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2013 VOl 1 u AVIAN INFLUENZA (H7N9) ............................... 1,2

u RECOMMENDATIONS ON DOSAGE ADJUSTMENT OF ANTI-DIABETIC MEDICATIONS DURING RAMADAN………...3,4,5

u SURVEY ON GENERIC PRESCRIBING AMONG CLINICS IN PKDMT …………...…………...6 Pharmacy Bulletin

Avian influenza (H7N9)

Influenza A(H7N9) is one of a subgroup of influ-enza viruses that normally circulate among birds. Until recently, this virus has not been seen in people. How-ever, human infections have now been detected. 1 On 1st April 2013 , the World Health Organization (WHO) announced that Avian Influenza A(H7N9) virus, a type of flu usually seen in birds, has been iden-tified in a number of people in China, which affected 8 provinces and 2 municipali-ties in China 2

Transmission Both the source of infec-tion and the mode of trans-mission are uncertain. The

Chinese health authorities are still investigating and heightened disease surveil-lance. So far, there is no evi-dence of ongoing human-to-human transmission. 1 But all cases had a history of di-rect exposure to poultry or live poultry markets, which have been contaminated first with the virus. 2,5(such as chickens, ducks, geese, and turkeys). Which, of 77 cases reported nationally, 18 (23%) reported no identified contact with poultry while 56 (72%) reported some re-cent contact with live poul-try and live poultry mar-kets.3

Editorial Board Advisor: Dr. Rusdi Bin Abd. Rahman Editors: Lee Mei Lin, Low Li Ying, Lai Poay Yen, Tan Huey Shyan, Nadiah Mokhtar

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The risk to people posed by the emergence of the H7N9 virus must be considered unusually serious, for several reasons. 3

• Has caused serious disease, including death.

• Does not appear to cause disease in poultry and there-fore could spread silently.

• Has caused more human infections and disease in a shorter period of time than any other known avian in-fluenza virus.

• Some H7N9 viruses show ge-netic changes that suggest they are partially adapted to infect humans more easily than other avian influenza viruses.

These findings suggest that the possibility of this virus becoming transmissible among people is higher than for any other known avian influenza virus and therefore it must not be ignored. 3

Sign and Symptom 1. Influenza-like illness (ILI) –

sudden onset of fever (>38oC) with cough and sore throat

2. Shortness of breath 3. Fatigue 4. Muscle aches 5. Hemoptysis, and Gastrointes-

tina symptoms 4

6. Common laboratory findings included normal white cell count, leukocytopenia, lym-phocytopenia, thrombocyto-penia, and mildly elevated liver enzymes 3

Treatment No vaccine for the prevention of avian influenza A (H7N9) virus infections is currently available. But the virus H7N9 is susceptible to Neuraminidase Inhibitors ( O S E L T A M I V I R & ZANAMIVIR). 3 Now the avail-able treatment is Oseltamivir (Tamiflu) 75mg BD given for 5 days.

Table above showed the cumulative cases of H7N9 reported by WHO. Patients are predominantly older (median 62 years) and male (69%).4 Further information can be found from the website: http://www.who.int/influenza/human_animal_interface/influenza_h7n9/Data_Reports/en/

Month Cumulative data reported by WHO (updated on 30 May 2013) 2

Laboratory Cases Death

February 2 2

March 30 12

April 87 7

May 3 0

Unknown month of onset

10 16

Total 132 37

References: 1. introduction of Avian influenza A (H7N9) virus (Version 1, 2013) available on WHO website: http://www.who.int/influenza/

human_animal_interface/influenza_h7n9/en/ 2. Latest update on H7N9, published on Institute for Medical Research (IMR), Malaysia – H7N9: (as at 31th May 2013, http://www.imr.gov.my/

highlights-featured-articles/1505-h7n9.html 3. China-WHO Joint Mission on Human Infection with Avian Influenza A (H7N9) 18-24 April 2013, published on WHO website: http://

www.who.int/influenza/human_animal_interface/influenza_h7n9/ChinaH7N9JointMissionReport2013.pdf 4. Epidemiological link between exposure to poultry and all influenza A (H7N9) confirmed cases in Huzhou City, China, March to May 2013.

Published on Eurosurveillance, Volume 18, Issue 20, 16 May 2013: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20481 5. Number of confirmed human cases of Avian influenza A (H7N9) reported to WHO. Available on WHO website: (As at 16 May 2013, http://

www.who.int/influenza/human_animal_interface/influenza_h7n9/06_ReportWebH7N9Number.pdf

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Dosage adjustment of insulin during Ramadan Insulin During Ramadan Recombinant Synthetic Human Biphasic Isophane Insulin (Mixtard®)

• Half of the evening dose at suhur • Usual morning dose at iftar E.g.

Morning Evening Suhur Iftar

20U 16U 8U 20U

Recombinant Synthetic Human Neutral Insulin Short Acting (Actrapid®)

• Morning dose reduced by 20% • Omit the 2nd / lunch dose E.g.

Morning Lunch Evening Suhur Iftar

10U 10U 10U 8U 10U

Recombinant Synthetic Human Intermediate Act-ing Insulin (Insulatard®)

• No dosage adjustment needed

References: 1. Hui E, Bravis V, Hassanein M, et al. 2010. Management of people with diabetes wanting to fast during Ramadan.BMJ

2010;340:c3053 doi: 10.1136/bmj.c3053 2. Maklumat untuk Penghidap Diabetes: Pengurusan Diabetes Ketika Berpuasa, Novocare leaflet. 3. Panduan Pertukaran Dos Ubat Diabetes Mellitus Semasa Bulan Ramadhan, terbitan Unit Kawalan Penyakit Tidak Berjangkit, Jabatan

Kesihatan Negeri Melaka, 2012.

Reference: www.glasbergen.com Reference: vrworlds.blogspot.com

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Recommendations on dosage adjustment of anti-diabetic medications during Ramadan

Reference: Panduan Pertukaran Dos Ubat Diabetes Mellitus Semasa Bulan Ramadhan, terbitan Unit Kawalan Penyakit Tidak Berjangkit, Jabatan Kesihatan Negeri Melaka, 2012.

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Survey on generic prescribing among clinics in PKDMT

NEWLY APPROVED

DRUGS: Formulary

PKDMT 2013

1. C a p . C ep ha l ex i n 500mg

2. Syrup Erythromycin 400mg/5ml

3. Telmisartan 80mg + Amlodipine 5mg (Twynsta® 80mg/5mg)

4. Telmisartan 80mg + Amlodipine 10mg (Twynsta® 80mg/10mg)

5. Tretinoin Cream 0.05% 6. Tretinoin Cream 0.1% 7. Supp. Paracetamol

250mg 8. Perindopril 4mg + In-

dapamide 1.25mg (Coversyl Plus® 4mg/1.25mg)

9. Levonogestrel 100mcg + Ethinylestradiol 20mcg (Loette® 100mcg/20mcg)

A survey involving prescribers in PKDMT was carried out from 22nd-26th Apr 2013 in all clinics, including UTC (Urban Transformation Centre) and 1Malaysia Clinics. The results are depicted in the graphs.

10507

8624

5516

5660

4073

3193

2039

2154

2388

1785

3917

664

216

774

5607

4087

3712

4107

2357

1825

1322

676

964

1054

2682

99

184

62

4900

4537

1804

1553

1716

1368

717

1478

1424

731

1235

565

32

712

0 2000 4000 6000 8000 10000 12000

PERINGGIT

AYER KEROH

TENGKERA

UJONG PASIR

AYER MOLEK

TENGKERA

JALAN GEREJA

BUKIT RAMBAI

KLEBANG

SUNGAI UDANG

CHENG

UTC

K1M BUKIT KATIL

K1M BATU BERENDAM

Non-genericGeneric

53.36

47.39

67.30

72.56

57.87

57.16

64.84

31.38

40.37

59.05

68.47

14.91

85.19

8.01

46.64

52.61

32.70

27.44

42.13

42.84

35.16

68.62

59.63

40.95

31.53

85.09

14.81

91.99

0.00 20.00 40.00 60.00 80.00 100.00

PERINGGIT

AYER KEROH

TENGKERA

UJONG PASIR

AYER MOLEK

TENGKERA

JALAN GEREJA

BUKIT RAMBAI

KLEBANG

SUNGAI UDANG

CHENG

UTC

K1M BUKIT KATIL

K1M BATU BERENDAM

Generic Name Prescribing at Clinics PKDMT 2013

Percentage of medications prescribed in generic name

Percentage of medications not prescribed in generic name