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.