1

INSIDE THIS

ISSUE:

HOT ISSUE: DENGUE WAR

1-5

ANTIMICROBIAL

RESISTANCE

6-8

QUIT SMOKING CLINIC

9-13

DRUG COMPARISON: B COMPLEX, NEURO-BION & MECOBALA-MIN IN NERVE RE-

GENERATION

14-15

BYDEUREON 16-18

QUMC IN PKDMT 19

TRUTH @ MYTHS:

STEVIA - A HEALTHY ALTERNATIVE SWEETENER?

20-22

PHARMACY BULLETIN

I S S U E 1 Y E A R 2 0 1 6

PKD MELAKA TENGAH

Editorial Board Advisor: Dr. Rusdi bin Abd. Rahman Chief Editor: Mardhiah binti Amir-uddin Editor: Chew Poh Chiong Contributors: Michelle Lim Bee Ping Noorafinah Mohd Zudin Foo Swee Yen Nursyahirah binti Abd Raof

INTRODUCTION

Dengue is a mosquito-borne viral disease that has rapidly spread in many regions

of the world. Dengue is found especially in tropical and subtropical regions of the

world. The geographical distribution of dengue is linked within the temperature

range where the mosquito species Aedes that transmits the disease can be found.

Dengue fever is caused by 4 closely related virus types, which is called serotypes.

The 4 Dengue Virus (DENV) serotypes are DENV-1, DENV-2, DENV-3 and

DENV-4.

DENGUE WAR By : Lee Ai Wei

EPIDEMIOLOGY

Epidemiology of dengue worldwide

The incidence of dengue has grown dramatically around the world in recent dec-

ades. Up to 3.6 billion people are estimated to now live in tropical and subtropi-

cal areas where the den-

gue viruses have the po-

tential to be transmitted.

Globally it is estimated

that approximately 50

million to 200 million

deng ue i n f e c t ion s ,

500,000 cases of severe

dengue, and over 20,000

dengue related deaths

occur annually.

2

Epidemiology of dengue in Malaysia

In Malaysia, dengue is predominantly an urban disease due to the abundance of the principle vec-

tor Aedes aegypti which is at a close proximity to high densities of susceptible hosts. The states of

Selangor, Wilayah Persekutuan Kuala Lumpur and Johor are the areas that have been largely af-

fected by the disease and are reporting high numbers of cases.

TRANSMISSION OF DENGUE

Spread through a human-to-mosquito-to-human cycle of transmission.

The two Aedes mosquito species that transmits the disease are Aedes aegypti, which is the

primary mosquito vector, and Aedes albopictus, which is the secondary mosquito vector.

When a dengue mosquito bites someone who is sick with dengue fever, that mosquito is

infected and becomes a carrier of the virus.

Mosquitoes are capable of spreading the disease within 8-12 days after biting infected person.

The virus will multiply in the salivary glands of the mosquito and then transferred into a

healthy human body during mosquito bites.

Female mosquitoes infected with dengue virus can also transfer the virus to infect its eggs

next newly hatched mosquito.

Once the mosquito is infected by the dengue virus, the mosquito is a carrier of the virus for

life and it can spread the virus to other people by biting them.

The dengue virus does not spread directly from person to person. Once inside the human

body, the virus takes 3-14 days to develop before the symptoms of dengue fever.

HOT ISSUE

3

Differences between Aedes aegypti and Aedes albopictus

Aedes aegypti

Aedes albopictus

Has bright silvery lyre-shaped dorsal pattern and white banded legs

Has a single longitudinal silvery dorsal stripe and white banded legs

Occupies urban areas with or without vege-tation

Associated with thickets and arboreal vegetation

Bites, rests, and lays eggs both indoors and outdoors

Mostly an outdoor (garden) mosquito

Sneaky biter Aggressive biter

High preference for taking blood meals from humans and to lesser extent from domestic mammals, which makes it a very capable vector of dengue viruses

Bites humans but also a variety of available domestic and wild vertebrates that do not carry the dengue viruses, which lowers its capacity to transmit them

Main dengue vector worldwide Main dengue vector in some areas but is mostly a secondary vector

The major production places are human-made containers, tree holes and bamboo internodes holding water

Shows preference for tree holes and bam-boo internodes with water but can also uti-lize human-made containers for its imma-ture development

SIGNS & SYMPTOMS

Dengue should be suspected when a high fever (40°C/104°F) is accompanied by 2 of the

following symptoms: severe headache

pain behind the eyes

muscle and joint pains

nausea, vomiting

swollen glands

rash

Symptoms usually last for 2–7 days, after an incubation period of 4–10 days after the bite from

an infected mosquito.

HOT ISSUE

MANAGEMENT OF DENGUE

No specific vaccine or medication to prevent or treat dengue fever currently.

Treatment is purely concerned with relief of the symptoms (symptomatic).

Rest and adequate hydration is important.

Paracetamol can be taken to reduce fever and relieve pain.

Avoid aspirin in children under the age of 12 years.

The use of antibiotics is not indicated in dengue infection.

4

HOT ISSUE CLINICAL COURSE OF DENGUE INFECTION

After the incubation period, the illness begins abruptly and will be followed by 3 phases.

Febrile phase

High grade fever (usually last

for 2-7 days)

Accompanied by facial flush-

ing, rash, generalized body

ache, vomiting and headache

Mild haemorrhagic manifesta-

tions may be seen

Enlarged and tender liver

Progressive decrease in

total white cell count fol-

lowed by platelet reduction

Critical phase

Occurs after third day of fever (may

occur earlier)

Lasts about 24- 48 hours

Rapid drop in temperature

Patient may deteriorate and manifest

third space plasma leakage or organ

dysfunction

In more severe forms of plasma leakage,

patient may develop compensated and

decompensated shock

Thrombocytopenia and haemoconcen-

tration are usually detectable in this

phase

Leucopenia with relative lymphocytosis,

clotting abnormalities, elevation of

transaminases, hypoproteinaemia and

hypoalbuminaemia are usually observed.

Recovery phase

Plasma leakage stops fol-

lowed by reabsorption of

extravascular fluid

Patient’s general well being

improves

May have a classical rash of

“isles of white in the sea of

red” with generalized

pruritus

Haematocrit level stabilises

and drops further due to

haemodilution following re-

absorption of extravascular

fluid

Recovery of platelet count is

preceded by recovery of

white cell count

WHO DENGUE CLASSIFICATION

5

USE OF PAPAYA LEAF EXTRACT IN DENGUE FEVER Papaya leaf extract is now being widely used as a treatment for dengue fever in

many countries and in some with the approval of their health authorities. Papaya leaf extracts have been

shown to have many beneficial effects, including reduction in the duration of fever, duration of illness,

hospital stay, rapid elevation of white blood cells and platelet counts. Randomised controlled trial has

been done by Institute for Medical Research (IMR) and Tengku Ampuan Rahimah Hospital, results

showed that there was a significant increase in platelet count among dengue patients administered with

50gm of fresh papaya leaf juice for three consecutive days.

Safety concern

Certain parties stated that papaya leaves contain a dangerous chemical known as cyanogenic glycoside

which could cause liver, kidney or heart failure and ultimately death. However, content of the deadly

chemical are very small (0.02 mg in every four leaves). A 60kg person would need to consume 12,000

papaya leaves at once to cause any acute poisoning. According to Health director-general Datuk Dr

Noor Hisham Abdullah, papaya leaf juice has been shown to increase blood platelet count and assist in

the recovery of those with lesser complications, and is unlikely to cause liver, kidney or heart failure.

HOT ISSUE

PREVENTION & CONTROL

OF DENGUE

Main method is to combat vector

mosquitoes through:

Environmental management

and modification

(prevent mosquitoes from ac

cessing egg-laying habitat)

Improving community partici-

pation and mobilization for

sustained vector control;

Active monitoring and surveil-

lance of vectors

REFERENCES 1. Ministry of Health Malaysia. Statistik denggi. Available from: http://idengue.remotesensing.gov.my/idengue/page2.php?kandungan=content/s_infopendidikan.html

2. World Health Organization. Dengue transmission. Available from: http://gamapserver.who.int/mapLibrary/Files/Maps/Global_DengueTransmission_ITHRiskMap.png?ua=1 3. World Health Organization. Dengue and severe dengue. 2016. Available from: http://www.who.int/mediacentre/factsheets/fs117/en/ 4. Centers for Disease Control and Prevention. Dengue homepage. 2015. Available from: http://www.cdc.gov/dengue/epidemiology/ 5. Ministry of Health Malaysia. History and epidemiology of dengue. 2015. Available from: http://denggi.myhealth.gov.my/history-and-epidemiology-of-dengue/?lang=en 6. Ministry of Health Malaysia. What is dengue. 2015. Available from: http://denggi.myhealth.gov.my/what-is-dengue/?lang=en

7. Centers for Disease Control and Prevention. Available from http://www.cdc.gov/dengue/resources/30Jan2012/comparisondenguevectors.pdf 8. Medical News Today. Prevention of dengue fever. 2015. Available from : http://www.medicalnewstoday.com/articles/179471.php?page=3 9. New Straits Time. Papaya leaves safe for the treatment of dengue, improve platelet counts: Health Ministry. 2016. Available from: http://www.nst.com.my/

news/2016/01/124921/papaya-leaves-safe-treatment-dengue-improve-platelet-counts-health-ministry 10. Ministry of Health Malaysia. Management of dengue infection in adults (third edition). 2015.

IMPORTANT POINTS

Manipulation of platelet count alone does not alter the clinical course of the disease as it is just a sur-

rogate marker of disease progression or evolution. Plasma leakage and organ dysfunction should be the

main focus of management.

6

ANTIMICROBIAL RESISTANCE

antimicrobial

RESistance

What is antimicrobial resistance?

Antimicrobial resistance (AMR) is the ability of microorganisms which enable them to continue to grow and

not be killed by drugs. Individuals who are infected by resistant microorganisms are usually hard to treat. They

usually required alternative treatments/drugs which are more expensive with more side effects/toxic effects (1).

The number of antimicrobial resistance cases has been increasing every year all over the world. For instance in

many Asian countries, more than 70 % of bacteria isolated were shown to be fully resistant to erythromycin (2).

It is of utmost importance to control and prevent antimicrobial resistance from spreading.

By : Chew Chun Siang

“Antibiotics resistance in Malaysia have increased when the National Antibiotics Resistance Studies

revealed an increased flow of Vancomycin antibiotics resistance to the bacteria Enterococcus faecium

went up to 9.3 percent in 2014 compared to 8.4 percent in 2013.”

“New superbugs such as carbapenem-resistant Enterobacteriaceae (CRE) showed the number of infec-

tions went up from 150 cases in 2013 to 181 cases in 2014, with number of deaths increasing from

25% in 2013 to 37% in 2014.”

Deputy Health Minister Dr Hilmi Yahya (4)

In Malaysia

Source of image (3)

7

How Resistance Happens and Spreads?

Microorganism can develop resistant through several ways. Some microorganism are naturally resistant to

antibiotics while some actually developed it through spontaneous mutation or acquiring resistant genes

through exchanging genes with other bacteria. Antibiotics which are prescribed for a longer duration than

which is needed to treat or prescribed for inappropriate indication will result in higher risk of spontaneous

mutation occurring. This is because microorganisms which are exposed to antibiotics for a long duration are

likely to mutate in order to survive (selective pressure) and later passing the resistant genes to other micro-

organisms. This contributed to the increasing number of resistant microorganisms (5). It has been shown

that up to 50% of the time antibiotics are prescribed for inappropriate indication, incorrect dosing or dura-

tion (6).

Source of image (6)

ANTIMICROBIAL RESISTANCE

8

Source of image (7)

Effects of growing antimicrobial resistance

1) Diseases are harder to treat and sometimes result in death as some infections by resistant microorganisms are in-

curables

2) Increasing cost of treatment as individuals infected by resistant microorganisms usually required longer stays at hos-

pitals and more expensive drugs

3) Patients are suffering from more side effects as usually more toxic drugs are needed to treat infections due to re-

sistant microorganisms.

How to prevent antimicrobial resistance?

1) Healthcare provider should prescribe antimicrobial drugs only if deemed appropriate and necessary. The benefits of

using antimicrobial drugs to treat should far outweigh the risk of not using them before a decision is made (8)

2) Patients should comply with medications prescribed and finish the whole course of antibiotics if prescribed by their

doctors (8)

3) Society needs to adopt a healthy lifestyle and practice good hygiene, such as frequent hand washing in order to pre-

vent/minimize the risk of spreading microorganisms from one individual to other individual (8)

4) Developing new drugs and diagnostic tests which are more effective in treating/detecting infections with lesser side

effects.

Conclusion

World Health Organization (WHO) has warned that antibiotic resistance has become one of the biggest threats to

global health today. United States' first known case of E. coli infection that is resistant to antibiotics, even Colistin,

which usually use as last resort-style kind of antibiotic was reported on 26th May 2016 by U.S. Department of Defense.(9) Hence, it is our responsibility to ensure antibiotics are used wisely to prevent the world from being cast back into

the dark ages of medicine.

References: 1) http://www.cdc.gov/drugresistance/threat-report-2013/

2) Kim SH, Song JH, Chung DR, Thamlikitkul V, Yang Y, Wang H, Lu M, So TM, Hsueh PR, Yasin RM, Carlos CC, Pham HV, Lalitha MK, Shimono N, Perera J, Shibl AM, Baek JY, Kang CI, Ko KS, Peck KR. ANSORP Study Group. Changing trends in antimicrobial resistance and serotypes of Streptococcus pneu-moniae isolates in Asian countries: an Asian Network for Surveillance of Resistant Pathogens (ANSORP) study. Antimicrob Agents Chemother. 2012;56:1418–1426 3) https://agenda.weforum.org/wp-content/uploads/2015/12/151119-antibiotics-resistance-deaths-bacteria-microbes-statista-chart.jpg 4) www.malaysiakini.com/news/319805 5)http://www.fda.gov/Drugs/ResourcesForYou/Consumers/ucm143568.htm 6) http://www.cdc.gov/drugresistance/images/2-how_antibiotic_resistance_spreads.jpg 7) http://www.who.int/mediacentre/events/2015/world-antibiotic-awareness-week/infographic-causes.jpg?ua=1 8)https:/www.niaid.nih.gov/topics/antimicrobialResistance/Understanding/Pages/prevention.aspx 9) http://edition.cnn.com/2016/05/26/health/first-superbug-cre-case-in-us/

ANTIMICROBIAL RESISTANCE

9

QUIT SMOKING CLINIC

By Nurul Atikah Binti Wahab

Men who smoke are 17 times more likely than non

-smokers to develop lung cancer and other compli-

cations. Therefore, smoking cessation programme

is significant to reduce morbidity and mortality due

to tobacco related diseases *3,4+.

Unfortunately quitting smoking is not easy. So

many smokers have undergone the dilemma of

wishing to quit and then been unsuccessful. Thus,

it is important for healthcare professionals to deliv-

er appropriate guidance for smoking cessation as

smoking is more than just a bad habit.

Malaysia has become a Member State or the Party

to the World Health Organization Framework Con-

vention on Tobacco Control (WHO FCTC) since De-

cember 15, 2005 and has responsibility for imple-

menting the provisions in this international agree-

ment.

Smoking is the most important preventable cause of ill health and death in Malaysia and all

over the world1,2+.

The objectives of National Quit Smoking Pro-

gramme are to*3+:

Provide comprehensive support and assistance to

help smokers quit smoking

Develop skills of assisting smokers to quit among all

health professionals

Make quit smoking services widely available and

accessible at all levels of health care

Encourage and motivate smokers utilise the ser-

vices provided

Involve all stakeholders in partnership to help

smokers quit

In current, Quit Smoking Clinic is available in all klinik

kesihatan of PKD Melaka Tengah to assist smokers to

stop smoking.

QUIT SMOKING CLINIC

10

Algorithm for management of tobacco use and dependence*3+:

Ask about tobacco use

Advise to quit

Assess willingness to make a quit attempt

Assist in quit attempt

Arrange follow-up

5A’S Of Brief Clinical Intervention*4+

5 R’S Strategies (For patient unwilling to quit) *4+

To enhance motivation to increase future quit attempts

Relevance : why quitting is relevance?

Risks : negative consequences of tobacco use

Rewards : benefits of stop smoking

Roadblocks : identify barriers to stop smoking

Repetition : motivational intervention should be

repeated every time an unmotivated patient visits

the clinic

QUIT SMOKING CLINIC

11

PHARMACOLOGICAL TREATMENT

VARENICLINE NICOTINE PATCH

Starter Pack

Champix 0.5mg & 1mg

film-coated tablets

Maintenance pack

Champix 1mg film-coated tablets

Availability Nicorette Transdermal Patch 10mg/16hr

Nicorette Transdermal Patch 15mg/16hr

Varenicline is highly selective and binds more

potently to α4ß2 receptor compared to nico-

tine, where it acts as partial agonist, stimulating

receptor-mediated activity but at a lower level

than nicotine. Hence, effectively block nicotine’s

ability to fully activate the receptor.

Mechanism

of action

Nicotine patch mimic fluctuation of nicotine

over the day in smokers. Nicotine released

bind and stimulate nicotinic receptors in the

brain and eventually cause release of dopa-

mine, hence reduce nicotine withdrawal

symptoms in smokers who abstain from

smoking.

Varenicline should be started 1-2 weeks be-

fore quit date.

Patient who cannot tolerate may have dose

lowered temporarily or permanently 0.5mg

BD.

Patient should be treated with varenicline

for 12 weeks.

Patient who stopped smoking at the end of

12 weeks, an additional course of 12 weeks

treatment may be considered if necessary.

Days 1-3 0.5mg once daily

Days 4-7 0.5mg twice daily

Day 8 – End of treat-

ment

1mg twice daily

Regime Adults & the elderly[5]:

Children and adolescents[5]:

Contraindicated in patients below than

18 years old.

Use of patch beyond 6 months is not

recommended.

QUIT SMOKING CLINIC

Varenicline Nicotine patch

Duration Dose

8 weeks 15mg/16 hours

Then 4 weeks 10mg/16 hours

12

VARENICLINE NICOTINE PATCH

A/KK Prescriber

category

A/KK

May impair the ability to drive or oper-

ate heavy machinery.

Nausea à Take on a full stomach

Insomnia à Take second pill at supper

time or after dinner

Trouble sleeping, abnormal/vivid/strange

dreams

Abdominal pain

Flatulence

Headache

Side effects Nausea

Vomiting

Fatigue

Hypersensitivity

Headache

Skin reaction à Rotate patch sites or treat

with steroidal creams

Insomnia and/or vivid dream

Take a full glass of water

Take with food (non-oily food)

Take at the same time everyday

Contact health care provider immediate-

ly if changes in behavior or thinking, de-

pressed mood, anxiety, or develop sui-

cidal ideation.

Counseling

[6]

-Patch should be applied as patient wakes up

each day to avoid sleep disruption

-Applied on clean, dry intact areas of hairless

skin (hip, upper arm or chest)

-Rotate sites (each week) to avoid skin irrita-

tion

1. Wash hands before applying patch

2. Cut open the pouch with scissors along

the side. Select a dry, clean, hairless intact

area of skin

3. Peel one part of the silvery aluminium.

4. Avoid touching the sticky surface of the

patch

5. Apply the sticky part of the patch onto

the skin and peel off the remaining half of

the silvery aluminium backing

6. Press the patch firmly onto the skin with

palm/finger tips

7. Rub finger firmly round the edge to en-

sure that the patch sticks firmly.

8. When the patch is removed, fold patch

and place it in its pouch before discarding

QUIT SMOKING CLINIC

13

VARENICLINE NICOTINE PATCH

Antipsychotic drugs, opioid, antihyper-

tensive, insulin, blood thinning drugs and

theophylline: Increased level or effect of

drug

Cimetidine: Increased level of nicotine

Interaction Antipsychotic drugs, opioid, antihy-

pertensive, insulin, blood thinning

drugs and theophylline: Increased

level or effect of drug

Cimetidine: Increased level of nico-

tine

Pregnancy, kidney disease, history of psy-

chiatric illness, change in mood

Patients with significant kidney disease

(creatinine clearance < 30mL/min) or

who are on dialysis à Reduce dose

Contraindica-

tion/ Precau-

tion

Cardiac problems such as immedi-

ate (within 2 weeks) post myocardi-

al infarction period

Arrhythmias,

Unstable angina pectoris

Pregnancy

RM 95 for each starter and maintenance

pack

(2 weeks supply for each box)

Price RM 47.50 / box

(1 week supply for each box)

QUIT SMOKING CLINIC

References:

1. Davis AL, Faust R, Ordentlich M. Selfhelp smoking cessation and maint enance programs: a comparative study

with 12 month follow up by the American Lung Association. Am J Public Health 1984;74(11):12127.

2. Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence.Clinical Practice Guideline. Rockville,

MD: U.S. Department of Health and Human Services. Public Health Service. 2000

3. Zarihah Z. Ministry of Health Malaysia. Malaysian Smoking Cessation Programme & Smoke-Free Air Laws. obacco

Control Unit & FCTC Secretariat Disease Control Division. 2007.

4. Ministry of Health Malaysia, Clinical Practice Guidelines on treatment of tobacco use and dependance.2003.

5. Mullen KA, Manuel DG. Canadian study shows effectiveness of hospital-initiated smoking cessation programs.

University of Ottawa Heart Institute. 2006.

6. Nicorette Invisi Transdermal Patch Product Insert.Johnson & Johnson Pte. Ltd, 2014.

7. Champix Product Insert. Pfizer Manufacturing Deutschland. Germany. 2016

8. Bahagian Perkhidmatan Farmasi Kementerian Kesihatan Malaysia.Garis Panduan Program Farmakoterapi Ber-

henti Merokok. Edisi Pertama. 2012.

14

by Khairunnisa Zuradi

DRUG COMPARISON

Vitamin B Complex Neurobion Mecobalamin

Indication [1] As a dietary supplement

For deficiency or raised re-

quirement of Vitamin B1, B6,

B12

- Peripheral neuropathies

- Megaloblastic anaemia

due to vitamin B12 defi-

ciency. [2]

Prescriber

Category [1]

C+

B

B

Price [1] RM0.004/ tablet

RM0.05/tablet

RM0.06/tablet

Contents [2] Thiamine: 1.0mg

(Vitamin B1)

Riboflavin: 1.5mg

(Vitamin B2)

Nicotinamide: 10.0mg

(Vitamin B3)

Thiamine : 100mg

(Vitamin B1)

Pyridoxine: 200mg

(Vitamin B6)

Cyanocobalamin: 200mcg

(Inactive form of Vitamin

B12) [3]

Mecobalamin: 500mcg

(Active form of Vitamin

B12) [3]

Dosage *1+ 1-2 tablets daily 1 - 3 tablets 3 times daily 1 tablet 3 times daily.

To be adjusted according

to patient’s age and se-

verity of symptoms

VITAMIN B, NEUROBION AND

MECOBALMIN IN NERVE REGENERATION

By : Wa Yin Pin

15

Vitamin B Complex Neurobion Mecobalamin

Administration *2+ To be taken after meal. To be taken after meal.

Swallow whole. Avoid

chewing.

To be taken after meal.

Mechanism of

Action *2+

Essential for carbohy-

drate and lipid metabo-

lism, cell respiration and

RBC integrity.

Thiamine:

For carbohydrate metabo-

lism.

Pyridoxine:

For protein, carbohydrate

and lipid metabolism.

Cyanocobalamin:

For production of RBC.

-Repairs damaged nerve

tissue

- Involves in erythroblast

maturation, promotion of

erythroblast division and

heme synthesis.

Common Side

effects *2+

Skin rashes in allergic

persons.

Do not cause any side

effects if taken accordingly

to the recommended dos-

age.

Infrequent: GI symptoms

e.g. anorexia, nausea, diar-

rhoea

Rare: Skin rashes

DRUG COMPARISON

Efficacy in Nerve Regeneration

Vitamin B12 is the most essential nutrient for the nervous system. Deficiency of this vitamin can lead to

peripheral neuropathy. People who get too little vitamin B12 can exhibit weakness, twitching, pain, numb-

ness, tingling, muscle cramps and burning sensation. *4+ One study even found that mecobalamin was more

effective than nortriptyline, an antidepressant commonly used to treat diabetic neuropathic pain (Talaei

2009). *5+

Since Mecobalamin contains the most abundant amount of vitamin B12, it is expected to be the most

effective drug for nerve regeneration compared to Neurobion and Vitamin B complex.

References

1. Bahagian Perkhidmatan Farmasi: Formulari Ubat Kementerian Kesihatan Malaysia

Bil.1.2016. Available at: http://www.pharmacy.gov.my/v2/sites/default/files/document-

upload/fukkm-web-116.pdf

2. Product Leaflets: Vitamin B Complex Tablet, Vitbion Forte ® Tablet, Mecovit® Tablet

3. Central Drugs Compounding Pharmacy: Brief Comparison of the Three Formulations of

Vitamin B12. Available at: http://centraldrugsrx.com/doctorblog/comments/brief-

comparison-of-the-three-formulations-of-vitamin-b12

4. Livestrong.com: Vitamins that Helps Nerves. Last updated 27 August 2013. Available at:

http://www.livestrong.com/article/30301-vitamins-nerves/

5. Life extension: DiabeticNeuropathy Targeted Natural Interventions. Available at: http://

www.lifeextension.com/protocols/neurological/neuropathy/page-08

Efficacy in Nerve Regeneration

1) Mecobalamin

2) Neurobion Reduced

3) B complex efficacy

16

MTAC RESPIRATORY

INTRODUCTION

Glucagon-like peptide (GLP)-1 agonist is one of the newer classes of medications for use in type

2 diabetes. Exenatide, a GLP-1 agonist, is available in two forms which are immediate release

(BYETTA) and extended release (BYDUREON) formulations.

WHAT IS BYDUREON?

BYDUREON is a new extended release formulation of exenatide and can be given once weekly

subcutaneously at any time of a day with or without meals. It can be used in combination with

metformin, sulfonylureas, or thiazolidinediones.

STUDIES DONE

In compare to twice daily dosing BYETTA, BYDUREON reduces glycosylated hemoglobin by

1.6%, with fewer gastrointestinal side effects, give a significant advantage in reduction of A1c and

fasting blood sugar, and with comparable weight loss of between 4– 4.5 kg. Progressive weight

loss is seen because of its effect on satiety and delay in gastric emptying.

In 3 years clinical trial, once-weekly BYDUREON showed advantage over once daily GLARGINE

insulin in term of reduction in HbA1c and hypoglycemia event. The proportion of patients who

reported serious adverse events in BYDUREON group was the same as that in GLARGINE

group. However, transient gastrointestinal adverse events were reported more frequently in pa-

tient receiving BYDUREON than glargine.

DOSAGE REGIMEN

Recommended dose for BYDUREON is 2mg weekly.

BYDUREON By : Nabilah binti Mohamad

BYDUREON

17

MTAC RESPIRATORY

MECHANISM OF ACTION

Exenatide is a GLP-1 receptor agonist that enhances glucose-dependent insulin secretion by the

pancreatic beta-cell, suppresses inappropriately elevated glucagon secretion, and slows gastric

emptying. BYDUREON is utilizing biodegradable microsphere technology for once-weekly dosing.

nausea (16.9%)

diarrhea (12.7%)

headache (8.0%)

vomiting (6.8%)

constipation (5.9%)

injection-site pruritus (5.9%)

injection-site nodule (5.3%)

dyspepsia (5.1%)

PRECAUTION

Exenatide should not be used in patients with severe gastrointestinal disease (e.g. diabetic gas-

troparesis) and previous medullary thyroid cancer (MTC) or family history of MTC or multi-

ple endocrine neoplasia 2A or 2B, type 1 diabetes mellitus, in a state of diabetic ketoacidosis

and in severe kidney disease or dialysis.

Exenatide has been associated with acute pancreatitis based on post marketing data, careful

observation after initiation required.

ADVERSE EFFECTS

MTAC RESPIRATORY BYDUREON

18

MTAC RESPIRATORY

INJECTION TECHNIQUE

It can be administered in the abdomen, thigh, or upper arm on a rotating basis.

AVAILABILITY

The Drug Control Authority of Malaysia has approved Bydureon 2mg powder formulation for

local use. Bydureon is manufactured by AstraZeneca. It has been in use for many years in

Europe and the United States.

REFERENCES

1. Diamant M, Van Gaal L, Guerci B, et al. Exenatide once weekly versus insulin glargine for type 2 diabetes (DURATION-3): 3-year results

of an open-label randomised trial. Lancet Diabetes Endocrinol. 2014;2(6):464-473.

2. Data on file, AstraZeneca Pharmaceuticals, LP, 3024913.

3. Data on file, AstraZeneca Pharmaceuticals LP, 3070101.

4. Henry RR, Klein EJ, Malloy J, et al. DURATION-1 extension: efficacy and tolerability of exenatide once weekly (QW) over 6 years in

patients with T2DM. Abstract presented at: 74th Scientific Sessions of the American Diabetes Association; June 13-17, 2014; San Fran-

cisco, CA. 964-P.

5. MIMS (27 March 2016) .New once-a-week diabetes drug Bydureon (exenatide) approved In Malaysia. Retrieved on 24 May 2016 from

http://today.mims.com/malaysia/topic/new-once-a-week-diabetes-drug-bydureon--exenatide--approved-in-malaysia

6. Nathan AP, Candis MM, Renu FS & Sarah EM. An Evidence-Based and Practical Approach to Using Bydureon™ in Patients With Type 2

Diabetes. .Journal of the American Board of Family Medicine(2013); 26(2): 203-210

7. MOH (2015). Clinical Practice Guideline on Management of Type 2 Diabetes Melitus 5th Edition.

MTAC RESPIRATORY BYDUREON

19

Golongan Sasaran: Pesakit di Klinik Kesihatan Cheng

Lokasi: Ruang Legar Klinik Kesihatan Cheng. Tarikh: 25 Januari 2016.

Golongan Sasaran: Pelajar (13-17 tahun).

Lokasi:Sekolah Menengah Kebangsaan Bukit Baru. Tarikh: 29 Februari 2016.

Golongan Sasaran: Orang Awam.

Lokasi: Persatuan Kecergasan Melaka dan Sahabat Farmasi di Kompleks Belia dan

Sukan Ayer Keroh.

Tarikh: 27 Mac 2016.

Golongan Sasaran: Orang Awam.

Lokasi: Karnival Jom Ler.. Kenali Ubat Anda. Tarikh: 7 Mei 2016.

MTAC RESPIRATORY QUMC

QUALITY USE OF MEDICINES

BY CONSUMERS (QUMC)

The objective of this campaign is to: 1. increase consumer awareness of the rational use of medicines

2. provide consumers with information on different issues related to health and medicine

3. ensure that consumers know their medicine, what they should and should not be taken, and why

4. increased adverse drug reporting through patient education

5. improve knowledge in the use of medicine by pregnant women, nursing mothers and children

6. assist senior citizens in the use of medicine

QUMC PROGRAM DONE BY PKDMT

IN 2016

By : Fauziah binti Taib

20

Stevia—A Healthy

Alternative Sweetener?

By : Wong Yen Ni Stevia leaves, also known as ‘‘the sweet herb of Paraguay’’

What is Stevia?

Stevia (stevia rebaudiana) is a natural sweetener plant that belongs to the Asteraceae family. This

perennial plant is native to Paraguay and Brazil1. Stevia is estimated to be 300 times sweeter than cane sugar1. This calorie-free plant has been used for centuries by Guarani Indians as sweetener in green teas and beverages1,2,3. Previous studies have revealed that artificial sugar substitutes such as saccharin, sucralose and aspartame might contribute to brain tumours in long-term use4. In 1970’s, stevia was used in large amount as sweeteners in Japan to replace saccharin1. Today, Stevia is being cultivated in many countries including Japan, Taiwan, Philippines, Hawaii, Malaysia and South Amer-ica for food and pharmaceutical products1.

STEVIA

21

Side Effects of Stevia?

No major adverse effect was reported by consuming

Stevia. Some people who are already allergic to com-

mon allergens such as chrysanthemums, marigolds

and ragweed may develop shortness of breath, hives,

wheezing and difficulty in swallowing after consuming

Stevia7. It has also been reported that the stevioside in

Stevia may cause nausea, bloating and stomach up-

set7. Besides, patients with hypertension and diabetes

are encouraged to monitor their blood pressure and

blood glucose regularly because some studies have

shown that Stevia can act as both anti-hypertensive

and anti-diabetic agent7. The safety of Stevia in preg-

nancy and breastfeeding has not been fully estab-

lished7.

How Does Stevia Work?

Sweetness is sensed when our taste buds react to the

glucose in glycoside2. The two main steviol glycosides

of Stevia plant are stevioside and rebaudioside A2.

Study has shown that both stevioside and rebaudi-

oside A were hydrolysed into steviol and glucose in

the gut5. Steviol was absorbed and conjugated to glu-

curonide before excreted through urine and faeces5.

The glucose released was used by the bacteria in the

colon and not absorbed into bloodstream5. Hence it is

said that the intake of Stevia does not increase blood

glucose level but exerts anti-hyperglycaemic effect by

improving insulin sensitivity and enhancing insulin

production2. Physiological and Pharmacological exper-

iments have also suggested that Stevioside is a sys-

temic vasodilator hence can reduce blood pressure6.

Other potential roles of Stevia include anti-oxidation,

anti-inflammatory, anticancer, antimicrobial and anti-

diarrheal therapeutics1,2.

STEVIA

22

Is Stevia Safe?

In 1991, Stevia was banned in the U.S because it

was thought to be carcinogenic but this was refut-

ed by a follow-up study and in 1995, the Food and

Drug Administration (FDA) finally allowed Stevia to

be imported and sold as food supplement, but not

as sweetener8. However FDA has not permitted the

use of whole-leaf stevia or crude stevia extracts for

use as a food additive9. In December 2008, FDA has

categorised Stevia ‘‘Generally Recognized as

Safe’’ (GRAS). The initial concerns that Stevia may

affect fertility have been put into rest after a few

good studies showed no negative outcomes. In Ma-

laysia, Stevia extract does not need KKM approval

because it falls in the Malaysian Food Act. To date,

more than 40,000 clinical studies have been con-

ducted on Stevia and it is considerably safe when

consumed in reasonable amount. However, further

studies on Stevia use and effects should be carried

out to investigate its long-term effect on human.

References

1. B. Ahmed Hossain, R. Islam, A. Kumar Saha, A. Mandal. (2011): A review on natural sweetener plant – stevia having medicinal and commercial importance. ISSN

0002- 1954: 75-91.

2. R. Gupta, V. Yadav, M. Rastogi. (2014). A Review On Importance of Natoral Sweetener, A Zero Calorie Plant – Stevia- Having Medicinal and Commercial Im-

portance. International Journal of Food And Nutritional Sciences: Vol 3 (Issue 3). Retrieved from http://www.ijfans.com/Volume_3_Issue_3_April_June_2014.html

3. Vanek, T., Nepovim, A., Valicek, P. (2001): Determination of Stevioside in plant material and fruit teas. J, food. Comp. anal. 14: 383-388.

4. Fowler SP, Williams K, Resendez RG, Hunt KJ, Hazuda HP, Stern MP (2008): Fueling the obesity epidemic? Artificaially sweetened beverage use and long term

weight gain. Obesity (Silver Spring) 16 (8): 1894-900.

5. Gardana C, Simonetti P, Canzi E, Zanchi R, Pietta P. (2003): Metabolism of stevioside and rebaudioside A from stevia rebaudiana by human microflora. J Agr Food

Chem. 51: 6618-6622

Diagrams adapted from: http://www.examiner.com/article/infographic-comparing-stevia-and-aspartame-sweeteners

STEVIA