If you have unused goody bag kindly donate to pharmacy.

Jika anda mempunyai beg kertas atau

beg kain yang tidak digunakan, anda digalakkan menyumbangkannya ke farmasi.

PHARMACY

BULLETIN

Editorial Board Advisor Dr. Zaleha Bt Md Noor Hospital Director

Chief Editor Pn. Nursahjohana Md Sahak (Chief Pharmacist) Pn Noorazlinda Yacob

Editor Tan Xin Yi Ng Kah Yeang

Contributors Low Jia Hui Siti Maslizah Bt Seto Nur Athirah Haziqah Mo-hamad Sobri

Happy New Year 2015! In the beginning of this great new year, the motive of our bulletin remains to continue sharing enticing and updated information on medicine use to improve patient’s healthcare. We would also like to share some activities in pharmacy over the past few months.

Volume 1/2015 Jan 2015 Hospital Jasin

Issues Page

The Role of Therapeutic Drug Monitoring:

Aminoglycosides

2-3

Management of Head Lice and Scabies 4-5

New Anticoagulants:

Dabigatran and Rivaroxaban

6-8

Look Alike Sound Alike Medications 9

Management of Needle Prick Injury 10-13

Management of Hypertension in

Pregnancy

14-18

High Alert Medications 19

Notification of the Change of Insulin

Brand & Pen

20-21

Pharmacy Events 22-27

2

Overview of Aminoglycosides

● broad spectrum activity and sensitivity against gram negative bacilli bacteria.

● bactericidal antibiotic which works by inhibiting protein synthesis of bacteria.

By Nursahjohana Md Sahak

EFFICACY & SAFETY OF AMINOGLYCOSIDE: THE ROLE OF THERAPEUTIC DRUG MONITORING (TDM)

Table 1. Dosing of Aminoglycoside Aminoglycosides Common Dose Category of prescriber

Amikacin 250mg/2ml 500mg/2ml

Injection

Adult: IM or IV 15mg/kd/day bd or tds for 7-10

days. Max 1.5g dly

Child: 15mg/kg/day bd-tds Max 1.5g/day.

Neonates: Initial LD of 10mg/kg followed by

15mg/kg/day bd.

A

For Specialist only

TDM is required.

Gentamicin 80mg/2ml Injection

Adults: IM or IV 3-5 mg/kg/day tds Severe cases: Up to 5mg/kg/day tds Child IM or IV 2.5-3.5mg/kg/dose tds

B

TDM is required.

DO YOU KNOW ?

Ototoxicity and nephrotoxicity can be prevented

by shortening the duration of therapy (3 to 5

days) rather than aim for a specific serum

concentration of aminoglycoside.

Slowing the rate of infusion from 30 to 60

minutes can prevent ototoxicity in selected

patients.

Daily monitoring of serum concentrations and

sign & symptom of toxicity can reduce risk of

serious event. (Refer Table 3)

Clinical Use of Aminoglycoside Despite its toxicities, aminoglycoside has been widely used for many types of infection such as:

●lower respiratory tract infection

●urinary tract infection

●bacteremia

●intra-abdominal infection

●skin & soft tissue infection

●liver abscess

●cholecystitis

●empirical treatment for serious infections

such as nosocomial respiratory tract infections

●complicated infections caused by Gram

negative bacilli

Toxic Effect of Aminoglycoside

●The most common adverse effects of

aminoglycoside are ototoxicity and nephrotoxicity. Both toxicities are related to serum concentrations.

●Other adverse effects of gentamicin are

neuromuscular blockade, hypersensitivity, hematologic and central nervous system toxicities.

27

Best Staff of the Month

Pharmacy Unit

Pn. Nor Suhaida binti

Ngah

Pn. Norhidayah

Zakaria

Pn.Nursahjohana

Md.Sahak

En. Rahman Saidee

26

Event: CME Topics

Organized by Pharmacy Unit (October - December 2014)

Pharmacy Drug Information Service (DIS) aimed to provide proper dissemination of information on medicines or pharmacy-related services to the members in the unit, and also to the staffs in Hospital Jasin.

3

References

1.Maglio, D., Nightingale, C. H., Nicolau, D. P. (2002). Extended interval aminoglycoside dosing: from concept to clinic. Int J Antimicrob Agents.19, 341-348.

2. Bourguignon, L., Goutelle, S., De Saint-Martin, J. B., Maire, P., Ducher, M. (2009). Evaluation of various gentamicin dosage regimens in geriatric patients: a simulation study. Fund ClinPharmacol. 24, 109-113.

3. Yam, C. F., AbRahman, A. F. (2002). Therapeutic drug monitoring of single daily dose gentamicin: determination of an appropriate sampling time. Malaysian Pharmaceutical Society Scientific Conference. 46. (abstract).

4. Balamurugan, T., Yahaya, H., Noorizan, A. A., Zubaidah, C. E. (2005). Prospective audit on the practice of single daily dosing of aminoglycoside.5th Asian Conference on Clinical Pharmacy.3, 57-58. 5. Mardhiah, A., Debbie, S. S. E., Nursahjohana, S., Suhadah, A. (2006). Once-daily dosing of aminoglycosides: Review and recommendations for clinical practice. 6th MPS Scientific Conference.34. (abstract).

6. Sweileh, W. M. (2009). A prospective comparative studyofgentamicin and amikacin inducednephrotoxicity in patients with normal baseline renal function. Fund ClinPharmacol. 23, 515-520.

7. Stabler, S. N., Ensom, M. H. H. (2011). Extended-interval aminoglycoside therapy for adult patientswith febrile neutropenia: a systematic review. Can J Hosp Pharm. 64(3), 182-191.

8. Shalansky, K., Hill, S. Once-daily aminoglycoside guidelines. [updated 30 October 2012]. Available: http://www.vhpharmsci.com/vhformulary/Tools/Tools-Index.htm. 9. Selimoglu, E. (2007). Aminoglycoside-induced ototoxicity.Current Pharmaceutical Design.13, 119-126.

10. Zaske, D. E. (1986). Aminoglycosides. P. 331-381. In: Evans, W. E., Schentag, J. J., Jusko, W. J. (Ed) Applied pharmacokinetics: princi-ples of therapeutic drug monitoring. 2nd edn.AppliedTherapeutics, Spokane, Wash.

Table 2. Pro and con of MDD and ODD aminoglycosides regimen

MDD ODD

Risk of nephrotoxicity

Higher Although trough concentration of aminoglycoside remains at 1-2 mg/L, it may accumulate with time, therefore, increases the risk of toxicity.

Lower Although the total single dose of aminoglycoside in ODD is higher than MDD, there will be lower percentage of dose accumulation due to the less dosing frequency. This longer dosing interval allows the aminoglycoside concentration to be eliminated from renal tubular and inner ear cells allowing it to fall below minimum inhibitory concentration (MIC) within 12 hours.

Table 3. Recommended Protocol to Monitor Serum Concentration of Aminoglycoside

Aminoglycoside

regimen

Type of

aminoglycoside

Therapeutic

range

Sampling time

Multiple daily

dosing (MDD)

Gentamicin Trough: < 2mg/L

Peak: 5-10mg/L

1)Pre-dose

30 minutes/prior to next dose.

2) Post-dose 1 hour after end of

infusion Amikacin Trough: < 5mg/L

Peak: 20-30mg/L

Once daily dosing

(ODD)

Gentamicin

Amikacin

Peak: Depends on dosage. The higher the dose, the higher the peak will be achieved. Trough: < 1mg/L (nearly 0)

1)Post 1

1 hour after end of infusion

2) Post 6

6 hours after end of infusion

(blood sample can be taken

between 6-14 hours after end of

Infusion)

Synergistic effects:

●Penicillins and cephalosporins have synergistic activities with aminoglycoside against gram

positive organisms.

●This synergistic activity is achieved by increasing the porosity of bacteria cell wall caused by beta

-lactam antibiotic, therefore allowing more aminoglycoside penetration into the bacteria.

●The combination is useful for life-threatening infections such as endocarditis, pneumonia or

bacteremia.

4

BY :

NU

R A

TH

IR

AH

HA

ZIQ

AH

BIN

TI M

OH

AM

AD S

OB

RI

Ma

na

gem

en

t o

f H

ea

d Lic

e

In

festa

tio

n a

nd

Sc

abies

What is Head Lice Infestation &

Scabies?

They are common parasitic diseases caused by ectoparasites type.

Transmission is through contact with an infected person.

DIFFERENCES

Head Lice Scabies

Types of parasites Head louse (Pediculus humanus capitis)

Human itch mites

(Sarcoptes scabei)

Transmission Very close human-to-human contact

Infested skin comes in contact with another skin

Symptoms Itchiness on the

scalp and neck

Itchiness and redness / rash caused by skin’s reaction to the mite and its feces

Visibility Can be seen with

naked eyes

Almost microscopic

(Once burrowed

under the skin, they

can’t be seen)

Treatment Application of pediculide / lice medicine Use of specialized comb

Application of scabicides, not only to affected parts, but to all parts of the body as well

25

EVENT: INNOVATION DAY 2014

Ezi Envy My trolley War-tags

During Malacca Innovation Day 2014, pharmacy department of Hospital Jasin had presented our innovative project as below:

24

Know Your Medicine

10, 000 STEPS ACTIVITY:

The second 10,000 Steps Activity organized by the Pharmacy Unit, from Hospital Jasin was held on 18 October 2014 (Saturday) in the Ayer Keroh Recreational Park Botanical Garden, Malacca. The participation was overwhelmed and supported by 150 hospital staffs and their family members.

1. The program started off with a brief warm-up

session.

2. Along the walking trail, every participants was

required to respond to 5 pop quiz posted on

particular tree trunks.

3. There were also colouring contest at the

endpoint, prize giving ceremony and lucky

draw.

5

Treatment available in Hospital Jasin

(1) Benzyl Benzoate Emulsion (EBB) Dosage : 25% (adult); 12.5% (child < 2 years old)

Head Lice : The hair should be coated and rubbed with the emulsion, left for 12-24 hours, then rinse off with soap and water.

Scabies : After bath, apply over the whole body (neck downwards) and leave for 24 hours, then wash off. Re-apply for another 24 hours, the 1st repeat application should be within 5 days of initial application, a 3rd appli-cation may be required in some cases.

Pregnancy Category : N/A Lactation : N/A

General advice

Parent should be educated about the condition and given a clear written information on applying the treatment.

Everyone in the household and any close contacts should be treated.

Contraindicated to :

Children < 2 years old

History of uncontrolled seizure disorder

Pregnant women

Breastfeeding mother

References : (1) Paediatric Protocols For Malaysian Hospitals (2) http://www.pharmacy.gov.my/intranet/ (3) Guidelines for the diagnosis and treatment of pediculosis capitis (head lice) in children and adults (4) http://reference.medscape.com/drug/lindane-topical-343501 (5) http://www.stjames.ie/GPsHealthcareProfessionals/Newsletters/NMICBulletins/NMICBulletins1996/VOL2-4.pdf (6) http://www.just.edu.jo/DIC/AZLibrary/Benzyl%20Benzoate.pdf (7) http://www.health24.com/Medical/Meds-and-you/Medication/Benzyl-Benzoate-20130927 (8) http://www.skincareguide.com/article/head-lice-vs-scabies-whats-the-difference.html

(2) Lindane (Gamma Benzene Hexachloride)

Dosage : 1%

Head Lice : Bathe and dry the hair; then apply lotion to the hair evenly. Leave for 4 minutes, then comb hair with a fine comb and rinse off . Dry the hair and it can repeat after 7 days.

Scabies : Apply lotion to entire body (neck downwards) for 8-12 hours, then rinse off.

Pregnancy Category : C

Lactation : Distributed in breast milk

(do not breastfed 24 hours post-application; express milk & discard)

6

Mechanism action of warfarin, dabigatran and rivaroxaban2 ( Refer figure 1) Warfarin: ●Inhibits the synthesis of vitamin K dependent clotting factors II, VII, IV and X, together with the anticoagulant protein C and S. ●Its anticoagulation effect occurs within 24 hours following administration but reaching peak effect in delayed 72 to 96 hours. The half life is also long at 2.5 days. Dabigratan and Rivaroxaban: ●New oral anticoagulant with low molecular weight drug molecules and specific anticoagulant activites. Dabigatran: ●Dabigatran etexilate is a competitive reversible non-peptide direct antagonist of thrombin. ●Thrombin is an enzyme responsible in conversion of fibrinogen to fibrin, leading to cascade of coagulation. ●These actions of thrombin were inhibited by dabigatran etexilate. ●Prodrug dabigatran etexilate has a low bioavailability, but its absorption and subsequent conversion to dabigatran is fast. ●Maximum plasma concentration is reached between 30 minutes and 2 hours after oral administration, leading to rapid onset of action with half life of 12 to 17 hours. Rivaroxaban: ●Rivaroxaban is a competitive reversible antagonist of activated factor X (Xa) of clotting. ●Factor Xa is the active component of prothrombinase complex that catalyses conversion of prothrombin (Factor II) to thrombin (Factor IIa). ● Dabigatran disrupts both intrinsic and extrinsic pathways of coagulation cascade, inhibiting the formation of thrombin and thrombus development. ● As compared to warfarin, it has a rapid onset, leading to maximum plasma concentration at 2 to 4 hours with half life of 5 to 13 hours.

Oral Anticoagulant (OAC)

Dabigatran, Rivaroxaban

versus Warfarin By Tan Xin Yi

Overview oral anticoagulant: Vitamin K antagonists (VKS; coumarins like warfarin) have been the sole oral anticoagulant (OAC) offered, and proven effective, over the last 6 decades. 1 A new class of drugs known as “target-specific oral anticoagulants” - dabigatran etexilate (Pradaxa®) and rivaroxaban (Xarelto®) were approved by the US Food and Drug Administration for patients with atrial fibrillation, deep vein thrombosis and pulmonary embolism, were registered in Malaysia since 2009 and 2010 respectively.

23

Medication Therapy Adherence Clinic

Pharmacists

in-charge:

Ms Low Jia Hui Extension No.:

501

Ms Siti Maslizah Extension No.:

510

What is MTAC? An ambulatory care service conducted by pharmacists in collaboration with physicians, to improve patient’s medication adherence level and condition control. MTAC in Hospital Jasin (HJ)

Diabetes MTAC (DMTAC) established in 2012.

Operate in Klinik Pakar Hospital Jasin, every Tuesday (2.00pm to 5.00 pm) and Wednesday (8.00 am to 1.00pm) Scopes of Services

Assess patients and address their needs

Documenting actions and plans

Provide education to patients

Complete follow ups

Drug Information Services

Have queries? Call us

Pharmacists

in-charge:

Pn. Nor Athirah Ha-ziqah Mohamad

Sobri

DIS Hotline Extension No.:

501 506 507

Did You Know? DIS serves to receive and answer all requests on drug information from HEALTHCARE PROFESSIONALS and PATIENTS, besides disseminate adequate information regarding medicines and pharmaceutical products. Our objectives:

To prevent medication error

To enhance quality of care, and use of medicine

To improve awareness and knowledge among public

Scopes of Services

Respond to queries on drug information

Arrange CME sessions for members in pharmacy

department and doctors, at least once a month

Collect, Report and Submit Medication Error Form &

Suspected Adverse Drug Reaction (ADR)

Process application of Proforma E:

proposal to request purchase of non-standard drugs

Publishing Pharmacy Bulletin & Informative Brochures

22

Sehari Bersama Ahli Farmasi (SBAF)

Sehari Bersama Ahli Farmasi ( SBAF) was successfully held on 30th December 2014 with the aim of promoting the services provided by the pharmacy unit, Hospital Jasin. With the join force from all the pharmacy staff, a few booths were set up on the day to educate the hospital staffs and public about: 1. Procedures for extemporaneous drug preparation 2. Medication & device counselling 3. Adulterated drugs 4. Reducing medications wastage and medication returned 5. Promoting Drug Information Service and Medication Therapy Adherence Clinic

Providing counselling to the patient

Educating patient related to adulterated drugs Registration Counter

Group photo with the mascot of the day

7

Table 1. Approved indications and dosing regimens for the anticoagulants

Figure 1. Mechanism of action of the oral anticoagulant.3

Dabigatran

(Pradaxa®)

Rivaroxaban

(Xarelto®)

Warfarin

(Coumadin®)

Drug Class Thrombin inhibitor Factor Xa inhibitor Vitamin K antagonist Malaysian Drug Control Authority (DCA) approved indications

Stroke

prevention and

systemic

embolism in

Non-valvular

Atrial

Fibrillation

(NVAF)

110mg & 150 mg

capsule

Usual dose 150 mg

BD

15 mg & 20 mg

Tablet

Usual dose 20mg

OD

1 mg, 2mg, 3mg, 5mg

tablets

Dose adjusted to attain

general

recommended INR of 2.5

(INR range 2- 3)

Primary

prevention of

venous

thromboembolic

events (VTE)

in hip or knee

replacement

surgery

75 mg & 110 mg

Capsule

10 mg Tablet

Usual dose 10 mg

OD

1 mg, 2mg, 3mg, 5mg

tablets

Dose adjusted to attain

general

recommended INR of 2.5

(INR range 2- 3)

Treatment of

deep vein

thrombosis

(DVT ) and

pulmonary

embolism (PE),

and

prevention of

recurrent DVT

and PE

NOT APPROVED 15 mg & 20 mg

Tablet:

Usual dose 20 mg

OD

1 mg, 2mg, 3mg, 5mg

tablets

Dose adjusted to attain

general

recommended INR of 2.5

(INR range 2- 3)

Dosage: Special

Population

For stroke

prevention:

Aged 80 years and

above: 110mg BD

For stroke

prevention:

Moderate/severe

renal impairment:

15 mg OD

-

8

Dabigatran

(Pradaxa®)

Rivaroxaban

(Xarelto®)

Warfarin

(Coumadin®)

Disadvantages BD dosing

Action not reversible

Drug must be kept in

original container and

used within 4 months

of opening

Action not

reversible

Routine INR

monitoring

Drug-food interactions

Advantages Routine monitoring not

required

Routine

monitoring not

required

Taken once daily

Long term healthcare

experience with

proven benefits

Taken once daily

Adverse

effects

Dyspepsia,

GI bleeding,

Possible increased

risk of myocardial

infarction (MI)

Bleeding/

hemorrhage/

hematoma

Bleeding/

Haemorrhage,

Necrosis,

Purple toes syndrome

Monitoring

Parameter

aPTT provides an

approximation of anti-

coagulant activity.

No specific

monitoring test is

recommended.

Rivaroxaban

prolongs aPTT,

and prothrombin

time (PT).

PT/ INR

Table 2. Summary Comparisons of Dabigatran, Rivaroxaban and Warfarin

References: 1. A. Gomez-Outes, M. L. Su ´ arez-Gea, G. Calvo-Rojas et al. “Discovery of anticoagulant drugs: a historical perspective” Current Drug Discovery Technologies, vol. 9, no. 2, pp. 83–104, 2012. 2. T. Brighton. New oral anticoagulant drugs—mechanisms of action. Aust Prescr. 2010. 33:p38-41. 3. G. Gomez-Moreno, A. Aguilar-Salvatierra M. A. Martin-Piedra, J. Guardia, J. L. Calvo-Guirado, M. Cabrera, et al. Dabigatran and rivaroxaban, new oral anticoagulants. New approaches in dentistry. J Clin Exp Dent. 2010. 2(1):e1-5. 4. Clinical Practice Guideline Prevention and Treatment of Venous Thromboembolism. 2013 August. Ministry of Health Malaysia. 5. Clinical Practice Guidelines Management of Ischaemic Stroke. 2nd ed. 2012. Ministry of Health Malaysia. 6. Prevention of stroke and systemic embolism in adult patients with non-valvular atrial fibrillation. 2012 April. Healthcare Improvement Scotland. 7. New Oral Anticoagulants. NHS Greater Glasgow and Clyde Medicines Information Service. 2012 October; 20(S).

21

Purple for : 1) Insuman Comb 30 2) Insuman Basal

Teal ( blue) for :1) Insuman Rapid

Notification on the Change of Insulin Pen

Insulin Pen Novopen

(Silver & Blue

Colour)

AllStar

(Teal & Purple

Colour)

CHANGE TO

20

NPH Intermediate

Insulin

Insulatard

Insuman Basal

Regular

Insulin Actrapid

Insuman Rapid

NPH Premixed

Insulin

Mixtard

Insuman Comb

30

CHANGE TO

CHANGE TO

CHANGE TO

Notification on the Change of Insulin Brand

9

LOOK ALIKE SOUND

ALIKE MEDICATIONS

By Siti Maslizah

DEFINITION Look Alike Sound Alike medications (LASA) involve medications

that are visually similar in physical appearance including colour,

packaging, shape and also names of medications that have spelling

similarities and/or similar phonetics.

PROBLEMS 1. Illegible handwriting

2. Incomplete knowledge of drug names

3. Newly available products

4. Similar packaging or labelling

5. Similar strengths, dosage form, frequency of administration

6. Similar clinical use

EXAMPLES

STRATEGIES

TO AVOID

ERRORS WITH

LASA

MEDICATIONS

1. Use Tall Man lettering. E.g : metFORMIN and metoPROLOL

2. Use additional warning labels for look-alike medicines.

3. Store LASA medications separately from their LASA pair.

4. Include the diagnosis or medication’s indication for use.

5. Read medications label carefully during the administration

process.

References:

1. Guide on Handling Look Alike Sound Alike Medications, First Edition 2012, Pharmaceutical Services

Division Ministry of Health Malaysia .

2. Look-Alike, Sound-Alike Medication Names, WHO Collaborating Centre for Patient Safety Solutions.

Ceftriaxone 1g &

Ceoftaxime 1g

Meropenem 500mg &

Meropenem 1g

Streptomycin 1gm &

Hydrocortisone 100mg

Madopar Methyldopa

Glucophage XR Glucovance

Gliclazide Glibenclamide

Lovastatin Loratadine

Amlodipine Felodipine

Losartan Valsartan

Enalapril Perindopril

10

♦ Needle prick injury is one of the most common forms of injuries sustained by Health Care Workers (HCW). ♦ In 2005, the Occupational Health Unit of Ministry of Health Malaysia has reported an incidence rate of 4.7 needle prick injuries in 1000 HCW. ♦ One survey carried out in 2010 by Rampal, G. and colleagues found that the prevalence of needle prick injury in a local hospital was as high as 23.5%. ♦ The risk of transmission of blood borne viruses (BBV) of HIV, Hepatitis B virus (HBV) and Hepatitis C virus (HCV) following needle prick injuries are 0.3%, 23-37% and 1.8% respectively. ♦ Thus it is crucial to understand the management of needle prick injury to reduce the risk of transmission. ♦ When a needle prick injury occurs, blood should be immediately expressed out by squeezing the tissue adjacent to the wound and washed with water and soap thoroughly. The wound should then be disinfected and dressed if necessary. ♦ The incidence must be reported promptly and recorded in Sharp Injury Management Registry to ensure the HCW is managed properly.

Risk assessment that defines the following is then performed to evaluate the likeliness of BBV transmission to HCW: The nature and extent of the injury/ exposure The nature of the object causing the exposure The volume of the blood / body fluid that the HCW was exposed to The vaccination and immune status of the HCW The possibility of pregnancy in HCW The BBV status of the source The likelihood of an unidentified source being HBV, HCV or HIV positive Post Exposure Prophylaxis (PEP) should be commenced, where indicated, if a delay in obtaining the result is anticipated and the source patient deemed high-risk. The management of the needle prick injury depends on the source BBV status: i) Source negative for HBV, HCV, HIV > Serology testing should be carried out after 3 months for reassurance. ii) Source unknown or unable to be tested > The possibility of the source being BBV-positive needs to be taken into account when managing the exposed HCW. > If there is a high risk of the source being infected with a BBV, the HCW shall be managed as if the source is positive for BBV. iii) Source likely to be in the window period for HIV, HBV, HCV >The window period is considered if there is a risk behaviour by the source within the last 6 months. >The source needs to be referred to check for seroconversion. >The exposed HCW should be tested baseline HIV antibody, HBsAg and HCV antibody (ELISA) and retested at 6 weeks, 3 months and 6 months.

Management of Needle

Prick Injury & Treatment By Low Jia Hui

19

DEFINITION High Alert Medications are medications that bear a heightened risk of causing significant patient harm when these medications are used in error.

PROBLEMS

CLASSES /

CATEGORIES

OFMEDICATIONS

STRATEGIES TO

AVOID ERRORS

WITH HAM

MEDICATIONS

1. Label all containers used for storing High Alert Medications as “High Alert Medications”

2. Prescribe oral liquid medications with the dose specified in milligrams. 3. Do not use trailing zero when prescribing. (e.g. 5.0 mg can be mistaken

as 50 mg)

HIGH ALERT

MEDICATIONS (HAM)

By Siti Maslizah

1. Poorly written medication orders.

2. Incorrect dilution procedures.

3. Confusion between IM, IV, Intrathecal, epidural preparations.

4. Confusion between different strengths of the same medications.

5. Wrong infusion rate.

6. Look alike or sound alike product and similar packaging.

1. Adrenergic agonists, IV

(e.g. adrenaline, noradrenaline)

11. Glyceryl Trinitrate injection

2. Adrenergic antagonist, IV (e.g. propranolol, labetalol)

12. Inotropic medications, IV (e.g. digoxin, dobutamine,

dopamine)

3. Anaesthetic agents, general, inhaled and IV

(e.g. propofol, ketamine, dexmedetomidine)

13. Insulin, subcutaneous and IV

4. Antiarrythmias IV (e.g. lignocaine (lidocaine),

amiodarone)

14. Magnesium Sulphate Injections

5. Antifibrinolytics, hemostatic 15. Moderate sedation agents, IV

6. Antithrombotic agents (e.g. warfarin, heparin, tenecteplase,

streptokinase)

16. Neuromuscular blocking agents

(e.g. pancuronium, atracurium, ocuronium, vecuronium)

7. Antivenom (e.g. Sea snake, cobra,

pit viper antivenom)

17. Opiates and narcotics

8. Chemotherapeutic agents, parenteral and oral

18. Parenteral Nutrition preparations

9. Dextrose, Hypertonic, 20% or greater 19. Potassium salt Injections

10. Epidural and intrathecal medications

20. Sodium Chloride Solution(>0.9%)

References: 1.Guideline On Safe Use of High Alert Medications, 1st Edt. 2011, Pharmaceutical Services Division Ministry of Health Malaysia .

18

Antihypertensive Treatment Post Partum and during Breastfeeding1,3, 8,10

: Blood pressure typically rises after delivery over the first five days. Women with gestational hypertension, or pre-eclampsia, are usually able to stop all antihypertensive within six weeks post partum. However the dose of antihypertensive should be tailored down slowly and not stopped suddenly. The drug of choice for management for antihypertensive treatment in post partum and during breastfeeding is summarized in table 8.

Table 8: Antihypertensive drug for post partum and during breastfeeding

1,3,8,10

● Modern management guideline recommended first line agent is labetalol, nifedipine or an ACE inhibitor ( i.e. captopril, and enalapril) if another agent is required. Enalapril is excreted in very small amounts in breast milk and is not thought to be harmful.

● Some older practice recommended atenolol as first line agent. However, atenolol and metoprolol are concentrated in breast milk, possibly to levels that could affect the infant; by contrast, exposure to labetalol seems low.

3,8,10

●Diuretics, however, are usually avoided if the woman wishes to breastfeed because of increased thirst.

●Methyldopa should be avoided post partum because of the risk of postnatal depression.

References: 1. P Racheal J and Catherine NP. Management of hypertension before, during, and after preg-nancy. Heart. Dec 2004; 90(12): 1499–1504 Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1768605/ Last assessed 20 Dec 2015 2. Malaysian Hypertension Consensus Guidelines 1998 3. American College of Obstetricians and Gynecologists, Task Force on Hypertension in Pregnan-cy. Hypertension in pregnancy.Report of the American College of Obstetricians and Gynecol-ogists’ Task Force on Hypertension in Pregnancy.ObstetGynecol 2013; 122:1122. 4. Clinical Practice Guideline; Management of Hypertension 2013 (4th edition) MOH 5. Diagnosis, Evaluation, and Management of the Hypertensive Disorders of Pregnancy: Execu-tive Summary. Laura AM., Anouk P, Michael HMD May 2014 (Replaces No. 206, March 2008) 6. Nice guideline. Available at:http://www.nice.org.uk/nicemedia/live/13098/50475/50475.pdf Ac-cessed 26/11/2014 7. CLASP TRIAL. Available at:http://action-on-pre-eclampsia.org.uk/pre-eclampsia-information/fact-sheet1-low-dose-aspirin-for-high-risk-pregnancy/Accessed 26/11/2014 8. Postpartum management of hypertension Kate B, Catherine NP,Morris JB, Lucy CC BMJ 2013;346:f894 9. Royal College of Obstetricians and Gynaecologists. The management of severe pre-eclampsia/eclampsia, guideline no. 10 (A). London: RCOG Press, March 2006 10. Atkinson H, Begg EJ. Concentrations of beta-blocking drugs in human milk. J Pediatr. 1990; 116: 156.

11

Table 1. The type of PEP regimen. Regimen Category Drug Regimen

Basic 2-Drug PEP

(2 NRTI)

1. Zidovudine (AZT) 300mg bd + Lamivudine (3TC) 150mg bd - 28days

Or 2. Combivir 1 tab bd - 28 days

Expanded 3-Drug PEP

(2 NRTI + Proteus

inhibitor)

1. Basic 2-drug PEP + Kaletra (Lopinavir+ Ritonavir) 3 tab bd - 28days

Or 2. Basic 2-drug PEP + Indinavir 800mg bd

+ Ritonavir 100mg bd - 28 days Or

3. Basic 2- drug+ Indinavir 800mg tds - 28days

The following tables summarize the PEP regime based on the extent of exposure.

Table 2. PEP regime for mucous membranes exposures and non-intact skin

exposures.

Exposure

Type

HIV

Positive

Class 1

HIV

Positive

Class 2

Source of

unknown HIV

status

Unknown

source

HIV

Negative

Small

volume

Basic 2-drug PEP No PEP warranted

Large

volume

Basic

2-drug PEP

Expanded

3-drug PEP

Generally, no

PEP warranted.

Consider 2-

drug PEP for

source with HIV

risk factors.

Generally, no PEP warranted. Consider 2-drug PEP if there is likeliness of exposure to infected source.

No PEP

warranted

12

Table 3. PEP regime for percutaneous membrane exposures.

Expo-

sure type

HIV Class 1 HIV Class 2 Source of unknown HIV

status

Unknown

source

HIV

negative

Less

severe

Basic 2-drug

PEP

Expanded 3-

drug PEP

Generally, no

PEP is

warranted.

Consider 2-drug

PEP for source

with HIV risk

factors

No PEP

warranted

Generally, no

PEP is

warranted.

Consider 2-drug

if there is

likeliness of

exposure to the

infected source

More

severe

Expanded 3-drug PEP No PEP

warranted

v) Source positive or likely to be positive for HCV > At present, there is no prophylaxis proven effective for post exposure treatment.

> However, the exposed HCW should have baseline HCV antibody tested and retested at 6 weeks, 3 months and 6 months.

> HCV RNA testing should also be carried out to rule out the risk of transmission. vi) Source positive or likely to be positive for HBV

> HBsAg status of the source, Hepatitis B vaccination and antibody response status of the exposed HCW needs to be assessed.

> Table 4 (Refer Page 13) summarizes the PEP for exposure to HBV. > When indicated, hepatitis B vaccination should be initiated within 24 hours. > It can be administered simultaneously with HBIG at a separate site but the vaccine should be administered in the deltoid muscle. > The treated HCW needs to be tested for HBsAG at 6 weeks, 3 months and 6 months. The exposed HCW should be informed of the risk of transmission to secondary contacts, especially during the first 6 months following the incidence. They should be advised to not donate plasma, blood, body tissue, breast milk or sperm and to practise safe sex.

References: 1. Occupational Health Unit, Ministry of Health Malaysia Guidelines on Occupational Exposure to HIV,HBV and Hepatitis C virus and Recommendations of Post Exposure Prophylaxis. 2. Rampal, G and Rampal, L et al ‘Needle Stick and Sharps Injury and Factors Associated Among Health Care Workers in a Malaysian Hospital’ European Journal of Social Sciences (2010) 13(3):354-362 3. Malaysian Society for HIV Medicine (2014) Management of Health Care Workers with Needle Stick Injuries [online] Available from: http://www.mashm.org.my/pep.html [accessed: 10 Dec 2014] 4.Hospital Melaka, Occupational Exposure to Blood Borne Viruses Programme

17

Table 6: Anti-hypertensive drug for severe preeclampsia with Acute Hypertensive Crisis e.g. blood pressure > 160/110 mm Hg4

Agent Dosage Onset Peak Duration Comments

Labetolol IV Bolus: 20mg over 2 min Then double every 10-15 minutes ( i.e. 40mg,80mg) up to 220mg I.V. Infusion: 20mg/hr (1-2mg/min) Then double every 30 minutes (i.e. 40mg/hr, 80mg/hr,160mg/hr) Then stop or reduce to 0.5mg/min. Then switch to oral.

5 min (IV)

30 min

4hr Best avoided in women with asth-ma or heart failure. To inform if the women is in labour as parenteral labetolol may cause neonatal bradycardia.

Nifedipine Oral 5-10mg stat (repeat in 30 minute if necessary) especially prior to transferring a patient from a peripheral clinic to hospital. After the initial emergency dose, 10-20mg can be given 3-6 hours until BP stabilizes.

5-20 mins

30 min

~2-6hr Staff should be aware short acting nifedipine used to treat severe hypertension whereas XL formulation for non-severe hypertension.

Hydralazine* IV bolus or IM: 5mg then repeat 5-10mg IV every 20-40 min or IV Infusion 0.5-10mg/hr ( up to maximum of 20mg IV or 30mg IM)

~10-20 min

10-80 min

3-8 hr May increase the risk of maternal hypotension.

*Hydralazine is no longer recommended as first line treatment for acute hypertensive crisis in pregnancy.

Table 7: Anti-convulsant for eclampsia ( and severe Preeclampsia)4

Agent Dosage Comment Magnesium Sulphate

IV: 4g slow bolus over 10 minutes, followed by 1-2g/hr maintenance infusion given via a controlled infusion pump. IM: 4g IV slow bolus over 10 minutes, followed immediately by 10g IM, then 5g IM every 4 hr in alternate buttock.

Clinical monitoring is of utmost importance, looking for signs of toxicity (especially loss of deep tendon reflexes, respiratory depression with rate <16/min) and renal impairment (hourly urine output < 30ml/hr). The therapeutic range for magnesium sulfate : 4-8 meq/L Respiratory despression occurs ~10 meq/L Respiratory arrest occurs > 12 meq/L Cardivascular collapse occurs >25 meq/L Antidote for respiratory arrest or severe respiratory depression: Calcium Gluconate is 1 gm IV over 5 min.

Diazepam IV bolus 10mg, followed by 40mg in 5% dextrose slow infusion so that patient remains sedated.

16

Table 4: The use of aspirin in preventing mother with the risk of pre-eclampsia3,7

When to start?

Recommended after 12 weeks of pregnancy, although women with a very bad previous history of pre-eclampsia may be recommended to start the treatment earlier – even before conception.

What is the dosage?

The normal dosage is 75mg once daily. The treatment usually stops two weeks before delivery to allow the blood clotting function to return to normal.

What is the benefits & main finding of Collaborative Low-dose Aspirin Study in Pregnancy (CLASP) study 7 ?

Risk of pre-eclampsia~12% Risk of premature delivery (i.e. before 37 weeks) ~ 14%

Drug of choice for management for hypertensive disorder: ( Refer Table 5,6,7)

Table 5: Oral drug agents for treatment of blood pressures 149-159 /90-105 mm Hg1,3,4

Agent Dosage Comments

Methyldopa Oral 250mg TDS doubling every 48 hours (up to 1 gm TDS) until BP well controlled. Maintenance: 0.5-2 g/day. Max: 3 g/day

￮ Centrally acting agent and best

safety profile

￮ Loading dose not required

￮ Avoid in patient with depression,

haemolytic anaemia, parkinsonism

Labetolol Oral 100 mg BD, doubling every 48 hours (up to 400mg BD) until BP well controlled. ( Max 800mg/d)

￮ Some experts recommend a starting

dose of 200mg BD.

￮ Caution: asthma, bronchitis,

hyperthyroidism, heart failure

Nifedipine Oral 10mg TDS, up to 20mg TDS, usually as second line antihypertensive when BP poorly controlled despite maximum doses of methyldopa + labetolol.

￮ May used concomitant with

magnesium sulfate with caution: abrupt hypotension

●Thiazide diuretics are used infrequently in pregnancy although the drug do not appear

to be teratogenic.1

●Atenolol use should probably be avoided in pregnancy, because it has been

associated with slightly lower birth weights.9

●Both ACE inhibitors and ARBs are fetotoxic and should be avoided in all trimesters but

there are no data to support teratogenicity. When administered in the second and third trimesters, they are associated with a characteristic fetopathy, neonatal renal failure, and death, and, thus, are contraindicated.1

13

Vaccination and antibody

response status of exposed

HCW

Treatment

Source HBsAg positive

Source HBsAg

negative

Source unknown or unable to be tested

Unvaccinated

Hepatitis B immune globulin (HBIG)

(Dose: IM 0.06mg/kg) ,

Initiate Hepatitis B (HB) vaccine series

Initiate HB vaccine series

Previously Vaccinated

Known responder

(Serum Anti HB ≥ 10 IU/

ML after receiving a full 3-dose

primary course)

No treatment

Known non-responder

(Serum anti-HB < 10Miu/

ml)

-HBIG X1+Revaccination

(Preferred for those do not complete

second 3-dose series

OR

-HBIG X 2 with one

month interval in between

(Preferred for those completed second 3

-dose series but failed to response)

No treatment If known high risk source, treat as if

source HBsAg positive

Antibody response unknown

Test exposed HCW for antibody for

HBsAg (anti-HB)

1. Adequate level, no treatment

2. Inadequate level, administer HBIGX1 and vaccine booster

No treatment Test exposed HCW for antibody for anti-HB

1. Adequate level, no

treatment

2. Inadequate level, administer and

vaccine booster and recheck titre in

1-2 months

Table 4. Summary of PEP for exposure to HBV

14

Management of hypertension in pregnancy: key points1

Main categories : chronic, gestational, pre-eclampsia, eclampsia

√ First line antihypertensive during pregnancy: methyldopa

√ First line antihypertensive post partum: labetalol, nifedipine or enalapril.

√ Oral nifedipine 10mg stat dose can be used to rapidly control BP in an acute hypertensive crisis prior transfer to hospital.

√ No antihypertensive has been shown to be teratogenic, but angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) are fetotoxic and should be avoid in all semester.

√ Commence aspirin in pregnant women with one or more high risk factor or two or more moderate risk factors for preeclampsia from 12 weeks.

√ Provide calcium supplement (of at least 1 g/d) from early pregnancy to prevent pre-eclampsia.

Background: Hypertension in pregnancy: ●also known as pre-eclampsia, toxemia of pregnancy and eclampsia ●complicates 10-20% of pregnancies ●major cause of premature birth and perinatal deaths and accounts for 20-33% of all maternal deaths. ●may also result in serious complications to the mother notably placental abruption, disseminated intravascular coagulation, cerebral haemorrhage, hepatic failure and acute renal failure. ●Pregnant women with hypertension should be (referred) to the obstetrician.2 The hypertensive disorder in pregnancy3: ●Preeclampsia: Preeclampsia refers to the syndrome of new onset of hypertension and either proteinuria (>300 mg/day) or end-organ dysfunction most often after 20 weeks of gestation in a previously normotensive woman. ●Eclampsia: Eclampsia is diagnosed when seizures have occurred. ●Gestational hypertension: Gestational hypertension refers to elevated blood pressure first detected after 20 weeks of gestation in the absence of proteinuria or other diagnostic features of preeclampsia.

Anticonvulsants in Pre-eclampsia-Eclampia4,7:

●Parenteral magnesium sulphate is currently the drug of choice for the prevention of

eclampsia and to abort an eclamptic fit. (Refer Table 3,7)

●Alternative is intravenous diazepam, bearing in mind that it is inferior in efficacy

compared to magnesium sulphate. Magnesium sulphate also provide fetal neuroprotection following pre-term birth with a significant in the incidence of cerebral pal-sy. Aspirin has been shown to reduce the risk of getting pre-eclampsia in women.6,7 (Refer Table 4)

Management of hypertension in pregnancy

By Ng Kah Yeang

15

Table 1: Basic diagnostic criteria for gestational hypertension1

Diastolic BP (mmHg) Systolic BP (mmHg)

Mild hypertension 90-99 140-149

Moderate hypertension 100-109 150-159

Severe hypertension >110 >160

Pharmacological treatment is indicated if SBP = 160 mm Hg and/or DBP = 100 mm Hg, aiming for a blood pressure of 130/90 mm Hg.

Table 2: Symptoms and signs of severe pre-eclampsia1

Left upper quadrant/epigastric pain due to liver oedema ± hepatic haemorrhage

Headache ± visual disturbance (cerebral oedema)

Occipital lobe blindness

Hyperreflexia ± clonus

Convulsions (cerebral oedema)

Table 3: Magnesium Sulphate for Preventing or Treating Eclampsia: Key Points 5

•Magnesium sulphate is recommended for 1st line treatment of eclampsia and as prophylaxis against eclampsia in women with severe preeclampsia.

•Magnesium sulphate may be considered as prophylaxis against eclampsia in women with non-severe preeclampsia but with severe hypertension, headaches/visual symptoms, right upper quadrant/epigastric pain, platelet count <100000×109/L, progressive renal insufficiency, and/or elevated liver enzymes, based on cost considerations.

•Magnesium sulphate should be used in standard dosing, usually 4 g intravenous loading dose followed by 1g/hour.

•In severe hypertension, magnesium sulphate is not recommended solely as an antihypertensive agent and can be used concomitant with nifedipine.

•Phenytoin and benzodiazepines should not be used for eclampsia prophylaxis or treatment, unless there is a contraindication to magnesium sulphate or it is ineffective.

Basic diagnostic criteria and recognizing pre-eclampsia: (Refer table 1 & 2)