page buletin penawar - hsajb.moh.gov.myhsajb.moh.gov.my/versibaru/uploads/farmasi/bulletin... ·...

BULETIN PENAWAR

VOLUME 4/2018

DISEMBER 2018

EDITORIAL BOARD

ADVISOR:

PN HJH ROHAYAH BINTI ABD. GHANI

EDITORS:

PN SITI ROSNAH BT. SURADI

EN MOHD SHAFIE BIN ZABIDI

CIK ZANARIAH BT. ABU BAKAR

HOSPITAL SULTANAH AMINAH

JOHOR BAHRU

KEMENTERIAN KESIHATAN MALAYSIA

JALAN PERSIARAN ABU BAKAR SULTAN

80100 JOHOR BAHRU

TEL: 07-2257000

FAX: 07-2242694

EMAIL: [email protected]

IN THIS ISSUE Updates on Clinical Practice Guideline of

Stable Coronary Artery Disease 2018

Pulmonary Arterial Hypertension in

Adults

Methanol Toxicity

PAGE

2-3

PAGE

4-5

PAGE

6-7

PAGE

8-9

Management of Rhinosinusitis in

Adolescents and Adults

Laporan Aktiviti Bergambar Pameran

dan Ceramah Kenali Ubat Anda di SMK

Infant Jesus Convent

PAGE

10

UPDATES ON CLINICAL PRACTICE GUIDELINE

OF STABLE CORONARY ARTERY DISEASE 2018 Prepared by: Lim Siew Er

JABATAN FARMASI, HOSPITAL SULTANAH AMINAH JOHOR BAHRU PAGE 2

CPG Stable Angina Pectoris 2010 CPG Stable Coronary Artery Disease 2018

Target Populations

1. Individual with stable angina pectoris.

2. Exclude individual with rest angina,

crescendo angina and new-onset

angina.

1. With other symptoms (e.g. dyspnea) which are known or suspected to be due to

coronary artery disease (CAD).

2. Had previous episode of ACS but who are now stable.

3. Undergone post revascularization.

4. Asymptomatic but are known to have CAD on non-invasive testing.

Signs and Symptoms

1. Chest pain ≤ 10 minutes.

2. May be accompanied by shortness

of breath.

Other than chest pain and shortness of breath;

• palpitation, near syncope or syncope may happen.

Diagnostic Tests

1. Laboratory tests.

2. Chest X-ray.

3. Non-invasive cardiac investigations.

4. Non-invasive techniques to assess coronary

calcification and anatomy.

5. Invasive techniques to assess coronary

anatomy.

Newly added recommendation:

In persons with suspected CAD and undergoing non-invasive cardiac testing, it is im-portant to determine the pre-test probability.

1) Pre-test probability (PTP)

• Shows the likelihood of CAD in the patient with chest pain. • Analyzed before diagnostic testing based on age, sex and clinical history of chest

pain. i) High PTP >85% - May have significant obstructive CAD. - Invasive coronary angiography maybe required. Ii) Intermediate PTP 15-85% requires further non-invasive testing. Iii) Low PTP <15% - May have no significant obstructive CAD. - CV risk factors should be treated.

*Additional non-invasive test recommendation: 1) Coronary Calcium Score (CAC)

• CAC score is obtained from coronary calcium scan and it must be adjusted for age and gender.

• This score has been used to detect CAD with high sensitivity but low specificity with an overall accuracy of 70%.

• Negative test (CAC = 0): - Presence of atherosclerotic plaques are unlikely.

- Is highly unlikely in the presence of significant luminal obstructive disease. - Occur in most patient with angiographically normal coronary arteries.

Updates

Updates

Updates

Ranolazine PR 375mg, 500mg, 750mg [Ranexa]

• Available as prolonged release formulation.

• Selectively inhibits the late inward sodium current in the

myocardium and thus reducing the intracellular calcium levels

and diastolic LV wall tension. As a result, it reduces myocardial

oxygen demand.

• Initial dose: 375mg BD then titrate to 500mg BD after 2-4

weeks. It can be further titrated to a maximum of 750mg BD.

• Adverse effects: QT interval prolongation or risk of renal fail-

ure in renal impairment patient.

Nicorandil [Adancor]

• Dual pharmacological mechanism of action with adenosine

triphosphate sensitive potassium (KATP) channel agonist and

nitrate-like properties.

• Usual starting dose is 10mg BD which can be titrated up to

20mg BD or maximum dose of 30mg BD.

• Adverse effects: Gastrointestinal ulceration or eye ulceration.

Triflusal 300mg [Grendis]

• An platelet anti-aggregant with structural similarities to

salicylates.

• Usual dose in myocardial infarction is 600mg OD within 24

hours of onset of symptoms.

• Frequency of non-haemorrhagic adverse effects (abdominal

pain, dyspepsia and peptic ulcer) is significantly higher.

• Benefit:

- Less incidence of intracranial and gastrointestinal

haemorrhage in comparison to aspirin.

Sacubitril / Valsartan 24/26mg, 49/51mg, 97/103mg [Entresto]

• Sacubitril inhibits neprilysin, a neutral endopeptidase (NEP)

which then increases levels of endogenous vasoactive

peptides including natriuretic peptides, bradykinin and

adrenomedullin.

• Starting dose: 49/51mg BD then doubling the dose every 2-4

weeks to maintenance dose of 97/103mg BD.

• Adverse reactions: angioedema, hypotension, impaired renal

function and hyperkalemia.

• Black box warnings: Discontinue as soon as possible when

pregnancy is detected as it may result in fetal injury or death.


Pharmacological Therapy

1) Prevention of cardiovascular events

- Aspirin (Clopidogrel or Ticlopidine for aspirin intolerant

patient).

- Statin therapy (to achieve LDL-C < 1.8mmol/l).

- ACEI / ARB, beta-blockers and mineralocorticoid

antagonists as tolerated .

• Dual antiplatelet therapy (DAPT) is recommended for 12

months post ACS.

- Aspirin and Thienopyridine (clopidogrel or

ticlopidine).

• New alternatives available:

i) Triflusal (for aspirin intolerant patient).

i) Angiotensin-receptor-neprilysin inhibitors

2) Symptomatic control/relieve

- First-line: Short acting nitrate + beta-blockers ± CCBs

to reduce angina.

- Add-on therapy: recommended in patients who

remain symptomatic.

i) Ivabradine,

ii) Trimetazidine,

iii) Long-acting nitrates

• 2 new agents can be used as add-on therapy:

i) Ranolazine

ii) Nicorandil

Updates

Updates

Updated Medications in CPG Stable CAD 2018

History, physical exam, screening

procedures, incidental findings

PULMONARY ARTERIAL HYPERTENSION(PAH)

PAH IN ADULTS

PAH was defined by a mean PAP (mPAP) >25mmHg at rest or >30 mmHg

with exercise.

PAH is now defined as a resting mPAP>25mmHg thereby eliminating the

diagnostic criteria associated with exercise.

The new Dana Point definition also suggests that a resting mPAP of 8 to

20mmHg should be considered as normal.

DEFINITION SYMPTOMS OF PAH

PATHOGENESIS

RISK FACTORS

UPDATES

SCREENING PAH suspicion

PAH detection ECG, CXR, Doppler echocardiography

PAH class

identification

VQ Scan, PFTs, high resolution/ spiral CT

PAH evaluation

Blood test and immunology, HIV test

6MWT

RHC with vasoreactivity

DIAGNOSIS

BY: Tan Ling Xin


6MWT=6-minute walk test; CT=computerized tomography,; CXR= chest X-ray; ECG=electrocardiogram; PFT=pulmonary function test; PH=pulmonary hypertension; RHC=right heart catheterisation; VQ scan=ventilation-perfusion scintigram

Doppler

echocardiography

- Patients with scleroderma.

- It is a test which very high frequency sound waves are bounced off from your heart and blood vessels. The echoes are picked up and turned into pictures to show how well the blood flow through the arteries and heart.

Genetic

testing

- Patients with more than one family member with PAH related to a mutation in Bone Morpho-genetic Protein Receptor Type II (BMPR2).

1. Ministry of Health Malaysia. MIMS Malaysia. (2018).

2.White RJ (2018). New Therapeutic Approaches in Pulmonary Arterial Hypertension. 137:2390–2392.

3. Ministry of Health Malaysia. Clinical Practice Guidelines: Management of Pulmonary Arterial Hypertension. (2011). Academy of Medicine Malaysia.

4. Sildenafil & Bosentan (2018). In Micromedex Drug Reference for Apple iOS (Version v1641) [Mobile application software].

5. Sildenafil (2018). In British national formulary 75. London: BMJ Publishing and the Royal Pharmaceutical Society.

CONVENTIONAL THERAPY PAH-SPECIFIC THERAPY

PAH-SPECIFIC THERAPY

COMBINATION THERAPY

DRUG-DRUG INTERACTION

REFERENCES :


Management of Rhinosinusitis in

Adolescents and Adults By: Vivian Chuah Yi Ting

Rhinosinusitis: Characterised by mucosal inflammation of the nose & paranasal sinuses

Characterized by two or more symptoms. One of which should either be nasal blockage/obstruction/congestion or nasal discharge:

• ± facial pain/pressure

• ± reduction or loss of smell

AND at least one of the following:

• Endoscopic signs of:

nasal polyps and/or

mucopurulent discharge primarily from middle meatus and/or

oedema/mucosal obstruction primarily in middle meatus

• CT changes: mucosal changes within the ostiomeatal complex and/or sinuses

• Past medical history of chronic rhinosinusitis (CRS) (medically diagnosed)

Clinical Diagnosis

Acute vs Chronic Rhinosinusitis

ARS CRS

Worsening of symptoms after

five days or symptoms persist

after 10 days. Duration <12

weeks with complete resolution

Symptoms persisting for more

than 12 weeks.

Acute Viral vs Bacterial Rhinosinusitis

Acute Viral RS Acute Bacterial (ABRS)

Majority of ARS cases are viral in

origin. Viral RS is a self-limiting

disease which is managed

symptomatically with analgesic

or antipyretic.

When there are at least three

symptoms/signs of:

• Discoloured discharge (with

unilateral predominance) and

purulent secretion in the nasal

cavity.

• Severe local pain (with unilateral

predominance).

• Fever (>38ºC).

• Elevated ESR/CRP level.

• Deterioration of signs and

symptoms.

Algorithm: Management of Acute Rhinosinusitis (ARS)

Predisposing

Factors

Infection

Allergies

Air pollution

*VAS=Visual Analogue Scale (0-10cm)

Clinical Presentations

• Nasal obstruction

• Headache

• Decreased sense of smell

• Facial pressure or pain

• Fever

• Sore throat and cough Presence of ≥2 symptoms. One of which should be nasal obstruction or purulent/

greenish nasal discharge

Symptoms <5 days or improving thereafter

Symptoms increasing after 5 days or persistent after 10 days

Common cold

Treat accordingly

Mild ARS

VAS >3 to 7

Symptomatic relief medication

No improvement after 10 days or worsening after 5 days

Topical steroid

No improvement after 14 days treatment

Consider referral to specialist

Moderate ARS

VAS> 3 to 7

Symptomatic relief medication + topical steroid

Severe ARS

VAS> 7 to 10

Symptomatic relief medication + topical steroid + consider antibiotic

Improvement

within 3 days

Yes No

Continue treatment 7-14 days

Refer to

specialist


ESR: erythrocyte sedimentation rate

CRP: c-reactive protein

Drug therapy Generic drug name Recommended dosage Remarks

Antibiotics Amoxicillin 250 - 500 mg PO q8hr x 5 - 10 days or

500 - 875 mg PO q12hr x 5 - 10 days

Should not be used routinely in CRS.

Preferred antibiotics in ABRS.

Amoxicillin &

Clavulanic acid

500/125 mg PO q8hr x 5 - 7 days or

875/125 mg PO q12hr x 5 - 7 days

Intranasal

Cortico-

steroids

Budesonide 64mcg/ dose nasal spray

Adults & children 6 years and older:

• Rhinitis: 2 sprays into each nostril OD in the morning or 1 spray into each nostril BD

• Nasal polyps: 2 sprays BD

Duration of treatment:

• ARS: 14 - 21 days

• CRS: 16 - 52 weeks

Compliance & correct technique are essential for effective delivery of the medi-cines.

Mometasone furoate 0.05% aqueous nasal spray

Allergic Rhinitis (adults & children >12 years):

• 100 mcg/day (2 sprays) to each nostril OD

• Max 200 mcg (4 sprays) OD

• Reduce to 1 spray OD when control achieved

Acute Rhinosinusitis:

• 2 sprays in each nostril BD (400 mcg/day)

Nasal polyphosis:

• 2 sprays in each nostril BD (400 mcg/day)

• Reduced to 2 sprays each nostril OD when symptoms are adequately controlled

Oral Cortico-

steroids

Prednisolone CRS: 25 mg daily for 14 days (to reduce nasal polyp size and hyposmia score up to 10 weeks)

Not given in ARS due to the possibility of exacerbation of bacterial infection.

Nasal Saline

Irrigation

— Irrigate each side of the nose once or twice, two to three times a day

Adjunct therapy in patients with rhinosinusitis.

Anti-

histamines

First generation: Chlorpheniramine

Second generation: Loratadine

Chlorpheniramine: 4mg TDS or PRN

Loratadine: 10mg OD or PRN

Prescribed in rhinosinusitis with associated symptoms suggestive of allergic rhinitis (sneezing, nasal itchiness, nasal obstruc-tion and rhinorrhea).

Newer generations are less sedative.

Topical

Decongestants

Oxymetazoline 0.05% Nasal Spray

2-3 sprays into each nostril BD, max 6 sprays per nostril per day Duration of treatment is 3-5 days.

Should not be prescribed for more than two weeks due to rebound nasal conges-tion.

Pharmacological Treatment

References:

1.Ministry of Health Malaysia. Clinical Practice Guideline: Management of Rhinosinusitis in Adolescents and Adults. Ministry of Health Malaysia; 2016. 2.Fokkens WJ., Lund VJ., Mullol J., Bachert C., et al. European Position Paper on Rhinosinusitis and Nasal Polyps 2012. Rhinology 2012; Volume 50(supplement 23): 1-298. 3.MyHEALTH Kementerian Kesihatan Malaysia. How to Use Nasal Spray. [Online]. 2013 [cited 2018 June 25]; Available from: http://www.myhealth.gov.my/en/how-to-use-nasal-spray/ 4.Pharmacy Times. Practical Aspects of OTC Intranasal Corticosteroid Use: Important Educational Points to Share with Patients. [Online]. 2015 [cited 2018 June 25]; Avail-able from: URL: http://www.pharmacytimes.com/publications/issue/2015/july2015/rd362_july2015 5.Sinuplasty. Instructions for Nasal Saline Irrigation. [Online]. 2001 [Cited 2018 June 25]; Available from: https://www.sinuplasty.com/download/attachment/nasalsalineinstructions.pdf 6.Kennedy DW, Bolger WE, Zinreich SJ. Diseases of the Sinuses: Diagnosis and Management. UK: B.C. Decker Inc.; 2011: P. 271-273. 7.American Academy of Allergy, Asthma, and Immunology. Saline sinus rinse recipe. [Online]. 2018 [cited 2018 June 25]; Available from: https://www.aaaai.org/

Steps to Use Nasal Saline Irrigation:

1.Mix 1 cup of distilled water or boiled water with 1/2 teaspoon of salt and a pinch of baking soda.

2.Pour some solution into a clean cup and fill the syringe from it. Avoid directly syringe out from the container to reduce the contamination. Standing near sink with head tilt forward.

3. Angle the tip of the syringe in the nostril towards the back of your head and gently squeeze the syringe. The solution should flow into one nostril and out from the other. Repeat for the other side.


Usage of Nasal Spray for the First Time (Priming): 1. Remove the dust cap and shake the nasal spray bottle. Press down a few times until a fine mist of spray comes out. 2. Priming is only done once for every nasal spray. How-ever, if the nasal spray has not been used for >1-2 weeks, the priming step has to be repeated.

Usage of Nasal Spray after Priming:

1. Gently blow your nose to clear the mucous and remove the dust cap. 2. Close one nostril with finger. Bend your head slightly forward. Careful-ly insert the applicator tip ¼ or ½ inch into the other nostril (point the applicator tip slightly outwards, away from the centre of the nose). 3. Press down the nasal spray once and breathe in slowly at the same time. Repeat this in other nostril. 4. Do not tilt your head backwards to prevent backflow into your throat. Slightly bitter sensation in mouth is normal if medicine drips into throat. Wipe the applicator tip with a clean tissue or cloth before put on the dust cap.

Tips While Using the Nasal Spray: 1. Do not breathe in strongly and quickly to prevent medication going into your throat. 2. The nasal spray will not drip from your nose nor into your oral cavity when used correctly. 3. If you experience any nosebleed following the used of nasal sprays, stop using the nasal spray and seek medical attention.

Early manifestation Delayed manifestation

Caused by methanol Caused by formic acid (the toxic

metabolite)

•Low overdose: nausea, vomiting,

abdominal pain, headache, vertigo

and confusion.

•Large overdose: obtundation,

convulsions and coma.

•increased anion gap

•metabolic acidosis

•retinal injury—Opthalmological

manifestations (occur 15-19h later)

include clouding and diminished

vision, dancing and flashing spots,

dilated or fixed pupils, hyperaemia

of the disc, retinal oedema and

blindness

ETHANOL PREFERRED OVER FOMEPIZOLE

✓ More readily available

✓ More clinical experience

× Significant adverse effects

× Requires intensive monitoring

Methanol Toxicity By Ameerah Budiono

INTRODUCTION

Methanol (CH3OH) is also known as me-

thyl alcohol or “wood alcohol”. It may

result from methanol contamination,

suicidal ingestion of methanol containing

products and unintended consumption of

such products. Methanol is cheaper than

ethanol and may be used as a substitute

for ethanol.

MECHANISM OF TOXICITY

Methanol itself is not highly toxic. It is metabolized by

alcohol dehydrogenase to formaldehyde and

subsequently to formic acid which can cause acidosis.

Acidosis will increase toxicity further by enabling greater

diffusion of formic acid into cells. Formic acid has been

shown to inhibit cytochrome oxidase in mitochondria.

Thus this prevents oxidative metabolism and leads to

“histotoxic hypoxia” which is the prime cause of ocular

toxicity.

MANIFESTATIONS OF METHANOL POISONING

DIAGNOSIS

History of methanol or ethylene

glycol ingestion with a *wide anion

gap metabolic acidosis.

Patients may also present with visual

disturbances, neurologic deficit,

abdominal pain and vomiting.

*wide anion gap metabolic acidosis

criteria (at least 2):

• Arterial pH <7.3

• Serum bicarbonate < 20 mmol/L

• Osmolal gap > 10 mOsm/L

MANAGEMENT: GENERAL

PRINCIPLES INDICATIONS FOR HEMODIALYSIS

FOR METHANOL INTOXICATION

TREATMENT

1. pH< 7.25 to 7.35

2. or visual signs and/or symptoms

3. or decreased vital signs despite

intensive supportive care

4. or kidney failure

5. or substantial electrolyte disturbances

unresponsive to supportive care


IV Sodium Bicarbonate to correct

acidosis to the normal range (7.35–

7.45).

Ethanol and Fomepizole. Inhibition of

methanol metabolism to block

production of toxic metabolite.

3. IV Folinic Acid to enhance formic acid

metabolism and elimination. Dose at 1

mg/kg/body weight IV (up to a total

dose of 50mg) every 4–6 hours until

methanol and formate have been

eliminated.

4. Hemodialysis may also be required to

correct severe metabolic abnormalities

and to enhance methanol and formate

elimination.

LOADING DOSE (LD) MAINTENANCE DOSE

0.8mg/kg (4ml/kg) diluted in juice

administered orally or via a nasogastric tube.

If the patient concurrently ingests ethanol,

the LD must be modified so that the blood

ethanol does not exceed 100-150mg/dL.

Non-drinker 80-130mg/kg/hr PO or via nasogastric tube.

Chronic alcoholic 150mg/kg/hr PO or via nasogastric tube.

During dialysis 250-350mg/kg/hr PO or via nasogastric tube.

ETHANOL 20% DOSING

In HSAJB, Undenatured

Ethanol 96% for Oral

Preparation is diluted to

20% for oral use.

Ethanol or fomepizole should be

administered as soon as possible after

methanol ingestion. Ethanol has

approximately 10 times greater

affinity than methanol for alcohol

dehydrogenase thus it competitively

inhibits the metabolism of methanol

to formate.

DILUTION FOR 20% ORAL

ETHANOL

Ingredients:

• Undenatured Ethanol 96% (EtOH) for oral

preparation.

• Dextrose 5% (D5%)

Procedures:

• Pour 500mL D5% in a separate container.

• Syringe out 116ml ethanol 96%.

• Mix 116ml ethanol 96% into the

container containing 500mL D5%. DURATION OF TREATMENT

Treatment should be titrated to a blood

ethanol level of 100mg/dL or patient’s

clinical condition i.e. patient starts to

show improvement without adverse

effects (if blood ethanol measurement

is not available).

Serum methanol concentration is <20

mg/dL (200 mg/L) and the patient is

asymptomatic with a normal arterial

pH.

1. Rietjens, S. J., De Lange, D. W., & Meulenbelt, J. (2014). Ethylene glycol or methanol intoxication: which antidote should be used, fomepizole or ethanol. Neth J Med, 72(2),

73-9.

2. Brent, J. (2009). Fomepizole for ethylene glycol and methanol poisoning. New England Journal of Medicine, 360(21), 2216-2223.

3. American Academy of Clinical toxicology Ad Hoc Committee on the treatment Guidelines for methanol Poisoning, Barceloux, D. G., Randall Bond, G., Krenzelok, E. P.,

Cooper, H., & Allister Vale, J. (2002). American Academy of Clinical Toxicology practice guidelines on the treatment of methanol poisoning. Journal of Toxicology: Clinical

Toxicology, 40(4), 415-446.

4. Garis Panduan Wabak Keracunan Metanol (2015), Bahagian Kawalan Penyakit, KKM.

R

E

F

E

R

E

N

C

E

S

Patient must be monitored in *ICU if IV Ethanol infusion is given due to potential adverse

effects of hypotension, tachycardia, CNS/respiratory depression, hypoglycemia,

electrolyte derangement, and gastritis.

Ethanol should be used with caution in patients:

Who have also ingested drugs that produce *CNS depression as ethanol may

enhance the depressant effect of these drugs.

Patients with hepatic disease.

Concomitant use of disulfiram, metronidazole, or chlorpropamide may cause

flushing and hypotension to occur.

History of gastrointestinal ulcers (for oral ethanol).

Avoid in pregnant patients in the first trimester due to concerns regarding the fetal

alcohol syndrome.

PRECAUTION

PAGE 9 JABATAN FARMASI, HOSPITAL SULTANAH AMINAH JOHOR BAHRU

Pameran dan ceramah KUA telah diadakan di SMK Infant Jesus Convent pada 1 November 2018.

Objektif pameran tersebut adalah untuk meningkatkan kesedaran dan pengetahuan mengenai

penggunaan ubat secara rasional di kalangan pelajar dan guru. Seramai 169 orang pelajar tingkatan 3

telah menyertai pameran tersebut.

3 orang Pegawai Farmasi dari Hospital Sultanah Aminah turut hadir untuk memberi ceramah

mengenai ubat-ubatan. Program ini diserikan lagi dengan kehadiran Pn Aynee binti Wahid, Duta

KUA . Program ini telah berjalan dengan lancar dan mendapat sambutan yang baik daripada

kalangan pelajar dan guru-guru.

PAMERAN DAN CERAMAH

KENALI UBAT ANDA (KUA)

page buletin penawar - hsajb.moh.gov.myhsajb.moh.gov.my/versibaru/uploads/farmasi/bulletin... ·...

Documents