator use increases. Therapy should not be abruptly stopped without physician supervision due to risk of symptom recurrence. Asthma-related adverse events and exacerbations may occur during treatment. Patients should continue treatment but seek medical advice if asthma symptoms remain uncontrolled or worsen after initiation of Relvar. Systemic effects: Systemic effects of inhaled corticosteroids may occur, particularly at high doses for long periods, but much less likely than with oral corticosteroids. Possible Systemic effects include: Cushing’s syndrome, Cushingoid features, adrenal suppression, decrease in bone mineral density, growth retardation in children and adolescents, cataract, glaucoma. More rarely, a range of psychological or behavioural effects including psychomotor hyperactivity, sleep disorders, anxiety, depression or aggression (particularly in children). Increased incidence of pneumonia, including pneumonia requiring hospitalisation, has been observed in patients with COPD receiving inhaled corticosteroids. If a patient presents with visual disturbance they should be considered for referral to an ophthalmologist for evaluation of possible causes which may include cataract, glaucoma, or rare diseases such as central serous chorioretinopathy. Physicians should remain vigilant for the possible development of pneumonia in patients with COPD as the clinical features of such infections overlap with the symptoms of COPD exacerbations. Risk factors for pneumonia include: current smoking, older age, low body mass index and severe COPD. The incidence of pneumonia in patients with asthma was common at the higher dose of Relvar (184/22mcg). Patients with rare hereditary problems of galactose intolerance, the total lactase deficiency or glucose-galactose malabsorption

should not use Relvar. Interactions with other medicinal products: Interaction studies have only been performed in adults. Avoid β-blockers. Caution is advised when co-administering with strong CYP 3A4 inhibitors (e.g. ketoconazole, ritonavir, cobicistat-containing products). Concomitant administration of other sympathomimetic medicinal products may potentiate the adverse reactions of FF/VI. Relvar should not be used in conjunction with other longacting β2-adrenergic agonists or medicinal products containing long-acting β2-adrenergic agonists. Pregnancy and breast-feeding: Experience limited. Balance risks against benefits. Side effects: Very Common (≥1/10): Headache, nasopharyngitis. Common (≥1/100 to <1/10): Candidiasis of the mouth and throat, pneumonia, bronchitis, upper respiratory tract infection, influenza, oropharyngeal pain, sinusitis, pharyngitis, rhinitis, cough, dysphonia, abdominal pain, arthralgia, back pain, muscle spasms, fractures, pyrexia. Uncommon (≥1/1,000 to <1/100): Hyperglycaemia, vision blurred, extrasystoles. Rare (≥1/10,000 to <1/1,000): Hypersensitivity reactions including anaphylaxis, angioedema, rash and urticaria; palpitations, tachycardia, tremor, anxiety, paradoxical bronchospasm. Marketing authorisation (MA) Holder: GlaxoSmithKline (Ireland) Limited, 12 Riverwalk, Citywest Business Campus, Dublin 24, Ireland. MA Nrs: 92/22mcg 1x30 doses [EU/1/13/886/002]; 184/22mcg 1x30 doses [EU/1/13/886/005].

Legal category: POM B. Last date of revision: January 2021. Code: PI-2046. Further information available on request from GlaxoSmithKline, 12 Riverwalk, Citywest Business Campus, Dublin 24. Tel: 01-4955000.

Adverse events should be reported directly to the Health Products Regulatory Authority (HPRA) on their website: www.hpra.ie. Adverse events should also be reported to GlaxoSmithKline on 1800 244 255.

References: 1. Bernstein DI et al. J Asthma 2015; 52: 1073-1083. 2. Relvar Ellipta SmPC, 2021, available

on www.medicines.ie

References: 1. Bernstein DI et al. J Asthma 2015; 52: 1073-1083.

reviewed regularly. As part of their asthma policy, it is also recommended that schools create an asthma record sheet for all students with asthma. The Asthma Society is warning teachers to be vigilant for asthma triggers at this dangerous time of year and to talk to parents to ensure they are aware of any students with asthma in the class.

Students with asthma – advice for teachers and schools

When a student with asthma joins your class, there are a number of steps you can take to ensure they are supported as much as possible. These include:

 Familiarise yourself with the school’s asthma policy.

 Always ensure that students with asthma have access to their reliever inhaler including during school trips, sports and PE. Relievers should never be locked away.

 Tell parents when their child has an attack or needs their reliever inhaler in school and encourage older students to tell you or another staff member if they use their reliever.

 Speak to parents about concerns over missed days, tiredness in class due to night-time symptoms or lack of concentration due to asthma. Students with severe or poorly controlled asthma may require extra support due to missed school days.

 Monitor students with asthma to ensure they don’t feel excluded or experience bullying.

 Provide opportunities for all students to learn about asthma in class.

 Think about requesting resources from the Asthma Society of Ireland to ensure the school is well informed about asthma and how to manage the condition.

Once you know what triggers the child’s asthma, you can take practical steps to reduce their impact.

 Damp dust chalkboard and classrooms regularly to get rid of

dust mites and pollen.

 Don’t keep furry or feathery pets in the classroom.

 Try to avoid fumes in science and art classes.

 Rigorously enforce a non-smoking policy on school grounds.

 Make sure the school is cleaned regularly.

 Heating and ventilation systems should be well maintained.

 Air classrooms to avoid mould and condensation.

 Avoid plants that give off high amounts of pollen.

 Use non-latex gloves.

32 schools in total were funded to take part in the Asthma Safe Schools Pre Hospital Care Council (PHECC). They received approved and certified training in basic life support and the administration of Salbutamol for emergency treatment of adults and children (<16 years) with an acute asthma attack. Schools were selected on a first come, first serve basis and each school nominated one teacher/SNA to attend the training day. The training was provided by the Irish Ambulance Training Institute. It involved an asthma safe school Webinar, asthma safe schools training day, and an asthma safe school pack. A survey carried out by the Asthma Society to evaluate the Asthma Safe Schools Programme 2021 showed that:

 55.5 per cent of teachers who participated in the programme felt they had gained considerable asthma management knowledge.

 Make sure that play areas and sports fields are free of autumn leaves as they are full of mould and fungal spores.

 Avoid mowing sports fields or grassy areas during school hours.

 Make sure changing rooms and bathrooms are well ventilated.

 Avoid opening windows and allow students with pollen allergies to stay indoors when pollen is high, such as during and after thunderstorms.

PE and sports

Exercise improves lung function and is an important part of a healthy lifestyle. Asthma symptoms shouldn't stop children from taking part in sport and PE, provided certain precautions are taken.

Asthma safe schools in 2021

This programme was delivered by the Asthma Society of Ireland. Some

 89 per cent of participating teachers believe that they have been provided with the training and tools to provide a supportive and safe environment to children with asthma.

 78 per cent of teachers gave a star rating of four or more when asked how confident they would be in the management of another person who is having an acute asthma attack in the out-of-hospital environment until handover to an appropriate person.

 When asked if the Asthma Safe School’s Programme had increased teachers overall knowledge of asthma, 45 per cent agreed and a further 46 per cent strongly agreed.

 90 per cent of teachers said that they would recommend this programme to others and it was found that both the webinar and the training day were were considered the most beneficial aspects of the programme.

 100 per cent of respondents said that they would use the Asthma Adviceline (1800 44 54 64) and the WhatsApp Messaging Service (086 059 1032) if they had any asthma-related queries. 

EXERCISE IMPROVES LUNG FUNCTION AND IS AN IMPORTANT PART OF A HEALTHY LIFESTYLE

55mcg and VI 22mcg. Each delivered dose contains approx. 25 mg lactose. Indications: COPD: Maintenance bronchodilator treatment to relieve symptoms in adult patients with COPD. Dose and administration: Inhalation only. COPD: One inhalation once daily at the same time of the day. Contraindications: Hypersensitivity to the active substances or to any of the excipients (lactose monohydrate and magnesium stearate).

years.

I was shape.

tachycardia, rhythm idioventricular, tachycardia, supraventricular extrasystoles and palpitations. Rare: Anaphylaxis, angioedema, urticaria, vision blurred, glaucoma, intraocular pressure increased, paradoxical bronchospasm, urinary retention, dysuria and bladder outlet obstruction. Frequency not known: Dizziness. Marketing Authorisation (MA) Holder: GlaxoSmithKline (Ireland) Limited, 12 Riverwalk, Citywest Business Campus, Dublin 24, Ireland. MA Nr: 55/22mcg 1x30 doses [EU/1/14/898/002]. Legal category: POM B. Last date of revision: January 2021. Job Ref: PI-3826. Further information available on request from GlaxoSmithKline, 12 Riverwalk, Citywest Business Campus, Dublin Tel: 01-4955000.

I’d smoked I just thought get ting out

Anoro Ellipta should be used with caution in patients with urinary retention, narrow angle glaucoma, convulsive disorders, thyrotoxicosis, hypokalaemia, hyperglycaemia and severe hepatic

LAMA/LABA to demonstrate function within the class. www.anoro.ie/head-to-head

Anoro Ellipta. Acute symptoms: Anoro Ellipta is not indicated for acute episodes of bronchospasm. Warn patients to seek medical advice if short-acting inhaled bronchodilator use increases, a re-evaluation of the patient and of the COPD treatment regimen should be undertaken. Interactions with other medicinal products: Interaction studies have only been performed in adults. Avoid β-blockers. Caution is advised when co-administering with strong CYP3A4 inhibitors (e.g. ketoconazole, clarithromycin, itraconazole, ritonavir, telithromycin). Anoro Ellipta should not be used in conjunction with other long-acting β2-adrenergic agonists or medicinal products containing long-acting muscarinic antagonists. Caution is advised with concomitant use with methylxanthine derivatives, steroids or non-potassiumsparing diuretics as it may potentiate possible hypokalaemic effect of β2-adrenergic agonists. Fertility, pregnancy, and breast-feeding: No available data. Balance risks against benefits. Side effects: Common: Urinary tract infection, sinusitis,

Ellipta is the superiority

Learn more

Adverse events should be reported directly to the Health Products Regulatory Authority (HPRA) on their website: www.hpra.ie. Adverse events should also be reported to GlaxoSmithKline on 1800 244 255.

▼This medicinal product is subject to additional monitoring. This will allow quick identification

Anoro® ▼ Ellipta® (umeclidinium bromide/vilanterol [as trifenatate]) Prescribing information

References:

1. Feldman GJ et al. Adv Ther 2017;34(11):2518-2533.

2. Alcázar Navarrette B et al. Pulm Ther 208;4:171-183.

3. Maltais F et al. Adv Ther 2019;36:2434-2449.

Anoro® Ellipta® 55/22mcg (umeclidinium bromide/vilanterol [as trifenatate]) inhalation powder. Each single inhalation of umeclidinium bromide (UMEC) 62.5 micrograms (mcg) and vilanterol (VI) 25mcg provides a delivered dose of UMEC 55mcg and VI 22mcg. Each delivered dose contains approx. 25 mg lactose. Indications: COPD: Maintenance bronchodilator treatment to relieve symptoms in adult patients with COPD. Dose and administration: Inhalation only. COPD: One inhalation once daily at the same time of the day. Contraindications: Hypersensitivity to the active substances or to any of the excipients (lactose monohydrate and magnesium stearate).

4. ANORO Ellipta SmPC 2021.

Precautions: Anoro Ellipta should not be used in patients with asthma. Treatment with Anoro Ellipta should be discontinued in the event of paradoxical bronchospasm and alternative therapy initiated if necessary. Cardiovascular effects may be seen after the administration of muscarinic receptor antagonists and sympathomimetics therefore Anoro Ellipta should be used with caution in patients with severe cardiovascular disease. Anoro Ellipta should be used with caution in patients with urinary retention, narrow angle glaucoma, convulsive disorders, thyrotoxicosis, hypokalaemia, hyperglycaemia and severe hepatic

information. Healthcare professionals are asked to report any suspected adverse reactions. consult the full Summary of Product Characteristics (SmPC) before prescribing) renal or mild to rare hereditary Lapp total lactase should not use is not indicated for patients to seek medical use increases, a treatment regimen other medicinal performed in adults. co-administering with ketoconazole, clarithromycin, Ellipta should not long-acting containing long-acting with concomitant or non-potassiumpossible hypokalaemic pregnancy, and Balance risks against infection, sinusitis, GlaxoSmithKline on 1800 244 255.

Anoro and Ellipta are registered trademarks the GlaxoSmithKline group of companies

impairment. No dose adjustment moderate hepatic impairment. problems of galactose deficiency or glucose-galactose Anoro Ellipta. Acute symptoms: acute episodes of bronchospasm. advice if short-acting re-evaluation of the patient should be undertaken.

products: Interaction studies Avoid β-blockers. Caution strong CYP3A4 inhibitors itraconazole, ritonavir, be used in conjunction agonists or medicinal muscarinic antagonists. use with methylxanthine sparing diuretics as it effect of β2-adrenergic breast-feeding: No benefits. Side effects:

References:

1. Feldman GJ et al. Adv Ther 2017;34(11):2518-2533.

superiority in lung function within the class.1-4

2. Alcázar Navarrette B et al. Pulm Ther 208;4:171-183.

Anoro and Ellipta are registered trademarks of the GlaxoSmithKline group of companies

PM-IE-UCV-ADVT-210003

Anoro and Ellipta are registered trademarks of the GlaxoSmithKline group of companies

3. Maltais F et al. Adv Ther 2019;36:2434-2449.

4. ANORO Ellipta SmPC 2021.

Learn more by visiting: www.anoro.ie/head-to-head

thyrotoxicosis, hypokalaemia, hyperglycaemia and severe hepatic benefits. Side effects: Common: Urinary tract infection, sinusitis, ANORO ELLIPTA was developed in collaboration with ©2022 GSK group of companies. All rights reserved.

Date of Preparation: January 2022

PM-IE-UCV-ADVT-210003

Date of Preparation: January 2022

for

and vilanterol (VI) 25mcg provides a delivered dose of UMEC

deficiency or glucose-galactose malabsorption should not use

tremor, dysgeusia, dysphonia, atrial fibrillation, supraventricular

NEOCATE SYNEO

Helps rebalance the gut microbiota

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RATES of infections and antibiotics

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For more information and to avail of our sampling service§

Use

IMPORTANT NOTICE: Breastfeeding is best. Neocate Syneo is a food for special medical purposes for the dietary management of Cow’s Milk Allergy, Multiple Food Protein Allergies and other conditions where an amino acid based formula is recommended. It should only be used under medical supervision, after full consideration of the feeding options available including breastfeeding. Suitable for use as the sole source of nutrition for infants under one year of age. Refer to label for details.

1. Burks AW et al. Pediatr Allergy Immunol. 2015 Mar 31; 26(4):316–322.

2. Candy DCA, et al. Pediatr Res. 2018 Dec 6; 83(3):677-686.

3. Fox A.T, et al. Clin. Transl. Allergy. 2019 Jan15; 9.5

4. Chatchatee P, et al. J Allergy Clin Immunol. 2021 Jul 2; S0091-6749(21)01053-8.

5. Martin R et al. Benef Microbes. 2010. 1(4):367–82.

6. Wopereis H et al. Pediatr Allergy Immunol. 2014. 25:428–38.

7. West CE et al. J Allergy Clin Immunol. 135(1):3–13.

8. Walker WA et al. Pediatr Res. 2015. 77(1):220–228.

9. Sorensen K, et al. Nutrients. 2021 Mar 14; 13(3):935. 10. Sorensen K, et al. Nutrients. 2021 Jun 27; 13(7):2205. ± Exploratory outcomes from randomised control trials, Neocate Syneo vs Neocate LCP; † Systematic review of 4 randomised controlled trials, Neocate Syneo vs Neocate LCP. ¥ UK Observational study of real world evidence in THIN GP database, Neocate Syneo vs Alfamino, Feb 2021 (Alfamino is not currently GMS listed in ROI); ^ Clinical journey: asymptomatic and not requiring hypoallergenic formula prescription for at least 3 months. § Product can be provided to patients upon the request of a healthcare professional. They are intended for the purpose of professional evaluation only.

Nutricia Ireland, Block 1 Deansgrange Business Park, Deansgrange, Co. Dublin. Date of publication: 02/2022

phone to scan the QR code THIS INFORMATION IS INTENDED FOR HEALTHCARE PROFESSIONALS ONLY

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AUTHOR: Denise Doherty

INFANT FEEDING IN IRELAND: BEST PRACTICE GUIDANCE FOR GPNS

THIS ARTICLE EXAMINES THE ROLE OF GPNS IN REVERSING IRELAND’S CURRENT BREASTFEEDING TRENDS AND IN IMPLEMENTING BEST PRACTICE RECOMMENDATIONS FOR INFANT FEEDING

The World Health Organisation (WHO), Department of Health (DOH), and UNICEF all recommend that breastfeeding be initiated within an hour of birth and continue exclusively for the first six months of life. After six months, they promote combined feeding of solids and breast milk up to two years and beyond.1,2,3 These recommendations are based on the conclusive and unanimously agreed evidence supporting the benefits of breast milk and its superiority over breast milk substitutes. In Ireland, however, these substitutes are by far the most popular choice and it is suggested that misconceptions about infant nutrition are a leading reason for this. It is essential that parents receive researchbased information and that breastfeeding myths are abolished if they are to make truly informed decisions. General practice nurses (GPNs) are an important link in the chain of services parents meet during the maternity journey and are often ideally placed to educate, inform, and promote best practice recommendations. It is therefore vital that they have the knowledge, skills, and tools to support all parents towards optimal outcomes for them and their infants.

Benefits of breastfeeding

Compared to substitutes, breast milk’s unique composition of bioactive and

bioavailable compounds offers better nutrient absorption, healthier growth and development, reduced risk of sudden infant death syndrome (SIDS), and improved infant immunity from gut infections, necrotising enterocolitis, respiratory tract infections, and others.4,5,6

This protective influence breast milk exerts appears to extend far beyond infancy and into adulthood too. Breastfed babies have a lower incidence of obesity, allergies, gut disorders, and chronic diseases, like diabetes and asthma,

throughout the lifespan.4,5,6 Growing evidence is emerging to suggest that the diverse microbial cultures that are present in human breast milk, which provides the breastfed infant with an equally diverse microbiome, may contribute to some of these associated benefits and does to many more.5,6,7

A meta-analysis of international studies published by the American Heart Association this year has confirmed previous indications that breastfeeding exerts a positive influence on the health

of mothers too. The study analysed the medical records of nearly 1.2 million women and found that those who breastfed were significantly less likely to develop coronary artery disease, stroke or suffer a cardiovascular-related death.8 Evidence exists to indicate that breastfeeding also significantly reduces maternal risk of developing diabetes and other metabolic disorders later in life.5,9 The HSE states that breastfeeding has exhibited the following benefits for women too:10

 Encourages uterine involution;

 Improves and promotes bonding;

 Reduces breast and ovarian cancer risks;

 Reduces the risk of diabetes;

 Is convenient, cost-effective and less time-consuming than formula feeding;

 Burns calories and aids post-partum weight loss.

Breastfeeding in Ireland

Despite the overwhelming and definitive evidence supporting breastfeeding, the vast majority of Irish babies are still formula fed. It is well documented that Ireland’s breastfeeding rates are notably low in comparison to other developed countries and trends are not improving.

According to a 2019 report from the Irish Maternity Indicator System (IMIS) in 2016, just under half of mothers breastfed after discharge from hospital and by 2019, this figure had dropped to 37 per cent.

Only 15 per cent of infants in Ireland are exclusively breastfed for the first six months compared to a global average of 38 per cent and European average of 25 per cent.11 The reasons for these suboptimal rates are multifaceted and intertwined with cultural norms, socio-economics, lifestyle, misinformation about breast milk substitutes, and the myriad myths that surround breastfeeding. Common myths about breastfeeding include:12

 It is not popular in Ireland.

 Fears that baby will not receive enough milk.

 Fears that partners will feel left out of the feeding experience.

 Breast milk substitutes are just as good

or more superior than breast milk.

 Breastfeeding is painful.

 Breastfeeding results in sagging breasts.

 Breastfeeding should be stopped if you have an infection.

 Medications cannot be taken while breastfeeding.

 Breastfeeding should be stopped at six months.

 Breastfeeding after 12 months adds no nutritional value.

National Standards for Infant Feeding in Maternity Services

In response to Irish breastfeeding trends and the mounting global evidence supporting breast milk over substitutes, the HSE introduced its National Standards for Infant Feeding in Maternity Services in May this year as part of its baby friendly initiative (BFI). Infant feeding in particular, is a core element of the BFI global quality improvement programme that has been implemented in over 100 countries to date. The BFI and its overall mission to bring optimum levels of care throughout the maternity experience to parents and baby, is central to all of our current policies, protocols, and best practice guidelines in Ireland. The new standards are informed by the National Standards for Safer Better Maternity Services, published by HIQA in 2016, and are aimed at achieving clinical excellence for all healthcare professionals that provide care

during the maternity experience.13 The core elements of the National Standards for Infant Feeding in Maternity Services are outlined in Box 1

The role of the GPN in infant feeding

Although the standards are primarily designed to guide maternity services in hospital settings, the advice, education, and support that women receive before and after hospitalisation will ultimately influence their inpatient decisions and experiences. GPNs play a core and valuable role in promoting and implementing best practice guidelines and supporting parents through the pregnancy and breastfeeding experiences. Kathryn Downey, Public Health Nurse (PHN), International Board-Certified Lactation Consultant (IBCLC), and member of the working group that contributed to the national standards told Nursing in General Practice (NiGP) “In many cases, the PHN and the GPN are the main, if not the only source of professional support a breastfeeding dyad encounter. Where GPNs, GPs, and PHNs can work together to provide support for breastfeeding dyads, we can achieve greater satisfaction. We need to recognise we are all part of the primary care team with the same goal. I would encourage more liaising between GPN and PHN. Timely and appropriate care is the core purpose of the standards. This purports to antenatal visits and the time mother and baby spend in the maternity services. As we are only too well aware, this support and care needs to continue once discharge from the maternity services occurs. To ensure we, as professional groups, are doing all we can to contribute to attaining national targets, it is imperative that we continue to make every contact count.”

The experienced Lactation Consultant also highlighted the need for evidencedbased, effective, and consistent practice, emphasising the importance of education, communication, and encouragement from GPNs caring for pregnant and postnatal parents. She reminds nurses that some parents receive conflicting information

DESPITE THE OVERWHELMING AND DEFINITIVE EVIDENCE SUPPORTING BREASTFEEDING, THE VAST MAJORITY OF IRISH BABIES ARE STILL FORMULA FED

about infant feeding from various sources and recommends the BOAT assessment tool14 (available online from the HSE) as a simple and effective resource to help GPNs identify if breastfeeding is working well and to help them direct care plans accordingly. She also added that knowing what services are available from statutory and voluntary organisations will help GPNs promote breastfeeding initiation, exclusive breastfeeding and prolonged breastfeeding of infants. Most importantly she concludes, “knowing what specialist breastfeeding supports are available in the community; most specifically where and if a PHN Lactation Consultant is available to give expert care” is paramount in achieving national targets and fulfilling the aims and objectives of the national standards.

Mairead O’Sullivan, Vice-President of the Association of Lactation Consultants Ireland (ALCI), also spoke to NiGP about the important role GPNs play in the promotion and protection of breastfeeding. She acknowledges that many patients have regular appointments throughout pregnancy; in many cases from the time of pregnancy confirmation and throughout the nine months. She recommends that GPNs “focus on providing specific antenatal breastfeeding preparation” and considers it hugely important that they become familiar with and can advise patients about the classes available in local maternity units, as well as the booking systems for them.

The overall message is that GPNs and many other healthcare workers play a role in improving breastfeeding trends in Ireland. Breast milk has been proven, beyond all reasonable doubt, to be superior to all substitutes and many GPNs are in a prime position to educate patients and support them towards the optimal source of infant nutrition. In Ireland, particular subgroups, including mothers who are younger, have less formal education and who are more likely to be economically deprived, appear to be at most risk of not starting or prematurely discontinuing breastfeeding.15 GPNs should be aware of socioeconomic

influences and address challenges these subgroups face to promote and support breastfeeding among them when possible. Eradicating fears, clarifying myths, and outlining the conclusive benefits of breastfeeding over substitute milks is central to any approach.

Care for parents who cannot or chose not to breastfeed

It is, however, also important to remember that many parents, such as women who have had double mastectomies, samesex male couples and adopting parents, cannot breastfeed. Other women choose not to for a variety of personal reasons or try and fail despite their best efforts. For these reasons, GPNs cannot always implement best practice recommendations for breastfeeding. Standard 6 in the national standards document advocates

Standard 1: Pregnant women and their partners/support person are supported to recognise the importance of breastfeeding and development of early relationships for the health and wellbeing of their baby, including what to expect when breastfeeding.

Standard 2: Support all mothers and babies to initiate a close relationship after birth.

Standard 3: Support mothers and babies to exclusively breastfeed and optimise breast milk feeding.

Standard 4.1: Support mothers to get breastfeeding off to a good start and manage challenges.

Standard 4.2: Support parents to have a nurturing relationship with their baby by recognising and responding to cues for feeding, closeness, and comfort.

Standard 5.1: There is a leadership team in place to support implementation of the National Infant Feeding Policy and National Standards

that staff have sufficient knowledge, skills, and confidence to support breastfeeding and other methods of infant feeding.13 Therefore, a knowledge of the science behind both breast milk and substitutes is required by GPNs and any staff that are supporting parents during all forms of infant feeding, as well as dietitian referral pathways if required. It is also important that these parents do not experience the stigma, guilt and other negative emotions that have been reported by formulafeeding parents in the past.16,17

In view of the definitive evidence supporting breast milk and concerns about affiliations with breast milk substitute companies, members of the Irish General Practice Nurses Education Association (IGPNEA) met to discuss whether engagement with these companies went against their ethos and objectives. They published their

for Infant Feeding in Maternity Services

Standard 5.2: The HSE Policy on the Marketing of Breast milk Substitutes (2021) is implemented to ensure there is no promotion of breast milk substitutes, bottles, teats or soothers in any part of its maternity services or by any of the staff.

Standard 5.3: Staff are educated to implement the National Standards for Infant Feeding in Maternity Services according to their role and the service provided.

Standard 6: Staff have sufficient knowledge, skills, and confidence to support breastfeeding and other methods of infant feeding.

Standard 7: Maternity services work with communities to improve infant feeding support services.

Standard 8: Maternity service providers systematically monitor, identify, and act on opportunities to improve the safety and quality of their infant feeding services.

Box 1: National Standards for Infant Feeding in Maternity Services13

conclusions in NiGP earlier this year and stated that in their experience, the breast milk substitute companies always reiterate that breast is best, that they deliver scientific and factual information and that GPNs require this information in order to guide parents who have chosen not to, or are unable to breastfeed.18

They also point out that many GPNs meet postnatal parents for the first time during immunisation visits and that by then, feeding choices have already

been established. Their overall message, however, is in complete agreement with other organisations; that breastfeeding should be encouraged, protected, and promoted by all healthcare professionals and is a far more superior source of infant nutrition than any breast milk substitute.

Education and support are needed for women who do not wish to breast feed as well as those that do. The role of healthcare professionals is to provide accurate, evidenced-based information,

REFERENCES

1. World Health Organisation (2021). Infant and young child feeding. Available at: www.who.int/news-room/fact-sheets/ detail/infant-and-young-child-feeding

2. Department of Health (2019). We’re breastfeeding friendly. Available at: www.gov.ie/en/policyinformation/48b128-healthy-irelandbreastfeeding-policy/

3. UNICEF (2019). Breastfeeding: A mother’s gift for every child. Available at: www.unicef.org/media/48046/file/ UNICEF_Breastfeeding_A_Mothers_ Gift_for_Every_Child.pdf

4. Health Service Executive (2017). Evidence for breastfeeding: Fact sheet for healthcare professionals. Available at: www.hse.ie/file-library/evidence-forbreastfeeding.pdf

5. Dieterich CM, Felice JP, O'Sullivan E, Rasmussen KM. Breastfeeding and health outcomes for the motherinfant dyad. Pediatric Clinics of North America. 2013 Feb; 60(1):31-48. doi: 10.1016/j.pcl.2012.09.010

6. Lyons KE, Ryan CA, Dempsey EM, Ross RP, Stanton C. Breast milk, a source of beneficial microbes and associated benefits for infant health. Nutrients. 2020 Apr 9;12(4):1039. doi: 10.3390/nu12041039

7. Fehr K, Moossavi S, Sbihi H, Boutin RCT, Bode L, Robertson B. Breast milk feeding practices are associated with the co-occurrence of bacteria in mothers' milk and the infant gut: The CHILD Cohort Study. Cell Host

Microbe. 2020 Aug 12; 28(2):285-297. e4. doi: 10.1016/j.chom.2020.06.009

8. Tschiderer L, Seekircher L, Kunutsor S, Peters SA, O’Keeffe L, Willeit, P. Breastfeeding is associated with a reduced maternal cardiovascular risk: Systematic review and meta -analysis involving data from eight studies and 1,192,700 parous women. Journal of the American Heart Association. 2022 Jan 18; 11(2). doi: 10.1161/JAHA.121.022746

9. Gunderson E, Lewis C, Lin Y, Sorel M, Gross M, Sidney S, et al. Lactation duration and progression to diabetes in women across the childbearing years. JAMA Internal Medicine, 2018 Mar; 78(3):328-337. doi: 10.1001/ jamainternmed.2017.7978

10. The Healthcare Executive (2019). The importance of breastfeeding. Available at: www.hse.ie/babies-children/ breastfeeding/a-good-start/importance/

11. Health Service Executive (2019). Irish Maternity Indicator System National Report 2019. Available at: www.hse.ie/eng/about/who/acutehospitals-division/woman-infants/ national-reports-on-womens-health/ imis-national-report-2019.pdf

12. Health Service Executive (2022). Common breastfeeding myths. Available at: www2.hse.ie/babieschildren/breastfeeding/a-good-start/ common-myths/

13. Health Service Executive (2022). National Standards for Infant Feeding in Maternity Services. Available at: www.hse.ie/eng/about/who/acute-

the essence of informed consent, to help patients make informed decisions that are right for them and their infants. Multidisciplinary collaboration will also be key. Utilising the core principles that underpin nursing practice, including a non-judgemental, supportive, individualised, holistic, person-centred, and evidenced-based approach, in keeping with best practice guidelines, will always promote the best outcomes for infants and their parents.

hospitals-division/woman-infants/ national-reports-on-womens-health/ national-standards-for-infant-feedingin-maternity-services.pdf

14. Health Service Executive (2022). Guideline on the observation of a breastfeed and use of the breastfeeding observation assessment tool (BOAT) resource. Available at: www.hse.ie/file-library/guideline-onthe-observation-of-a-breastfeed-anduse-of-the-breastfeeding-observationassessment-tool-boat-resource.pdf

15. Health Service Executive (2016). Breastfeeding in a Healthy Ireland: Health Service Breastfeeding Action Plan 2016-2021. Available at: www.hse. ie/eng/about/who/healthwellbeing/ healthy-ireland/publications/ breastfeeding-in-a-healthy-ireland.pdf

16. Fallon V, Komninou S, Bennett KM, Halford JCG, Harrold JA. The emotional and practical experiences of formula-feeding mothers. Maternal and Child Nutrition. 2017 Oct;13(4):12392. doi: 10.1111/mcn.12392

17. Lagan BM, Symon A, Dalzell J, Whitford H. 'The midwives aren't allowed to tell you': Perceived infant feeding policy restrictions in a formula feeding culture - the feeding your baby study. Midwifery. 2014 Mar;30(3):49-55. doi:10.1016/j.midw.2013.10.017

18. Jordan M. IGPNEA. Position on sponsorship and advertising revenue from breast milk substitute companies. Nursing in General Practice. 2022 Jan/ Feb 15(1):36-37



IMPORTANT NOTICE: Breastfeeding is best. Aptamil Pepti Syneo is a food for special medical purposes for the dietary management of Cow’s Milk Allergy. It should only be used under medical supervision, after full consideration of the feeding options available including breastfeeding. Suitable for use as the sole source of nutrition for infants under one year of age. Refer to label for details.

* Short chain galacto-oligosaccharides / long chain fructo-oligosaccharides;

2. Giampietro PG et al. Pediatr Allergy Immunol 2001;12:83-86.

5. Browne et al. Poster Presentation.

3. Van der Aa LB et al. Clin Exp Allergy. 2010;(40):795–804

1. MIMS Ireland, March 2022.

^Single arm UK study in infants with non-IgE mediated CMA, baseline non-synbiotic formulas vs Aptamil Pepti Syneo, 4 week intervention; † Subgroup of n=48 infants with IgE associated AD, difference in SCORAD score Aptamil Pepti Syneo vs EHF without synbiotics, -4.6, 95%CI, p=0.04. ‡ Products can be provided to patients upon request of a healthcare professional. They are intended for the purpose of professional evaluation only.

4. Atwal K et al. Poster Presentation. EAACI/FAAM 2020.

EAACI/PAAM 2019. 6. Browne et al. Poster Presentation. BSACI Meeting 2019 7. Data on file, updated independent taste panel report, Campden BRI, October 2020. n=102 HCPs, Campden BRI home usage taste testing. N=102 Dietitians and GPs. Aptamil Pepti 1 & Aptamil Pepti Syneo vs all UK EHFs suitable from birth. Nutricia Ireland, Block 1 Deansgrange Business Park, Deansgrange, Co. Dublin. Date of publication: 03/2022

THIS INFORMATION IS INTENDED FOR HEALTHCARE PROFESSIONALS ONLY NEW OURP For more information or to avail of our sampling service ‡ scan the QR code, freephone 1800 923 404 or visit www.nutricia.ie Use your phone to scan the QR code GREATER REDUCTION constipation,3,4^ dry stools,3 abdominal discomfort 4^ and atopic dermatitis severity3†, 4-5^

PALATABILITY compared to other EHFs in Ireland7

APTAMIL PEPTI SYNEO

SUPERIOR

The only 1 Extensively Hydrolysed Formula (EHF) to contain clinically proven to manage cow’s milk allergy symptoms in formula fed infants modulate the gut microbiome Bifidobacterium breve M-16V + scGOS / lcFOS* fibres

ATRIAL FIBRILLATION AND ATRIAL FLUTTER

AN ESTIMATED 1.4 PER CENT OF ALL ADULTS OVER 65 YEARS LIVING WITH UNDIAGNOSED AF MEANS MORE UNMANAGED CASES WILL CREATE EVEN FURTHER ECONOMIC STRAIN ON OUR HEALTHCARE SYSTEMS

Atrial fibrillation (AF) is the most common cardiac arrhythmia diagnosed in clinical practice and affects more than 33 million people worldwide. Characterised by the rapid and irregular beating of the atrial chambers of the heart; episodes of which may become longer or continuous over time, AF is associated with a significant risk of transient ischaemic attack, ischaemic stroke, systemic embolism, and death. While not immediately life-threatening like some cardiac arrhythmias, AF carries a five-fold higher risk of stroke caused by the formation of blood clots in the heart and blocked blood vessels in the brain. The percentage of people with AF increases with age, with 0.1 per cent under 50 years, 4 per cent between 60-to-70 years and 14 per cent over 80 years of age being affected. Due to increased lifespan, AF is on the rise and predicted to affect 14-to-17 million people in Europe by 2030, with 120,000-215,000 new cases per year (estimated incidence 0.23–0.41 per 1,000 person/years). In particular, 7-8.5 million people will be affected by permanent AF, 3.5-4.2 by persistent AF, and 3.5-4.2 by paroxysmal AF. A further 280,000–340,000 new ischaemic strokes, 3.5-4 million hospitalisations for AF and 100-120 million outpatient visits can also be added to these figures. AF constitutes

a public health challenge with high comorbidity and increased mortality risk and is a significant cause of increasing healthcare costs globally. An estimated 1.4 per cent of all adults over 65 years living with undiagnosed AF means more cases of unmanaged AF will create even further economic strain on our healthcare systems.

Aetiology

AF is multi factorial in nature. Abnormalities or damage to the heart's structure are the most common causes. AF is more common with increased age and affects certain groups of people more than others. While it can sometimes affect people who are physically very fit, AF is more common in people with other heart conditions, such as hypertension, atherosclerosis, cardiomyopathy, pericarditis, heart valve and congenital heart disease. A family history of AF may

also increase the risk. AF is also associated with other medical conditions, such as pneumonia, lung cancer, pulmonary embolism, sarcoidosis, obstructive sleep apnoea, hyperthyroidism and obesity. A number of triggers are associated with the condition, including smoking, excessive alcohol, and/or coffee consumption. When no other medical conditions are associated with it, it is called lone AF.

Symptoms

AF is often asymptomatic, especially in the elderly, but many patients experience palpitations, rapid and irregular heartbeat, vague chest discomfort or symptoms of heart failure, such as weakness, lightheadedness and dyspnoea, particularly when the ventricular rate is very rapid (140to-160 beats/minute). Patients may also present with signs and symptoms of acute cerebrovascular accident (CVA) or other organ damage due to systemic emboli.

Diagnosis and screening

Diagnostic investigation of AF typically includes a complete medical history and physical examination, ECG, full blood count, urea and electrolytes, and serum thyroid stimulating hormone level. All patients who present with symptoms of AF should have, at a minimum their pulse checked for irregularities as well as a 12-lead ECG.

ECG findings for AF indicate the absence of P waves, irregularly irregular R-R

AUTHOR: Theresa Lowry-Lehnen, RGN, PG Dip Coronary Care, RNP, BSc, MSc, PG Dip ED (QTS), M Ed, PhD Clinical Nurse Practitioner, and Associate Lecturer, South East Technological University

PATIENTS MAY ALSO PRESENT WITH SIGNS AND SYMPTOMS OF ACUTE CVA OR OTHER ORGAN DAMAGE DUE TO SYSTEMIC EMBOLI

intervals and the presence of f (fibrillatory) waves between the QRS complexes. Fibrillatory waves are irregular in timing and morphology with baseline undulations at rates up to or >300/minute, best seen in lead V1 and not always apparent in all leads.

Other diagnostic tests for AF include CXR and echocardiogram. Echocardiography is carried out to assess for structural heart defects, such as left atrial enlargement, left ventricular wall motion abnormalities, suggesting past or present ischaemia, valvular disorders, cardiomyopathy, and to identify additional risk factors for stroke, such as atrial blood stasis, thrombus or complex aortic plaque. Atrial thrombi are more likely in the atrial appendages, where they are best detected by transoesophageal rather than transthoracic echocardiography.

AF is a progressive disorder. The exact electro-pathological mechanisms underlying the persistence of AF are at present unknown and none of the available recording techniques can determine the degree and extensiveness

of atrial electro-pathology, or determine the stage of the condition at any time in the process. Identifying individuals at risk of developing AF is important, however, as there is strong evidence that early detection and treatment of modifiable risk factors can reduce morbidity and mortality.

Classification of AF

The European Society of Cardiology (ESC) distinguishes five types of AF based on presentation and duration of arrhythmia.

First diagnosed AF

Every patient who presents with AF for the first time, irrespective of the duration or the presence and severity of AF related symptoms.

Paroxysmal AF

AF that terminates spontaneously, usually within 48 hours although AF paroxysms may continue for up to seven days. After 48 hours, spontaneous conversion is low and anticoagulation must be considered.

Persistent AF

Continuous AF sustained for more than seven days or requires termination by cardioversion, either with drugs or by direct current cardioversion.

Long-standing persistent AF

Continuous AF of greater than 12 months duration. It is usually decided to adopt a rhythm control strategy at this stage.

Permanent AF

Permanent AF is said to exist when the presence of the arrhythmia is accepted by the patient and physician. Rhythm control interventions, by definition, are not pursued in patients with permanent AF.

Complications of AF

The absence of atrial contractions in AF predisposes the patient to thrombus formation. Risk of stroke is higher in older patients and in those with mechanical heart valves, rheumatic valvular disease, hyperthyroidism, hypertension, diabetes,

FIRST DIAGNOSED AF

Every patient who presents with AF for the first time irrespective of the duration or the presence and severity of AF-related symptoms.

PAROXYSMAL AF AF that terminates spontaneously, usually within 48 hours, although AF paroxysms may continue for up to seven days. After 48 hours spontaneous conversion is low and anticoagulation must be considered.

PERSISTENT AF

Continuous AF sustained for more than seven days or requires termination by cardioversion, either with drugs or by direct current cardioversion.

such as propranolol or atenolol, and nonhydropyridine calcium channel blockers, such as diltiazem or verapamil, which slow the conduction of impulses to the ventricles. Digoxin may be added to control the heart rate further. Digoxin is usually only effective for controlling the ventricular rate at rest and should therefore only be used as a monotherapy in predominantly sedentary patients.

LONG-STANDING PERSISTENT AF

PERMANENT AF

Continuous AF of greater than 12 month’s duration. It is usually decided to adopt a rhythm control strategy at this stage.

Permanent AF is said to exist when the presence of the arrhythmia is accepted by the patient and physician. Rhythm control interventions, by definition, are not pursued in patients with permanent AF.

Reference: Taskforce for the management of atrial fibrillation of the European Society of Cardiology

left ventricular systolic dysfunction or previous thromboembolic events. Systemic emboli can also cause malfunction or necrosis of other organs. AF may impair cardiac output. Loss of atrial contraction can lower cardiac output at normal heart rate by about 10 per cent. Such a decrease is usually well tolerated except when the ventricular rate becomes too fast (>140 beats/minute), or when patients already have borderline or low cardiac output. In such cases, cardiac failure may develop.

Treatment

Treatment of AF varies from person to person and depends on the type of AF, symptoms, treatment of any underlying cause, age, and overall health. The first step is to try to find the cause of the AF. For example, hyperthyroidism can sometimes be the underlying cause of AF and medication to control the condition can then correct the symptoms of AF. If no underlying cause is found, treatment of AF is usually aimed at either rhythm or rate control. Since

AF induces electrical, structural, and contractile remodelling, therapy aimed at prevention or restoration of remodelling and consequently, restoration of sinus rhythm should be the first choice strategy. The different AF treatment modalities include pharmacological therapy, electrical cardioversion, pacemaker implantation combined with HIS bundle ablation or surgical isolation of the pulmonary veins, with or without additional linear lesions/ substrate modification.

Anti-arrhythmic medication can control AF by restoring normal heart rhythm and controlling the rate at which the heart beats. The choice of anti-arrhythmic depends on the type of AF, comorbidities, side-effects of the medicine chosen and response to therapy. Some patients may need more than one anti-arrhythmic to control AF and a variety of medications are available to restore normal heart rhythm. The aim is to reduce the resting heart rate to <90 beats per minute (bpm), however, in some people the target is <110bpm.

First-line drugs include beta blockers,

Anti-arrhythmic drugs can be classified clinically into those that act on supraventricular arrhythmias (example verapamil), both supraventricular and ventricular arrhythmias (example amiodarone) and those that act on ventricular arrhythmias (example lidocaine). They can also be classified according to their effect on the electrical behaviour of myocardial cells during activity (Vaughan Williams classification). Class I antiarrhythmic medications are membrane stabilising drugs; examples are lidocaine and flecanide. Class II are beta blockers. Class III include amiodarone and sotalol and class IV are calcium channel blockers, including verapamil, but not dihydropyridines. The negative inotropic effects of antiarrhythmic drugs tend to be additive. Special care should be taken if two or more are used, especially if myocardial function is impaired. Many medications that are effective in countering arrhythmias can also provoke them in some instances. Patients must be monitored closely as common side-effects of anti-arrhythmic medications include hypotension, fatigue, nausea, vomiting, possible issues with liver, kidneys, thyroid or lungs, and heart rhythm disorders. Amiodarone causes sensitivity to sunlight and skin changes are common, therefore, sun protection is important when taking this medication.

Aspirin is not recommended to prevent strokes caused by AF. Patients with a high or moderate level of risk of stroke or thrombus formation due to AF, are usually prescribed an anticoagulant, such as warfarin or a newer type of anticoagulantnovel oral anticoagulants (NOACs) also called direct oral anticoagulants

(DOACs), such as dabigatran, rivaroxaban, apixaban or edoxaban. There are fewer dietary and medication interactions with the newer agents and less need for monitoring. NOACs are at least as effective or superior to warfarin for stroke prevention in patients with non-valvular atrial fibrillation and are at least as safe, or safer in terms of bleeding risk, according to three large clinical trials. NOACs have major pharmacologic advantages over warfarin, which is a vitamin K antagonist, including rapid onset/offset of action, few drug interactions and predictable pharmacokinetics. Practical advantages of novel oral anticoagulants over warfarin include fixed once or twice-daily oral dosing without the need for coagulation monitoring. Potential drawbacks include a risk of bleeding that might be increased in patients over 75 years of age, the lack of a routine laboratory test to reliably measure anticoagulant effect and previously, the lack of an antidote for reversal. Choice of NOAC is influenced by the patients individual characteristics, including risk of stroke or venous thromboembolism (VTE), risk of bleeding and comorbidity, in particular renal dysfunction. It is also recommended that one of the bleeding risk scores, such as the HAS-BLED score, be used to help risk-assess patients. The choice of agent should take into consideration the patient’s age, weight and creatinine clearance, as dose adjustment may be required.

Cardioversion is a medical procedure carried out in a hospital setting, by which a tachycardia or other cardiac arrhythmia is converted to a normal rhythm using an electric current or pharmacology. Synchronised electrical cardioversion uses a therapeutic dose of electric current to the heart at a specific moment in the cardiac cycle, restoring the activity of the electrical conduction system of the heart. Electrical cardioversion has success rates between 65-to-90 per cent and can be performed safely as a day case procedure. The likelihood of success can be further improved by the co-administration of

antiarrhythmic drug therapy. Pharmacologic cardioversion, also referred to as chemical cardioversion, uses anti-arrhythmic medication instead of an electrical shock. Pharmacological cardioversion is often used for the treatment of AF of recent onset.

Flecainide, ibutilide, propafenone, and vernakalant can be used in patients with no structural heart disease. Where structural heart disease is present, intravenous amiodarone is the drug of choice. Flecainide administered intravenously in patients with AF of recent onset has been shown to restore sinus rhythm in 72-to-95 per cent of patients, with greatest success rates in those who receive treatment within 24 hours of AF onset. When AF has persisted for >48 hours, pharmacological cardioversion is much less likely to be effective. Amiodarone appears to be the most effective agent for restoring sinus rhythm in patients with persistent AF.

For patients who have been in AF for longer than 12-to-24 hours, or in whom the duration of the arrhythmia is not clear, a minimum period of anticoagulation of three weeks is recommended before cardioversion. Even if echocardiography has demonstrated no thrombus before cardioversion, patients should be anticoagulated for at least one month post cardioversion, since mechanical atrial function may return slowly after cardioversion.

Catheter ablation is performed by a cardiac doctor who specialises in heart rhythms and is an option if medical treatment for AF has not been successful. The procedure restores the heart's normal rhythm by electrically isolating the left atrium from the pulmonary veins, where most abnormal electrical activity that promotes AF originates. The procedure destroys or ablates the diseased area of the heart and interrupts abnormal electrical circuits.

The principal reason to place a pacemaker in a patient with AF is to treat symptomatic bradycardia, especially due to sick sinus syndrome (tachycardia-

bradycardia syndrome). This tends to be mainly used in people aged 80 or over.

Differentiation between atrial flutter and AF

Atrial flutter is much less common than AF, but its causes and haemodynamic consequences are similar. About a third of people with atrial flutter also have AF. Both conditions carry increased risk of stroke. In AF, the atria beat irregularly. In atrial flutter, the atria beat regularly, but faster than usual and more often than the ventricles, and there may be four atrial beats to every one ventricular beat. During atrial flutter, unlike AF, electrical activity in the atria is coordinated. The atria do contract, but at a very rapid rate of 250-to350 times per minute. This rate is too fast to allow every impulse to be conducted through the atrioventricular node to the ventricles. Because the AV node cannot usually conduct at this rate, typically half of the impulses get through (2:1 block), resulting in a regular ventricular rate of 150 beats/minute. The diagnosis of atrial flutter is by electrocardiography. In typical flutter, ECG shows continuous and regular atrial activation with a sawtooth pattern, most obvious in leads II, III, and aVF.

Carotid sinus massage can increase AV block and better expose the typical flutter waves. A similar response may follow pharmacologic AV nodal blockade, example with adenosine, but such therapy does not terminate atrial flutter. Treatment of atrial flutter focuses on ventricular rate control, rhythm control, and prevention of thromboembolism. Patients with chronic or recurrent atrial flutter require an oral anticoagulant. The choice among the therapies is based on the same considerations as for AF. Patients often require cardioversion or atrial flutter substrate ablation.

AF associated with one-in-three strokes in Ireland

AF is the most common cardiac arrhythmia affecting at least 3 per cent of Irish adults over 60 and is associated with almost

one-in-three strokes in Ireland. Globally the prevalence of AF is rising and approximately 600 men and 375 women per 100,000 population are affected. In the 2017 report Burden of Stroke in Europe, the Stroke Alliance for Europe signalled a possible 58 per cent increase in the absolute number of strokes in Ireland over the next decade. Much of this can be accounted for by increasing numbers of AF-related stroke as our population ages. The population aged 65 years and over in Ireland is increasing at the rate of 4 per cent annually. The CSO predicts that over 65s will represent between 21.5-to-27.9 per cent of the Irish population by 2046. As a result AF is a growing public health concern.

Screening for AF in general practice

Projections show that the number of people living with stroke as a chronic condition will rise from 3,718,785 in 2015 to 4,631,050 in 2035, representing an increase of 25 per cent or almost one million people across Europe. There are approximately 8,000 strokes in Ireland annually, a third of which

are associated with AF. In 2015, HIQA published a Health technology assessment (HTA) of a national screening programme for atrial fibrillation in primary care. The HTA announced that a national screening programme for AF for over 65s in primary care would be cost-effective. HIQA’s Director of Health Technology Assessment Dr Máirín Ryan, said: “Based on the best available evidence, annual opportunistic pulse palpation for those aged 65 and older is expected to lead to reductions in the incidence and severity of AF-related strokes assuming that those detected by screening have a comparable risk of stroke as those detected through routine care.” Analysis estimated that screening would result in the detection of one additional AF case for every 22 people screened from age 65 onwards, and one stroke avoided for every 270 people screened over the same period. The total incremental cost to the HSE was estimated at €3.7 million over the first five years. This included the additional costs associated with screening, ECGs, and atrial fibrillation drug therapy in diagnosed cases, as well as the cost savings resulting from a gradual decrease in stroke incidence over a

period of five years.

Almost 11 per cent of Irish adults aged 65 years and over attending general practice have AF. The HSE (2015) study Atrial Fibrillation Screening in General Practice concluded that “opportunistic screening for an irregular pulse in general practice to assist in the detection of AF is both feasible and beneficial”. This multi-site prospective observational study found that approximately 8,415 new cases of AF could be identified by opportunistic screening in general practice each year. Each GP could expect to diagnose 17 new cases per 1,000 patients annually through opportunistic screening in practice. General practices are well placed to opportunistically screen older patients and are ideal in terms of the pathway for treatment for those identified. Opportunistic screening for an irregular pulse carried out by GPs and GPNs “has the potential to be an extremely important stroke prevention strategy, capable of saving society and the health service significant social and economic costs”.

References available on request

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ACROSS

Across

1 - Measure of heaviness (6)

Down

2 - Look into (7)

3 - Belonging to the past (8)

4 - Unattractive (4)

9 - Adolescence (5)

5 - Distress (7)

6 - Possibly (7)

10 - Besides; in addition (8)

16 Compact (5)

12 - Scattered rubbish; brides (anag) (6)

21 Therefore (5)

14 - Judge (6)

19 Temporary outside shelter (4)

17 - Look similar to (8)

18 - Smallest quantity (5)

20 - Brother or sister (7)

7 - Summed together (5)

11 - Gather together (8)

12 - Deteriorate (7)

13 - Respire (7)

15 - Absence of sound (7)

16 - Compact (5)

Measure of heaviness (6) Turn upside down (3) Extreme displeasure (5) ___ to: Disagreeing with (7) Adolescence (5) Besides; in addition (8) Scattered rubbish; brides (anag) (6) Judge (6) Look similar to (8) Smallest quantity (5) Brother or sister (7) Organ of sight (3) Abode of God (6) SCRIBBLE BOX DOWN Look into (7) Belonging to the past (8) Unattractive (4) Distress (7) Possibly (7) Summed together (5) Gather together (8) Deteriorate (7) Respire (7) Absence of sound (7)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

- Turn upside down (3) - Extreme displeasure (5) - ___ to: disagreeing with (7)

HPRA INVITES CLINICAL EXPERTS TO JOIN EXPERT PANEL

The Health Products Regulatory Authority (HPRA) is inviting clinical experts from an array of disciplines to participate in the regulatory assessment, evaluation, and decisionmaking processes for the safety and efficacy of medicines and medical devices. The national regulator is forming an expert panel and inviting doctors, pharmacists, and other healthcare professionals to provide advice and ensure decision-making accurately reflects clinical practice.

External experts may be asked to provide input in relation to clinical research, scientific advice for new products under development, applications to market new treatment options for patients, and any emerging quality or safety concerns in relation to medicines and medical devices

currently on the market. It is essential that the expert is registered in Ireland or another EU/EEA country with their professional and regulatory body; that his or her expertise is demonstrable through clinical experience, research, and publication, and that their expertise is in one of the following areas:

 Oncology and haematology;

 Cardiovascular, endocrinology, renal, respiratory;

 Gastroenterology, rheumatology, immunology, dermatology;

 Neurology, pain, and psychiatry;

 Infectious diseases;

 Ophthalmology;

 Paediatrics and geriatrics;

 Clinical pharmacology;

 Diagnostic and therapeutic radiopharmaceuticals.

Membership of the HPRA’s panel

will provide clinical experts with an opportunity to develop a greater understanding of how health products are regulated nationally and in Europe, gain an insight into the development of innovative health products and contribute to ensuring that health products are safe and effective for patients. Expressions of interest should be submitted via email to scientificaffairs@hpra. ie by 30 September 2022. Following an evaluation of the expressions of interest received, successful experts will be notified and their appointment will be confirmed following completion and review of a declaration of interest and confidentiality undertaking. Further information, including details on how to apply, is available on the HPRA website (www.hpra.ie).

BOOTS IRELAND IS TEAMING UP WITH THE HYGIENE BANK TO TACKLE POVERTY

Boots Ireland has announced a new partnership with The Hygiene Bank Ireland, providing drop off points in 10 stores, where people can donate hygiene products that are then delivered to those in need. This new partnership is being announced ahead of National Hygiene Week, from 12-18 September 2022, which aims to raise awareness about hygiene poverty and its impact on those who are affected.

People are invited to donate a range of unopened and unused products, such as dental products, deodorants, body wash, nappies, baby wipes, razors and shaving

foam, period products, hairbrushes, shampoo, and conditioner. Speaking at the launch of the new partnership, Ciára Dalton, Head of Marketing, The Hygiene Bank Ireland said: “Everyone has the right to an adequate standard of living, yet with 640,000 people at risk of poverty and the cost of living on the rise, hygiene products can often be at the bottom of the shopping list for people who are struggling to make ends meet. The impact of this can be immense.” Initially, Boots Ireland will be operating 10 drop-off points around the country. The stores in the initial phase include five locations in Dublin – Dundrum, Carrickmines, Swords, Liffey Valley and

Blanchardstown, Letterkenny Retail Park, Letterkenny, two locations in Cork – Blackpool and Half Moon Street – as well as Shop Street, Galway, and Abbey Street, Wicklow town.

Martha Ryan, Head of Human Resources Boots Ireland and Corporate Social Responsibility

Lead said: “We are proud to be partnering with The Hygiene Bank Ireland in supporting them with the expansion of its network of drop-off points for people to donate unused and unopened hygiene products. We encourage everyone who is able, to donate products to any of our stores that are participating in this important initiative.”

Latest module

Atrial Fibrillation

On completion of this module, the reader should have an enhanced understanding of atrial fibrillation, including different types of arrhythmia, diagnostic methods, and the drugs and procedures that can be used to treat the condition.

Free independent CPD for Irish nurses A B C Successful completion of this module will earn you 2 CPD credits Visit www.medilearning.ie/nursecpd Free CPD – now accessible on android, iPhone and tablet

Author: Eamonn Brady MPSI (Pharmacist), Whelehans Pharmacies, Mullingar, Co Westmeath