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BULETI
N PENAWA
R
VOLUME 1/2017
JULY 2017
EDITORIAL BOARD ADVISOR: DR. SITI NORLINA BT. MD SAID EDITORS: PN SITI ROSNAH BT. SURADI PN NG WANG SING PN PATRICIA LIM MING HUA PN LI SHIN GIE
HOSPITAL SULTANAH AMINAH JOHOR BAHRU KEMENTERIAN KESIHATAN MALAYSIA JALAN PERSIARAN ABU BAKAR SULTAN 80100 JOHOR BAHRU TEL: 07-2257000 FAX: 07-2242694 EMAIL: publichsajb@moh.gov.my
IN THIS ISSUE MANAGEMENT AND TREATMENT OF HEADLICE & SCABIES
HORMONE REPLACEMENT THERAPY
IDARUCIZUMAB AS AN ANTIDOTE FOR DABIGATRAN
ZIKA VIRUS UPDATES
LAPORAN MAJLIS SAMBUTAN HARI JADI BULAN JAN-MAC JAWATANKUASA KEBAJIKAN DAN SOSIAL JABATAN FARMASI
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MANAGEMENT AND TREATMENT OF HEADLICE AND SCABIES BY ZULLHELMY BIN ABDUL RAFAR
1) Inspection :
First, examine the base of the hair around the ears, crown and across the back of the neck (common areas where nits are found). Examine carefully hair strands, nits are small and normally glued to the hair scalp. Nits are more easily seen than live lice. carefully hair strands, nits are small normally glued to the
2) Treatment : There are two basic way to get rid of head lice which are by using chemical treatment ( insecticides) or just combing the head lice out. Lotions or shampoo that poison head lice are called insecticides. Individual patient factor should be assessed prior to choosing a topical therapy (age, allergy history, prior treatment, etc.) It is advisable to re-treat with topical therapies 7-9 days after initial therapy to kill newly hatched lice.
The head lice is a tiny, wingless parasitic insect that lives among human hairs and feeds on tiny amounts of blood drawn from the scalp. Lice are very common among children.
What is head lice ?
Life cycle :
Nymph hatches to the size of pin head (1mm)
Grow to triple size before becoming an adult (3mm)
Reaches adulthood about 9-12 days after hatching
Signs and symptoms:
Severe itching on the scalps
Nits
Steps to getting rid of head lice :
J A B A T A N F A R M A S I , H O S P I T A L S U L T A N A H A M I N A H J O H O R B A H R U P A G E 2
Not following instructions given by
doctor or pharmacist
Resistance of head lice to the
chemical used
Not repeating the treatment in 7-10
days (to kill head lice that have
hatched from eggs that are not killed
in the first treatment)
Getting head lice again from
untreated person.
Treatment failure may due to :
> Avoid direct head-to-head contact > Avoid sharing brushes, combs, ribbons, hats and helmets > Cleaning brushes, combs, towel, pillow cases with hot water and detergent (60°C for 30 seconds)
> Checking the scalp for head lice regularly.
Prevention
Therapy Use Risks/side
effects
Lindane Shampoo 0.1% (gamma benzene hexachloride)
Apply 30-60 mL to
dry hair.
Maximun: 60 mL.
Massage into dry
hair for 4 minutes, then rinse thor-oughly with warm water.
Risk group
Infants and small chil-
dren
patients <50 kg
history of seizures or
conditions which may increase risk of sei-zures.
Hepatic impairment.
Pregnancy
Permerthrin 1% w/v lotion
Apply lotion over
dried hair by en-suring every strand comes in contact with the lotion at least 10 minutes
Side effect
Skin irritation
redness or rash
WHAT IS SCABIES ? Scabies is caused by the mite, Sarcoptes
scabiei var. hominis which burrows into the
stratum corneum. The female lays eggs in
the tracks of the burrows.
Signs and symptoms:
· Itchiness, which usually develops within 2 to 6 weeks after infestation ·The itchiness is localised, very intense and intractable which gets worst at night
(A): Papules and burrows on medial aspect of the feet)
(B): Vesiculopustular lesions on lateral aspect of the hands.
(C): Scabies nodules in the axillary region
Drug therapy:
General measures: - The entire skin surface must be applied with topical treatment. -Treating the face is controversial in adult with classical scabies, but in babies the face must be treated, because transmission may occur from breastfeeding. -The person who has no symptoms but has physical contact with patients must also receive treatment at the same time. -Person who helps to apply topical treatment to the patient should wear medical gloves to avoid transmission. -Patient should use fresh, clean bedding and clothing after completion of treatment.
Treatment Treatment regime Contraindication/ Caution Side effects
Permethrin 5% Cream /lotion
Apply thoroughly to all body
parts . Rinse off after 8 to 12
hours & repeat 1 week later
Percutaneous absorption
in animal tests shows 40-
400 times lower than Lindane 1%
Itching, burning and
stinging sensation on
application
Benzyl Benzoate
10 – 25%
emulsion
Apply over whole body, neck
down and leave for 24 hours then
wash off. Reapply for another 24 hours, repeat application within
5 days after initial application
Pregnant & breast feed-ing women and infants
less than 2 years
Skin irritation and
burning sensation.
May cause conjuncti-vitis if exposed to
eyes. May worsen/
cause post- scabetic
eczematous reaction.
Affect compliance
Crotamiton 10% cream
Apply over whole body, neck
down and leave for 24 hours then
without washing, apply a second dose. Thoroughly wash off the
medication after 48 hours
Avoid massive & pro-
longed use in pregnant
women and infants
Irritant contact der-
matitis
Treatment of secondary infection in scabies: -Treat with systemic antibiotics which covers gram positive organism for a minimum of 7 days. -Use antiseptic soaks/bath e.g. KMnO4 (1:10,000) in scabies.
Treatment failure : 1.New papules or vesicles or burrows appearing at any stage after completion of a course of scabicides. 2.The itch still persists at least 6 weeks after the first course of treatment of scabicides (particularly, if it persists at the same intensity or is increasing in intensity). Management of treatment failure: ·Re-educate and re-counsel patient and family members. ·Re-treat with topical scabicides using an alternative agent.
References:
American Academy of Pediatrics. Summaries of Infectious Diseases. In:Pickering LK, ed. Red Book: 2006 Report of the Committee on Infectious Diseases. 26th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2003:584-587.
Pickering LK, Baker CJ, Long SS, McMillan JA. Summaries of Infectious Diseases, pp: 335-55. Red Book, 2006 Report of the Committee on Infec-tious Diseases. 2006;27.
Vander Stichele RH, Dezeure EM, Bogaert MG. Systematic review of clinical efficacy of topical treatments for head lice. BMj. 1995 Sep 2;311(7005):604-8.
Bonilla DL. Bartonella quintana in Body Lice and Head Lice from Homeless Persons, San Francisco, California, USA-Volume 15, Number 6—June 2009-Emerging Infectious Disease journal-CDC.
Strong M, Johnstone P. Cochrane Review: Interventions for treating scabies. Evidence‐Based Child Health: A Cochrane Review Journal. 2011 Nov
1;6(6):1790-862.
J A B A T A N F A R M A S I , H O S P I T A L S U L T A N A H A M I N A H J O H O R B A H R U P A G E 3
Menopausal Effects
Menopause symptoms Vasomotor instability (60%): Hot flushes, palpitation Urogenital : Vaginal dryness, soreness, urinary frequency and ur-gency Psychological: Mood changes, insomnia, depression, anxiety Long Term Effects Bone metabolism: Osteoporosis Cardiac: Increase susceptibility to heart disease
TYPES OF MENOPAUSE
HORMONE REPLACEMENT THERAPY (HRT)
Progesterone is added into HRT to
reduce the risk of cystic hyperpla-
sia of endometrium and possible
transformation to cancer
Note: the increase in cancer risks is relatively small com-pared to many lifestyle risk factors such as smoking and obesity.
A. Estrogen taken daily B. Cyclic or sequential regimens: Progesterone is added for 10-14 days every 4 weeks. For those who are still menstruating but have menopausal like symptoms C. Continuous combined regimens: Estrogen and Progesterone are taken daily. For postmenopausal patient
HRT still considered as an effective short-term treatment for menopausal symptoms, whereby the benefits outweigh risks for women <60 years old.
PRINCIPLES
SHORTEST TIME POSSIBLE
SMALLEST DOSE POSSIBLE
COUNSEL ON ALL SHORT & LONG TERM EFFECTS
CONTRAINDICATION
History of breast & endo-metrial cancer, porphyria, severe active liver disease, h y p e r t r i g l y c e r i d e m i a , fibroids, endometriosis, undi-agnosed vaginal bleeding,
thromboembolic disorder
Schedule of HRT
Natural: menstruation stops for 12 months in absence of pathological cause Induced: May be due to surgical (oophorectomy), radiological after irradiation at ovaries and exposure to chemotherapy
J A B A T A N F A R M A S I , H O S P I T A L S U L T A N A H A M I N A H J O H O R B A H R U P A G E 4
BY BOO AO RAN
Alternatives to HRT
1.Tibolone (STEAR):
Oestrogenic action on bone, vagina, vasomotor symptoms an l ipid; Progestogenic & antiestrogenic action on endometrium and breast, weak androgenic activity.
2.Raloxifen (SERM):
Estrogenic agonist in bone, prevent bone loss and increase BMD. Antagonizes estrogen activity in breast and uterine tissues. However, it fails to control vasomotor symptoms and may even aggravate it.
3.Mirena (an intrauterine system to deliver levonorgestrel 20mcg/24 hours)
Licensed as an alternative for endometrial protection (for 4 years) with estrogen component.
REFERENCE:
1. Kaur K. Menopausal Hormone Replacement Therapy: Practice Essentials, Overview, Symptoms and Effects of Menopause [Internet]. Emedi-
cine.medscape.com. 2016 [cited 7 February 2017]. Available from: http://emedicine.medscape.com/article/276104-overview
2. Committee J. British National Formulary. 1st ed. London and Chicago: Pharmaceutical Press; 2014.
3. HRT and cancer [Internet]. Cancer Research UK. 2015 [cited 10 February 2017]. Available from: http://www.cancerresearchuk.org/about-cancer/
causes-of-cancer/hormones-and-cancer/hrt-and-cancer
4. De Villiers T, Stevenson J. The WHI: the effect of hormone replacement therapy on fracture prevention. Climacteric. 2012;15(3):263-266.
5. MHRA/CHM (Drug Safety Update 2007;1(2):2-6.
Comparison of Clinical Profiles between different treatment modalities
+: Positive (beneficial effect); =: Neutral effect; Negative (detrimental ) effect , *:to a lesser extent than estrogen
Examples of Estrogen & Progestin
A. ESTROGEN
i. Natural -Estradiol, Estrone, Estriol, CEE
ii. Synthetic: Micronized 17β Estradiol, and Ethinyl Estradiol (EE), Mestranol
B. PROGESTOGEN & PROGESTERONE RECEPTOR MODULATOR
i. Progesterone Bioidentical -Crinone, Prometrium, Cyclogest pessaries Progesterone Analogue -MPA, Dydrogesterone
ii. 19 Norethisterone Types (Androgenic): -Norethisterone, Norethindrone Acetate (NETA), Norgestrel, Levonogestrel
NOTE: Synthetic Progestins i.e. MPA, NETA has less favorable VTE and cancer profile. Bioidentical Progesterone remains the preferred method of HRT.
J A B A T A N F A R M A S I , H O S P I T A L S U L T A N A H A M I N A H J O H O R B A H R U P A G E 5
Dabigatran etexilate is a rapid-acting competitive and
reversible direct inhibitor of thrombin where thrombin
is responsible for the conversion of fibrinogen to fibrin
in the coagulation cascade.
Dabigatran is a new oral anti-
coagulant (NOAC). It has few
primary advantages compared
to warfarin (Vitamin K an-
tagonist) such as no routine
blood monitoring, no dietary
restrictions, less inter– andin-
trapatient variability and also
fewer drug-drug interactions.
Dabigatran specifically block-
ing the activity of thrombin.
There are a few approved
indications for Dabigatran
such as :
1. Prevention of stroke and
systemic embolism in patients
with non-valvular atrial fibril-
lation and a risk factor for
stroke.
2. Treatment of deep vein
thrombosis (DVT) and pul-
monary embolism (PE) and
prevention of recurrent
DVT and PE in adults.
3. Prevention of venous
thromboembolic events in
patients who have undergone
total knee replacement or
total hip replacement
surgery.
Idarucizumab is indicated
for reversal of the
anticoagulant effects of
Dabigatran when patients
are needed for emergency
surgery/ urgent
procedures or in life
threatening or uncon-
trolled bleeding.
This antidote is a
humanized monoclonal
antibody that binds
359 folds higher than
the binding affinity of
Dabigatran to throm-
bin which will
neutralize Dabigatran’s
anticoagulant effect.
It is used for intravenous
only and the recom-
mended dose of Idaruci-
zumab is 5g, provided as
2 separate vials each
containing 2.5g/50mL.
ABOUT DABIGATRAN
ABOUT IDARUCIZUMAB
Idarucizumab as
an Antidote for
Dabigatran
P A G E 6 J A B A T A N F A R M A S I , H O S P I T A L S U L T A N A H A M I N A H J O H O R B A H R U
BY JASON YOONG
There are no adequate and well
controlled studies of Idarucizumab
in pregnant women. It should be
given only if clearly needed.
Use in special population
Hence, Idarucizumab is being used
when there is emergency surgery
or urgent procedures where the
surgery cannot be delayed.
Reversing dabigatran therapy
exposes patients to the thrombotic
risk of their underlying disease. To
reduce this risk, resumption of anti-
coagulant therapy should be
considered as soon as medically
appropriate. Dabigatran can be
initiated 24 hours after admini-
stration of Idarucizumab.
Dabigatran etexilate has a half
-life of 12-14 hours in people
with normal renal function,
but this is increased in people
with renal impairment. There-
fore the timing of the last dose
of dabigatran is likely to be a
factor in whether reversal of
its anticoagulant effect is
needed.
WHEN AND WHY
SHOULD WE USE?
There are no data on the effects of Ida-
rucizumab on milk production. Not rec-
ommended as many drugs are excreted
in human milk.
No renal adjustment is required in
renal impaired patients.
There are 2 different ways
to administer Idarucizumab,
one is using 2 consecutive
infusion and another one is
through bolus injection.
(Figure 1)
1. Inspect visually, make
sure everything is
correct.
2. Flush line using 0.9%
sodium chloride injec-
tion, USP solution prior
to infusion. No other
infusion should be ad-
ministered in parallel
via the same intrave-
nous access.
3. Hang vials and
administer as 2
consecutive infusions.
4. Or similarly inject
both vials consecu-
tively via syringe
(bolus injection).
ADMINISTRATION OF IDARUCIZUMAB
I d a r u c i z u m a b a s a n A n t i d o t e f o r D a b i g a t r a n
References:
2013 Thrombosis Canada, Comparison of New Oral Anticoagulants and Frequently Asked Questions from Patients. Di Nisio M. Et Al. Direct Thrombin Inhibitors. N Engl J Med. 2005;353:1028–40 and Physicians
Pradaxa European Summary of Product Characteristics, 2015
Dabigatran Etexilate - Drugbank [Internet]. Drugbank.Ca. 2010 [Cited 13 February 2017]. Available From: Https://
Www.Drugbank.Ca/Drugs/Db06695
U. S. Food and Drug Administration,2015 National Institute for Health and Care Excellence (2016), Reversal of The Anticoagulant Effect Of Dabigatran: Idarucizumab.
Nice Guideline (Esnm73)
J A B A T A N F A R M A S I , H O S P I T A L S U L T A N A H A M I N A H J O H O R B A H R U P A G E 7
ZIKA VIRUS UPDATESZIKA VIRUS UPDATES
Affected areas
TRANSMISSION
1. Bite from an infected mosquito
2. Maternal-fetal
3. Sexual transmission from an infected per-
son to his or her partners
4. Laboratory exposure (1 case recorded in
US)
5. Blood transfusion
DIAGNOSTIC TESTING
1. RNA nucleic acid testing (NAT) on serum and urine and possibly whole blood,
cerebral spinal fluid, or amniotic fluid.
2. Serology assays can also be used to detect Zika virus-specific IgM.
TESTING FOR INFANTS
CDC recommends laboratory testing for
◦All infants born to mothers with laboratory evidence of possible Zika virus
infection during pregnancy.
◦Infants who have abnormal clinical or neuroimaging finds suggestive of
congenital Zika syndrome and a mother with a possible exposure to Zika virus,
regardless of maternal Zika virus testing results.
BY VITTHIA A/P RAMA MURTI
J A B A T A N F A R M A S I , H O S P I T A L S U L T A N A H A M I N A H J O H O R B A H R U P A G E 8
ZIKA AND PREGNANCY
Recognizing that Zika is a cause of certain birth
defects does not mean that every pregnant woman
infected with Zika will have a baby with birth
defect.
It means that infection with Zika during pregnancy
increases the chance for these problems.
No reports of infants getting Zika through breast-
feeding even though Zika virus has been detected
in breast milk.
Based on available evidence, the benefits of
breastfeeding outweigh any possible risk.
No evidence that previous infection will affect
future pregnancies.
SEXUAL TRANSMISSION
1. Zika has been found in genital fluids, including semen and vaginal fluids.
2. Current research indicates that Zika can remain in semen longer than in other body fluids, including
vaginal fluids, urine, and blood.
3. CDC and other public health partners are doing continuous research that may help us find out
-How long Zika can stay in genital fluids.
-How common it is for Zika to be passed during sex.
-If Zika passed to a pregnant woman during sex has a different risk for birth defects than Zika
transmitted by a mosquito bite.
VACCINE
Advanced Candidates already in clinical development:
(NIAID(VRC)) DNA-based vaccine candidate, on-
going phase I, scheduled phase II in early 2017. A
placebo-controlled phase 2b study of 2400 people
will be initiated early next year at 30 sites in the
Caribbean, Central and South America, and, if war-
ranted, the southern United States.
(NIAID/Butantan) a pentavalent live-attenuated
vaccine candidate (Zika + dengue) (based on the
dengue vaccine currently in phase III in Brazil),
phase I planned in early 2017
References
World Health Organization (WHO): Overview on Zika Virus 2016.
Centers for Disease Control and Prevention (CDC) Zika Virus update 2017
International Association for Medical Assistance to Travelers (IAMAT) 2017
Thomas R.Frieden, MD, MPH. Zika Virus 6 Months Later. Journal of American Medical Association October 11, 2016
Volume 316.
Broutet N, Krauer F, Riesen M, et al. Zika virus as a cause of neurologic disorders. N Engl J Med 2016; 374: 1506-9.
National Healthcare Services (NHS) Zika Virus Infection, England.Gov.UK 2016
Zika Vaccine working Group Overview. Global Research Collabration for Infectious Disease Preparedness (GLOPID-R)
November 2016.
J A B A T A N F A R M A S I , H O S P I T A L S U L T A N A H A M I N A H J O H O R B A H R U P A G E 9
LAPORAN MAJLIS SAMBUTAN HARI JADI BULAN JAN-MAC
JAWATANKUASA KEBAJIKAN DAN SOSIAL JABATAN FARMASI
J A B A T A N F A R M A S I , H O S P I T A L S U L T A N A H A M I N A H J O H O R B A H R U P A G E 1 0
BY MONISHAH MOHANAN PILLAI
Pada 7 Mei 2017 yang lalu, Jawatankuasa Kebajikan dan Sosial Jabatan Farmasi telah
menganjurkan Majlis Sambutan Hari Lahir untuk meraikan staf yang dilahir antara bulan April
hingga bulan Jun. Sambutan ini telah diadakan di ruang tengah Unit Farmasi Logistik, Hospital
Sultanah Aminah Johor Bahru . Dengan adanya sambutan ini, warga jabatan farmasi dapat secara
langsung mengeratkan silaturrahim staf HSAJB.
Tepat jam 12.45 tengah hari majlis dimulakan dengan ketibaan Dr Siti Norlina Bt Md. Said
selaku penaung Jawatankuasa Kebajikan Dan Sosial Jabatan Farmasi. Majlis diiringi dengan ba-
caan doa dan disusuli dengan ucapan daripada Dr Siti Norlina Bt Md. Said. Seterusnya, majlis
dimeriahkan lagi dengan acara potong kek bagi staf yang dilahir pada bulan April, Mei, dan Jun.
Mereka yang terlibat telah menerima cenderahati sumbangan ikhlas daripada pihak jawatankuasa.
Majlis kali ini juga dimeriahkan dengan satu cabutan bertuah bagi setiap staf yang menyambut hari
lahir antara bulan April hingga bulan Jun. Tidak lupa juga penyampaian hadiah kepada staf yang
ditukarkan ke tempat baru, staf yang telah melahirkan cahaya mata dan staf yang telah mendirikan
rumahtangga.
Majlis diakhiri dengan jamuan makan tengahari yang disertai oleh Ketua-ketua Unit dari-
pada Jabatan Farmasi. Pelbagai juadah enak disediakan untuk para tetamu menjamu selera. Se-
cara keseluruhannya, sambutan hari jadi bulan April - Jun Jabatan Farmasi berjalan dengan lan-
car dan meriah.
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