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HPJ Pharmacy Bulletin Issue 1/2013
Allergic
conjunctivitis
2
Osteoarthritis (OA) is a painful
condition in which joints
become swollen and stiffs. In
patient with osteoarthritis, the
tissue called cartilage start to
break down. page 2
PHARMACY BULLETIN (Issue 1/2013)
April 2013 Edition
1
Osteoarthritis
Primary open angle glaucoma
(POAG) is a progressive,
chronic optic neuropathy that
commonly involves decrease in
aqueous humor outflow from
anterior chamber of eye. page 6
3
Management
of Glaucoma
Allergic conjunctivitis is a
common ocular disorder. There
are few types of conjunctival
allergic reactions. page 5
Editorial Board:
Cik Salmi Abdul Razak
Pn Aina Yazrin Ali Nasaruddin
Pn Nadiah Mohamed Khazin
Hemananthini Suppiah
Muhammad Farid Ismail
Eddil Farhan Zawawi
Koon Ee Reen
Zahirah Zaharuddin
Yellow Fever
4
Yellow fever is a severe arthropod-borne hemorrhagic fever transmitted by infected
mosquitoes. page 9
Editorial Members:
Pn Kamarunnesa Mokhtar Ahmad
Advisor:
Look Alike Medication
page 12
High Alert Medication
page 15
Adverse Drug Reaction
Report
page 18
Other Issues
5
2
Issue 1/2013 HPJ Pharmacy Bulletin
Osteoarthritis & Buprenorphine
Osteoarthritis (OA) is a painful condition in which joints become swollen and stiffs. In patient with osteoarthritis, the tissue called cartilage starts to break down. Cartilage is a
soft tissue acts as a cushion between the bones that meet at a joint. It allows the connecting bones to move smoothly
without rubbing against each other. Diminished of this
cartilage causes pain, joint swelling and damage and may get
worse over time.6 Factors that can accelerate osteoarthritis are age, obesity, physical activity, work activity, history of injury, bone mineral density, genetic, systemic disease.6, 7
Osteoarthritis pain classified as nociceptive pain which the pain is arising from disease injury or dysfunction of muscles,
joint, skin, bone etc (somatic) or internal organ (visceral). 8
Osteoarthritis pain as well as improve function can be managed by exercise, weight control, rest, pain relief, alternative therapies and surgery. Usually people with
osteoarthritis have joint pain and stiffness. Osteoarthritis affects only joint function compared to some other forms of
arthritis, such as rheumatoid arthritis. It does not affect skin tissue, the lungs, the eyes, or the blood vessels.11,12
Parts of body usually affected in OA
Figure shows the parts of body where as osteoarthritis
most often occurs in the hands (at the ends of the
fingers and thumbs), spine (neck and lower back),
knees, and hips. 11,12
A Healthy Joint (Representation) A Joint with Severe Osteoarthritis (Representation)
Figure shows differences between a healthy joint and a joint with severe osteoarthritis. In the healthy joints of the ends of bones are encased in smooth cartilage. Together, they are protected by a joint capsule lined with a synovial membrane that produces synovial fluid. The capsule and fluid protect the cartilage, muscles, and connective tissues. With osteoarthritis, the cartilage is worn away. Bone spurs grow out from the edge of the bone, and synovial fluid increases. This contributes to joint stiffness and sore.
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Issue 1/2013 HPJ Pharmacy Bulletin
Buprenorphine is a partial mu (µ) agonist, which has a ceiling effect on its agonist activity. Buprenorphine is classified as strong opioid and can be used for managing osteoarthritis in patient
whom non-opioid analgesic is insufficient to provide analgesic effect. Buprenorphine is formulated as sublingual tablets and trandermal patch. Other opioids that can also be used to give an analgecis
effect in osteoarthritis patient are fentanyl, morphine, pethidine, methadone, tramadol, dihyrocodeine etc. However, Ministry of Health (MOH) only approved tramadol and dihydrocodeine as analgesic for non-malignant moderate to severe chronic pain.
World Health Organization (WHO) analgesic ladder for chronic nociceptive pain suggests that opioid should be used if non-opioid + adjuvant are not adequate to provide analgesic as stated beside.
Classification of opioids
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Issue 1/2013 HPJ Pharmacy Bulletin
There are clinical trials and studies that show the effectiveness of buprenorphine compared other opiods analgesic. In patients with chronic, moderate to severe OA pain of the hip and/or knee, 7-day low-dose buprenorphine patches were an effective and well-tolerated analgesic. The buprenorphine
patches were non inferior to prolonged-release tramadol tablets 13. In a randomized, double-blind, placebo controlled, maintenance-of-analgesia study which conducted in adult subjects with persistent
non cancer-related pain who required opioid therapy, 7-day buprenorphine transdermal patch system (BTDS) treatment was associated with analgesic efficacy and was generally well tolerated14.
In a study involving 315 patients with osteoarthritis of the knee or hip, buprenorphine transdermal patch is compared with placebo over a seven-day assessment phase. Significantly more
patients in the buprenorphine group achieved the primary outcome of successful pain management.
Failure is defined as early discontinuation from the study due to ineffective treatment or a final score of
poor or fair on a patient satisfaction with study medication scale (44% vs. 32%, p=0.036; adjusted odds ratio 1.66 (95% CI, 1.04 to 2.69)).
In different clinical study shows the most adverse events were mild to moderate in
intensity in patient who receiving buprenorphine. This study involves
buprenorphine patches and sublingual tablets in patients with OA. The result significantly
shows fewer patients in the buprenorphine patch group reported an adverse event during treatment compared with those using the
tablets (81% vs. 92%) 15
Buprenorphine is categorized as C for
pregnant ladies. There is limited human data to suggest the safety in pregnant women.
However, animal studies have demonstrated dose-related maternal, embryo, and fetal
toxicity and dose-related behavioral changes in offspring but no congenital malformations.16
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Issue 1/2013 HPJ Pharmacy Bulletin
Treatment for allergic
conjunctivitis
Allergic conjunctivitis is a common ocular disorder. There are few types of conjunctival allergic reactions. The
pathophysiology of allergic conjunctivitis involves primarily a type I hypersensitivity mechanism, with release of histamine and other chemical mediators from mast cells. However, a type IV
hypersensitivity with participation of secondary inflammatory cells, such as T-helper cells, eosinophils, and their chemical
mediators, also plays a role. Current therapy of allergic conjunctivitis is based on general measures that aim at
eliminating exposure to the allergen, and medical treatment. The main classes of drugs involved in medical therapy are antihistamines (used with or without vasoconstrictors), mast-cell
stabilizers, nonsteroidal antiinilammatory drugs, and corticosteroids.
The most common symptom of ocular allergy is itching. Without itching, a condition should not be considered ocular
allergy. The accompanying vasodilation appears superficial and pink rather than a deep red. Swelling of the conjunctiva, also
known as chemosis can be present, although it is usually subtle and thus only visible on slit lamp examination. More readily
observable is the glassy appearance of the eye. Swelling can also become apparent in the lids. Although lid swelling peaks within 15 to 30minutes after exposure, it tends to dissipate slowly and is
often more visible on examination. Although transient, the initial intensity of this swelling can induce structural changes in the
delicate collagen fibers of the skin surrounding the eye.
In relieving the acute symptom
of allergic conjunctivitis,
topical application of lowest
potency steroid is usually
effective. Potential adverse
effect associated with steroid
such as risk of increased
intraocular pressure and
cataract formation limits its use
in acute symptom suppression.
Ketorolac as a topical NSAIDS
is also effective in reducing
signs and symptoms of allergic
conjunctivitis. Topical anti-
histamine such as levocabastine
hydrochloride 0.05% and
azelastine hydrochloride 0.05%
is effective in relieving
symptoms of allergic
conjunctivitis. Mast cell
stabiliser such as sodium
cromoglycate is more effective
when used in combination with
steroids or anti-histamine and
also reduces the dose. Apart
from that, olopatadine may be
more effective in targeting
subtype of mast cell of
conjunctiva than other mast cell
stabilising agent like sodium
cromoglycate.
Allergic Conjunctivitis
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Issue 1/2013 HPJ Pharmacy Bulletin
Management of Glaucoma
PHARMACY BULLETIN
2012 Edition (Volume 2/2012)
Primary open angle glaucoma (POAG) is a progressive, chronic optic neuropathy that commonly involves decrease in aqueous humor outflow from anterior chamber of eye. Glaucoma can result in irreversible blindness. Ocular hypertension refers to any eye condition with intraocular pressure > 21 mm Hg. In ocular hypertension, visual field and optic nerves can be normal and with absence of any other ocular
diseases.
Elevated intraocular pressure (IOP) is the primary risk factor for glaucoma and ocular hypertension. It can result in progression of optic nerve deterioration and visual field loss.
Effectiveness of IOP lowering is shown in recent randomized, controlled clinical trials in which it can delay or prevent the development of glaucoma in patients with ocular hypertension and to delay or inhibit progression of established glaucoma. Lowering of IOP to target individualized IOP is by either increasing aqueous outflow or reducing aqueous production or both. In general, IOP lowering agents in which topical agents are the mainstay of treatment in glaucoma and ocular
hypertension.
Major classes of topical IOP lowering agents include beta blockers, prostaglandin analogues, carbonic anhydrase inhibitors, alpha-2 selective adrenergic agonists, miotics and mydriatics. Ocular beta blockers include timolol, betaxolol, and levonubolol have beta-adrenergic receptor blocking effect that results in reduced aqueous humor production and IOP loweing. Beta blockers are the most commonly prescribed first line
IOP lowering agent if no contraindication.
Prostaglandin analogues such as latanoprost
and travoprost act as selective prostaglandin receptor agonist that increase uveoscleral aqueous
outflow that reduce IOP.
Prostaglandin analogues should be used once daily at bedtime only as administration more than once daily is associated with decreased IOP lowering effect or causing paradoxical elevations in IOP. Prostaglandin analogues are often used as first line agent due to its convenient once daily dosing, effectiveness that are comparable to ocular beta
blockers and with minimal adverse effects.
Topical carbonic anhydrase inhibitors (CAI) such as dorzolamide and brinzolamide are alternative to oral CAI (e.g acetazolamide) in treatment of elevated IOP as they have a favorable safety profile, and are better tolerated with less systemic side effects. Mechanism of action is inhibiting CA isoenzyme in ciliary processes of eye, reducing bicarbonate and aqueous humor production and thus loweing IOP. Caution in use in patient allergic to sulfonamides drugs as both dorzolamide and brinzolamide are
sulfonamides.
Alpha-adrenergic agonists such as bromonidine and apraclonidine decrease production of aqueous humor, increasing uveoscleral outflow that leads to IOP lowering. In a large, open label study involving 2335 patients, brimonidine as the selective alpha-2 adrenergic agonist effectively lowered IOP whether used as monotherapy, replacement therapy or adjunctive therapy. A significant mean additional IOP lowering is achieved when brimonidine is used as adjunctive therapy concurrent with other ocular hypotensive agents such as beta-blockers, carbonic anhydrase inhibitors and the prostaglandin analogue
latanoprost. Apart from IOP lowering, a study found that brimonidine has potential neuroprotection that is beneficial in preventing the progression of functional changes and visual field loss in glaucoma and ocular hypertension.
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Issue 1/2013 HPJ Pharmacy Bulletin
Comparison table of topical IOP lowering agents
Generic
Name
Brimonidine
Tartrate 0.15%
Ophthalmic
Latanoprost
0.005% Eye
Drops
Dorzolamide
HCl 2%
Ophthalmic
Solution
Betaxolol
0.25% Eye
Suspension
Timolol
Maleate
0.5% Eye
Drops
Trade Names Alphagan P Xalatan Trusopt Betoptic Timolol-POS®
Drug Class Selective alpha-2 adrenergic agonist
Prostaglandin derivative/prostamide (Analogs of prostaglandin Fα - Selective prostaglandin Fα receptor agonist )
Carbonic anhydrase inhibitor (CAI)
Selective beta-blockers (beta-1 adrenergic antagonist)
Non –selective beta-blockers (beta adrenergic antagonist)
Mechanism of Action Decrease production of aqueous humor & increase in uveoscleral outflow
Increase in uveoscleral outflow
Reduction of aqueous production
Reduction of aqueous production
Reduction of aqueous production
Treatment option 1st or 2nd choice 1st or 2nd choice 2nd choice 1st or 2nd choice 1st or 2nd choice
Dosage 1 drop in the affected eye(s) 3 times daily
The recommended dosage is one drop (1.5 ug) in the affected eye(s) once daily in the evening. If more than one topical ophthalmic drug is being used, the drugs should be administered at least five (5) minutes apart
Monotherapy : 1 drop 3 times daily. Adjunctive therapy with an ophthalmic beta-blocker : 1 drop 2 times daily. When substituting for another ophthalmic antiglaucoma agent with this product, discontinue the other agent after proper dosing on one day and start Trusopt on the next day. If more than 1 topical ophthalmic drug is used, the drugs should be administered at least 10 mins apart
One to two drops in the affected eye(s) twice daily
Initially, 1 drop of 0.25% 2 times daily, if clinical response is not adequate, 1 drop of 0.5% 2 times daily
IOP reduction efficacy
20-25%
Brimonidine lowers IOP by mean values of approximately 4-6 mmHg.
25-30 %
Latanoprost lowers IOP by mean values of approximately 4-6 mmHg.
15-20%
Dorzolamide lowers IOP by mean values of approximately 3-5 mmHg.
20-25%
Clinical studies show
that topical Betaxolol
Hydrochloride
Ophthalmic Solution
reduces mean
intraocular pressure
25% from baseline.
20-25%
Timolol lowers IOP by mean values of approximately 6 mmHg.
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Issue 1/2013 HPJ Pharmacy Bulletin
Generic
Name
Brimonidine
Tartrate 0.15%
Ophthalmic
Latanoprost
0.005% Eye
Drops
Dorzolamide
HCl 2%
Ophthalmic
Solution
Betaxolol
0.25% Eye
Suspension
Timolol
Maleate
0.5% Eye
Drops
Pharmacokinetics
Mean apparent half-life in the systemic circulation ~ 3 hours.
Rapid onset of action, with peak ocular hypotensive effect seen at 2-3 hours post-dosing
Brimonidine is extensively metabolized in liver.
75% of the bromonidine was excreted as metabolites in urine within five days in which no unchanged drug was detected in urine.
Half life ~ 17 minutes.
Reduction in intraocular pressure starts about three to four hours after administration and maximum effect is reached after eight to twelve hours.
Pressure reduction is maintained for at least 24 hours.
The main liver metabolites, the 1,2-dinor and 1,2,3,4-tetranor metabolites are excreted primarily in the urine.
Half-life ~four months.
Dorzolamide and its metabolites accumulate in red blood cells during chronic dosing as a result of selective binding to CA-II while extremely low concentrations of free drug in plasma are maintained.
Reduction in intraocular pressure persists for 8 hours or longer.
Dorzolamide binds moderately to plasma proteins (approximately 33%).
Dorzolamide is primarily excreted unchanged in the urine with its liver metabolites also excreted in urine.
Half-life ~16-22 hours.
Onset of action is within 30 minutes and the maximal effect can usually be detected 2 hours after topical administration.
A single dose provides a 12-hour reduction in intraocular pressure
Major liver metabolites include two carboxylic acid forms plus unchanged betaxolol in the urine (approximately 16% of the administered dose).
The elimination of betaxolol is primarily by the renal rather than faecal route.
Half life ~ 7 hours.
Timolol is not extensively bound to plasma protein.
Part of the dose is absorbed systemically where it is extensively metabolised in the liver.
Timolol is partially metabolised by the liver with timolol metabolites excreted by the kidney.
Side effects Very common: Oral dryness, ocular hyperemia, burning and stinging, headache, blurring, foreign body sensation, fatigue, drowsiness, conjunctival follicles, ocular pruritus.
Common: Dizziness, abnormal taste
Very common: Slight discomfort, mild to moderate conjunctival hyperaemia(burning grittiness, itching, stinging and foreign body sensation), transient punctate ephitelial erosions, increased pigmentation of iris, rash.
Common:Transient punctate epithelial erosions, mostly without symptoms; blepharitis.
Very common: Burning and stinging.
Common: Slight discomfort, mild to moderate conjunctival hyperaemia, transient punctate ephitelial erosions, increased pigmentation of iris, rash
Common: Ocular
stinging, pain, itching,
erythema, dry eyes
and allergic
blepharoconjunctivitis,
corneal disorders
Very common: Burning and stinging upon instillation (approximately one in eight patients).
Less frequently: Bradycardia, hypotension, confusion, depression, dizziness, fatigue, abdominal pain, diarrhoea, dyspepsia, dry eye, corneal anaesthesia.
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Issue 1/2013 HPJ Pharmacy Bulletin
WHAT IS YELLOW FEVER?
Yellow fever is a severe arthropod-borne hemorrhagic fever transmitted by infected
mosquitoes. The "yellow" in the name refers to the jaundice that affects some patients. Up to
50% of severely affected persons without treatment will die from yellow fever. There are an
estimated 200 000 cases of yellow fever, and the
fatality rate is about 20%-50%. The virus is endemic in tropical areas of Africa and Latin
America, with a combined population of over 900 million people. Yellow fever cases have been
uprising for the past two decades due to declining population immunity to infection, deforestation,
urbanization, population movements and climate change. Unfortunately there is no cure for yellow fever and treatment is symptomatic which aimed
at reducing the symptoms only. Vaccination is the most important preventive measure against
yellow fever. The vaccine is safe, affordable and highly effective, and appears to provide
protection for 30–35 years or more. The vaccine provides effective immunity within one week for 95% of persons vaccinated.
SYMPTOMS
TRANSMISSION
There are several different species of the Aedes
and Haemogogus mosquitoes that transmit the
virus. These mosquitoes either breed around houses (domestic), in the jungle (wild) or in both habitats (semi-domestic). There are three types of
transmission cycles.
Sylvatic (or jungle) yellow fever: In tropical
rainforests, yellow fever occurs in monkeys that are infected by wild mosquitoes. The infected mosquitoes bite humans entering the forest,
resulting in occasional cases of yellow fever.
Intermediate yellow fever: In humid or semi-
humid parts of Africa, small-scale epidemics occur. Semi-domestic mosquitoes (that breed in
the wild and around households) infect both monkeys and humans. Increased contact between people and infected mosquitoes leads to
transmission. This is the most common type of outbreak in Africa. An outbreak can become a
more severe epidemic if the infection is carried into an area populated with both domestic
mosquitoes and unvaccinated people.
Urban yellow fever: Large epidemics occur
when infected people introduce the virus into
densely populated areas with a high number of non-immune people and Aedes mosquitoes.
YELLOW FEVER
The yellow fever virus is an arbovirus of the
flavivirus genus, and the mosquito is the
primary vector. It carries the virus from one
host to another and it normally spread to humans from bites by infected mosquitoes.
People cannot spread yellow fever among
themselves through casual contact, although the infection can be transmitted directly into the blood through needles.
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Issue 1/2013 HPJ Pharmacy Bulletin
TREATMENT
Since it has no cure, the medical treatment is mostly focusing on resolving the symptoms of
yellow fever such as fever, muscle pain, and dehydration. Due to the risk of internal bleeding, it is advisable to avoid aspirin and other non-
steroidal anti-inflammatory drugs such as ibuprofen or naproxen. Hospitalization is often
needed.
PREVENTION OF YELLOW FEVER
THROUGH VACCINATION
The yellow fever vaccine is recommended for:
those ≥9 months of age travelling or living
in any country in West Africa regardless
of where they will be in that country, those ≥9 months of age travelling or living
outside urban areas of all other yellow
fever endemic countries , and laboratory personnel who routinely work with yellow
fever virus
Nowadays countries like Africa and South America which has the highest risk exposure to
yellow fever require proof of yellow fever vaccination before you are allowed to travel there.
People who should not be vaccinated include:
children aged less than 9 months for
routine immunization (or less than 6 months during an epidemic);
pregnant women – except during a yellow fever outbreak when the risk of infection is high;
people with severe allergies to egg protein; and
people with severe immunodeficiency due to symptomatic HIV/AIDS or other
causes, or in the presence of a thymus disorder.
Dosage and administration
Administration : IM or SC Dose : 0.5 mL of reconstituted vaccine regardless of age.
VACCINE
Yellow fever vaccine contains neither antibiotics
nor preservatives, and does not contain gelatin.The vaccine is a live, freeze-dried preparation of the 17D attenuated strain of
yellow fever virus cultured in, and harvested from, embryonated chicken eggs.
Vaccination elicits protective levels of neutralising
antibodies in approximately 90% of adult vaccinees by day 14, and in virtually all by day
28.The Immunity is long lasting and sometimes it is life-long, however revaccination is required
after 10 years under the International Health Regulations for a valid International Certificate of Vaccination. This is due to the fact that vaccine
produces a transient very low level viraemia in healthy adult recipients; they cannot serve as a
source of infection for mosquitoes.
The effectiveness of the yellow fever vaccine has never been determined in prospective clinical
trials however there is considerable observational evidence that it is very effective in preventing the disease.
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Issue 1/2013 HPJ Pharmacy Bulletin
Transport, storage and handling Transport according to National Vaccine Storage
Guidelines: Strive for 5.
vaccine and diluent should be stored at +2oC to +8oC.
Do not freeze.
Protect from light.
should be used within 1 hour of reconstitution.
Contraindications
1) Known anaphylactic sensitivity
anaphylaxis following a previous dose, or anaphylaxis following any of the vaccine
components. known anaphylaxis to eggs.
2) Infants <9 months of age.
3) Altered immune status due to either disease or medical treatment
4) People with history of any thymus disorder (myasthenia gravis, thymoma, thymectomy and
DiGeorge syndrome).
Precautions! 1)Adults ≥60 years of age Due to the greater risk of severe adverse effects than younger adult. Recommended only if they
are traveling to endemic countries and have been informed about the risk of developing severe
complication.
2) Pregnancy
Recommended only if they insisted on going to endemic places. The yellow fever vaccine has been given to a number of pregnant women and
showed no evidence of any adverse effect.
3) Administration of other vaccines on the same
day The administration of other live virus vaccines (MMR, varicella vaccine) should be on the same
day as yellow fever vaccine, or separated by a 4-week interval. Other vaccines relevant to travel
can be given with, or at any time before or after, yellow fever vaccine.
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Issue 1/2013 HPJ Pharmacy Bulletin
From left-right: Maxitrol sterile opthtalmic
ointment 3.5 g & Gutt. Maxitrol sterile ophthalmic preparation 5 ml.
From left-right: Clomatrimazole vaginal inserts USP 500 mg & Clomatrimazole vaginal inserts USP 200 mg.
From left-right: Ampicillin 0.5 g injection & Penicillin G sod. 1,00000IU/IU(0.6 g) injection.
From left-right: Clexane 20 mg injection, Clexane 60 mg injection & Clexane 40 mg
injection.
LOOK ALIKE MEDICATIONS
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Issue 1/2013 HPJ Pharmacy Bulletin
From left-right: Mirtazapine 30 mg orodispersible tablet & Mirtazapine 15 mg orodispersible tablet.
From left-right: Cefuroxime axetil 250 mg tablet
& Sodium fusidate 250 mg tablet.
From left-right: Vitamin B complex tablet & Folic acid 5mg tablet.
From left-right: Enalapril 5 mg tablet &
Enalapril 10 mg tablet.
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Issue 1/2013 HPJ Pharmacy Bulletin
From left-right: Medroxyprogesterone Acetate 5
mg tablet & Trimetazidine dihydrochloride 20 mg tablet
From left-right: Mist expectorant stimulant, &
Ferric ammonium citrate 400mg/5ml.
From left-right: Gutt. Phenylephrine HCl 2.5%, Gutt. Isopto-Atropine 1%,
Gutt. Tropicamide 1%, Gutt. Cyclopentolate HCl 1%
From left-right: Ticlopidine HCL 250 mg tablet, Clopidogrel 75 mg tablet & Eterocoxib 90 mg tablet.
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Issue 1/2013 HPJ Pharmacy Bulletin
High alert medications are defined as those medications which could cause an immediate life
threatening condition for the patient if an error in administration occurs.
How to avoid HAM errors:
Risk awareness – Be aware of high alert
medications arrangement in pharmacy.
Review Floor Stocks in ward to reduce
availability of HAM items, as well as,
quantities.
Physicians should be alert with the
medications that they administer e.g.
dose, route, common adverse effect &
monitoring
Read the label repetitively during
prescription filling and counter checking.
Additional product labels for high alert
medication during dispensing medication
from pharmacy to the nurse unit.
Storage of high alert medication in cabinet
with HAM labels.
Common Risk Factors Associated with HAM:-
Incorrect dilution procedures
Confusion between IM, IV, Intrathecal,
Epidural preparations
Confusion between different strength of
the same medications
Ambiguous labeling on concentration and
total volume of medications
Wrong infusion rate
Significantly risky HAM in acute care setting:-
Drugs Serious Adverse
Events
Heparin Severe bleeding & heparin induced
thrombocytopenia
IV Potassium Chloride
Cardiac arrest, potassium intoxication,
life threatening hyperkalemia
Neuromuscular
agents (Atracurium)
Prolonged skeletal
muscle paralysis, respiratory insufficiency
Opioids Oversedation,
respiratory depression
Chemotherapy drugs
Myelosuppression, Immunosupression
High Alert Medication (HAM)
HPJ Pharmacy Bulletin Issue 1/2013
*List of High Alert Medication
Class / Category Medication
Adrenergic Agonists, IV
Adrenaline 1mg/ml Inj
Noradrenaline 4mg/4ml Inj
Ephedrine 30mg/ml Inj
Isoprenaline 0.2mg/ml Inj
Phenylephrine HCl 10mg/ml Inj
Salbutamol 0.5mg/ml Inj
Salbutamol 5mg/5ml Inj
Terbutaline 0.5mg/ml Inj
Adrenergic Antagonists, IV
Labetalol 25mg/5ml Inj
Propranolol 1mg/ml Inj
Anaesthetic Agents, general, inhaled, and IV
Dexmedetomidine 200mcg/2ml
Inj
Ketamine Inj
Propofol 1% Inj
Bupivicaine 0.5% Adrenaline
1:200,000 Inj
Bupivicaine 0.5% Heavy Inj
Bupivicaine 0.5% Inj
Ropivacaine 7.5mg Inj
Ropivacine 2mg/ml (0.2%) Inj
Desflurane (Suprane) 240ml
Ethyl Chloride Spray
Isoflurane 250ml Liquid
Sevorane Liquid 250ml (Sevoflurane)
Class / Category Medication
Antiarrhythmias IV Amiodarone 150mg/3ml Inj
Lignocaine 2% Inj
Lignocaine 100mg/5ml Inj
Lignocaine 500mg/5ml Inj
Antifibrinolytics, haemostatics
Vitamin K Inj (10mg; 1mg)
Tranexamic Acid 500mg/5ml Inj
Antithrombotic Agents
Heparin Inj
Streptokinase 1.5 miu Inj
Tenecteplase 50mg Inj
Warfarin
Antivenom Sea Snake Antivenom
Cobra Antivenom
Pit Viper Antivenom
Polyvalent Antivenom
Chemotherapeutic Agents, Parenteral & Oral
Methotrexate Inj & Tab
Fluorouracil Inj
Epirubicin Inj
Cyclophosphamide Inj
Docetaxel Inj
Bleomycin Inj
Dextrose, hypertonic, 20% or greater<
Dextrose 50% Inj
Epidural & Intrathecal Medications
PCA Morphine
Epidural Cocktail 0.05%
Epidural Cocktail 0.1%
Epidural Pethidine 2%
Glyceryl Trinitrate Injection
GTN Inj 50mg/10ml Inj
Issue 1/2013 HPJ Pharmacy Bulletin
Class / Category Medication
Inotropic Medications, IV
Digoxin 0.5mg/2ml Inj
Dobutamine 250mg/20ml Inj
Dopamine 200mg/5ml Inj
Insulin, s/c & iv Actrapid
Magnesium Sulphate Injections
Mg Sulphate 2.47mg/5ml (10mmol) Inj
Moderate Sedation Agents, IV
Midazolam 5mg/ml; 15mg/3ml Inj
Diazepam 10mg/2ml Inj
Neuromusular Blocking Agents
Atracurium 25mg/2.5ml Inj
Pancuronium 4mg/2ml Inj
Rocuronium 50mg/5ml Inj
Vecuronium 4mg/ml Inj
Opiates & Narcotics Naloxone 0.4mg/ml Inj
Cocaine Powder
Morphine 10mg/ml Inj
Fentanyl Inj
Remifentanyl Inj
Nalbuphine 10mg/ml inj
Sodium Chloride 20%
*List adapted from ISMP’s List of Hight-Alert Medications & Guideline On Safe Use Of High Alert Medications Ministry of Health
Malaysia Pharmaceutical Services Division 2012
Class / Category Medication
Parenteral Nutrition Preparations
Nutriflex Lipid Peri 955kcal
(Regimen 1)
Kabiven Peripheral 1000kcal
(Regimen 2)
Nutriflex Lipid Peri 1435kcal (Regimen 3)
Kabiven Peripheral 1400kcal (Regimen 4)
Kabiven Central 1900kcal (Regimen 5)
Nutriflex Lipid Special
1475kcal(Regimen 6)
Amino Acids 11.4% (Vamin
18EF) 500ml
Lipid LCT 20% (Intralipid)
Lipid MCT/LCT 10% (Lipofundin)
Amino acid 6.5% (Vaminolact)
100ml
Amino acid 6.5% (Vaminolact)
500ml
Amino acid 13.4% (Dipeptiven) 100ml
Potassium Salts Injection
Potassium Chloride 1g/10ml (13.41mEq) Inj
Potassium Dihydrogen Phosphate 10mmol/10ml Inj
Sodium Chloride Solutions (greater than 0.9%)
Sodium Chloride 3%
Sodium Chloride 20%
HPJ Pharmacy Bulletin Issue 1/2013
In the year 2012, total number of adverse drug
reactions reported was 62 cases, which consist of
various pharmacological categories with highest
number in anti-infective group (18 cases). Anti-
infective that causes the most adverse reaction
fall into beta-lactam antibiotics with most
common in Amoxycillin-Clavulanic Acid drug.
The next leading ADR group was cardiovascular
group with total number of 9 cases. Tailing very
close to cardiovascular gro up was analgesics and
endocrine with 7 cases respectively. For the least
number of cases were among nutrition & blood
disorder drug and neuromuscular drug with only
1 case.
According to the statistics of ADR as of March
2013, the leading is still anti-infective group with
7 cases among total of 11 cases reported. Beta-
lactam antibiotics hold the most number with 4
cases consists of Amoxycillin-Clavulanic Acid,
Cloxacillin and Bacampicillin. The remaining
groups- rheumatology, respiratory, analgesics
and cardiovascular reported each a case.
Majority of cases reported about anti-infectives is
related to dermatogical problem such as
angioedema, pruritis, macular papular rash and
rashes. Other severe cases reported include severe
bronchospam, hypoglycemia, leukopenia and
liver transaminitis.
To conclude, these statistics showed that
antiinfectives are the main ADR causing group,
with this in mind proper care and caution should
be applied during usage of anti-infectives in
future. Vast exposure in usage of antibiotics is
needed among medical personnel in order to
reduce the occurrence of adverse drug reactions
which could be life threatening. So all watch
out!!!!!!
Adverse Drug Reaction Report
19
Issue 1/2013 HPJ Pharmacy Bulletin
Adverse Drug Reaction (ADR) Cases Reported Year 2012
Adverse Drug Reaction (ADR) Cases Reported Year 2013 (As of March 2013)
20
Issue 1/2013 HPJ Pharmacy Bulletin
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