1

Advisors

Puan Saidatul Raihan Ibrahim

Editor

Atiqah Mohamad Ali

Contributers

Chong Li Wen

Tan Su Ping

Loo Sui Yin

Editorial Board

Ms Tay Eek Poei

Puan Syamsiah Haji Shariff

Puan Julia Shamsudin

PHARMACY NEWSLETTER H O S P I TA L M E L A K A ● VO L 3 1 : S E P T — O K T 2 0 1 5

2

NO TOPICS PAGES

1

~ HAZE

How it happen?

Impact

Precautions

2 ~ Naturopathy

3 ~ Rivaroxaban Versus Dabigatran in Atrial Fibrillation

4 ~ Sevelamer Carbonate 800mg Tablet

5 ~ Medic Alert

6

~ Metoclopromide

7 Laughter is the best medicines

8 ~ Sambutan Hari Keluarga 2015

“ Keluarga Bahagia, Organisasi Cemerlang”

3

The haze we see in our city skyline is caused by tiny particulates

suspended in the atmosphere resulting in diminished horizontal visibility. The

haze that affected Malaysia was the worst since 2005, starting with the Air

Pollution Index (API) hitting 172 on 19 June 2015.

Sumatera and Kalimantan possess large area of peatlands, which is highly

combustible during dry season.

Peat, which is made up of layers of dead vegetation and other organic matter,

contributed heavily to carbon emissions because of the substance's density.

Fires caused by firms and farmers who engage in illegal slash-and-burn practices

as a relatively inexpensive means of clearing land resulted in haze.

The El Niño phenomenon which has caused drier conditions, allowing the fires

to spread more. Thus, the haze has been more severe in 2015

By : Tan Su Ping

4

Children and the elderly in general are more likely to be

affected.

Persons with medical problems like asthma, chronic lung

disease, chronic sinusitis and allergic skin conditions such as

eczema are likely to be more affected by the haze and they

may experience more severe symptoms

1. It is important to take medication regularly.

2. Do not skip the dose.

3. Minimize outdoor activities.

PERSON UNDER MEDICAL TREATMENT

1. Are advised not to engage in outdoor sporting

activities if the PSI is above 100.

2. Should always ensure that medications are on hand

and readily available.

PERSONS WITH CHRONIC HEART AND LUNG

PROBLEMS

1. Drink plenty of water to stay hydrated

2. Persons who are feeling unwell, are advised to seek

medical care.

3. Use mask if for persons who has to be outdoors for

several hours when air quality is in the hazardous

range ( PSI > 300 )

GENERAL PUBLIC

References

1. Impact of Haze on Health, Health Board Promotion, 14 September 2015, http://hpb.gov.sg/HOPPortal/health-article/HPB051226

2. "South East Asia haze: What is slash-and-burn?". BBC. 24 June 2013. Retrieved25 September 2015.

3. Chew Hui Min (15 September 2015). "Malaysia and Indonesia begin cloud seeding to fight haze: How cloud seeding works". The Straits Times. Retrieved 15 September 2015.

4."What causes South East Asia's haze?". News. BBC. 16 September 2015. Retrieved16 September 2015.

5

Principle of naturopathy

Naturopathic medicine is a

distinct primary health care

profession, emphasizing

prevention, treatment, and

optimal health through the

use of therapeutic methods

and substances that

encourage individuals’

inherent self-healing process.

Naturopathy, or naturopathic

medicine, is a system of

medicine based on the

healing power of nature.

There are 2 areas of focus in

naturopathy:

one is supporting the body's

own healing abilities, and the

other is empowering people

to make lifestyle changes

necessary for the best

possible health.

While naturopathic doctors

treat both short bouts of

illness and chronic conditions,

their emphasis is on

preventing disease and

educating patients.

The following principles are

the foundation of

naturopathic medical

practice:

The Healing Power of

Nature (Vis Medicatrix

Naturae): Naturopathic

doctor trust in body inherent

wisdom to heal itself.

Identify and Treat the

Causes (Tolle

Causam): Effectively identify

and remove the

underlying causes of illness

rather than eliminate or

suppress symptoms.

First Do No Harm

(Primum Non Nocere):

Seek to utilize the most

natural, least invasive, and

least toxic therapies first.

Doctor as Teacher

(Docere):

Naturopathic doctor educate

their patients and encourage

self-responsibility for health.

Treat the Whole

Person: : Total health

includes physical,

emotional, mental, genetic,

environmental, social,

spiritual, and other factors.

Prevention:

Encourage and emphasize

disease prevention and

focus on promoting health

and wellness.

Introduction

By : Cheong Li Wen

6

There is little depth research on the

effectiveness of some therapies,

supplements or herbs. Although

some are validated by the use of

these remedies in a thousand years.

Sometimes the dose in each patient

is a matter of trial and error to

adjust the dose.

Further studies are needed on the

interaction between natural

One of the main disadvantages of

natural medicine that is not as

efficient as the allopathic to treat

medical emergencies and even less

if severe.

Natural remedies are slower to seek

healing and calm the symptoms, but

at any given time is a disadvantage

because these symptoms can be

very aggressive and require rapid

elimination.

remedies and allopathic medicines

since in some cases may detract

from some or / and others or even

cause some inconvenience.

Disadvantages

Advantages

Naturopathic practitioners use many different treatment

approaches. Examples include:

Dietary and lifestyle changes

Stress reduction

Hydrotherapy

Herbs and other die-

tary supplements

Acupuncture

Homeopathy

Manipulative therapies

Exercise therapy

Practitioner-guided detoxification

Psychotherapy and counseling.

Some practitioners use other methods

as well or, if appropriate, may refer

patients to conventional health

care providers.

References:

1. http://www.naturopathic.org/content.asp?contentid=59

It aims to treat the root cause of your illness, not just the symptoms

It is a totally natural and drug free treatment method

Used for maintaining wellness once the initial condition is rectified

Naturopathy is safe and effective for both adults and children

7

Rivaroxaban Dabigatran

Indication in AF

Reduce the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation

Prevention of stroke and systemic embolism associated with nonvalvular atrial fibrillation

Dose

● CrCl >50 mL/min: 20 mg/day PO ● CrCl 15-50 mL/min: 15 mg/day PO ● CrCl <15 mL/min: Avoid use ● If acute renal failure develops while on rivaroxaban, discontinue treatment

● CrCl >30 mL/min: 150 mg PO BD ● CrCl 15-30 mL/min: 75 mg PO BD ● CrCl <15 mL/min or dialysis: No data available; not recommended

Mode of Action

● Factor Xa inhibitor that inhibits platelet activation by selectively blocking the active site of factor Xa without requiring a cofactor (eg, antithrombin III) for activity

● Prevents thrombus development through direct, competitive inhibition of thrombin (thrombin enables fibrinogen conversion to fibrin during the coagulation cascade) ● Inhibits free and clot-bound thrombin and thrombin-induced platelet aggregation

Pharmacokinetic

● Absorption - Bioavailability: 80-100% - Peak plasma time: 2-4 hr ● Distribution - Protein bound: 92-95% (mainly albumin) - Vd: 50 L ● Metabolism - Metabolized by the liver via oxidative deg-radation catalyzed by CYP3A4/5 and CYP2J2 - hydrolysis ● Elimination - Half-life: 5-9 hr; 11-13 hr (elderly) - Excretion: Feces (21% as metabolites; 28% unchanged), Urine (30% as metabolites; 36% unchanged)

● Absorption - Bioavailability: 3-7% - Peak plasma time: 1 hr ● Distribution - Protein bound: 35% - Vd: 50-70 L ● Metabolism -Prodrug dabigatran etexilate (substrate of the effux transporter P-gp) is converted to dabigatran - Not a substrate, inhibitor, or inducer of CYP450 enzymes ● Elimination - Half-life : 12-17 hr - Excretion : Urine (80%)

Storage

Store at 25⁰C

Store at 25⁰C

Price

● Rivaroxaban 15mg Tablet - RM 213.80 / 30 Tab ● Rivaroxaban 20mg Tablet - RM 213.80 / 30 Tablet

●Dabigatran Etexilate 75 mg Capsule - RM 5.95 / 30 Cap ●Dabigatran Etexilate 110 mg Capsule - RM5.95 / 30 Cap ●Dabigatran Etexilate 150 mg -RM5.95 / 30 Cap

By : Atiqah Ali

RIVAROXABAN VERSUS DABIGATRAN IN ATRIAL FIBRILLATION

References : 1. http://online1.mimsgateway.com.my/

2. http://reference.medscape.com/

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● Sevelamer carbonate is a polymeric phosphate binder used to treat

hyperphosphatemia in ESRF patient undergoing hemodialysis.

● When taken with meals, it binds to dietary phosphate within intestinal

lumen, limiting absorption and decreasing serum phosphate

concentration without changing calcium, aluminum, or bicarbonate

concentrations.

● Sevelamer carbonate is currently marketed by Sanofi under the trade

names Renvela

Pharmacokinetic : Sevelamer carbonate is orally administered

and not systemically absorbed, according to results of a mass

balance study using 14C-sevelamer hydrochloride in 16 healthy

volunteers. No absorption studies have been conducted in patients

with kidney disease. It is excreted via feces.

Maintenance dose

Dosage adjustment based on serum phosphate

concentration (goal 1.13-1.78 mmol/L)

Serum PO4 [>1.78 mmol/L]: Increase dose by 400

-800 mg per meal

Serum PO4 [1.13-1.78 mmol/L]: Maintain current

dose

Serum PO4 [1.13 mmol/L]: decrease by 400-800

mg per meal

Initial dose

Serum PO4 [>2.91 mmol/L]:

1600 mg PO q8hr with meals

Serum PO4 [2.42-2.91 mmol/L]:

1200-1600 mg PO q8hr with

meals

Serum PO4 [1.78-2.42 mmol/L]:

800 mg PO q8hr with meals

DRUG PROFILE SEVELAMER CARBONATE

By : Loo Sui Yin

9

Pharmacodynamics:

● Sevelamer carbonate, a non-absorbed phosphate binding cross-linked polymer, free of metal

and calcium.

● It contains multiple amines separated by one carbon from the polymer backbone.

●These amines exist in a protonated form in the intestine and interact with phosphate molecules

through ionic and hydrogen bonding.

● By binding phosphate in the dietary tract and decreasing absorption, sevelamer carbonate

lowers the phosphate concentration in the serum.

● Sevelamer does not contain calcium and decreases the incidence of hypercalcaemic episodes

as compared to patients using calcium based phosphate binders alone.

● The effects of sevelamer on phosphorus and calcium were proven to be maintained throughout

a study with one year follow-up.

References;

Renvela (sevelamer carbonate) Product Monograph Page 10 of 22

Barna, M. M., Kapoian, T., & O'Mara, N. B. (2010). Sevelamer carbonate.Annals of Pharmacotherapy, 44(1), 127-134.

Fan, S., Ross, C., Mitra, S., Kalra, P., Heaton, J., Hunter, J., ... & Pritchard, N. (2009). A randomized, crossover design study of sevelamer carbonate pow-der and sevelamer hydrochloride tablets in chronic kidney disease patients on haemodialysis. Nephrology Dialysis Transplantation, 24(12), 3794-3799.

Finn, W. F., Joy, M. S., & Hladik, G. (2004). Efficacy and safety of lanthanum carbonate for reduction of serum phosphorus in patients with chronic renal failure receiving hemodialysis. Clinical nephrology, 62(3), 193-201

Finn WF.Lanthanum carbonate versus standard therapy for the treatment of hyperphosphatemia: safety and efficacy in chronic maintenance hemodialysis patients. SPD 405-307 Lanthanum Study Group. Clin Nephrol. 2006;65:191-202

evaluated long term (2 years)

safety and tolerability of

lanthanum carbonate.

Lanthanum is demonstrated

to be as effective and

tolerable as the standard

therapy (any approved

phosphate binder), with

lower serum calcium levels

and improved PTH levels.

Lanthanum carbonate has

similar efficacy to sevelamer in

reducing phosphate levels, with

the initial dose of 750mg or

1500mg/day and titrated

according to serum phosphate

levels.

An open-label, parallel-group

active comparator-controlled

trial involving 1566 patients

Alternative:

Lanthanum carbonate is also

free of calcium and aluminum.

This agent has no known

biotransformation and does

not have and known local or

systemic drug interactions. It

does not cross blood-brain

barrier and thus has a low

potential for central venous

system effects.

Adverse effect:

Most frequently occurring adverse reaction in short term, 8 weeks, cross over study were nausea and

vomiting. In long term studies, the most common adverse events included vomiting, nausea, diarrhea,

dyspepsia, abdominal pain, flatulence and constipation.

SEVELAMER CARBONATE

10

What Is MedicAlert® And What MedicAlert® Does?

MedicAlert®

By : Cheong Li Wen

MedicAlert® is a device or a system that is used to send out an alert in case one has a medical emergency like a

fall, an injury or a sudden attack by a disease like a heart attack or asthma. MedicAlert® Foundation helps these

people by providing them through their doctors, with “MedicAlert®” pendants or bracelets on which their special

disabilities are engraved, so that when the need arises, attending doctors will be able to provide the correct

treatment which may help save their life.

Ambulance paramedics and health care professionals are trained to look for genuine MedicAlert® emblems.

The bracelets and pendants have a reputation for accurate information and high product standards ensuring

correct diagnosis and identification. It can be the only source of identification for patients who are unconscious,

disoriented or unable to speak.

● a bracelet or pendant customized engraved with vital

emergency information,

● a 24 hour hotline number and a member ID number;

the information on the bracelet or pendant alerts health

care professionals to medical conditions, allergies and

special instructions which would all speed diagnosis and

treatment,

● the 24 hour confidential emergency telephone

hotline, providing additional medical/personal details

from confidential computerized records, including

medication, physician’s and emergency contacts,

● all registrations include a membership card

providing additional protection and identification

Who needs it? ● Person with any medical problems such as

~ diabetes, allergies or epilepsy

~person with pacemakers or artificial hips need such a medical

information system.

~ Under normal circumstances they would be able to inform doctors of

their condition, but in times of emergency or when they are unconscious

or otherwise unable to speak, MedicAlert® speaks for them.

● The MedicAlert® emblem, worn on the wrist or round the neck, is

recognized the world over. It incorporates the symbol on one side (the

snake round a stick), and the medical problem of the wearer on the

other side, along with a telephone number of the 24-Hour hotline

maintained by the foundation.

MedicAlert® comprehensive services are:

11

How to apply?

Membership Plan

1. Ordinary Plan: 5 Years of membership including emblem and wallet card

2. Life Plan: Life time membership including emblem and wallet card

Benefits Includes

1. Faster treatment and care, especially in emergencies

2. Reduced risk of complications or uncertainties

3. Assurance of personal information security while safeguarding your life

4. Reduced fear and anxiety for you and your loved ones

What Do You Get ?

1. MedicAlert® emblem—A high quality MedicAlert® emblem is personalized with free engraving and recognized by emergency responders around the world.

2. Emergency Wallet Card—Your wallet card is personalized and includes our live 24-hour emergency response number

The Step By Step Guide To MedicAlert®

Step 1 | Fill in the downloadable registration form and make sure it is

approved by a certified doctor.

Step 2 | All details of new member will be recorded in the

MedicAlert® main database.

Step 3 | Medical details of new member will be engraved at the back

MedicAlert® bracelet/pendant.

References :

1. http://www.medicalert.org/

2. http://www.medicalert.org/

101 Menara Mutiara Majestic,

15 Jalan Othman,

46000 Petaling Jaya, Selangor Darul Ehsan,

Malaysia.

MedicAlert® Foundatio

n

Phone: +603-77820515

Fax: +603-77820515

Hotline: +6012-3411137

E-mail: medicalertmalaysia@gmail.com

We’re on the web

medicalert.com.my

Help to protect and save lives.

ORDINARY LIFE RENEWAL

MEMBERSHIP FEE RM 100

( for 5 years )

RM 500

( for a lifetime)

RM 100

( for 5 years )

BASIC EMBLEM

COST

RM 50 each RM 50 each RM 50 each

12

The European Medicines

Agency’s Committee has

reviewed the benefits and

risks of the antiemetic

metoclopramide. The review

confirmed the well-known

risks of neurological effects

such as short-term

extrapyramidal disorders

and tardive dyskinesia.

The risk of acute

neurological effects is

higher in children, although

tardive dyskinesia is

reported more often in the

elderly, and the risk is

increased at high doses or

with long-term treatment.

The conclusion of the review

was that these risks

outweigh the benefits in

long-term or high-dose

treatment. There have also

been very rare cases of

serious effects on the heart

or circulation, particularly

after injection.

The review has

recommended changes that

include a restriction to the

dose and duration of use to

help minimize the risk of

potentially serious

neurological adverse effects.

The risk of acute

neurological effects is

higher in children than in

adults.

By : Loo Sui Yin

Adults Paediatrics ( 1-18 years old )

Injection ● Prevention of post-operative nausea and

vomiting, symptomatic treatment of

nausea and vomiting, including nausea

and vomiting induced by migraine attacks.

● Prevention of radiotherapy-induced

nausea and vomiting.

● Prevention of delayed chemotherapy-

induced nausea and vomiting (CINV) as a

second-line option.

● Prevention of post-operative nausea and

vomiting (PONV) as a second-line option.

Oral ● Prevention of delayed chemotherapy

induced nausea and vomiting (CINV).

● Prevention of radiotherapy induced

nausea and vomiting (RINV) Symptomatic

treatment of nausea and vomiting,

including acute migraine induced nausea

and vomiting.

● Prevention of delayed chemotherapy

induced nausea and vomiting (CINV) as a

second line option.

Rectal ● Prevention of delayed chemotherapy

induced nausea and vomiting (CINV).

● Prevention of radiotherapy induced

nausea and vomiting (RINV).

● Not indicated.

Indication and dose of metoclopramide

1.INDICATION

13

References;

European Medicine Agency, 2013.

Biro Pengawalan Farmaseutikal Kebangsaan www.bpfk.com.my

2. RECOMMENDED DOSE

Adult Paediatrics ( 1-18 years old )

● The solution can be administered by the intravenous or intramuscular route.

● The intravenous doses must be administered as a slow bolus (for at least 3 minutes)

Injection

● 10 mg per dose, 1 to 3 times daily.

● The maximum recommended daily dose

is 30 mg or 0.5 mg/kg.

● Treatment duration when administering

by injection should be as short as possible

and a switch to administration via oral or

rectal route should be instituted as

quickly as possible.

● The recommended dosage is 0.1 to 0.15

mg/kg, 1 to 3 times daily, by intravenous

route.

● The maximum daily dose is 0.5 mg/kg.

(please refer to the dosing table for

paediatrics below)

Oral ● 10 mg, repeated up to 3 times daily.

● The maximum recommended daily dose

is 30 mg or 0.5mg/kg body weight.

● The maximum recommended treatment

duration is 5 days

● The recommended dose is 0.1 to 0.15 mg/

kg body weight, repeated up to three times

daily by oral route.

● The maximum dose in 24 hours is 0.5 mg/

kg body weight. For the prevention of

delayed CINV, the maximum treatment

duration is 5 days.

● For the prevention of PONV,the maximum

treatment duration is 48 hours.

● Tablet are not suitable for use in children

weighing < 30kg. (please refer to the

dosing table for paediatrics below)

Rectal A minimum interval of 6 hours between

two administrations is to be respected,

even if vomiting or rejection of the dose

occurs

Not indicated

Dosing for paediatrics

Age ( years old ) Body Weight (kg) Dose (mg) Frequency

1-3 10—14 1

Up to 3 times a day

3-5 15—19 2

5-9 20—29 2.5

9-18 30—60 5

15-18 >60 10

Generally, it is advisable to maintain the gap between the dose for at least 6 hours.

14

Can we just...

….get along??

Sources :

1. https://www.cartoonstock.com/directory/p/pharmacy.asp

2. https://sciencebasedpharmacy.wordpress.com

15

Tu dia… Semua ahli keluarga dalam Jabatan Farmasi ni

stabil dan fleksibel tau.

Salah satu aktiviti untuk adik—adik yang comel adalah

mewarna!

Antara wajah—wajah gembira keluarga besar Farmasi Hospital Melaka yang menghadiri Hari Keluarga

Aktiviti yang dinamakan Boling Kelapa Ini pula aktiviti tradisional menganyam ketupat