volume 2/2019 july 2019 penawar - hsajb.moh.gov.myhsajb.moh.gov.my/versibaru/uploads/farmasi/buletin...

EDITORIAL BOARD ADVISOR: PN HJH ROHAYAH BINTI ABD. GHANI

BULETIN

JULY 2019 VOLUME 2/2019

PENAWAR

HOSPITAL SULTANAH AMINAH JOHOR BAHRU KEMENTERIAN KESIHATAN MALAYSIA JALAN PERSIARAN ABU BAKAR SULTAN, 80100 JOHOR BAHRU

TEL: 07-2257000 FAX: 07-2242694 EMAIL: [email protected]

EDITORS: PN SITI ROSNAH BT SURADI PN NG WANG SING CIK ZANARIAH BT ABU BAKAR PN LI SHIN GIE

HOSPITAL SULTANAH AMINAH JOHOR BAHRU

ACUTE ISCHAEMIC STROKE PROTOCOL HSAJB PAGE 2-3

INFLUENZA VACCINES PAGE 4-5

MANAGEMENT OF DIABETES IN PREGNANCY PAGE 6-7

CYANIDE POISONING PAGE 8-9

PROGRAM KENALI UBAT ANDA PAGE 10

ACUTE ISCHAEMIC STROKE PROTOCOL HSAJB Stroke is a global health problem. It has consistently seen as one of the top five leading cause of death since year 2000’s.

Algorithm

Service’s Introduction Started on 12 November 2017 and applied only

during office hours.

Protocol for IV tPA for Acute Stroke

Inclusion criteria

Absolute contraindication

Relative Contraindication

Significant trauma within 3 months

(include CPR with chest compressions

within past 10 days)

Stroke within 3 months

History of intracranial hemorrhage or

symptoms suspicious.

Major surgery within past 14 days

Minor surgery within past 10 days,

including liver and kidney biopsy,

thoracentesis and lumbar puncture.

Arterial puncture at non-compressible site

within past 14 days

Pregnant (up to 10 days postpartum) or

nursing women

Gastrointestinal, urologic or respiratory

hemorrhage within past 21 days

Known bleeding diathesis (include renal

& hepatic insufficiency)

Peritoneal dialysis or hemodialysis

PTT > 40 seconds; PT >15 seconds

(INR>1.7; platelet count< 100,000)

SBP >180mmHg or DBP> 110 mmHg,

Seizure at onset of stroke

Glucose <2.8 or >22 mmol/L

Consideration should be given to the

increased risk of hemorrhage in patients

with severe deficits (NIHSS >20), age >75

or early edema with mass effect on CT

Mild or rapidly improving deficits

JABATAN FARMASI, HOSPITAL SULTANAH AMINAH JOHOR BAHRU PAGE 2

BY NURAINI BINTI ARSHAD

Abbreviation: tPA: tissue plasminogen

activator

rTPA: recombinant tPa

NIHSS: NIH Stroke Scale

ASPECT: Alberta Stroke

Program Early CT

Pre-Treatment Work Up

Alteplase Infusion Pre and Post Treatment Management

• ICU/HDU/General Medical Ward Acute Bed admission for monitoring for at least 24 hour

• Vital signs every 15 mins for 2 hours, then every 30mins for 6 hours, then every hour for 24 hours

• Strict control of BP for 24 hours per protocol (SBP<180mmHg, DBP<110mmHg)

• Neurological check hourly for 24 hours (GCS) • Maintain oxygen saturation 95% • No antiplatelet agents or anticoagulants in the first 24 hours • No Foley catheter, nasogastric tube, arterial catheter or

central venous catheter for 24h (unless absolutely necessary)

Blood Pressure Control after IV tPA SBP(mmHg) DBP(mmHg) Management

180-230 105-120 Give IV Labetalol 10mg over 1-2 minutes. May repeat or double every 10-20 minutes up to a total dose of 150mg. Monitor BP every 15 minutes.

>230 121-140 Same with above management, but if no response, infuse Sodium Nitroprusside (0.5-10µg/kg per minute).

- >140 Infuse Sodium Nitroprusside (0.5-10µg/kg per min). Monitor BP every 15min.

Symptomatic Hemorrhage After IV tPa 1. STAT head CT, if intracelebral hemorrhage is suspected. 2. Refer neurosurgery and ICU. 3. Check FBC, PT, PTT, platelets, fibrinogen and D-dimer. Repeat every 2 hours until bleeding is con-

trolled. 4. Give 2 units Fresh Frozen Plasma every 6 hours for 24 hours. 5. Give 6 units Cryoprecipitate. If fibrinogen level <200mg/dl at 1h, repeat Cryoprecipitate dose. 6. Give 4 units platelets. 7. Give Mannitol 20% 200ml stat and TDS. 8. Institute frequent neurological checks and therapy of acutely elevated in, as needed.


BY NURAINI BINTI ARSHAD

Influenza Vaccines

Influenza: A contagious respiratory illness caused by influenza viruses that infect nose,

throat and lungs.

• Physical exam

• Look for signs and symptoms of influenza

• Laboratory diagnost ic p r o c e d u r e s i n v o l v e collection of appropriate respiratory samples .

• Rapid influenza diagnostic tests (RIDTs) are commonly used but have lower sensitivity compared to Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) methods that detect influenza-specific RNA by RT-PCR

Clinical Diagnosis

Complications

Uncomplicated Serious

Typically resolves

after 3-7 days

Cough and

malaise may

persist for >2

weeks

Pneumonia is the

most common

complication

Others: otitis media,

tracheobronchitis,

rhabdomyolysis with

renal failure

Distribution of Influenza Viruses Subtype Worldwide

Clinical Presentations

• Abrupt onset of fever

• Severe myalgia and/or arthralgia

• Severe dry cough

• Loss of appetite

• Headache

• Malaise

• Sore throat

Aetiology

Seasonal Influenza Avian Influenza

Types of virus: A, B and C

Types A & B are the main

causes of influenza outbreaks

Also known as ‘bird flu’

Caused by type A

strains such as H5N1

How Does Vaccine Work?

Stimulates your body’s immune

system to make antibodies to attack

the influenza viruses

Reduces flu-related doctor’s

visits or hospitalizations

Important preventive tool for

people with chronic health

conditions

Helps protect women during

and after pregnancy

Can be life-saving in children

Uncomplicated Vaccines

Prevention

-Should be given annually for those ≥6 months old with no contraindi-cation to any of its components

-People who have a history of severe egg allergy should be vaccinated in a medical setting

Treatment

Symptomatic

Therapy

Fever & Myalgia:

non-opioid analge-

sics & antipyretics

Cough & cold

preparations:

expectorants,

mucolytics

Influenza Management

Complicated

Antiviral

Therapy

M2 inhibitors

(Amantadine or

Rimantadine)

Neuraminidase

inhibitor

(Oseltamivir or

Zanamivir)

Benefits of Vaccines


BY ER PEY LING

WHO Recommended Vaccines’ Compositions

References: 1.World Health Organization. Influenza. Available from: https://www.who.int/influenza/en/ [Accessed 29th Jan 2019]. 2. Centers for Disease Control and Prevention (CDC). Key Facts About Seasonal Flu Vaccine. Available from: https://www.cdc.gov/flu/protect/keyfacts.htm [Accessed 30th Jan 2019]. 3. Treanor JJ. Clinical Practice. Influenza Vaccination. New Eng-land Journal of Medicine.2016; 375:1261-1268. 4. Grohskopf LA, Sokolow LZ, Broder KR, Walter EB, Fry AM, Jernigan DB. Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Im-munization Practices-United States, 2018-19 Influenza Season. MMWR Recomm Rep. 2018;67(3):1-20.

Possible Side Effects: Very common: Injection site reactions such as

pain, swelling & redness, headache, myalgia Common: Nausea, vomiting and

diarrhoea Uncommon: Rash, thrombocy-

topenia, convulsions, cellulitis

Southern Hemisphere Northern Hemisphere

Trivalent: A/Michigan/45/2015

(H1N1) pdm09-like virus, A/

Switzerland/8060/2017 (H3N2)-

like virus & B/Colorado/06/2017

-like virus

Quadrivalent: the above-

mentioned antigens plus B/

Phuket/3073/2013-like virus

Trivalent: A/Michigan/45/2015

(H1N1) pdm09-like virus, A/

Singapore/INFIMH-

160019/2016(H3N2)-like virus

& B/Colorado/06/2017-like vi-

rus

Quadrivalent: the above-

mentioned antigens plus B/

Phuket/3073/2013-like virus

Trivalent or Quadrivalent Vaccines

Trivalent

B H3N2 H1N1

Quadrivalent

Methods of Production Vaccine Categories Vaccine Delivery

Egg-based

Cell-based

Recombinant

Live Attenuated (LAIV)

Inactivated (IIV)

Recombinant (RIV)

Nasal spray (2-49 age

Injectable Flu Vaccine

Comparisons between IIV, LAIV and RIV

Vaccine Type IIV LAIV RIV

No. of virus strains 3 or 4 4 4

Approved age ≥6 months 2-49 years ≥18 years

Route of administration Intramuscular or

intradermal

Intranasal spray Intramuscular

Dosage 1 or 2 doses depending

on vaccination history

1 or 2 doses depending

on vaccination history

Single dose

(annually)

Contraindicated in chronic medical

conditions/immunocompromised/

pregnant woman

No

Yes No

Brand names Afluria®, Fluarix®,

Fluzone®

FluMist® FluBlok®

Children: 6 months to 5 years old

Immuno-compromised

Eg. HIV/AIDS, cancer

Elderly > 65 years old

Chronic medical conditions

Eg. asthma,

diabetes, cardiac diseases

Pregnant women at any stage of

pregnancy

Healthcare workers

BY ER PEY LING


B H3N2 H1N1 B

MANAGEMENT OF DIABETES IN PREGNANCY

INTRODUCTION

Diabetes during pregnancy can be separated in two groups:

(a) Pregestational diabetes

diagnosed before pregnancy with either insulin dependent or insulin independent

(b) Gestational diabetes mellitus (GDM)

carbohydrate intolerance first detected during pregnancy.

SCREENING AND DIAGNOSIS RISK FACTOR

• Previous history of GDM

• Body mass index (BMI) >27 kg/m²

• First-degree relative with diabetes mellitus

• History of macrosomia (birth weight >4 kg)

• Bad obstetric history (unexplained intrauterine

death, congenital anomalies, shoulder dystocia)

• Glycosuria ≥2+ on two occasions

• Current obstetric problems (essential

hypertension, pregnancy induced hypertension,

polyhydramnios and current use of

corticosteroids)

COMPLICATION

• Neural tube defects

• Incidence of stillbirth is greatest after 36 weeks’ gestation in women with poor

glycaemic control

• Macrosomia, defined as birthweight >4 kg

• Shoulder dystocia

• Infants of diabetic mothers also are at increased risk for prolonged

hypoglycaemia after delivery, respiratory distress syndrome,

hypocalcaemia, polycythaemia and hyperbilirubinaemia during the neonatal

period

GOAL OF TREATMENT

To reduce the maternal and fetal morbidity and mortality associated with diabetes


BY LOW YI WEN

TREATMENT OF GDM

1. ORAL ANTIDIABETIC AGENT 2. INSULIN

Metformin (Biguanide)

MOA: Decreases hepatic glucose production and intestinal

absorption and improves insulin sensitivity by increasing

peripheral glucose uptake and utilization.

Pregnancy category: B (Animal study has failed to demonstrate a

risk to the fetus and there are no adequate and well-controlled

studies in pregnant women).

Compared with insulin, metformin is associated with less

maternal weight gain but higher incidence of premature birth

(<37 weeks gestation).

Prandial insulin: short or rapid onset of action for controlling the

post-prandial glucose excursion.

Basal insulin: intermediate or long-acting pharmacokinetic profile to

cover the basal insulin requirements in between meals and

overnight.

Premixed insulin: biphasic insulin that incorporates the combination

of short or rapid-acting insulin with its intermediate-acting.

Supplement of 5 mg folic acid per day should be given to women

with diabetes who plan to become pregnant at least three months

prior to conception and continue until 12 weeks of gestation.

BLOOD GLUCOSE TARGET IN

PREGNANCY

POSTPARTUM LIFESTYLE

MODIFICATION

Moderate physical activity (brisk walking, swimming or modified

yoga), 20-30 minutes, four days per week.

OGTT should be performed at six weeks after delivery.

If the result is negative, annual screening should be performed.

References 1. CPG of Management of diabetes in pregnancy. (2017). Malaysia Health Technology Assessment Section (MaHTAS) Medical Development Division, Ministry of Health

Malaysia Level 4, Block E1, Precinct 1 Federal Government Administrative Centre 62590, Putrajaya, Malaysia.

2. Alldredge, B., Koda-Kimble, M. and Young, L. (n.d.). Koda-Kimble Applied therapeutics. 9th ed.

POSTPARTUM MONITORING

FOLIC ACID SUPPLEMENT

SELF MONITORING BLOOD

GLUCOSE (SMBG) MONITORING

BY LOW YI WEN


Timing of Blood Glucose Target Value (mmol/L)

Fasting or preprandial 5.1

1-hour after the start of a meal 7.8

2-hours after the start of a meal 6.7

CYANIDE POISONING

• Remove Casualty from further exposure to cyanides.

• Support ABC (Airway, Breathing, Circulation)

• Decontaminated

• Transfer patient to medical facility

What is Cyanide?

• Fast acting and highly toxic chemical.

• Presented in Cyanide salts (Potassium/Sodium) & Hydrogen

cyanide gas.

• Commonly used in chemical industry, mining and

electroplating industries.

• Odour of bitter almonds.

Controlling Risk

Personal Protective Equipment:

• Gloves

• Protective apron

• Rubber boots

• Face Shield/goggles

• Appropriate respiratory equipment

First Aid

Patient should always be taken

to the nearest hospital for

assessment and monitoring.

Poisoning by Ingestion • Vomiting should not be induced

unless told by a registered medical practitioner

• Rinse the mouth with water

• Go to nearest hospital ASAP

Exposure of cyanide by eye contamination • Wash the eye with

copious water or saline for at least 10 minutes

• Monitor signs and symptoms of poisoning

Routes of Exposure

Mouth-to-mouth

resuscitation should

be avoided

• Inhalation (Most Common)

• Eye Contact

• Skin Contact

• Ingestion (Less common)


By Yong Guo Shen

Pathophysiology

Binds with ferric ion in mitochondrial

cytochrome oxidase

Prevent electron transport chain

(Inhibit oxidative phosphorylation & ATP

production)

Prevent utilisation of oxygen in cellular

metabolism

Increased demands on anaerobic glycolysis

Excessive lactic acid production

Severe acid-base imbalance

*CNS, myocardium are particularly

sensitive to the toxic effects of cyanide*

Medical Facility Care

Signs of Cyanide Poisoning

Arterial and venous blood gases

• Arteriovenous oxygen differences (<10%)

• Metabolic acidosis

Blood Lactate Level

• Smoke Inhalation - > 10 mmol/L

• Pure Poisoning - > 6 mmol/L

Altered Mental Status

• e.g. confusion, disorientation

Prioritise first aids, oxygen therapy & other life supporting measures (e.g. metabolic acidosis correction) Cyanide antidotes only be given when:

Patient’s condition deteriorates

Severe symptoms of cyanide poisoning *Panic symptoms (tachypnoea, vomiting) may mimic early cyanide poisoning symptoms. Hence, true cyanide poisoning is needed to confirm before antidote administration.

Monitoring of Patient: • At least 48-72 hours after initial emergency

treatment (especially after antidote administration)

• Continuation of 100% oxygen administration should be determined based on the response to antidote

• Watch for development of pulmonary oedema, aspiration pneumonia and seizures in comatose patient

• Correct any further metabolic acidosis

Symptoms of Cyanide Poisoning

• Fast onset

• Depends on: Cyanide form, route of exposure, amount of

cyanide exposed to.

Acute (Severe)

• Seizures

• Gasping for breath

• Cardiac arrest

• Rapid Loss of

consciousness

*Death may occur within few minutes of expo-sure to moderate or high amounts of cyanide.

Headache Anxiety

Shortness

of Breath

Dizziness

General

Weakness Nausea,

Vomiting

Acute (Mild)

References

1. Safe Work Australia. Guide for preventing and responding to cyanide poisoning in the workplace. Australia: SWA; 2013. 20 p.

2. Cyanokit (single 5-g vial) [package insert]. Columbia, MD: Meridian Medical Technologies, Inc.; 2011.

3. National Institute for Occupational Safety and Health (NIOSH), 2016. Respirator Trusted-Source Information – Section 3: Ancillary

Respirator Information.

4. Atsdr.cdc.gov. (2019). ATSDR - Medical Management Guidelines (MMGs): Cyanide. [online] Available at: https://

www.atsdr.cdc.gov/mmg/mmg.asp?id=1073&tid=19 [Accessed 4 May 2019].


By Yong Guo Shen

Antidotes (IV)

Types of

Antidotes

Mechanism of

Action

Dosage & Administration Redosing Adverse Ef-

fects

Monitoring

Hydroxo-

cobalamin

(Cyanokit)

Binds to

cyanide ions to

form cyanoco-

balamin then

excreted in the

urine

Adult: IV 5g over 15 mins; may

repeat if necessary

(Max cumulative dose: 10g)

Second dose of 5g

may be

administered if

signs of cyanide

poisoning

reappear

Transient

chromaturia,

increased

blood pres-

sure, nausea,

headache

• Renal functions for 7 days after treatment

• Blood pressure • Allergic reaction: ana-

phylaxis, rash, chest tightness

Sodium

Thiosulphate

12.5g/50mL

Acts as

sulphur

donor for

rhodanese and to

enhance

endogenous

cyanide

detoxification

capacity of the

body

Adult: IV 12.5g over 10 mins,

repeat if necessary with half of

first dose.

Children: IV 412.5mg/kg at rate

0.625 to 1.25g/min. Max dose:

12.5g

If signs of

cyanide poisoning

reappear after 30

minutes to 2 hours

after administra-

tion, may repeat

with half of first

dose

Hypotension,

headache,

disorientation

• Signs & symptoms of

thiocyanate poisoning

(Serum thiocyanate >

10mg/100mL)

Sodium

Nitrite*

300mg/10mL

* Indicated for

sequential use

with

sodium

thiosulfate

Reacts

Haemoglobin

↓

Methaemoglobin

Cyanide

preferably binds

to methaemoglo-

bin than

ferric ion of

mitochondrial

oxidase. Hence

restoring

cytochrome

oxidase

activity

Adult:

• Sodium Nitrite - IV 10mL at

rate 2.5 to 5 mL/min

• Sodium Thiosulfate - IV 50mL

immediately following

administration of Sodium

Nitrite.

Children:

• Sodium Nitrite - IV 0.2mL/kg

at rate 2.5 to 5 mL/min

• Sodium Thiosulfate - IV 1mL/

kg but not exceed 50 mL total

dose immediately following

administration of Sodium

If signs of

cyanide

poisoning

reappear, repeat

treatment using

half of

original dose of

both Sodium

Nitrite and

Sodium

Thiosulphate

Syncope,

hypotension,

methemoglo-

binaemia,

tachycardia,

palpitation

• Blood pressure moni-

toring is a MUST.

• Pulse oximetry

(oxyhaemoglobin, car-

boxyhaemoglobin, met-

haemoglobin level) in

patient with anaemia/

smoke inhalation injury

*Monitor at least 1-2 days

after antidotes administra-

tion

*Renal impairment patient

has higher risk of toxic

reactions to this drug

Guide for Preventing and Responding to

Cyanide Poisoning in the Workplace

Empty containers cannot be reused

Thoroughly rinsed with large amounts of

water

Container should be crushed and disposed

Disposal

Storage • Small quantities of cyanides should be stored

separately

• Storage areas should be fire-resistant with a con-

crete floor

• Keep cyanides in original containers and keep

them securely closed and the oldest material is

used first.

• Do not eat, drink or smoke in a cyanide store

• Minimise the likelihood of unintended reactions

with incompatible materials (acids, oxidising

agents)


PROGRAM KENALI UBAT ANDA

Jabatan Farmasi Hospital Sultanah Aminah telah menganjurkan Program Kenali Ubat

Anda pada 16 Mei 2019 di Dewan Sekolah Menengah Foon Yew, Johor Bahru. Program ini

telah melibatkan pelajar Tingkatan 5 dan 6.

Program ini dijalankan untuk memastikan pelajar mengenali ubat-ubatan dan

mengambilnya secara rasional. Selain itu, sesi ceramah, kuiz and aktiviti ini memberi

peluang kepada pelajar untuk menimba pengetahuan baru. Secara tidak langsung, Jabatan

Farmasi dapat memastikan maklumat yang betul telah disampaikan kepada pelajar. Secara

keseluruhannya, pameran ini telah berjalan dengan lancar dan meriah.

Program ini bermula pada jam 9.30 pagi hingga 11.30 pagi. Program ini terdiri

daripada pelbagai pameran, kuiz, ceramah dan aktiviti. Terdapat dua ceramah yang

disampaikan kepada pelajar:

1) Kenali Ubat Anda

2) Pemilihan komestik yang selamat dan bahaya penggunaan kosmetik yang tidak

bernotifikasi

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