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TECHNICAL REPORT SELANGOR STATE HEALTH DEPARTMENT

2011

ISSN 2229-9483

SELANGOR STATE HEALTH DEPARTMENT, MINISTRY OF HEALTH MALAYSIA

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TECHNICAL REPORT

2011

SELANGOR STATE HEALTH DEPARTMENT

MINISTRY OF HEALTH MALAYSIA

Dato' Dr. Hj Azman bin Abu Bakar

Director, Selangor State Health Department

Mdm. Zawiyah binti Mat Johor Deputy State Director of Health (Pharmacy), Selangor State Health Department Datin Ainon Elony binti Othman Deputy Director (Pharmacy Practice and Development Branch), Pharmaceutical Services Division, Selangor State Health Department

Dr. Nor Hayati binti Ibrahim Senior Principal Assistant Director, Medical Division, Selangor State Health Department

Dr. Zaharah binti Zainuddin Senior Principal Assistant Director, Public Health Division, Selangor State Health Department

Dr. Mazlina binti Mat Desa Senior Principal Assistant Director, Oral Health Division, Selangor State Health Department

Mdm. Zaiton binti Shato Pharmacist In-Charge, Petaling District Health Office

Dr. Khairul Rafizah binti Hairodin Principal Assistant Director, Public Health Division, Selangor State Health Department

Mdm. Hazlinda Nazli Binti Naem Principal Assistant Director, Pharmaceutical Services Division, Selangor State Health Department

Ms. Anusuya a/p Krishnarajah Pharmacist, Hospital Tengku Ampuan Rahimah, Klang Mdm. Lee Li Fung Senior Assistant Director, Pharmaceutical Services Division, Selangor State Health Department

Mdm. Chan Lin Yee Senior Assistant Director, Pharmaceutical Services Division, Selangor State Health Department Mdm. Aida Baizura binti Abdul Rahman Assistant Director, Administration Division, Selangor State Health Department

EDITORIAL COMMITTEE

ADVISOR

CHIEF EDITOR

EDITORS

The first Technical Report was prepared by the Selangor State

Health Department in 2009. This year marks the 3rd year of

continuing effort by all the health staff in the various health

departments in the State. A milestone has been marked in our

effort to document research findings and quality studies that are

still being carried out among the various health departments in

the State. This continuum of effort has encouraged more

studies to be conducted, which in turn will improve the quality of

health care services provided to our clients.

A big thank you goes out to all the health staff who has shared

their vision, strategies, project findings, outcome and activities

for the benefit of their colleagues and peers. These studies in

turn have been tirelessly documented for the betterment of the

healthcare services.

Director, Selangor State Health Department, Ministry of Health Malaysia.

laimer:

The views expressed in this Technical Report 2011 are for the information of the staff

of Ministry of Health only, and are not necessarily reflecting those of the

management of the Ministry of Health, unless stated expressly. The Selangor State

Health Department does not warrant or assume any legal liability or responsibility for

the accuracy, completeness or usefulness of any information, apparatus, product or

process disclosed in this report.

The Technical Report 2011 is a publication of the Selangor State Health Department

of the Ministry of Health Malaysia. Enquires are to be directed to the Publisher and

the Publisher reserves copyright on all published materials and such material may

not be reproduced in any form without the written permission of the Publisher.

For internal use only and not to be reproduced or used for any commercial purposes.

DISCLAIMER

FOREWORD

Director,

Selangor State Health

Department,

Ministry of Health Malaysia

PAGE

EDITORIAL COMMITTEE

FOREWORD

1

A PROSPECTIVE STUDY ON THE ADHERENCE OF HUMAN IMMUNODEFICIENCY VIRUS (HIV) TOWARDS HIGHLY ACTIVE ANTIRETROVIRAL THERAPY (HAART) IN HOSPITAL TENGKU AMPUAN RAHIMAH (HTAR) KLANG –A PRE-STUDY Ko Kar-Maine, Mohammad Zaki Yusof, Wong Hon Shen.

1

2 AN AUDIT ON DIABETIC FOOT CARE CAMPAIGN - DOES IT HELP? Norsabrina Sabri, Felix Loong Yew Seng

12

3 AN AUDIT ON REDUCING “AGAINST THE RULE ASTIGMATISM” IN SUPERIOR INCISION PHACOEMULSIFICATION Zalifa Zakiah Asnir, Duratul Ain Hussin, Rusnah Hussain

15

4

COMPARISON OF FONDAPARINUX AND ENOXAPARIN USE FOR

ACUTE CORONARY SYNDROME IN HOSPITAL SUNGAI BULOH

Jonathan James Arulappu, Sia Hee Peng, Pang Chia Wen

19

5 DRUG UTILIZATION REVIEW OF SELECTED PROTON PUMP INHIBITORS (PPIs) IN OUTPATIENT PHARMACY HOSPITAL SUNGAI BULOH Nurhayati Abdul Wahab, Kalaivani A/P Subramaniam, Nurnadia Shazreen Abd Wahab

28

6

EFFECTIVENESS OF POST-OPERATIVE ANALGESICS AFTER SURGICAL REMOVAL OF IMPACTED THIRD MOLAR UNDER LOCAL ANAESTHESIA Dr. J. Sureinthiren A/L Jeya Raman, Dr.Lim Yee Chin, Dr. Mohd. Noor Fareezul bin Noor Shahidan, Dr. Sivakama Sunthari A/P M. Kanagaratnam

37

7

MEDICATION RECONCILIATION IN HEMODIALYSIS UNIT: IDENTIFYING THE TYPES AND FACTORS CONTRIBUTING TO MEDICATION DISCREPANCIES Heryohana Jamaludin, Lee Yoke Ching, Maryam Omar Zaki, Noor Azimah Abdullah, Nurah Zainal Abidin, Ros Aimi Osman, Norkasihan Ibrahim, Shahirah Zainudi

41

8 STATUS KESIHATAN PERIODONTIUM DI KALANGAN PESAKIT DIABETES DI KLINIK DIABETES KLINIK KESIHATAN ANIKA KLANG, SELANGOR Azirah Bt Muhammad

55

9 THE EFFICACY OF PSYCHIATRY MEDICATION ADHERENCE CLINIC (MTAC) AT HOSPITAL TENGKU AMPUAN RAHIMAH (HTAR) KLANG, SELANGOR Khaw P.H., Manimegahlai S., Anusuya K

63

10 THE PRESCRIBING PATTERN OF ANTIHYPERTENSIVES IN PATIENTS WITH CHRONIC RENAL FAILURE. Nur Arina Binti Sariffudin, Tee Xin Yi

76

11 TRAUMA PERGIGIAN KANAK-KANAK DI HOSPITAL SUNGAI BULOH Gunasundari Devi a/p Kumara Rao

89

12 YELLOW FEVER SURVEILLANCE KLIA EXPERIENCE

Azmi AR, Balachandran K., Senthilvasan J., Mohd. Shahir M., Adi Nor Y 97

TABLE OF CONTENT

TABLE OF CONTENT

TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT

1

A Prospective Study On The Adherence Of Human Immunodeficiency Virus (HIV) Patients Towards Highly Active Antiretroviral Therapy (HAART) In Hospital Tengku Ampuan Rahimah, Klang (HTAR) [A Pre-study]

A PROSPECTIVE STUDY ON THE ADHERENCE OF HUMAN IMMUNODEFICIENCY

VIRUS (HIV) PATIENTS TOWARDS HIGHLY ACTIVE ANTIRETROVIRAL THERAPY

(HAART) IN HOSPITAL TENGKU AMPUAN RAHIMAH, KLANG (HTAR) [A PRE-STUDY]

Ko Kar-Maine, Mohammad Zaki bin Yusof, Wong Hon Shen

Department of Pharmacy, Hospital Tengku Ampuan Rahimah, Klang

ABSTRACT

Introduction : Counselling or patient education can provide benefits in terms of patient

compliance and understanding towards a certain disease and its management. In this

prospective pre-baseline study, 31 random patients were interviewed during a 3 month

period at the Retroviral Disease (RVD) clinic Hospital Tengku Ampuan Rahimah (HTAR).

Objective : As the RVD clinic did not have a pharmacist, this study was conducted to

observe the benefits of having a pharmacist in the clinic towards improving the adherence of

the patients to their HAART regime.

Methodology : The data from these patients were compiled and measured and certain

promising data went on to show that patient education was one of the important factors that

played a role towards adherence to HAART.

Results : In general, the patients who were not counselled on HAART before were more

likely to not know much about HIV thus leading to non-compliance which was clearly shown

in the results.

Conclusions : A crosstabulation was done to differentiate whether being counselled on

HAART had significantly contributed to better compliance, and the results proved to show

that counselling done by pharmacists played an important role in patients conformance

towards HAART. However there were a few limitations to the study which included small

sample size and unwillingness of patients to take part in the study.

INTRODUCTION

The HIV/AIDS pandemic has been among the most serious natural disasters in recent

centuries.1,2 Twenty years ago, the subject of HIV, which has been found to be the cause of

AIDS (acquired immunodeficiency syndrome), would not have been the topic of a major and

serious worldwide catastrophe. Over the past 27 years, nearly 25 million people have died

from AIDS1. Malaysia is home to one of the fastest growing AIDS epidemics in the East Asia

and Pacific Region. Between the first detected case in 1986 and 2008, 84,630 men, women

and children have been infected with HIV; while 11,234 have died of AIDS.3 HIV or

AIDS causes debilitating illnesses and leads to premature death in people during their prime

years of life and has devastated families and communities. Through unprecedented global

attention and interventional efforts, the rate of new HIV infections has slowed the prevalence

rates globally. Despite the progress seen in some countries and regions, the total number of

people living with HIV continues to rise. In 2008, globally, about 2 million people died of

AIDS, 33.4 million were living with HIV and 2.7 million people were newly infected with the

virus. 4

In order to address the importance of HIV therapy in HIV patients, a comprehensive measure

is needed that can be used with samples from culturally diverse populations. Therefore, this

paper will assess the patient‟s awareness on knowledge, prejudice, personal risk, and

misconceptions about HIV. This paper aims to enhance the adherence of HIV patient to

treatment by introducing the RVD MTAC. AIDS is a late stage of HIV disease. Medications


2


can help people living with HIV or AIDS live longer, healthier lives.8 To date, HIV patients are

widely treated under HAART, which is a combination of a few antiretroviral drugs.5,8 Some

people have lived for more than 20 years and have taken medicines for more than 10 years.

Specifically, greater adherence is associated with better viral suppression.8,11 Despite good

public healthcare infrastructure and greater availability of antiretroviral drugs in Malaysia

since 2005, the number of HIV-infected patients who have continuously been receiving

treatment remain disproportionately small due to the lack of adherence to the treatment

itself.1,2 This may be due to the lack of awareness on the importance of the treatment.

Recognizing variables associated with adherence is essential in identifying patients at high

risk of being non-adherent in order to develop strategies for improving compliance.

The usual treatment of HIV includes a combination of one Non-nucleoside Reverse

Transcriptase Inhibitor (NNRTI) such as Efavirenz with two Nucleoside Reverse

Transcriptase Inhibitors (NRTI) such as Zidovudine and Lamivudine. This is also known as

the first regimen. Efavirenz plus Indinavir, and Indinavir plus Zidovudine and Lamivudine was

considered as the second regimen if the patient failed or is resistant to the first regimen.

Suppression of plasma HIV-1 RNA to undetectable levels was achieved in patients given

Efavirenz plus Indinavir plus two NRTIs which are 70 percent and 48 percent (P<0.001)

respectively. The efficacy of the regimen of Efavirenz plus Indinavir was similar (53

percent) to that of the regimen of Indinavir, Zidovudine, and Lamivudine. CD4 cell counts

increased significantly with all combinations of antiretroviral (range of increases, 180 to 201

cells per cubic millimeter). 7

Antiretroviral therapy reduces mortality rates in compliant patients infected with HIV by 56

percent in a randomized clinical trial of 642 patients.12 In a 2001 study of 673 mostly poor

patients with HIV in Sao Paolo (Brazil), overall adherence to ARV among participants was

69%.13 Reviews of numerous studies revealed that 95% or greater adherence is necessary in

order to achieve and maintain undetectable viral loads among most patients treated with

highly active antiretroviral therapy (HAART). 11 In the real world of AIDS treatment, only 50%

of patients were positively affected by the HAART treatment. The explanation for this

alarming disparity of results was that "the main reason for these 'failures' was poor

adherence to HAART regimen.6

OBJECTIVES

i) To obtain the baseline knowledge or understanding of the patients regarding HIV and

its treatment (pre counselling study)

ii) To reduce non-compliancy in patients undergoing HAART.

iii) To provide a better understanding of HIV and HIV medications to new patients

starting on HAART.

METHODOLOGY

The study aims to discover the level of understanding and compliance of RVD patients

towards their antiretroviral medications. Previously, there were no pharmacists at the RVD

MTAC in HTAR and this has lead to the possibility of assessing whether the need of a RVD

MTAC pharmacist provides beneficial effects. The ultimate goal of this pre-study is to see

the difference between the patient‟s compliance and the patient‟s level of understanding of

HIV when a pharmacist is involved in the RVD clinic.


3


A questionnaire was constructed by collecting a few sample questions that were used in

other hospitals that had RVD clinics. The questionnaire consists of a few basic questions

regarding HIV and HAART. The questionnaire would consist of 13 questions ranging from

“What is HIV?” to “Reasons for missing/delaying taking off medications?”

Patients were interviewed during the RVD MTAC which was held on every Wednesdays and

Thursdays in HTAR from 2 pm to 5 pm. Patients were asked on their willingness to partake in

the study and their answers were noted in the questionnaire. The duration of the study was

held for 3 months starting from March to June 2010.

The results of the questionnaire were shown by the percentage of the level of understanding

using the SPSS 15.0 for Windows. The demographic data was also correlated with the

results of the questionnaire which would directly or indirectly relate to the understanding and

compliance of the patients towards HAART.

The sample size for this study was 35 patients for both newly diagnosed patients and those

previously on HAART.

Inclusion criteria comprised of:-

i) Patients of different race

a. Malay

b. Chinese

c. Indian

ii) Patients with ages ranging from 20-80 years old

iii) Two different sexes – male and female

iv) Patients confirmed diagnosed with HIV and on HAART

Exclusion criteria

i) Patients who are deaf

ii) Patients who are blind

iii) Patients who were unwilling to participate in this study

The questionnaire would be distributed to the patients to answer by themselves or if patients

are unable to read, the questionnaire would be read to the patients.

RESULTS

The aim of the study was to interview all the patients involved in the HIV clinic but this was

difficult to achieve due to time constraint and unwillingness of patients to cooperate. This

reduced the sample size to 31 patients who were successfully interviewed. There were 19

males and 12 females on HAART and coming from various demographic backgrounds.

Charts 1 to 13 show the frequency of answers from each patient for each question in the

questionnaire.


4


Chart 1: Pie chart showing frequency of patient’s answer to “What is HIV?”

Chart 2: Pie chart showing frequency of answers to question “What is HAART?”

Chart 3: Frequency of answers to question “How long do you need to be on HAART?”

Missing

Virus infection

Infection

AIDS

Weak

antibodies

Disease that

has not

progressed

into AIDS

No immunity

Strong virus in

the body

None curable

illness

Do not know

What is HIV?

Missing

Place for

HIV patients

Do not know

Others

Amtiviral

What is HAART?

Missing

Do not know

Until feeling

well

Life long

How long to take HAART?


5


Chart 4: Frequency of answers to question “How long to take HAART?”

Chart 5: Frequency of answers to question “How long have you been on HAART?”

Chart 6: Frequency of answers to question “Have you been counselled on HAART

before?”

Missing

Do not know

Until feeling

well

Life long

How long to take HAART?

Missing

More than a

year

Less than a

year

How long have you been on HAART?

Missing

No

yes

Counselled on HAART before?


6


Chart 7: Frequency of answers to question “Have you ever missed/delayed taking a

dose?”

Chart 8: Frequency of answers to question “How many times in a month have you

missed/delayed taking a dose?”

Chart 9: Frequency of answers to question “When did you last missed/delayed your

dose?”

Missing

No

Yes

Missed/delayed taking a dose before?

Missing

3-5

1-2

How many times in a month miss/delayed a dose?

Missing

A few

months ago

Last month

Last week

Last 3 days

Yesterday

When did you last miss/delayed a dose?


7


Chart 10: Frequency of answers to question “What are the reasons for

missing/delaying a dose?”

Chart 11: Frequency of answers to question “Do you know about the side effects of

HAART?”

Chart 12: Frequency of answers to question “Where do you store your medication?

Missing

Stomach

ache

Unsuitable

timing

Unwell

Too busy

Forgot

Reasons for missing/delaying a dose?

Missing

Do not know

No

Yes

Do you know about the side effects of HAART?

Missing

Office/house

Cupboard

Floor cabinet

Specific

drawer for

pills

Room

cupboard

Kitchen

Bag

On table

Drawer

Where do you store your medication?


8


Chart 13: Frequency of answers to question “How do you remind yourself to take

medication?”

DISCUSSION

From the results of this study, it was generally seen that the patients who have attended the

RVD clinics were mostly not counselled on HAART before. This led to poorer understanding

of an overview of HIV and HAART as seen from charts 1, 2, 6 and 11. It was shown that the

adherence of patients improved significantly with counselling and adapting HAART regimen

into the lifestyle of the patients.17

Non-adherence to any medical therapy is common and is almost impossible to achieve one

hundred percent compliance in one patient. It is unstable and usually underestimated by

health physicians.14 Many factors come into play towards achieving adherence to therapy.

This is undeniably true in HIV patients taking HAART as non-compliance towards HAART is

common.14,15 Studies have shown that on average 50 – 70% of patients on HAART

regiments are non-adherent to medications.16

Patient education about HAART in the context of an office visit with the physician assistant

and other healthcare providers has become an important component in the design of the

HAART regimen.15

Based on the data analyzed, it was shown that 20% of the respondent knew what HAART

was while 67% of them did not know or had never heard of the word HAART, p = 0.001 from

Pearson Chi-Square (p< 0.0.5 providing significant values). This clearly reflects the lack of

knowledge on the general idea of HIV and its effects. Lack of counselling on the patient‟s

disease and its treatment may be a contributing factor towards non-adherence towards the

patient‟s medications. Patient should be informed and educated on the importance of

understanding their treatment regime as this will increase their adherence and

compliance.5,12 It can be concluded that the importance of counselling RVD MTAC for HIV

patients would hopefully increase patient‟s knowledge and understanding about their own

treatment thus increasing their compliance and reducing the number of missing doses.13

A correlation analysis was also done on patients who have been counselled on HAART

before and their understanding of HAART. The data went on to show that most of the

patients who have been counselled on the RVD treatment knew about the side effects of

their medications. From the survey, 71% of patients who were counselled about HAART

understood its side effects as compared to the 50% who have not had any counselling on

Missing

News

Remember

naturally

Handphone

reminder

Family

members

Alarm clock

How do you remind yourself to take medication?


9


HAART before, p=0.568. This correlates with certain studies showing that by having the

patient educated by healthcare personnels, the overall understanding as such in this case,

the understanding and management of HAART side effects can be thorougly understood by

patient and properly managed.13

Questions 6 and 7 were also extracted for analysis to show the correlation between patients

who were counselled on HAAR on missing/delaying their medications at least once in a

month. The results proved that 19 out of 20 patients who missed their doses are those who

have never been counselled before on HAART. Patients who were counselled on HAART

were found to adhere to their medications. Almost 80% of patient who were not counselled

on HAART often missed their dose, p=0.002. This may be due to the lack of knowledge and

understanding on the importance of taking their medications. According to one study, in the

United States, 50% to 70% of patients do not properly take prescribed medication.5,13 Thus, it

is important to implement proper counselling techniques as this will also help build a trusting

relationship between the patient and healthcare provider. A qualitative study using focus

groups of HIV-positive men and women showed improved adherence when a patient has an

established and trusting relationship with a single healthworker.12 The study also continued to

state that minor increment in adherence of patients led to marked improvement in outcomes.

People from all groups of treated individuals commonly have difficulty maintaining such a

high level of medication adherence. To help patients benefit fully from their treatment,

healthcare providers need to take time to ask about and support medication adherence.12

Our data also went on to show that there were no significant difference correlating and

comparing compliance of older and newer patients against their respective duration of

medication therapy, p=0.135. This could suggest that counselling plays an important role in

differentiating between compliant and non-compliant patients. By providing counselling, the

patient can be educated on the basic knowledge of their illness and treatment. These will

also provide them a general idea on what to expect from their treatment, which consequently

will improved their adherence to the treatment.13 For most patients, near-perfect (>95%)

adherence is necessary to achieve lasting viral suppression.5, 12, 13

This study also analyzed correlation between sex, race, working status, and marital status

against patients missing their HAART doses. All these demographic factors were found to

not have a significant impact on their missing doses with a p-value of 0.179, 0.066, 0.717,

0.676 in the same order.

There were 3 types of education level in the sample size whereby 4 patients reached primary

level, 21 secondary and 6 tertiary levels. Out of these, some patients missed a few doses

and some claimed to have never missed a single dose of their HAART medication. The

result between education level and whether patients missed their doses was calculated and

was shown to not have a significant effect (p = 0.507) This is comparable to a study showing

that having a high school or higher education level is not associated with the decision to start

HAART regimen but depended on the belief of the patient on their health status and ability to

master that regimen as well as clinical status.18 Another study also showed that education

level proved to be not statistically significant when associated with adherence to

antiretrovirals.19


10


Limitations Of The Study

The small sample size could only provide limited statistical data. This limitation could be due

to patients‟ unwillingness to take part in this study and the limited time to collect the data

during HIV clinics as they are held every Wednesday and Thursday afternoon.

CONCLUSION

This sudy has shown,that providing patients with proper education in the form of counselling

would increase the patients adherence and understanding which ultimately leads to a better

treatment outcome.

Therefore, it can be safely presumed that the role of a HIV MTAC pharmacist plays an

important role in increasing the adherence and the basic understanding of what is HIV and

it‟s management in the RVD clinic at HTAR.

REFERENCES

1. Helen O. Komolafe-Opadeji, Promoting Public Awareness of HIV/AIDS in Africa: Follow-

Up to a Pilot Study 2008,Library Philosophy and Practice, July 2008; ISSN 1522-0222.

2. Unicef. AIDS in Malaysia. (online) . 2008. (cited on 2010 May 7). Available from URL :

http://www.unicef.org/malaysia/hiv_aids.html

3. UNAIDS. AIDS Epidemic Update 2009 (online). November 2009. (cited on 2010 May 7).

Available from URL : http://www.avert.org/worldstats.htm

4. The Lancet. Life expectancy of individuals on combination antiretroviral therapy in high-

income countries: a collaborative analysis of 14 cohort studies (online) 2008 July (cited

on 2010 May 7). Available from URL : http://www.natap.org/2010/HIV/011910_01.htm

5. Albert I. Wertheimes, Thomas M. Santella, Medication Compliance Research: Still So Far

to Go (online). 2010 (cited on 2010 May 7). Available from URL :

http://jrnlappliedresearch.com/articles/Vol3Iss3/Wertheimer.htm

6. Schlomo Staszewski, Javier Morales-Ramirez, Karen T. Tashima, Anita Rachlis, Daniel

Skiest, James Stanford and et al. Efavirenz plus Zidovudine and Lamivudine, Efavirenz

plus Indinavir, and Indinavir plus Zidovudine and Lamivudine in the Treatment of HIV-1

Infection in Adults. The New England Journal Of MedicineVolume 341 (issue 25):1865-

1873

7. Pam Belperio, Melinda Neuhauser Treatment_Naive_HIV_10 (online) December 2009

(cited 2010 May) Available from URL : pbm.va.gov/Clinical Guidance/Clinical

Recommendations

8. BERNAMA. Global HIV/AIDS Epidemic Remains Serious (online) 14 march 2010 (cited

2010 May) Available from URL : http://www.crisishome.org/2010/03/global-aids-epidemic-

remains-serious/

9. ACTUP. Experts Warn that HIV Treatment Excludes Drug Users

Even When They Are Vast Majority of Those in Need (online) 2008 (cited 2010 May)

Available from URL : http://www.actupny.org/reports/Bangkok/treatdrugusers.html

10. Rachel Jean-Baptiste. Factors Associated with Adherence to Antiretroviral Therapy in

Rwanda (online) September 2008 (cited 2010 May) Available from URL :

http://pdf.usaid.gov/pdf_docs/PNADN461.pdf

11. Ne ws- Med ic a l .Ne t . Antiretroviral therapy reduces mortality rates in patients co-

infected with HIV and TB (online). February 2010 (cited 2010 may 14). Available from

URL: http://www.news-medical.net/news/20100226/Antiretroviral-therapy-reduces-

mortality-rates-in-patients-co-infected-with-HIV-and-TB.aspx

mailto:[email protected]

http://www.unicef.org/malaysia/hiv_aids.html

http://www.biomedcentral.com/

http://www.natap.org/2010/HIV/011910_01.htm

http://www.crisishome.org/2010/03/global-aids-epidemic-remains-serious/

http://www.actupny.org/reports/Bangkok/treatdrugusers.html

http://pdf.usaid.gov/pdf_docs/PNADN461.pdf

http://www.news-medical.net/news/20100226/Antiretroviral-therapy-reduces-mortality-rates-in-patients-co-infected-with-HIV-and-TB.aspx





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12. Edward L. Machtinger, David R. Bangsberg. Adherence to HIV Antiretroviral Therapy.

HIV InSite Knowledge Base Chapter. May 2005;

13. Paula Toynton. New Jersey Standards of Practice for Community Based HIV Treatment

Adherence (online) 2005 (cited 2010 May 7). Available from URL:

http://ccoe.umdnj.edu/catalog/aids/pdf/AIDSLine4.pdf

14. Sutton EL, Transue ER, Comes S, et al. Placebo HAART Regimen as a Method for

Teaching Medication Adherence Issues to Students. J Gen Intern Med. 2005 June;

Volume 20 (Issue 6): 541–545.

15. M. Day. Patient Adherence To HAART Regimens: Challenges For Physician Assistants

And Health Care Providers . The Internet Journal of Academic Physician Assistants. 2003

Volume 3 Number 1

16. Chesney MA. Factors affecting adherence to antiretroviral therapy. Clin Infect Dis. 2000

Volume 30(Issue 2): S171-S176

17. Knobel H, Carmona A, Lopez JL, et al. Adherence to very active antiretroviral treatment.

impact of individualized assessment [in Spanish] Enferm Infecc Microbiol Clin. 1999

Volume 17: 78–81

18. Schwarz DF, Henry-Reid L, Houser J., et al. The association of perceived health clinical

status, and initiation of HAART (highly active antiretroviral therapy) in adolescents.

Journal of Adolescent Health 2001 Voulme 29 (Issue 3) Supplement 1: 115-122

19. Ogundahunsi O.A, Daniel OJ, Oladapo OT. Adherence to antiretroviral drugs among

AIDS patients in Sagamu, Nigeria. International Journal of Biomedical and Health

Sciences, 2008 Volume 4 (Issue 2): 41-45


12 An Audit On Diabetic Foot Care Campaign – Does It Help?

AN AUDIT ON DIABETIC FOOT CARE CAMPAIGN - DOES IT HELP?

Norsabrina Sabri MD (UPM), Felix Loong Yew Seng MBBS (Malaya),

MS Orthopaedic (UKM)

Department of Orthopaedics, Hospital Ampang, Selangor

ABSTRACT

Introduction : The prevalence of diabetes mellitus in our country is on the rise along with its

complications. Orthopaedic department in Ampang Hospital encounters more and more

diabetic foot cases and some are newly diagnosed case of diabetes. Some patients are

indicated for ray amputation; however some delay their decisions and prolonged hospital

stay. A course regarding management of amputee was organized and wish to improve health

care providers‟ mindset. This is in turn hoped to help in counseling patients they attended

and help patients to make rational decision.

Objective : To determine whether diabetic foot care awareness campaign will help us in

managing diabetic foot ulcer and thereby reducing the cost of management in this group of

patients.

Methodology : Data was gathered from patients presented to us 5 months prior and 5

months after the campaign. The patients whom will respond to ray amputation and IV

antibiotics were selected. The comparison of how many patients agreed for the proposed op

on 1st advice pre and post campaign was made. The cost involved on prolonged hospital stay

has also looked into.

Results : There are 19 patients prior to campaign and 13 patients after the campaign. Pre-

campaign, 10.5% of patients agreed for Ray on 1st advice and 21.1% took almost a day to

decide. Post campaign, 76.9% of patients agreed for op on 1st advice. Average hospital stay

pre-campaign is 10 days while post-campaign is 3.6 days.

Conclusion : Better understanding among health care providers help them to counsel

patients regarding their condition and help patients to make decisions. Earlier surgery leads

to earlier discharge and obviously cutting the cost hospital has to bear.

INTRODUCTION

Diabetes mellitus prevalence rate in Malaysia has risen much faster than expected, almost

doubling the magnitude over the last decade which obviously causing the rise in diabetic

complications [1]. One of the debilitating complication is diabetic foot infection. Foot

infections in persons with diabetes are a common, complex, and costly problem [2-5].

Orthopaedic department in Ampang Hospital particularly, encounters more and more diabetic

foot cases and some are newly diagnosed diabetes mellitus. Some patients require ray

amputation of the toes. Early surgery purportedly leads to early discharge, better wound

outcome and eventually reduces the cost that hospital has to bear. One of the common

problems faced is that some patients delay their decisions which lead to delayed

intervention, more complicated management thus prolonging hospital stay. We have

organized a workshop regarding management of amputee and wish to improve health care

providers‟ mindset in terms of perception towards amputees. We hope that this will in turn

help them to counsel patients they attended and encourage patients to make rational

decision.



METHODOLOGY

Data were gathered from patients presented to us 5 months prior and 5 months after the

campaign. Patients with ulcer Wagner class 3 (deep ulcer with abscess or osteomyelitis)

whom expected to respond to ray amputation and IV antibiotics were chosen. Number of

patients agreed for the proposed op on 1st advice pre and post campaign was compared.

The cost involved on prolonged hospital stay has also looked into.

Inclusion criteria:

• Diabetic patients

• Ulcer: Wagner class 3

• Infection is indicated for Ray amputation

• Stable

• No other illnesses requiring hospitalization

• Fit to give consent, sound mind

Exclusion criteria:

• Unstable, septic patients

• Needs more aggressive surgical procedure than Ray amputation

• Expected for repeated debridements

• Concurrent illness requiring hospitalization

Categories Cost

Simple dressing RM 24.60

IV Unasyn RM 27.00

Food RM22.50(4 meals/day)

Estimated minimum cost per day : RM 74.10 per patient

RESULTS

There are 19 patients prior to campaign and 13 patients after the campaign. Pre-campaign,

an estimated total of RM 4823.70 spent (simple dressing, IV Unasyn and meals) with

average of RM 253.88 per patient. Average length of stay was 10 days. Out of 19 patients,

10.5% of patients agreed for ray amputation on 1st advice (2 patients) and 21.1% took almost

a day to decide whereas the rest (13 patients) delayed their decision for 1-2 days. Post-

campaign, 76.9% of patients (10 patients) agreed for op on 1st advice with average length of

stay is 3.6 days.

Timing of decision making

0

5

10

15

A B C

24

1310

2 1

Precampaign Postcampaign

A: Agree on 1st advise

B: Delay decision by 24 hours C: Delay decision 1-2 days



Average length of stay

DISCUSSION

In this short small-sampled clinical audit, whether organizing awareness campaign will help

in managing diabetic foot ulcer was looked into. The campaign was targeted to the

paramedics whom are the first-liners managing simple wounds in the peripheral settings.

This is in turn hoped to help them in counseling patients who are indicated for early simple

surgery and patient already have better understanding of the surgery itself when they come

to be assessed by the orthopaedic team. The responds were quite good though numbers are

small. Brochures and posters used were found to be helpful in improving patients‟

perspective towards early surgical intervention.

CONCLUSION

Better understanding among health care providers help them to counsel patients regarding

their condition and help patients to make decisions. Earlier surgery leads to earlier discharge

and obviously cutting the cost hospital has to bear. We hope to implement this kind of

workshop as a biannual program and aim to a larger group of healthcare providers as well as

diabetic population themselves.

REFERENCES

1. Zanariah H, Chandran LR , Wan Mohamad WB, Wan Nazaimoon WM, Letchuman GR,

Jamaiyah H, Fatanah I, Nurain MN, Helen Tee GH, Mohd Rodi. NHMS III Diabetes

Study Group, Ministry of Health, Malaysia. Universiti Sains Malaysia, 2006.

2. Lipsky BA. A report from the international consensus on diagnosing and treating the

infected diabetic foot. Diabetes Metab Res Rev 2004; 20(l1):68-77

3. Jeffcoate WJ, Harding KG. Diabetic foot ulcers. Lancet 2003; 361:1545-51

4. Tennvall GR, Apelqvist J, Eneroth M. Costs of deep foot infections in patients with

diabetes mellitus. Pharmacoeconomics 2000; 18:225-38

5. Ramsey SD, Newton K, Blough D, et al. Incidence, outcomes, and cost of foot ulcers in

patients with diabetes. Diabetes Care 1999; 22:382-7

0

2

4

6

8

10

Precampaign Postcampaign

No of days


15 An Audit On Reducing “Against The Rule Astigmatism” In Superior Incision Phacoemulsification

AN AUDIT ON REDUCING “AGAINST THE RULE ASTIGMATISM” IN SUPERIOR

INCISION PHACOEMULSIFICATION

Zalifa Zakiah Asnir MD (UKM),MS Ophthalmology (UKM), Duratul Ain Hussin B. Optom

(UKM), MHsc. Optom (UKM), Rusnah Hussain MD (UKM),MS Ophthalmology (UKM)

Department of Ophthalmology, Hospital Ampang, Selangor

ABSTRACT

Introduction : Significant attention is focused on attaining a good post-operative refractive

outcomes in superior incision phacoemulsification, especially in reducing Against the Rule

(ATR) astigmatism.

Objective : The purpose of this audit is to compare the amount of ATR astigmatism (Diopter

Cylinder) between sutured versus unsutured superior corneal incision phacoemulsification.

Methodology : This audit was conducted between January to December 2009, in Hospital

Ampang, Selangor, based on the patients data of phacoemulsification surgery performed by

one surgeon. Data collections were done in 2 phase. Group one were patients with ATR

astigmatism who underwent sutureless superior corneal incision in the first half of the year

while group two were patients with ATR astigmatism who underwent phacoemulsification

with sutured superior corneal incision during second half of the year. Pre–operative and post-

operative data on amount of astigmatism (DC) were obtained for analysis.

Results : Preoperatively, the mean astigmatism was 1.05 ± 0.51 DC in group one and 1.08

± 0.71 DC in group two. At twelve weeks postoperatively, mean astigmatism for group one

had increased to 2.15 ± 1.32 DC (P= 0.007) but the amount was reduced in group two, 1.00

± 0.58 DC (p= 0.804).

Conclusion : Applying a suture on superior corneal incision wound is a helpful technique to

correct pre-existing ATR astigmatism in superior incision phacoemulsification.

INTRODUCTION

Astigmatism may cause blurred vision, glare sensation, monocular diplopia, asthenopia and

visual aberrations. Regular astigmatism can be divided into With-the-rule (WTR)

astigmatism, Against-the-rule (ATR) astigmatism and the less common Oblique astigmatism

(Benjamin WJ 2006). There are numerous techniques to correct astigmatism at the time of

cataract surgery; the simplest being to place the main corneal incision along the steep

corneal meridian (Gusowski M. et al 2002). Corneal incisions cause flattening of the incised

meridian. In With-the-rule astigmatism, the vertical meridian is steepest (an American

football lying on its side), therefore a superior clear cornea incision is adequate enough to

reduce the astigmatism. Whereas in Against-the-rule astigmatism (an American football

standing on its end), temporal clear cornea incision is necessary.

However, in a clinical setting where temporal incision is not perform due to rectangular

operating theater (OT) table, small OT space, and surgeon preference, superior incision will

still be performed. This will result in further increase in the pre-existing ATR astigmatism

(Morlet M. et al 2001). A clinical audit of our surgical visual outcome in mid 2009 showed

significant amount of ATR astigmatism among our post superior incision phacoemulsification

patients. The effect of this would mean unsatisfactory vision, resulting in potential unsatisfied

patients in Eye Clinic, Hospital Ampang.



Gimbel HV et al (1993) and Bazzazi N. et al (2008) have commented in their study that in

those patients with ATR astigmatism that underwent superior incision phacoemulsification,

suturing the wound significantly reduced the astigmatism. Therefore for the second half of

year 2009, we had sutured all the superior incision wound of patients that have ATR

astigmatism. At the end of the year, our department have done a clinical audit to compare

the astigmatism outcome post superior incision phacoemulsification in patients with ATR

astigmatism who underwent sutureless wound in the 1st half of 2009 compare to those

sutured wound in the 2nd half of 2009.

Currently, those patients with post op significant ATR astigmatism may require spectacles to

obtain better vision. Thus with this audit we hope to reduced the post-operative astigmatism,

therefore improving the unaided visual acuity and reduce the need for corrective glasses post

cataract surgery.

OBJECTIVE

The audit was to compare the amount of ATR astigmatism (Diopter Cylinder) between

sutured versus unsutured group of patients who underwent superior corneal incision

phacoemulsification.

METHODOLOGY

The study comprised of 2 parts :

1. Restrospective clinical audit of astigmatism outcome on all patients with ATR

astigmatism who underwent sutureless superior incision phacoemulsification from

January till June 2009 by a single surgeon.

2. Prospective clinical audit were performed on all patients with ATR astigmatism who

were planned for superior incision phacoemulsification from July till Dec 2009. These

patients were identified preopeperatively. A single suture was put on the superior

phacoemulsification wound upon completion of surgery. Refraction was performed at

3 month post surgery. Results were documented. Analysis made.

Exclusion Criteria

1. History of ocular comorbidity

2. Other Intra-operative complications

3. Post-operative infections

4. Incomplete / missing 12 weeks clinical notes

RESULTS

All data were calculated for descriptive purposes and dependant t-test was performed using

SPSS software version 17.



Demographic No of patients Percentage (%)

Group Sutureless 9 41.0

Suture 13 59.0

Gender Female 15 68.2

Male 7 31.8

Race

Chinese 15 68.2

Malay 4 18.2

Indian 3 13.6

Age (years old)

50-59 2 9.0

60-69 2 9.0

70-79 18 82.0

Pre-operative Astigmatism

Technique N Mean S.D Std. Error Mean

Pre-operative

Astigmatism

Sutureless 9 1.05 0.51 0.17

Suture 13 1.07 0.71 0.19

The mean amount of astigmatism preoperatively for the sutureless group was 1.05 ± 0.51

DC, while for the suture group was 1.08 ± 0.71 DC.

dependent t–test : t = 0.936, p >0.05.

Post-operative astigmatism

Technique N Mean SD Std. Error Mean

Post Operative

Astigmatism

No Suture 9 2.15 1.32 0.44

Suture 13 1.00 0.58 0.16

The mean amount of astigmatism postoperatively for was higher in the sutureless group,

2.15 ± 1.32 DC as compared to the suture group, 1.00 ± 0.58 DC.

dependent t–test : t = 0.011, p < 0.05.



DISCUSSION

In our study, we noted that there is preponderance for female to have ATR astigmatism. The

ratio is 2:1. However, this finding is not similar to a study by Goto T et al (2001) who reported

that male have a higher potential to develop ATR astigmatism.

More than 50% of the study populations were Chinese. Malays and Indians were similar in

percentage. This reflects the local population in the community that Hospital Ampang serves.

We observed that the higher age group has more tendencies to have ATR astigmatism.

Etiology of astigmatism is unknown but it is suggested that eyelid tension steepen the vertical

cornea meridian. However, ATR astigmatism is experienced by person aged over 40 years

old because there is a decrease in the lid tension as we get older (Benjamin WJ 2006).

The amount of astigmatism for both groups before surgery was similar, no significant

difference. However, our study showed that after surgery, the suture group has a significantly

lower amount of astigmatism if compared to the no suture group. This supports the findings

by Gimbel HV et al (1993) that adding a suture to the superior incision in a patient with ATR

astigmatism is beneficial. The suture helps in steepening the vertical meridian once rendered

flattened by the incision.

CONCLUSION

In conclusion our study showed that suturing the main wound in superior incision

phacoemulsification reduces the amount of post-operative ATR astigmatism. Reduced

astigmatism means better unaided vision. Thus, it can minimize financial burden for patient

to purchase glasses. This technique is another option other than temporal wound approach.

REFERENCES

1. Benjamin WJ. Borish clinical refraction. Boston : Butterworths Heinemann : 2006

2. Gusowski M, Rochtchina E, Wang JJ, Mitchell P. Refractive changes following cataract

surgery: the Blue Mountain Eye Study. Clinical Experiment Ophthalmol 2002; 30:159-

162

3. Morlet M, Minassian D, Dart John. Astigmatism and the analysis of its surgical correction.

British J Ophthalmol 2001; 85:1127-1138

4 Gimbel HV, Sun R. Postoperative Astigmatism following phacoemulsification with sutured

versus unsutured wound. Can J Ophthalmol. 1993; 28(6):259-262

5. Bazzazi N, Barazandeh B, Kashani M, Rasouli M. Opposite clear corneal incisions versus

steep meridian incision phacoemulsification for correction of pre-existing astigmatism. J

Ophthalmic Vis Res 2008; 3(2):87-90

6. Goto T, Klyce SD, Zheng X, Maeda N. Gender and age related differences in corneal

topography. Cornea 2001; 20(3):270-276


19 Comparison Of Fondaparinux And Enoxaparin Use For Acute Coronary Syndrome In Hospital Sungai Buloh

COMPARISON OF FONDAPARINUX AND ENOXAPARIN USE FOR

ACUTE CORONARY SYNDROME IN HOSPITAL SUNGAI BULOH

Arulappu JJ, Sia HP, Pang CW

Pharmacy Department , Sungai Buloh Hospital

ABSTRACT

Introduction : Fondaparinux and Enoxaparin are parenteral anticoagulants used for the

resolution of acute coronary syndromes (ACS). It has been demonstrated that

Fondaparinux has similar efficacy with fewer bleeding incidences and severity versus

Enoxaparin in ACS treatment. However, there was a noted increase in readmissions

amongst Fondaparinux treated patients in Hospital Sungai Buloh (HSB).

Objective : To determine whether Fondaparinux increases the risk of subsequent

readmissions, death and bleeding incidences versus Enoxaparin, the clinical

effectiveness of both agents and the correlation between treatment duration and

readmission rates.

Methodology : An eight week pilot prospective study was performed to test a suitable

study protocol to compare effectiveness and subsequent readmission rates amongst

ACS patients treated with these drugs in HSB from April to May 2011. The list of patients

was obtained via cross-referencing the dispensing records and the respective patient‟s

medical case notes through the e-HIS system. Patient‟s background, past medical

history, current medical progress, duration of treatment, Creatinine Kinase changes and

coagulation profile parameters were determined and monitored throughout the duration of

admission. At the end of the study, all the respective patient records were reviewed for

subsequent readmissions with any reasons for readmission being noted.

Results :Fondaparinux was more commonly used during the study period

(Fondaparinux= 84 patients, Enoxaparin =11 patients). The mean duration of treatment

was similar for both Fondaparinux and Enoxaparin (Fondaparinux: 3.1 days, Enoxaparin:

3.4 days). Similar short term readmission rates were observed, regardless of treatment

with Fondaparinux and Enoxaparin. (9.5 % versus 9.1%). There was a significant

reduction in cretinine kinase from baseline among patients treated with these agents

(p<0.05). Only one rebleeding episode and six fatalities were observed with

Fondaparinux. These readmissions and mortalities were not due to recurrent ACS

events. All patients treated with Enoxaparin were discharged without any complications.

Conclusion : The use of Fondaparinux has similar efficacy in resolving ACS events

versus Enoxaparin, with similar readmission rates following treatment. Thus, the current

practice of a three day Fondaparinux regiment should be continued for treating ACS in

non-renal impaired patients.

INTRODUCTION

Acute Coronary Syndrome (ACS) defines a spectrum of clinical presentations. It is

classified into ST-elevation myocardial infacrtion (STEMI) or non-ST-elevation myocardial

infarction (NSTEMI) and unstable angina (UA) based on levels of cardiac enzyme

markers (troponin and creatinine kinase) and ischemic symptoms.1,2,3,4 ACS is triggered

by impaired perfusion of myocardial tissue, mainly via thrombosis of coronary arteries.

The parental anticoagulants Fondaparinux and Enoxaparin resolve and prevent further

thrombus formation, treating ACS. Enoxaparin is a low molecular weight heparin



(LMWH) that increases anticoagulant effects of Antithrombin III.1,2 Fondaparinux inhibits

formation of activated Factor X, thus reduces formation of thrombin needed for

coagulation. 1,2 The Organization to Assess Strategies in Acute Ischemic Syndromes

(OASIS) 5 studies showed Fondaparinux has similar efficacy in resolving ACS (8.0

versus 8.6 % mortality and risk of recurrent MI)with significantly lower bleeding risks

(2.2% versus 4.1%)5 versus Enoxaparin. Current clinical guidelines advocate the use of

either Fondaparinux or Enoxaparin in treatment of UA, NSTEMI, and treating STEMI

events unresolved with prior thrombolytic agents such as Streptokinase, Alteplase or

Tenecteplase.1, 2, 3, 4

In Sungai Buloh Hospital (HSB), Fondaparinux is preferred due to its simpler once daily

dosing regimen (weight independent) and lower cost versus Enoxaparin

(Fondaparinux:RM 19.65/syringe vs. Enoxaparin RM 39.69/40mg syringe or RM

48.55/60mg syringe). Fondaparinux is porcine free, unlike Enoxaparin, thus making it

suitable for Muslim patients. 3, 4. However, increased readmissions were seen in patients

previously treated with Fondaparinux versus Enoxaparin in HSB for ACS events.

METHODOLOGY

This pilot project was carried out using a prospective study model. This short study was

performed to determine whether Fondaparinux truly increases risk of subsequent

readmissions, death and bleeding incidences versus Enoxaparin. The clinical

effectiveness of Fondaparinux and Enoxaparin was examined and compared via changes

in patients Creatinine Kinase levels. Finally, treatment duration of Fondaparinux or

Enoxaparin and subsequent readmissions were examined to detect any correlation

between treatment duration and readmission rates.

The data collected was for admitted patients diagnosed with acute coronary syndrome

and initiated treatment on Fondaparinux and Enoxaparin from 1 April 2011 to 27 May

2011 (8 weeks). The list of patients was obtained via cross-referencing the dispensing

records of Fondaparinux and Enoxaparin and the respective patient‟s medical case notes

through the e-HIS system. Only patients in the medical wards 4A, 4D and the Cardiac

Care Unit (CCU) were studied, as ACS patients are admitted to these wards.

Patient‟s background, past medical history, current medical progress and duration of

treatment with Fondaparinux or Enoxpaarin were determined, followed up and recorded.

The patients‟ Creatinine Kinase changes and coagulation profile parameters, namely the

patient‟s International Normalised Ratio (INR) and Haemoglobin (Hb) levels were

monitored throughout the duration of admission. At the end of the study, all the

respective patient records were traced back to see if there were any subsequent

readmissions throughout the period of the study, with any reasons for readmission being

noted and recorded to determine if readmission were due to recurrence of ACS. The lab

results (CK, Hb and INR values) at the start and end of treatment were compared with a

paired t-test.

Inclusion and Exclusion Criteria

The main inclusion criteria are that patients studied were diagnosed with Acute Coronary

Syndrome (ACS) and started on Fondaparinux or Enoxaparin. Patients treated for Deep

Vein Thrombosis and Pulmonary Embolism were excluded. Patients were excluded if



Fondaparinux and Enoxaparin was interchangeably used during treatment. Furthermore,

patients treated for less than two days with Fondaparinux or Enoxaparin were excluded.

Patients with severe renal impairment (Creatinine clearance (CrCl) of <30ml/min) were

excluded as Fondaparinux is contraindicated in severe renal impairment. Pregnant

patients and those currently on other anticoagulant treatments except prior streptokinase,

alteplase and tenecteplase for STEMI were excluded.

RESULTS

.

A total of 95 patients were observed during this study. 51% were diagnosed with Unstable

angina, 42% with NSTEMI and 6% with STEMI. Fondaparinux treatment was initiated in 84

patients and 11 patients were treated with Enoxaparin.

Figure 2: Comparison between number of patients on Fondaparinux and on

Enoxaparin

6.32%

42.11%51.58%

Figure 1: Percentage of Unstable Angina, NSTEMI and STEMI in patients (N=95)

STEMI NONSTEMI UNSTABLE ANGINA

84

11

0 10 20 30 40 50 60 70 80 90

Number of patients

Dru

g U

sed

Enoxaparin Fondaparinux



Figure 3: Percentage of patients versus duration of Fondaparinux treatment

Figure 4: Percentage of patients versus duration of Enoxaparin treatment

The duration of treatment ranged from two to five days, Majority of patients in both

groups were treated for 3 days {Fondaparinux (71.4%), Enoxaparin (54.5%)}. A

subsequent two tailed- test showed no significant difference in the mean duration of

Fondaparinux or Enoxaparin treatment. [3.1786(Fondaparinux) vs. 3.455 (Enoxaparin),

p= 0.365 (p>0.05%)

Table 1: Summary of treatment efficacy of Fondaparinux and Enoxaparin

Drug Changes in CK levels Comments

Fondaparinux -300.9 + 647.8,

(p= 0.000)

95% CI:(154.9,-447.0)

Only 78 patients with repeated CK

readings

Enoxaparin -201 + 333

p= 0.073

95% CI :(-22, 425)

Excluding outlier value:

259.5 + 286.7 ,p=0.019

95% CI :(54.4, 464.6)

0%

10%

20%

30%

40%

50%

60%

70%

80%

Days on Fondaparinux treatment

9.50%

71.40%

10.70% 8.30%

pe

rce

nta

ge o

f p

atie

nts

2 days 3 days 4 days 5 days

0%

10%

20%

30%

40%

50%

60%

Days on Enoxaparin treatment

9.10%

54.50%

18.20% 18.20%

pe

rce

nta

ge o

f p

atie

nts

2 days 3 days 4 days 5 days



Table 1 shows mean Creatinine Kinase values were reduced by 300 points with

Fondaparinux and 201 points with Enoxaparin treatment. These reductions are clinically and

statistically significant, (p<0.05).

Table 2: Baseline Haemoglobin and International Normalised Ratio of treated patients

Table 3: Summary of Changes in patients Haemoglobin and International Normalised

Ratio on Fondaparinux and Enoxaparin

The observed Haemoglobin and INR values in the patients were at normal levels, prior to

Fondaparinux or Enoxaparin treatment. Most patients‟ Haemoglobin and INR values were

not followed up due to short duration of admission. Statistically insignificant changes were

seen in Haemoglobin and INR values after treatment with these drugs. These results are not

reliable since Hb and INR values were only followed up in a fraction of the studied patients.

Table 4: Summary of patient’s outcomes following Fondaparinux and Enoxaparin

treatment

Table 5: Comparison of readmission rate versus treatment duration with Fondaparinux

Drug Duration of

treatment

Readmissions % Readmissions over treated

patients

Fondaparinux 3 7 11.67

4 1 11.1

Coagulation Marker Sample No Baseline Mean

Hb 66 13.876 + 1.891 , 95% CI: (13.876 + 1.891)

INR 46 1.0887 + 0.1878, 95% CI : (1.0329, 1.1445)

Monitored

parameter No Drug Baseline mean Changes

Haemoglobin 27 Fondaparinux 14.167 + 2.047 0.167 +1.532

95% CI :(-0.439, 0.773)

p=0.577

6 Enoxaparin 13.5 + 2.86

P=0.2

-0.333 + 1.258,

95% CI :(-3.459, 2.792)

p = 0.691

International

Normalised

Ratio (INR)

4 Fondaparinux 1.310 + 0.341 0.242 + 0.333

95% CI: (-0.288, 0.773)

p=0.242

1 Enoxaparin Unable to perform statistical analysis

Initial INR = 0.99

End INR: 1.02

Drug Discharged Deaths Bleeding Readmissions

Fondaparinux 80 6 1 8

Enoxaparin 11 0 0 1



Multiple outcomes were observed in some patients, especially successful discharges prior to

later readmissions. The bleeding episode was successfully resolved and patient was later

discharged. A 100% discharge rate was seen with Enoxaparin and 95% (80/84) discharge

rate with Fondparinux. Six fatalities were observed with Fondaparinux treatment. However, it

was attributed to non-ACS causes, namely stroke, sepsis and Hospital Acquired Pneumonia.

Only one patient was readmitted after treatment with Enoxaparin. Eight patients were

readmitted after Fondaparinux treatment. The readmission rates observed in Fondaparinux

were similar regardless of the duration of treatment. The higher readmissions in

Fondaparinux were due to sample size.

Both Fondaparinux and Enoxaparin demonstrated efficacy in resolving ACS, with

Fondaparinux linked to a greater reduction in CK values. Furthermore, the total readmission

rate was less with fondaparinux versus enoxaparin (9.5% versus 9.1%). Majority of the

patients studied presented with unstable angina and NSTEMI. Furthermore, no fatalities or

bleeding episodes were seen in Enoxaparin treated patients, unlike six fatalities and one

bleeding episode with Fondaparinux.

DISCUSSION

The findings of the study corroborates past findings that Fondaparinux and Enoxaparin are

effective treatments of Acute Coronary Syndrome (ACS) events. The majority of patients

were diagnosed with Unstable Angina (51.58%) and NSTEMI (42.1%), thus following the

recommended treatment guidelines for ACS 7. The significant reduction in patients

Creatinine Kinase values proved that ACS events were resolved. Furthermore, patients

presenting with Unstable Angina presented CK values within the normal range throughout

admission have lower mortality rates 1, 2. This corroborates with the results of a study

associating low CK levels with reduced MI recurrence and fatality. (14% risk when CK values

are 2X the normal range versus 10% when CK values are within normal range)7. The short

mean treatment duration of 3.1 days on Fondaparinux and 3.4 days on Enoxaparin

respectively did not compromise treatment efficacy. It also clinically demonstrated that the

recommended Fondaparinux and Enoxaparin treatment period for two to eight days

successfully resolves ACS events.

Four out of the six deaths observed in the Fondaparinux group were in STEMI patients. This

corroborates findings that STEMI patients have higher mortality rates,(9.7%,2.3%) 5.6.

Furthermore, the bleeding episode observed (1.1%) matches the 2.3% bleeding rate in the

OASIS 5 study 5. The observed mortality rate (7.1%) is similarwith the OASIS 5 study (5.8%)

rather than the OASIS 6 study 5, 6. This is since most patients were treated for UA and

NSTEMI, rather than STEMI. The absence of recurrent ACS event may be due to the short

duration of the study (2 months) versus the OASIS 5 study of 6 months and the small sample

size versus that used in OASIS 5 ( 84 versus 20078 patients)5,6.

The imbalanced ratio of Fondaparinux to Enoxaparin prevents direct and accurate

comparison between the drugs, unlike the OASIS 5 study. There were no fatalities, recurrent

ACS or bleeding incidences observed in patients treated on Enoxaparin, and only one case

of readmission. The results do not corroborate with the OASIS 5 results of increased

bleeding and mortality risks from Enoxaparin as compared to Fondaparinux (9.0 % versus

7.3% )5. This may be due to the small sample size studied. Furthermore, these results



colludes with the ACUTE and TIMI studies, which show a 1.9-2% bleeding rate in

Enoxaparin treated patients , with 5% reinfarction rate and a 9% mortality rate. 8.9.

The absence of reinfarctions and one bleeding episode may be due to the small sample

size10,11,12. This corroborates with the overall bleeding rate of 3.9 % observed in the GRACE

studies and 4.3% in the ACQUITY trial.11,12.Majority of the patients studied are diagnosed

with NSTEMI (4.7%) and UA (2.3%), that have lower rebleeding and mortality rates versus

STEMI (4.8%)11,12. Furthermore, the absence of Percutaneous Coronary Intervention (PCI)

treatment in HSB contributes to low bleeding rates. The GRACE study demonstrated that

PCI is linked to increased bleeding rates (6.0 with PCI versus 3.2% without OCI)12. The

baseline patient INR values were not elevated indicating unincreased bleeding risks. This

contributes to the low mortality rate seen, predicted by mortality results from the ACQUITY

trial (7.3% in major bleeding versus 1.2% in no major bleeding) 11. The studied patients were

at a low risk of bleeding episodes, as they lack renal impairment (6.5 versus 3.7%), and

anaemia ,associated with increased bleeding and mortality risks.10,12The six fatalities and

nine readmissions observed were due to other causes (:eg: Hospital Acquired Pneumonia

and Stroke). Thus, neither Fondaparinux nor Enoxaparin directly contributes to short term

post ACS mortality rates.

Limitations

The pilot study demonstrated that a progressive model study was not suitable to compare the

readmission rate in patients. This study was limited by the short study duration of two

months. Other studies involving Fondaparinux and Enoxaparin in ACS were for at least three

months 5.6. Thus, long term recurrence rates of myocardial infarction, readmission rates and

mortality could not be determined.

Another limitation is the small sample size (N= 95) patients. This will compensate for the

small predicted rate of recurrent ACS (less than 10%). Furthermore, the ratio of

Fondaparinux to Enoxaparin was 7.6:1, so the direct comparison between the two drugs

without prior extrapolation of the Enoxaparin results. The proceeding study should have at

least 200 patients, with an equal number of patients treated with Fondparinux or Enoxaprin

respectively. This will allow a direct comparison between the drugs and detection of the

actual ACS recurrence rates in patients.

Furthermore, patient‟s weight was estimated upon admission. Thus, their predicted renal

function may be inaccurate. Thus, patients with severe renal failure may be unintentionally

included. Thus, patient‟s weight should be taken upon admission to determine patient‟s renal

function. Patients CK, Hb and INR values were sometimes not recorded daily. Thus, the true

trend in patients ACS resolution and bleeding risks was not obtained. So, these biological

markers should be taken daily in the following study.

Finally, the patient‟s medical history was only obtained from family members and past

admissions in Hospital Sungai Buloh. Thus, it may be incomplete and failed to include prior

ACS triggered admissions in other hospitals. Furthermore, the true recurrence rate of ACS

and readmission of patients remains unknown as most patients were either transferred to or

followed up at other hospitals. The following study should include collaboration with other

hospitals to detect subsequent admissions to determine the true recurrence rate of ACS.



Thus, based on these limitations, the best model is a retrospective double blind study with

roughly equal numbers of patients on Fondaparinux and Enoxaparin from December 2010 to

February 2011, while recording any subsequent readmissions and recurrence of ACS from

December 2010 to May 2011.

CONCLUSION

Although this pilot study was flawed, it still demonstrated that Fondaparinux and Enoxaparin

were effective in resolving ACS events in patients in HSB. The shorter duration of treatment

did not adversely affect patient outcome, as demonstrated by the reductions in patients CK

values. Both drugs did not significantly increase bleeding risk due to insignificant changes in

Haemoglobin and INR values. The readmission rates, though more in Fondaparinux were

similar between both drugs. Fondaparinux was linked to a small risk of bleeding (1/84).

There were no treatment failures with any readmissions or fatalities due to recurrent ACS.

Conclusively, Fondaparinux does not have higher short term readmission rates and bleeding

incidences versus Enoxaparin. Thus, current three day protocol of Fondaparinux treatment of

ACS in patients with normal renal function is safe and should be maintained.

REFERENCES

1) SIGN guideline 93: Acute Coronary Syndrome (ACS), 2007, NHS Scotland

2), Jean-Pierre.B, Hamm.C, Ardisinno.C, Boersma.E, Budaj.A, Hadsai.D, et al, Guidelines for

the diagnosis and treatment of non-ST elevation Acute coronary Syndromes, The Task Force

for the Diagnosis and Treatment of Non-ST elevated Acute Coronary Syndromes of the

European Society of Cardiology . European heart journal 2007;28:1598-1660

3) Malaysian Ministry of Health Clinical Practice Guidelines on the Management of ST

Elevated Myocardial Infarction, 2007, (MOH/P/PAK/127.07

4) Malaysian Ministry of Health Clinical Practice Guidelines on the Management of Unstable

angina/ NSTEMI, 2002

5) Yusuf.M, Metha.S, Pouge.J, Chrolavicus.S, Afzal.R, Granger.C, et al. Comparison of

Fondaparinux and Enoxaparin in Acute Coronary Syndrome (OASIS 5), New england journal

of medicine 2006;354:1464-1476

6) Yusuf.M, Metha.S, Pouge.J, Chrolavicus.S, Afzal.R, Granger.C, et al . Effects of

Fondaparinux on Mortality and Reinfarction in Patients With Acute ST-Segment Elevation

Myocardial Infarction ,The OASIS-6 Randomized Trial. Journal of the american medical

association 2006;295(13):1519-1530

7) Savotinno.S, Granger.C, Ardissino.D, Gardner.L, Cavallini.C, Galvani.M, et al, The

prognostic values of Creatinine Kinase elevations extends across the whole spectrum of

acute coronary syndromes. American journal of cardiology 2002;39:22-29

8) Rubboli.A, Cappechi.A, Pasquele.G, Utilising enoxaparin in the management of STEMI.

Vascular health and risk management.,2007;3:691-700

9) Scmidt- Luke.C, Schultheiss.H, Enoxaparin injection for the treatment of high risk patients

with acute coronacy syndrome. Vascular health and risk management, 2007;3:221-227

10)Spencer.A, Moscussi.M, Granger.C, Gore.J, Goldberg.R,Goodman.S, et al, Does

comorbidity account for the excess mortality in patients with acute bleeding in acute

myocardial infarction. Circulation. 2007;116:2973-2801

11) Manoukian.S, Federick.F, Mehran.S, Voeltz.M, Ebrahinmi,R, Hamon.M, et al: Impact of

Major Bleeding on 30 day mortality and clinical outcomes in patients with acute coronary

syndrome. Journal of the american college of cardiology. 2007;49:1362-1368



12) Moscussi.M, Cannon.C , Klien.W, Montalescot.S, White.K, Goldberg.R, et al, Predictors

of Major Bleeding in Acute Coronary Syndromes, the Global Registry of Acute Coronary

Events (GRACE). European heart journal. 2003;24:1815-1823


28 Drug Utilization Review Of Selected Proton Pump Inhibitors (PPIs) In Outpatient Pharmacy Hospital Sungai Buloh

DRUG UTILIZATION REVIEW OF SELECTED PROTON PUMP INHIBITORS (PPIs) IN

OUTPATIENT PHARMACY HOSPITAL SUNGAI BULOH

Nurhayati Abdul Wahab, Kalaivani A/P Subramaniam, Nurnadia Shazreen Abd Wahab

Department of Pharmacy, Hospital Sungai Buloh

ABSTRACT

Introduction: This study is to review the drug utilization of selected proton pump inhibitors

(PPIs) in Outpatient Pharmacy Hospital Sungai Buloh.

Objective: To study the prescribing pattern and to compare the utilization of selected PPIs

which are available in Outpatient Pharmacy Hospital Sungai Buloh.

Methodology: This retrospective drug utilization review included patients from any outpatient

clinics in Hospital Sungai Buloh. Subjects must have been prescribed with Esomeprazole,

Lansoprazole or Rabeprazole from 1st January 2009 to 31st December 2009. Subjects that

were patients from ward (inpatient) as well as subjects whose medical records were unable

to be retrieved from eHIS system were excluded for this review. Data was collected through

eHIS system using PH Statistic-Dispensing Statistic by Drug. Data was collected using Data

Collection Form and analyzed using Microsoft Excel.

Results: 65% of patients were prescribed with Esomeprazole 40 mg. 42.7% of patients

within age group > 60 years old were treated with selected PPIs. More males than females

were prescribed with selected PPIs. Malay patients topped the list (64%) compared to other

races. Most patients (77.3%) were prescribed with the selected PPIs for the indication of

PUD. Once daily dosing (OD or ON) were the most common frequency (85.3%) prescribed

among patients taking the selected PPIs. These PPIs were generally most prescribed by

surgical clinics (60%). 49.3% of patients were past-treated with different type of PPI within

the same year.

Conclusion: Prescribing pattern of selected PPIs in Outpatient Pharmacy Hospital Sungai

Buloh is predominantly conquered by esomeprazole. This agrees with clinical trials which

showed that esomeprazole is superior in efficacy among all selected PPIs. The general

pattern of prescribing also agrees with current standard guidelines in practice. Selected PPIs

which are available in Outpatient Pharmacy Hospital Sungai Buloh are mostly utilized by

elderly group of patients for peptic ulcer disease prophylaxis.

INTRODUCTION

Dyspepsia is a common presenting complaint to general practitioners, and there is continuing

debate on its management1 Since the introduction of proton pump inhibitors (PPIs) in the late

1980s, these efficacious acid inhibitory agents have rapidly assumed the role for the

treatment of acid-peptic disorders1.They are now among the most widely selling drugs

worldwide due to their outstanding efficacy and safety1. They are considered the most

effective acid-suppressing medications available, and are considered first-line therapy for the

symptoms of GERD and the maintenance of esophageal healing in patients with erosive

esophagitis1. They are also highly effective for PUD, Barrett's esophagus, Zollinger-Ellison

syndrome, and as a component of combination therapy in the eradication of H. pylori1.

Nevertheless, it has been suggested that PPIs are “probably too widely prescribed for minor

symptoms, and the cost implication of this is clear”1.



PPIs are selected for this review because of their high cost, high volume prescribed and they

are a clinically important drug1. There has been rapid increase in PPIs prescribing in recent

years, as such controlling the cost and improving the quality of prescribing is an issue of

concern. Recently in Hospital Sungai Buloh (HSB), their use has been increasing. Only 4

PPIs have been selected in this review: esomeprazole 20mg, esomeprazole 40mg,

lansoprazole 30mg and rabeprazole 20mg. The reason being they are among the most

expensive of the PPI group, the sample sizes are not too big as well as they are not too

overly prescribed for minor symptoms.

Pharmacology

The mechanism of action of PPIs are by the reduction of gastric acid secretion via the

selective and irreversible inhibition of proton-activated and potassium-activated adenosine

triphosphate (H/K-ATPase), an enzyme within the gastric parietal cells2.

The timing of administration is crucial; PPIs inactivate only active proton pumps and proton

pumps are activated primarily at mealtimes2. Thus, PPIs should be taken on an empty

stomach about 30 minutes before meals for maximum benefit2.

AIM

To review the drug utilization of selected proton pump inhibitors (PPIs) in Outpatient

Pharmacy Hospital Sungai Buloh.

OBJECTIVES

To study the prescribing pattern of selected PPIs in Outpatient Pharmacy Hospital Sungai

Buloh.

To compare the utilization of the selected PPIs which are available in Outpatient

Pharmacy Hospital Sungai Buloh.

PROBLEM STATEMENT

1. There has been a rapid increase in PPIs prescribing in recent years; as such monitoring

the pattern of prescribing is an issue of concern

2. Recently in Outpatient Department Hospital Sungai Buloh, their use have been

increasing

METHODOLOGY

A retrospective drug utilization review was conducted in this study. This meant that the drug

would be reviewed after the patient had received the medication and it might identify patterns

in prescribing, dispensing or administering drugs. In this study however, it focused mainly on

prescribing pattern of PPIs in HSB. Subjects for this study included patients from outpatient

clinics HSB prescribed with Esomeprazole, Lansoprazole or Rabeprazole. They were

identified by retrieving records using the HIS system. This review was conducted in

outpatient pharmacy HSB setting. Subjects that were included in this retrospective review

must have been prescribed with any of these three drugs irrespective of its indication from 1st

January 2009 to 31st December 2009. There was no maximum/minimum number of subjects

that could be included in this review. Subjects could either be from any specialist clinics in

Hospital Sungai Buloh (outpatient). Exclusion criteria included subjects that were patients

from ward (inpatient) as well as subjects whose medical records were not being able to



retrieve from HIS system. Based on patients‟ identification number, patients‟ profile were

reviewed from HIS system. Data that were reviewed included:

Patient‟s demographic profile

Patient‟s drug profile

Prescriber‟s information

Indications for PPI usage

Dose prescribed

History of treatment with PPIs

Patients‟ confidentiality was maintained while data was being collected. A data collection

form was formulated to collect all these data. Data was analyzed using Microsoft Excel

software.

RESULTS

Table 1: Results tabulated based on demographic & clinical data of patients on

selected PPIs

TOTAL

LANSOPRAZOLE

30 MG

RABEPRAZOLE

20 MG

ESOMEPRAZOLE

20 MG

ESOMEPRAZOLE

40 MG

No. Of

Patients 1 10 16 48

AGE

<10

11-20 1

21-30 1 4

31-40 2 4 6

41-50 4 6

51-60 2 4 9

>60 1 6 3 22

GENDER MALE 2 9 34

FEMALE 1 8 7 14

RACE

MALAY 1 4 8 23

CHINESE 1 3 11

INDIAN 5 4 11

OTHERS 1 3

PRESCRIBER

MED 1

SURG 10 13 22

ID

ENT 1

OTHERS 1 2 25

INDICATION

HP 1

PUD 1 8 8 41

GERD 2 7 7

FREQUENCY

ON 5

BD 11

OD 1 5 16 37

HISTORY

SAME 1 1

DIFF 9 9 19

NO 1 1 6 28



Figure 1: Total patients on selected PPIs in 2009

Figure 2: Patients on selected PPIs according to age group

Figure 3: Patients on selected PPIs according to gender

T OT AL P AT IE NT ON P P Is IN 2009

1%13%

21%

65%

L ansoprazole 30 mg

R abeprazole 20 mg

E someprazole 20 mg

E someprazole 40 mg

n = 75

P AT IE NT S ON P P Is AC C OR DING T O AG E

12 2

6

1

4 4 43

1

4

6 6

9

22

0

5

10

15

20

25

<10 11-20 21-30 31-40 41-50 51-60 >60

AG E G R OUP

L ansoprazole 30 mg R abeprazole 20 mg E someprazole 20 mg E someprazole 40 mg

1

8 714

2

9

34

0

5

10

15

20

25

30

35

L ansoprazole 30mg

R abeprazole 20mg

E someprazole20 mg

E someprazole40 mg

P AT IE NT S ON P P Is AC C OR DING T O G E NDE R

Male

F emale



Figure 4: Patients on selected PPIs according to race

Figure 5: Indications patient being prescribed with selected PPIs

Figure 6: The frequency of taking selected PPIs as being prescribed

1

4

1

5

8

34

1

23

11 11

3

0

5

10

15

20

25

L ansoprazole 30mg

R abeprazole 20mg

E someprazole20 mg

E someprazole40 mg

P AT IE NT S ON P P Is AC C OR DING T O R AC E

Malay

C hinese

Indian

Others

INDIC AT IONS P AT IE NT B E ING P R E S C R IB E D WIT H

P P Is

1

2

8

7

8

1

7

41

0 10 20 30 40 50 60 70

G E R D

P UD

H. pylorieradication

Lans opraz ole 30 mg

R abepraz ole 20 mg

E s omepraz ole 20 mg

E s omepraz ole 40 mg

T HE F R E QUE NC Y OF T AK ING P P Is AS B E ING

P R E S C R IB E D

1

5

16

3711

5

0 5 10 15 20 25 30 35 40

L ansoprazole 30 mg

R abeprazole 20 mg

E someprazole 20 mg

E someprazole 40 mg

ON

B D

OD



Figure 7: Prescriber of selected PPIs based on clinics

Figure 8: History of past-treatment with PPIs within a year

RESULTS AND DISCUSSION

Majority of subjects; that is 65%, were prescribed with Esomeprazole 40 mg. 42.7% of

subjects aged more than 60 years old. 60% of subjects were male compared to only 40%

female. Malay subjects topped the list (64%) compared to other races. Most subjects, 77.3%,

were prescribed with the selected PPIs for the indication of peptic ulcer diasease. 85.3% of

subjects were prescribed with once daily dosing (either OD or ON dosing). These PPIs were

mostly prescribed by surgical clinics (60%). Most subjects, 49.3%, were past-treated with

different type of PPI within the same year.

Majority of patients were prescribed with Esomeprazole 40mg; followed by Esomeprazole

20mg, Rabeprazole 20mg, and Lansoprazole 30mg. This agrees with many clinical trials

which showed that esomeprazole is superior in efficacy compared to other selected PPIs:-

Miner et al, Wilder-Smith et al, Lind et al, Röhss et al showed that esomeprazole

provided excellent gastric acid control compared with other selected PPIs18-23, 28

Healing rates of disease is higher when esomeprazole used (Castell et al & Fennerty

et al25-26, 28); maintenance of healing is also higher (Lauritsen et al)27, 28

Esomeprazole provided better day & night symptom relief (Castell et al)25, 28

Esomeprazole taken on-demand has higher therapeutic gain over placebo compared

with other selected PPIs (Bytzer et al)24, 28

Majority of patients within age group > 60 years old were treated with selected

P R E S C R IB E R OF P P Is B AS E D ON C L INIC S

1

10

1

13

2

22

1

25

0

5

10

15

20

25

30

Medical clinic S urgical clinic ID clinic E NT clinic Others

P R E S C R IB E R

L ansoprazole 30 mg R abeprazole 20 mg E someprazole 20 mg E someprazole 40 mg

HIS T OR Y OF P AS T -T R E AT ME NT WIT H P P Is WIT HIN A

YE AR

1

1

9

9

19

1

1

6

28

0 10 20 30 40 50 60

L ansoprazole 30 mg

R abeprazole 20 mg

E someprazole 20 mg

E someprazole 40 mg

S AME

D IF F E R E NT

NO



PPIs. This was followed by age group 51-60 years old. Elderly group have a higher

incidences of getting gastro-intestinal diseases than younger people13.

Once daily dosing (OD or ON dosing) were the most common frequency prescribed for

selected PPIs. This indicates for prophylaxis. According to NICE guideline on PPI usage,

PPIs should be prescribed in a 'step down' manner; that is, the dose should be lowered to a

maintenance level after healing has been achieved, depending on the condition3.

Most PPIs were prescribed for peptic ulcer disease. According to CPG (Malaysian) guideline,

PPIs are often the drug of choice in treating PUD & for maintenance therapy after healing16.

Majority patients were past treated with PPIs within the same year. This indicates recurrence

of disease. Most patients will experience recurrence within one year following completion of

initial treatment3&17.

To investigate the cost analysis of selected PPIs, cost estimation was done based on the

following criteria:-

patients with peptic ulcer disease prescribed with selected PPIs in 2009

daily OD dosing

duration for 1 month.

Table 2: Cost analysis for selected PPIs

Drug Daily dose Price per tablet Number of patients Expected yearly

cost

Esomeprazole 20mg RM 1.80 8 RM 432.00

Esomeprazole 40mg RM 1.80 41 RM 2214.00

Lansoprazole 30mg RM 2.56 1 RM 76.80

Rabeprazole 20mg RM 1.53 8 RM 367.20

Limitation

There were some factors which limit the study:

Errors within the system – affect data collection

Doctors stopping medication in system after pharmacy have dispensed to patients;

this could not be captured because only the amount dispensed was able to be

generated through system

CONCLUSION

Prescribing pattern of selected PPIs in Outpatient Pharmacy Hospital Sungai Buloh is

predominantly conquered by esomeprazole. This agrees with clinical trials which showed that

esomeprazole is superior in efficacy among all selected PPIs. The general pattern of

prescribing also agrees with current standard guidelines in practice. Selected PPIs which are

available in Outpatient Pharmacy Hospital Sungai Buloh are mostly utilized by elderly group

of patients for peptic ulcer disease prophylaxis.



REFERENCES

1. ”Why patients are prescribed Proton Pump Inhibitors? Retrospective analysis of link

between morbidity and prescribing in the General Practice Research Database”; James

NR Bashford et al.; British Medical Journal; 1998.

2. Basic & Clinical Pharmacology, 9th edition; Bertram G. Katzung.; 2004.

3. “Dyspepsia: Management of dyspepsia in adults in primary care”; National Institute for

Clinical Excellence; Clinical Guideline 17; August 2004.

4. The National Medicines Survey: Malaysian Statistics on Medicine 2005; Publication of

Pharmaceutical Services Division and Clinical Research Centre Ministry of Health

Malaysia; 2007.

5. “Costs of Acid-Related Disorders to a Health Maintenance Organization”; Theodore

R Levin MD, Julie A Schmittdiel MA, Kimberly Kunz MPP, James M Henning MS,

Curtis J Henke PhD, Chris J Colby PhD, Joseph V Selby MD; The American Journal of

Medicine, Vol. 103 Issue 6; December 1997.

6. “Chronic acid-related disorders are common and underinvestigated”; Majumdar SR,

Soumerai SB, Farraye FA, Lee M, Kemp JA, Henning JM, Schrammel P, LeCates RF,

Ross-Degnan D.; Department of Ambulatory Care and Prevention, Harvard Medical

School and Harvard Pilgrim Health Care, Boston, Massachusetts, USA; Am J

Gastroenterol, 98 (11): 2409-14; November 2003.

7. “Acid-related disorders in the elderly”; Marilisa Franceschi, MD, Ph.D (Research

Fellow), Francesco Di Mario, MD (Professor of Gastroenterology), Gioacchino Leandro,

MD (Senior Consultant), Stefania Maggi, MD (Senior Researcher), Alberto Pilotto, MD

(Head of Department); Clinical Gastroenterology, Vol. 23 Issue 6; December 2009.

8. “Helicobacter pylori Infection in Peptic Ulcer Disease: The Importance of Smoking and

Ethnicity”; KVK Pillay1, M Htun, NN Naing and B Norsa‟adah; Department of Surgery,

2Unit of Biostatistics and Research Methodology, School of Medical Sciences,

Universiti Sains Malaysia, Health Campus, Kubang Kerian, Kelantan, Malaysia; Vol. 38

No. 6; November 2007.

9. Statistik Pesakit Mengikut Kaum, Jabatan Rekod Hospital Sungai Buloh.

10. Drug Information Handbook, 17th edition; 2008-2009.

11. “Prevalent Prescribing of Proton Pump Inhibitors: Prudent or Pernicious?”; Co Q. D.

Pham, BSc, BA, BScPharm, PharmD, Linda M. Sadowski-Hayes, PharmD, and

Randolph E. Regal, BS, PharmD; Vol. 31 No. 3; March 2006.

12. Fitton A & Wiseman L. Pantoprazole: A review of its pharmacological properties and

therapeutic use in acid-related disorders (1996)

13. Yarnell J. Epidemiology & prevention: a system-based approach. Oxford Core Texts.

Oxford University Press. 2007

14. Vonkeman HE, Braakman-Jansen LMA, Klok RM, Postma MJ, Brouwers JRBJ, van

der Laar MAFJ. Incremental cost effectiveness of proton pump inhibitors for the

prevention of NSAID ulcers: a pharmacoeconomic analysis linked to a case-control

study. Arthritis Research & Therapy; Volume 10 Number 6 Page 144.

15. Statistik Pesakit Mengikut Kaum 2009; Jabatan Rekod Hospital Sungai Buloh

16. CPG (Malaysian): Consensus on Management of Peptic Ulcer Disease 1996

17. Jeong YJ, Lee DH, Choi TH, Hwang TJ, Lee BH, Nah JC, Lee SH, Park YS, Hwang JH,

Kim JW, Jeong SH, Kim W, Jung HC, Song IS. Clinical Analysis of Recurrence Rate

and Symptoms Improvement in Gastroesophageal Reflux Disease patients. Korean J

Gastroenterol 2010; 055 (02): 100-108

http://www.amjmed.com/article/S0002-9343(97)00308-2/abstract









http://www.ncbi.nlm.nih.gov/pubmed?term=









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http://www.bpgastro.com/issues?Vol=23

http://www.bpgastro.com/issues/contents?issue_key=S1521-6918(09)X0008-9



18. Miner P Jr, Katz PO, Chen Y, et al. Gastric acid control with esomeprazole,

lansoprazole, omeprazole, pantoprazole and rabeprazole: a five-way crossover study.

Am J Gastroenterol 2003; 98: 2616-2620

19. Miner P Jr, Katz PO, Chen Y et al. Reanalysis of Intragastric pH Results based on

Updated Correction Factors for Slimline® and ZineticsTM 24 Single-Use pH Catheters.

Am J Gastroenterol 2006; 101: 404-405

20. Wilder-Smith C, Lind T, Lundin C et al. Acid control with esomeprazole and

lansoprazole: A comparative dose-response study. Scand J Gastroenterol 2007; 42:

157-164

21. Lind T, Rydberg L, Kylebäck A et al. Esomeprazole provides improved acid control vs.

omeprazole in patients with symptoms of gastro-oesophageal reflux disease. Aliment

Pharmacol Ther 2000; 14: 861-867

22. Röhss K, Hasselgren G, Hedenström H. Effect of Esomeprazole 40mg vs Omeprazole

40mg on 24-Hour Intragastric pH in Patients with Symptoms of Gastroesophageal

Reflux Disease. Dig Dis Sci 2002; 47: 954-958

23. Röhss K, Wilder-Smith C, Naucler E. Esomeprazole 20mg Provides More Effective

Intragastric Acid Control than Maintenance-Dose Rabeprazole, Lansoprazole or

Pantoprazole in Healthy Volunteers. Clin Drug Invest 2004; 24(1): 1-7

24. Bytzer P et al. Rationale and proposed algorithms for symptom-based proton pump

inhibitor therapy for gastro-oesophageal reflux disease. Aliment Pharmacol Ther 2004;

20: 389-398

25. Castell DO et al. Esomeprazole Compared With Lansoprazole in the Treatment of

Erosive Esophagitis. Am J Gastroenterol 2002; 97: 575-583

26. Fennerty MB et al. Efficacy of esomeprazole vs lansoprazole for healing moderate to

severe erosive oesophagitis. Aliment Pharmacol Ther 2005; 4: 455-463

27. Lauritsen K et al. Esomeprazole 20mg and lansoprazole 15mg in maintaning healed

reflux oesophagitis: Metropole study results. Aliment Pharmacol Ther 2003: 17: 333-

341

28. www.nexiumtouchpoints.com


37 Effectiveness Of Post-Operative Analgesics After Surgical Removal Of Impacted Third Molar Under Local Anaesthesia

EFFECTIVENESS OF POST-OPERATIVE ANALGESICS AFTER SURGICAL REMOVAL

OF IMPACTED THIRD MOLAR UNDER LOCAL ANAESTHESIA

Dr. J. Sureinthiren A/L Jeya Raman, BDS (Malaya), Dr.Lim Yee Chin, BDS (Malaya), Dr.

Mohd. Noor Fareezul bin Noor Shahidan, BDS (Malaya), Dr. Sivakama Sunthari A/P M.

Kanagaratnam, BDS (Malaya), FDSRCS (Eng)

Department of Oral Surgery Department, Hospital Ampang

ABSTRACT

Introduction : A Clinical Audit was carried out involving patients who underwent surgical

removal of impacted mandibular third molar under Local Anaesthesia at Oral Surgery

Department, Ampang Hospital.

Objective: To assess levels of post-operative analgesia achieved with prescription of routine

oral analgesics.

Methodology : A prospective study was conducted and involved 2 phases. Results of Phase

I was reviewed and practice modification was carried out prior to commencement of Phase II.

Data was collected using a Proforma and data analysis was done using SPSS software. Fifty

two patients (81.3%) completed the study in Phase I whereas 83 patients (95.4%) completed

the Phase II.

Results : Overall mean Pain Score for the first 3 days (PS 3) and 7 days (PS 7) post-

operatively for the study population in Phase I were 4.76 (SD ± 2.31) and 3.69 (SD ± 1.66),

respectively and in Phase II were 4.76 (SD ± 2.39) and 3.69 (SD ± 2.06), respectively. PS 3

and PS 7 were lowest in T. Diclofenac sodium 50mg and C. Tramadol 50mg group with the

scores being 3.92 (SD ± 2.57) and 3.07 (SD ± 2.13), respectively.

Conclusion : Overall, post-operative analgesia levels that were achieved within the centre

with the use of routine oral analgesics were acceptable.

INTRODUCTION

Impacted tooth is inability of a tooth to completely erupt into a normal functional position due

to lack of space (in the dental arch), obstruction by another tooth or development in an

abnormal position1. Main reason for removal of impacted tooth is caries on the impacted

tooth itself or its adjacent tooth and presence of recurrent infection of soft tissue around the

impacted tooth.

The pain post-extraction of third molar is the most widely used model in acute analgesia

clinical trials. This pain model‟s reproducibility has been well established2. Besides that, the

pain model is standardized and sensitive and provides a reliable method for comparing

analgesics in the treatment of acute pain3, 4.

OBJECTIVE

The objective of the study in general was to assess the level of post-operative analgesia

achieved and effectiveness of routine oral analgesics prescribed by our department. The

specific objectives were:

To assess average pain score:

First 3 days post-surgical removal of impacted third molar under LA

First 7 days post-surgical removal of impacted third molar under LA



The standard for the study was:

Average pain score for the first 3 days post-operatively to be below 6 for more than

70% of patients

Average pain score for the first 7 days post-operatively to be below 4 for more than

70% of patients

METHODOLOGY

The study was prospective in nature and was conducted in two phases (Phase I and Phase

II). Phase II of the study was conducted after results of Phase I was reviewed and practice

modifications were carried out. Target population for both phases were patients who undergo

surgical removal of impacted mandibular third molar under Local Anaesthesia at Oral

Surgery Department, Hospital Ampang. Data for both phases of study was collected using a

standard Proforma and included demographic details, types of analgesics prescribed post-

operatively and pain score levels for 7 days post-operatively.

All patients were prescribed with 2 types of analgesics post-surgery and average pain score

for the first 3 days and first 7 days post-operatively was recorded using Numeric Rating

Scale (NRS). The analgesic combinations used for the study were as follows:

Tablet Diclofenac Sodium 50mg with Tablet Paracetamol 1000mg (Phase I & II)

Capsule Tramadol 50mg with Tablet Paracetamol 1000mg (Phase I & II. In Phase I,

this group was only given to patients who are contraindicated for the prescription of

Tablet Diclofenac Sodium)

Tablet Diclofenac Sodium 50mg with Capsule Tramadol 50mg (Phase II only)

Data collection for Phase I was carried out from July 2009 until November 2009 and data for

Phase II of the study was collected from January 2010 until July 2010. Patients requiring

surgical removal of impacted mandibular third molar under General Anaesthesia were

excluded. Data was analyzed using SPSS software and Descriptive Statistics were

employed.

RESULTS

Sixty four patients were recruited for Phase I but only 52 patients (81.3%) completed the

study. Phase II recruited 87 patients and 83 patients (95.4%) completed the study. The

results of each phase are as shown below.

Table 1: Average Pain Score in Phase I of study

n = 52 Mean (Pain Score) Std. Dev

First 3 days 4.76 2.31


Table 2: Average Pain Score in Phase II of study

n = 83 Mean (Pain Score) Std. Dev





Table 3: Percentage of patients fulfilling the standard in the study

Phase I Phase II

Percentage of patients with average pain score below 6

for the first 3 days post-operatively 69.23% 74.69%

Percentage of patients with average pain score below 4

for the first 7 days post-operatively 57.69% 61.45%

The following comparisons were only carried out in Phase II of the study.

Table 4: Average Pain Score achieved with use of T. Diclofenac sodium 50mg and T.

Paracetamol 1000mg in Phase II of study

DICLO + PCM

(n = 28 )

Mean (Pain Score) Std. Dev



Table 5: Average Pain Score achieved with use of C.Tramadol 50mg and T.

Paracetamol 1000mg in Phase II of study

TRAMADOL + PCM

(n = 30 ) Mean (Pain Score) Std. Dev



Table 6: Average Pain Score achieved with use of T. Diclofenac sodium 50mg and

C.Tramadol 50mg in Phase II of study

DICLO + TRAMADOL

(n= 25 )

Mean (Pain Score)

Std. Dev



Table 7: Fulfillment of standard in Phase II of study according to analgesic groups

ANALGESIC GROUP

Percentage of patients

with Pain Score below 6

in the first 3 days

Percentage of patients

with

Pain Score below 4 in the

first 7 days

DICLO + PCM

(n = 28 ) 64.29% 50.00%

TRAMADOL + PCM

(n = 30 ) 80.00% 56.67%

DICLO + TRAMADOL

(n= 25 ) 80.00% 80.00%



CONCLUSION

Post-operative analgesia levels achieved within the centre with the use of routine oral

analgesics were acceptable. Combination of Tablet Diclofenac sodium 50mg and Capsule

Tramadol 50mg were able to achieve the lowest mean pain score levels among the study

population. Therefore, the addition of this combination of drugs to analgesic regime in Phase

II of the study was beneficial. Among the limitation of the study was its small sample size,

especially in Phase I of the study. In addition to that, certain factors which could have had an

influence on the pain score, for example, the presence of infection post-operatively were not

taken into consideration. Usage of more potent analgesics such as selective cyclo-

oxygenase 2 (COX-2) inhibitors and usage of adjunct medications, for example, oral

corticosteroids might be worthwhile in future studies for comparison with the current study.

REFERENCES

1. Working Party Faculty of Dental Surgery Royal College of Surgeons of England. Current

clinical practice and parameters of care: The management of patients with third molar

teeth. Faculty of Dental Surgery, Royal College of Surgeons of England. 1997

2. Mordechai A, Meyer K. Severity of baseline pain and degree of analgesia in the third

molar post-extraction dental pain model. Anesth Analg 2003; 97:163–167

3. Chang DJ, Desjardins PJ, King TR, Erb T, Geba GP. The analgesic efficacy of Etoricoxib

compared with Oxycodone/Acetaminophen in an acute postoperative pain model: A

randomized, double-blind clinical trial. Anesth Analg 2004; 99:807–815

4. Kleinert R, Lange C, Steup A, Black P, Goldberg J, Desjardins P. Single dose analgesic

efficacy of Tapentadol in postsurgical dental pain: The results of a randomized, double-

blind, placebo-controlled study. Anesth Analg 2008; 107:2048 –2055


41 Medication Reconciliation In Hemodialysis Unit: Identifying The Types And Factors Contributing To Medication Discrepancies

MEDICATION RECONCILIATION IN HEMODIALYSIS UNIT: IDENTIFYING THE TYPES

AND FACTORS CONTRIBUTING TO MEDICATION DISCREPANCIES

Heryohana Jamaludin, Lee Yoke Ching, Maryam Omar Zaki, Noor Azimah Abdullah,

Nurah Zainal Abidin, Ros Aimi Osman, Norkasihan Ibrahim, Shahirah Zainudi

Department of Pharmacy, Hospital Selayang

ABSTRACT

Introduction : Medication reconciliation is the process of comparing a patient‟s medication

orders to all of the medications that the patient has been taking in terms of name, dosage,

frequency, and route of administration at the time of hospital admission, discharge or during

transfer between institutions. While medication discrepancies are defined as a lack of

agreement between prescribed drug therapy indicated on the hospital discharge record and

the therapy actually received by the patient. Medication reconciliation is done to identify

medication discrepancies.

Objective : To conduct medication reconciliation in patients who undergo hemodialysis and

to find out about the types of medication discrepancies and the prevalence of medication

discrepancies if medication reconciliation is not done.

Methodology : An observational study on medication discrepencies amongst patients that

are undergoing hemodialysis at Hemodialysis Unit of Selayang Hospital.

Results : The percentage of medication discrepancies obtained in this study of 61 samples

are 15.83%, and the types of medication discrepancies commonly occurring in the

Hemodialysis Unit of Selayang Hospital are (1) change in the frequency; (2) change in the

dose; (3) omission of the drug; (4) addition of a new drug; (5) change of the drug; all in order

of the most common to the least common.

Conclusion : This study identified the factors that lead to medication discrepancies that

commonly occur in the Hemodialysis Unit of Selayang Hospital either the Patient factor or the

System factor, whereby the Patient factor comprises majority of the factors. From this study

also, the medications that are commonly associated with medication discrepancies are

obtained, namely the antihypertensives, electrolyte therapy, hematinics, cardiovascular, and

antidiabetics (in order or most common to the least common).

INTRODUCTION

Medication reconciliation is the process of comparing a patient‟s medication orders to all of

the medications that the patient has been taking in terms of name, dosage, frequency, and

route of administration at the time of hospital admission, discharge or during transfer

between institutions. This reconciliation is done to avoid medication errors such as

omissions, duplications, dosing errors, or drug interactions. It should be done at every

transition of care in which new medications are ordered or existing orders are re-written.

Transitions in care include changes in setting, service, practitioner, or level of care. This

process comprises five steps: (1) develop a list of current medications; (2) develop a list of

medications to be prescribed; (3) compare the medications on the two lists; (4) make clinical

decisions based on the comparison; and (5) communicate the new list to appropriate

caregivers and to the patient.

Any inconsistency identified during the reconciliation process is referred to as medication

discrepancies, and it could be either intentional or unintentional. An unintentional



discrepancy is one in which the prescriber unintentionally changed, added or omitted a

medication the patient was taking prior to admission within the same therapeutic class, and

different dosage, frequency or route of administration. All unintended medication

discrepancies are classified into different classes as according to the severity of the potential

consequences that they might bring. Class 1 discrepancies are those unlikely to cause

significant deterioration in patient, Class 2 discrepancies have the potential to cause

moderate discomfort or clinical deterioration, and Class 3 have the potential to cause severe

complications.

Generally, the pharmacist‟s services today include more patient-oriented administrative and

public health functions. There are many functions of public health that can benefit from

pharmacist‟s unique expertise that may include pharmacotherapy, access to care, and

prevention services such as drug related problem. Major role of pharmacist includes

performing or obtaining necessary assessment of patient‟s health status; formulating a

medication treatment plan; selecting, initiating, modifying or administering medication

therapy; monitoring and evaluating the patient‟s response to therapy, including safety and

effectiveness; performing a comprehensive medication review to identify, resolve and

prevent medication-related problems, including adverse drug events; documenting the care

delivered and communicating essential information to the patient‟s or primary caregivers;

providing verbal education and training designed to enhance patient understanding and

appropriate use of his or her medications; providing information, support services, and

resources designed to enhance patient adherence with his or her therapy; and coordinating

and integrating medication therapy management services within the broader healthcare-

management services being provided to the patient.

Problem Statement

Medication reconciliation is done to identify medication discrepancies. It is usually done to

compare a patient‟s medication orders to the existing medications that the patients are

already taking. In our study, the population sample consists of the patients who come for

their routine hemodialysis. These patients are usually on a long list of medications on a long-

term basis. They come and go without their medications thoroughly reviewed by health care

providers which may lead to medication discrepancies. Thus it is our interest to know if the

patients are taking their medications as prescribed by their doctors.

OBJECTIVE

The objective of the study is to conduct the medication reconciliation in patients who undergo

hemodialysis to find out about their medication discrepancies.

The specific objectives were :

To identify the percentage of medication discrepancies.

To identify the types of medication discrepancies.

To identify the medications that are commonly involved in the medication discrepancies.

To investigate the factors that lead to medication discrepancies.

METHODOLOGY

Study design

An observational study on medication discrepancy amongst patients that are undergoing

hemodialysis at the Hemodialysis Unit of Selayang Hospital. This medication reconciliation



project is conducted from the beginning of March to the end of May 2010. The goal of this

project is to interview 61 hemodialysis patients, depending on the inclusion/ exclusion

criteria. Patients are reconciled over 3 months period.

Sampling

All haemodialysis patients registered at the Selayang Hospital Haemodialysis Unit taking into

account the inclusion and exclusion criteria.

Sampling procedure is as shown below:

Obtain the name list of patient that undergoing hemodialysis at Hemodialysis Unit of Hospital Selayang.

Obtain the most recent medication list prescribed from Electronic Medical Record (EMR) – list A.

Obtain patient’s agreement to participate the interview.

Interview patient to obtain a list of medications taken by patient at home – list B.

Identify discrepancies between list A and list B.

Identify types of discrepancies (patient factor vs system factor).

Perform intervention

•Counseling

•Allergy card

•Modify drug order



The list of medications prescribed during the last hospital visit will be obtained from

Medication Order Form in the Selayang Hospital Electronic Medical Record (EMR). The list

of medications that patient‟s has been taking at home will be obtained from the following

resources : patient‟s medication profile, clinical referral notes and by interviewing the patients

and their care giver.

Study Tools

A medication chart contains majority of the kind of medicine that patients in the hemodialysis

unit is taking.

All data will be recorded in the Medication Reconciliation data collection form (MRF1).

RESULTS AND DISCUSSION

Patients Demography Data

Table 1 : Patients Demography

Mean

Gender

Male 34

Female 27

Age

>65 years 20

<65 years 41

Years on Hemodialysis

<5 years 23

5 - 10 years 24

>10 years 14

Co-morbidity

Diabetes mellitus 16

Hypertension 31

Cardiovascular Disease 14

Have been counselled on medication previously

Yes 38

No 23

Allergy history

Yes 8

No 53

In this study, the subjects consist of 34 males and 27 females. 41 of them are less than

65 years old and the remaining 20 are more than 65 years old. 14 patients have been on

hemodialysis for more than ten years while 23 patients less than five years and 24

patients between five to ten years. The number of patients with diabetes, hypertension

and cardiovascular diseases are 16, 31 and 14 respectively. After the interview it was

found out that 38 patients have been counseled on their medications previously while rest

claimed to have not been counseled. Only 8 patients out of 61 claimed to have

medication allergies.



Reconciliation Error Per 100 Hemodialysis Patients

Table 2 :Reconciliation error per 100 hemodialysis patients

Patients

Total number of

medication per

PS

No. of

Discrepancies

Patients

Total number of

medication per

PS

No. of

Discrepancies

1 10 0

31 14 0

2 9 3

32 10 2

3 10 1

33 9 0

4 8 2

34 9 0

5 5 1

35 8 1

6 11 3

36 13 3

7 12 1

37 7 12

8 8 1

38 8 2

9 13 1

39 8 2

10 9 0

40 8 2

11 12 0

41 8 2

12 11 6

42 6 1

13 5 0

43 8 0

14 8 0

44 6 0

15 8 1

45 10 0

16 11 2

46 12 3

17 9 1

47 11 1

18 8 3

48 8 1

19 10 1

49 9 2

20 4 0

50 8 1

21 12 1

51 4 0

22 7 0

52 9 1

23 5 0

53 14 0

24 7 0

54 11 4

25 4 1

55 6 2

26 9 1

56 7 2

27 10 3

57 4 1

28 7 2

58 8 0

29 5 0

59 7 1

30 9 0

60 5 0

61 7 1

The percentage of medication discrepancies is derived from the total number of

discrepancies over the total number of medications that the patients are on. There were 82

medication discrepancies out of 518 medications, giving the percentage of the discrepancies

as 15.83%.

From these data we can calculate the prevalence of medication discrepancies if medication

reconciliation is not done. The formula used is:



Prevalence of medication discrepancies in Hemodialysis Unit

= Number of prescription with medication discrepancies / Total number of prescriptions

The result is that if medication reconciliation is not implemented, there would be 75

medication errors in every 100 hemodialysis patients. Thus suggesting the need of a full time

pharmacist at the hemodialysis unit.

Types of Discrepancy

Figure 1: Bar graph shows types of discrepancy during medication reconciliation

Alteration in the frequency of medication prescribed lead to highest number of discrepancy

with a total of 34 discrepancies. Discrepancies lead by changes in the frequency might be

due to need of adjustment of dose and frequency of medications in patient with kidney

problems. 23 discrepancies were due to the adjustment of the dose. Frequent changes in

dosage in hemodialysis patients might lead to the high number of discrepancies. Omission of

medications results in 14 discrepancies. Deterioration in patients‟ condition might be the

rationale behind the number of discrepancies. 3 discrepancies were due to addition of new

medication. In order for a better management of patients‟ health status new drugs might be

required. There were no discrepancies from alteration of route of administration. Changes of

medications only caused 2 discrepancies.

Figure 2: Percentage of Patient Factors and System Factors that contributed to

Medication Discrepancies

2 3

14

22

33

00

5

10

15

20

25

30

35

Change the

drug

Added new

drug

Omitted the

drug

Change the

dose

Change the

frequency

Change the

route

No

. o

f D

iscr

epa

ncy

Types of Discrepancy

Types of discrepancy

System factor

Patient factor



From the bar graph, it illustrates that patient‟s factor is the main contributing factor for

medication discrepancies in hemodialysis patients with a total of 54 patients. While System‟s

factor only appeared in 14 patients. Coleman et. al explained that patient‟s factor might be

due to non-adherence, deficit in performance, unable to tolerate side effects and adverse

drug reactions. While system‟s factor was either due to prescriber unable to recognize

cognitive impairment in their patients, incomplete instructions given to patients and patients

receiving conflicting information from different sources as described by Coleman. Coleman

also stated that both system and patient associated factor contribute equally to the identified

medication discrepancies. Coleman stated in order to reduce the medication discrepancies

attention need to be given for both types of factors in general.

Types of Patient Factor

Figure 3: Bar graphs showing types of patient factor

In this study involving 61 patients, non-adherence has the highest percentage of 58 thus

making it the most common type of patient factor in causing discrepancies. It is then followed

by deficit in performance of 26%. 7% of patient complained of the inability to tolerate the side

effects of the medication. This is followed by adverse drug reaction which results in 6% of

patients. 2% of patients assured that their prescriptions are either not filled or the repeat

prescription was not collected and the feel that the medication is unnecessary. None of the

patients complained of financial barrier since the medications collected by patients at

Selayang Hospital as well as other government hospitals and clinics are subsidized by the

government and thus are free of charge.

58.1

25.5

7.3 5.51.8 1.8 0

0

10

20

30

40

50

60

70

Per

cen

tag

e o

f

Pa

tien

t fa

cto

r

Types of Patient factor

Patient Factor



Types of System Factor

Figure 4: Bar chart showing types of system factor

The highest percentage of system factor in this study is where the prescriber is unable to

recognize cognitive impairment in their patients causing drugs not to be taken as intended

which is 42.9%. This is followed by incomplete or illegible and incorrect instruction given to

the patient with percentage of 28.6. 21.4% of patients admitted that they receive conflicting

information from different sources namely physician, pharmacist and nurses. Next is followed

by incorrect dosage, label and quantity with 7.1% occurrence. None of the patients are being

prescribed drugs with known allergies to the drugs. There are neither issues of confusion

between generic and brand name by the prescribers nor duplication of prescriptions.

42.9

28.6

21.4

7.1

0 0 005

101520253035404550

Prescriber is

unable to

recognize

cognitive

impairment

in their

patients

causing drugs

not to be

taken as

intended

Incomplete/

illegible and

incorrect

instruction

given to the

patient

Patient

received

conflicting

information

from

different

sources

Incorrect

dosage, label

and quantity

Patient being

prescribed

with known

allergies to

the drugs

Confusion

between

generic and

brand name

by

prescribers

Duplication

of

prescription

Per

cen

tag

e o

f

Sy

stem

fa

cto

r

Types of System Factor

System Factor



Common Factors Causing Discrepancies

Figure 5: Bar graphs showing the common factors causing medication discrepancies.

The common types of identified medication discrepancies are provided in graph above. More

than 1 explanatory factor (i.e. patient associated or system associated) may have been used

to categorize each medication discrepancy. At the patient level, non-adherence accounted for

the greatest percentage of identified contributing factors, followed by deficit in performance

and unable to tolerate side effects. At the system level, prescriber is unable to recognize

cognitive impairment in their patient was the most common of the identified contributing

factors, followed by incomplete, inaccurate, or illegible instructions (as a result of either

handwriting or use of Latin abbreviations). Patient-associated factors were found to

contribute more to the identified medication discrepancies than system-associated factors.

There may be many factors that are affecting the patient or caregiver‟s ability to take their

medications, which need assessed and addressed. The term non-adherence is applied to

patients when they are not following the prescribed treatment. Lower educational level, less

affluent economic status, cognitive or physical impairment and some diseases such as

chronic renal failure are commonly reported poorly modifiable correlates of non-adherence.

Non-adherence rates are high in the haemodialysis population with pill burden, complex and

dynamic of medication regimens and patient motivation all being pertinent factors5. Non-

adherence to the prescribed regimen is a common problem in hemodialysis and is associated

with increased morbidity and mortality6.

Physical well-being is a fundamental component of health and quality of life, underpinning

the ability to engage in activities of daily living and participate in social, recreational and

33

14

64 4

0

5

10

15

20

25

30

35

Non-adherence Deficit in

performance

Prescriber is unable

to recognize

cognitive

impairment in their

patients causing

drugs not to be

taken as intended

Unable to tolerate

side effects

Incomplete/

illegible and

incorrect

instruction given to

the patient

PATIENT FACTOR SYSTEM

FACTOR

PATIENT

FACTOR

SYSTEM

FACTOR

Nu

mb

er o

f p

ati

ents

Factors

Common Factors Causing Discrepancies



vocational roles. It has long been recognized that physical function is compromised in

patients with end-stage renal disease (ESRD). This can be attributed primarily to the effects

of uraemia and the comorbidity associated with chronic renal failure, but inactivity also

contributes to physical deconditioning and debilitation7. Dialysis patients suffer physical

limitations which interfere with self-reported health status and quality of life8.

Typically clinicians look at the primary physical or cognitive impairments, but a more detailed

assessment is needed, related to the complex process of medication management.

Physicians are unaware of cognitive impairment in more than 40% of their cognitively

impaired patients9. Clinicians intend to use their "clinical eye" to detect and monitor

cognitive deficits. Many express confidence in their ability to "see" cognitive problems in

patients, despite evidence that unstructured clinical assessments of cognition do not reliably

match neuropsychological test scores10. Clinician education may need to emphasize that

prescribing decisions should be based on valid and reliable assessments rather than clinical

presentations. Clinician education could also address the role for caregivers' and family

members' reports of patients' cognitive functioning11.

Another factor found to contribute to the potential for medication discrepancies among

patients, is the instructions incomplete or inaccurate or illegible either the patient cannot

make out the hand-writing or the information is not written in lay terms. Unclear

communication between physicians and patients often leads to uncertainty in patient care

decisions and may compromise patient safety.

Classes Of Drug Commonly Associated With Medication Discrepancies

Figure 6: Bar graphs showing Classes of drugs commonly associated with medication

discrepancies.

The following 5 medication classes accounted for mostly identified medication discrepancies:

antihypertensive 37.3% (25 cases), electrolyte 23.9% (16 cases), hematinics 20.9% (14

cases), cardiovascular 11.9% (8 cases) and antidiabetics 6.0% (4 cases).

37.3

23.920.9

11.9

6.0

0

5

10

15

20

25

30

35

40

Per

cen

tag

e o

f

dis

crep

an

cies

Classes of drugs

Class of drugs commonly associated with discrepancies



Hypertension is a chronic condition that may result in stroke and heart failure.

Noncompliance is a major factor in the increasing number of deaths related to cardiovascular

disease12. Clearly, noncompliance with regard to hypertension is a major medical problem.

Reason is that patients often do not feel any adverse physical effects. Because of this,

patients do not experience any physical improvements due to the strict compliance to the

medical regimen. The most commonly cited reasons for noncompliance include, not being

convinced of the need for treatment, fear of adverse effects, difficulty in managing more than

1 dose a day, or multiple drug regimens13.

Clinical experience suggests that phosphate binders are probably the single largest

contributor to the daily pill burden14. The high pill burden from phosphate binders may affect

patients‟ adherence to therapy and their ability to maintain optimal serum phosphorus

levels15.

Cardiovascular disease (CVD) is the leading cause of mortality in ESRD patients, accounting

for approximately 50% of deaths16. There is much opportunity to increase use of medications

with known cardio-protective benefit such as aspirin, clopidogrel and ticlopidine.

Interventions Performed

Figure 7: Pie chart showing the types of intervention performed.

Throughout this study, only two types of intervention were made namely „Modify drug orders‟

and „Counseling‟. 98.5% of the intervention involves patient counseling while the rest 1.5%

involves modifying the drug orders in the Electronic Medical Record (EMR) by

communicating with the physician in charge of the patients in the Hemodialysis Unit of

Hospital Selayang.

Limitation

This study has several limitations, mainly its small sample size. Only 61 patients undergoing

hemodialysis in Hospital Selayang are involved in this study. It is a single centre study and

there may be a bias in detecting medication errors.

The medication lists by the prescribers obtained from Selayang Hospital Electronic Medical

Record (EMR) are thought to be up to date when this study was conducted. When

inaccurate lists or not-updated lists are used, errors are more likely to occur, possibly

resulting in harm to the patient.

Performed Intervention

Counselling

Allergy card

Modify drug orders (EMR)98.5%

1.5%



The patient‟s own medication lists obtained from the patients themselves but in some

patients, their medications are not taken care by themselves but their caregivers. While

interviews were done, the caregivers were not around so the accuracy of the medications

cannot be justified.

CONCLUSION

The percentage of medication discrepancies obtained in this study of 61 samples are 15.83%

and the types of medication discrepancies commonly occurring in the Hemodialysis Unit of

Selayang Hospital are (1) change in the frequency; (2) change in the dose; (3) omission of

the drug; (4) addition of a new drug; (5) change of the drug; all in order of the most common

to the least common. This study identified the factors that lead to medication discrepancies

that commonly occurring in the Hemodialysis Unit of Selayang Hospital that are the Patient

factor as well as the System factor, and the patient factor comprises of the major factors.

From this study also, the medications that are commonly associated with medication

discrepancy are obtained, namely the antihypertensives, electrolyte therapy, hematinics,

cardiovascular, and antidiabetics (in order or most common to the least common).

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20. Coraline Claeys, P.M. Tulkens, J. Neve, A. Spinewine – Content validation of a modified

translated version of the medication discrepancy tool, Institute of Pharmacy, Universite

Libre de Bruxelles, School of Pharmacy, Universite Calholique de Louvain, Bruxelles,

Belgium. Retrieved on January 4, 2010 from

http://www.farm.ucl.ac.be/cfcl/Posters/2009/ESCP-2009/Clayes-ESCP-Poster-

2009.pdfAd

21. Kathleen B. Orrico – Sources and Types of Discrepancies between Electronic Medical

Records and Actual Outpatient Medication Use – Journal of Managed Care Pharmacy

(JMCP), September 2008, Vol. 14, No.7. Retrieved on January 4, 2010 from

http://www.amcp.org/data/jmcp/626-631_8040-Final.pdf

22. Retrieved on January 2, 2010 from

http://www.micromedex.com/solutions/medicationreconciliation/

23. Electronic Medication Reconciliation FAQs. Retrieved on January 3, 2010 from

http://www.seattlechildrens.org/pdf/electronic_medication_reconciliation_faqs.pdf

24. Medication Reconciliation. Retrieved on January 3, 2010 from

http://www.nmh.org/nmh/pdf/Edu%20-%20Pocket%20Card%20Supplement.pdf

http://www.ashp.org/s_ashp/docs/files/MedRec_MCM06_Abstract_322.pdf

http://www.medscape.com/viewarticle/712270

http://www.nmh.org/nmh/pdf/Edu%20%20Unintended%20Med%20Discrepancies.pdf

http://www.farm.ucl.ac.be/cfcl/Posters/2009/ESCP-2009/Clayes-ESCP-Poster-2009.pdf

http://www.farm.ucl.ac.be/cfcl/Posters/2009/ESCP-2009/Clayes-ESCP-Poster-2009.pdf

http://www.amcp.org/data/jmcp/626-631_8040-Final.pdf

http://www.micromedex.com/solutions/medicationreconciliation/

http://www.seattlechildrens.org/pdf/electronic_medication_reconciliation_faqs.pdf

http://www.nmh.org/nmh/pdf/Edu%20-%20Pocket%20Card%20Supplement.pdf



APPENDICES

1.0 Data collection timetable

HD

Sessions

1 2 3 4 5 6

Session 1

Session 2

Session 3

Session 4

Researcher A B C D E F

* to fill in the number of patients and the name of patient for the appropriate session that the

researcher wishes to interview.

2.0 Medication Reconciliation data collection form (MRF1)

Medication Chart


55 Status Kesihatan Periodontium Di Kalangan Pesakit Diabetes Di Klinik Diabetes Klinik Kesihatan Anika Klang, Selangor

STATUS KESIHATAN PERIODONTIUM DI KALANGAN PESAKIT DIABETES

DI KLINIK DIABETES KLINIK KESIHATAN ANIKA KLANG, SELANGOR

Azirah Bt Muhammad

Dip ( Kejururawatan Pergigian ), Pos Basik ( Periodontik )

Klinik Pergigian Kelana Jaya,

Bahagian Kesihatan Pergigian, Jabatan Kesihatan Negeri Selangor

ABSTRAK

Pengenalan: Ramai pesakit Diabetes mellitus (DM) dikatakan cenderung untuk menghidapi

penyakit periodontal. Setakat ini tiada kajian pernah dilakukan untuk melihat prevalens

penyakit periodontal di kalangan pesakit ini di Klinik Diabetes, Klinik Kesihatan Anika Klang.

Sekiranya benar, maka semua pesakit Diabetes harus mendapat bimbingan dan rawatan

dari Klinik Pergigian untuk mencegah penyakit periodontal ini.

Objektif: Objektif utama kajian ini adalah untuk menentusah kejadian penyakit periodontal di

kalangan pesakit DM dan mengenalpasti kaitan faktor lain seperti umur, jantina dan paras

gula dalam darah pesakit.

Methodologi : Kajian ini adalah kajian cross-sectional yang melibatkan sampel mudah

seramai 30 peserta pesakit DM yang hadir di Klink Diabetes. Hanya mereka yang memberi

persetujuan sahaja yang terlibat. Pengumpulan data dilakukan dari bulan September hingga

Oktober 2009 iaitu selama dua bulan. Pengukuran skor penyakit periodontal dilakukan

mengunakan Skor BPE kod 0 hingga kod 4. Paras gula dalam darah pesakit adalah

berdasarkan keputusan ujian kimia yang dibuat oleh makmal di Klinik Kesihatan Anika Klang.

Keputusan: Di dapati semua pesakit DM mempunyai penyakit periodontal.Tahap skor yang

diperolehi adalah peringkat BPE kod 3 (33.7%) dan BPE kod 4 (66.3%). Pada tahap paras

gula yang sama, kaum lelaki di dapati mempunyai risiko yang lebih tinggi dibanding kaum

perempuan. Peringkat umur juga ada kaitan dengan keparahan penyakit periodontal di mana

mereka yang lebih tua adalah lebih cenderung untuk mendapat skor yang tertinggi. Pesakit

yang mempunyai paras gula 13mmol/l kebawah mendapati skor BPE kod 3 sementara

semua pesakit yang mempunyai paras gula lebih dari 13mmol/l mendapat skor penyakit

periodontal yang teruk (BPE kod 4).

Kesimpulan: Prevalens kejadian penyakit periodontal adalah 100% bagi pesakit Diabetes

Mellitus. Kejadian ini berkaitan dengan jantina, paras gula dalam darah dan peringkat umur

pesakit. Semua pesakit DM perlu menjaga kebersihan mulut dan mendapat rawatan gusi

seawal mungkin. Paras gula dalam darah harus dijaga ketahap yang baik.

PENGENALAN

Penyakit Diabetes Mellitus (DM) di takrifkan sebagai pesakit yang mempunyai paras glukos

melebihi 10mmol/l didalam darah. Banyak kajian telah menunjukkan bahawa penyakit

Diabetes Mellitus (DM) mempunyai hubungkait dengan penyakit periodontium. Setakat ini

,tiada kajian pernah dijalankan di Klinik Anika Klang untuk menentukan hubungkait antara

status kesihatan periodontium dengan paras gula didalam darah pesakit DM. Kajian ini boleh

membantu menambah informasi mengenai kaitan penyakit periodontium didalam pesakit

yang sedang menghadapi penyakit DM dan dengan itu boleh mengambil langkah pemulihan

dan pencegahan yang sewajarnya.



KAJIAN LITERATURE

Periodontium adalah tisu–tisu yang mengelilingi dan menyokong struktur gigi. Struktur

penyokong gigi terdiri dari gingiva, ligamen periodontium, simentum dan tulang alveolus.

Fungsi utama periodontium adalah untuk pelekatan gigi pada tulang dan pengekalan integriti

mukosa kunyahan. Kesihatan periodontium sering di ancam oleh kehadiran lapisan plak iaitu

satu lapisan nipis yang lembut, melekit dan mudah melekat erat keatas permukaan gigi.

Permukaan plak ini jika di biarkan akan menjadi keras hasil terkalsifikasi menjadikan

permukaannya kasar dan memudahkan bakteria terkumpul. Bakteria akan berkongsi

makanan apa yang kita makan dan seterusnya akan mengeluarkan bahan buangan yang

terdiri daripada asid dan toksin. Pendedahan yang berpanjangan dari asid ini boleh

menyebabkan karies gigi .Hasil pengeluaran toksin berterusan meningkatkan kemungkinan

masuknya bakteria dan bahan toksik ini kedalam gusi untuk menyebabkan gingivitis. Dalam

keadaan ini gusi akan menjadi merah, bengkak dan mudah berdarah.

Jika gingivitis tidak di rawat, penyakit gusi akan melarat ke kawasan tisu ligamen

periodontium. Keadaan ini di panggil penyakit periodontium atau periodontitis. Penyebab

utama penyakit gusi adalah pembersihan plak yang tidak di kawal sehingga kemusnahan

struktur periodontium. Periodontitis boleh di kesan dengan adanya tanda-tanda gingivitis

bersama-sama dengan terbentuknya poket periodontal. Melalui pemeriksaan x-ray

Opthopanthogram (OPG) pula, penyakit periodontium dapat di kesan dengan kehilangan

tulang alveolus keseluruhannya. Penyakit periodontium boleh mengurangkan kualiti

kehidupan seseorang individu (Quality of Life) dari segi;

1) Paras rupa kurang sempurna.

2) Masalah pemakanan dan nutrisi kerana kefungsian gigi yang tidak sempurna.

3) Masalah sosial kerana mulut berbau dan gusi berdarah.

Tanda dan simptom periodontitis adalah

• Tanda seperti gingivitis seperti merah, keradangan dan mudah berdarah.

• Sebahagian gingiva boleh menjadi bengkak dan bernanah.

• Halitosis atau nafas berbau.

• Poket atau ruang di pinggir gingiva yang melebihi 3mm bila diukur dengan prob

periodontium.

• Pada peringkat lewat gigi akan menjadi longgar atau goyang.

Terdapat juga golongan yang lebih ramai mengidap periodontitis seperti pesakit diabetes

mellitus, perokok dan beberapa penyakit keturunan atau kongenital seperti Ehlers-Danlos.

Malaysia telah di kelaskan sebagai negara keempat tertinggi di Asia yang menghidap

diabetes. Menurut Kajian Kesihatan dan Mobiditi Kebangsaan 2006 menunjukkan 1.6 juta

rakyat atau setiap seorang daripada 8 penduduk negara ini yang berusia 30 tahun keatas

menghidap kencing manis. Ini adalah peningkatan sebanyak 80 peratus dalam tempoh 10

tahun iaitu daripada 8.3 peratus pada 1996 kepada 14.9 peratus pada 2006 dan di

anggarkan bertambah kepada 25 peratus pada 2020. Kesatuan Diabetes Antarabangsa

menjangkakan jumlah pesakit akan melonjak kepada lebih 435 juta menjelang 2020. Oleh itu

kajian tentang penyakit periodontal di kalangan pengidap diabetes perlu di lakukan. Kajian ini

boleh menyumbang untuk mengenali keperluan beban kerja dibidang periodontal serta cara

mengatasinya.



OBJEKTIF KAJIAN

Objektif umum kajian ini adalah untuk menentukan apakah benar penyakit periodontium

berlaku dikalangan pesakit DM.

Objektif khusus adalah untuk menentukan kekerapan berlakunya penyakit periodontal

dikalangan pesakit DM dan kaitan paras gula pesakit DM dengan skor penyakit

periodontium yang dialami. Tahap kebersihan mulut turut diukur untuk memberi gambaran

mengenai status kebersihan mulut pesakit DM yang di kaji.

METHODOLOGI

Jenis kajian : Kajian ini dilakukan secara cross-sectional selama dua bulan dari

September 2009 hingga Oktober 2009. Pensampelan diambil dari kalangan pesakit diabetes

Mellitus yang hadir di Klinik Kesihatan Anika Klang. Hanya mereka yang memberi

persetujuan secara verbal diambil sebagai peserta kajian ini. Sampel diperolehi dengan

memilih pesakit diabetes yang mempunyai tahap gula dalam darah melebihi 10mmol/l .

Pemilihan Sampel dan Saiz : Seramai 30 orang pesakit (16 perempuan dan 14 lelaki)

melibatkan diri dalam kajian ini.

Kaedah ukuran : Status penyakit periodontal di ukur mengunakan Kod BPE 0 hingga kod

BPE 4 dimana kod 4 adalah paling teruk dan 0 adalah paling baik. Disclosing tablet telah

digunakan untuk menambah penglihatan semasa mengukur status kesihatan periodontium.

Ujian gula didalam darah pesakit DM diambil untuk menentukan paras gula semasa kajian

dijalankan. Dibawah adalah panduan untuk pengukuran status periodontal :

Kod Kreteria Rawatan

0 Sihat, tiada pendarahan/poket,

Jalur hitam kelihatan sepenuhnya. Tiada Rawatan yang diperlukan

1

Pendarahan semasa diprob tanpa

kehadiran poket yang melebihi

3.5mm/kalkulus. Jalur hitam

kelihatan sepenuhnya.

Tunjuk Ajar Higin Mulut

2

Terdapat faktor pengumpulan plak

tetapi tiada poket yang melebihi

305mm, Jalur hitam kelihatan

sepenuhnya.

Tunjuk Ajar Higin Mulut, Penskaleran,

Buang Faktor Pengumpulan Plak

3 Poket di antara 3.5mm-5.5mm,

Jalur hitam kelihatan separuh.

Tunjuk Ajar Higin Mulut, Penskaleran

Supra dan Subgingiva

4 Poket melebihi ≥6mm, Jalur hitam

tidak kelihatan.

Rawatan Terperinci diperlukan,

Penskaleran Subgingiva, Pembedahan

* Jika melibatkan furkasi, resesi

gingiva, mobolity / kegoyahan gigi.



Kaedah Pengumpulan Data

Kebenaran rawatan dan pemeriksaan di perolehi selepas penerangan secara verbal

diterangkan kepada pesakit tentang kajian ini. Maklumat pesakit seperti umur, jantina dan

paras gula dikumpul. Pemeriksaan saringan periodontium dilakukan dan dicatit.

Penganalisaan Data

Kiraan mudah digunakan untuk mencerakinkan data yang telah dikumpul seperti

mengunakan kekerapan dan peratusan. Hasil analisa juga diproses mengikut jantina,

peringkat umur dan paras gula dalam darah pesakit. Graf dihasilkan daripada keputusan

analisa ini untuk mengambarkan hasil kajian dengan lebih jelas.

HASIL KAJIAN

Sosiodemografik Sampel

7.1 Peratus sampel mengikut jantina dan umur.

Jadual 1: Peratus Sampel Mengikut Jantina dan Umur

Demografik Ciri-ciri sampel Bilangan dlm sampel (n) Peratus

Jantina

Lelaki

Perempuan

Jumlah

14

16

30

46.6%

53.4%

100.0%

Umur

30-39

40-49

50-59

60-69

Semua

4

12

7

7

30

13.3%

40.0%

23.0%

23.0%

100.0%

Bilangan pesakit diabetes yang terlibat dalam kajian ini adalah seramai 30 orang seperti di

Jadual 1 iaitu 14 orang adalah lelaki manakala 16 orang adalah perempuan. Dari segi umur

pula, pesakit yang berumur 30-39 adalah seramai 4 orang, 40-49 adalah seramai 12 orang

dan pesakit yang berumur 50-59 dan 60-69 adalah masing-masing seramai 7 orang.

7.2 Prevalens keseluruhan

Rajah 1: Prevalen Kejadian Penyakit Periodontal

0

5

10

15

20

BPE 0 BPE1 BPE2 BPE3 BPE4

0 0 0

11

19

Bila

nga

n

Tahap skor penyakit periodontal

63.3%

%

36.7%



Prevalen kejadian penyakit periodontal adalah 100% dimana skor BPE kod 3 adalah 36.7%

dan BPE kod 4 adalah 63.3%.

7.3 Prevalens Mengikut Jantina

Rajah 2: Prevalen Kejadian Penyakit Periodontal Mengikut Jantina

Rajah 2 menunjukkan bahawa 100% pesakit DM mempunyai penyakit periodontium tanpa

mengira jantina. Tahap skor penyakit periodontium yang dialami adalah di peringkat yang

teruk iaitu BPE 3 ( 37.0%) dan BPE 4 (63.0%). Sekiranya dibanding mengikut jantina: lebih

ramai kaum lelaki mendapat Skor BPE kod 4 iaitu 85.7%, (n=12) dibanding Skor BPE kod 3

iaitu 14.3% (n=2). Bagi kaum perempuan Skor BPE kod 3 terdiri dari 56.3% (n=9)

sementara skor BPE kod 4 adalah lebih rendah iaitu 43,7% (n=7).

7.4 Prevalen Mengikut Peringkat Umur

Rajah 3: Prevalen Kejadian Penyakit Periodontal Mengikut Umur

0

1

2

3

4

5

6

7

8

30-39thn 40-49thn 50-59thn 60-69thn

0 0 0 00 0 0 00 0 0 0

1

4

1

33

8

6

4BPE 0

BPE1

BPE2

BPE3

BPE4

85.7%

43.7%

) 14.3%

%

56.3%



Rajah 3 menunjukkan peratus bilangan pesakit diabetes yang diperiksa mengikut umur.

Pada keseluruhannya, skor BPE4 adalah lebih prevalen dari BPE3 di semua lapisan umur

terbabit.

7.5 Prevalen Mengikut Paras Gula Dalam Darah Pesakit Dalam Mmol/l

Rajah 4: Prevalen Kejadian Penyakit Periodontal Mengikut Paras Gula Dalam Darah

Rajah 4 menunjukkan perbandingan skor BPE mengikut paras gula dalam darah.

Skor BPE3 dikaitkan dengan mereka yang mempunyai paras gula dalam darah yang kurang

daripada 13mmol/l dan Skor BPE4 dikaitkan dengan paras gula melebihi 13mmol/l. Ini

menunjukan, pesakit DM yang mempunyai paras gula melebihi 13mmol/l menunjukkan

keadaan penyakit periodontal yang lebih teruk iaitu skor BPE kod 4.

7.6 Status Kebersihan Mulut Pesakit DM yang dikaji

Rajah 5: Status Kebersihan Mulut Pesakit DM yang dikaji.

BPE0

BPE2

BPE4

0

2

4

6

8

10

1211

0 0 0 0

0

87

2 2

BPE0

BPE1

BPE2

BPE3

BPE4

0%

10%

20%

30%

40%

50%

60%

70%

Tidak memuaskan

sederhana baik sangat baik

kebersihan mulut 67% 16.70% 9.90% 6.60%



Rajah 5 diatas menunjukkan kebersihan mulut pesakit diabetes. Sebilangan besar dari

pesakit DM mempunyai kebersihan mulut yang tidak memuaskan iaitu 67.0%. Selebihnya

hanya 6.6 % mempunyai kebersihan mulut yang sangat baik; diikuti dengan 9.9% baik.

Pesakit yang mempunyai kebersihan sederhana seramai 16.7% masih perlu meningkatkan

kebersihan mulut supaya tidak menjadi teruk. Gambaran ini menunjukkan agak ramai

pesakit DM menghidapi kebersihan yang kurang sempurna. Ini menunjukkan perlunya

pendidikan kesihatan pergigian bagi meningkatkan kesedaran dan amalan pesakit.

PERBINCANGAN

Ada beberapa faktor yang mungkin memberi limitasi kepada kajian ini. Pertamanya sampel

saiz agak kecil dan pemilihan peserta bergantung kepada kesudian pesakit mengambil

bahagian didalam kajian ini. Ini tidak dapat dielakkan kerana kesuntukan masa. Pengambilan

sampel berdasarkan bilangan pesakit yang hadir di Kinik Diabetes Klinik Kesihatan Anika

Klang. Disamping itu, pesakit yang berumur lingkungan 40-49 tahun mempunyai peratus

paling tinggi iaitu sebanyak (40.0%), diikuti pesakit yang berumur diantara 50-59 (23.0%)

dan 60-69 tahun sebanyak (23.0 %) berbanding dengan peringkat umur 30-39 tahun

sebanyak 13.3 % ( jadual 1 ). Ini mungkin menunujukan bahawa penyakit DM adalah lebih

kerap berlaku diperingkat umur 40-49 tahun.

Jika dibanding mengikut jantina, lebih ramai kaum lelaki mengalami skor BPE kod 4 (85.7%)

berbanding dengan kaum perempuan (43.7%). Ini menunjukan, pada paras gula yang sama,

risiko penyakit periodontal bagi kaum lelaki (rajah 1) adalah lebih tinggi.

Hasil kajian ini menunjukkan jantina, umur dan paras gula dalam darah pesakit mempunyai

kaitan dengan risiko penyakit periodontal. Hasil kajian yang dijalankan oleh Kementerian

Kesihatan Malaysia (NOHSA, 2000), menunjukkan lebih tinggi peringkat umur, lebih tinggi

risiko penyakit periodontal.

Skor BPE kod 3 dan 4 dalam kajian ini memberi implikasi bahawa kesemua pesakit DM

memerlukan rawatan periodonti dan pergigian yang lebih kompleks dari keadaan biasa. Oleh

itu pesakit diabetes, perlu mengawal penyakit mereka dengan mengawal pemakanan dan

ubat-ubatan yang betul supaya boleh mengekalkan paras gula yang optimum. Nasihat

daripada doktor dan pakar pemakanan adalah mustahak untuk membantu pesakit mengawal

keadaan yang tidak diingini. Glukos yang tinggi dalam darah boleh menjadi medium yang

sesuai untuk pembiakan bakteria oral. Ia juga akan menyebabkan aktiviti sel-sel pertahanan

dalam darah menurun. Kehadiran keadaan ini bersama dengan penjagaan higin mulut

kurang memuaskan, boleh memburukkan lagi masalah periodontium, memusnahkan tisu-tisu

sokongan gigi dan menyebabkan kelonggaran gigi.

Bagi pesakit diabetes yang mempunyai tahap gula dalam darah yang lebih rendah iaitu 10-

12mmol/l, skor BPE yang tertinggi adalah 3 manakala pesakit yang mempunyai tahap gula

13mmol/l dan ke atas mendapat skor BPE 4 (rajah 4). Maka mengawal tahap gula dalam

darah amat perlu dipantau untuk mengurangkan penyakit periodontium daripada menjadi

lebih teruk.

Yang amat merisaukan dalam kajian ini adalah 66.8% daripada pesakit DM mempunyai

kebersihan mulut yang tidak optimum; kerana tahap kebersihan mulut yang tidak sempurna

boleh memberi impak negatif kepada status kesihatan mulut ( rajah 4 ).



Menurut kajian yang dilakukan oleh Snbberg et.al ( 2001 ) 85.0% pesakit DM didapati tidak

pernah menerima sebarang maklumat yang spesifik tentang kaitan penyakit diabetes dan

kebersihan mulut dan 83.0% tidak mengetahui kaitan diri pesakit dengan risiko kesihatan

mulut dan lalai tentang kesan-kesan sampingan penyakit tersebut mahupun kesan dari

pengambilan ubat-ubatan tertentu terhadap penyakit gusi. Bagi pesakit DM di Klinik Anika

Klang, sesuatu harus dipertingkatkan untuk memastikan pesakit DM mendapat bimbingan

kesihatan pergigian yang diperlukan.

KESIMPULAN

Prevalens penyakit periodontal bagi pesakit DM adalah 100%. Ini bermaksud penyakit

periodontium mempunyai kaitan yang rapat dengan kejadian penyakit DM. Paras gula dalam

darah pesakit DM ada satu faktor penyumbang terhadap keparahan penyakit periodontal

yang dialami. Lebih tinggi paras gula lebih teruk penyakit periodontal dialami. Didalam kajian

ini paras gula >13mmol/l merupakan suatu penanda aras yang boleh menentukan kejadian

status penyakit periodontal yang paling teruk (skor BPE4). Kebersihan mulut yang sihat

boleh mengurangkan penyakit periodontal tetapi didalam kajian ini, 66.8% pesakit adalah

pada tahap kebersihan mulut yang tidak baik.

Ini bermaksud , setiap pesakit DM perlu di beri dedahan tentang cara menjaga kebersihan

mulut dengan betul dan perlu ambil berat mengenai paras gula dalam darah mereka.

Implikasi klinikal: Pesakit DM cenderung untuk mengalami penyakit gusi. Oleh itu,

disamping mengawal paras glukos ketahap kurang dari 10mmol/l, pesakit perlu menjaga

kesihatan mulut dengan baik untuk mencegah penyakit periodontal supaya boleh mengecapi

kualiti hidup yang sempurna berpanjangan.

RUJUKAN

1. Cairo F, Rotundo R, Frazinggaro G, Muzzi L, Pini Prato GP. Minerva Stomatol, 2001

Sep-Oct : 50(9-10) 321-320.

2. Nota-nota syarahan.

3. National Oral Health Survey on Adults,2000.Kementarian kesihatan Malaysia, 2001.

4. Ronderos, M & Ryder, M.I Risk Assessment in Clinical Practice Periodontology .200-

2004:34:120-135.

5. Sanbberg, DM and Oral Care, Dental Update .May 2004 : 195.

6. Surat akhbar Metro Ahad, 15 november 2009 : E2


63 The Efficacy Of Psychiatry Medication Adherence Clinic (MTAC) At Hospital Tengku Ampuan Rahimah (HTAR) Klang, Selangor

THE EFFICACY OF PSYCHIATRY MEDICATION ADHERENCE CLINIC (MTAC) AT

HOSPITAL TENGKU AMPUAN RAHIMAH (HTAR) KLANG, SELANGOR

Khaw P.H., Manimegahlai S., Anusuya K.

Department of Pharmacy, Hospital Tengku Ampuan Rahimah (HTAR) Klang, Selangor

ABSTRACT

Introduction: Some of the common mental illnesses include major depressive disorder,

anxiety disorder, sleep disorder, cognitive disorder, schizophrenia, bipolar affective disorder,

substance abuse disorder, psychiatric syndrome, personality disorder and attention deficit

hyperactive disorder.

Objective: To improve patients‟ medication adherence and to improve patients‟ knowledge

on their disease and medication prescribed.

Methodology: Data was collected from the forms used in the Medication Therapy

Adherence Clinic (MTAC) which are; the Modified Morisky Scale; Pharmacist‟s intervention

form and from the DFIT (medications Dosage, Frequency, Indication and Time) score.

Results : The number of non-compliant patients decreased from 34 patients (68%) to 11

patients (22%) and the number of compliant patients increased from 16 patients (32%) to 39

patients (78%) between the first and second visits showing significant increase in compliance

towards medications (P-value < 0.001). In addition to that, there was significant reduction in

drug related problems (P-value < 0.01) from 48 drug related problems during patient‟s first

visit, and a reduction to 27 drug related problems during the second visit. There was also

significant reduction in non-compliance due to effective counselling sessions by pharmacist

during MTAC sessions (P-value < 0.05). Knowledge on how to take their medications

correctly increased from 74.5% to 92.7% showing significant improvement in DFIT (P-value <

0.001). From the 50 patients who were interviewed, 31 interventions (62%) were identified.

Difference in the mean of total drug related problems (0.42) was compared to the number of

interventions identified, showing intervention by pharmacists significantly reduced drug

related problems (P-value < 0.05).

Conclusion: The MTAC psychiatry program conducted in Hospital Tengku Ampuan

Rahimah (HTAR), Klang played a vital role in improving patient‟s adherence towards

medication and improving patients‟ knowledge on their disease and medication prescribed,

hence improving the treatment outcome and improving the overall management of the

disease.

INTRODUCTION

Mental health is defined as a state of balance in physical, mental and social well-being where

the individual is aware of his or her abilities; is able to cope with normal stresses of life; is

able to work productively; and is able to make contribution to his or her community. In a

rapidly developing country such as Malaysia; people often strive hard to survive with the

stress and tension, which may eventually contribute to mental health problems.1 Mental

illness is commonly termed to describe any significant interference to the cognitive,

emotional or social abilities; which is diagnosed base on the standardized criteria for

diagnosis listed in the International Classification of Diseases (ICD-10) or the Diagnostic and

Statistical Manual of Mental Disorders (DSM-IV).1,2

Some of the common mental illnesses include major depressive disorder, anxiety disorder,

sleep disorder, cognitive disorder, schizophrenia, bipolar affective disorder, substance abuse



disorder, psychiatric syndrome, personality disorder and attention deficit hyperactive

disorder.3

The concept of pharmaceutical care had been introduced where the health care team which

comprises of physicians, pharmacists and other related health care professional; plays an

important role in the development of treatment therapy which will improve the patients‟

quality of life.6

However, treatment of mental illness requires good adherence in the treatment therapy.

Thus, a more comprehensive measure is required to increase the knowledge of this illness,

importance of treatment and to clarify misconception about mental illness. Introduction of the

psychiatry Medication Therapy Adherence Clinic (MTAC) is an effort to improve the

treatment therapy by cultivating adherence, monitoring of clinical progression and detection

of adverse effect.

Shoka et al. (2007) had estimated the rate of non-compliance in psychotic disorder maybe as

high as 80%; which may be confused with non-responsive to treatment and result in

switching of alternative antipsychotic.7 A separate study by Llorca et al. (2007) had discussed

partial compliance where patients do not follow the treatment therapy as instructed and thus,

unable to receive the benefits from their treatment.8 Among the ways to cultivate adherence

to treatment therapy includes illness and medication knowledge; effective and well-tolerated

treatment; frequent follow-up; social support; and family motivation.8,9 These can be done

through the operation of MTAC; where patients are monitored, counselled; and dispensed

with medications at monthly interval by the pharmacists.

Amongst the adverse effects and drug related problems which could be monitored through

MTAC includes the extrapyramidal symptoms (EPS), prolactin level and weight gain. EPS

which is very common with the usage of typical antipsychotic should be treated accordingly

to improve patients‟ quality of life. Increment in prolactin hormone which causes lactation,

occur more with the usage of typical antipsychotic.10 In females, hyperprolactinaemia may

also disrupt the ovarian function causing heavy menstruation.10 The excessive weight gain

which is more common in patients‟ using atypical antipsychotic should be cautioned as it

would eventually lead to type-2 diabetes mellitus, hyperlipidaemia and cardiovascular

disorders.11

The Pharmacy Department of Hospital Tengku Ampuan Rahimah (HTAR), Klang, had

established the Psychiatry MTAC in April 2009 which aims to assist the psychiatrists and

medical officers in the psychiatry department. The service provided by the pharmacists

includes providing adequate and relevant information to patients; cultivating adherence; and

monitoring and addressing drug related problems to improve patient‟s quality of life. The

pharmacist would act as a point of coordination and communication between the patient, the

primary health-care team, the community mental-health team and hospital-based health

professionals.

The service of MTAC is not limited to psychiatric outpatients only; but to patients whom are

warded where they will be monitored in the ward by a ward pharmacist and they in turn will

be referred to the MTAC clinic upon discharge if adherence to medication is found to be

poor. The role of the pharmacists extends to the community psychiatry team. The community



psychiatry team is a multi disciplinary team where the pharmacist plays a role in addressing

any drug related problems and enforcing compliance towards the medications. This study

aims to identify the efficacy and benefits of the Psychiatry MTAC.

Research Objective

The objectives of the project are:

To improve patients‟ medication adherence

To improve patients‟ knowledge on their disease and medication prescribed

METHODOLOGY

Data Collection Form

Data was collected from the forms used in the MTAC which are: the Modified Morisky scale;

Pharmacist‟s intervention form and from the medications Dosage, Frequency, Indication and

Time (DFIT).

The Modified Morisky form has an eight items questionnaire which covered topics about

patient‟s knowledge on treatment regimens and treatment concerns; such as side effects,

risks and benefits. Patients‟ adherence was obtained from the values given; where Morisky

score of ≤ 3 is compliant, while Morisky score of 4 – 11 is non-compliant.

The drug related problems comprises of seventeen items which are common problems

encountered by patients. An additional column is allocated for other problems apart from the

stated. Relevant laboratory results are recorded to identify side effects of medication.

Appropriate interventions are carried out whenever necessary to resolve the drug related

problems.

The medication knowledge aims to assess patients‟ medication knowledge on the dosage,

frequency, indication and time (DFIT). A DFIT score is then generated by:

Research Design

The Psychiatry MTAC is located in the Ambulatory Care Centre (ACC) of HTAR. It operates

every Tuesdays and Thursdays from 9.00am to 1.00pm. Patients are referred to the MTAC

by the specialists and medical officers. Subsequent follow-up with the pharmacists were

recruited to this study based on the inclusion and exclusion criteria. The duration of the study

was scheduled to be six months starting from August 2010 to January 2011.

During the initial visit, referred patients will be interviewed and introduced to the MTAC and

the pharmacist will then proceed with the education of the disease and prescribed

medications; followed by adherence enforcement. The pharmacist will monitor the patient for

any drug-drug interactions, side effects and drug related problems. After the initial interview,

the pharmacist will schedule a follow-up appointment at monthly interval to evaluate the

patients‟ compliance issues, change in medications, drug-related problem, side effects of

DFIT SCORE = Patient‟s score x 100%

Number of medications x 4



medications and monitoring of medications with narrow therapeutic index. Monitoring will be

conducted at every visit follow by necessary intervention.

For this study, data was collected on the first visit and the subsequent visit.

Sampling

The sample size collected was 50 patients who included newly diagnosed patients, referred

patients and follow-up patients. For this study, patients were recruited according to the

inclusion and exclusion criteria.

Inclusion Criteria

Patients of different races.

Patients ranging from the age of 20 to 65 years old.

Patients from both the sexes.

Patients who had been referred to MTAC by the prescriber.

Patients who were on antipsychotic medication therapy in HTAR for indications such

as schizophrenia, bipolar disorder, major depressive disorder, general anxiety

disorder, obsessive compulsive disorder ,panic disorder and drug induced disorders,

mental retardation and dementia

Exclusion Criteria

Patients who are either dumb or deaf.

Patient who were transferred to other health facilities.

Patients who have passed away.

Statistical Analysis

The answer for each data collection item was scored accordingly and all data were analyzed

using Statistical Package for Social Science© (SPSS©), version 16.0. The variables

analyzed were adherence to dosage regimen, drug related problem and medication

knowledge.

Test of normality (Shapiro-Wilk test) was conducted and it was found to be not significant.

Hence, non-parametric statistical test was used to analyze the results. For Morisky score,

drug related problems and DFIT; Wilcoxon signed-ranks test was used to analyze the results.

A P-value < 0.05 would indicate a significant difference in the result between the first month

and second month visit. For the interventions; Kruskal-Wallis test was conducted. A P-value

< 0.05 would indicate there is a significant difference in the findings.

RESULTS

Patient demographics

Based on Figure 1, majority of patients were from the age group of 21-30 years old. This is

followed by age group of 31-40 years old. The least number of patients were from the age

group of less than 21 years old. The mean age of the patients was 40 years old (range

between 41-50 years old).



Figure 1: Distribution of patients according to age (n = 50)

In this study, a total of 50 psychiatric patients were recruited. The number of male patients

(52%) was slightly higher than the female patients (48%).

Figure 2: Distribution of patients according to gender (n = 50)

Based on Figure 3, highest percentage of patients were of Indians (42%), followed by

Chinese (32%) and Malays (24%).

Figure 3: Distribution of patients according to race (n = 50)

6%

28%

26%

10%

30%<21

21-30

31-40

41-50

>50

52%

48%

Female

Male

32%42%

24% 2%

Chinese

Indian

Malay

Others



According to Figure 4, majority of patients (46%) were suffering from schizophrenia. This is

followed by major depression disorder (30%), psychosis and bipolar mania disorder both

having 6% of total population.

Figure 4: Distribution of patients according to diagnosis (n = 50)

Morisky Score

Based on Figure 5, 16 patients (32%) were classified as compliant to medication based on

the Morisky score on the first visit. The remaining 34 patients (68%) who were non-compliant

were recruited into the MTAC. Morisky score of 0-3 was categorized as compliant to

medication and 4-11 was categorized as non-compliant to medication. On the second visit,

the number of patients who were compliant increased to 39 patients (78%) and the number

of patients who were non-compliant decreased to 11 patients (22%). After comparing the

Morisky score between the first and subsequent visit using statistical analysis (Wilcoxon

signed-ranks test), there is a significant increase in the number of patients who are compliant

to medication between the first and second visit (P < 0.001).

Figure 5: Comparison of Morisky Score between first and second visit (n = 50)

6% 2%4%

2%

30%

2%2%

6%

46%

Bipolar Mania Disorder

Dementia

Drug Induce Psychosis

General Anxiety Disorder

Major Depression DisorderMental Retardation

Obsessive Compulsive DisorderPsychosis

Schizophrenia

16

39

34

11

0

5

10

15

20

25

30

35

40

45

Nu

mb

er o

f p

atie

nts

Compliant

Non-compliant

Second VisitFirst Visit



Drug Related Problems

Figure 6 shows the example of drug related problems identified during the first and

subsequent visit in MTAC. A total of 48 drug related problems were identified on the first visit.

Upon the subsequent visit to MTAC, the number of drug related problems reduced to 27

whereby there was a reduction of 43.8%.

Figure 6: Drug related problems identified during the first and subsequent visit

Figure 7 shows the comparison of total mean of drug related problems between first and

second visit. The mean of drug related problems were 0.96 on the first visit. After being

referred to MTAC psychiatry, the mean of drug related problems reduced to 0.54 whereby

there is reduction by 43.8%. The P-value was < 0.005 showing significant reduction in drug

related problem between first and second visit.

Figure 7: Comparison of total mean of drug related problems between first and second

visit

0 2 4 6 8 10 12 14

Extrapyrimidal symptoms

Tardive dyskinesia

Oculogyric crisis

Hypersalivation

Blurring of vision

Palpitation

Rash

Alopecia

Amenorrhoea

First Visit Second Visit

0.96

0.54

0

0.2

0.4

0.6

0.8

1

1.2

Dru

g R

ela

ted

Pro

ble

ms




Figure 8 shows comparison of number of patients who were non-compliant to their

medications between the first and the second visit. On the first visit, 31 patients (62%) were

non-compliant to their medication. After being seen by the pharmacist at MTAC, there was a

reduction in the number of patients who were non-compliant towards their medication to 20

patients (40%). There was a significant reduction in the number of patients who were non-

compliant. The P-value was < 0.05.

Figure 8: Comparison of number of patients who were non-compliant to their

medications between the first and the second visit

DFIT

According to Figure 9, patients‟ mean DFIT score was only 74.50% on the first visit. Upon the

subsequent visit, the mean DFIT score increased to 92.71% (P < 0.001), showing a

significant increase in patients knowledge on medications dosage, frequency, indication and

time.

Figure 9: Comparison of DFIT score between first and subsequent visit

31

20

0

5

10

15

20

25

30

35

Nu

mb

er o

f p

atie

nts


74.50%

92.71%

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

90.00

100.00

Pe

rce

nta

ge




Interventions

Figure 10 shows the list of interventions identified during the first and second visit in MTAC.

From the 50 patients who were interviewed, a total of 31 interventions (62%) were identified.

The interventions were then classified into 6 categories as shown in Figure 3.10. The highest

percentage of intervention was regarding side effects (29%). This was followed by

inappropriate dosing, 23% of total interventions.

Figure 10: List of interventions identified during first and second visit

Figure 11 shows total mean of drug related problems between the first and the second visit

and the difference of mean drug related problem. The P-value was found to be < 0.05

showing intervention by the MTAC pharmacists significantly reduced the difference of total

mean drug related problems.

Figure 11: List of interventions identified during first and second visit

29%

10%

13%

23%

6%

19% Side effects

Drug interaction

Cross tappering of medication

Inappropriate dose

Compliant issues

Medication querry

0.96

0.54

0.42

0

0.2

0.4

0.6

0.8

1

1.2

Dru

g R

ela

ted

Pro

ble

ms

First Visit

Second Visit

Difference of Mean

DRP



RESULT AND DISCUSSION

From the demographic data, the average age of patients recruited in the study was 40.2

years. Out of the total number of patients 52% of patients were male and 48% were female.

Out of the 50 patients, 42% were Indians, 32% were Chinese and 24% were Malay. The

remaining 2% were of other races. This composition of patients shows that the major races in

Malaysia were taken into consideration. The highest number of patient (46%) was suffering

from schizophrenia reflecting a major concern in this disorder.

Normality test was run to determine if the data was normally distributed or otherwise. Since

the data was not normally distributed, non-parametric test, Wilcoxon signed-ranks test were

carried out to analyze the data12. The sum of the positive and negative signed-ranks is used

to generate a P-value for each questionnaire item to determine if the result of the test and

retest are significantly different12. For example, to evaluate if there is a significant

improvement in patients, Morisky scoring between the first and the subsequent visits, the

sums of the signed ranks were evaluated. If the mean ranks were far from zero with a small

P-value, it shows significant difference in Morisky score between the first and subsequent

visits12.

According to Vitolins et al. (2000), the most common way to measure compliance to

pharmacological interventions is the use of self-report measures which includes patient

interviews and questionnaires.13 The strengths of these measures are that they are fast,

flexible, inexpensive, easy, and have face validity.13, 14 They have a high degree of specificity

for non-compliance and potentially can be a rich source of data on adherence patterns and

reasons for missed doses.13, 14

In this study, compliance was assessed using the modified Morisky score. Morisky scoring of

3 or less was classified as compliant to medication and a score of 4 to 11 were classified as

non-compliant to medication. There was a decrease in the number of non-compliant patients

from 34 patients (68%) to 11 patients (22%) and increase in the number of compliant patients

from 16 patients (32%) to 39 patients (78%) between the first and second visits. Significant

improvement in the modified Morisky score between the first and the subsequent visit (P-

value < 0.001) explains patients increased compliance towards anti-psychotic medications. A

study by Novick et al. (2008) on treatment adherence in outpatients, had reported that

medication compliance was associated with a lower risk of relapse.15, 16 This shows that

compliance towards medication will lead to improvement in treatment outcome.15, 16

A total of 48 drug related problems were identified during patient‟s first visit to MTAC. Upon

the second visit, the number of drug related problems reduced to 27. The percentage of

reduction was 43.8%. When the total mean of drug related problems in the first visit were

compared to that of from the second visit, there was a significant reduction (P-value < 0.01).

Adverse medication events and often compliance issues arising due to it can also be

reduced. This was supported by Remington et al. (2003), which reported significant

improvement in compliancy and better outcome could be achieve through identification and

addressing of adverse drug reaction.17 A systematic review of the role of pharmacists in

mental health care by Finley et al. (2003), concluded that pharmacists can bring about

improvements in the safe and efficacious use of psychotropic medications.18



In addition to that, there was also a significant reduction in the number of patients whom

were non-compliant (P-value < 0.05). Counselling sessions by pharmacist during MTAC

sessions are proven to be effective by this significant result. In a systemic review by Bell et

al. (2005) which evaluates optimal use of medication in mental illness describes pharmacists‟

medication counselling and treatment monitoring can improve adherence to antidepressant

medications.19 The authors emphasize on the importance of providing comprehensive

medication information to patients to cultivate adherence.19 In a separate study by Al-Saffar

et al. (2008) reported that 90% of patients favour the idea of receiving information about

therapy; and counselling was found to be significantly associated with much higher recall of

medication name, management of missed dose and correct use of medications.20 In

addition, Razali et al. (1995) reported that patients with poor adherence who were allocated

to receive pharmacist medication counselling had significantly fewer relapses that required

hospitalisation.21 Report by Bell et al. (2005) showed that medication counselling conducted

by pharmacists can improve medication adherence among people commencing

antidepressant therapy.22

Another significant result that shows the role of pharmacist towards better management of

psychiatric patients is medication knowledge after joining the MTAC program as seen by

significant increase in DFIT score (P-value < 0.001) between the first and subsequent visits.

Knowledge on how to take their medications correctly has increased from 74.5% to 92.7%

hence improving patients‟ adherence towards medication. Konarzewska et al. (1997) found

that adherence to medical and behavioural regimens is important as inadequate adherence

can adversely impact the effectiveness of an intervention.23 The author also reported that

complexity of the medication regimen and number of medications prescribed will affect the

chances of patients adherence. Hence, good understanding of medication regimen will

encourages good adherence.23

Another area that was analyzed in this study was interventions. From the 50 patients who

were interviewed, 31 interventions (62%) were identified. The interventions were then

categorized into six categories namely side effects, drug interaction, cross tapering of

medication, inappropriate dose, compliance issues and medication queries. Among the side

effects identified were inability to sleep, drowsiness and increase in blood pressure.

Appropriate action was taken by the pharmacist to rectify the interventions identified by

discussing with the prescriber. A systemic review by Kaboli et al. (2006) had concluded that

interacting with the health care team, interviewing patient and counselling on medications

resulted in reduction in adverse drug events, medication errors, and improvement in

medication adherence and knowledge.24 A separate study by Stoner et al. (2002); reported

82% of pharmacists‟ interventions were accepted which lead to a 90% successful outcome

achieved.25 In additional, patients are generally very receptive and cooperative in the

treatment plan as there is a positive outcome.25

An extension of the Wilcoxon test, Kruskal-Wallis test was used to analyze numerical value

versus categorical value. Total mean of drug related problem during the first visit was 0.96

which then reduced to 0.54 during the second visit. The difference of mean of drug related

problem between the first and second visit was 0.42. When the difference in the mean of

total drug related problem were compared to the number of intervention identified, the P-

value was found to be < 0.05 showing intervention by the MTAC pharmacists significantly

reduced the difference of total mean drug related problems. With reference to Novik et al.



(2009), non-adherence was significantly associated with an increased risk of relapse; and

reversal of risk factors may improve adherence.26 Strategies such as MTAC Psychiatry that

addresses drug related problems associated with non-adherence may lead to improved

adherence and also improved patient outcomes.26

Limitation

As with other studies, this study comes with some limitations. The small number of patients

(n = 50), may affect the significance of some results analyzed. Another limitation would be

time constraint which only allowed comparison between the first and the second visit. Hence,

long term effectiveness could not be evaluated.

CONCLUSION

This study proves that the MTAC psychiatry program conducted in HTAR, Klang plays a vital

role in improving patient‟s adherence towards medication and improving patients‟ knowledge

on their disease and medication prescribed, hence improving the treatment outcome and

improving the overall management of the disease.

RECOMMENDATION

A quality of life (QOL) study can be done as a continuation of this study. In addition to that, a

pharmacoeconomic study such as a cost benefit analysis and cost saving analysis may also

be carried out in the future.

REFERENCES

1. Yeap R, Low WY. Mental health knowledge, attitude and help seeking tendency: A

Malaysian context. Singapore Med J 2009; 50:1169-76.

2. Peters H. Mental Health: Special needs and education. Asean Journal of Psychiatry

2010; 11:1-7.

3. Australian Pharmacy Council and Committee of Heads of Pharmacy Schools of Australia

and New Zealand. Statement of mental health care capabilities for pharmacists 2009.

4. Tandor R, Nasrallah HA, Keshavan MS. Schizophrenia, "Just the Facts". Schizophr Res

2010.

5. Falkai P. Limitation of current therapies: Why do patients switches therapies? European

neuropsychopharmacology 2008; 18:135-9.

6. Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am J

Hosp Pharm. 1990; 47:533.

7. Shoka A. The wheel of compliance in schizophrenia. European Psychiatry 2007; 22:50.

8. Llorca PM. Partial compliance in schizophrenia and impact on patient outcomes.

Psychiatry Research 2008; 161:235-47.

9. Vlasnik JJ, Aliotta SL, DeLor B. Medication adherence: Factor influencing compliance

with prescribed medication plans. TCM 2005:47-51.

10. Canoso MC, Goldstein JM, Wojcik J, Dawson R, Brandmand D, Klibanski A, Schildkraut

JJ, Green AI. Antipsychotic medication, prolactin elevation and ovarian function in women

with schizophrenia and schizoaffective disorder. Psychiatry research 2002; 111:11-20.

11. Bobes J. Schizophrenia and overweight/obesity:Pathophysiology and medical

consequences. 2007; 22:89-95.

12. Sheridan JC, Lyendall S. SPSS version 14.0 for Windows. Anaysis without Anguish.

2007.



13. Mara Z. Vitolins, Cynthia S.Rand, Stephen R. Rapp. Measuring Adherence to Behavioral

and Medical Interventions. Department of Public Health Sciences. 2000; 21:188S-194S.

14. Palmer LA, Russo P, Vasey J. Schizophrenia care and assessment program (SCAP):

The impact of clinical and functional characteristic and antipsychotic medication

treatment on outpatient and inpatient psychiatric utilization. International Congress on

Schizophrenia Research 2003.

15. Novick D, Suarez D, Haro JM. The impact Of Medication Compliance on Relapse in the

Outpatient Setting: Schizophrenia Outpatients Health Outcomes (SOHO) Study 2008; 1-

279.

16. Gianfrancesco FD, Rajagopalan K, Sajatovic M, Wang RH. Treatment adherence among

patients with schizophrenia treated with atypical and typical antipsychotic. Psychiatry

Research 2006; 144:177-189.

17. Remington G, Light M, Lasser R, Bossie C, Zhu Y, Gharabawi G. Can stable patients

with schizophrenia improve? The impact of partial compliance versus constant therapy.

International Congress on Schizophrenia Research 2003:300.

18. Finley PR, Crismon ML, Rush AJ. Evaluating the impact of pharmacists in mental health:

a systematic review of Clinical Pharmacy. Department Pharmacotherapy 2003 Dec;

23(12):1634-44.

19. Bell S, McLachan AJ, Aslani P, Whitehead P, Chen TF. Community pharmacy service to

optimise the use of medication for mental illness: A systemic review. Australia and New

Zealand Health Policy 2005.

20. Al-Saffar N, Abdulkareem A, Abdulhakeem A, Salah AQ, Heba M. Depressed patients‟

preference for education about medication by pharmacist in Kuwait. Patient Educ Couns

2008; 72(1): 94-101.

21. Razali MS, Yahya H. Compliance with treatment in schizophrenia: a drug intervention

program in a developing country. Source Department of Psychiatry, School of Medical

Sciences, Universiti Sains Malaysia, Kelantan 1995 May; 91(5):331-5.

22. Simon Bell, Andrew J McLachlan, Parisa Aslani. Community pharmacy services to

optimise the use of medications for mental illness: a systematic 2005

23. Kouarzewska B, Ruduik I, Juchnowicz D, Poplawska R. Male sexual dysfunction,

adherence to antipsychotic therapy and the quality of life in schizophrenia. Comparison of

olanzapine and risperidone. Department of Psychiatry 1997.

24. Kaboli PJ, Hoth AB, McClimon BJ. Clinical Pharmacist and Inpatient Medical Care: A

Systematic Review. Arch Intern Med. 2006:955-964.

25. Stoner SC, Worrel JA, Jones MT. Pharmacist-Designed and -Implemented

Pharmaceutical Care Plan for Antipsychotic-Induced Movement Disorders.

Pharmacotherapy 2000; 20(5).

26. Novick D, Haro JM, Suarez D. Predictors and clinical consequences of non-adherence

with antipsychotic medication in the outpatient treatment of schizophrenia. Department of

Psychiatry 2009.


76 The Prescribing Pattern Of Antihypertensives In Patients With Chronic Renal Failure

THE PRESCRIBING PATTERN OF ANTIHYPERTENSIVES IN PATIENTS WITH CHRONIC

RENAL FAILURE.

Nur Arina Binti Sariffudin, Tee Xin Yi

Pharmacy Department, Hospital Sungai Buloh

ABSTRACT

Introduction: To observe the prescribing pattern of antihypertensives in patients with

chronic renal failure in medical wards (Ward 4A and 4D) of Hospital Sungai Buloh (HSB).

Objectives: i) To characterise the pattern of prescribing of antihypertensives in patients with

chronic renal failure. ii) To investigate the level of conformity to the recommended guideline

by the medical wards in HSB. iii) To observe the most commonly prescribed class of

antihypertensives for patients with chronic renal failure in medical wards of HSB. iv)To

analyse the data in relation to the selected population characteristics.

Methodology: Sample was taken from medical wards (4A and 4D) of Hospital Sungai Buloh.

All patients that were admitted and discharged within 1st Jan to 31st March were included in

this study. Data was then analysed through SPSS statistical software and the

antihypertensive prescribing pattern were compared with national guideline of Hypertension

in Chronic Kidney Disease by the Malaysian Society of Nephrology.

Result: Calcium channel blocker (CCB) is the most prescribed antihypertensive either as

single or multiple antihypertensive therapies. This finding corresponds with the national

guidelines for hypertension with chronic kidney disease, which does not specify any agent as

initial therapy.

Conclusion: Findings from other studies showed that CCB has renoprotective function.

However, CCB is still not the most preferred antihypertensive that can provide excellent

renoprotective function. Other studies also concluded that maintaining adequate blood

pressure is not the key to prevent kidney function from deteriorating. In fact, choosing the

correct class of antihypertensive is more important than controlling blood pressure. We can

conclude that this study shows that CCB is the most preferred antihypertensive agent in

patients with chronic renal failure.

INTRODUCTION

High blood pressure or hypertension is a common condition in which the force of the blood

against your artery walls is high enough that it may eventually cause health problems, such

as heart disease. More specifically, hypertension is defined as persistent elevation of systolic

BP of 140 mmHg or greater and/or diastolic BP of 90 mmHg or greater. Blood pressure is

determined by the amount of blood your heart pumps and the amount of resistance to blood

flow in your arteries1. The more blood your heart pumps and the narrower your arteries, the

higher your blood pressure. Hypertension can be going on for years without any symptoms.

Uncontrolled high blood pressure increases risk of serious health problems, including heart

attack and stroke. It typically develops over many years, and it affects nearly everyone

eventually. Fortunately, high blood pressure can be easily detected2.

Two forms of high blood pressure have been described: essential hypertension and

secondary hypertension. Essential hypertension is a far more common condition and

accounts for 95% of hypertension1. The cause of essential hypertension is multifactorial, that

is, there are several factors whose combined effects produce hypertension. In secondary



hypertension, which accounts for 5% of hypertension, the high blood pressure is secondary

to a specific abnormality in one of the organs or systems of the body.

Essential hypertension affects approximately 72 million Americans, yet its basic causes or

underlying defects are not always known. Nevertheless, certain associations have been

recognized in people with essential hypertension3. For example, essential hypertension

develops only in groups or societies that have a fairly high intake of salt, exceeding 5.8

grams daily. Salt intake may be a particularly important factor in relation to essential

hypertension in several situations, and excess salt may be involved in the hypertension that

is associated with advancing age, African American background, obesity, hereditary

susceptibility, and kidney failure (renal insufficiency). The Institute of Medicine of the National

Academies recommends healthy 19 to 50-year-old adults consume only 3.8 grams of salt to

replace the average amount lost daily through perspiration and to achieve a diet that

provides sufficient amounts of other essential nutrients4.

Genetic factors are thought to play a prominent role in the development of essential

hypertension. However, the genes for hypertension have not yet been identified. The current

research in this area is focused on the genetic factors that affect the renin-angiotensin-

aldosterone system. This system helps to regulate blood pressure by controlling salt balance

and the tone (state of elasticity) of the arteries2,3.

Approximately 30% of cases of essential hypertension are attributable to genetic factors. For

example, in the United States, the incidence of high blood pressure is greater among African

Americans than among Caucasians or Asians. Also, in individuals who have one or two

parents with hypertension, high blood pressure is twice as common as in the general

population5. Rarely, certain unusual genetic disorders affecting the hormones of the adrenal

glands may lead to hypertension. (These identified genetic disorders are considered

secondary hypertension.)

The vast majority of patients with essential hypertension have in common a particular

abnormality of the arteries: an increased resistance (stiffness or lack of elasticity) in the tiny

arteries that are most distant from the heart (peripheral arteries or arterioles). The arterioles

supply oxygen-containing blood and nutrients to all of the tissues of the body. The arterioles

are connected by capillaries in the tissues to the veins (the venous system), which returns

the blood to the heart and lungs. Just what makes the peripheral arteries become stiff is not

known6. Yet, this increased peripheral arteriolar stiffness is present in those individuals

whose essential hypertension is associated with genetic factors, obesity, lack of exercise,

overuse of salt, and aging. Inflammation also may play a role in hypertension since a

predictor of the development of hypertension is the presence of an elevated C reactive

protein level (a blood test marker of inflammation) in some individuals5,6. As mentioned

previously, 5% of people with hypertension have what is called secondary hypertension. This

means that the hypertension in these individuals is secondary to a specific disorder of a

particular organ or blood vessel, such as the kidney, adrenal gland, or aortic artery4.

Diseases of the kidneys can cause secondary hypertension. This type of secondary

hypertension is called renal hypertension because it is caused by a problem in the kidneys.

One important cause of renal hypertension is narrowing (stenosis) of the artery that supplies

blood to the kidneys (renal artery). In younger individuals, usually women, the narrowing is



caused by a thickening of the muscular wall of the arteries going to the kidney (fibro

muscular hyperplasia). In older individuals, the narrowing generally is due to hard, fat-

containing (atherosclerotic) plaques that are blocking the renal artery7.

How does narrowing of the renal artery cause hypertension? First, the narrowed renal artery

impairs the circulation of blood to the affected kidney. This deprivation of blood then

stimulates the kidney to produce the hormones, renin and angiotensin3,6. These hormones,

along with aldosterone from the adrenal gland, cause a constriction and increased stiffness

(resistance) in the peripheral arteries throughout the body, which results in high blood

pressure8.

Renal hypertension is usually first suspected when high blood pressure is found in a young

individual or a new onset of high blood pressure is discovered in an older person. Screening

for renal artery narrowing then may include renal isotope (radioactive) imaging,

ultrasonography (sound wave) imaging, or magnetic resonance imaging (MRI) of the renal

arteries. The purpose of these tests is to determine whether there is a restricted blood flow to

the kidney and whether angioplasty (removal of the restriction in the renal arteries) is likely to

be beneficial. However, if the ultrasonic assessment indicates a high resistive index within

the kidney (high resistance to blood flow), angioplasty may not improve the blood pressure

because chronic damage in the kidney from long-standing hypertension already exists. If any

of these tests are abnormal or the doctor's suspicion of renal artery narrowing is high

enough, renal angiography (an X-ray study in which dye is injected into the renal artery) is

done. Angiography is the ultimate test to actually visualize the narrowed renal artery9.

A narrowing of the renal artery may be treated by balloon angioplasty. In this procedure, the

physician threads a long narrow tube (catheter) into the renal artery. Once the catheter is

there, the renal artery is widened by inflating a balloon at the end of the catheter and placing

a permanent stent (a device that stretches the narrowing) in the artery at the site of the

narrowing7,8,9. This procedure usually results in an improved blood flow to the kidneys and

lower blood pressure. Moreover, the procedure also preserves the function of the kidney that

was partially deprived of its normal blood supply. Only rarely is surgery needed these days to

open up the narrowing of the renal artery9.

Any of the other types of chronic kidney disease that reduces the function of the kidneys can

also cause hypertension due to hormonal disturbances and/or retention of salt. It is important

to remember that not only can kidney disease cause hypertension, but hypertension can also

cause kidney disease. Therefore, all patients with high blood pressure should be evaluated

for the presence of kidney disease so they can be treated appropriately10.

Uncomplicated high blood pressure usually occurs without any symptoms (silently) and so

hypertension has been labelled "the silent killer." It is called this because the disease can

progress to finally develop any one or more of the several potentially fatal complications of

hypertension such as heart attacks or strokes10. Uncomplicated hypertension may be present

and remain unnoticed for many years, or even decades. This happens when there are no

symptoms, and those affected fail to undergo periodic blood pressure screening.

Some people with uncomplicated hypertension, however, may experience symptoms such

as headache dizziness, shortness of breath, and blurred vision. The presence of symptoms



can be a good thing in that they can prompt people to consult a doctor for treatment and

make them more compliant in taking their medications11. Often, however, a person's first

contact with a physician may be after significant damage to the end-organs has occurred. In

many cases, a person visits or is brought to the doctor or an emergency room with a heart

attack, stroke, kidney failure, or impaired vision (due to damage to the back part of the

retina). Greater public awareness and frequent blood pressure screening may help to identify

patients with undiagnosed high blood pressure before significant complications have

developed10,11.

About one out of every 100 (1%) people with hypertension is diagnosed with severe high

blood pressure (accelerated or malignant hypertension) at their first visit to the doctor. In

these patients, the diastolic blood pressure exceeds 140 mmHg. Affected persons often

experience severe headache, nausea, visual symptoms, dizziness, and sometimes kidney

failure9,11. Malignant hypertension is a medical emergency and requires urgent treatment to

prevent a stroke.

Damage of organs fed by the circulatory system due to uncontrolled hypertension is called

end-organ damage. As already mentioned, chronic high blood pressure can lead to an

enlarged heart, kidney failure, brain or neurological damage, and changes in the retina at the

back of the eyes12. Examination of the eyes in patients with severe hypertension may reveal

damage; narrowing of the small arteries, small haemorrhages (leaking of blood) in the retina,

and swelling of the eye nerve. From the amount of damage, the doctor can gauge the

severity of the hypertension.

People with high blood pressure have an increased stiffness, or resistance, in the peripheral

arteries throughout the tissues of the body. This increased resistance causes the heart

muscle to work harder to pump the blood through these blood vessels. The increased

workload can put a strain on the heart, which can lead to heart abnormalities that are usually

first seen as enlarged heart muscle12,13. Enlargement of the heart can be evaluated by chest

X-Ray, electrocardiogram and most accurately by echocardiography (ECG) ECG is

especially useful in determining the thickness (enlargement) of the left side (the main

pumping side) of the heart. Heart enlargement may be a forerunner heart failure, coronary

(heart) artery disease, and abnormal heart rate or murmurs (cardiac arrhythmias). Proper

treatment of the high blood pressure and its complications can reverse some of these heart

abnormalities.

Blood and urine tests may be helpful in detecting kidney abnormalities in people with high

blood pressure. (Remember that kidney damage can be the cause or the result of

hypertension.) Measuring the serum creatinine in a blood test can assess how well the

kidneys are functioning. An elevated level of serum creatinine indicates damage to the

kidney. In addition, the presence of protein in the urine (proteinuria) may reflect chronic

kidney damage from hypertension, even if the kidney function (as represented by the blood

creatinine level) is normal14. Protein in the urine alone signals the risk of deterioration in

kidney function if the blood pressure is not controlled. Even small amounts of

microalbuminuria may be a signal of impending kidney failure and other vascular

complications from uncontrolled hypertension. African American patients with poorly

controlled hypertension are at a higher risk than Caucasians for most end-organ damage and

particularly kidney damage15.



Uncontrolled hypertension can cause strokes, which can lead to brain or neurological

damage. The strokes are usually due to a haemorrhage (leaking blood) or a blood clot

(thrombosis) of the blood vessels that supply blood to the brain14. The patient's symptoms

and signs (findings on physical examination) are evaluated to assess the neurological

damage. A stroke can cause weakness, tingling, or paralysis of the arms or legs and

difficulties with speech or vision. Multiple small strokes can lead to dementia (impaired

intellectual capacity). The best prevention for this complication of hypertension or, for that

matter, for any of the complications, is control of the blood pressure. Recent studies have

also suggested the angiotensin receptor blocking drugs may offer an additional protective

effect against strokes above and beyond control of blood pressure14,15.

In patients co-morbid with non-diabetic renal disease, the combination of Angiotensin

Converting Enzyme Inhibitor (ACEIs) and Angiotensin Receptor Blockers (ARBs) are proven

to reduce the rate of doubling of serum creatinine and End-stage renal disease (ESRD) more

than monotherapy with either agent in non-diabetic proteinuric renal disease. Hypertension

may be a cause or consequence of renal failure. Renal disease is the most important cause

of secondary hypertension. Hypertension in renal disease is often associated with an

elevated serum creatinine, proteinuria and/or haematuria. Approximately 50-75% of

individuals with GFR<60 ml/min/1.72m2 [Chronic kidney disease (CKD) stages 3-5] have

hypertension. Hypertension accelerates the progression of renal disease and may lead to

end stage renal disease (ESRD). Tight control of BP is therefore important16,17. The target

BP should be < 130/80 mmHg for those with proteinuria of < 1g/24 hours and < 125/75

mmHg for those with proteinuria of > 1g/24 hours. (Level I) All antihypertensive drug classes

can be used to achieve this goal. In the management of hypertension in renal disease,

control of BP and proteinuria are the most important factors in terms of retarding the

progression of renal disease. Antihypertensive agents that reduce proteinuria thus have an

advantage17. Meta-analyses of 49 randomized trials obtained from MEDLINE and Cochrane

Library Central Register of Controlled Trials from January 1990 to September 2006

concluded that ACEI conferred an anti-proteinuric effect greater than other anti-hypertensive

drugs18. Overall 30% reduction in incidence of ESRD with ACEI can be expected. The anti-

proteinuric effect and reduction in ESRD was beyond that attributable to the BP lowering

effect. This anti-proteinuric effect of ACEI was most prominent in patients on a low sodium

diet or those treated with diuretics. Patients with proteinuria >3g/24 hours benefited the

most18.

The advantage of ACEI is most readily apparent in patients with rapid progression of renal

disease associated with proteinuria. ARBs are similar to ACEI in lowering BP and reducing

proteinuria. The combination of ACEIs and ARBs has also been proven to reduce the rate of

doubling of serum creatinine and ESRD more than monotherapy with either agent in non-

diabetic proteinuric renal diseases17.

Renal insufficiency should not be a contraindication to starting ACEI or ARB therapy, nor

should it be a reason for discontinuing therapy. Serum creatinine level should be checked

within the first two weeks of initiation of therapy. If there is a persistent rise of serum

creatinine of ≥30% from baseline within two months, ACEIs should be stopped. Similar

caution should be exercised with the use of ARBs16,17. In patients with renal disease and



hypertension with an elevated serum creatinine of >200 mmol/L, thiazide diuretics may not

be effective antihypertensive agents and therefore loop diuretics are preferred.

Concurrent diuretic therapy will often be necessary in patients with renal insufficiency since

salt and water retention is an important determinant of hypertension in this setting. CCBs

may be used in renal disease. In those with proteinuria, the non-dihydropyridine group of

CCBs namely diltiazem or verapamil are preferred, as they have an additional antiproteinuric

effect. The combination of an ACEI and a non-dihydropyridine CCB is more anti-proteinuric

than either drug alone. More recently, aldosterone antagonists have been shown to have

additive antiproteinuric effects when administered with ACEI and/or ARB in patients with

CKD. However, larger randomised prospective trials are needed to confirm the efficacy and

safety of aldosterone antagonists on proteinuria and CKD progression18.

Several recommendations for a good control of BP would be target BP should be <130/80

mmHg for those with proteinuria of <1g/24 hours and <125/75 mmHg for those with

proteinuria of >1g/24 hours; ACEIs are recommended as initial anti-hypertensive therapy;

ARBs should be used in patients intolerant to ACEIs; dietary salt and protein restriction is

important; concurrent diuretic therapy is useful in patients with fluid overload; and non-

dihydropyridine CCBs can be added on if the BP goal is still not achieved19.

Research Objective

The aim of the research is to observe the prescribing pattern of antihypertensives in patients

with chronic renal failure in medical wards (Ward 4A and 4D) of Hospital Sungai Buloh

(HSB).

Objective of the study

i. To characterise the pattern of prescribing of antihypertensives in patients with chronic

renal failure.

ii. To investigate the level of conformity to the recommended guideline by the medical

wards in HSB.

iii. To observe the most commonly prescribed class of antihypertensives for patients with

chronic renal failure in medical wards of HSB.

iv. To analyse the data in relation to the selected population characteristics.

METHODOLOGY

This research project is a retrospective cross sectional study. Patients were selected from 1st

January till 31st March from the medical wards (ward 4A and 4D) of Hospital Sungai Buloh.

All the patients admitted and discharged during that period will have their case notes studied

through the eHIS program in the hospital‟s computer system. eHIS is a database that collects

patient‟s medical records into an online system. Only patients who fit the inclusion criteria

were selected as the sample population for this study. Inclusion criteria were: patients that

have been diagnosed with chronic kidney disease (persisting serum creatinine values higher

than the reference level of >150 umol/L for men and >125umol/L for women) either in the

ward or before admission and patients that had been diagnosed with hypertension prior to

admission (BP >130/90mmHg). The exclusion criteria were: patients that had chronic heart

failure, patient with diabetes, patients diagnosed with end-stage renal failure (creatinine

clearance<15ml/min), patients that were receiving renal replacement therapy or renal

transplant or dialysis. The prescribed antihypertensive during the admission period and



discharged medication was compiled and compared against the national guideline of

Hypertension in Chronic Kidney Disease by the Malaysian Society of Nephrology.

Data that had been collected were then being analysed to select the sample population that

fits the inclusion criteria whilst excluding those that fits the exclusion criteria. The data was

compiled and analysed using statistical software known as the SPSS Statistical Editor.

Quantitative analysis was being used to analyse the data. Data such as gender are known as

nominal data as they have no ranking order while data such as age groups were classified as

ordinal data as these data had a ranking order. Besides analysing the frequency of a certain

prescribed antihypertensive and also the general prescribing pattern, there were two main

tests that had been carried out to determine the significance difference or correlations

between the data which are Mann-Whitney test and Spearman correlation ranking test. A

Mann-Whitney test is a non-parametric test used to analyze the whether there was a

statistical significant data difference between an ordinal and a nominal data. Spearman

correlation test is used to analyze whether there‟s a statistical significant correlation between

two ordinal data. A data is said to be significant when the p value is lesser than 0.05. A

Spearman correlation coefficient of lesser than 0.3 is said to have a weak correlation, a

moderate level of correlation when the value is between 0.3 to 0.6 and a strong correlation

for a value of more than 0.6. The correlation value can be positive or negative.

The proposal of the title was done in April 2011 and gotten an approval within the same

month. Data compilation was carried out right after the title had been approved. The final

presentation of the research was carried out in May 2011 and a final report write up was

submitted on 15th July 2011.

RESULTS

Out of all the patients admitted during the period of 1st Jan 2011 to 31st March 2011 to Ward

4A and Ward 4D in Hospital Sungai Buloh, only 38 patients fulfilled the aforementioned

inclusion criteria. Therefore, the sample size for this research is 38 patients. Among these 38

patients, the male patients had a slight majority of 58% (n=22) while female patients made up

the remaining 42% (n=16) of the sample population, as shown in Table 1. The age of sample

population ranges from 30 years old to 89 years old, with majority of the patients are from the

age group of 60 to 69 years old (44%, n=17), followed by those in the age group of 70 to 79

years old (32%, n=12). Table 2 shows the age distribution of the sample population. There

was no statistical significant gender difference in age. (Mann-Whitney U=160.5, p=0.625,

mean rank for male=18.8, female=20.47) and in this sample population, female tend to be

older than male. There was no statistically significant correlation between age and the

number of antihypertensive prescribed (Spearman correlation coefficient=-0.292, p=0.075).

Table 1: The gender distribution of the sample population

Frequency Percent

Male 22 58

Female 16 42

Total 38 100.0



Table 2: The age distribution of the sample population

Age Group Frequency Percent

30-39 1 2.6

40-49 2 5.3

50-59 5 13.2

60-69 17 44.7

70-79 12 31.6

80-89 1 2.6

Total 38 100.0

The six types of antihypertensives that have been prescribed to the sample population are:

angiotensin-converting enzyme inhibitors (ACE inhibitors), angiotensin receptor blockers

(ARB), beta-adrenergic antagonist (β-blocker), calcium channel blocker (CCB), diuretics and

α-adrenergic-antagonist (α blocker).

As shown in Table 3, majority of the sample population are on combinations of two

antihypertensive (39.5%, n=15), while those with a single antihypertensive made up of 36.8%

of the sample population (n=14); 13.2% of them are on combinations of 4 antihypertensive

(n=5), while the smallest percentage of the sample population are on combinations of three

antihypertensive (10.5%, n=4).

Table 3: The frequency of patients in terms of number of antihypertensive prescribed

Number of antihypertensives Frequency Percent

1 14 36.8

2 15 39.5

3 4 10.5

4 5 13.2

Total 38 100.0

Out of the 6 types of antihypertensive, the most commonly prescribed antihypertensive is

calcium channel blockers (38%, n=29), followed by β-blocker (28%, n=21), diuretics (20%,

n=15), ACE inhibitor (12%, n=9), ARB (1%, n=1) and lastly, α blocker (1%, n=1).

Table 4: The frequency of all types of antihypertensive prescribed

Antihypertensive Frequency Percentage (%)

ACE inhibitor 9 12

ARB 1 1

β-blocker 21 28

Calcium Channel Blocker 29 38

Diuretics 15 20

α blocker 1 1



Based on Table 3, there are 14 patients that are on single antihypertensive therapy. Among

them, 64% are on calcium channel blocker (n=9), 21% of them are on diuretics (n=3), and

14% of the patients that have been prescribed only one antihypertensive are on beta

adrenergic receptor blockers (n=2). A breakdown of the percentage is shown in Table 5.

Table 5: The breakdown of types of antihypertensive prescribed for patients on mono-

antihypertensive therapy

Frequency Percentage (%)

Beta Blockers 2 14.3

CCB 9 64.3

Diuretics 3 21.4

Total 14 100.0

Out of the 15 patients that are on double antihypertensive combinations, majority of the

patients (60%, n=9) are on a combination of CCB and β blockers, while the rest are either on

a combination of ACE inhibitor with diuretic (13.3%, n=2); CCB with diuretic (13.3%, n=2);

ACE inhibitor with CCB (6.7%, n=1) or ACE inhibitor with β blocker (6.7%, n=1), as shown in

Table 6.

Table 6: A breakdown of the types of antihypertensive prescribed for patients with

combinations of 2 antihypertensive

Frequency Percentage (%)

ACEi and B 1 6.7

ACEi and CCB 1 6.7

ACEi and D 2 13.3

B and CCB 9 60.0

CCB and D 2 13.3

Total 15 100.0

As shown in Table 7, half of the patients with combinations of 3 antihypertensive had been

prescribed a combination which consists of beta blockers, CCB and diuretics (50%, n=2),

while a quarter of them had been prescribed a combination that consists of ACE inhibitor,

beta-blocker, and a diuretic (25%, n=1) while another quarter of them had been prescribed a

combination that consists of ACE inhibitor, beta-blocker, and CCB.

Table 7: Types of antihypertensives prescribed for combinations of 3 antihypertensive

Frequency Percentage

ACEi + B + D 1 25

ACEi + B + C 1 25

B + C + D 2 50

Total 4 100



Out of the 5 patients that have been prescribed a combination of 4 antihypertensive, majority

of them are on a combination of ACE inhibitor, beta-blockers, CCB and diuretics (60%, n=3)

while only 1 patient each was being prescribed a combination of either: beta-blocker, CCB,

diuretic, alpha-blocker (20%, n=1), or ARB, beta blocker, CCB and diuretic (20%, n=1). Table

8 summarizes a breakdown of the above findings.

Table 8: Types of antihypertensives prescribed for combinations of 4 antihypertensive

Frequency Percentage

ACEi + B + C + D 3 60

B + C + D + alpha blocker 1 20

ARB + B + C + D 1 20

Total 5 100

DISCUSSION

There is no doubt that having a strict and good control over blood pressure in patients with

renal impairment is really beneficial. In a study which consists of two randomized, multicentre

trials had shown a not significant but a definite reduction of glomerular filtration rate (GFR)

over 3 years with good control of protein intake and blood pressure20. However in another

study done in the United States, there seems to be no significant benefit of having a tight

control of blood pressure even in patients with hypertensive kidney disease. All but

angiotensin-converting enzyme inhibitors have a significant benefit in slowing down the rate

of GFR declining compared to other antihypertensive such as calcium channel blockers and

beta blockers21.

From the results above, we observed a prescribing pattern favouring calcium channel

blockers, including patients on single antihypertensive and also multiple antihypertensive

combinations. An investigation done by medical centre in USA showed that calcium channel

blocker had significantly helped to reduce the decline of reciprocal creatinine and also helped

to reduce the rate of decline in renal function compared to other antihypertensives22. The

Journal of The American Society of Nephrology published a paper based on several large

multicentre trials back in 2005 which supports the benefit of using calcium channel blockers

especially in cases of patients with CKD. In this report, it summarizes that CCB is as equally

as renoprotective as other antihypertensive agent such as diuretics. Also, the concurrent use

of CCB with either ARB or ACE inhibitor does not affect the renoprotective function of CCB.

An ARB or ACE inhibitor can be added to CCB in cases of patients with proteinuria22,23.

Therefore, CCB is an excellent antihypertensive agent as a single agent or with combination

therapy, even in patients without the presence of renal impairment24.

The other two other major trial, which are the Controlled ONset Verapamil INvestigation of

Cardiovascular Endpoints (CONVINCE) and African-American Study of Kidney Disease and

Hypertension (AASK) trial, concluded that maintaining good blood pressure is not enough to

ensure kidney function from deteriorating. The class of drug prescribed is more important. In

the CONVICE trial, CCB is equivalent to other standard antihypertensive such as beta

blockers as the initial antihypertensive therapy. However, there were more hospitalizations

due to haemorrhagic events. The AASK trial concluded that ACE inhibitor has the best



renoprotective function compared to CCB and beta blockers in hypertension cases

complicated by mild to moderate renal impairment, and beta blockers are more effective in

renal protection than CCB25.

As shown in Table 4, there were more than one type of antihypertensive that had been

prescribed to certain patients; therefore the total number of times the antihypertensive had

been prescribed was amount to more than the total number of sample population. This

shows that in cases of patients with uncontrolled hypertension, more than one type of

antihypertensives are needed to maintain adequate control and also to protect renal function

from worsening. However, the choice of antihypertensive must achieve maximal renal

protection but at the same time maintaining the minimal side effect profile possible. However,

based on the national guideline of Hypertension in Chronic Kidney Disease by the Malaysian

Society of Nephrology, there wasn‟t any preferred first line agent for patients with non-

diabetic kidney diseases26. The K/DOQI Clinical Practice Guidelines on Hypertension and

Antihypertensive Agents in Chronic Kidney Disease, patients that have >20mmHg of their

targeted blood pressure should be prescribed can be initiated with 2 antihypertensive

instead of one as one antihypertensive at maximum dose still couldn‟t maintain adequate

control of good blood pressure27.

CONCLUSION

From this study, we can conclude that CCB is the mainstay of treatment option for

hypertension as we observed an overwhelming use of CCB and it is the most frequently

prescribed antihypertensive whether as a single antihypertensive agent or combination with

other antihypertensive. There is no doubt the CCB is one of the recommended initial

antihypertensive therapy, but it still lacks the efficacy in renoprotective function that ACE

inhibitor or ARB has. Furthermore, this study also showed that the prescribing pattern in

medical wards of HSB conforms to the recommended guideline as there are no specific

antihypertensive agent that are preferred over the others in cases of hypertension with

chronic renal failure.

The limitation of this study would be the lack of sample data to make any significant findings

to support the data. This can be overcome through a longer period of study and also to

extend the sample population to other medical wards in HSB.

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27. Praga U, De Vinuesa M. "The reno-protective effect of the dual blockade of the renin

angiotensin system (RAS)". Current pharmaceutical design 2005; 11 (10): 1291–300.


89 Trauma Pergigian Kanak-kanak Di Hospital Sungai Buloh

TRAUMA PERGIGIAN KANAK-KANAK DI HOSPITAL SUNGAI BULOH

Gunasundari Devi a/p Kumara Rao,

Dip. (Kejururawatan Pergigian), Pos Basik (Pergigian Pediatrik)

Klinik Pergigian Kelana Jaya,

Bahagian Kesihatan Pergigian, Jabatan Kesihatan Negeri Selangor

ABSTRAK

Pengenalan: Tujuan kajian ini dijalankan adalah untuk mengetahui pola kes klinikal trauma

pergigian dengan mengenalpasti kekerapan kes trauma pergigian mengikut bangsa, jantina,

umur, punca trauma, jenis trauma, jenis gigi yang terlibat dan rawatan.

Objektif: Menjalankan kajiselidik ke atas kejadian dan jenis trauma pergigian di kalangan

kanak-kanak yang di rujuk ke Hospital Sungai Buloh, dari Disember 2008 hingga Jun 2010.

Metodologi: Kajian dijalankan secara retrospektif. Sampel terdiri daripada seramai 108

pesakit kanak-kanak yang berumur di antara 0 hingga 16 tahun. Borang Pengumpulan Data

telah dibentuk mengikut kehendak objektif.

Hasil: Hasil kajian menunjukkan bahawa kanak-kanak berbangsa Melayu mengalami kadar

trauma pergigian yang paling tinggi (94.0%). Kanak-kanak lelaki lebih ramai mengalami

trauma pergigian (77.0%) berbanding dengan kanak-kanak perempuan (23.0%). Kanak-

kanak yang berumur di antara 0 hingga 6 tahun yang paling kerap mengalami trauma

pergigian (40.0%). Punca utama kejadian trauma pergigian adalah akibat terjatuh (54.0%).

Jenis gigi yang kerap mengalami trauma adalah gigi insisor sentral rahang maksila sama

ada kegigian primer (61.0%) ataupun kegigian sekunder (66.0%). Jenis trauma yang sering

terjadi pada kegigian primer adalah subluksatan (41.0%) manakala trauma avulsi (41.0%)

paling kerap berlaku pada kegigian sekunder. Sebanyak 94.0% kegigian primer dirawat

sebagai rawatan konservatif. Manakala bagi kegigian sekunder pula, sebanyak 26.0%

dirawat sebagai rawatan konservatif dan 18.0% rawatan tampalan.

Kesimpulan: Secara keseluruhannya didapati, trauma pergigian semakin meningkat di

kalangan kanak-kanak. Oleh itu, langkah-langkah pencegahan haruslah ditekankan lagi.

PENGENALAN

Kekerapan kecederaan gigi di kalangan kanak-kanak sekolah di serata dunia adalah di

antara 2.6% (Macko et al.1979) sehingga 43.8% (Marcenes dan Murray, 2001).

Kebanyakkan daripada trauma pergigian melibatkan gigi insisor sentral maksila, di mana

ianya akan memberi impak dalam psikologikal yang akan menjejaskan kualiti kehidupan

seorang kanak-kanak dan juga ibubapanya. Kanak-kanak yang baru bertatih iaitu dalam

lingkungan berumur 1 hingga 3 tahun lebih terdedah kepada kecederaan ke atas gigi primer

mereka. Kanak-kanak lelaki mengalami trauma pergigian dua kali ganda lebih dari kanak-

kanak perempuan. Perbezaan ini disebabkan oleh tingkahlaku dan aktiviti harian di antara

kedua-dua jantina.

Punca trauma pergigian akan berbeza mengikut umur kanak-kanak, di mana kanak-kanak

kecil lebih mengalami trauma di sebabkan terjatuh manakala kanak-kanak yang lebih

dewasa akan cenderung ke atas kemalangan jalanraya. Kecederaan yang lazim berlaku

adalah trauma terhadap tisu lembut, tisu keras dan tisu periodontium. Tujuan kajian ini

dijalankan adalah untuk memahami tentang prevalen kes-kes trauma pergigian di kalangan

kanak-kanak, mengenali jenis-jenis trauma pergigian serta rawatannya dan dapat



mengesyorkan beberapa langkah pencegahan yang bersesuaian untuk mengekalkan

kesihatan gigi seumur hidup.

OBJEKTIF

Objektif Umum

Menjalankan kajiselidik ke atas kejadian dan jenis trauma pergigian di kalangan kanak-kanak

yang dirujuk ke Hospital Sungai Buloh, Selangor dari Disember 2008 hingga Jun 2010.

Objektif Spesifik

i. Mengenali kes-kes trauma pergigian mengikut umur, jantina dan bangsa.

ii. Mengenalpasti punca kejadian trauma di kalangan kanak-kanak.

iii. Mengenalpasti jenis-jenis trauma pergigian di kalangan kanak- kanak.

iv. Kaedah rawatan tisu keras, tisu lembut dan gigi yang terlibat.

METODOLOGI

Jenis Kajian

Jenis kajian yang dijalankan adalah secara retrospektif.

Pemilihan Sampel

Sampel seramai 108 pesakit kanak-kanak yang berumur 0-16 tahun diambilkira. Tempoh

data yang dikumpul ialah selama 1 tahun 7 bulan iaitu dari bulan Disember 2008 hingga Jun

2010. Sampel dikelaskan kepada bangsa, jantina, umur, punca trauma, tempat kejadian, dan

juga jenis gigi yang terlibat. Jenis trauma terhadap tisu keras, tisu periodontum dan tisu

lembut turut diambilkira.

Kaedah Pengumpulan Data

Borang Pengumpulan Data telah disediakan mengikut kehendak objektif.

Pemprosesan dan Penganalisisan Data

Data diproses dengan menggunakan perisian Microsoft Excel Versi 2007. Kaedah

pengolahan data adalah secara statistik deskriptif dengan penggunaan kekerapan dan

peratusan.

HASIL KAJIAN

Prevalen

Hasil kajian ini dikategorikan mengikut prevalen seperti berikut:

a) Bangsa

Rajah 1 menunjukan peratusan kes trauma pergigian di kalangan kanak-kanak mengikut

bangsa. didapati kanak-kanak berbangsa Melayu paling ramai terlibat dalam kejadian trauma

pergigian (94.0%).

.



Rajah 1: Kes Trauma Pergigian Mengikut Bangsa

b) Jantina


jantina. Daripada rajah di bawah, didapati kanak-kanak lelaki mengalami trauma pergigian

lebih daripada kanak-kanak perempuan.

Rajah 2: Kes trauma pergigian mengikut jantina

c) Umur


umur. Daripada rajah di bawah, didapati kanak-kanak berusia dari umur 0 hingga 6 tahun

mengalami trauma pergigian yang paling tinggi (40.0%).

Rajah 3: Kes Trauma Pergigian Mengikut Umur



Etiologi


punca. Berpandukan rajah di bawah, didapati punca terjatuh adalah yang paling tinggi

(54.0%) diikuti dengan kemalangan (32.0%).

Rajah 4: Kes trauma pergigian mengikut punca

Jenis- Jenis Trauma

a) Gigi yang Lazim Mengalami Trauma

Jadual 1: Kekerapan dan Peratusan Jenis Gigi Yang Mengalami Trauma Pada Kegigian

Primer dan Sekunder.

Jenis Gigi yang

Mengalami Trauma

Gigi Primer

(Kegigian Susu)

Gigi Sekunder

(Kegigian Kekal)

Kekerapan (n) % Kekerapan (n) %

Insisor Sentral Maksila 32 61.0 91 66.0

Insisor Lateral Maksila 11 21.0 25 18.0

Kanin Maksila 2 4.0 3 2.0

Insisor Sentral Mandibel 3 6.0 12 9.0

Insisor Lateral Mandibel 2 4.0 5 4.0

Kanin Mandibel 2 4.0 2 1.0

Jumlah 52 100.0 138 100.0

Jadual 1 di atas menunjukkan, gigi Insisor Sentral Maksila Kegigian Primer (61.0%) dan

Kegigian Sekunder (66.0%) paling kerap mengalami trauma.

Jadual 2: Kekerapan dan Peratusan Jenis Trauma Pada Tisu Keras yang Sering

Berlaku Pada Kegigian Primer dan Sekunder.

Jenis trauma

(Tisu keras)

Gigi Primer Gigi Sekunder


Korona 2 25.0 24 45.0

Korona & pulpa 5 62.5 22 42.0

Korona & apeks 1 12.5 6 11.0

Apeks 0 0.0 1 2.0

Jumlah 8 100.0 53 100.0



Jadual 2 menunjukkan, trauma korona dan pulpa Gigi Primer (62.5%) dan trauma yang

melibatkan korona Gigi Sekunder (45.0%) paling kerap berlaku.

b) Jenis Trauma Pada Tisu Periodontium

Jadual 3: Kekerapan dan Peratusan Jenis Trauma Pada Tisu Periodontium Kegigian

Primer Dan Sekunder.

Jenis trauma

(Tisu

periodontium)

Gigi Primer Gigi Sekunder


Konkusi 0 0.0 4 5.0

Subluksatan 18 41.0 22 26.0

Intrusi 3 7.0 8 9.0

Ekstrusi 1 2.0 6 7.0

Peluksatan 7 16.0 10 12.0

Avulsi 15 34.0 35 41.0

Jumlah 44 100.0 85 100.0

Berpandukan Jadual 3, subluksatan adalah kerap berlaku di kalangan Gigi Primer (41.0%).

manakala pada Gigi Sekunder, avulsi adalah tertinggi (41.0%).

c) Jenis Trauma Pada Tisu Lembut

Jadual 4: Kekerapan dan Peratusan Trauma yang Melibatkan Tisu Lembut.

Tisu lembut Kekerapan (n) %

Laserasi 82 74.0

Abrasi 29 26.0

Jumlah 101 100.0

Daripada Jadual 4, didapati laserasi pada tisu lembut (74.0%) yang paling kerap berlaku

berbanding dengan abrasi (26.0%).

d) Jenis trauma yang melibatkan rahang

Jadual 5: Kekerapan dan Peratusan Trauma yang Melibatkan Tulang Rahang.

Rahang Kekerapan (n) %

Maksila 2 50.0

Mandibel 2 50.0

Jumlah 4 100.0

Jadual 5 menunjukkan kekerapan trauma yang melibatkan tulang rahang adalah sama ke

atas rahang maksila dan rahang mandibel.



Rawatan

Rawatan yang diberikan kepada trauma tisu lembut iaitu laserasi dan abrasi adalah

pembersihan dan sutur. Ini diikuti dengan pemberian ubat antibiotik jika perlu. Kajian

menunjukkan kebanyakan kes trauma bagi kegigian primer telah dirawat secara konservatif

(94.0%) dan cabutan (6.0%). Manakala bagi gigi sekunder pula, terdapat beberapa jenis

rawatan yang dapat diberikan bagi mengekalkan gigi tersebut di dalam mulut. Jenis-jenis

rawatan yang diberikan adalah seperti rajah di bawah di mana rawatan konservatif (26.0%),

rawatan tampalan (18.0%) dan sebagainya.

Rajah 5: Jenis Rawatan Trauma Pergigian Gigi Sekunder.

PERBINCANGAN

Dari segi taburan bangsa, bangsa Melayu (94.0%) didapati paling ramai mengalami trauma

pergigian berbanding dengan bangsa India dan Cina. Ini adalah berkait rapat dengan

demografi penduduk di kawasan Sungai Buloh. Kajian ini juga turut disokong oleh kajian

yang di lakukan oleh Leong dan rakan-rakan pada tahun 2002 ( Leong et al. 2002). Dari hasil

kajian ini, didapati kanak-kanak yang berumur di bawah 6 tahun (40.0%) adalah yang paling

ramai terlibat dalam trauma pergigian.

Dari segi hasil kajian yang telah diperolehi, kanak-kanak lelaki (77.0%) adalah yang paling

ramai mengalami trauma pergigian. Kajian ini bertepatan dengan kajian yang telah

dijalankan oleh Nik Hussein et al. (2001) dan Adekoya et al. (2005). Ini kerana kanak-kanak

lelaki lebih gemar melakukan aktiviti yang mencabar dan aktiviti luar yang lasak serta agresif.

Punca utama trauma pergigian adalah terjatuh (54.0%) dan diikuti dengan kemalangan

jalanraya (32.0%). Ianya telah disokong oleh beberapa kajian, (Altay et al. 2001; Soriano et

al. 2004; Saroglu et al. 2002).

Secara keseluruhannya, gigi anterior merupakan gigi yang paling kerap mengalami trauma

berbanding dengan gigi posterior. Ini disokong oleh Andreasen et al. (1972) dan Fried et al.

(1995). Ini bertepatan dengan hasil kajian yang telah dilakukan, di mana gigi insisor sentral

maksila lebih kerap mengalami trauma. Jenis kecederaan luksatan adalah yang paling



banyak dialami oleh kanak-kanak. Fraktur enamel adalah jenis trauma yang paling kerap

berlaku dalam kajian ini.

Setiap kes trauma pergigian memerlukan perhatian dan rawatan serta-merta. Jenis rawatan

adalah bergantung kepada jenis trauma dan jenis gigi yang terlibat. Pelbagai jenis rawatan

telah diadakan bagi merawat kegigian sekunder dalam mengekalkan gigi seumur hidup.

Manakala bagi kegigian primer, rawatan konservatif sudah mencukupi. Bagi fraktur rahang

maksila dan mandibel, rawatan jenis reduksi terbuka dan reduksi tertutup akan dilakukan.

KESIMPULAN

Daripada kajian ini dapat disimpulkan bahawa bangsa Melayu lebih ramai terlibat dalam kes

trauma pergigian. Ini di sebabkan oleh demografi penduduk di kawasan Sungai Buloh. Kadar

kejadian (prevalen) trauma pergigian di kalangan kanak-kanak lelaki adalah lebih tinggi.

Tambahan pula, trauma pergigian lebih kerap berlaku pada kanak-kanak dalam lingkungan

umur di antara 0 - 6 tahun.

Terjatuh dan kemalangan jalanraya merupakan punca utama terjadinya trauma pergigian.

Hasil kajian menunjukkan trauma jenis luksatan adalah paling banyak terjadi, diikuti dengan

kecederaan korona yang tidak rumit. Manakala gigi insisor sentral rahang maksila adalah

gigi yang paling kerap mengalami trauma. Ini mungkin disebabkan kedudukan gigi yang lebih

terdedah kepada persekitaran.

Secara amnya didapati, trauma pergigian semakin meningkat di kalangan kanak-kanak. Oleh

sebab itu, langkah-langkah pencegahan terhadap trauma pergigian haruslah ditekankan

melalui risalah-risalah serta media massa kepada ibubapa dan kanak-kanak yang terlibat.

RUJUKAN

1. Adekoya C – Sofowora, R.Bruimah & E.Ogunbodede : Traumatic Dental Injuries

Experience in Suburban Nigerian Adolescents. The internet journal of Dental Science.

2005 Volume 3 Number 1.

2. Altay N dan Gungor HC. Retrospective study of dento – alveolar injuries of children in

Ankara, Turkey. Dental Traumatology. 2001: 17: 201-204. Journal of the American

Academy of Family Ph.

3. Andreasen JO, Bakland LK, Matas RC dan Andreasen FM . Traumaatic intrusion of

permanent teeth in a Danish population sample. International Journal of Oral Surgery.

1972: 1: 235-239.

4. Dewhurst SN, Mason C dan Roberts GJ. Emergency treatment of orodental injuries: a

review British Journal of oral and maxillofacial surgery. 1998: 36: 165-175.

5. Flores MT,Andreasen JO dan BaklandLK. Guidelines for the evaluation and management

of traumatic dental injuries. Dental Traumatology. 2001: 17: 193-196.

6. Fried I dan Erikson P. Anterior tooth trauma in the primary dentition; Incidence,

classification, treatment methods and sequelae: A review of the literature, Journal of

Dentistry for Children. 1995: 256-261.

7. Leong PL, Ahmad F dan Ahmad A. An exploratory study on dental and maxillo-facial

injuries treated by dental officers in Kulim District. A compendium of Abstracts. Oral

Health Division. Ministry of Health Malaysia. 2002:13.

8. Macko DJ, Grasso JE, Powell EA, Dohrty NJ. A study of fractured teeth ia a school

population. J Dent Child 1979: 46: 130-133.



9. Marcenes W, Murray S.Social deprivation and traumatic dental injuries among 14 year old

schoolchildren in Newham, London. Dent Traumatol 2001: 17(1): 17-21.

10. Nick – Hussein P. Traumatic injuries to anterior teeth among schoolchildren in Malaysia,

Dental Traumatology 2001: 17: 149-152.

11. Soriano EP, Caldas Jr AF, Goes PSA. Risk factors related to traumatic dental injuries in

Brazilian schoolchildren. Dent Traumatol 2004: 246-250.


97 Yellow Fever Surveillance KLIA Experience

YELLOW FEVER SURVEILLANCE KLIA EXPERIENCE

Azmi AR, Balachandran K., Senthilvasan J., Mohd. Shahir M., Adi Nor Y,

KLIA Health Office

ABSTRACT

Introduction: Yellow fever is an acute viral haemorrhagic disease cause by an arbovirus

transmitted by infected Aedes and other mosquitoes in the forests of Africa and South America.

Case fatality rate 15 – 50%.

Objective: The purpose of this report is to highlight various issues pertaining to Yellow Fever,

it‟s epidemiology, case definition, diagnosis, treatment and control globally and the control

programmes of this disease in our countries.

Methodology: Data for the Yellow Fever Surveillance collected from the return collected in

monthly basis and presented in tables and graphs.

Results: Several issues have been identified related to Yellow Fever surveillance: poor

compliance of vaccination requirement among the travellers from Yellow Fever Risk Countries,

insufficient monitoring among arriving Malaysian, lack of referral from Immigration, ineffective

control of mosquitoes breeding by premise owners, failure of Pest control operators (PCOs) to

play an important role in preventing breeding of Aedes.

Recommendation: Awareness activities need to be enhanced further by distributing brochures

and through website, regular briefings and training on Yellow Fever requirement to Immigration

Officers, enforcement of Destruction of Disease-Bearing Insects Act 1975 amended in 2000 will

be enhanced, activities by the PCOs should monitored closely and regulation related to

disinsectisation requirement which is being drafted at Ministry of Health should be expedited.

Keywords: Yellow Fever, Yellow Fever Risk Countries, Aedes aegypti, disinsectisation.

INTRODUCTION

Yellow fever is an acute viral haemorrhagic disease transmitted by infected mosquitoes. The

"yellow" in the name refers to the jaundice that affects some patients 1.

It is caused by the the yellow fever virus, an arbovirus of the Flavivirus genus and is transmitted

by the bite of an infective Aedes aegypti mosquitoes and by other mosquitoes in the forests of

Africa and South America2.

Up to 50% of severely affected persons without treatment will die from yellow fever. There are

an estimated 200 000 cases of yellow fever, causing 30 000 deaths, worldwide each year1.

The virus is endemic in tropical areas of Africa and Latin America. The number of yellow fever

cases has increased over the past two decades due to declining population immunity to

infection, deforestation, urbanization, population movements and climate change1.There is no

cure for yellow fever. Treatment is symptomatic, aimed at reducing the symptoms for the

comfort of the patient1. Vaccination is the most important preventive measure against yellow

fever.



The purpose of this report is to highlight various issues pertaining to Yellow Fever, it‟s

epidemiology, case definition, diagnosis, treatment and control globally and the control

programmes of this disease in our country.

Forty-five risk countries in Africa and Latin America are at risk. There are an estimated 200 000

cases of yellow fever (causing 30 000 deaths) worldwide each year. Although the disease has

never been reported in Asia, the region is at risk because the conditions required for

transmission are present there3.

The latest list of countries at risk of Yellow Fever is show in the following Table13.

Table 1. Countries with risk of yellow fever virus (YFV) transmission1

AFRICA CENTRAL AND SOUTH AMERICA

Angola

Benin

Burkina Faso

Burundi

Cameroon

Central African Republic

Chad2

Congo, Republic of the

Côte d‟Ivoire

Democratic Republic of the

Congo2

Equatorial Guinea

Ethiopia2

Gabon

Gambia, The

Ghana

Guinea

Guinea-Bissau

Kenya2

Liberia

Mali2

Mauritania2

Niger2

Nigeria

Rwanda

Senegal

Sierra Leone

Sudan2

Togo

Uganda

Argentina2

Bolivia2

Brazil2

Colombia2

Ecuador2

French Guiana

Guyana

Panama2

Paraguay

Peru2

Suriname

Trinidad and Tobago2

Venezuela2 1Countries/areas where “a risk of yellow fever transmission is present,” as defined by the World

Health Organization, are countries or areas where “yellow fever has been reported currently or

in the past, plus vectors and animal reservoirs currently exist” (see the current country list within

the International Travel and Health publication (Annex 1) at www.who.int/ith/en/index.html ). 2These countries are not holoendemic (only a portion of the country has risk of yellow fever

transmission). See Maps 3-18 and 3-19 and yellow fever vaccine recommendations (Yellow

Fever and Malaria Information, by Country) for details.

A traveler‟s risk for acquiring yellow fever is determined by various factors, including

immunization status, location of travel, season, duration of exposure, occupational and

recreational activities while traveling, and local rate of virus transmission at the time of travel1,3,.

Yellow Fever Virus (YFV) transmission in rural West Africa is seasonal, with an elevated risk

during the end of the rainy season and the beginning of the dry season (usually July–October)3.

Whereas the risk for infection in South America is highest during the rainy season (January–

May, with a peak incidence in February and March). Given the high level of viremia that may

occur in infected humans and the widespread distribution of Ae.aegypti in many towns and

cities, South America is at risk for a large-scale urban epidemic1,3,.

The risk of acquiring yellow fever is difficult to predict because of variations in ecologic

determinants of virus transmission. For a 2-week stay, the risks for illness and death due to

yellow fever for an unvaccinated traveler traveling to an endemic area in:

http://www.who.int/ith/en/index.html

http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-3-infectious-diseases-related-to-travel/yellow-fever.htm#2853

http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-3-infectious-diseases-related-to-travel/yellow-fever.htm#2854

http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-3-infectious-diseases-related-to-travel/yellow-fever-and-malaria-information-by-country.htm





West Africa are 50 per 100,000 and 10 per 100,000, respectively

South America are 5 per 100,000 and 1 per 100,000, respectively3

CLINICAL PRESENTATION OF YELLOW FEVER

Once contracted, the virus incubates in the body for 3 to 6 days, followed by infection that can

occur in one or two phases. The first, "acute", phase usually causes fever, muscle pain with

prominent backache, headache, shivers, loss of appetite, and nausea or vomiting. Most patients

improve and their symptoms disappear after 3 to 4 days 1,4,5. However, 15% of patients enter a

second, more toxic phase within 24 hours of the initial remission1,4,5. The patient rapidly

develops jaundice and complains of abdominal pain with vomiting. Bleeding can occur from the

mouth, nose, eyes or stomach. Kidney function deteriorates. Half of the patients who enter the

toxic phase die within 10 to 14 days, the rest recover without significant organ damage1,4,5.

MALAYSIAN’S POLICY ON YELLOW FEVER SURVEILLANCE AND ACTIVITIES AT KLIA

HEALTH DEPARTMENT

World Health Organization (WHO) in 1998 in a Yellow Fever Technical Consensus Meeting,

Geneva, 2-3 March 1998 has already recognized the need for surveillance of Yellow Fever 6.

Malaysia is free from Yellow Fever but it has the yellow fever vector Aedes aegypti. Therefore

Malaysia continues to monitor the incidence of Yellow Fever. This disease has been included in

the list of 29 diseases that must be notified under the Infectious Disease Control and Prevention

1988 (Act 342)7.

Prevention and control at the main entry points are:

1. Surveillance of Yellow Fever

2. Vector Control activities as required by IHR 2005.

3. Monitoring of disinsectisation of international aircraft

YELLOW FEVER SURVEILLANCE

Surveillance of Yellow Fever at KLIA Health Office began in 2004 and is carried out by the

Health Quarantine Unit and the Communicable Disease Control Unit. This surveillance involves

travelers arriving from various international destinations to KLIA Main Terminal Building and the

Low Cost Carrier Terminal.

The objective of this activity is to ensure that Malaysia is kept free from Yellow Fever and this is

done by conducting surveillance on arriving travelers to ensure that they do not bring the

disease in to Malaysia. The activities are :

1. Screening for Yellow Fever involving travelers including distinguished delegates who

arrive from/through Yellow Fever risk countries. The travellers arriving in Malaysia

within 6 days from the last date of embarkation from a Yellow Fever risk country without

a valid vaccination certificate shall be quarantined at the Health Quarantine Centre upon

arrival for a period not exceeding 6 days i.e. the incubation period of Yellow Fever.8

The travellers arriving in Malaysia after 6 days from the last date of embarkation from a

Yellow Fever risk country will be allowed entry into Malaysia even without a valid

vaccination certificate as the period has exceeded the incubation period of Yellow Fever.

The international yellow fever vaccination certificate becomes valid 10 days after

vaccination and remains valid for a period of 10 years.10,14



2. Carrying out quarantine procedures and surveillance upon travelers not fulfilling the

conditions of a valid Yellow Fever vaccination certificate in accordance with the

requirements under the Communicable Diseases Act, 1988.

3. Conducting talks and training to Immigration Officers at KLIA who are actively involved in

assisting KLIA Health Office in screening arriving international travelers from Yellow

Fever risk countries to be referred to Health Quarantine Centre.

From 2006 till 2010, 1.2 million travellers have visited YF risk countries. Out of this 1,682

(1.44%) didn‟t posses a valid YF vaccination certificate. From this 1,682, 1407 (84%) were

placed under quarantine and the remaining 275 (16%) were placed under surveillance (Table

2). 9

Table 2 : Number of travelers with valid and non valid certificate, quarantined and under

health surveillance from 2006 till 2010

Year No. of

travellers

visited YF

risk

countries

Travellers

with valid

certificate

( 0 – 6

days)

Travellers

without

valid

certificate

( 0– 6 days

)

Travellers

depart

from risk

YF > 6

days

Travellers

with valid

certificate

and depart

> 6 days

YF risk

countries

Traveller been

quarantined

Travellers under

health surveillance

Non

VIP

VIP Total Non

VIP

VIP Total

2006 11205 8805 378 2022 10827 281 0 281 88(*A ) 9 97

2007 19420 15962 498 2960 18922 426 0 426 71(*B ) 1 72

2008 26620 23424 440 2756 26180 395 0 395 43 2 45

2009 28884 26800 217 1867 28710 181 0 182 33 2 35

2010 30658 29250 149 1259 30482 123 0 123 26 0 26

Total 116787 104241 1682 10864 115121 1406 0 1407 102 14 275

VECTOR CONTROL ACTIVITIES

In ensuring the airport is free of Aedes aegypti, KLIA Health Office has implemented two

methods of monitoring which are Aedes inspection and Ovitrap study.

Ovitrap study is carried out to detect the presence of Aedes mosquito and it‟s species in the

vicinity. It is done within the perimeter of airport up to 400 meter from the perimeter. Ovitrap

study is carried out using Mosquito Larvae Trapping Devices or MLTD. Installation of traps and

reexamination is done every seven days. (the mosquito aedes aegypti life cycle).

In accordance with IHR 2005 all entry points should be free from Aedes aeypti (Ovitrap Aedes

aegypti should be 0 )10 and Overall Aedes Index should be less than 10% (< 10%). Studies

carried out by KLIA Health Office from 2006 until 2010 shows that, KLIA has been free from

Aedes aegypti until 2009 (Figure 1). One breeding was found in the year 2010.



Figure 1 : Trend of Ovitrap Breeding at KLIA from 2006 till 2010

Premises inspection within the perimeter was carried out weekly to trace the source of Aedes

breeding and to identify a potential breeding. Any premises found with breeding of Aedes will be

issued a compound of maximum value of RM 500.00 under Section 13 (1) of Destruction of

Disease-Bearing Insects Act 1975 amended in 2000.

Trend of Aedes breeding from 2006 till 2010 has increased as shown in the Figure 2

Figure 2: Trend of Aedes Breeding at KLIA from 2006 till 2010

A total of 12 compounds, and two Notices under Section 13 (1) and Section 8 of the Destruction

of Disease-Bearing Insects 1975 amendment 2000 were issued to owners of premises.

MONITORING OF DISINSECTISATION OF INTERNATIONAL AIRCRAFT

Inspection and disinsectisation of international aircraft was implemented at KLIA from 2003 with

the objective to ensure no disease-bearing insects are introduced into Malaysia and to monitor

the cleanliness of international aircraft. There are two options / methods of disinsectisation i.e.

Residual and spraying (Pre-Embarkation, Top of Descent, On Arrival). WHO recommends the

use of the active ingredient d-phenothrin (2%) for space spraying, and permethrin (2%) for

residual disinsection11.

This procedures requires the flight operator to ensure that the disinsectisation is done before

landing at any international airport in Malaysia. Documents relating to disinsectisation and

General Declaration of Health must be submitted to the Health Quarantine Center. Information

on disinsectisation of the aircraft will be recorded monthly. The report will be sent to the Ministry

of Health Malaysia.

0

10

20

30

2006 2007 2008 2009 2010

27

17 15

710

0 0 0 0 1

Aedes albopictus Aedes aegypti

0

2

4

6

8

10

2006 2007 2008 2009 2010

4 4

8 89

0 0 0 0

5

Aedes albopictus Aedes aegypti



ISSUES AND DISCUSSION

Compliance of vaccination requirement among travellers from Yellow Fever Risk Countries has

improved. However there are still travellers who fail to produce vaccination certificate on

arrival. Among the reasons quoted is that they are unaware of this requirement.

The existing monitoring mechanism for Malaysians arriving from Yellow Fever Risk Countries

whereby random check are carry out at the Immigration autogate is insufficient to ensure

compliances among Malaysian.

There were travellers from Yellow Fever Risk Countries were not referred by the Immigration

officer to Health Quarantine Centre at entry point. This could be due to lack of knowledge as a

result of high turnover of Immigration Officers at entry point.

Owners of premises within the airport had been found ineffective in their effort to identify and

control the breeding and potential breeding areas.

Pest control operators (PCOs) appointed by the airport authorities have not played an important

role in preventing breeding of Aedes.

Personnel involved in monitoring of Aedes breeding have been burdened with other public

health activities at KLIA.

Disinsectisation of inbound international flight was unsatisfactorily carried out as required under

IHR 2005. Disinsectisation is important to prevent the disease bearing vector transmission into

Malaysia. At this moment this is not a legal require

RECOMMENDATIONS

To improve the compliance among arriving travelers. Awareness activities need to be enhanced

further.

To improve the awareness among Malaysians who travel to Yellow Fever Risk Countries. The

travel agencies and Embassy (Malaysia and Foreign) should play an important role to ensure

this vaccination requirement is full filled prior travelling to Malaysia. This can be done by

distributing brochures and through their website.

Regular briefings and training on Yellow Fever requirement to Immigration Officers can

increase referrals of travellers from Yellow Fever Risk Countries to Health Quarantine Centre.

Regular education activities on prevention on mosquito breeding and the enforcement of

Destruction of Disease Bearing Insects Act 1975 amended in 2000 will be enhanced to curb

Aedes breeding.

Activities by the PCOs should monitored closely in ensuring the activities carry out are effective

in preventing Aedes breeding.



Regulation related to disinsectisation requirement which is being drafted at Ministry of Health

should be expedited

REFERENCES

1. WHO 2011 – fact sheets of YF from http://www.who.int/mediacentre/factsheets/fs100/en/

2. WHO 2010 International travel and health

3. Yellow Book 2012: Chapter 3: Infectious Diseases Related To Travel

4. WHO 1998 (2) - District guidelines for yellow fever

5. Mosquito-Borne Illnesses in Travelers: A Review of Risk and Prevention: Yellow Fever

from http://www.medscape.com/viewarticle/730561_7 18 August 2011

6. WHO 1998, Yellow Fever Technical Consensus Meeting, Geneva 2-3

7. Laws of Malaysia Act 342 Prevention and Control of Infectious Disease Act

8. Case Definitions for infectious Diseases in Malaysia, 2nd Edition 2006, Ministry of Health

Malaysia

9. Laporan Teknikal dan Pengurusan Pejabat Kesihatan KLIA 2010. (Unpublished)

10. International Health Regulation 2005, WHO 2005

11. Schedule of Aircraft Disinsection Procedures, Australian Quarantine and Inspection

Services V2.0, Page 5

http://www.who.int/mediacentre/factsheets/fs100/en/

http://www.medscape.com/viewarticle/730561_7%2018%20August%202011