24

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1

HIGHLIGHTS :

Hand Foot and Mouth Disease

Geriatric Medicine

Type-2 Diabetic Mellitus Guideline updates

Mercury Content in Cosmetic Products

Approaches in Anti-malarial Treatment

VOLUME 2/2016 AUGUST 2016

2

EDITORIAL BOARD

ADVISOR Dr Zaleha Bt Md Noor

CHIEF EDITOR Nursahjohana Md Sahak

EDITOR Tan Xin Yi

CONTRIBUTORS Izrul Azwa Mohd Latiff

Ng Shy Pyng

Low Jia Hui

Adillah Bt Ahmad

Shoniya A/P Jayasegaran

Nur Athirah Haziqah Mohamad Sobri

UPDATES ON GLYCEMIC TARGET AND TREATMENT 3

HAND, FOOT AND MOUTH DISEASE 6

APPROACHES IN ANTI-MALARIA TREATMENT 8

GERIATRIC PHARMACOTHERAPY 12

A LOOK INTO: STREPTOKINASE THROMBOLYTIC 17

MERCURY CONTENT IN COSMETICS 18

ADVERSE DRUG REACTION & MEDICATION ERROR 20

BEST EMPLOYEE OF THE MONTH (JAN– JUN 2016) 21

PHARMACY CME/ EVENTS 22

ISSUE AUGUST 2016

‘Salam Merdeka, Malaysia!’ - Sudut Unit Farmasi Hospital Jasin

23

OTHER EVENTS

NO DATE EVENTS

1 02-04-2016 GOTONG ROYONG EKSA

2 14-04-2016 HARI INOVASI PERINGKAT NEGERI

MELAKA

3 07-05-2016 AJK TREASURE HUNT: KARNIVAL

JOM LER.. KENALI UBAT ANDA DI

MELAKA MALL

4 14-05-2016 JOM JALAN SANTAI BERUANG HILL

5 27-05-2016 PENYERTAAN DALAM AKTIVITI JOM

JELAJAH KENALI UBAT ANDA DI

MASJID AL-GHAFFAR, JASIN

6 28-05-2016 AKTIVITI 10RIBU LANGKAH : JALAN-

JALAN KENALI UBAT ANDA DI TA-

MAN BOTANIKAL, AYER KEROH

7 03-06-2016 MAJLIS PERPISAHAN EN RIZAL,

SAMBUTAN HARI LAHIR APR-JUN,

JAMUAN PRA-RAMADAN 2016

8 24-06-2016 PENGANJUR PERHIMPUNAN PAGI

BULANAN HOSPITAL JASIN

22

CME ORGANIZED BY PHARMACY (APRIL-JUNE 2016)

DATE TITLE

08-04-2016 EXFORGE®

27-04-2016 EPILIM®

29-04-2016 TAKLIMAT PENUNTUTAN MATA CPD

18-05-2016 GLUCOMETER TRAINING

26-05-2016 ASTHMA

22-06-2016 MEDICATION ERROR

29-06-2016 TEKNIK MEMBACA TERMOMETER

MINIMAX

3

GLYCEMIC TARGET & TREATMENT

Aims of Treatment The overall aims of management in patients with Type 2 Diabetes Mellitus (T2DM) are to improve quality of life, reduce complications and prevent premature death.

1. Short term:

Relieve of symptoms and acute complications 2. Long term:

Achievement of appropriate glycaemic level Reduction of concurrent risk factor

Identification and treatment of chronic complications It is important to achieve glycaemic target to avoid complications. Glycaemic target for control of T2DM is as shown in Table 1.

By: Nursahjohana Md Sahak

Table 1: Targets for Control of Type 2 Diabetes Mellitus

** Measured at least 90 minutes after meals.

A1c target reflects average glycaemia over several months has strong predictive value for diabetes complications. In the new CPG, A1c target should be individualized as in Table 2: A1c Targets

Parameters Levels

Glycaemic control

Fasting or pre-prandial 4.4-7.0 mmol/L

Post-prandial** 4.4-8.5 mmol/L

A1c** ≤ 6.5%

Management of Type 2 Diabetes Mellitus

General Guidelines for Use of Oral Anti-diabetic Agents

Individualised A1c Targets and Patients’ Profile

Tight (6.0-6.5%) 6.6-7.0% Less tight (7.1-8.0%)

Newly diagnosed Younger age

Healthier (long life expectancy, no CVD complications)

Low risk of hypoglycaemia

All others Comorbodities (coronary disease, heart failure, renal failure, liver failure)

Short life expectancy Prone to hypoglycaemia

OAD can be used as monotherapy or in combination with other OAD(s), and/or injectable agents (e.g insulin).

As first line therapy, metformin is the preferred choice. Other OAD agents are acceptable alternatives.

If targets are not met after optimal OAD therapy, consider adding basal insulin.

If glycaemic targets are not achieved, intensification of treatment should be made every 3 months.

4

References: 1. Clinical Practice Guidelines. Management of Type 2 Diabetes Mellitus. 5th Edition. 2016. 2. American Diabetes Association. Glycemic targets. Sec. 5. In Standards of medical Care in Diabetes-

2016. Diabetes Care 2016;39(suppl. 1):S39-S46.

Initiation, Optimisation & Intensification of Insulin Therapy.

The choice of insulin regimen should be individualised, based on the patient’s glycaemic profile, dietary pattern and lifestyle.

The biggest barrier is compliance and this should be adequately ascertained prior to any effort to intensify insulin therapy.

Optimisation of insulin therapy should be done within the first 3 months of insulin initiation.

General Guidelines for Long Term Use of Insulin.

The basal intermediate acting insulin should be administered pre-bed (preferably not earlier than 10pm) because of the risk of hypoglycaemia in the early hours of the morning if given earlier.

It is not necessary to have an extra meal or snack after intermediate or long acting insulin.

There is no maximum dose of insulin that can be injected. The rate of absorption from the injections depends on the site. Patients should be

encouraged rotate all their injection sites in the abdomen.

Table 3.

21

P H A R M A C Y A C T I V I T I E S

BEST STAFF OF THE MONTH

JANUARY : PN IZRUL AZWA ABDUL LATIFF

FEBRUARY : EN ROSLI JINAL

MARCH : EN LUQMAN NUR HAKIM ABD RAZAK

APRIL : PN NUR ATHIRAH HAZIQAH MOHAMAD SOBRI

MAY : EN YUSOF HAMZAH

JUNE : MS TAN XIN YI

ZAHURIN BIN MD ISA (STARTING 01-06-2016)

HANA RADHIAH MOHD DIN (STARTING 25-07-2016)

20

ADVERSE DRUG REACTIONS (ADR) REPORTED JAN-JUN 2016

MEDICATION ERRORS REPORTED JAN-JUN 2016

The commonly reported ADR involves electrolyte imbalances, urticaria (itching), coughing, nausea/ vomiting.

Pharmacological Category

Number of Patients

Analgesic 9

Anti-Infective 13

Anti-Coagulant 1

Cardiovascular 22

Anti-Diabetic 2

Gastro-intestinal 4

Respiratory 2

Anabolic Agents/ Steroids 1

Nutrients 1

Miscellaneous 1

TOTAL 56

Number of Cases

Category of Error

5

Treatment Algorithm for Type 2 Diabetes Mellitus on Follow-Up

Suggested Treatment Approaches for Specific Patient Profiles

6

Hand, Foot and Mouth Disease

Special points of interest: Introduction Symptoms of

hand, foot and mouth disease

What to do if you have hand, foot and mouth disease

How hand, foot and mouth disease spreads

Preventing hand, foot and mouth disease

Introduction

Hand, foot and mouth disease (HFMD) is a viral infection that can affect young children. Coxsackievirus A type 16 (CVA16) is the etiologic agent involved in most cases of HFMD . It doesn’t usually pose a serious threat to a child’s health, but it can be an unpleasant condition, particularly if it affects younger children. It's most common in young children – particularly those under 10 – but can affect older children and adults as well. It will usually clear up by

itself within 7 to 10 days. Outbreaks are most common during the warm summer and early fall months, but can happen year-round in tropical parts of the world. Hand, foot, and mouth disease is not the same as hoof and mouth disease, which is an unrelated illness that affects barnyard animals and livestock.

Symptoms of HFMD

The symptoms of hand, foot and mouth disease usually develop between three and five days after being exposed to the infection. A) a high temperature (fever), usually around 38-39 degree C (100.4-102.2F) B) After one or two days, red spots appear on the tongue and inside the mouth. These quickly develop into mouth ulcers with red edges. The ulcers can be painful and make eating, drinking and swallowing difficult. They should pass within a week. C) Soon after the mouth ulcers appear, you'll probably notice a rash made up of small, raised red spots on the skin. These typically develop on the fingers, the backs or palms of the hand, the soles of the feet, and occasionally on the buttocks and groin.

Images:

Left - Spotty Rash

and Blisters

Right - Mouth Ulcers

By: Adillah binti Ahmad

19

HAZARDS OF MERCURY &

MERCURY CONTAINING

COMPOUNDS

The toxicity of mercury and its compounds is extensively documented in scientific literature.

Some mercury compounds can be absorbed through the skin on topical application and accumulate in the body.

The main adverse effect of the inorganic mercury contained in skin lightening soaps and creams is kidney damage. It may also cause skin rashes, skin discoloration and scarring, as well as a reduction in the skin’s resistance to bacterial and fungal infections.

Other effects include anxiety, depression or psychosis and peripheral neuropathy

In conclusion, mercury-containing skin lightening products are hazardous to health and as a result have been banned in many countries.

Cosmetics With High-Levels Of

Mercury In Malaysia….

Kuala Lumpur, Jan 22 - The Health Ministry today banned the sale of a beauty product by Malaysian manufacturers Qu Puteh for containing hazardous amounts of mercury. The Qu Puteh Whitening Pro 9, used for skin whitening, was said to contain high levels of mercury that could cause kidney and nerve damage. “The above mentioned product has been tested and found to contain mercury which is not allowed in cosmetics.’

As such, the Qu Puteh Whitening Pro 9 is not allowed to be sold in Malaysia. The product also stunt brain development in children and fetuses. The Ministry also received reports of users suffering from tinnitus, the ringing in the ears & as well as from hair fall but noted the symptoms stopped once the user were not using this product.

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MERCURY CONTENT IN COSMETICS

By: Shoniya A/P Jayasegaran

Mercury is a metallic element that

is naturally occurring in the environment. Mercury can have

several forms but is most often recognized as a shiny, silver-white,

dense liquid.

Metallic mercury finds many uses including in thermometers, electrical

switches, dental amalgams and some industrial manufacturing. In

addition to metallic (liquid) mercury, the element can exist in combination

with other elements to form compounds. Mercury compounds are the

most common form that exists naturally in the environment. As noted

above, the use of such compounds in cosmetic products is strictly

regulated by the FDA.

Function Of Mercury In

Cosmetics

References: 1. Mercury in skin lightening products. Geneva: World Health Organization; 2011.

2. Malay Mail ,Friday, January 22, 2016.

Mercury salts inhibit the formation of melanin, resulting in a lighter skin tone. It exists in two forms for cosmetics:

Inorganic mercury (e.g. ammoniated mercury) is used in skin lightening soaps and creams.

Organic mercury compounds ( thiomersal [ethyl mercury] and phenyl mercuric salts) are used as cosmetic preservatives in eye makeup cleansing products and mascara.

7

Counseling Points for Patients or Caregivers

If you have hand, foot and mouth disease, the best thing to do is to stay at home until you're feeling better. There's no cure for it, so you have to let it run its course.

To help ease you or your child's symptoms: A) drink plenty of fluids to avoid dehydration – water or milk are ideal; it may help to give a baby smaller but more frequent bottle or breast milk feeds B) eat soft foods such as mashed potatoes, yoghurt and soups if eating and swallowing is uncomfortable – avoid hot, acidic or spicy foods and drinks

C) take over-the-counter painkillers, such as paracetamol or ibuprofen, to ease a sore throat and fever – aspirin shouldn't be given to children under the age of 16, paracetamol is best if you're pregnant D) try gargling with warm, salty water to relieve discomfort from mouth ulcers – it's important not to swallow the mixture, so this isn't recommended for young children

How HFMD spreads?

The causative viruses can be found in an infected person's: Nose and throat secretions (such as

saliva, sputum, or nasal mucus) Blister fluid Feces (poop) HFMD spreads through: Close contact, such as kissing, hug-

ging, or sharing cups and eating utensils

Coughing and sneezing Contact with feces, for example

when changing a diaper Contact with blister fluid Touching objects or surfaces that

have the virus on them Preventing Hand, Foot and Mouth Disease

There is no vaccine to protect against HFMD. However, the risk of getting infected with the viruses that cause HFMD can be reduced by following steps: A) Wash hands often with soap and water for 20 seconds, especially after changing

diapers, and help young children do the same B) Avoid touching eyes, nose and mouth with unwashed hands C) Avoid close contact such as kissing, hugging, and sharing cups and eating utensils

with people who have HFMD D) Disinfect frequently touched surfaces and objects, such as toys and doorknobs,

especially if someone is sick E) Wash bedding or clothing that have contaminated separately on a hot wash.

People with HFMD are most contagious during the first week of their illness. How-ever, they may sometimes remain conta-gious for weeks after symptoms go away. Some people, especially adults, may not develop any symptoms, but they can still spread the viruses to others. Thus, it is important to maintain good hygiene, like washing hands often with soap and water, to minimize the chance of getting and spreading infections.

References: 1. Hand, Foot & Mouth Disease. Georgia (USA): Centers for Disease Control and Prevention; 2016 July 5.

2. Hand, Foot And Mouth Disease - NHS Choices. Nhs.uk. N.p., 2016. February 10.

8

APPROACHES IN ANTI-MALARIAL

TREATMENT By: LOW JIA HUI

The infection of red blood cells by protozoan parasites of Plasmodium genus, which is introduced into the human host by a feeding female Anopheles mosquito, results in malaria. P. falciparum, P. vivax, P. ovale, P. malariae and increasingly, P. knowlesi are indicated for humans-to-humans transmission.

Cases of malaria in Malaysia has decreased from 12705 in year 2000 to 4725 cases in 2012. However, the ease of travelling to malaria endemic countries and the influx of job-seekers from those areas may pose a risk to the outbreak of the disease. This article discusses the anti-malaria treatment approaches available in Hospital Jasin as at July 2016. ( Drugs marked * are not available in this hospital)

ADULT:

Plasmodium falciparum

i) Non-complicated, new infection:

First line:

Riamet

(Artemether 20mg/Lumenfantrine 120mg tab)

To be given for 3 days (total 6 doses)

1st dose,

2nd dose to be given 8Hrs later, followed by

Next doses @ BD for following 2 days

To be taken with fatty meal eg. milk to increase bioavailability

Alternative:

i) Artesunate/ Mefloquine* (AS+MQ) Tab

Ii) T. Quinine* + C. Doxycycline

Primaquine 0.75mg/kg (max 45mg) to be added on day 1 to the artemisin or quinine

regime; except in pregnancy, infant < 1 y/o, lactation

Px with unknown G6PD status, primaquine dose at 0.25mg/kg

Pregnant patient:

- Quinine is recommended due to limited safety data of artemisinin during the 1st trimester.

- Exposure of artemisinin derivatives during 2nd and 3rd trimester have shown no adverse effects on the mother or fetus

-Artesunate/ Mefloquine* Tab is contraindicated in pregnancy.

Weight (kg) No. of Tab/ Dose

5– 14 1

15– 24 2

25 - 34 3

≥ 35 4

17

By: IZRUL AZWA BINTI MOHD LATIFF

INTRODUCTION

1. Streptokinase is one of fibrinolytic enzymes which acts as preferred agent for thrombolytic therapy.

2. Streptokinase, acts with plasminogen to produce an "activator complex" that converts plasminogen to the proteolytic enzyme plasmin.

3. Streptokinase is indicated up to 12 hours after onset of symptoms of acute myocardial infarction; administered as IV infusion over 1 hour.

4. Preferred therapy in patient age above 65 years and weighs below 60 kg, as tenecteplase increases risk of haemorrhage.

5. Patient who received streptokinase therapy in Hospital Jasin will be provided with STREPTOKINASE CARD.

6. Because streptokinase is produced from streptococcal bacteria, it often causes febrile reactions and other allergic problems. It can also cause hypotension that appears to be dose-related.

7. Streptokinase usually cannot be administered safely a second time within 6 months, because it is highly antigenic and results in high levels of antistreptococcal antibodies for resistance.

8. Repeat treatment with streptokinase administered more than 5 days and less than 12 months after initial treatment may not be effective.

INDICATION

1. Acute Evolving Transmural Myocardial Infarction

2. Pulmonary Embolism 3. Deep Vein Thrombosis

4. Arterial Thrombosis or Embolism

5. Occlusion of Arteriovenous Cannulae

IMPORTANT INFO: 1. Bring your Streptokinase

Alert Card and inform pre-scriber regarding any strep-tokinase treatment before.

2. Inform prescriber if you experienced any sign and symptoms of drug allergy

Streptokinase card

References: 1.Steptokinase- Summary Of Product Char-acteristics (SPC)- Emc. Medicines.org.uk., 2015.

2.Nikhil Sikri, Amit Bardia. A History of Streptokinase Use in Acute Myocardial Infarction. Tex Heart Inst J. 2007; 34(3): 318–327.

3. Wanda LR et al. Thrombolytic therapy. Medscapre; WebMD LLC. 2015 December 8.

16

Drugs or Category of Drugs Rationale Recommendation

Cardiovascular

Digoxin

Atrial fibrillation (AF): should not be used as a first-line agent, because more-effective alternatives exist and it may be associated with increased mortality.

Use in heart failure: questionable effects on risk of hospitalization and may be associated with increased mortality in older adults with heart failure; in heart failure, higher dosages not associated with additional benefit and may increase risk of toxicity.

Decreased renal clearance of digoxin may lead to increased risk of toxic effects; further dose reduction may be necessary in those with Stage 4 or 5 chronic kidney disease.

Avoid as first-line therapy for AF

Avoid as first-line therapy for heart failure

If used for atrial fibrillation or heart failure, avoid dosages > 0.125 mg/d

Cardiovascular

Amiodarone

Amiodarone is effective for maintaining sinus rhythm but has greater toxicities than other anti-arrhythmics in AF.

May be reasonable first-line therapy in patients with concomitant heart failure or substantial left ventricular hypertrophy if rhythm control is preferred over rate control.

Avoid as first-line therapy for AF, unless the patient has heart failure or substantial left ventricular hypertrophy

References:

1. The American Geriatrics Society (2015). American Geriatrics Society 2015 Updated Beer s Criteria For Potentially Inappopriate Medication Use In Older Adults. Journal American Geriatrics Society, 1-20.

2. Wooten , J.M (2012). Pharmacotherapy Considerations In Elderly Adults. Retrieved from http://www.medscape.com/viewarticle/769412_2

3. Mangoni, A.A & Jackson , S.H.D (2004). Age Related Changes In Pharmacokinetics and Pharmacodynam-ics: Basic Principles And Practical Applications. British Journal Clinical Pharmacological, 57( 1) , 6– 14 . http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1884408/

4. Ruscin , J.M & Linnebur S.A (2014) . Introduction To Drug Therapy In The Elderly. Retrieved from http://www.merckmanuals.com/professional/geriatrics/drug-therapy-in-the-elderly/introduction-to-drug-therapy-in-the-elderly

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Plasmodium falciparum

ii) Non-complicated, treatment relapse/ failure:

First line:

An alternative Artemisinin Combination Therapy (ACT)

Eg. if patient was previously treated with T. Artemether/ Lumenfantrine, changed to Artesunate/ Mefloquine* and vice versa

Alternative:

T. Quinine* + C. Doxycycline

Plasmodium falciparum, Plasmodium vivax: Severe

Day 1

IV Artesunate 2.4mg/kg at 0 hour, 12 hour, 24 hour THEN od subsequently till day 7#

AND C. Doxycycline 100mg BD (given together with IV Artesunate)

# Parenteral artesunate should be given for a minimum of 24 hours (3 doses) or until patient can tolerate orally then it can be switched to a complete course of oral ACT

## For all stages of pregnancy: IV Artesunate as for normal adults

Day1:

IV Quinine + C. Doxycycline for 7 days

For the above Plasmodium falciparum cases: Primaquine 0.75mg/kg( max 45mg ) to be given on Day 1 of treatment in addition to

artemisin regime and quinine, except for pregnant women and infant < 1 y/o. If possible, check G6PD status before use

Plasmodium Vivax/ Ovale i) New infection: T.Chloroquine 10mg base/kg (max 600mg) stat, THEN 5mg base/kg (max 300mg) 6 hours later, on Day2 and Day 3 AND T.Primaquine 0.5 mg/kg (max 30mg) OD for 14 days

ii) Treatment failure / suspected chloroquine resistant T. Artemether/ Lumenfantrine for 3 days AND T. Primaquine 30mg od for 14 days

Pregnant patient: - Full of course of T. Chloroquine followed by 300mg/week until delivery - The full course of T. Primaquine is to be given post-delivery.

Primaquine in G6PD Deficiency: - 0.75 mg base/kg body weight once a week for 8 weeks. - STOP primaquine if significant haemolysis occurs

Primaquine in adult > 70kg: - continue 30 mg daily beyond 14 days until a total cumulative dose of 6 mg/kg is reached

10

Plasmodium malariae/ knowlesi i) New infection First line: Treat as uncomplicated, new infection of P. falciparum with T. Artemether 20mg/Lumenfantrine 120mg .

Alternative: Artesunate/ Mefloquine* (AS+MQ) tab for 3 days OR T. Chloroquine 10mg base/kg (max 600mg) stat. Then,5mg base/kg (max 300mg) 6 hours later, on Day2 and Day3

Plasmodium malariae/ knowlesi: Severe Treat as severe P. falciparum infection with IV Artesunate AND C. Doxycycline 100mg bd for 7 days

Plasmodium falciparum i) Non-complicated, new infection: First line: Artesunate/ Mefloquine* (AS+MQ) Tab. Contraindicated in children with epilepsy

Alternative: Artemether 20mg/ Lumenfantrine 120mg tab,dose as in treatment for uncomplicated, new infection of P. falciparum mentioned earlier. Dose according to the weight of patient.

Primaquine 0.75mg/kg (max 45mg) to be added on day 1 to the artemisin; except in infant < 1 y/o, lactation Px with unknown G6PD status, primaquine dose at 0.25mg/kg

Plasmodium falciparum: treatment failure An alternative Artemisinin Combined Therapy ( if Riamet were used in the first regimen, use Artesunate/ Mefloquine* for treatment failure and vice-versa) OR Artesunate (oral)* 4mg/kg OD + clindamycin 10mg/kg bd for a total of 7 days OR Quinine* 10mgsalt/kg 8 hourly +clindamycin 10mg/kg bd for a total of 7 days. Add primaquine 0.75mg base/kg single dose OD if gametocyte is present at any time during treatment. Check G6PD before giving primaquine.

Radical cure with primaquine is not needed in P. malariae/knowlesi infection due to the lack of hypnozoites formed.

Malaria fast fact:

>> First identified in 1880, the name 'Malaria’ comes from the Italian word mal'aria, meaning "bad air" >> P. falciparum - located worldwide in tropical and suburban areas, but predominately in Africa >>P. vivax - located in Latin America, Africa, and Asia >> P. ovale - mainly in West Africa >> P. malariae - located worldwide >>P. knowlesi - located in Southeast Asia

Paediatrics:

15

Drugs and Categories of Drugs Rationale Recommendation

Gastrointestinal (GI)

Metoclopramide

Can cause extrapyramidal effecs, including tardive dyskinesia

Risk maybe greater in frail older adults

Avoid,

unless for gastroparesis

Gastrointestinal (GI)

Proton pump inhibitors

Risk of clostridium difficile infection and bone loss and fractures

Avoid use for > 8 weeks unless in high risk patients (e.g, oral corticosteroids or chronic NSAID use ), erosive esophagitis, Barrett’s esophagitis, pathological hypersecretory condition, or need for maintenance treatment (e.g. failure of drug discontinuation trial or H2 blockers)

Pain medications

Non-cyclooxygenaseselective NSAIDs,

oral: Aspirin >325 mg/d

Diclofenac

Ibuprofen

Ketoprofen

Mefenamic acid

Meloxicam

Naproxen

Piroxicam

Increased risk of GI bleeding or peptic ulcer disease in high-risk groups, including those aged >75 or taking oral or parenteral corticosteroids, anticoagulants, or antiplatelet agents; use of proton-pump inhibitor or misoprostol reduces but does not eliminate risk.

Upper GI ulcers, gross bleeding, or perforation caused by NSAIDs occur in approximately 1% of patients treated for 3–6 months and in ~2–4% of patients treated for 1 year; these trends continue with longer duration of use.

Avoid chronic use, unless other alternatives are not effective and patient can take gastroprotective agent (proton pump inhibitor or misoprostol)

Pain medications

Indomethacin Ketorolac, includes parenteral

Indomethacin is more likely to have adverse CNS effects. Of all the NSAIDs, it has the most adverse effects.

Increased risk of GI bleed-ing/ peptic ulcer disease, and acute kidney injury in older

Avoid

14

Parameter Physiological Changes Effects

Excretion ↓ Renal blood flow

↓ GFR

↓Tubular secretion

↓ Renal mass

Drugs accumulation may occur with renally cleared drugs,

eg. Digoxin: maintenance daily dose of digoxin should be reduced.

•Reduction in renal plasma flow causes decreased tubular secretion of frusemide

List of POTENTIALLY inappropriate medications for use in older aldults

Published by the American Geriatrics Society

Last updated 2015

Guidelines for health care professionals to improve the safety of prescribing medications for older adults.

Below is an extract of common drugs used in elderly.

The full list for 2015 Updated Beers Criteria can be referred online in the Journal of American Geriatric Society.

Drugs and Categories of Drugs Rationale Recommendation

Anticholinergic Drugs Clearance reduced with advanced age, and tolerance develops when used as hypnotic; Risk of confusion, dry mouth, constipation, and other anticholinergic effects or toxicity

Avoid

Use of diphenhydramine in situations such as acute treatment of severe allergic reaction may be appropriate

First generation Antihistamines: Chlorpheniramine Dexchlorpheniramine Dimenhydrinate Diphenhydramine (oral) Hydroxyzine Meclizine Promethazine Triprolidine

Antiparkinsonian agents

Trihexyphenidy

(i.e. Benzhexol)

Not recommended for prevention of extrapyrami-dal symptoms with antipsychotics;

More effective agents available for treatment of Parkinson disease

Avoid

11

Plasmodium vivax Total chloroquine 25mg base/kg divided over 3 days; Day 1: 10 mg base/kg stat then 5 mg base/kg 6 hours later Day 2: 5 mg base/kg OD Day 3: 5 mg base/kg OD AND T.Primaquine 0.5 mg base/kg daily for 14 days

Plasmodium malariae/ knowlesi Treat as Plasmodium vivax with T. Chloroquine, WITHOUT T. Primaquine

Chloroquine-resistant Plasmodium vivax/malariae/knowlesi: Artemisinin Combined Therapy (T.Artemether 20mg/ Lumenfantrine 120mg or AS+MQ*.) OR Quinine + Primaquine OR Mefloquine 15mg/kg (single dose)

Complicated P. falciparum/vivax/malariae/knowlesi

i) First line: Day1: IV artesunate 2.4 mg/kg on admission, then repeat again at 12 hr Day2-7: IV artesunate 2.4 mg/kg OD OR switch to oral Artemisinin Combined Therapy

Parenteral artesunate should be given for a minimum of 24h or until patient is able to take orally and thereafter to complete treatment with a complete course of either one of the oral Artemisinin Combined Therapy

Children with severe malaria should be started on broad-spectrum antibiotic treatment immediately at the same time as antimalarial treatment.

ii) Second line: Day1 : IV Quinine Day2-7 : IV Quinine 10mg/kg AND Doxycycline (>8yrs) (3.5 mg/kg OD) OR Clindamycin (<8yrs) (10 mg/kg/dose bd) given for 7 days

In the case of P.vivax, a 14-day primaquine treatment is added to the regimen.

References:

1.MALAYSIA, VECTOR BOURNE DISEASE SECTOR DISEASE CONTROL DIVISION AND HEALTH EDUCATION DIVISION, MOH (2014) Management Guidelines of Malaria in Malaysia

2.MIMSGATEWAY entry for respective drugs

3.MALAYSIA, PHARMACEUTICAL SERVICES DIVISION,MOH (2014) National Antibiotic Guideline 2014

4. UK, MEDILEXICON INTERNATIONAL LTD (2004-2016) Malaria: Causes, Symptoms and TreatmentsAvailable from:http://www.medicalnewstoday.com/articles/150670.php [accessed: 21 July 2016]

12

Geriatric

Pharmacotherapy

By Ng Shy Pyng

Geriatrics refers to medical care for the elderly whose age > 65 .

Effective drug therapy for the elderly is challenging for many reasons:

• They use more drugs than any other age group, increasing risk of adverse effects and drug interactions, and making adherence more difficult.

• They are more likely to have chronic disorders that may be worsened by the drug or affect drug response.

• Their physiologic reserves are generally reduced and can be further reduced by acute and chronic disorders.

• Aging can alter pharmacodynamics and pharmacokinetics

There are 2 main approaches to optimizing drug therapy in the elderly:

Using appropriate drugs as indicated to maximize cost-effectiveness

Avoiding adverse drug effects

Pharmacodynamic Changes In Elderlys

Cardiovascular

↓ β-adrenergic receptors

↓ Effect of β-adrenergic agonists

↓ Effect of beta blocker on heart rate & stroke volume; ↓ Effect of salbutamol.

↓ Baroreceptor reflex response & Prone to has orthostatic hypotension

Central Nervous System

Structural and neurochemical changes , less effective blood-brain barrier

The brain may be exposed to higher drug levels

The acetylcholine neurotransmission may be affected

Anticholinergic drugs may induce delirium or increase delirium symptom severity

Electrolytes

↓ Electrolyte homeostatic mechanisms Greater susceptibility to adverse drug effects, for example, hyperkalaemia or hyponatremia.

13

Pharmakokinetic Changes In Elderlys

Parameter Physiological Changes Effects

Absorption ↓ Gastric emptying

↑ Gastric PH

↓ Splanchnic blood flow

↓ GI motility

• ↑ Calcium absorption & ↑ risk of constipation

• Early release of enteric–coated dosage forms

with gastric pH.

Distribution ↓ Cardiac output

↓ Total body water

↓ Lean body mass

↓ Serum albumin

↑ Body fat

↓ Altered relative tissue perfusion

• ↑ Volume of distribution for highly lipophilic drugs (eg. less drug distribution to muscle tissue for drugs such as digoxin, while fat-soluble drugs such as diazepam have a relative increase in drug distribution)

• Phenytoin and Warfarin are drugs with a high risk of toxic effects when serum albumin level decreases (only unbound drug has a pharmacologic effect).

• Polar drugs such as Gentamicin, Digoxin, Ethanol, Theophylline, and Cimetidine that are mainly water-soluble tend to have smaller volumes of distribution (V) resulting in higher serum levels in older people.

Metabolism ↓ Hepatic mass

↓ Enyzme activity

↓ Hepatic blood flow

↓ Phase 1 metabolism

•The rate of metabolism is often diminished for drugs dependent upon hepatic blood flow, such as lidocaine, propranolol, and meperidine

• Diazepam, undergo Phase I metabolism, where the rate of elimination will be slower than in younger adults. This may result in drug accumulation over time, potentially causing over-sedation, impaired psychomotor skills, or confusion.

Lorazepam, metabolized primarily by Phase II reactions, which are not affected by aging; while their shorter half-life makes it less likely to accumulate.