PKD MELAKA TENGAH - Jabatan Kesihatan Negeri Melaka PKD MELAKA TENGAH Editorial oard Advisor: Dr....
Transcript of PKD MELAKA TENGAH - Jabatan Kesihatan Negeri Melaka PKD MELAKA TENGAH Editorial oard Advisor: Dr....
1
INSIDE THIS
ISSUE:
HOT ISSUE: DENGUE WAR
1-5
ANTIMICROBIAL
RESISTANCE
6-8
QUIT SMOKING CLINIC
9-13
DRUG COMPARISON: B COMPLEX, NEURO-BION & MECOBALA-MIN IN NERVE RE-
GENERATION
14-15
BYDEUREON 16-18
QUMC IN PKDMT 19
TRUTH @ MYTHS:
STEVIA - A HEALTHY ALTERNATIVE SWEETENER?
20-22
PHARMACY BULLETIN
I S S U E 1 Y E A R 2 0 1 6
PKD MELAKA TENGAH
Editorial Board Advisor: Dr. Rusdi bin Abd. Rahman Chief Editor: Mardhiah binti Amir-uddin Editor: Chew Poh Chiong Contributors: Michelle Lim Bee Ping Noorafinah Mohd Zudin Foo Swee Yen Nursyahirah binti Abd Raof
INTRODUCTION
Dengue is a mosquito-borne viral disease that has rapidly spread in many regions
of the world. Dengue is found especially in tropical and subtropical regions of the
world. The geographical distribution of dengue is linked within the temperature
range where the mosquito species Aedes that transmits the disease can be found.
Dengue fever is caused by 4 closely related virus types, which is called serotypes.
The 4 Dengue Virus (DENV) serotypes are DENV-1, DENV-2, DENV-3 and
DENV-4.
DENGUE WAR By : Lee Ai Wei
EPIDEMIOLOGY
Epidemiology of dengue worldwide
The incidence of dengue has grown dramatically around the world in recent dec-
ades. Up to 3.6 billion people are estimated to now live in tropical and subtropi-
cal areas where the den-
gue viruses have the po-
tential to be transmitted.
Globally it is estimated
that approximately 50
million to 200 million
deng ue i n f e c t ion s ,
500,000 cases of severe
dengue, and over 20,000
dengue related deaths
occur annually.
2
Epidemiology of dengue in Malaysia
In Malaysia, dengue is predominantly an urban disease due to the abundance of the principle vec-
tor Aedes aegypti which is at a close proximity to high densities of susceptible hosts. The states of
Selangor, Wilayah Persekutuan Kuala Lumpur and Johor are the areas that have been largely af-
fected by the disease and are reporting high numbers of cases.
TRANSMISSION OF DENGUE
Spread through a human-to-mosquito-to-human cycle of transmission.
The two Aedes mosquito species that transmits the disease are Aedes aegypti, which is the
primary mosquito vector, and Aedes albopictus, which is the secondary mosquito vector.
When a dengue mosquito bites someone who is sick with dengue fever, that mosquito is
infected and becomes a carrier of the virus.
Mosquitoes are capable of spreading the disease within 8-12 days after biting infected person.
The virus will multiply in the salivary glands of the mosquito and then transferred into a
healthy human body during mosquito bites.
Female mosquitoes infected with dengue virus can also transfer the virus to infect its eggs
next newly hatched mosquito.
Once the mosquito is infected by the dengue virus, the mosquito is a carrier of the virus for
life and it can spread the virus to other people by biting them.
The dengue virus does not spread directly from person to person. Once inside the human
body, the virus takes 3-14 days to develop before the symptoms of dengue fever.
HOT ISSUE
3
Differences between Aedes aegypti and Aedes albopictus
Aedes aegypti
Aedes albopictus
Has bright silvery lyre-shaped dorsal pattern and white banded legs
Has a single longitudinal silvery dorsal stripe and white banded legs
Occupies urban areas with or without vege-tation
Associated with thickets and arboreal vegetation
Bites, rests, and lays eggs both indoors and outdoors
Mostly an outdoor (garden) mosquito
Sneaky biter Aggressive biter
High preference for taking blood meals from humans and to lesser extent from domestic mammals, which makes it a very capable vector of dengue viruses
Bites humans but also a variety of available domestic and wild vertebrates that do not carry the dengue viruses, which lowers its capacity to transmit them
Main dengue vector worldwide Main dengue vector in some areas but is mostly a secondary vector
The major production places are human-made containers, tree holes and bamboo internodes holding water
Shows preference for tree holes and bam-boo internodes with water but can also uti-lize human-made containers for its imma-ture development
SIGNS & SYMPTOMS
Dengue should be suspected when a high fever (40°C/104°F) is accompanied by 2 of the
following symptoms: severe headache
pain behind the eyes
muscle and joint pains
nausea, vomiting
swollen glands
rash
Symptoms usually last for 2–7 days, after an incubation period of 4–10 days after the bite from
an infected mosquito.
HOT ISSUE
MANAGEMENT OF DENGUE
No specific vaccine or medication to prevent or treat dengue fever currently.
Treatment is purely concerned with relief of the symptoms (symptomatic).
Rest and adequate hydration is important.
Paracetamol can be taken to reduce fever and relieve pain.
Avoid aspirin in children under the age of 12 years.
The use of antibiotics is not indicated in dengue infection.
4
HOT ISSUE CLINICAL COURSE OF DENGUE INFECTION
After the incubation period, the illness begins abruptly and will be followed by 3 phases.
Febrile phase
High grade fever (usually last
for 2-7 days)
Accompanied by facial flush-
ing, rash, generalized body
ache, vomiting and headache
Mild haemorrhagic manifesta-
tions may be seen
Enlarged and tender liver
Progressive decrease in
total white cell count fol-
lowed by platelet reduction
Critical phase
Occurs after third day of fever (may
occur earlier)
Lasts about 24- 48 hours
Rapid drop in temperature
Patient may deteriorate and manifest
third space plasma leakage or organ
dysfunction
In more severe forms of plasma leakage,
patient may develop compensated and
decompensated shock
Thrombocytopenia and haemoconcen-
tration are usually detectable in this
phase
Leucopenia with relative lymphocytosis,
clotting abnormalities, elevation of
transaminases, hypoproteinaemia and
hypoalbuminaemia are usually observed.
Recovery phase
Plasma leakage stops fol-
lowed by reabsorption of
extravascular fluid
Patient’s general well being
improves
May have a classical rash of
“isles of white in the sea of
red” with generalized
pruritus
Haematocrit level stabilises
and drops further due to
haemodilution following re-
absorption of extravascular
fluid
Recovery of platelet count is
preceded by recovery of
white cell count
WHO DENGUE CLASSIFICATION
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USE OF PAPAYA LEAF EXTRACT IN DENGUE FEVER Papaya leaf extract is now being widely used as a treatment for dengue fever in
many countries and in some with the approval of their health authorities. Papaya leaf extracts have been
shown to have many beneficial effects, including reduction in the duration of fever, duration of illness,
hospital stay, rapid elevation of white blood cells and platelet counts. Randomised controlled trial has
been done by Institute for Medical Research (IMR) and Tengku Ampuan Rahimah Hospital, results
showed that there was a significant increase in platelet count among dengue patients administered with
50gm of fresh papaya leaf juice for three consecutive days.
Safety concern
Certain parties stated that papaya leaves contain a dangerous chemical known as cyanogenic glycoside
which could cause liver, kidney or heart failure and ultimately death. However, content of the deadly
chemical are very small (0.02 mg in every four leaves). A 60kg person would need to consume 12,000
papaya leaves at once to cause any acute poisoning. According to Health director-general Datuk Dr
Noor Hisham Abdullah, papaya leaf juice has been shown to increase blood platelet count and assist in
the recovery of those with lesser complications, and is unlikely to cause liver, kidney or heart failure.
HOT ISSUE
PREVENTION & CONTROL
OF DENGUE
Main method is to combat vector
mosquitoes through:
Environmental management
and modification
(prevent mosquitoes from ac
cessing egg-laying habitat)
Improving community partici-
pation and mobilization for
sustained vector control;
Active monitoring and surveil-
lance of vectors
REFERENCES 1. Ministry of Health Malaysia. Statistik denggi. Available from: http://idengue.remotesensing.gov.my/idengue/page2.php?kandungan=content/s_infopendidikan.html
2. World Health Organization. Dengue transmission. Available from: http://gamapserver.who.int/mapLibrary/Files/Maps/Global_DengueTransmission_ITHRiskMap.png?ua=1 3. World Health Organization. Dengue and severe dengue. 2016. Available from: http://www.who.int/mediacentre/factsheets/fs117/en/ 4. Centers for Disease Control and Prevention. Dengue homepage. 2015. Available from: http://www.cdc.gov/dengue/epidemiology/ 5. Ministry of Health Malaysia. History and epidemiology of dengue. 2015. Available from: http://denggi.myhealth.gov.my/history-and-epidemiology-of-dengue/?lang=en 6. Ministry of Health Malaysia. What is dengue. 2015. Available from: http://denggi.myhealth.gov.my/what-is-dengue/?lang=en
7. Centers for Disease Control and Prevention. Available from http://www.cdc.gov/dengue/resources/30Jan2012/comparisondenguevectors.pdf 8. Medical News Today. Prevention of dengue fever. 2015. Available from : http://www.medicalnewstoday.com/articles/179471.php?page=3 9. New Straits Time. Papaya leaves safe for the treatment of dengue, improve platelet counts: Health Ministry. 2016. Available from: http://www.nst.com.my/
news/2016/01/124921/papaya-leaves-safe-treatment-dengue-improve-platelet-counts-health-ministry 10. Ministry of Health Malaysia. Management of dengue infection in adults (third edition). 2015.
IMPORTANT POINTS
Manipulation of platelet count alone does not alter the clinical course of the disease as it is just a sur-
rogate marker of disease progression or evolution. Plasma leakage and organ dysfunction should be the
main focus of management.
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ANTIMICROBIAL RESISTANCE
antimicrobial
RESistance
What is antimicrobial resistance?
Antimicrobial resistance (AMR) is the ability of microorganisms which enable them to continue to grow and
not be killed by drugs. Individuals who are infected by resistant microorganisms are usually hard to treat. They
usually required alternative treatments/drugs which are more expensive with more side effects/toxic effects (1).
The number of antimicrobial resistance cases has been increasing every year all over the world. For instance in
many Asian countries, more than 70 % of bacteria isolated were shown to be fully resistant to erythromycin (2).
It is of utmost importance to control and prevent antimicrobial resistance from spreading.
By : Chew Chun Siang
“Antibiotics resistance in Malaysia have increased when the National Antibiotics Resistance Studies
revealed an increased flow of Vancomycin antibiotics resistance to the bacteria Enterococcus faecium
went up to 9.3 percent in 2014 compared to 8.4 percent in 2013.”
“New superbugs such as carbapenem-resistant Enterobacteriaceae (CRE) showed the number of infec-
tions went up from 150 cases in 2013 to 181 cases in 2014, with number of deaths increasing from
25% in 2013 to 37% in 2014.”
Deputy Health Minister Dr Hilmi Yahya (4)
In Malaysia
Source of image (3)
7
How Resistance Happens and Spreads?
Microorganism can develop resistant through several ways. Some microorganism are naturally resistant to
antibiotics while some actually developed it through spontaneous mutation or acquiring resistant genes
through exchanging genes with other bacteria. Antibiotics which are prescribed for a longer duration than
which is needed to treat or prescribed for inappropriate indication will result in higher risk of spontaneous
mutation occurring. This is because microorganisms which are exposed to antibiotics for a long duration are
likely to mutate in order to survive (selective pressure) and later passing the resistant genes to other micro-
organisms. This contributed to the increasing number of resistant microorganisms (5). It has been shown
that up to 50% of the time antibiotics are prescribed for inappropriate indication, incorrect dosing or dura-
tion (6).
Source of image (6)
ANTIMICROBIAL RESISTANCE
8
Source of image (7)
Effects of growing antimicrobial resistance
1) Diseases are harder to treat and sometimes result in death as some infections by resistant microorganisms are in-
curables
2) Increasing cost of treatment as individuals infected by resistant microorganisms usually required longer stays at hos-
pitals and more expensive drugs
3) Patients are suffering from more side effects as usually more toxic drugs are needed to treat infections due to re-
sistant microorganisms.
How to prevent antimicrobial resistance?
1) Healthcare provider should prescribe antimicrobial drugs only if deemed appropriate and necessary. The benefits of
using antimicrobial drugs to treat should far outweigh the risk of not using them before a decision is made (8)
2) Patients should comply with medications prescribed and finish the whole course of antibiotics if prescribed by their
doctors (8)
3) Society needs to adopt a healthy lifestyle and practice good hygiene, such as frequent hand washing in order to pre-
vent/minimize the risk of spreading microorganisms from one individual to other individual (8)
4) Developing new drugs and diagnostic tests which are more effective in treating/detecting infections with lesser side
effects.
Conclusion
World Health Organization (WHO) has warned that antibiotic resistance has become one of the biggest threats to
global health today. United States' first known case of E. coli infection that is resistant to antibiotics, even Colistin,
which usually use as last resort-style kind of antibiotic was reported on 26th May 2016 by U.S. Department of Defense.(9) Hence, it is our responsibility to ensure antibiotics are used wisely to prevent the world from being cast back into
the dark ages of medicine.
References: 1) http://www.cdc.gov/drugresistance/threat-report-2013/
2) Kim SH, Song JH, Chung DR, Thamlikitkul V, Yang Y, Wang H, Lu M, So TM, Hsueh PR, Yasin RM, Carlos CC, Pham HV, Lalitha MK, Shimono N, Perera J, Shibl AM, Baek JY, Kang CI, Ko KS, Peck KR. ANSORP Study Group. Changing trends in antimicrobial resistance and serotypes of Streptococcus pneu-moniae isolates in Asian countries: an Asian Network for Surveillance of Resistant Pathogens (ANSORP) study. Antimicrob Agents Chemother. 2012;56:1418–1426 3) https://agenda.weforum.org/wp-content/uploads/2015/12/151119-antibiotics-resistance-deaths-bacteria-microbes-statista-chart.jpg 4) www.malaysiakini.com/news/319805 5)http://www.fda.gov/Drugs/ResourcesForYou/Consumers/ucm143568.htm 6) http://www.cdc.gov/drugresistance/images/2-how_antibiotic_resistance_spreads.jpg 7) http://www.who.int/mediacentre/events/2015/world-antibiotic-awareness-week/infographic-causes.jpg?ua=1 8)https:/www.niaid.nih.gov/topics/antimicrobialResistance/Understanding/Pages/prevention.aspx 9) http://edition.cnn.com/2016/05/26/health/first-superbug-cre-case-in-us/
ANTIMICROBIAL RESISTANCE
9
QUIT SMOKING CLINIC
By Nurul Atikah Binti Wahab
Men who smoke are 17 times more likely than non
-smokers to develop lung cancer and other compli-
cations. Therefore, smoking cessation programme
is significant to reduce morbidity and mortality due
to tobacco related diseases *3,4+.
Unfortunately quitting smoking is not easy. So
many smokers have undergone the dilemma of
wishing to quit and then been unsuccessful. Thus,
it is important for healthcare professionals to deliv-
er appropriate guidance for smoking cessation as
smoking is more than just a bad habit.
Malaysia has become a Member State or the Party
to the World Health Organization Framework Con-
vention on Tobacco Control (WHO FCTC) since De-
cember 15, 2005 and has responsibility for imple-
menting the provisions in this international agree-
ment.
Smoking is the most important preventable cause of ill health and death in Malaysia and all
over the world1,2+.
The objectives of National Quit Smoking Pro-
gramme are to*3+:
Provide comprehensive support and assistance to
help smokers quit smoking
Develop skills of assisting smokers to quit among all
health professionals
Make quit smoking services widely available and
accessible at all levels of health care
Encourage and motivate smokers utilise the ser-
vices provided
Involve all stakeholders in partnership to help
smokers quit
In current, Quit Smoking Clinic is available in all klinik
kesihatan of PKD Melaka Tengah to assist smokers to
stop smoking.
QUIT SMOKING CLINIC
10
Algorithm for management of tobacco use and dependence*3+:
Ask about tobacco use
Advise to quit
Assess willingness to make a quit attempt
Assist in quit attempt
Arrange follow-up
5A’S Of Brief Clinical Intervention*4+
5 R’S Strategies (For patient unwilling to quit) *4+
To enhance motivation to increase future quit attempts
Relevance : why quitting is relevance?
Risks : negative consequences of tobacco use
Rewards : benefits of stop smoking
Roadblocks : identify barriers to stop smoking
Repetition : motivational intervention should be
repeated every time an unmotivated patient visits
the clinic
QUIT SMOKING CLINIC
11
PHARMACOLOGICAL TREATMENT
VARENICLINE NICOTINE PATCH
Starter Pack
Champix 0.5mg & 1mg
film-coated tablets
Maintenance pack
Champix 1mg film-coated tablets
Availability Nicorette Transdermal Patch 10mg/16hr
Nicorette Transdermal Patch 15mg/16hr
Varenicline is highly selective and binds more
potently to α4ß2 receptor compared to nico-
tine, where it acts as partial agonist, stimulating
receptor-mediated activity but at a lower level
than nicotine. Hence, effectively block nicotine’s
ability to fully activate the receptor.
Mechanism
of action
Nicotine patch mimic fluctuation of nicotine
over the day in smokers. Nicotine released
bind and stimulate nicotinic receptors in the
brain and eventually cause release of dopa-
mine, hence reduce nicotine withdrawal
symptoms in smokers who abstain from
smoking.
Varenicline should be started 1-2 weeks be-
fore quit date.
Patient who cannot tolerate may have dose
lowered temporarily or permanently 0.5mg
BD.
Patient should be treated with varenicline
for 12 weeks.
Patient who stopped smoking at the end of
12 weeks, an additional course of 12 weeks
treatment may be considered if necessary.
Days 1-3 0.5mg once daily
Days 4-7 0.5mg twice daily
Day 8 – End of treat-
ment
1mg twice daily
Regime Adults & the elderly[5]:
Children and adolescents[5]:
Contraindicated in patients below than
18 years old.
Use of patch beyond 6 months is not
recommended.
QUIT SMOKING CLINIC
Varenicline Nicotine patch
Duration Dose
8 weeks 15mg/16 hours
Then 4 weeks 10mg/16 hours
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VARENICLINE NICOTINE PATCH
A/KK Prescriber
category
A/KK
May impair the ability to drive or oper-
ate heavy machinery.
Nausea à Take on a full stomach
Insomnia à Take second pill at supper
time or after dinner
Trouble sleeping, abnormal/vivid/strange
dreams
Abdominal pain
Flatulence
Headache
Side effects Nausea
Vomiting
Fatigue
Hypersensitivity
Headache
Skin reaction à Rotate patch sites or treat
with steroidal creams
Insomnia and/or vivid dream
Take a full glass of water
Take with food (non-oily food)
Take at the same time everyday
Contact health care provider immediate-
ly if changes in behavior or thinking, de-
pressed mood, anxiety, or develop sui-
cidal ideation.
Counseling
[6]
-Patch should be applied as patient wakes up
each day to avoid sleep disruption
-Applied on clean, dry intact areas of hairless
skin (hip, upper arm or chest)
-Rotate sites (each week) to avoid skin irrita-
tion
1. Wash hands before applying patch
2. Cut open the pouch with scissors along
the side. Select a dry, clean, hairless intact
area of skin
3. Peel one part of the silvery aluminium.
4. Avoid touching the sticky surface of the
patch
5. Apply the sticky part of the patch onto
the skin and peel off the remaining half of
the silvery aluminium backing
6. Press the patch firmly onto the skin with
palm/finger tips
7. Rub finger firmly round the edge to en-
sure that the patch sticks firmly.
8. When the patch is removed, fold patch
and place it in its pouch before discarding
QUIT SMOKING CLINIC
13
VARENICLINE NICOTINE PATCH
Antipsychotic drugs, opioid, antihyper-
tensive, insulin, blood thinning drugs and
theophylline: Increased level or effect of
drug
Cimetidine: Increased level of nicotine
Interaction Antipsychotic drugs, opioid, antihy-
pertensive, insulin, blood thinning
drugs and theophylline: Increased
level or effect of drug
Cimetidine: Increased level of nico-
tine
Pregnancy, kidney disease, history of psy-
chiatric illness, change in mood
Patients with significant kidney disease
(creatinine clearance < 30mL/min) or
who are on dialysis à Reduce dose
Contraindica-
tion/ Precau-
tion
Cardiac problems such as immedi-
ate (within 2 weeks) post myocardi-
al infarction period
Arrhythmias,
Unstable angina pectoris
Pregnancy
RM 95 for each starter and maintenance
pack
(2 weeks supply for each box)
Price RM 47.50 / box
(1 week supply for each box)
QUIT SMOKING CLINIC
References:
1. Davis AL, Faust R, Ordentlich M. Selfhelp smoking cessation and maint enance programs: a comparative study
with 12 month follow up by the American Lung Association. Am J Public Health 1984;74(11):12127.
2. Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence.Clinical Practice Guideline. Rockville,
MD: U.S. Department of Health and Human Services. Public Health Service. 2000
3. Zarihah Z. Ministry of Health Malaysia. Malaysian Smoking Cessation Programme & Smoke-Free Air Laws. obacco
Control Unit & FCTC Secretariat Disease Control Division. 2007.
4. Ministry of Health Malaysia, Clinical Practice Guidelines on treatment of tobacco use and dependance.2003.
5. Mullen KA, Manuel DG. Canadian study shows effectiveness of hospital-initiated smoking cessation programs.
University of Ottawa Heart Institute. 2006.
6. Nicorette Invisi Transdermal Patch Product Insert.Johnson & Johnson Pte. Ltd, 2014.
7. Champix Product Insert. Pfizer Manufacturing Deutschland. Germany. 2016
8. Bahagian Perkhidmatan Farmasi Kementerian Kesihatan Malaysia.Garis Panduan Program Farmakoterapi Ber-
henti Merokok. Edisi Pertama. 2012.
14
by Khairunnisa Zuradi
DRUG COMPARISON
Vitamin B Complex Neurobion Mecobalamin
Indication [1] As a dietary supplement
For deficiency or raised re-
quirement of Vitamin B1, B6,
B12
- Peripheral neuropathies
- Megaloblastic anaemia
due to vitamin B12 defi-
ciency. [2]
Prescriber
Category [1]
C+
B
B
Price [1] RM0.004/ tablet
RM0.05/tablet
RM0.06/tablet
Contents [2] Thiamine: 1.0mg
(Vitamin B1)
Riboflavin: 1.5mg
(Vitamin B2)
Nicotinamide: 10.0mg
(Vitamin B3)
Thiamine : 100mg
(Vitamin B1)
Pyridoxine: 200mg
(Vitamin B6)
Cyanocobalamin: 200mcg
(Inactive form of Vitamin
B12) [3]
Mecobalamin: 500mcg
(Active form of Vitamin
B12) [3]
Dosage *1+ 1-2 tablets daily 1 - 3 tablets 3 times daily 1 tablet 3 times daily.
To be adjusted according
to patient’s age and se-
verity of symptoms
VITAMIN B, NEUROBION AND
MECOBALMIN IN NERVE REGENERATION
By : Wa Yin Pin
15
Vitamin B Complex Neurobion Mecobalamin
Administration *2+ To be taken after meal. To be taken after meal.
Swallow whole. Avoid
chewing.
To be taken after meal.
Mechanism of
Action *2+
Essential for carbohy-
drate and lipid metabo-
lism, cell respiration and
RBC integrity.
Thiamine:
For carbohydrate metabo-
lism.
Pyridoxine:
For protein, carbohydrate
and lipid metabolism.
Cyanocobalamin:
For production of RBC.
-Repairs damaged nerve
tissue
- Involves in erythroblast
maturation, promotion of
erythroblast division and
heme synthesis.
Common Side
effects *2+
Skin rashes in allergic
persons.
Do not cause any side
effects if taken accordingly
to the recommended dos-
age.
Infrequent: GI symptoms
e.g. anorexia, nausea, diar-
rhoea
Rare: Skin rashes
DRUG COMPARISON
Efficacy in Nerve Regeneration
Vitamin B12 is the most essential nutrient for the nervous system. Deficiency of this vitamin can lead to
peripheral neuropathy. People who get too little vitamin B12 can exhibit weakness, twitching, pain, numb-
ness, tingling, muscle cramps and burning sensation. *4+ One study even found that mecobalamin was more
effective than nortriptyline, an antidepressant commonly used to treat diabetic neuropathic pain (Talaei
2009). *5+
Since Mecobalamin contains the most abundant amount of vitamin B12, it is expected to be the most
effective drug for nerve regeneration compared to Neurobion and Vitamin B complex.
References
1. Bahagian Perkhidmatan Farmasi: Formulari Ubat Kementerian Kesihatan Malaysia
Bil.1.2016. Available at: http://www.pharmacy.gov.my/v2/sites/default/files/document-
upload/fukkm-web-116.pdf
2. Product Leaflets: Vitamin B Complex Tablet, Vitbion Forte ® Tablet, Mecovit® Tablet
3. Central Drugs Compounding Pharmacy: Brief Comparison of the Three Formulations of
Vitamin B12. Available at: http://centraldrugsrx.com/doctorblog/comments/brief-
comparison-of-the-three-formulations-of-vitamin-b12
4. Livestrong.com: Vitamins that Helps Nerves. Last updated 27 August 2013. Available at:
http://www.livestrong.com/article/30301-vitamins-nerves/
5. Life extension: DiabeticNeuropathy Targeted Natural Interventions. Available at: http://
www.lifeextension.com/protocols/neurological/neuropathy/page-08
Efficacy in Nerve Regeneration
1) Mecobalamin
2) Neurobion Reduced
3) B complex efficacy
16
MTAC RESPIRATORY
INTRODUCTION
Glucagon-like peptide (GLP)-1 agonist is one of the newer classes of medications for use in type
2 diabetes. Exenatide, a GLP-1 agonist, is available in two forms which are immediate release
(BYETTA) and extended release (BYDUREON) formulations.
WHAT IS BYDUREON?
BYDUREON is a new extended release formulation of exenatide and can be given once weekly
subcutaneously at any time of a day with or without meals. It can be used in combination with
metformin, sulfonylureas, or thiazolidinediones.
STUDIES DONE
In compare to twice daily dosing BYETTA, BYDUREON reduces glycosylated hemoglobin by
1.6%, with fewer gastrointestinal side effects, give a significant advantage in reduction of A1c and
fasting blood sugar, and with comparable weight loss of between 4– 4.5 kg. Progressive weight
loss is seen because of its effect on satiety and delay in gastric emptying.
In 3 years clinical trial, once-weekly BYDUREON showed advantage over once daily GLARGINE
insulin in term of reduction in HbA1c and hypoglycemia event. The proportion of patients who
reported serious adverse events in BYDUREON group was the same as that in GLARGINE
group. However, transient gastrointestinal adverse events were reported more frequently in pa-
tient receiving BYDUREON than glargine.
DOSAGE REGIMEN
Recommended dose for BYDUREON is 2mg weekly.
BYDUREON By : Nabilah binti Mohamad
BYDUREON
17
MTAC RESPIRATORY
MECHANISM OF ACTION
Exenatide is a GLP-1 receptor agonist that enhances glucose-dependent insulin secretion by the
pancreatic beta-cell, suppresses inappropriately elevated glucagon secretion, and slows gastric
emptying. BYDUREON is utilizing biodegradable microsphere technology for once-weekly dosing.
nausea (16.9%)
diarrhea (12.7%)
headache (8.0%)
vomiting (6.8%)
constipation (5.9%)
injection-site pruritus (5.9%)
injection-site nodule (5.3%)
dyspepsia (5.1%)
PRECAUTION
Exenatide should not be used in patients with severe gastrointestinal disease (e.g. diabetic gas-
troparesis) and previous medullary thyroid cancer (MTC) or family history of MTC or multi-
ple endocrine neoplasia 2A or 2B, type 1 diabetes mellitus, in a state of diabetic ketoacidosis
and in severe kidney disease or dialysis.
Exenatide has been associated with acute pancreatitis based on post marketing data, careful
observation after initiation required.
ADVERSE EFFECTS
MTAC RESPIRATORY BYDUREON
18
MTAC RESPIRATORY
INJECTION TECHNIQUE
It can be administered in the abdomen, thigh, or upper arm on a rotating basis.
AVAILABILITY
The Drug Control Authority of Malaysia has approved Bydureon 2mg powder formulation for
local use. Bydureon is manufactured by AstraZeneca. It has been in use for many years in
Europe and the United States.
REFERENCES
1. Diamant M, Van Gaal L, Guerci B, et al. Exenatide once weekly versus insulin glargine for type 2 diabetes (DURATION-3): 3-year results
of an open-label randomised trial. Lancet Diabetes Endocrinol. 2014;2(6):464-473.
2. Data on file, AstraZeneca Pharmaceuticals, LP, 3024913.
3. Data on file, AstraZeneca Pharmaceuticals LP, 3070101.
4. Henry RR, Klein EJ, Malloy J, et al. DURATION-1 extension: efficacy and tolerability of exenatide once weekly (QW) over 6 years in
patients with T2DM. Abstract presented at: 74th Scientific Sessions of the American Diabetes Association; June 13-17, 2014; San Fran-
cisco, CA. 964-P.
5. MIMS (27 March 2016) .New once-a-week diabetes drug Bydureon (exenatide) approved In Malaysia. Retrieved on 24 May 2016 from
http://today.mims.com/malaysia/topic/new-once-a-week-diabetes-drug-bydureon--exenatide--approved-in-malaysia
6. Nathan AP, Candis MM, Renu FS & Sarah EM. An Evidence-Based and Practical Approach to Using Bydureon™ in Patients With Type 2
Diabetes. .Journal of the American Board of Family Medicine(2013); 26(2): 203-210
7. MOH (2015). Clinical Practice Guideline on Management of Type 2 Diabetes Melitus 5th Edition.
MTAC RESPIRATORY BYDUREON
19
Golongan Sasaran: Pesakit di Klinik Kesihatan Cheng
Lokasi: Ruang Legar Klinik Kesihatan Cheng. Tarikh: 25 Januari 2016.
Golongan Sasaran: Pelajar (13-17 tahun).
Lokasi:Sekolah Menengah Kebangsaan Bukit Baru. Tarikh: 29 Februari 2016.
Golongan Sasaran: Orang Awam.
Lokasi: Persatuan Kecergasan Melaka dan Sahabat Farmasi di Kompleks Belia dan
Sukan Ayer Keroh.
Tarikh: 27 Mac 2016.
Golongan Sasaran: Orang Awam.
Lokasi: Karnival Jom Ler.. Kenali Ubat Anda. Tarikh: 7 Mei 2016.
MTAC RESPIRATORY QUMC
QUALITY USE OF MEDICINES
BY CONSUMERS (QUMC)
The objective of this campaign is to: 1. increase consumer awareness of the rational use of medicines
2. provide consumers with information on different issues related to health and medicine
3. ensure that consumers know their medicine, what they should and should not be taken, and why
4. increased adverse drug reporting through patient education
5. improve knowledge in the use of medicine by pregnant women, nursing mothers and children
6. assist senior citizens in the use of medicine
QUMC PROGRAM DONE BY PKDMT
IN 2016
By : Fauziah binti Taib
20
Stevia—A Healthy
Alternative Sweetener?
By : Wong Yen Ni Stevia leaves, also known as ‘‘the sweet herb of Paraguay’’
What is Stevia?
Stevia (stevia rebaudiana) is a natural sweetener plant that belongs to the Asteraceae family. This
perennial plant is native to Paraguay and Brazil1. Stevia is estimated to be 300 times sweeter than cane sugar1. This calorie-free plant has been used for centuries by Guarani Indians as sweetener in green teas and beverages1,2,3. Previous studies have revealed that artificial sugar substitutes such as saccharin, sucralose and aspartame might contribute to brain tumours in long-term use4. In 1970’s, stevia was used in large amount as sweeteners in Japan to replace saccharin1. Today, Stevia is being cultivated in many countries including Japan, Taiwan, Philippines, Hawaii, Malaysia and South Amer-ica for food and pharmaceutical products1.
STEVIA
21
Side Effects of Stevia?
No major adverse effect was reported by consuming
Stevia. Some people who are already allergic to com-
mon allergens such as chrysanthemums, marigolds
and ragweed may develop shortness of breath, hives,
wheezing and difficulty in swallowing after consuming
Stevia7. It has also been reported that the stevioside in
Stevia may cause nausea, bloating and stomach up-
set7. Besides, patients with hypertension and diabetes
are encouraged to monitor their blood pressure and
blood glucose regularly because some studies have
shown that Stevia can act as both anti-hypertensive
and anti-diabetic agent7. The safety of Stevia in preg-
nancy and breastfeeding has not been fully estab-
lished7.
How Does Stevia Work?
Sweetness is sensed when our taste buds react to the
glucose in glycoside2. The two main steviol glycosides
of Stevia plant are stevioside and rebaudioside A2.
Study has shown that both stevioside and rebaudi-
oside A were hydrolysed into steviol and glucose in
the gut5. Steviol was absorbed and conjugated to glu-
curonide before excreted through urine and faeces5.
The glucose released was used by the bacteria in the
colon and not absorbed into bloodstream5. Hence it is
said that the intake of Stevia does not increase blood
glucose level but exerts anti-hyperglycaemic effect by
improving insulin sensitivity and enhancing insulin
production2. Physiological and Pharmacological exper-
iments have also suggested that Stevioside is a sys-
temic vasodilator hence can reduce blood pressure6.
Other potential roles of Stevia include anti-oxidation,
anti-inflammatory, anticancer, antimicrobial and anti-
diarrheal therapeutics1,2.
STEVIA
22
Is Stevia Safe?
In 1991, Stevia was banned in the U.S because it
was thought to be carcinogenic but this was refut-
ed by a follow-up study and in 1995, the Food and
Drug Administration (FDA) finally allowed Stevia to
be imported and sold as food supplement, but not
as sweetener8. However FDA has not permitted the
use of whole-leaf stevia or crude stevia extracts for
use as a food additive9. In December 2008, FDA has
categorised Stevia ‘‘Generally Recognized as
Safe’’ (GRAS). The initial concerns that Stevia may
affect fertility have been put into rest after a few
good studies showed no negative outcomes. In Ma-
laysia, Stevia extract does not need KKM approval
because it falls in the Malaysian Food Act. To date,
more than 40,000 clinical studies have been con-
ducted on Stevia and it is considerably safe when
consumed in reasonable amount. However, further
studies on Stevia use and effects should be carried
out to investigate its long-term effect on human.
References
1. B. Ahmed Hossain, R. Islam, A. Kumar Saha, A. Mandal. (2011): A review on natural sweetener plant – stevia having medicinal and commercial importance. ISSN
0002- 1954: 75-91.
2. R. Gupta, V. Yadav, M. Rastogi. (2014). A Review On Importance of Natoral Sweetener, A Zero Calorie Plant – Stevia- Having Medicinal and Commercial Im-
portance. International Journal of Food And Nutritional Sciences: Vol 3 (Issue 3). Retrieved from http://www.ijfans.com/Volume_3_Issue_3_April_June_2014.html
3. Vanek, T., Nepovim, A., Valicek, P. (2001): Determination of Stevioside in plant material and fruit teas. J, food. Comp. anal. 14: 383-388.
4. Fowler SP, Williams K, Resendez RG, Hunt KJ, Hazuda HP, Stern MP (2008): Fueling the obesity epidemic? Artificaially sweetened beverage use and long term
weight gain. Obesity (Silver Spring) 16 (8): 1894-900.
5. Gardana C, Simonetti P, Canzi E, Zanchi R, Pietta P. (2003): Metabolism of stevioside and rebaudioside A from stevia rebaudiana by human microflora. J Agr Food
Chem. 51: 6618-6622
Diagrams adapted from: http://www.examiner.com/article/infographic-comparing-stevia-and-aspartame-sweeteners
STEVIA