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COMPILED BY:
UNIT FARMASI
KLINIKAL DAN
MAKLUMAT DRUG
HOSPITAL USM Drug Use Flow Charts
2019
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Contents GUIDELINES FOR USING PROTON PUMP INHIBITOR (PPI) HUSM .......................................................1 FLOW CHART USAGE OF PPI IN HUSM ...........................................................................................................3 LIPID LOWERING THERAPY USM GUIDELINES ............................................................................................4 INDICATION OF USING AMLODIPINE (AND FELODIPINE) IN HUSM (SUGGESTION) ..............9 PROPOSAL GUIDELINES ON PLAVIX PRESCRIPTION FOR CARDIOLOGY PATIENTS HUSM..... 15 SIMPLIFIED NOVOSEVEN PROTOCOL FOR HAEMATOLOGY USM ................................................... 16 SIMPLIFIED NOVOSEVEN PROTOCOL FOR NEUROSURGERY USM ................................................... 16 GUIDELINE FOR OFF-LABEL USE OF RECOMBINANT ACTIVATED FACTOR VII (rFVIIa) ........... 18 GUIDELINE FOR THE USE OF RECOMBINANT ACTIVATED FACTOR VII (RFVIIA) IN NON-HEMOPHILIC PATIENTS WITH LIFE-THREATENING HEMORRHAGE ............................................... 21 GUIDELINES FOR OUTPATIENT TREATMENT OF CHRONIC ASTHMA DEPARTMENT OF MEDICINE HOSPITAL USM ............................................................................................................................... 30 GUIDELINES FOR USING INFLUENZA VACCINE ....................................................................................... 33 FLOW CHART PENGGUNAAN DRUG UNTUK RAWATAN ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD) ............................................................................................................ 34 ALGORITHM FOR MEDICATIONS OF SCHIZOPHRENIA ........................................................................ 36 ACUTE TREATMENT OF MANIA ...................................................................................................................... 38 ACUTE TREATMENT OF BIPOLAR DEPRESSION......................................................................................... 39 PSYCOPHARMACOLOGICAL TREATMENT ALGORITHM FOR GENERALUIZED ANXIETY DISORDER (GAD) .................................................................................................................................................. 40 ALGORITHM (2) FOR THE PHARMACOTHERAPY OF MAJOR DEPRESSIVE DISORDER (MDD) ..................................................................................................................................................................................... 41 ALGORITHM FOR MANAGEMENT OF DEMENTIA ................................................................................... 42 ALZHEIMER’S DISEASE TREATMENT STRATEGY ....................................................................................... 43 PARKINSON DISEASE ........................................................................................................................................... 44 FLOW CHART FOR TREATMENT HEPATITIS B IN TREATMENT NAÏVE PATIENTS ........................ 45 FLOW CHART OF CHRONIC VIRAL HEPATITIS B PRE CORE MUTANT HBEAG NEGATIVE ....... 46 FLOW CHART FOR GENITAL ULCER SYNDROME ..................................................................................... 47 TREATMENT FOR SYPHILIS AND CHANCROID ......................................................................................... 47 FLOW CHART FOR VAGINAL DISCHARGE SYNDROME ......................................................................... 48 FLOW CHART FOR URETHRAL DISCHARGE SYNDROME IN MEN ..................................................... 49 OUTPATIENT TREATMENT OF CAP ................................................................................................................ 50 FLOW CHART OF USING SULPERAZONE IN ICU ...................................................................................... 52 GUIDELINES FOR USING NOVOMIX 30 FLEXPEN HOSPITAL UNIVERSITI SAINS MALAYSIA .. 53 FLOWCHART FOR USE OF GLUCOPHAGE XR ............................................................................................ 54 FLOWCHART FOR USE OF INSULIN DETEMIR ........................................................................................... 55 ALGORITHM FOR THE MANAGEMENT OF POSTMENOPAUSAL OSTEOPOROSIS ....................... 56 ZOLENDRONIC ACID PRESCRIPTION FLOW CHART .............................................................................. 57
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FLOW CHART FOR USING IMATINIB IN CHRONIC MYELOID LEUKEMIA (CML), PH+ ACUTE LYMPHOBLASTIC LEUKEMIA (ALL) ............................................................................................................... 58 ARCOXIA PRESCRIPTION FLOW CHART ...................................................................................................... 59 OUTPATIENT PAIN PRESCRIPTION FLOW CHART .................................................................................... 60 FLOWCHART OF PATIENTS DIAGNOSED WITH BACTERIAL CONJUNCTIVITIS ........................... 61 FLOWCHART OF PATIENTS DIAGNOSED WITH BACTERIAL KERATITIS ......................................... 62 FLOWCHART OF PATIENTS REQUIRING PRE AND POST CATARACT SURGERY ANTIBIOTIC PROPHYLAXIS ......................................................................................................................................................... 63 FLOW CHART FOR USING OLOPATADINE 0.1% ....................................................................................... 64 TREATMENT ALGORITHM OF ALLERGIC RHINITIS (AR) ........................................................................ 65 FLOW CHART OF THALASSAEMIA PATIENT WITH IRON OVERLOAD ............................................. 66 INTERFERON BETA-1B FLOWCHART ............................................................................................................ 67 FLOW CHART FOR INSULIN ANALOGUE AT KRK ..................................................................................... 68
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GUIDELINES FOR USING PROTON PUMP INHIBITOR (PPI) HUSM
Upper GIT bleed
Mucosal break lesion
Treatment Prophylatic / suspected
Upper GIT bleed confirm on OGDS Tab / IV PPI 40 mg OD
Chronic
T. PPI 40mg OD x 3-6/12
Long term – if has other risk factors eg:
- Age > 65 years - On anti-platelet / NSAIDs /
STEROIDs
Acute
IV PPI 80 mg stat
Emergency OGDS within 24 hour
IV PPI 8mg/hr x 72 hours
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Maintenance T. PPI 40 mg BD x 4-6/52 therapy
If not properly heal
If symptom persisted
Maintenance T. PPI OD x 3-6/12
Remarks:
1st line Pantoprazole
2nd line Esomeprazole
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FLOW CHART USAGE OF PPI IN HUSM ENDOSCOPY MEETING ON 7/2/12
Bleeding cases (Non variceal bleed) 1st Endoscopic procedure, then 2nd Proton pump inhibitor (PPI), then 3rd Mucosal protective therapy (oral sucralfate), then 4th Surgival intervention Bleeding cases (variceal bleed) 1st line I/V Octreotide 25-50mcg, then 25-50mcg/hr Or Somatostatin 250mcg stat then 250mcg/hr 2nd line PPI infusion PPI 1st line I/V PPI 80 mg stat, then I/V PPI 8 mg/hr for 3 – 5/7, then I/V PPI 40 mg BD Follow-up by tab.PPI 40 mg BD x 8 – 12/52 and to repeat endoscopy if rebleed or after complete treatment. Mucosal break lesion (Prophylaxis) 1st line I/V Pantoprazole 40mg stat 2nd line I/V Esomeprazole 40 mg BD 3rd line Oral Sucralfate 4th line I/V Ranitidine or tablet Peptic Ulser disease (PUD) 1st line Tab. Pantoprazole 40mg OD/BD, then 2nd line Tab. Esomeprazole 40 mg OD/BD, then 3rd line Tab. Omeprazole 20 mg BD
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In cases of PUD (No. OGDS) (No. PPI test) Tab. Ganaton 50 mg BD/TDS with 1st line Tab. Pantoprazole 40 mg OD/BD 2nd line Tab. Esomeprazole 40 mg OD/BD If not improve after 2/52 refer results endoscopy investigation (Gastro/Surgical) In cases of no OGDS for PPI test 1st line Tab. Pantoprazole 40 mg BD x 2/52 then decision OR 2nd line Tab. Esomeprazole 40 mg BD x 2/52 then decision. In Cases of Biliary gastritis/ recurrent GERD/ GERD (Gastrooesophageal disease)
1) T. Ganaton 50 mg BD/TDS with 1st line T. Esomeprazole 40 mg BD/TDS
2) T. Ganaton 50 mg BD/TDS with 2 nd line T. Pantoprazole 40 mg BD
In Cases of PUD with normal OGDS/ NERD (non erosive gastritis) T. Ganaton 50 mg BD/TDS WITH 1st line Tab. Esomeprazole 40 mg OD/BD 2 nd line Tab. Pantoprazole 40 mg OD/BD
Last Update: February 2012
LIPID LOWERING THERAPY USM GUIDELINES
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Indications for use
1. Coronary heart disease (CHD) 2. CHD disease equivalent
a) Diabetes Mellitus b) Carotid artery disease c) Peripheral artery disease d) Abdominal aortic aneurysm
3. Familial hyperlipidaemia (or total chol > 8, LDL chol > 6) 4. CHD high risk individuals
a) Individuals with 2 or more risk factors 5. CHD low risk
a) Individuals with less than 2 risk factors 6. If asymptomatic but total cholesterol ≥ 5.0 mmol/l, LDL cholesterol ≥ 3.0
mmol/l and total CVD risk of projected CVD risk at 60 years of age is ≥ 5%. 7. Others
a) Individuals with chronic renal disease (Creatinine > 133 umol/L or GFR < 60 ml/min/1.73 m2)
b) Metabolic syndrome
Drug Dose range ( mg )
LDL reduction Cost for 1/12 rx RM
Pravastatin 10 - 40 19 – 40 %
Simvastatin 10 - 80 28 - 48 %
Lovastatin 20 - 80 29 – 48 %
Atorvastatin 10 - 80 38 – 54 %
Rosuvastatin 10 - 40 52 – 63 %
Indications 1-4
• Aggressive lipid lowering therapy required
• High dose and high potency drug required
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• Suggestion
Indications 5-7:
• Lipid lowering therapy can be step wise intensification
• Suggestions
1. Coronary heart disease (CHD) 2. CHD disease equivalent
i) Diabetes Mellitus ii) Carotid artery disease iii) Peripheral artery disease iv) Abdominal aortic aneurysm
3. Familial hyperlipidaemia (or total chol > 8, LDL, chol >6) 4. CHD high risk individuals- Individuals with 2 or more
Check FLP
Start atorvastatin
10 – 20 mg od
Check FLP after
3/12
TLC
Total C > 4.5 or
LDL > 2.5
Total C < 4.5 or
LDL < 2.5
Intensification of Rx
Increase dose of
Atovarstatin or change
to Rosuvastatin
Continue medication or
consider de-escalation of Rx
ie change to Simvastatin or
Pravastatin as per indicated TLC
TLC = Therapeutic lifestyle changes
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Drug therapy indicated
1. CHD low risk
a) Individuals with less than 2 risk factors
2. If asymptomatic but total cholesterol ≥ 5.0 mmol/l, LDL cholesterol ≥ 3.0
mmol/l and total CVD risk of projected CVD risk at 60 years of age is ≥ 5 %.
3. Others
a) Individuals with chronic renal disease
(Creatinine > 1.33 umol/L or GFR < 60 ml/min/1.73 m2)
b) Metabolic syndrome
Total chol
Risk score: 10 year risk for CV death
Total risk 5.0
LDL chol > 3.0
Continue TLC Continue TLC
Reassess risk yearly
Start drug
therapy If risk ≥ 5 % and
Total chol < 4.5 and
LDL chol < 2.5
TLC = Therapeutic
lifestyle changes
Consider drug
therapy
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Prepared by Dr Tee Meng Hun & AP Dr Zulkurnai Yusof, Med Dept
Total chol 5.0 – 5.9
LDL chol 2.5 – 3.5
Total chol 6.0 – 6.9
LDL chol 3.5- 4.5
Total chol 7.0
LDL chol 4.5
Pravastatin or
simvastatin
Simvastatin or
atorvastatin
Atorvatatin or
rosuvastatin
If targets not achieved : Total chol > 4.5 or LDL > 2.5
CHECK COMPLIANCE TO TLC AND DRUG THERAPY
Consider intensifying treatment
Simvastatin
Ezetimide
Or
Atorvastatin
Or
Rosuvastatin
Combination therapy
Atorvastatin
Or
Rosuvastatin
And or
Ezetimibe
And or
Fibrates etc
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INDICATION OF USING AMLODIPINE (AND FELODIPINE) IN HUSM (SUGGESTION) 1. Introduction Calcium channel blockers work by blocking the initial calcium influx into myocytes and vascular smooth muscle cells. Amlodipine and felodipine are long acting second generation dihydropyridine that have vascular smooth muscle relaxing activity with no or minimal negative inotropic effects. They have a greater selectivity for vascular smooth muscle compared to the myocardium. They vasodilate coronary arteries reduce coronary resistance, increase coronary blood flow and may enhance the development of coronary collaterals. 2.Indication of using calcium channel blocker (CCB) 2a. The use of CCB as anti-ischemic agent -calcium channel blocker has been shown to exert anti-angina properties in various ways such as reduction in heart rate, reduction in contractility, reduction in afterload and direct vasodilatation. -calcium channel blocker should be considered if there are contraindications or adverse reactions to either beta blockers of nitrates or if symptoms are not well controlled with a combination of these agents. 2b.The use in acute coronary syndrome (ACS) patients. - The potential benefits of either amlodipine or felodipine in acute MI has not been examined directly. - Amlodipine is often used in patients with acute MI when hypertension is not adequately controlled by other therapy of proven benefit (beta blockers and ACE inhibitors ). - Study in stable coronary heart disease (PREVENT trial) found no or little benefit of amlodipine but also has no harm. - Therefore amlodipine is not indicated as first line therapy on ACS patients unlike ACE inhibitors and beta blockers. 2c. The use of CCB in patients with heart failure - The potential benefit of either amlodipine or felodipine in acute MI has not been examined directly. However, clinical trial that have evaluated these drugs in heart failure (V- HeFT III and the PRAISE trials) found no or little benefit but also no harm. - In patient with heart failure, amlodipine in at a drug choice as compared to ACE inhibitors, beta blockers and aldosterone antagonist.
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2d.The use of CCB in hypertension patients. - Although recommendations for initiating medical therapy in essential hypertension have been proposed, there is no uniform agreement on which antihypertensive agent should be given as initial therapy. A variety of different classes of drugs can be used in this setting. These include the thiazide diuretics, beta blockers, angiotensin converting enzyme (ACE) inhibitors, angiotensin II receptor blockers and calcium channel blockers. - There have been limited data as to whether different antihypertensive drugs have variable effects upon patient outcomes, particularly cardiovascular morbidity and mortality. However, an increasing number of trials have provided evidence that at the same level of blood pressure control, most antihypertensive drugs provide the same degree of cardiovascular protection provided there are no other compelling indications. - The choice of drug should be based on the patient’s individual risk profile and the tolerability of the drugs. - “First-line” drugs should have the following properties : 1. reduce long-term morbidity and mortality 2. high efficacy of once-daily administration 3. no adverse effects on concomitant risk factor 4. good tolerability - based on JNC VII guidelines, hypertensive naïve patient should receive diuretics as first line drug. 2e. The use of CCB in anti-arrythmic agents -the use of amlodipine as anti- arrythmic agents therapy was not well studied unlike verapamil and diltiazem, therefore it is not recommended as anti-arrythmic therapy. 2f. The use of CCB in patients with renal disease/nephropathy - Hypertension is common in chronic renal disease and is risk factor for progression of renal damage, and reduction of blood pressure (BP) is an efficient way of preventing or slowing the progression of this damage. BP – lowering effects are common to all antihypertensive drugs, but intra-renal effects differ between classes and between individual drugs within certain classes. Angiotensin – converting enzyme (ACE) inhibitors and angiotensin receptors blockers (ARB) have beneficial effects on proteinuria and declining renal function that appear to be mediated by factors additional to their effects on BP. These RAS inhibitors are recommended as first-line antihypertensive approach in patients with chronic kidney disease. - Calcium channel antagonist are highly a heterogenous class of compounds, and it appears that some agents are more suitable for use in patients with chronic renal disease than others. Most common calcium channel blockers are nondihydropyridine group like verapamil and diltiazem. - Dihydropyridine calcium channel blockers (eg nifedipine and amlodipine) may worsen proteinuria and accelerate the progression of disease in patients with nondiabetic or diabetic nephropathy. 2g. The use of CCB in peripheral vascular disease (PVD) patient.
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- Unlike verapamil, the use of amlodipine and felodipine in treating peripheral
vascular disease patients are not well studied. Therefore, it is not recommended to use these drugs to treat PVD patients.
2h. The use of CCB in Pulmonary Artery Hypertension patients.
- The oral vasodilators of choice are the calcium channel blockers nifedipine and diltiazem. Verapamil is not recommended, since it tends to posses significant negative inotropic properties.
- Amlodipine has been a useful alternative for patients who are intolerant of the other agents (eg. Because of edema, bradycardia, tachycardia, or hypotension)
- The use of Felodipine in pulmonary artery hypertension is not well studied. 3. Advantages of Amlodipine (and felodipine) above other antihypertensive. 3a.Single daily dose, therefore this will improve patient compliance. 3b. No need for renal function monitoring. 3c. Among the least side effects compared to other anti-hypertensive. 3d. In comparison between amlodipine and felodipine, on of the retrospective study has shown that amlodipine has better patient’s adherence compared to felodipine. 4. Disadvantages of CCB above other antihypertensive. 4a. The potential benefit of either amlodipine or felodipine in ACS has not been examined directly in ACS patients. A systematic analysis of all randomized calcium blocker trials in unstable angina suggests calcium channel blockers that as a class do not prevent the development of acute myocardial infarction or reduce mortality, and it also has no harm to these group of patients. 4b. Short-acting CCB (i.e. Nifedipine) has a relatively high incidence of adverse side effects, including peripheral edema (not related to heart failure), flushing, headaches, and lightheadedness, which is due to peripheral vasodilatation. 4c. There was a study (cross sectional) showed that there was a higher rate of depression among hypertensive patients who were on calcium channel blocker as compared to other anti-hypertensive. 4d. Both amlodipine and felodipine are long acting calcium channel blockers, therefore it is not recommended as first line therapy for hypertensive urgency. List of Tables Table 1 Comparative pharmacokinetics of selected dihydropyridine calcium channel antagonists
Nifedipine Nisoldipine Felodipine Amlodipine Diodipine
Oral absorption >90 >90 >90 >90 >90
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Oral bioavailability
30-50 5-15 10-25 60-65 5-15
Elimination half-life
3-5 4-10 2-8 35-50 3-15
Table-Dosing and costs of the Calcium Channel Blockers
Drug Initial Dose Usual Dosage Range Cost x 30 days
Verapamil - regular (Isoptia® generic) - long acting (Isoptin SR®)
(Varelan®)
80mg TID 180 mg daily 180 mg daily
80-160 mg TID 120 mg daily-240mg BID 120-480 mg daily
$37.33-$68.15 $37.52-$99.94 $32.87-$85.92
Diltiazem - regular (Cardizem® generic) - long acting (Cardizem
SR®)** (Cardizem CD®)
30mg TID 60 mg BID 120 mg daily
30mg TID-90 mg QID 60-80 mg BID 120 mg-300mg daily
$28.51- $83.61 $51.63- $126.31** $47.12- $95.89
Felodipine (Plendil®, Renedil®) Nifedipine - regular capsules
(Adalat®generic) - long acting (Adalat PA®)** (Adalt XL®) Amlodipine (Norvasc®) Nicardipine (Cardene®)
5mg daily 10mg TID 10 mg BID 30 mg daily 5 mg daily 10mg TID
2.5-20 mg daily 10mg TID-30 mg QID 10-40mg BID 30-120 mg daily 5-10 mg daily 20-40 mg TID
$23.13-$83.61 $27.25-$89.52 $37.90-$104.72** $37.81-$104.72 $46.14-$65.34 $62.04-$117.58
**Base on wholesale acquisition cost Feb. 1995 of least expensive product and professional fee of $6.50 as April 1, 1995. Pharmcare no longer covers Cardizem SR and Adalat PA
5. References
1. Antiischemic Agents in the Management of Unstable Angina and Acute Non-ST Elevation (Non-Q Wave) Myocardial Infarction. Michael Simons, MD. Up to date version 13.3
2. Calcium Channel Blockers in Acute Myocardial Infarction. Robert S Rosenson,
MD Harold L Keneddy, MD, MPH. Up to date version 13.3.
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3. Calcium Channel Blockers in the Management of Stable Angina Pectoris.
Joseph P. Kannam, MD. Julian M Aroesty, MD. Bernard J Gersh, MB, ChB, DPhil, FRCP. UpToDate version 13.3.
4. Choice of Therapy in Essential Hypertension: Clinical Trials. Norman M Kaplan,
MD, Burton D Rose, MD. UpToDate version 13.3.
5. Wenzel, Rene R. Renal Protection in Hypertensive Patients: Selection of Antihypertensive Therapy. (Review). Dugs. 65 (Suppl 2):29-39, 2005.
6. JNC VII guidelines. 7. Medical Management of Claudication. UpToDate version 13.3.
8. Non Diabetic Kidney Disease (Andrew S) N Engl J Med. VOl 347. No 19.
November 7, 2002. 9. Nephropathy in Patient with Type 2 Diabetes. Remuzzi et al. N Engl J Med. Vol.
346, No. 15 April 11, 2002.
10. Adherence to Calcium Channel Blocker Therapy in Older Adults: A Comparison of Amlodipine and Felodipine. Menzin J et al. J Int Med Res. 2004 May-June; 32(3) :233-9.
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FLOW CHART
Diagnosis of hypertension
Initiate lifestyle modification
If still not achieve BP target (100mmHg) –
consider 2 drugs
Use appropriate
anti-hypertensive
agent
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PROPOSAL GUIDELINES ON PLAVIX PRESCRIPTION FOR CARDIOLOGY PATIENTS HUSM
ACUTE CORONARY SYNDROME
PERCUTANEOUS CORONARY
INTERVENTION (PCI)
INTRACEPT ASD CLOSURE DEVICE
CABG
• NSTEMI/UA = 9 months
• STEMI = 8 days
• Bare metal stent = 3-4 weeks
• Drug eluting stent (DES) = 6-12 months
• Plavix x 3 months
• No indication
* Contraindication for aspirin, ticlopidine is a substitution
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SIMPLIFIED NOVOSEVEN PROTOCOL FOR HAEMATOLOGY USM
FLOW CHART
1. HAEMOPHILIA A OR B WITH INHIBITOR 2. CONGENITAL FACTOR VII DEFICIENCY 3. GLANZMANN’S THROMBASTHENIA
4. AN INHERITED PLATELET FUNCTION DISORDER (ANY OTHER HAEMOTOLOGICAL CONDITIONS: SEE OFF-LABEL USE PROTOCOL FOR
NOVOSEVEN)
IN SEVERE DIVC OR COAGULOPATHY AND THREATEN LIFE OF THE PATIENT
GIVE NOVOSEVEN (THE DOSAGE: HAEMATOLOGIST’S DECISION)
DIVC OR COAGULOPATHY CORRECTED Last update: 24 JANUARY 2012
SIMPLIFIED NOVOSEVEN PROTOCOL FOR NEUROSURGERY USM
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FLOW CHART
(POLY)TRAUMA PATIENT
IN SEVERE DIVC OR COAGULOPATHY. AND FOR URGENT/EMERGENCY LIFE-SAVING
SURGERY
GIVE NOVOSEVEN (GENERALLY THE DOSAGE: 1-3 AMPOULES DEPENDS ON: SEVERITY AND PATIENT’S BODY WEIGHT)
DIVC CORRECTED
SURGERY Last update: 24 JANUARY 2012
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GUIDELINE FOR OFF-LABEL USE OF RECOMBINANT ACTIVATED FACTOR VII (rFVIIa) Jan 2010
Malaysian Society of Haematology
Algorithm for use of rFVIIa
Massive
Haemorrhage
- Control of bleeding source with surgery or embolisation - Blood components therapy
- Reversal of any anticoagulation
[PPH: Uterine massage/compression, uterotonic agents]
Attempt to correct:
Hct to > 24%
Fibrinogen > 0.5-1.0g/L
Platelets > 50 x 109/L
pH ≥ 7.2
Bleeding
Stopped
- Consider rFVIIa - Discuss with on-call Consultant in-charge - Fill up registry form for off-label use of
rFVIIa
Administer rFVIIa (Single bolus over 3-5mins – Dose as per
institution practice)
Persistent bleeding & generalized oozing
despite surgical control
Consider after 30-60mins
Persistent bleeding & generalized oozing
despite surgical control
Bleeding
Stopped
Guideline for the use of rFVIIa
1. Use of rFVIIa in non-haemophilic patients and any decision to use
rFVIIa rests exclusively with the
prescribing clinicians.
2. Appropriate medical and surgical interventions should be carried out to
reduce the magnitude of critical
bleeding before initiating
administration of rFVIIa.
3. RFVIIa should only be used where the clinician considers the benefit
outweighs the risk of thrombosis.
4. The algorithm provided here serves as a guide only. Adherence to this
guideline is encourage but not
mandatory.
5. Following administration of rFVIIa, all patients should be monitored for
signs of improvement and adverse
events.
6. The prescribing clinican should report all off-label use of rFVIIa to the
rFVIIa Registry in Managing
Critical Bleeds in Non-Haemophilia
Patients through completion of the
relevant data collection form.
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Control of bleeding source with surgery or embolisation
Re-administer rFVIIa
[PPH: Consider hysterectomy if
bleeding persists after 2 doses of
rFVIIa]
Attempt to correct:
Hct to > 24%
Fibrinogen > 0.5-1.0g/L
Platelets > 50 x 109/L
pH ≥ 7.2
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GUIDELINE FOR OFF-LABEL USE OF RECOMBINANT ACTIVATED FACTOR VII (rFVIIa)
Malaysian Society of Haematology
(Member in USM preparing this new protocol: AP Dr Zamzuri Idris; Neurosains)
Jan 2010
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GUIDELINE FOR THE USE OF RECOMBINANT ACTIVATED FACTOR VII (RFVIIA) IN NON-HEMOPHILIC PATIENTS WITH LIFE-THREATENING HEMORRHAGE
Introduction
Recombinant FVIIa (Novoseven) was developed for the treatment of bleeding in patients with hemophilia who have inhibitors against factor VIII or IX. It is manufactured by recombinant technology using baby hamster kidneys.1
Licensed indications 2 It is currently licensed for the treatment of bleeding episodes and for controlling bleeding during surgery in the following conditions: 5. Inherited or acquired hemophilia with inhibitors 6. Congenital factor VII deficiency and 7. Glanzmann’s thrombasthenia, an inherited platelet function disorder Out-of license or off-label use There is a growing trend for out-of license use of rFVIIa in non-hemophilic patients with life-threatening or massive hemorrhage* such as from trauma, surgery, post-partum, liver transplant/ failure and intracerebral hemorrhage. Definition of massive hemorrhage* 3
▪ replacement of total blood volume within 24 hours (>10 units of packed red cell in a 70kg patient)
▪ loss of 50% of circulating blood volume in 3 hours or ▪ loss of 150 ml of blood per minute
Mode of action Administration of pharmacologic doses of exogenous rFVIIa directly enhances thrombin generation on the platelet surface at the site of injury independently of factor VIII or IX resulting in a stable fibrin clot. Recombinant FVIIa has a short half-life of 2.5 hours.1,4,5
Recommended dose The recommended dose of rFVIIa for hemophilia with inhibitors is 90 to 120 ug/kg by slow iv bolus over 2 to 5 minutes. The optimal dosing for off-label use is not known. A second dose can be repeated after 1 to 2 hours if bleeding is still not controlled.1,4
* Note that inhibitors in hemophilia patients render factor VIII/ IX concentrates or plasma useless by neutralizing the coagulation factors VIII or IX. The recommended dose of 90 to 120 ug/kg is the amount of rFVIIa required to generate enough thrombin to form a tight fibrin clot in these patients. This dose cannot be extrapolated to patients with life-threatening bleeding with otherwise normal coagulation or in whom any abnormal coagulation can be corrected with plasma. Furthermore tissue injury following trauma, surgery or post-partum releases tissue factor which activates the coagulation system; hence by giving the recommended dose of rFVIIa (for inhibitor patients) for life-threatening hemorrhage in these patients may result in thrombotic
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complications. Smaller doses between 30 to 60 ug/kg have been used with good response in these situations.6,7
Contraindications 3 Absolute
▪ Unsalvageable patients ▪ Allergy to mouse, hamster or bovine proteins
Relative ▪ Known thrombophilia ▪ History of recent thromboembolic events within the last 6 months eg. myocardial
infarction, stroke or deep vein thrombosis Precautions 3
▪ Patients with prosthetic heart valve ▪ Patients with recent coronary angioplasty and stent insertion ▪ Patients with coronary artery disease ▪ Patients with cerebrovascular disease ▪ Patients on ECMO or VAD ▪ Patients with disseminated intravascular coagulation or sepsis
Preconditions before rFVIIa administration 3
▪ Appropriate surgical interventions to secure hemostasis have been carried out if indicated
▪ Appropriate blood component therapy has been instituted in abnormal coagulation states to attempt to achieve a fibrinogen level >1 g/L and platelet count >50 x109/L
▪ Attempt to correct anaemia to keep Hb >7 g/dL or Hct >24% with blood transfusion
▪ Keep pH ≥ 7.2 ▪ Core temperature ≥ 34°C ▪ Normal serum calcium
Timing and appropriateness of administration For best outcome, consider rFVIIa early after the first blood component replacement fails to control the hemorrhage or after failing appropriate surgical intervention. Do not use in non-salvageable patients or if the overall outlook of the patient is so poor that arresting the hemorrhage does not alter the outcome.3
Monitoring There is no specific laboratory test to monitor the efficacy of rFVIIa. The clinical response of cessation of bleeding, the amount of blood loss and transfusion requirement are monitored and recorded.1,4
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Complications There is a continuing concern that rFVIIa can cause thromboembolic complications because it is an activated factor given in doses to cause a non-physiological rise in factor VII levels by more than 1000-fold. In hemophilia with inhibitors there is a 1% incidence of thromboembolic events eg. myocardial infarction, ischemic stroke, deep vein thrombosis or pulmonary embolism.5 Similar events have been reported in non-hemophilic patients but the true incidence is not known. Hence, administration of rFVIIa should be used with caution in patients who have a predisposition to thrombosis such as diabetes mellitus, cardiovascular disease, cancer, obesity and the elderly.4,6 Specific situations Disseminated intravascular coagulation A literature review found 15 uncontrolled studies with 32 cases on the use of rFVIIa for disseminated intravascular coagulation due to postpartum hemorrhage. A single dose of rFVIIa was able to control bleeding in 80% of patients with a median dose of 67.6 ug/kg (range 30-120 ug/kg). In another series of 18 patients with DIC associated with metastatic cancer, 80% of patients responded to a median of 5 doses of rFVIIa at 90 ug/kg with no thromboembolic complications. 7, 8
Intracerebral hemorrhage Following an intracerebral hemorrhage, evidence shows that there is expansion of the hematoma mass in 50% of patients for up to 6 hours. This suggests that early arrest of hematoma growth would improve outcome. In a double-blind, placebo-controlled trial of 399 patients with intracerebral hemorrhage diagnosed within 3 hours of onset by CT scan, patients were randomly included to receive placebo or rFVIIa at doses of 40 ug/kg, 80 ug/kg or 160 ug/kg. Treatment with rFVIIa was found to limit the growth of the hematoma, reduce mortality by 35% and improve functional outcome at 90 days in all 3 dosing groups but with an increase frequency of thromboembolic events with the highest dose. Best outcomes are seen in patients treated early with a Glasgow Coma Scale of ≥13.9,10
This study was followed by a larger phase III randomized, multicenter, double-blind, placebo-controlled trial to confirm the above findings. Eight hundred and forty one patients with inracerebral hemorrhage were randomized to receive placebo or rFVIIa at doses of 20 ug/kg or 80 ug/kg within 4 hours after the onset of stroke. The hemostatic effect was similar but there was no difference in severe disability or mortality at 90 days between the placebo and rFVIIa treatment arms.11 Liver transplant/ failure There have been anecdotal reports of the successful use of rFVIIa in controlling bleeding in patients with liver disease but failures and recurrent bleeding have also been reported. Recombinant FVIIa has been successfully used in controlling bleeding in liver transplant in non-cirrhotic patients.6,12,13
24 | P a g e
Postpartum hemorrhage (PPH) There are no randomized studies, only case series of the use of rFVIIa in PPH reporting good response with cessation of bleeding in > 80% at a mean dose of 1.9 and a dose range between 30-120 ug/kg.6, 8,14,15,16 Prostatectomy Prostatectomy is often associated with major blood loss due to a high content of fibrinolytic activators in the prostate gland. In a double-blind, placebo-controlled trial with 36 patients undergoing retropubic prostatectomy, patients were randomly assigned to receive placebo or a single dose of rFVIIa at 20 ug/kg or 40 ug/kg in the early operative phase. More than 50% of the placebo group required red cell transfusion while none in the rFVIIa required any transfusion.17
Surgery There are reports of successful use of rFVIIa in controlling hemorrhage following general and cardiac surgery as well as some suggesting that it is not always effective.18,19,20. In a trial on spinal surgery, it was reported that there were no statistically significant differences in mortality, serious adverse events or thromboembolic adverse events between patients who were treated with 30μg/kg, 60μg/kg and 120μg/kg and those treated with placebo.21 After adjusting for factors (duration of surgery, number of vertebral segments fused and estimated blood volume); the volume and percentage of estimated blood volume lost, total transfusion volumes, mean number of allogenic blood products transfused and number of RBC units transfused in spinal surgery were statistically significantly lower for all three dosages of rFVIIa relative to placebo. 21 A meta-analysis of 5 clinical trials that included 298 patients undergoing cardiac surgery using rFVIIa porphylactically or for refractory bleeding showed a non-significant reduction in the rate of surgical re-exploration.22 Gill et al. reported in their study involving 172 patients that patients receiving rFVIIa for bleeding in post cardiac surgery had significantly fewer re-operations and significantly less transfusion of allogenic blood and blood products. However, these results must be interpreted cautiously because the trial is underpowered.23 Thrombocytopenia There are several reports showing variable success with the use of rFVIIa in patients with thrombocytopenia and uncontrolled bleeding.24,25 Only one randomized placebo-controlled study looked at bleeding complications in 100 thrombocytopenic patients following bone marrow transplantation. Bleedings in these patients were triggered by aplasia, septicemia and graft-versus-host disease. The most common were gastrointestinal hemorrhage and hemorrhagic cystitis. The results showed that there was no overall effect of rFVIIa administration at doses of 40, 80 or 160 ug/kg 6 hourly for 36 hours.26
25 | P a g e
Trauma In a randomized, placebo-controlled double-blind trial of 301 trauma patients, treatment with rFVIIa at doses of 200 ug/kg initially followed by 100 ug/kg, 1 and 3 hours later showed a reduced requirement for red cell transfusion but no reduction in overall mortality.27 The risk of ARDS alone in patients with blunt trauma was statistically significantly reduced compared to placebo. 27 There are other several reports on the successful use of rFVIIa in patients with extensive trauma and uncontrolled hemorrhage while there were no response in some. Patients with acidosis and profound shock were less likely to respond.3 Guideline for the use of rFVIIa 1. Use of rFVIIa in non-haemophilic patients and any decision to use rFVIIa rests
exclusively with the prescribing clinicians. 2. Appropriate medical and surgical interventions should be carried out to reduce the
magnitude of critical bleeding before initiating administration of rFVIIa. 3. RFVIIa should only be used where the clinician considers the benefit outweighs the
risk of thrombosis. 4. The algorithm provided here serves as a guide only. Adherence to this guideline is
encourage but not mandatory. 5. Following administration of rFVIIa, all patients should be monitored for signs of
improvement and adverse events. 6. The prescribing clinican should report all off-label use of rFVIIa to the rFVIIa Registry
in Managing Critical Bleeds in Non-Haemophilia Patients through completion of the relevant data collection form.
26 | P a g e
Algorithm for use of rFVIIa 28, 29
Control of bleeding source with surgery or embolisation
References:
Massive
Haemorrhage
- Consider rFVIIa - Discuss with on-call Consultant in-charge - Fill up registry form for off-label use of rFVIIa
Administer rFVIIa (Single bolus over 3-5mins – Dose as per
institution practice)
Persistent bleeding & generalized oozing
despite surgical control
Re-administer rFVIIa
[PPH: Consider hysterectomy if bleeding
persists after 2 doses of rFVIIa]
Consider after 30-60mins
- Control of bleeding source with surgery or embolisation
- Blood components therapy
- Reversal of any anticoagulation
[PPH: Uterine massage/compression, uterotonic agents]
Attempt to correct:
Hct to > 24%
Fibrinogen > 0.5-1.0g/L
Platelets > 50 x 109/L
pH ≥ 7.2
Persistent bleeding & generalized oozing
despite surgical control Bleeding
Stopped
Attempt to correct:
Hct to > 24%
Fibrinogen > 0.5-1.0g/L
Platelets > 50 x 109/L
pH ≥ 7.2
Bleeding
Stopped
27 | P a g e
1. Hedner U. Mechanism of action of factor VIIa in the treatment of coagulopathies. Semin Hemost Thromb 2006;vol 32, suppl 1
2. NovoSeven Approved Package Insert (Malaysia), 2008
3. Martinowitz U, Michaelson M. Guidelines for the use of recombinant activated
factor VII (rFVIIa) in uncontrolled bleeding: a report by the Israeli Multidisciplinary rFVIIa Task Force. J Thromb Haemost 2005;3:640-648
4. Negrier C, Lienhart A. Overall experience with NovoSeven. Blood Coagul
Fibrinolysis 2000;11(suppl 1)
5. Abshire T, Kenet G. Recombinant VIIa: review of efficacy, dosing regimens and safety in patients with congenital or acquired factor VIII or IX inhibitors. J Haemost Thromb 2004;2:899-909
6. Roberts HR, Monroe DM, White GC. The use of recombinant factor VIIa in the
treatment of bleeding disorders. Blood 2004;104:3858-3864
7. Sobieszczyk S, Breborowicz G, Platicanov V, et al. Recombinant factor VIIa in the management of postpartum bleeds: an audit of clinical use. Acta Obstet Gynecol 2006;85:1239-1247
8. Franchini M, Manzato F, Salvagno GL, et al. Potential role of recombinant
activated factor VII for the treatment of severe bleeding associated with disseminated intravascular coagulation: a systemic review. Blood Coagul Fibrinolysis 2007:18:589-593
9. Mayer SA, Brun NC, Begtrup K, et al. Recombinant Activated Factor VII for Acute
Intracerebral Hemorrhage. N Engl J Med 2005;352:777-785 10. Broderick JP, Brott TG, Duldner JE, Tomsick T, et al. A powerful and easy-to-use
predictor of 30-day mortality. Stroke 1993;24:987-993
11. Mayer SA et al. Can a subset of Intracerebral Hemorrhage Patients Benefit from Hemostatic Therapy with Recombinant Activated Factor VII? Stroke 2009;40:833-840.
12. Caldwell SH, Chang C, Macik BG. Recombinant activated factor VIIa as a
hemostatic agent in liver disease: a break from convention in need of controlled trials. Hepatology 2004;39:592-598
13. Hendriks HG, Meijer K, de Wolf JT et al. Reduced transfusion requirements by
recombinant factor VIIa in orthotropic liver transplantation: a pilot study. Transplantation 2001;71:402-405
28 | P a g e
14. Segal S, Shemesh IY, Blumenthal R, et al. Treatment of obstetric hemorrhage with
recombinant activated factor VII (rFVIIa) Arch Gynecol Obstet 2003;268:266-267
15. Bouma SL, Bolte CA, van Geijn PH. Use of recombinant activated factor VII in massive postpartum haemorrhage. Eu J Obs Gyn Repr Biol 2008;137:172-177
16. Ahonen J, Jokela R. Recombinant factor VIIa for life-threatening post-partum
haemorrhage. Br J Anaesth 2005; 94:592-595
17. Friederich PW, Henry CP, Messelink EJ, et al. Effect of recombinant activated factor VII on perioperative blood loss in patients undergoing retropubic prostatectomy: a double-blind placebo-controlled randomized trial. Lancet 2003;361:201-205
18. Dietrich W, Spannagl M. Caveat against the use of recombinant activated factor
VII for intractable bleeding in cardiac surgery. Anesth Anagl 2002;94:1369-70
19. Eikelboom JW, Bird R, Blythe D, et al. Recombinant activated factor VII for the treatment of life-threatening hemorrhage. Blood Coagul Fibrinolysis 2003;14:713-717
20. Tanaka KA, Waly AA, Cooper WA. Treatment of excessive bleeding in Jehovah’s
witness patients after cardiac surgery with recombinant factor VIIa (NovoSeven). Anesthesiology 2003; 98:1513-1515
21. Pohar SL, Tsakonas E, Murphy G et al. Recombinant activated factor VII in
treatment of hemorrhage unrelated to haemophilia. The Cochrane Database of Systematic Reviews, 2009;4
22. Zangrillo A et al. Recombinant Activated Favtor VII in Cardiac Surgery: A Meta-
analysis. J Cardiothor Vasc Anesth 2009;23:34040
23. Gill R, Herbertson M, Vuylsteke A. Et al. Safety and efficacy of recombinant activated factor VII. A randomized placebo-controlled trial in the setting of bleeding after cardiac surgery. Circulation. 2009; 120: 21-27
24. Goodnough LT. Experiences with human recombinant factor VIIa in patients with
thrombocytopenia. Semin Hematol 2004;41:25-29
25. Vidarsson B, Onundarson PT. Recombinant factor VIIa for bleeding in refractory thrombocytopenia. Thromb Haemost 2000;83:634-635
29 | P a g e
26. Pihusch M, Bacigalupo A, Szer J, et al. Recombinant activated factor VII in treatment of bleeding complications following hematopoietic stem cell transplantation. J Thromb Haemost 2005;1935-1944
27. Boffard KD, Riou B, Warren B, et al. Recombinant factor VIIa as adjunctive therapy
for bleeding control in severely injured trauma patients: two parallel, randomized, placebo-controlled, double-blind clinical trials. J Trauma 2005; 59:8-15
28. Vincen JL, Rossaint R, Riou B, Ozier Y, Zideman D and Spahn DR,
Recommendations on the use of recombinant activated factor VII as an adjunctive treatment for massive bleeding – a European perspective. Critical Care 2006, 10:R120
29. Welsh A, McLintock C, Gatt S, Somerset D, Popham P and Ogle R, Guidelines for
the use of recombinant activated factor VII in massive obstetric haemorrhage, Australian and New Zealand Journal of Obstetrics and Gynaecology 2008; 48; 12-16
30 | P a g e
GUIDELINES FOR OUTPATIENT TREATMENT OF CHRONIC ASTHMA DEPARTMENT OF MEDICINE HOSPITAL USM CLASSIFICATION BY SEVERITY1
CLASSIFY SEVERITY Clinical Feature Before Treatment
Symptoms Nocturnal Symptoms
FEV1 or PEF
STEP 4 Severe
Persistent
Continuous Limited physical activity
Frequent ≤ 60% predicted Variability > 30%
STEP 3 Moderate Persistent
Daily attack affect activity
> 1 time a week 60-80% predicted Variability > 30%
STEP 2 Mild Persistent
> 1 time a week but < 1 time a day
> 2 times a month ≥ 80% predicted Variability 20-30%
STEP 1 Intermittent
< 1 time a week Asymptomatic and normal PEF between attacks
≤ 2 times a month ≥ 80% predicted Variability < 20%
TREATMENT
STEP 1- Salbutamol Inhaler as required STEP 2- Move to step 2 if symptoms as above or failure of step 1
Does the patient has:
Allergic rhinitis?
Definite aspirin allergy?
Exercise induced asthma?
Yes
No
T. Montelukast 10 mg daily2
Salbutamol inhaler as required
Budesonide MDI/Turbuhaler 100-800ug BD
Beclomethasone MDI 50-500 ug BD/TDS
Ciclesonide MDI 160 ug OD/BD
Salbutamol MDI as required
Start steroid at high dose, taper down later1
31 | P a g e
STEP 3- Move to step 3 if symptoms as above or failure of step 2 STEP 4 – Move to step 4 if step 3 fails
Treatment options:
Formoterol/ Budesonide
4.5/160Turbuhaler (Symbicort®) 1 inh BD
or
Salmeterol/ Fluticasone 50/250 Accuhaler
(Seretide®) 1 inhalation BD
Salbutamol inhaler as required
Consider Symbicort® if patient is educated
because
• the dose can be adjusted according
to the patients need i.e. 1 inhalation
BD when symptomatic and 1
inhalation daily if stable3
• Symbicort® may be used as rescue
medication
Treatment options:
Formoterol/ Budesonide
4.5/160Turbuhaler (Symbicort®) 1 inh BD
or
Salmeterol/ Fluticasone 50/250 Accuhaler
(Seretide®) 1 inhalation BD
Salbutamol inhaler as required
Plus
Montelukast 10 mg daily
KIV
Theophyline SR 250 mg BD
Still symptomatic
32 | P a g e
Please note:
• Do reversibility test if diagnosis of asthma is questionable
• Do spirometry as baseline before starting any treatment
• Do spirometry before any change of treatment regime
• Discuss with chest physician before starting daily prednisolone References:
1. Global Initiative For Asthma 2002. www.ginaasthma.com 2. Mastalertz L, et al. Clin Exp Allergyu 2002 Sep;32(9):1360-5 3. Aalbers R, et al. Curr Med Res Opin 2004;20:225-240
Prepared by: Dr. Che Wan Aminud-din Hashim Respiratory Physician Department of Medicine
Version 1 Nov 2006
Add
Prednisolone 5-10 mg OD
http://www.ginaasthma.com/
33 | P a g e
GUIDELINES FOR USING INFLUENZA VACCINE Indication: Patients with the following criteria:-
1. Moderate to severe Chronic Obstructive Pulmonary Disease (Defined by GOLD guideline, HUSM guideline)
2. Asthma with recurrent exacerbation due to flu / URTI 3. Moderate to severe bronchiectasis with recurrent exacerbation 4. Any other chronic lung disease eg. Post-tuberculosis infection, insterstitial lung
disease, etc with recurrent secondary infection. Management Plan: Influenza vaccine will be administered as yearly basis. Prepared by: Dr. Che Wan Aminud-din b Hashim Repiratory Physician HUSM
34 | P a g e
FLOW CHART PENGGUNAAN DRUG UNTUK RAWATAN ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD)
• METHYLPHENIDATE IR (IMMEDIATE RELEASE)
• METHYLPHENIDATE SR (SLOW RELEASE)
• METHYLPHENIDATE LA (LONG ACTING)
• METHYLPHENIDATE (EXTENDED RELEASE) OR CONCERTA
• ATOMOXETINE (STRATERA)
Pesakit dirujuk ke klinik
Diagnosa ADHD
Disediakan oleh:
‘Pure ADHD’ ‘ADHD with comorbidities’
Umur di atas 6 tahun Umur di bawah 6 tahun
IR Methylphenidate (dly-tds)
Methylphenidate (dly-bd)
Methylphenidate LA (single dose)
Concerta (single dose)
Behavior modification
Adult ADHD
Epilepsy
Tics
Gilles de la
Tourette
Complicated
Pervasive SR
Development
Disorders
Severe untoward
events due to
methylphenidate
Atomoxetine (Stratera)
35 | P a g e
Dr Mohd Jamil Yaacob, Klinik Psikiatri Kanak-kanak & Remaja. 12 Mac 2012
Lampiran A Departmental policy on the use of antipsychotics* and non-standard drugs
1. Since olanzapine and quetiapine are currently available as original products which are expensive; please evaluate the cost-effectiveness of the treatment when prescribing these drugs as a first line in the management of patients with schizophrenia; especially in unproductive and chronic patients.
2. The use of expensive drugs such as olanzapine and quetiapine in poor compliance patients are also discouraged. Typical antipsychotics combined with depot preparation should be strongly considered.
3. Any patient treated with a new non-standard drug (not in the formulary), it is the responsibility of the drug company to supply the drug till the patient completed treatment. In such situation the department cannot guarantee that the new drug would be approved as a standard drug in the formulary.
*Note: this policy may be not relevant any more in future if olanzapine and quetiapine are supplied as generic products.
36 | P a g e
ALGORITHM FOR MEDICATIONS OF SCHIZOPHRENIA
37 | P a g e
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ACUTE TREATMENT OF MANIA
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ACUTE TREATMENT OF BIPOLAR DEPRESSION
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PSYCOPHARMACOLOGICAL TREATMENT ALGORITHM FOR GENERALUIZED ANXIETY DISORDER (GAD)
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ALGORITHM (2) FOR THE PHARMACOTHERAPY OF MAJOR DEPRESSIVE DISORDER (MDD)
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ALGORITHM FOR MANAGEMENT OF DEMENTIA
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ALZHEIMER’S DISEASE TREATMENT STRATEGY Mild to moderate cases a) F.D.A. Approval drugs (cholinestherase inhibitors) b) Use Supported by Clinical Trials Moderate to severe cases a) NMDA. Antagonist- Memantine 10-20mg/day
b) Combination of cholinestherase inhibitors + N.M.D.A. Antagonist ‘
1) Donepezil 5-10mg/day
2) Rivastigmine 6-12mg/day
3) Galantamine 16-24mg/day
1) Seligeline 5mg BD.
2) Vit. E 2000I.U./day
44 | P a g e
PARKINSON DISEASE
Last update: February 2012
1 Consider Surgical Treatment
Deep Brain Stimulation
Very advanced motor
Complications of Levodopa Therapy
Severe Symptoms-Motor
Complications of L. Dopa
Moderate motor symptoms
interfering with activities
Early stage with minimal symptoms-
sign
1 Add on Dopamine Receptor
agonist and reduce dose of
Levodopa
2 Add on COMT Inhibitor Ento
Capone (COMTAN)
3 Starton STALLEVO a
combination of Levodopa-
carbidopa Entocaps
4 Adjunctivies – Amantadine Anti-
Cholinergics
1 Add small titrating dose of
Levodopa- dopa de carboxylase
Inhibitor Combination
(L-Dopa-Carbidopa) – Madopar
(L-Dopa-Benzeraside)-Sinement
1 Defer use of Levodopa if age below
60
2 Seligeline
3 Amantadine
4 Dopamine Receptor Agonists
Ropinerol
Pramipexol
Peribedil
5 Anti-cholinergics
45 | P a g e
FLOW CHART FOR TREATMENT HEPATITIS B IN TREATMENT NAÏVE PATIENTS
HBSAg positive
HBeAg status Positive HBeAg Negative HBeAg Is ALT Elevated Is ALT Elevated
End points of treatment 1. ALT Normalisation 2. HBeAg Seroconversion/ HBeAntibody 3. HBVDNA (PCR) suppression x 2 undetected 6 months apart (less than 300 copies/ml x 2)
YES
ALT less
2x normal
ALT more than
2x normal
NO YES
NO
ALT less 2x
normal
ALT more than
2x normal
Oral therapy 18 months (minimum)
First choice:
1. Lamivudine 100 mg OD 2. Entecavir 0.5 mg OD 3. Telbivudine 600 mg OD
Second choice:
1. Interferon Alpha (injection)
Liver Biopsy
Ishak Score >2.0
HBVDNA (PCR)
Quantitative more than
100,000 copies/ml
Oral therapy
Minimum duration 2
years
Liver Biopsy
Ishak Score >2.0
HBVDNA (PCR)
Quantitative more
than 10,000 copies/ml
No treatment.
Monitor ALT
every 1-3
months.
46 | P a g e
FLOW CHART OF CHRONIC VIRAL HEPATITIS B PRE CORE MUTANT HBEAG NEGATIVE
HBSAg POSITIVE MORE THAN 6 MONTHS
LIVER ENZYME ALT > 2 × NORMAL
HBVDNA (PCR) QUANTITATIVE HBVDNA > 10,000 COPIES/ML
LIVER BIOPSY
HPE BIOPSY SCORE > 2 ISHAK SCORE
THERAPY FOR MINIMUM 18 MONTHS 1. LAMIVUDINE 100 MG OD 2. TELBIVUDINE 600 MG OD
3. ENTECAVIR 0.5 MG OD 4. PEGYLATED INTERFERON 48 WEEKS
HBVDNA (PCR) QUANTITATIVE
MONITORED AT 24, 48, 72 WEEKS OF THERAPY
THERAPY STOPPED AFTER MINIMUM 18 MONTHS IF HBVDNA (PCR) UNDETECTABLE X 2 AT 6 MONTHS APART
(HBVDNA (PCR) LESS THAN 300 COPIES/ML X 2)
Prepared by: Dr. Amry A. Rahim Physician / Clinical Specialist Gastroenterology / Hepatology HUSM January 2012
47 | P a g e
FLOW CHART FOR GENITAL ULCER SYNDROME Treatment Protocol For Genital Ulcer Syndrome TREATMENT FOR SYPHILIS AND CHANCROID
1ST FIRST CHOICE: IM BenzathinePenicillin 2.4 million units weekly x 2
(once a week x 2 weeks) PLUS Azythromycin 1.0 gm single oral dose
2nd SECOND CHOICE: IM Benzathine Penicilin 2.4 million units weekly x 2 (once a week x 2 weeks) PLUS Cotrimoxazole 2 tablets orally twice daily x 7 days
3rd THIRD CHOICE: IM Benzathine Penicillin 2.4 million units weekly x 2 (once a week x 2 weeks) PLUS IM Ceftriaxone 250mg single dose
Note: If patient develops allergic reaction to the 1st dose of IM Benzathine Penicillin, DO NOT give the second dose.If patient is allergic to Penicillin, use EITHER Doxycycline 100mg orally bd x 15 days OR Erythromycin ES 800 mg bd x 15 days.
Patient complains of GENITAL ULCER or SORE
Take history and examine
INVESTIGATIONS NEEDED:-
1. Dark ground microscopy for syphilis (IF AVAILABLE) 2. Gramstain for haemophilus ducreyi 3. Tzanck’s smear 4. VDRL, TPHA 5. HIV Ab.
Ulser present? Multiple superficial erosions or vesicular lesions
PRESENT?
• Treat for SYPHILIS and CHANCROID
• Educate for behaviour change
• Partner management
• Follow-up regime For confirmed syphilis
√ 2 weeks for results
√ monthly x 3 visits
√ 3 monthly x 3 visits
√ 3 monthly x 2 visits
• 3 months repeat HIV Ab. And VDRL/TPHA if initial results were negative
• Health Education
• Educate for behaviour change
• TCA x 2 weeks and review results of inv.
• Genitial herpes management
• Educate for behaviour change
• TCA x 2 weeks and review results
YES
48 | P a g e
NO
FLOW CHART FOR VAGINAL DISCHARGE SYNDROME
Treatment Protocol For Vaginal Discharge Syndrome (Cervicitis And Vaginitis) 1st FIRST CHOICE: Azithromycin 1 gm single oral dose 2nd SECOND CHOICE: IM Ceftriaxone 250 mg single dose
+ Doxycycline 100 mg bd x 10 –14 days
3rd THIRD CHOICE: IM Ceftriaxone 250 mg single dose +
Erythromycin ES 800 mg bd x 10 – 14 days PLUS Metronidazole 2 gm STAT PLUS Nystatin pessaries 100,000 units daily x 14 days On follow-up: If no improvement or not effective to
continue Metronidazole 400 mg bd x 7 days OR TREATMENT FOR VAGINITIS ONLY
Patient complains of VAGINAL DISCHARGE
Take history and do physical examination
INVESTIGATION NEEDED:-
• Vaginal swab √ Wet mount for trichomonas vaginalis
√ Gram stain for candidia albicans and clue cells
• Cervical swab √ Gram stain for gonococci and pus cells
√ Culture for gonococci ( using Amies charcoal transport media )
• VDRL, TPHA, and HIV ab.
Refer to NEAREST Hospital
Patient has LOWER
ABDOMINAL PAIN?
RISK ASSESSMENT
• Partner has symptoms OR
• Risk factor positive
• Treat for VAGINITIS
• Educate for behaviour change
• Follow up for 2 weeks for results
• Treat for CERVICITIS and Vaginitis
• Educate for behaviour change
• Partner management
• Follow- up ---2 weeks for result 3 months to repeat VDRL, TPHA & HIV Ab,
IF INITIAL TEST WERE NEGATIVE
RISK FACTORS
1. Less than 21 years old 2. Single 3. Recent partner ( less than 3
monts)
4. Multiple partners
Treatment for Vaginal Discharge Syndrome ( Cervicitis)
Treatment for Vaginal Discharge Syndrome ( Cervicitis)
YES
NO
YES
49 | P a g e
Discharge
PRESENT?
Traetment for CHLAMYDIA
FLOW CHART FOR URETHRAL DISCHARGE SYNDROME IN MEN Treatment Protocol for Urethral Discharge Syndrome 1st CHOICE: Azithromycin 1gm orally single dose 2nd CHOICE: IM Ceftriaxone 250mg single dose + Erythromycin ES800mg orally bd x 10-14 days 3rd CHOICE: IM Ceftriaxone 250mg single dose + Erythromycin ES 800mg orally bd x 10-14 days IM Spectinomycin 2gm STAT + Doxycycline 100mg orally bd x 10-14 days OR IM Spectinomycin 2gm STAT +Erythromycin ES 800 mg orally bd x 10-14 days
Patient complains of Urethal
Discharge/Dysuria or irritation
Take history and examine (milk URETHRA
if necessary)
INVESTIGATIONS NEEDED:-
- Urethral smear √ Gram stain for gonococci & pus cells
√ Culture for gonococci (use AMIE’S
charcoal transport media)
- 2 glass urine test
- VDRL,TPHA & HIV Ab
1. Do 2 glass test
2. result POSITIVE? ULCER PRESENT?
• Treat for GONORRHEA and CHLAMYDIA
• Educate for behaviour change
• Partner management
• Follow-up √ Two weeks for result
√ Three months to repeat
VDRL, TPHA & HIV Ab.
REFER TO
Appropriate
flow chart
Health Education
Follow-up for 2 weeks
No
No
No
Yes Yes
Yes
Treatment for Gonorhea and Chlamvdia
If Patient is allergic to penicillin and azithromycin is not available
50 | P a g e
OUTPATIENT TREATMENT OF CAP
TREATMENT PLAN
YES
YES
NO
PRIMARY CARE OF EMERGENCY DEPT
VISIT Patient presents w/ symptoms suggestive of
community-acquired pneumonia (CAP)
DIAGNOSIS
Does history, physical
Exam & chest x-ray
confirm CAP ?
SITE OF CARE
DECISION
Does patient have any of
the core adverse prognistic
factors?
ALTERNATIVE
DIAGNOSIS
Treat patient appropriately
NO
Yes, 2 core
adverse prognostic
factors are present No core adverse
prognostic factors
are present
EVALUATION
Does patient have
preexisting adverse
prognostic factors?
CLINICAL DECISION
Should patient be admitted to hospital?
Base decision on clinical judgement,
additional adverse prognostic factors,
the patient’s social circumstances &
patient preferences
OUTPATIENT TREATMENT
Non-pharmacological
• Patient education ➢ Avoid smoking ➢ Adequate hydration &
nutrition
Pharmacotherapy
• Symptomatic therapy ➢ Analgesics for pleuritic
pain
• Antibiotics therapy
NO
Yes, 1 core adverse prognostic
factors are present
HOSPITAL
ADMISSION
YES
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TREATMENT PLAN (CONT’D)
EMPIRIC OUTPATIENT CAP
ANTIBIOTIC THERAPY
EMPIRIC ORAL ANTIBIOTICS
Local epidemiologic patterns need to be considered to target the antimicrobial therapy against the likely pathogens
Previously healthy individual
Any one of the following :
• High-dose Amoxycillin
• Doxycycline
• Macrolide – Erythromycin ➢ Preferred agent in many guidelines
Comorbidity is present (DM, renal insufficiency, CHF, alcohol abuse, COPD)
Any one of the following :
• Advanced macrolide - Azithromycin
• Beta-lactam or beta lactam-beta-lactamase inhibitor
• Quinolone Patient has multiple medical condirions , has COPD & received antibiotics or oral steriods in the last 3 months or any other risk factors for Gram –ve organisms
• Macrolide (Azithromycin) + beta lactam or beta-lactam (beta – lactamase inhibitor)
• Quinolone (alone) Suspected aspiration pneumonia
Any one of the following :
• Beta-lactam, beta-lactamase inhibitor w/ or w/o macrolide (Azithromycin)
• (Clindamycin or metronidazole w/ quinolone)
FOLLOW UP • Follow up will depend on initial severity assessment
• Recommended follow up in 48-72 hr
• If patient fails to improve consider the following : ➢ Chest X-ray ➢ Hospital admission
• Possible reasons for failure to improve ➢ Host factors associated w/ a delayed response ➢ Inadequate antimicrobial selection (eg. Resistant organism or bacteria not covered by initial antibiotic therapy) ➢ Metastatic infections (eg. Meningitis, endocarditis, empysema etc) ➢ Noninfections illness
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FLOW CHART OF USING SULPERAZONE IN ICU
ICU Patient
Ventilated/NonVentilated
Nosocomial Infection
Acinetobacter Non Acinetobacter
Non-Drug Multi Resistance
Multi-Drug Resistance (MDR) Quinolones or
3rd Generation or
4th Generation or
Carbapename
Sulperazone Unasyn
±Aminoglycoside
±Aminoglycoside
Responding
Non-Responding Within 24-48 Hr or Suspicious of MDR
Continue Treatment
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GUIDELINES FOR USING NOVOMIX 30 FLEXPEN HOSPITAL UNIVERSITI SAINS MALAYSIA
PRE-MIXED INSULIN
Mixtard 30 Penfill NovoMix 30
FlexPen
OAD’s
failures
OAD’s failure
1. elderly
2. hypoglycaemic prone
3. fasting (ramadhan) or puasa
sunat)
Patients on Mixtard (switch
to)
1. frequent hypoglycaemia
2. poor control
3. post prandial
hyperglyacemic
4. fasting (ramadhan) or puasa
sunat)
OAD Failure
PRE-MIX INSULIN
(eg: Mixtard, Humulin 30/70)
NovoMix30
1. Hypoglycemia 2. Poor glycemic control
54 | P a g e
FLOWCHART FOR USE OF GLUCOPHAGE XR
Type 2 Diabetes Mellitus
Metformin (immediate release) BID/TID
Poor compliance or
Gastro-intestinal side-effects
Metformin (extended release)
(Glucophage XR) once daily
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FLOWCHART FOR USE OF INSULIN DETEMIR
Insulin requiring diabetes mellitus
NPH insulin
Hypoglycemia
Insulin Detemir/Glargine
Last update: February 2012
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ALGORITHM FOR THE MANAGEMENT OF POSTMENOPAUSAL OSTEOPOROSIS
Clinical Assessment
Patients with risk General measures: Patients with prior factor but no - Calcium intake (B) incidental low
fracture - Physical activity (B) trauma fracture In the elderly: - Vitamin D + calcium (A) - Prevention of falls (B) BMD measurement
T score: T score: T score:
≥ -1 -2.5 ≤ -2.5
NORMAL OSTEOPENIA* OSTEOPOROSIS OSTEOPOROSIS (BMD if available)
Monitor If multiple risk factor present (C) Treatment options: Treatment options:
-Strontium ranelate -Strontium ranelate -SERMs/ - Bishosphonate (A) -Bishosphonates (A) -SERMs (A) -Activated vitamin D (A) -Activated vitamin D (A) -Calcitonin (A)
-rPTH**(A) Reassess with BMD after 2 years (A) NO YES
Follow up with BMD if available If BMD
deteriorates Reassess Treatment options: BMD yearly (C) - Strontium ranelate - SERMs (A) - Alendronate (A) - HRT (A)
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ZOLENDRONIC ACID PRESCRIPTION FLOW CHART
Bone Metastasis –Confirmed By Bone Scan
Primary By:
1) Breast Carcinoma
2) Nasopharyngeal Carcinoma
3) Lung Carcinoma (NSCLC)
4) Prostate Carcinoma
1st Line
IV Zolendronic Acid 4 mg
over 15 minutes every 4
weeks for 6 months.
Palliative Intension.
To stop and reduce bone
metastases/damage
especially when bone
involvement is wide
spread
+/- Hypercalcaemia
Severe pain. Scale > 7/10
2nd Line
IV Zolendronic Acid 4
mg over 15 minutes
every 4 weeks for 6
months
Further pain +/-
Hypercalcaemia
1st Line
IV Pamidronate 90 mg
Over 2 hours every 4/52
For 6 months
Severe Hypercalcaemia Mild To Moderate Pain
Symptoms of Pain
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FLOW CHART FOR USING IMATINIB IN CHRONIC MYELOID LEUKEMIA (CML), PH+ ACUTE LYMPHOBLASTIC LEUKEMIA (ALL)
Patients with Ph+CML (all phases)
Begin imatinib at 400mg daily
Assess response at 3, 6, 12, 18 months as
per European Leukemia Net guidelines
Good response
Suboptimal
response
Poor / No
response
Continue imatinib
400 mg daily Increase imatinib to
600-800 mg daily
Stop imatinib
Consider alternative
treatment
Good response
Poor / No
response
Continue imatinib
600-800 mg daily
Stop imatinib
Consider alternative
treatment
NB
1. Chronic phase CML patients responding to imatinib should continue treatment indefinitely until disease progression (expected rate of
progression 1-5 %/year)
2. In accelerated, blast phase CML and Ph+ALL imatinib is usually used as induction +/- chemotherapy prior to more definitive treatment like
stem cell with an anticipated duration of imatinib use of 4-8 weeks.
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Lampiran1 Dr. Shamsul Kamaruljan
ARCOXIA PRESCRIPTION FLOW CHART
*Prescription: Maximum only for 3/52 Dose: 60mg, 90mg and 120mg (Depends on severity of the pain and condition of the pain)
Lampiran 2 Setelah diubahsuai oleh Jabatan Ortopedik
1st line:
T. Celebrex 200-400mg dly
T. Meloxicam 7.5mg bd
T. Tramadol 50-100mg tds
Oral opiods e.g. T. DF118,
Oral morphine
1st line:
NSAIDS e.g Voltaren, Mefenamic
acid, Ibuprofen
History of Gastritis
2nd line:
T. Celebrex 200-400mg dly
T. Meloxicam 7.5mg bd
Oral opiods e.g. T.DF118, Oral
morphine
2nd line:
T. Arcoxia 60-120mg dly
T. Oxycontin 10-40mg bd
3rd line:
T. Arcoxia 60-120mg dly
T. Oxycontin 10-40mg bd
Yes No
Pain not
relieved
Pain not
relieved
Pain not
relieved
Acute/chronic pain
60 | P a g e
OUTPATIENT PAIN PRESCRIPTION FLOW CHART
*COX2 Prescription for acute pain: Maximun only for 3/52 Arcoxia Dose: 60mg (OA), 90mg (RA) and 120mg (Acute pain e.g. gouty arthritis) (Depends on severity of the pain and condition of the pain) 3rd line is same in both pathways
1st line:
AC: T. Celebrex 200-400mg dly
AC Gouty arthritis : T Arcoxia
120mg daily
CHR: T. Meloxicam 7.5mg dly
T Celebrex 200mg dly
1st line:
AC: Voltaren, Mefenamic acid,
Ibuprofen
CHR: Feldene, Neprosyn
Acute/chronic pain
History of Gastritis
2nd line:
AC: Oral opiods e.g. T.DF118,
T. Arcoxia 120mg dly
CHR: T. Celebrex 200 dly
T. Meloxicam 7.5mg dly
2nd line:
Oral opiods e.g. T.DF118,
T. Arcoxia 60-120mg dly
3rd line:
Oral morphine
T. Oxycontin 10-40mg bd
3rd line:
Oral morphine
T. Oxycontin 10-40mg bd
Yes No
Pain not
relieved
Pain not
relieved
Pain not
relieved
AC – acute
CHR - chronic
61 | P a g e
FLOWCHART OF PATIENTS DIAGNOSED WITH BACTERIAL CONJUNCTIVITIS
Bacterial Conjunctivitis
1st line:
Gutt. Chloramphenicol
Perform Culture and Sensitivity test Not resolved
2nd line:
Gutt. Ciprofloxacin (Ciloxan)
Not resolved
3rd line:
Gutt. Moxifloxacin (Vigamox)
62 | P a g e
FLOWCHART OF PATIENTS DIAGNOSED WITH BACTERIAL KERATITIS
Bacterial Keratitis
1st line:
Gutt. Ciprofloxacin (Ciloxan)
Perform Cornea Scrapping/ Culture Not resolved and Sensitivity test
2nd line:
Gutt. Moxifloxacin (Vigamox)
63 | P a g e
FLOWCHART OF PATIENTS REQUIRING PRE AND POST CATARACT SURGERY ANTIBIOTIC PROPHYLAXIS
Cataract Surgery
Prophylaxis
Pre–op prophylaxis:
• Gutt. Moxifloxacin 0.5 % (Vigamox) 1 drop every 15 minutes 1 hour prior to surgery.
• 5 % Povidone – iodine ( 1 drop ) on the ocular surface.
Intra-cameral injection:
• 1mg in 0.1 mL cefuroxime* or
• 0.1 mL Gutt. Moxifloxacin 0.5% (Vigamox)1 - at the end of surgery *Dilution is required as standard cefuroxime injection is 100 mg/mL.
Reference:
1) CRG Espiritu et. al. Safety of Prophylactic Intracameral Moxifloxacin 0.5% Opthalmic Solution in Cataract Surgery Patients. J Cataract Refract Surg 2007: 33: 63-68
Post–op prophylaxis:
• Gutt. Moxifloxacin 0.5% (Vigamox) 4 times daily for 1 month.
64 | P a g e
FLOW CHART FOR USING OLOPATADINE 0.1%
i. Kegunaan ubat tersebut adalah untuk rawatan kes “Allergic conjunctivitis” terutama “Vernal kerato conjunctivitis” di kalangan kanak-kanak dan remaja.
“Flow chart” penggunaan kedua-dua drug bagi membezakan kes-kes tersebut seperti berikut; Last update: January 2012
Ubat titis Olopatadine
Pesakit “Allergic conjunctivitis”
terutama “Vernal kerato
conjunctivitis”
Pesakit
65 | P a g e
TREATMENT ALGORITHM OF ALLERGIC RHINITIS (AR)
Intermittent Symptoms Persistent Symptoms
Xyzal * (Bachert C et al. J. Allergy Clin. Immunol 2004; 114: 838-844) The XPERT, Xyzal in Persistent Allergic Rhinitis Trial – Published RCT data. Indication approved by FDA / DCA.
Diagnosis of AR
Allergen Avoidance
Drug Therapy (Antihistamines)
Moderate - Severe
Moderate - Severe
Mild Mild
Xyzal Xyzal * Xyzal Xyzal *
1st & 2nd generation antihistaminics
1st & 2nd generation antihistaminics (No clinical data
available to support this indication
66 | P a g e
FLOW CHART OF THALASSAEMIA PATIENT WITH IRON OVERLOAD
DIAGNOSIS OF THALASSAEMIA ON REGULAR BLOOD TRANSFUSION
REGULAR 3-4 MONTHLY FOLLOW-UP IN PAEDIATRIC HAEMATOLOGY CLINIC
REGULAR 3-4 WEEKLY FOLLOW-UP IN THALASSAEMIA DAY CARE UNIT FOR BLOOD
TRANSFUSION
3 MONTHLY MONITORING SERUM FERRITIN LEVEL
EVIDENCE OF IRON OVERLOAD, SERUM FERRITIN > 1000 MCG/L
INTRODUCE TO SUBCUTANEOUS DESFERAL (deferoxamine) WITH TRAINING AND
MONITORING
ASSESSMENT OF COMPLIANCE TO DESFERAL (Growth, Se Ferritin, yearly echo of heart)
POOR COMPLIANCE GOOD COMPLIANCE TO DESFERAL TO DESFERAL Se Ferritin Se Ferritin < 2500mcg/L > 2500mcg/L CONTINUE DESFERAL
DEFERASIROX DEFERIPRONE
67 | P a g e
INTERFERON BETA-1B FLOWCHART
Multiple Sclerosis
1) Remitting and Relapsing type.
2) Clinically Isolated syndrome with MRI evidence of multiple
plaques.
DIAGNOSIS ESTABLISHED AS PER Mc DONALD CRITERIA
TREAT THE ACUTE EPISODE WITH I.V METHYL PREDNISOLONE
THEN CONSIDER THE THERAPEUTIC OPTION OF STARTING BETA-INTERFERON
THERAPY.
(Beta interferon is the only evidence based treatment for the above condition, to reduce the risk of relapses and slow down the disease progression).
68 | P a g e
FLOW CHART FOR INSULIN ANALOGUE AT KRK
Type 2 Diabetes Mellitus patient requiring insulin
Start with:
Human intermediate acting insulin prebed (NPH)
Or Human premixed insulin predinner
Change to :
*Analogue Insulin : Long Acting analogue
(Glargine / Determir)
Change to :
*Analogue Insulin : Long Acting analogue
(Glargine / Determir)
Start with:
Human Premixed Insulin
(Mixtard 30/70 or Humulin 30/70)
Start with:
Human Premixed Insulin
(Mixtard 30/70 or Humulin 30/70)
Change to:
*Premixed Analogue Insulin :
Ex: Novomix 30/70 or Humalog 25/75
Humalog 50/50
Change to:
*Premixed Analogue Insulin :
Ex: Novomix 30/70 or Humalog 25/75
Humalog 50/50
Start with:
Short acting Human Insulin
(Actrapid/Humulin R OD/BD /TDS)
Start with:
Short acting Human Insulin
(Actrapid/Humulin R OD/BD /TDS)
Change to:
*Rapid acting Analogue Insulin
Novorapid/Apidra/glulisine/Lispro
Change to:
*Rapid acting Analogue Insulin
Novorapid/Apidra/glulisine/Lispro
Need BD dose insulin
Need Basal plus (+1 or +2)/Basal
bolus
Need Basal plus (+1 or +2)/Basal
bolus
if ≥ 40 unit change to Toujeo
(option)
if ≥ 40 unit change to Toujeo
(option)
HYPOGLYCEMIA
HYPOGLYCEMIA
HYPOGLYCEMIA
HYPOGLYCEMIA
69 | P a g e
Notes:
1. Patients that require insulin :
i) HbA1c > 10%
ii) Maximum dosage of two or three ODA with HbA1c > 7%
2. Patients who required insulin should be started with human insulin first.
3. Optimize and/or intensify the Human insulin dose according to SMBG/ DM
4. Indication to switching to analogue insulin regime ONLY when patient
develop hypoglycemia on human insulin.
References
1) CPG Management of Type 2 Diabetes Mellitus (5th Edition) 2) Practical guide to Insulin Therapy in Type 2 Therapy in Type 2 DM
Committee members:
1 AP Dr Rosediani Muhamad
2 Dr Nani Draman
3 Dr Siti Suhaila Muhamad