Streptokinase VS Tenecteplase in Acute Coronary Syndrome

Management

Role Of SGLT-2 Inhibitors In Glycaemic Control For Patients

With T2DM

Antimicrobial Stewardship Activity: Antibiotic IV To Oral

Switch

Adverse Drug Reactions of Allopurinol and Precautions

Lifestyle Intervention in Managing Asthma

Pain Management In Pediatrics

Updates on New Drugs

Available in Hospital Jasin

VOLUME 1/2017

APRIL 2017

PHARMACY

BULLETIN

2

Adverse Drug Reactions of

Allopurinol and Precautions

3

Lifestyle Intervention in

Managing Asthma

5

Pain Management In Pediatrics 7

Streptokinase VS Tenecteplase

in Acute Coronary Syndrome

Management

10

Role Of SGLT-2 Inhibitors In

Glycaemic Control For Patients

With T2DM

12

Updates on New Drugs Available

in Hospital Jasin Formulary 2016

14

Antimicrobial Stewardship

Activity: Antibiotic IV To Oral

Switch

17

Best Staff Of The Month

(July - Dec 2016)

20

Pharmacy Events/Activities 22

EDITORIAL BOARD ADVISOR

Dr Zaleha Bt Md NoorDr Zaleha Bt Md NoorDr Zaleha Bt Md NoorDr Zaleha Bt Md Noor

CHIEF EDITOR

Nursahjohana Md SahakNursahjohana Md SahakNursahjohana Md SahakNursahjohana Md Sahak

EDITOR

Tan Xin YiTan Xin YiTan Xin YiTan Xin Yi

Nurul Atika WahabNurul Atika WahabNurul Atika WahabNurul Atika Wahab

CONTRIBUTORS

Izrul Azwa Mohd LatiffIzrul Azwa Mohd LatiffIzrul Azwa Mohd LatiffIzrul Azwa Mohd Latiff

Hana RadhiahHana RadhiahHana RadhiahHana Radhiah

Ng Shy PyngNg Shy PyngNg Shy PyngNg Shy Pyng

Low Jia HuiLow Jia HuiLow Jia HuiLow Jia Hui

Shoniya A/P JayasegaranShoniya A/P JayasegaranShoniya A/P JayasegaranShoniya A/P Jayasegaran Nur Athirah Haziqah Mohamad Nur Athirah Haziqah Mohamad Nur Athirah Haziqah Mohamad Nur Athirah Haziqah Mohamad

SobriSobriSobriSobri

3

Allopurinol is one of the most effective medications to:

• Reduce the production of uric acid in patients who

have gout or certain types of kidney stones.

• Decrease levels of uric acid in people who are

receiving cancer treatment. (Patients have increased

uric acid levels due to release of uric acid from the

dying cancer cells)

However, allopurinol can lower blood cells that help your

body fight infections. This can make it easier for you to

bleed from an injury or get sick from being around others

INTRODUCTION

Adverse Drug Reactions of Allopurinol and

Precautions

HOW SHOULD I TAKE ALLOPURINOL? Take each dose with a full glass of water. To reduce risk of

kidney stones forming, drink 8-10 full glasses of fluid

every day, unless your doctor tells you otherwise.

You may have gout attacks more often when first start

taking allopurinol. Doctor may recommend other gout

medication to take with allopurinol.

Keep using your medication as directed and tell doctor if

symptoms do not improve after a few months of treatment

ADVERSE DRUG REACTIONS • The Malaysian Adverse Drug Reactions Advisory

Committee (MADRAC) has received 280 reports of

adverse reactions related to the use of allopurinol

since the year 2000. 12 reports involved fatality.

• Among the adverse reactions reported, 80% were skin

reactions, including mild reactions such as rash and

itchiness as well as severe life threatening reactions

such as Stevens Johnsons Syndrome and Toxic

Epidermal Necrolysis.

Mechanism of Action:

Allopurinol inhibits xanthine

oxidase, the enzyme that catalyses

the conversion of hypoxanthine to

xanthine then uric acid.

What is uric acid?

It is a protein metabolite that is

present in the blood and released in

INDICATIONS APPROVED

BY DRUG CONTROL

AUTHORITY (DCA)

1. Recurrent gouty arthritis attacks

2. Primary/secondary hy-

peruricaemia associated with

gouty arthritis

3. Uric acid nephropathy

4. Recurrent uric acid stone

formation

NOT indicated for:

• Moderately elevated uric acid or

non-gouty arthralgia or arthritis.

• Treatment of asymptomatic

hyperuricaemia

It has no pain or anti-inflammatory

activity. Therefore it has no value in

3

4

Summary of ADR Associated With Allopurinol

No Common Uncom-

mon

Rare Very rare

% 1% to 10% 0.1% to 1% < 0.1% < 0.01%

Dermatologic

1 Rash, maculopapular rash Ecchymosis Steven-Johnson

syndrome,

Lyell syndrome

Vasculitis

Hypersensitivity

2 Generalized

hypersensitivity

Anaphylaxis,

angioedema

Hepatic

3 Increases in alkaline

phosphatase & serum

transaminase

Hepatitis, hepa-

tomegaly, cholestatic

jaundice

Gastrointestinal

4 Diarrhoea, nausea,

vomiting

Intermittent

abdominal pain,

gastritis, dyspepsia

Steatorrhea, recurrent

hematemesis,

stomatitis, changed

bowel habit

Hematologic

5 Leukocytosis,

leukopenia,

eosinophilia,

thrombocytopenia,

Renal

6 Renal failure /

insufficiency

Xanthine crystalluria,

azotemia

Nervous system

7 Ataxia, somnolence,

coma, paralysis,

paresthesia,

neuropathy, taste

perversion

Metabolic

8 Diabetes mellitus,

hyperlipidemia

Cardiovascular

9 Angina, bradycardia,

hypertension

Endocrine 10 Gynecomastia

Genitourinary 11 Infertility, impotence,

nocturnal emission

Uremia, hematuria,

male infertility,

impotence, erectile

dysfunction

Respiratory 12 Epistaxis

1. https://www.drugs.com/sfx/allopurinol-side-effects.html

2. www.mps.org.my/view_file.cfm?

3. http://www.webmd.com/drugs/2/drug-8610/allopurinol-oral/details fileid=2059

5

What is ASTHMA?

Asthma is defined as a condition characterized by recurrent or

chronic wheeze and/or cough, with recognizable variable airway

obstruction due to bronchial hyper-reactivity secondary to airway

Lifestyle Intervention

in Managing Asthma

Although many people with asthma rely on medications to prevent

and relieve symptoms, you can do several things on your own to

maintain your health and lessen the possibility of asthma attacks.

1. AVOID TRIGGERS

Taking steps to reduce your exposure asthma triggers is a key part of

asthma control, including:

♦ Use your air conditioner

♦ Decontaminate your decor

♦ Maintain optimal humidity

♦ Prevent mold spores

♦ Reduce pet dander

♦ Clean regularly

♦ Cover your nose and mouth if it’s cold out

References

1. CPG Guidelines on Management of Asthma, Jan 2008 MClinic

2. www.mayoclinic.org/disease-conditions/asthma/basics/lifestyle,/Aug 30,2016

By Shoniya A/P Jayasegaran

6

2. STAY HEALTHY

3. ALTERNATIVE MEDICINE

Taking care of yourself can help keep your symptoms under control,

including:

• Get regular exercise

• Maintain a healthy weight

• Control heartburn & gastroesophageal reflux disease (GERD)

Certain alternative treatments may help with asthma symptoms.

However, keep in mind that these treatments are not a replacement for

medical treatment — especially if you have severe asthma. Talk to

your doctor before taking any herbs or supplements, as some may

interact with medications you take. E.g.

◊ Breathing exercises

4. COPING & SUPPORT

The best way to overcome anxiety and a feeling of helplessness is to

understand your condition and take control of your treatment. Here are

some suggestions that may help;

♦ Pace yourself

♦ Make a daily to-do list

♦ Talk to others with your condition

♦ If your child has asthma, be encouraging

6

7

Acute pain is one of the most adverse stimuli experienced by children,

occurring as a result of injury, illness and necessary medical procedures.

It is associated with increased anxiety, avoidance, somatic symptoms and

increased parent’s distress. Despite the magnitude of effects that acute

pain can have on children, it is often inadequately assessed and treated.

Misconceptions about pain and its management in children include the

fear of side effects like respiratory depression, cardiovascular collapse,

addiction and the notion that children especially infants and neonates

have an immature nervous system and do not feel or react to pain, and

therefore do not require analgesic like adults. It is now quite clear that

the development of the physiologic mechanism and pathways for pain

perception take place during the late fetal and neonatal life. Children of

all ages including newborns feel and react to pain. There is mounting

evidence that adequate pain relief after surgery reduces period of

recovery, lowers morbidity and improves outcome.

PRINCIPLES OF PAIN MANAGEMENT

There are differences between pediatric and adult pain relief : 1. For children, analgesics are calculated on mg/kg body weight basis. 2. Children do not like intramuscular (IM) injection. IM injection is

unpredictable, largely ineffective and children will deny having pain to avoid injection.

3. Pain is best prevented rather than treated. Requirements for analgesics are lower if children are allowed to wake up comfortable and pain free following surgery or are pretreated before painful procedures.

4. Severe pain is best treated with continuous methods of analgesic administration (e.g. infusion, PCA).

5. Neonates and some ex-premature infants (up to 60 weeks post-conceptual age) may be sensitive to opioids. After administration of opioids, they must be closely monitored in a high dependency unit or ICU.

6. Post-operative pain relief should be planned before the surgery.

PAIN MANAGEMENT IN PAEDIATRICS

OVERVIEW

By Hana Radhiah Mohd Din/

Tan Xin Yi

8

References: 1. Pain Management Handbook. Ministry of Health, Malaysia. 2013 October. 2. Pediatric Pain and Symptom Management Guidelines. Dana Farber Cancer Institute/

Boston Children’s Hospital. 2014. 3. WHO guidelines on the pharmacological treatment of persisting pain in children with

medical illnesses. World Health Organization. 2012.

Medication Route Initial Dose

(Maximum Daily Dose)

Escalation of

Analgesia

Non-Opioids

Acetaminophen PO

PR

Neonates to 3 months: 5-10mg/kg 6

hourly

> 3 months: 20mg/kg stat,

then 15mg/kg 6 hourly

(Max 4g/day)

Ibuprofen PO 3-6 months: 5mg/kg 8 hourly

>6 months: 10mg/kg 8 hourly

(Max 1.2g/day)

Diclofenac

Sodium

PO NOT RECOMMENDED IN

CHILDREN < 6 MONTHS

0.5mg to 1mg/kg 8 hourly

(Max 150mg/day)

Opioids

Morphine PO

<12 months: 50mcg/kg 4 hourly

>12 months: 100-300mcg/kg 4 hourly

(Max 15mg/day)

IV, SC 1-6 months: 100mcg/kg 6 hourly

>6 months: 100mcg/kg 4 hourly

Guideline for Paediatric Analgesia

Recommendations:

1. Paracetamol/ Acetaminophen and ibuprofen are the choice of analgesia

in first step for mild pain.

2. Morphine is the first-line strong opioid for treatment of persisting

moderate to severe pain in children with medical illnesses.

3. Tramadol is generally NOT registered for use in children below age of 12

years.

4. The least invasive and most effective routes of administration should be used in children, wherever possible.

9

CME ORGANIZED BY PHARMACY (JULYCME ORGANIZED BY PHARMACY (JULYCME ORGANIZED BY PHARMACY (JULYCME ORGANIZED BY PHARMACY (JULY----DEC 2016)DEC 2016)DEC 2016)DEC 2016)

DATE TITLE

10.08.2016 Tywnsta® (Telmisartan & Amlodipine)

26.08.2016 Catch Chronic Obstructive Pulmonary Disease (COPD)

01.09.2016 Taklimat Pelan Tindakan Kebakaran

02.09.2016 Atrial Fibrillation

14.09.2016 MIMS Gateway

05.10.2016 Biosimilar Insulin– Safety & Efficacy Among Malaysia Patients

28.10.2016 Updates in the Management of Iron Deficiency Anaemia

11.11.2016 Symbicort® with SMART Therapy

30.11.2016 Antibiotic Awareness & Hand Hygiene

(a) Care Bundle to Reduce Catheter-Related Bloodstream

Infection

(b) Appropriate Antibiotic Use

(c) Antibiotic Stewardship Guideline & Sharing of Hospital

Melaka Antibiotic Stewardship Team Experience

(d) Hand Hygiene

28.12.2016 Alahan Ubat

28.12.2016 Echo Training Pengendalian Bahan Psikotropik di Dewan

Bedah

10

BY :

NUR ATHIRAH

HAZIQAH BINTI

MOHAMAD SOBRI

ACS is a clinical spectrum of ischaemic heart disease ranging

from unstable angina, non-ST segment elevation myocardial

infarction(NSTEMI) to STEMI depending upon the degree

and acuteness of coronary occlusion.

In-Hospital Management

Acute Coronary Syndrome (ACS) ?

STREPTOKINASE VS TENECTEPLASE I

N

ACUTE CORONARY SYNDROME MANAG

EMENT

In myocardial infarction (MI) for both NSTEMI and STEMI : There is myocardial

injury, so cardiac biomarkers (Troponin) are raised

In unstable angina : Myocardial injury is absent so that the cardiac biomarkers

(Troponin) are normal.

Early management of STEMI are :

1. Pain relief.

2. Establishing early reperfusion, including fibrinolytic

therapy.

3. Treatment of complications.

11

♥ Fibrinolytic therapy has been shown to reduce mortality when given within the

appropriate time frame.

♥ When given within the “golden hour”, it is most beneficial and has been

shown to be able to abort the infarction and reduce mortality by up to 50%.

♥ Choice of fibrinolytic agents available in Hospital Jasin are :

1. Streptokinase

2. Tenecteplase

Fibrinolytic

Therapy

REFERENCES :

1) Clinical Practice Guideline : Management of Acute ST Segment Elevation Myocardial Infarction (Stemi) (3rd

Edition), 2014

2) Tenecteplase versus Streptokinase for thrombolysis; Sri Lanka Heart Association, 2015

3) Product insert of Metylase

4) Dundar Y, Hill R, Dickson R, Walley T, et al. 2003 Comparative efficacy of thrombolytics in acute myocardial

infarction: a systematic review

Derived from culture filtrate of

β-haemolytic Streptococci of Lancefield

group C

Origin Recombinant DNA technology

No Fibrin-specific

agent

Yes (High)

Forms a complex with plasminogen

which then converts plasminogen to

plasmin.

Plasmin breaks down clots as well as

fibrinogen and other plasma proteins.

Mechanism of

action

Converts plasminogen to plasmin.

Plasmin breaks down clots as well as

fibrinogen and other plasma proteins.

Within 12 hours of onset of acute MI

with persistent ST-segment elevation

or recent left bundle-branch block

“Golden

hour”

As soon as possible (within 30 mins)

after onset of acute MI

1.5 mega unit Dose Based on body weight

<60 kg: 30 mg ; 60-70 kg: 35 mg ;

70-80 kg: 40 mg ; 80-90 kg: 45 mg ; >90

kg: 50 mg

1 hour IV infusion Administration 5-10 secs slow IV bolus

Repeated treatment >5 days & <12

months from initial treatment, is not

effective because of the increase

likelihood of resistance due to

antistreptokinase antibodies.

Important

information

It is incompatible with dextrose

solution, so the pre-existing IV line may

be used in 0.9% sodium chloride solution

only. Other medicinal products should

not be added to the injection solution.

STREPTOKINASE

VS

TENECTEPLASE

11

12

ROLE OF SGLT-2 INHIBITORS IN

GLYCAEMIC CONTROL FOR PATIENTS WITH

TYPE 2 DIABETES MELLITUS By Low Jia Hui

How does SGLT-2 work?

Type 2 Diabetes is a progressive disease and a patient may end up

with a combinations of medicines with differing mechanism of action to

keep glucose level at bay.

Current antidiabetic agents sometimes have properties that appear undesirable

by the patients as well as the prescribers, for examples some agents predispose

the patients to hypoglycaemia, gastro-intestinal irritations, weight gain, renal

impairment etc. Agents with a different mechanism of action and properties can

minimise the occurrence of adverse events while helping patients in managing

One of the novel antidiabetics agents is classified as sodium-glucose

cotransporter 2 (SGLT-2) inhibitors.

Kidney reabsorbs most of the glucose (nearly 90%) from renal filtrate via SGLT-2

transporters which are primarily located in the proximal renal tubule.

In addition to that, a small drop

in blood pressure can be observed

as a result of osmotic diuresis.

SGLT-2 doesn’t have a role in

stimulating the secretion of insu-

lin and it ceases to function when

the blood glucose drop. Thus,

hypoglycaemia is not likely to

occur.

Inhibition of SGLT-2 can reduce the reabsorption of glucose while increase the

elimination of glucose. This reduces the blood glucose concentration and the

loss of glucose also results in weight loss (1g of glucose= 4 cal).

12

13

The benefits of SGLT-2 Inhibitors

• Weight reduction

• Low risk of Hypoglycaemia

• Blood pressure reduction

• Reduction in serum uric acid

The undesirable effects

• Vaginal irritation in women

• Urinary tract infection

• Raised hematocrit

• Hypotension

• Volume depletion

The contraindications

• Type 1 Diabetes

• eGFR < 60ml/min (Dapagliflozin, Canagliflozin)

• eGFR < 45ml/min (Empagliflozin)

References:

1. Bailey, A.V.& Day, C (2014) The Role of SGLT2 Inhibitors in Type 2 Diabetes British Journal of Family Medicine [online]

2 4, July/August 2014. Available from: https://www.bjfm.co.uk/the-role-of-sglt2-inhibitors-in-type-2-diabetes.aspx [Accessed

17th December 2016]

2. Andrianesis, V& Doupis, J. (2013) The Role of Kidney in Glucose Homeostasis-SGLT-2 Inhibitors, A New Approach In

Diabetes Treatment Expert Review of Clinical Pharmacology [online] 6(5):519-539. Available from:

http://www.medscape.com/viewarticle/812072_2 [Accessed 17th December 2016]

3. MALAYSIA, MINISTRY OF HEALTH (2015) Clinical Practice Guidelines: Management of Type 2 Diabetes Mellitus

4. Rosenstock, J, Aggarwal, N et al (2012) Dose-Ranging Effects of Canagliflozin, a Sodium-Glucose Cotransporter 2 Inhibitor, as Add-On to Metformin

in Subjects With Type 2 Diabetes Diabetes Care [online] 35(6): 1232-1238. Available from:

http://care.diabetesjournals.org/content/35/6/1232.full [Accessed 17 December 2016]

5. Bakris,GL, Fonseka VA et al (2009) Renal Sodium-Glucose Transport: Role in Diabetes Mellitus and Potential Clinical

Implications [online] Kidney International Vol 75, Issue 12, 2 June 2009: 1272-1277. Available from:

http://www.sciencedirect.com/science/article/pii/S008525381553651X [Accessed 17 December 2016]

6. Faustino, BS, Reis Costa JR, Aj et al (2016) The Benefits of SGLT-2 Inhibitors in Cardiovascular Prevention, Glycemic

Control and Weight Loss, In The Treatment of Diabetes [online] Open Journal of Endocrine and Metabolic Disease 2016 (6):

87-94. Available from: http://file.scirp.org/pdf/OJEMD_2016012814411861.pdf [Accessed 17 December 2016]

14

No Drugs name Proformer Quota Status

Prescriber

Category

1

Dr. Ruhaiza

Bt Mohamad

10 In Stock A*

2

Dr. Ruhaiza

Bt Mohamad

20 In Stock A/KK

3

Dr. Ruhaiza

Bt Mohamad

10 In Stock A/KK

Updates on New Drugs Available in Hospital Jasin Formulary 2016

By: Izrul Azwa Mohd Latiff

In 2016, 12 new drugs were

requested via Proforma E form

and had been approved by

Hospital Jasin Director to be

listed in Hospital Jasin Formulary.

Most of them were listed under

List A category which should be

started by specialist.

Tablet Levofloxacin 250mg

Tablet Fenofibrate 145mg

Symbicort Turbohaler

(Budesonide 320mcg/

Formoterol 9mcg)

15

No Nama Ubat Proformer Quota Status

Prescriber

category

6

Tablet Rifampicin 150mg,

Isoniazide 75mg (Akurit-2)

Dr. Ruhaiza Bt

Mohamad

1 In Stock B

7 Tablet Primaquine 7.5mg

Dr. Ruhaiza Bt

Mohamad

5 In Stock B

8 Tablet Artemether 20mg/

Lumefantrine 120mg (Riamet)

Dr. Ruhaiza Bt

Mohamad

5 In Stock B

4 Tablet Dabigatran 150mg

(Pradaxa) Dr. Ruhaiza Bt

Mohamad 10 In Stock A*

5 Dr. Ruhaiza

Bt Mohamad 3 Tablet Rivaroxaban

20mg (Xarelto)

In Stock A*

16

No. Nama Ubat Proformer Quota Status

Prescriber

category

10 Anti RhD Gamma

Globulin 300mcg/

2ml (Rhogum)

Dr. Masyitah

Bt Md Radzi 10 In Stock B

11 Tenecteplase

10,000 unit (50mg)

Injection (Metalyse)

Dr. Ruhaiza

Bt Mohamad 5 In Stock A*

12 Hepatitis B Immu-

noglobulin (Human)

Injection (200U/ml)

Dr. Ruhaiza

Bt Mohamad 4 In Stock A

9 Tablet Ticagrelor

90mg (Brilinta)

Dr. Ruhaiza Bt

Mohamad 5 In Stock A*

17

Antimicrobial Stewardship Activity:

Benefits Of Early Switch To Oral

Therapy

■ Reduced risk of cannula-related

infections

■ Reduced risk of thrombophlebitis

■ Less expensive than IV therapy

■ Earlier discharge

■ Reduced hidden cost

Criteria For IV To Oral Switch

Inclusion criteria:

1. Oral alternative available

2. In the absence of positive culture, the alternative

oral agent empirically covers the commonly sus-

pected organism

3. Tolerating food or enteral feedings

BY NG SHY PYNG

18

Exclusion Criteria For IV To Oral

1. Patient is unstable or their clinical condition is worsening as

evidenced by any of the following in the past 24 hours:

♦ Fever >38°C

♦ Abnormal WBC count that is not improving

♦ Systolic blood pressure ≤ 90mm Hg

♦ Heart rate > 90 bpm

♦ RR > 20/min

♦ Worsening chest X-ray

2. Deep seated infection

♦ Endocarditis ♦ Brain abscess

♦ Osteomyelitis ♦ Endophtalmitis

♦ Sepsis ♦ Melioidosis

♦ Severe cellulitis ♦ Meningitis

3. IV antibiotic used for less than 48 hours or is scheduled to be discontin-

ued in the next 24 hours.

4. Active GI bleed

5. GI obstruction, ileus or malabsorption syndrome

6. Hematological maglinancy (e.g leukemia, lymphoma) or documented

neutropenia

7. Nothing by mouth

8. Severe or persistent nausea or vomiting

9. Used of vasopressor in the past 24 hours (e.g dobutamine)

18

19

IV To Oral Switch Protocol

References:

1. Malaysia,Pharmaceutical Services Division, MOH (2014) Protocol On

Antimicrobial Stewardship Program In Healthcare

2. Omnicare CVS Health Company. Focus On Coverting IV to PO Antibiotic Therapy

[Internet]. [updated 2016] Available from: https://www.omnicare.com/ me-

dia/1093/4_iv_to_po_antibiotic_therapy.pdf

20

En Mohamad Khamis

August 2016

En Suhaimi Sulaiman

July 2016

En Rosli Dris

September 2016

Cik Shoniya Jayasegaran

October 2016

Pn Juliana Mahat

November 2016

Pn Ruslinda Mat Termizi

December 2016

BEST STAFF OF

THE MONTH

21

Pn Ruslinda Mat Termizi

EN ABDUL AZIZ MOHD

PENOLONG PEGAWAI FARMASI U36

SELAMAT BERSARA! :)

PN ADILLAH AHMAD

PEGAWAI FARMASI UF44

SELAMAT BERTUGAS DI

TEMPAT BARU

KEMASUKAN STAFF BARU

Cik Nurul Atika

Wahab (PF UF41)

En Navinshankar

A/L Gnanaseharan

PF UF41 (PRP)

Cik Sarohmena

Rawisandran

PF UF41 (PRP)

22

MAJLIS BACAAN YASSIN

AUGUST 2016

SAMBUTAN WORLD PHARMACISTS DAY

13 OCTOBER 2016

23

MEDICATION SAFETY ROAD SHOW

21 OCTOBER 2016

ANTIBIOTIC

AWARENESS WEEK

11 November 2016:

Exhibition and Counseling

30 November 2016: CME

on Antibiotic Awareness

and Hand Hygiene

24

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Farmasi

Ext: 501/ 507

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2. Login with username & password

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