january 2018 page s disease -...

BU

LE

TIN

VOLUME 1/2018

JANUARY 2018

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: [email protected]

IN THIS ISSUE ULCERATIVE COLITIS VS CROHN’S DISEASE

MANAGEMENT OF GOUT

MANAGEMENT OF SNAKEBITES

SUPPLEMENTATION IN PREGNANCY

PAGE 2 - 3

PAGE 4 - 5

PAGE 6 - 7

PAGE 8 - 9

MAJLIS PENGHARGAAN DR. SITI NORLINA BT MD SAID

PAGE 10

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

By: Pan Xue Hua

CROHN’S DISEASE (CD) ULCERATIVE COLITIS (UC)

DEFINITION

BY Centers for Disease Control and Prevention (2017)

Inflammatory Bowel Disease (IBD) is a broad

term that describes conditions characterized

by chronic inflammation of the gastrointestinal

tract.

Two most common inflammatory bowel

diseases are UC and CD. Both illnesses involve

an abnormal response to the body’s immune

system.

Inflammatory Bowel Disease

ANATOMY FEATURES & COMMON CLINICAL FEATURES

Ulcerative Colitis (UC) Crohn’s Disease (CD)

• Confined to colon,

may involve entire

colon

• Only involve inflamma-

tion of 2 layers

(mucosa & submuco-

sa)

• Manifested as

continuous

inflammation

• May involve entire GI

tract

• Transmural involve-

ment (4 layers)

• Manifested as

discontinuous

inflammation (skipped

lesions)

• Gross rectal bleeding

• Crypt abscesses

• Toxic megacolon

• Tenesmus

• Fissuring with sinus

formation

• Non caseating

granulomas

• Strictures

• Fistulae

• Abdominal mass

UC can be classified by severity (mild, moderate or

severe) and site of inflammation (proctitis,

proctosigmoiditis, left-sided colitis, extensive colitis or

pancolitis).

CD can be classified by severity (mild to moderate,

moderate to severe or severe fulminant) and site of

inflammation ( ileocecal, colonic or fistulizing).

TREATMENT

Goals of Therapy:

1) Complete relief from symptoms (induction &

maintenance of remission)

2) Improve quality of life

3) Maintain adequate nutritional status

4) Relieve intestinal inflammation, dysfunction

and the development of cancer

5) Reduce the need for surgery or chronic use of

corticosteroid

Induction

-Control symptoms

Maintenance

-Prevent recurrence

TREATMENTS OF ULCERATIVE COLITIS

TYPE OF UC INDUCTION MAINTENANCE REFRACTORY

Proctitis Topical 5-ASA (enema)

4g at bedtime, retained

overnight (8 hours)

Topical 5-ASA (enema)

2g at bedtime daily or 4g at

bedtime every 2 to 3 days

Oral 5-ASA

0.5-1 g 4x/ d

Mild to moderate

distal UC

5-ASA Oral: 4g at bedtime, retained overnight

(8 hours) or enema 0.5-1 g 4x/ d

Treat as mild to moderate pancolitis

Mild to moderate

Pancolitis

Oral 5-ASA

0.5-1 g 4x/ d

Corticosteroids if 5-ASA

ineffective prednisolone

40mg/day

Oral 5-ASA

0.5g to 1 g 4x daily

Azathioprine 1.5-2.5mg/kg/

day or Mercaptopurine

1-1.5mg/kg/day

if 5-ASA ineffective

Anti-TNF

Adalimumab: initially 160mg on day 1, 80mg on

day 15 , 40mg every other week begin from day 29.

Ustekinumab: single dose of 6mg/kg in week 0,

repeat if patient not response in week 8 and 16 . If

remission achieve in week 8 or 16, go to mainte-

nance SC 90mg every 8-12 weeks.

or Surgery

Severe pancolitis IV Corticosteroids

hydrocortisone 400 mg/

day or methylpredniso-

lone 60 mg/day

*5-ASA refer to sulfasalazine and mesalazine. Study shows no significant difference in efficacy for both drugs.

REFERENCES:

1. Guidelines for the management of inflammatory bowel

disease in adults, 2011

2. Drug information handbook 24th edition

3. Applied Therapeutics: The Clinical Use of Drugs 10th edi-

tion.

4. A Study to Evaluate the Safety and Efficacy of Usteki-

numab Induction and Maintenance Therapy in Participants

With Moderately to Severely Active Ulcerative Colitis (UNIFI)

5. Simon, E. G., Ghosh, S., Iacucci, M., & Moran, G. W. (2016).

Ustekinumab for the treatment of Crohn’s disease: can it

find its niche? Therapeutic Advances in Gastroenterology,

9, 26–36. doi:10.1177/1756283X15618130


TREATMENT OF CROHN’S DISEASE

TYPE OF

CD INDUCTION

INDUCTION

MODALITIES MAINTENANCE

Ileocecal Oral corticosteroids if

mild to moderate,

Systemic steroid if

severe

Remission achieved?

If yes, go to maintenance

If NO, add Mercaptopurine

or Azathioprine

+/- Anti-TNF (Adalimumab

or Ustekinumab)

Corticosteroids Taper corticosteroids.

Start Mercaptopurine or Azathioprine

if moderate or severe symptoms or

relapse. Methotrexate as alternative.

Colonic 5-ASA if mild other-

wise systemic

corticosteroids

Mercaptopurine

or Azathioprine

Continue Mercaptopurine or Azathi-

oprine. Methotrexate as alternative

Fistulizing Mercaptopurine

or Azathioprine

or Anti-TNF

(Adalimumab)*

Fistula closure?

If yes, continue

Mercaptopurine

or Azathioprine

or Anti-TNF (Adalimumab or

Ustekinumab)

If NO, consider surgery

Anti-TNF

(Adalimumab or

Ustekinumab)

Continue Anti-TNF (Adalimumab or

Ustekinumab)

DOSE:

5-ASA:1g 4x /day, Oral corticosteroid: prednisolone 40mg/day, systemic corticosteroids: hydrocortisone 400 mg/day or

methylprednisolone 60 mg/day, Mercaptopurine: 1-1.5mg/kg/day, Azathioprine: 2-3mg/kg/day, Methotrexate: induction

SC 25mg once weekly (max:25mg), Adalimumab: induction 160mg on day 1 then 80mg on day 15 then maintenance

40mg every other week beginning day 29, Ustekinumab: induction SC 90mg at weeks 0, 1, 2 and 3, or IV 4.5 mg/kg at

week 0, repeat same regime from weeks 8 if no response. If remission achieved, go to maintenance SC 90mg every 8-12

weeks5.

*Only adalimumab can be used in fistulizing CD1.

COMPARISON BETWEEN TREATMENTS UC & CD

UC CD

Induction

• Proctitis & distal colon

(enema)

• Cyclosporine/ anti-TNF

are reserved for severe

UC refractory to other

agents

Induction

• 5-ASA only for mild

colonic CD

• Methotrexate is ineffec-

tive to induction and

maintenance of UC but

reserved for CD intoler-

ant to Azathioprine and

Mercaptopurine

Maintenance

• Continue same drug given in induction of remission

• Corticosteroid not used in maintenance (taper down

and start 6MP/AZA if 5-ASA is ineffective)

Relapse

• Relatively higher

• Disease flare if they stop

smoking (for those who

are smokers).

• Increased intake of red

meat and alcohol may

be associated with an

increased relapse rate

in UC.

• Patient who had

appendectomy will

have fewer relapses.

Relapse

• Relatively lower

• Smoke have a worse

disease course, and are

more likely to relapse

after medically and

surgically induced

remission.

Other adjunctive treatments may needed:

Antibiotics (Metronidazole)

Total parenteral nutrition therapy

Supportive therapy (antidiarrheal, hydration, pain

relief, vitamin supplementation)3

ISSUES Possible delay of growth and puberty in children

and young people. Monitor the height and body

weight of children and young people against

expected values on percentile charts.

Fertility, pregnancy and breastfeeding concern:

Vaccination in IBD patient treated with immuno-

modulators and biologic drugs. Those drugs may

lead to infectious complication but preventable

with immunization. Live virus vaccinations should be

avoided.

• Sulfasalazine may cause male infertility.

• Sulfasalazine, mercaptopurine, azathioprine,

adalimumab and ustekinumab are safe for

pregnant woman

• Methotrexate is CONTRAINDICATED in breast-

feeding mothers.

References

1. Janssens HJ et al. Use of oral prednisolone or naproxen for the treatment of gout arthritis: a double-blind, randomised equivalence trial. - PubMed - NCBI [Internet]. Ncbi.nlm.nih.gov. 2017 [cited 1 November 2017]. Available from: https://www.ncbi.nlm.nih.gov/pubmed?term=18514729

2. Prevention of recurrent gout: Pharmacologic urate-lowering therapy and treatment of tophi [Internet]. Uptodate.com. 2017 [cited 5 November 2017]. Avail-able from: www.uptodate.com/contents/prevention-of-recurrent-gout-pharmacologic-urate-lowering-therapy-and-treatment-of-tophi?source=history_widget

3. Clinical manifestations and diagnosis of gout [Internet]. Uptodate.com. 2017 [cited 5 November 2017]. Available from: https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-gout?source=search_result&search=gout&selectedTitle=2~150#H4

4. Clinical Practice Guidelines Malaysia. Management of Gout. 2008.

T R E A T M E N T F O R A C U T E G O U T

GLUCOCORTICOID

(Oral/ Intraarticular/ IM/ IV)

• Highly effective & rapidly acting.

• Route of administration depends on the number of involved joints, patient prefer-ence & clinician.

• [Oral] Tab. Prednisolone 30-40mg OD until flare resolution begins, then taper the dose over 7-10 days. If patient experience re-bound attacks , suggest slower tapering (10-14 days or even 21 days).

• [Intraarticular] Triamcinolone acetonide 40mg/mL with usual dose of 40mg (large joint), 30mg (medium joint), 10mg (small joint).

• [IV/IM] for polyarticular involvement .

IV methylprednisolone sodium succinate 0.5g or 1g administer as IV pulse dosing over ≥30 mins. The regimen may be repeated if no improvement within a week after therapy, with dose of 1g/day for 1-4days, or 1g/month for 6 months.

IM triamcinolone acetonide 40mg/mL with initial dose of 60mg. Adjust within 40-80mg. Repeats once/ twice at interval of ≥48hours if no resolution of flare.

NSAID

• Most effective when initiated ≤48 hours from symptoms onset.

• Potent NSAID such as Tab. Naproxen 550mg BD/ Cap. Indomethacin 50mg TDS are effec-tive and able to relieve pain & reduce in-flammation rapidly.

• Aspirin should not be given due to the para-doxical effect where low dose will cause urate retention and high dose will lead to uricosuria.

COLCHICINE

• In patients intolerant or contraindicated for glucocorticoid & NSAID & for patients who initiate ≤24 hours from symptoms onset .

• Do not initiate as first line if >36 hours from symptoms onset.

• Initial dose of 1mg followed by 0.5mg an hour later (FDA recommendation 2009, findings suggested that prior use of high-dose colchicine may have exposed patients to increased toxicity with no greater efficacy than the low-dose regimen).

M A N A G E M E N T O F G O U T

B Y L O W K A I X I N

I N T R O D U C T I O N

NO single best agent for all patients!

D I F F E R E N T I A L D I A G N O S I S O F G O U T

•↑ Uric acid production (overproduction) •↓ Renal uric acid secretion (underexcretion)

Serum urate level > 6.8mg/dL or >405µmol/L (Hyperuricemia)

Deposition of monosodium urate crystals in synovial fluid & surrounding tissues.

GOUT

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

Differential Diagnosis Gout Osteoarthritis (OA) Rheumatoid Arthritis (RA)

Gender

More common in men than women

Women predomi-nate from age 40-70, after which men & women are equally affected

More common in women than men

Age of onset

Usually develops during middle age in men, after meno-pause in women

Usually old age Any age, but usually be-tween 35-50 years old

Joint sym-metry

Asymmetrical joints are affected initially

Asymmetrical joints are affected initially

Characteristically symmet-rical

Joints com-monly

affected

Big toe (Podagra) Knees, hips, and the small joints of hands

Small joints of hands & feet

Duration of morning stiffness

None Lasts > 30 minutes Lasts > 60 minutes

Associated symptoms

•Possible fever dur-ing an acute attack. •Tophi (urate crys-tals) may form, com-monly on the fingers, hands, feet, or even the organs.

None

•Rheumatoid nodules (hard, firm swellings). •Generalised afternoon fatigue, anorexia, general-ised weakness, and low-grade fever occasionally.

Speed of onset

Sudden onset, often during the night

Gradual onset over the years

Variable onset

P A G E 4

L I F E S T Y L E M O D I F I C A T I O N / R I S K R E D U C T I O N

S E C O N D - L I N E P H A R M A C O T H E R A P Y

F I R S T - L I N E P H A R M A C O T H E R A P Y

Febuxostat is used

only in patients with

high risk of adverse

reaction to

allopurinol/ Not

achieving target uric

acid range with

maximal allopurinol

dose.

P R E V E N T I O N O F R E C U R R E N T G O U T

• Weight Loss (For Overweight individuals)

• Dietary Modification

Caloric restriction but allows ↑ protein (from low-fat dairy products & plant

sources), replace refined with complex carbohydrates, and ↓ saturated fat

↑ Cherries intake (↓ risk of gout)

↑ Intake of vitamin C (↓ serum urate level)

Avoid beverages containing fructose (↑ risk of gout)

Avoid fatty meals/ organ-rich foods/ beer & spirits

• For patients with recurrent gout attacks, concurrent medications need to be screened by health care professionals to suggest for alternative treatment whenever possible.

(Eg: Thiazide diuretics as antihypertensive for patients with recurrent gout can be

Goals

Serum urate <6mg/dL OR <357 µmol/L

Serum urate <5mg/dL OR <298 µmol/L (In patients with tophi)

Uricosuric Agents

Probenecid Benzbromarone Lesinurad

Advantages/ Disad-

vantages

•Multiple drug interactions

•Multiple daily dosing

•Ineffective in patients with CrCl <50mL/min

•Highly effective even as monotherapy

•Daily dosing

•Effective for patients with mild to moderate renal in-sufficiency (CrCl 30-59mL/min)

•Only used in combination with Xanthine Oxidase Inhibitor (XOI)

•Further reduction of serum urate level in combination with XOI

Initiation •250mg BD •25-50mg/day •200mg OD with XOI

Titration

•Dose titration every few weeks to maintenance dose of 500-1000mg BD or TDS

•Max: 3g/day

•25-50mg increments to max of 200mg/ day to achieve desired serum urate level

•Usual dose: 100mg/ day

•N/A

Adverse Effects

•Headache, influenza, increased blood creatinine, and gas-troesophageal reflux disease

•Rash, precipitation of acute gouty arthritis, gastrointestinal intolerance, and uric acid stone for-mation.

Availability

•Available in HSA in tablet form with dose of 500mg

•Registered in Malaysia (Not in FUKKM) as Lanolone (Allopurinol 100mg + Benzbromarone 20mg)

•Not available in Malaysia

Xanthine Oxidase Inhibitor

Allopurinol

Febuxostat (Registered in Malaysia, not in FUKKM)

Initiation

•CrCl> 60mL/min → 100mg OD

•Renal insufficiency → <1.5mg per mL/min of CrCl

•40mg OD •No dose adjustment needed for mild- moderate renal impairment (30-89mL/min)

Titration Increase 100mg at weekly interval until goal range of serum urate achieved (Max: 800mg/day)

Titrate to 80mg OD after 2 weeks if goal serum urate not achieved

Adverse Effects

•Rash Severe cutaneous reactions [Eg: Toxic epi-dermal necrolysis/ Stevens-Johnson syndrome] •Allopurinol hypersensitivity syndrome (AHS) including erythematous rash, fever, hepatitis, eosinophilia & acute renal failure •Gastrointestinal intolerance

•Vasculitis

•Interstitial nephritis

•Liver function test abnormalities

•Nausea •Arthralgia

•Rash

•Thromboembolic cardiovascular events •Increased risk of acute gout attacks

CONTRAINDICATIONS Prior nephrolithiasis (↑ urinary calcium excretion) Patients with cystinuria

INDICATIONS TO INITIATE URATE-LOWERING THERAPY

• Frequent/ disabling attacks of gouty arthritis (≥2 annually)

• Clinical/ radiographic signs of chronic gouty joint disease (gouty arthropathy)

• Tophaceous deposits in soft tissues/ subchondral bone

• Gout with renal insufficiency (CrCl <60 mL/min)

• Recurrent uric acid nephrolithiasis despite treatment with hydration & urinary alkalisation were given

• Urinary uric acid excretion >1100mg/day or >6.5mmol (In men <25 yearsold/ in premenopausal women)

PROPHYLAXIS

Low dose colchicine

•0.5mg OD/ BD (normal renal function)

•0.5mg OD (CrCl= 35-49mL/min)

•0.5mg every 2-3 days (CrCl= 10-34mL/min)

•Avoid in patients undergoing hemodialysis.

Alternative → NSAID

•Naproxen 275mg BD OR

•Indomethacin 25mg BD

The duration of prophylaxis is usually 3-6

months (patients without tophi) to

6months (patients with ≥ 1 tophi)

after achieving target serum uric acid

Acute fall in serum urate often precipi-tates acute gouty arthritis!

When to use febuxostat?


1. Neurotoxic (may

appear as soon as 15-20

minutes)

Snake species: Elapids

Objective signs:

Ptosis

Paralysis of up-

ward gaze

Total external

opthalmoplegia

Inability to open

mouth

Clinical Features

Signs and symptoms as well as severity after a venomous snake bite

depend on the type of snake, amount of venom, number of bites and site of bites. Snake venom acts in three

different ways.

Following a venomous snake bite, some symptoms may occur rapidly while others may occur at a

later stage. Symptoms that occur early:

• Local pain, swelling, discoloration at the bite site (sea snake bites often do not cause reaction

or pain).

• Early generalized symptoms may appear in some cases within 10-15 minutes such as anxiety,

weakness, vomiting, headache, dizziness, sweating, breathing difficulties, confusion, convulsion,

paralysis and death.

Symptoms that occur later (6– 24hours after bite) include:

• Local (around the bite site) : increase swelling, blistering, bleeding in skin and muscle, reduced

circulation to limb with tissue death of skin and muscle.

• General symptoms: dizziness, vomiting, breathing difficulty, fever, shock, bleeding from gums,

blood in stool, urine or vomit and paralysis.

B Y G I S E L L E

L E E X I N Y I

Management of Snakebite Bite by venous snake causes local and/or systemic envenomation that can result in life-threatening medical emergency in Malaysia. From 2001 to 2014, there were 15798 cases of snakebites recorded in Malaysia.

There are more than

140 species of land

snakes found in

Malaysia. Only 17 of

these are poisonous. 2. Hemotoxic

Snake species: Vipers

Haemostatic abnormalities:

Spontaneous systemic

bleeding e.g. at gingiva,

nose, GI tract, skin

and intracranially.

Defibrination which

causes incoagulable

blood/ thrombocyto-

penia ( <100 x 109 /L)

3. Cardiotoxic

Cardiac arrhythmias and

ECG abnormalities

Sn

akes o

f Med

ical Im

po

rta

nce in

Mala

ysia

Elapidae: King Cobra,

Cobra, Kraits, sea

snakes, coral snakes.

Viperae; True viper or Old World Vipers and pit vipers

Natricidae: Most keel-backs do not cause significant harm, ex-cept red-necked keel-back

Biochemical Composition of Snake Venoms

1. Elapid venoms

• Proteins/ peptides of low– moderate MW (<15kDa)

• With one key toxin group (three-finger toxins) which includes neurotoxins and

cytotoxins.

2. Viper venoms

• Proteins with higher MW (>15kDa)

• Mainly enzymes such as procoagulant serine proteases, hemorrhagic metallopro-

teases and cytotoxic L-amino acid oxidases.

Antivenom

• Snake antivenom immunoglob-

ulins are the only

specific treatment for

envenoming by snakebites.

• Give early for best results.

• It can be given as long as signs

of systemic envenomation are

still present.


1. Monovalent/ Mono-specific antivenom

Types of Antivenom

Antivenom Snake Species Dosage Price per

unit/

Treatment

cost per

patient

Indication

1. Neuro-polyvalent snake

Antivenim 10ml

Malayan Krait (Bungatus

candidus) , Banded krait

(Bungarus fasciatus),

King Cobra

(Ophiophagus Hannah)

Initial dose: 50ml of reconstituted

antivenin. Given slowly by IV infu-

sion, ~2ml/min.

Subsequent dose 1-2 hour accord-

ing to clinical symptoms.

RM462.00/

RM2310.00

Neurotoxicity

2. Hemato Polyvalent Snake

antivenim 10ml

Russel’s Viper, Green pit

viper, Malayan pit viper


antivenon. Given by IV infusion,

~2ml/min

Subsequent dose 1-2 hour

RM462.00/

RM1386.00

Hematotoxicity

3. Polyvalent Sea Snake

Antivenom 1000IU/vial

Hydrophis schistosus,

Laticauda colubrina

Initial dose: 1000 IU IV infusion

over ½ to 1 hour.

Severe cases: 3000- 10000 IU

RM13224/

RM13224

Neurotoxicity

Anivenom Snake species Dosage Price per

unit/

Treatment

cost per pa-

tient

Indication

1. Cobra Antivenim

(Purified) 0.6mg/10ml

Monocled Cobra, Naja

kaouthia), Equatorial

spitting cobra (Naja

Sumatran)


antivenin. Given slowly by IV infu-

sion, ~2ml/min.


RM 295.00/

RM1475.00 Neurotoxicity

2. Purified equine immuno-

globulin King Cobra antivenin

0.8mg/10ml

King Cobra

(Ophiophagus Han-

nah)


antivenom. Given by IV infusion,

~2ml/min


RM353.85/

RM1769.25

Neurotoxicity

3. Malayan Pit Viper Antiven-

in (Purified) 0.4mg/10ml

Malayan Pit Viper

(Calloselasma rhodos-

toma)


antivenin. Given by slow IV infusion

~ 2ml/min

Subsequent dose 6 hour

RM389.65/

RM1558.60

Hematotoxicity

4. Green Pit Viper Antivenin

0.7mg/10ml

Green Pit Vi

(Trimeresurus albo-

labris)


antivenin. Given by slow IV infusion

~ 2ml/min

Subsequent dose 6 hour

RM335.61/

RM1006.83

Hematotoxicity

2. Polyvalent antivenom

References: 1. Management of Snakebite. (2017). Ministry of Health Malaysia. 2. Ismail, A.K.,2015. Snakebite and Envenomation Management in Malaysia, Clinical Toxicology in Asia

Pacific and Africa. Springer Netherlands, pp. 71-102.

3. Tan, C.H., Tan, N.H., 2015. Toxinology of Snake Venoms: The Malaysian Context, in: Gopalakrishna-kone, P., Inagaki, H., Mukherjee, A.K., Rahmy, T.R., Vogel, C.-W. (Eds.), Snake Venoms. Springer Nether-lands, pp. 1-37.

Cobra Antivenim (Purified) 0.6mg/10ml

Purified equine immu-noglobulin King Cobra antivenin 0.8mg/10ml

Malayan Pit Viper Antivenin (Purified) 0.4mg/10ml

Neuro-polyvalent snake Antivenim 10ml

Hemato Polyvalent Snake antivenim 10ml

Polyvalent Sea Snake Antivenom 1000IU/vial

Monovalent Antivenim Polyvalent Antivenim

Green Pit Viper Anti-venin 0.7mg/10ml


BY NUR FARAHIM AMIRUDIN

INTRODUCTION

Pregnancy is the period of time when a fetus develops in a women’s uterus and ends with the birth of an infant.

A normal pregnancy lasts about 40 weeks or 280 days where it is divided into 3 trimesters.

The 1st trimester is a time where rapid cell division and organ development happens as well as preparation for the rapid fetal growth that occurs in 2nd and 3rd trimester. Iron and folate are essential nutrients during 1st trimester.

In 2nd and 3rd trimester, energy intake is important since 90% of fetal growth occurs during the last half of gestation. During this phase, iron folate, calcium and omega-3 are especially vital.

• Reduce the risk of neural tube defects.

• As neural tube closes by day 28 of pregnancy, folic acid supplementation after the 1st month of pregnancy will not prevent neural tube defects.

• Recommended daily dose is 400 micrograms.

• Ideally, all women contemplating pregnancy is advisable to receive folic acid prior to conception and throughout pregnancy.

• Women with high risk of having child with neural tube defects is recommended to take higher dose of folic acid 5 milligrams daily 1 month prior to conception and to be continued for at least 12 weeks after conception.

• Essential for transporting oxygenated blood from the lungs to the tissues throughout the body.

• Maternal anaemia has been linked to low birth weight, preterm delivery, perinatal mortality and maternal depression.

• Recommended daily dose is 100 micrograms.

• High dose iron supplements commonly associated with constipation and other GI effects.

According to the WHO survey, 38% of pregnant women in Malaysia have anaemia.

Defined as haemoglobin (Hb) level of <11.0 g/dL in pregnant women in the 1st and 3rd trimester, <10.5 g/dL in the 2nd trimester.

Iron deficiency anaemia (IDA) : presence of anaemia and low serum ferritin level (<12-15 g/L), usually with low serum transferrin saturation (<15-16%).

Moderate anaemia (Hb 7- <9 g/dl)

Ferrous fumarate 400mg daily

Folic acid 5 mg daily

Vitamin B Complex 1 tab daily

Vitamin C 100 mg daily

Preparation Elemental iron (mg/tablet)

Ferrous fumarate (200mg)

60 mg

Iberet 105 mg of ferrous sulphate

Obimin 30 mg of ferrous fumarate

Iron dextran (Cosmofer ®) Iron sucrose (Venofer ®)

100mg iron / 2ml amp 100mg iron / 5ml amp

IV (Injection/Infusion): Generally 100 - 200mg iron up to 3 times a week. For rapid delivery of iron to iron store, may be administered as total dose infusion up to 20mg/kg/day. IM: Up to 200mg iron per injection.

IV Injection: Total IV single dose can not more than 200mg, up to 3 times in a week. IV Infusion: Max single tolerated dose 7mg/kg once a week (max 500mg).

More specific dosing goes by calculation (IRON DEXTRAN ONLY): Total iron deficit (mg) = weight (kg) x (target Hb - actual Hb [g/dl]) x 2.4 + 500mg iron for iron stores

TREATMENT

ANEMIA DURING PREGNANCY

ORAL

PARENTERAL

FACTS


Helps in maintaining strong bones and teeth as it helps the body absorb calcium.

Maternal deficiency puts the baby at risk for growth retardation and skeletal deformities.

Maternal deficiency has been linked to an increased risk of preeclampsia and C-section delivery.

Current recommendation intake from for women at risk of vitamin D deficiency is 10 mcg/daily.

RNI values for pregnant women is 15 mcg/day.

Essential as it is involved in mineralization of bones & teeth, energy and cell production.

Foetal bone and teeth calcification primarily occurs in last trimester of pregnancy.

In calcium deficiency, the body will take calcium from the mother’s bones and transfer the mineral to the baby.

Inadequate intake increases the risk of maternal osteoporosis later in life.

Based from RNI, recommended dose of elemental calcium for pregnant mothers are 1000 mg.

(age 20 - 49 years old).

Preparation Elemental calcium (mg/tablet)

Calcium carbonate

40%

Calcium citrate

21%

Calcium gluconate

9%

Calcium lactate

13%

Vital for early formation and development of brain and nerves of the baby.

An enormous growth spurt in human brain during last trimester of pregnancy, with large increase in the

cerebral content of AA and DHA.

EPA supports the heart, immune system and inflammatory response.

DHA supports the brain, eyes and central nervous system.

Increased intake of EPA and DHA has been shown to prevent preterm labor and delivery, lower the risk of preeclampsia and may increase birth weight.

Recommended daily dosage : 300mg

Only folic acid is recommended to all women: folic acid (400 mcg/day) prior to conception and for the first 12 weeks of pregnancy.

Other micronutrients such as Vitamin D (10 mcg/day), iron (100 mg/day) or calcium (1 g/day) may be targeted prophylactically to at-risk populations.

Others vitamins and micronutrients should only be used where specifically indicated.

Duhig, K., Chappell, L., & Shennan, A. (2010). Recommended micronutrient supplementation in pregnancy. Prescriber, 21(9), 23-29.

Recommended Nutrient Intakes for Malaysia (2017). Recommended Nutrient Intakes for Malaysia.

Perinatal Care Manual. Antenatal Care, Section 2. Division of Family Health Development. Ministry of Health Malaysia, 3rd ed. 2013

WHO. Guideline: Daily iron and folic acid supplementation in pregnant women. Geneva, World Health Organization, 2012.

NICE Guideline: Antenatal care for uncomplicated pregnancies. National Institute for Health and Care Excellence.

http://www.myhealth.gov.my/en/vitamins-health-supplements-pregnant-mothers/

Milman N (2015) Iron Deficiency and Anaemia in Pregnant Women in Malaysia – Still a Significant and Challenging Health Problem. J Preg Child Health 2:168. doi: 10.4172/2376-127X.1000168

Vitamin, Supplements and You : for Pregnant or Breastfeeding Women, and Babies and Young Children. National Health Service, United Kingdom. Retrieved at www.nhs.uk/

REFERENCES

P A G E 9 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

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

MAJLIS PENGHARGAAN

DR. SITI NORLINA BINTI MD SAID Oleh Jaswinder Kaur

Majlis Malam Sekalung Budi Ketua Pegawai Farmasi dan Masquerade Night 2018 Hospital Sultanah Aminah Johor Bahru (HSAJB) anjuran bersama Kelab Sukan dan Kebajikan Perubatan, Kesihatan dan Pergigian Johor Bahru telah diadakan pada 25hb Januari 2018 di KSL Hotel & Resort. Majlis ini merupakan majlis khusus yang diadakan sempena meraikan persaraan Dr. Siti Norlina binti Md Said sebagai Ketua Pegawai Farmasi. Majlis ini telah diadakan bagi mengenang jasa dan keringat yang telah dicurahkan oleh beliau selama berkhidmat di Jabatan Farmasi, HSAJB.

Majlis ini turut sama dihadiri oleh Dr. Aman bin Rabu (Pengarah HSAJB), Pn Sarinah binti Apisah (Timbalan Pengarah Pengurusan) dan Cik Suraya Hanim binti Sith (Penolong Pengarah Kanan). Para Pesara Jabatan Farmasi juga dijemput bagi memeriahkan majlis pada hari tersebut.

Majlis dimulakan dengan bacaan doa bagi memberkati majlis dan diteruskan dengan ucapan oleh tetamu jemputan. Majlis dimeriahkan dengan jamuan makan malam, acara potong kek, dan persembahan oleh Pegawai Farmasi, Pegawai Farmasi Provisional dan Penolong Pegawai Farmasi. Sebanyak 3 sesi cabutan bertuah dan acara permainan ringkas diadakan pada hari tersebut.

Majlis diteruskan dengan ucapan oleh Dr. Siti Norlina binti Md Said. Beliau mengambil kesempatan mengucapkan setinggi-tinggi penghargaan dan terima kasih kepada warga farmasi HSAJB yang selama ini banyak membantu dan memberi kerjasama kepada beliau. Majlis diteruskan dengan acara penyampaian hadiah kepada Dr. Siti Norlina binti Md Said.

Majlis diakhiri dengan penyampaian hadiah kepada pemenang “Best Dress”, sesi cabutan bertuah “Grand Price”dan sesi fotografi berkumpulan. Secara keseluruhan, majlis berjalan dengan lancar sepertimana yang telah dirancangkan.

january 2018 page s disease -...

Documents