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August 2013

Asthma on the rise

Feeding Difficulties in Children

CCM wins Pharma Company of the Year

News Feature

News | Pharmacy Today | August 2013 3

By Leonard Yap

A survey by Asthma Insight and Man-agement in Europe and Canada (EU-CAN AIM) has shown an increase in

the prevalence of asthma.“Asthma has significantly increased in

prevalence over the past 40 years. According to the EUCAN AIM survey, asthma exacerba-tions can greatly impact a patient’s quality of life and disrupt normal activities,” said Prof Roslina Abdul Manap, consultant respiratory physician, Universiti Kebangsaan Malaysia Medical Centre.

The survey found that sudden, severe epi-sodes are considered far worse by patients than day-to-day asthma symptoms, and that these episodes can be so severe that more than half of respondents stopped exercising as a result, more than a quarter skipped work or school and almost 10% had to enter intensive care. (Highlights from Asthma Insight and Management in Europe and Canada (EUCAN AIM): A Multicountry Survey of Asthma Pa-tients. Merck, Sharp & Dohme. 2010)

“Most importantly, the survey found that most asthma patients believed their asthma was under control, when in fact, it was not. Nearly one in five patients was found to have needed acute care for asthma over the course of a year, with 6.7% of them requiring over-night hospitalization. Approximately 41% of patients needed quick relief of an inhaler at least once a week to relieve their asthma symptoms. These statistics underscore the need for proper treatment,” she said.

“There is also a significant economic cost associated with asthma. In Europe, approxi-mately €17.7 billion (RM71.5 billion) is spent on asthma treatment and management, with €3.8 billion (RM15.3 billion) of that in outpa-

tient treatment costs alone,” she added. (Eu-ropean Lung White Book http://dev.ersnet.org/268-white-book.htm Accessed on 24 June)

“Asthma is a common, chronic lung dis-ease characterized by inflammation of the air passages, affecting over 300 million people worldwide. Asthma can be triggered by aller-gens such as pollen, dust mites, cockroaches, animal dander and molds, and other irritants such as cigarette smoke, automobile emis-sions, changes in weather, toxic chemicals, viral infections, or personal habits such as stress, anxiety, strenuous exercise and even laughter. Asthma symptoms are due to acute bronchospasm and chronic airway inflamma-tion,” said Abdul Razak Muttalif, a consultant chest physician and head of the Institute of Respiratory Medicine, Kuala Lumpur. [Glob-al Strategy for Asthma Management and Pre-vention 2009. Global Initiative for Asthma, www.ginasthma.org/documents/1 Accessed on 24 June]

The symptoms include difficulty in breath-

Asthma rates have been increasing in recent years

Asthma on the rise


ing, wheezing, coughing, shortness of breath and chest tightness. Annual worldwide deaths from asthma have been estimated at 250,000. [Global Strategy for Asthma Man-agement and Prevention 2009. Global Initia-tive for Asthma. www.ginasthma.org/docu-ments/1 Accessed on 24 June]

Patients with asthma usually find their lives adversely impacted. According to the EUCAN AIM survey, approximately 40% of patients reported limitations in sports and rec-reation, nearly a third reported limitations in normal physical exertion, nearly 20% missed a median of 6 work or school days due to their asthma, while a 40% decrease in productivity was experienced by patients when symptoms were at their worst.

While asthma is a chronic disease that cur-

rently has no cure, patients can achieve asthma control with a combination of reliever and/or controller medication, Dato. Dr Razak said.

The level of asthma severity should be as-sessed to determine if it is intermittent, mild, moderate or severe, and the appropriate treat-ment initiated. (www.nhlbi.nih.gov/health/health-topics/topics/asthma/diagnosis.html Accessed on 24 June)

Razak and Prof Roslina were speaking at the launch of a fixed-dose long-term asthma controller for patients aged above 12 years. The combination of formoterol fumarate dihydrate, a bronchodilator which relaxes the smooth muscles of the airway, and mometa-sone furoate, an anti-inflammatory agent, work to address the two important compo-nents in the pathogenesis of asthma.

A new Diabetes Conversation Map has been specifically tailored and devel-oped by Muslim endocrinologists to

advocate proper management of diabetes to all Muslims during Ramadan.

“Complications associated with diabetic fasting can range from mild to severe, but can be easily avoided if managed appropri-ately with proper food intake and medica-tion, which is why this new map is important in outlining the importance of fasting safely during Ramadan,” said Wan Mohamad Wan Bebakar, senior consultant endocrinologist, Universiti Sains Malaysia.

“The map provides patients the opportu-

nity to interact with others who suffer from the same condition and with their healthcare providers to realize key facts about diabetes and beliefs or attitudes that they need to ad-dress to ensure their health is not compro-mised while fasting,” said Prof Datuk Wan Mohamad.

As fasting involves a change in the dietary intake pattern, diabetics who fast face chal-lenges as their chronic metabolic disorder places them at risk for various complications if not properly managed. When fasting, the body enters into a fasting state around eight hours after the last meal, and will initially use stored sources of glucose before finally break-

Map to aid fasting patients manage their sugar levels


ing down fat for energy. (www.diabetes.nhs.uk/ramadan/what_happens_to_your_body_during_fasting/?#)

In patients with diabetes, insulin secretion is affected by medications, which function to enhance or supplement insulin secretion, ul-timately leading to difficulties in maintain-ing blood glucose levels and causing several complications. (Diabetes Care 2005;28:2305-11)

One of the major complications associated with fasting is hypoglycemia, when blood glucose levels fall below 4 mmol/L. Although usually mild in its initial onset, this condition if left untreated can cause confusion, clumsi-ness or fainting. Over time, severe hypoglyce-mia can lead to seizure, coma and even death.

Another complication is hyperglycemia, as indicated by blood glucose levels above 7.8 mmol/L, after fasting for at least eight hours. This can result in damage to nerves, blood vessels and organs, as well as more serious conditions including ketoacidosis.

“We need more effort in engaging patients, caregivers and healthcare professionals to have conversations about diabetes and fast-ing so that understanding of treatment and

management can be fostered. The Diabetes Conversation Map is an approach which all relevant stakeholders can be part of,” said Noor Hisham Abdullah, director-general of health.

“To date, we have incorporated the Diabe-tes Conversation Map in 35 health institutes throughout Malaysia. We hope to increase the number of participating institutes to widen our reach to as many diabetic patients as pos-sible,” said Datuk Dr Noor Hisham.

“With the Diabetes Conversation Map, we want to create a positive environment in which patients will be inspired and educated to make changes to live and fast successfully,” said Ham Taejin, general manager of Eli Lilly Malaysia and Singapore.

Mr Taejin said the Diabetes Conversation Map will be launched in 16 other countries and translated into seven languages.

Prof Datuk Wan Mohamad, Datuk Dr Noor Hisham and Mr Taejin were speaking at the launch of the Diabetes Conversation Map re-cently.

For further information, call the Lilly Diabe-tes helpline at: 1800-88-1631 (Monday-Friday: 10 am-6 pm, except public holidays).

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Chemical Company of Malaysia Berhad (CCM) has been awarded the 2013 Frost & Sullivan Malaysia Excellence

Award for Pharmaceutical Company of the Year (Generics Drug Category), reflecting the group’s commitment to offering innova-tive and high-quality generic pharmaceutical products to customers.

The award was among 41 prestigious titles presented by Frost & Sullivan to Malaysian companies for outstanding achievements and superior performance in areas such as leader-ship, technological innovation, customer ser-vice and strategic product development.

CCM Pharmaceuticals Division director Leonard Ariff Abdul Shatar said the award is a recognition of and testament to the group’s philosophy and commitment of delivering value to its stakeholders, while inspiring in-novation and a spirit of excellence among employees to establish new industry bench-marks.

“The pharmaceuticals division is the core of our business and has consistently contrib-uted significant growth to the group’s top and bottom lines throughout the years. It has an excellent track record in delivering to our cus-tomers a diverse range of high-quality and in-novative products, reinforcing the underlying strength of the business.

“This recognition augurs well for the future growth of CCM, especially as we celebrate our 50th anniversary, and we are committed to continuously developing new products in line with our vision to enhance quality of life while meeting and exceeding customers’ ex-pectations with high-quality and affordable medicines trusted by healthcare professionals and patients. We are also pursuing an aggres-sive growth strategy to deepen and widen our portfolio of products as well as exploring

new markets to expand our footprint in the region,” said Mr Leonard Ariff.

“In 2012, CCM Pharmaceuticals captured approximately 27% of the generics market in Malaysia, which was a growth of about 2% from the previous year. In terms of OTC products, CCM Pharmaceuticals captured ap-proximately 5% of the overall market. These achievements resulted in the division gen-erating RM286.5 million in revenue in 2012 compared to RM203 million in the preceding year,” said Hannah Nawi, Associate director for healthcare, Frost & Sullivan Asia Pacific.

As the largest local manufacturer of generic drugs, CCM is committed to offering innova-tive and high-quality bioequivalent products which deliver therapeutic efficiencies and safety, while providing the public with great-er access to quality, affordable and innovative medicines.

CCM recently secured exclusive license and distribution rights from Biocon Ltd, In-dia, to market, sell and distribute a range of insulin products in Malaysia and Brunei. CCM has also signed a definitive agreement with Korea’s PanGen Biotech Inc. to pioneer

Ms Rhenu Bhuller, Vice President of Healthcare, Frost & Sullivan, present-ing the Pharmaceutical Company of the Year Award (Generics Drug Cat-egory) to CCM Pharmaceuticals Director Leonard Ariff Abdul Shatar

CCM wins Pharma Company of the Year


a clinical trial of Erythropoietin (EPO) in Ma-laysia to treat end-stage renal failure patients. The agreement was signed by CCM Duophar-ma Biotech Berhad through its wholly owned subsidiary, Duopharma (M) Sdn Bhd. Under the agreement, Duopharma will obtain com-mercialization rights for product marketing and distribution in Malaysia, Singapore and Brunei.

CCM has been championing Halal in phar-maceuticals products, assuring both Muslims and non-Muslims that its products strictly ad-here to stringent Islamic requirements which

have high standards of hygiene, quality, safe-ty and sanitary conditions.

“CCM Pharmaceuticals’ commitment to supplying the Malaysian population with quality generics has ensured that the com-pany has continued to innovate and broaden its product offering over the years since its inception. With plans to expand its presence in the Asia-Pacific region as well as its foray into bio generics, CCM Pharmaceuticals looks poised to continue with its growth within the generics and bio-generics sectors,” said Ms Hannah.

By Malvinderjit Kaur Dhillon

A recent Child Health Intelligence & Performance (CHIP) survey conduct-ed by Dettol confirms that children

who are exposed to infectious diseases such as diarrhea and food poisoning may have a hampered ability to learn.

The study showed that hygiene behavior not only affects the physical development of a child, it also affects intellectual development.

“Committed to ensuring a bright and healthy nation through hygiene education, Dettol conceptualised the CHIP study to ex-amine Malaysian pediatricians’ standpoint on the correlation between infection and cogni-tive development in children. We wanted a re-affirmation from local experts on the scientific link between infectious disease and cogni-tive development in children,” said Abhishek

Chuckarbutty, marketing director of Reckitt Benckiser Malaysia and Singapore.

A previous study published in Proceedings of The Royal Society B: Biological Sciences showed that the brain of a newborn requires 87% of the body’s total metabolic energy for development. At age five, the brain needs about half of the body’s metabolic energy. Competition with the brain for metabolic en-ergy can be deleterious to the brain’s ability to

Study shows infections can impact child’s intelligence

Good hygiene practices should be instilled in children at a young age


develop to its full capacity. The CHIP study, which surveyed 80 pe-

diatricians in Kuala Lumpur and Selangor, showed that 82% of participants concurred that frequent exposure to transmissible dis-eases will result in a loss of nutrients, disrupt the development of a child’s brain and im-pede intellectual growth.

Exposure to infectious disease might also affect a child’s performance in school and dis-rupt the learning routine. A majority of the pediatricians surveyed said they saw more than 40 cases of infectious diseases a month. More than half of these patients requested sick leave from school. Almost three-quarters of pediatricians agreed that being frequently absent from school would lead to a deteriora-tion of academic performance. Missing school might also leave children feeling demotivated and frustrated as they are faced with the over-whelming task of catching up with the sylla-bus they missed.

In the second part of the CHIP study, all the pediatricians agreed that early hygiene intervention, especially among children aged up to five years, was crucial. They also agreed that hand washing was the most important method to prevent the spread of infection.

More than 60% of pediatricians said the use of disinfectant on toys and home surfaces was also important in good hygiene, while 80% said the use of antibacterial products to effectively kill germs was also important.

“In Malaysia, it is common for parents to send their young children to daycare or kin-dergarten for early development in education. Therefore, it is very critical that we keep not only our homes, but also the daycare centers, free from germs. Personal hygiene should be parents’ number one priority as it is critical in breaking the chain of infectious disease, keep-ing children healthy and allowing them to make the most of their childhood,” said Mr Abhishek.


By Pank Jit Sin

Aspen, which operates on the unique business model of acquiring non-core originator brands and market-

ing them as its own brands, began its Malay-sian operations in July, and will work closely with pharmaceutical companies and medical institutions.

Greg Lan, chief executive officer of Aspen Australia, said the company’s niche in the in-dustry is being able to revive and rejuvenate older original drugs and to give them a “new lease on life.”

One of the success stories of such a venture is Aspen’s purchase of the immunosuppres-sant azathioprine from GlaxoSmithKline. An-drew Ooi, country manager of Aspen Malay-sia, said the drug has seen a resurgence in use and popularity due to the efforts by his sales and support teams.

Mr Lan said: “We are trying to achieve in Malaysia what we did in Australia because Australia is a very successful business mod-el.” He said many older drugs and brands were neglected and ignored by major phar-maceutical companies in favor of current blockbusters. These older drugs, with a tried and tested track record and strong evidence base, would be ignored unless an entity such as Aspen picked them up and gave them the attention they deserve.

Rejuvenating an old originator brand can also mean cost savings for patients as they need not opt for the newer and often more ex-pensive drugs.

By reminding doctors and pharmacists of the relevance of older drugs and educating patients on their benefits, a win-win situation is created for both parties.

Aspen has its roots in South Africa. Formed in 1999, the company quickly grew to be a suc-cessful entity and branched out to Australia in 2001. Although known as a generics drug supplier in its original country, its Malaysian branch is looking to expand on its strength of rejuvenating originator, off patent medications.

The group plans to expand its presence to Japan, Thailand and Indonesia in the near future.

Aspen opens Malaysian branch

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Not all about sex: Testosterone’s effects on aging

All men experience a decline in serum testosterone from the age of 40, and this has been associated with a de-

crease in libido and its associated sexual dys-function. But what is often forgotten are the non-sexual aspects of lowered testosterone like cognitive dysfunction and obesity, says an expert.

Decline in the hormone has been linked to myriad diseases such as osteoporosis, meta-bolic syndrome, poor cognitive function and Alzheimer’s disease, said ProfMichael Klen-tze, medical director of the Klentze Institute of Anti-Aging Munich, Germany, and an ad-visor to the American Academy of Anti-Ag-ing Medicine (A4M).

There is a tendency to overemphasize the sexual aspects of low testosterone ie, erectile dysfunction and decrease in libido, ignoring what could be the more important and more damaging effects of low testosterone, Prof Klentze said.

Serum testosterone levels correlate posi-tively with fat-free mass and negatively with fat mass. Low testosterone (hypoandrogen-ism) in young men has also been associat-ed with a decline in fat-free mass and with skeletal muscle seen in older men. Muscle mass has been shown to be related to body strength, and higher strength is associated with greater bioavailable testosterone. Tes-tosterone replacement therapy appears to re-verse hypoandrogenism, both in young men with low testosterone and in older men, he said. (J Androl 1997;18(2):103-6)

Metabolic syndrome, particularly the com-

bination of hyperinsulinemia and abdominal obesity, has been associated with decreased blood testosterone levels. Clinically, it is rel-atively typical to observe marked changes in an aging man’s body composition (loss of muscle and increase in fat around the belly). Men with metabolic syndrome and type 2 diabetes have been found to possess lower than average testosterone levels compared to their healthy counterparts. (Am J Epidemiol 1990;132(5):895-901)

The effects of serum testosterone decline have led to the belief that replenishing the hormone may be useful in restoring muscle mass and strength, improving metabolic sta-tus and, possibly, lowering cardiovascular risk, he said.

The effects of testosterone on cognitive function and Alzheimer’s disease have also been studied. A study following a group of men in the US examined the link between se-rum free testosterone and the development of Alzheimer’s disease. Participants were from a community-dwelling volunteer sample of 574 men aged between 32 and 87, and ob-served for a period of 4 to 37 years. (Neurology 2004;62(2):188-93)

The study found that calculated free testos-terone concentrations were lower in men who developed Alzheimer’s disease, and this dif-ference occurred before diagnosis. The study also suggested that higher endogenous free testosterone levels may protect against Al-zheimer’s disease in older men.

A study in 2006 attempted to address the compelling need for therapies that prevent,


Mobile app to help diabetics during Ramadan

By Leonard Yap

Fasting during Ramadan is a yearly rit-ual for millions of Malaysian Muslims. Diabetics who are keen to fast should

be well aware of the risks associated with fast-ing and undergo a medical check-up before the start of Ramadan. In addition, by using technology, patients can now keep track of blood sugar levels and even be told the time to break fast.

Two customized tools – the Ramadan, Diabetes and Me mobile app and the Facts about Fasting during Ramadan information kit – were recently launched in Kuala Lum-pur. The Apple-based app displays important

Ramadan-related information such as prayer, sunrise and sunset times based on a user’s lo-cation, and a built-in compass for prayer di-rection. It also includes a blood sugar tracker

defer the onset, slow progression or improve the symptoms of Alzheimer’s disease. The 24-week, randomized, double-blind, placebo-controlled, parallel-group study enrolled par-ticipants in memory disorders clinics as well as general neurology, and from clinics at the University of California medical centers in Los Angeles, San Francisco and Irvine, US.

Patients were randomized to either receive testosterone supplementation or placebo via a daily application to the skin. In the patients with AD, the testosterone-treated group had significantly greater improvements in scores on the self-rated quality-of-life scales. No sig-nificant treatment group differences were de-tected in the cognitive scores at the end of the study. (Arch Neurol 2006;63(2):177-85)

Prof Klentze said exogenous testosterone can be used to treat low serum testosterone when it is suspected to be involved in meta-bolic syndrome, obesity or erectile dysfunc-tion if no contraindications are noted. If testos-terone treatment for a determined amount of time does not make a difference in the health of the patient, treatment strategies must be changed. He also noted that patients on long-term androgen therapy must be followed up every 6 to 12 months, with the status of pros-tate specific antigen (PSA), hematocrit and liver enzymes assessed.

Prof Klentze was speaking at the 10th Ma-laysian Conference and Exhibition on Anti-Aging, Aesthetic and Regenerative Medicine in Kuala Lumpur.


that allows patients to record blood sugar levels throughout the day and sends this in-formation to their healthcare providers via email.

The app also provides general recommen-dations on when fasting should be stopped to avoid the risk of hypoglycemia. Another key feature of the app is a section featuring ques-tions to ask a healthcare professional before beginning Ramadan fasting, including di-etary intake and possible therapies.

To supplement the app, The Facts about Fasting during Ramadan information kit lays out some key facts on fasting, tips prior to fasting, a blood sugar level tracker to track blood sugar levels on a daily basis, as well as a calendar to document the time for prayer and breaking fast.

“MSD [Merck Sharp and Dohme] recogniz-es the unique challenges faced by millions of people with diabetes around the world who choose to fast during Ramadan,” said Annie Chin, MSD’s managing director.

“We hope the app will support type 2 dia-betes (T2D) patients in better managing the potential health issues they may face as a re-sult of changing their eating patterns during Ramadan,” Ms Chin said.

“T2D patients in Malaysia who plan to fast

are strongly advised to undergo a pre-Rama-dan medical assessment with their health-care professional well before the month of Ramadan. Being able to record sugar levels throughout the day is extremely important and will allow physicians to better support diabetic patients in the management of their diabetes to ensure they don’t put themselves at risk of hypoglycemia or other diabetic com-plications,” said Nor Azmi Kamaruddin, a se-nior consultant endocrinologist and professor of medicine at Universiti Kebangsaan Malay-sia.

Prof Nor Azmi said patients should be on the lookout for symptoms of hypoglycemia, which could include sweating, headache, confusion and dizziness, anxiety, irritability and heart palpitations. He said it is important to remain well hydrated and to avoid unnec-essary exposure to heat, which increases the risk of hypoglycemia.

He also cautioned patients not to consume overly sweet drinks at the breaking of fast and eating too many dates as this causes spikes in blood sugar levels which are detrimental to health.

The Ramadan, Diabetes and Me mobile app is available for free via iTunes in English, Ara-bic and Bahasa Malaysia.

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Feature | Pharmacy Today | August 2013 Pediatric Digestive Health15


Feature

The escalating problem of childhood obe-sity globally has sparked interest in the influence of children’s eating styles on

dietary adequacy and maintenance of healthy weight. There is increasing recognition that problematic eating behaviors in early child-hood may predispose to later life eating be-haviors.

Picky or fussy eaters in early childhood can be worrisome for parents. Lacking the ability to express themselves coherently, young chil-

dren with feeding difficulties may cry, fuss, refuse to feed, choke or even regurgitate after feeding. Parents have every reason to be con-cerned because feeding difficulties in children may lead to undesirable consequences such as weight loss, delayed development, frequent infections and failure to thrive.

Fussy eaters equal stressful mealtimesMealtimes with fussy eaters can be extremely challenging for parents or caregivers. In order



to get their children to eat, more than 90% of parents with young children prepared foods that their children liked, accommodated spe-cific requests, and bribed, rewarded or even pacified them with sweets.1

Recently, a survey suggested that inappro-priate feeding habits practiced by Asian par-ents and caregivers may lead to feeding dif-ficulties in children. This survey noted that more than 65% of parents fed their children inappropriately:l13% of parents lacked time and relied on

grandparents’ or nannies to feed their children

l14% pressured their children to eat de-spite their crying and resistance

l19% continued to hand-feed their older children

l23% used distractions like TV programs or toys to bribe their children to eat

While the intention is noble – to endorse good nutrition and healthy growth – such meth-ods may actually backfire. Children may ex-perience fear of or even develop aversion to eating which can lead to feeding difficulties. Numerous studies have demonstrated that children who are pressured to eat actually ate less and are smaller in size. Interestingly, chil-dren consumed more food when they are not pressured to eat.2-4

The feeding process: Role of mothers in trusting the childMost, if not all, mothers worry that their chil-dren are not eating enough. Feeding is ex-tremely important in a child’s early life when viewed in terms of actual time spent and its consequences to normal growth and devel-opment. However, feeding goes beyond just good nutrition and healthy growth. It can be regarded as one of the earliest ways to estab-lish a nurturing relationship between mother and child.

Appropriate feeding practices right from the start support children in achieving devel-opmental tasks at every stage. It also helps to instil positive eating attitudes and behaviors, which have long-term benefits. Feeding dif-ficulties, therefore, not only impede normal growth and development, but also reflect dis-tortions in parent-child interactions that can interfere with the child’s positive psychosocial development.5

The feeding process can be regarded as a complex of mother-child interactions as they engage in food selection, ingestion and regula-tion of eating behaviors. Mothers need to realize that their role in this is to provide healthy food, establish meal times and to determine where meals are given. On the other end, the child is responsible for how much is eaten or even whether anything is eaten. Successful feeding, therefore, requires a caretaker (i.e. mothers) who trusts and depends on information/cues coming from the child about timing, amount, preference, pacing and eating capability.6

In our weight-obsessed society, a robust child with a hearty appetite may be restricted from enjoying the food he or she likes because parents assume that the child may get fat. Such parental behavior may breed ‘forbid-den food’ syndrome where children who don’t get enough to eat or fear they won’t, become preoccupied with food and overeat whenever they have the chance to. Similarly, parents may push a small, thin child with a small appetite to “finish what’s on your plate” or “just three more mouthfuls”, assuming that they need to fatten him or her up. It usually backfires be-cause the child becomes turned off by the food and tends to undereat when he/she gets the chance.

Regardless of their physical sizes or appe-tites, all children instinctively know how much to eat and will stop when they are full (even in the middle of a bowl of ice cream). There-fore, to establish early competent eating habits


that will help them to eat the right amount and choose what is appropriate in their lifetime of eating, children need to be allowed to be sensi-tive to their internal sensations of hunger, ap-petite and satiety.

The Satter Feeding Dynamics Model The Satter Feeding Dynamics Model (fdSat-ter) illustrates that at each stage of childhood development, when parents take leadership and feed according to the developmentally appropriate Satter Division of Responsibil-ity (below), children gradually develop eat-ing competence step-by-step throughout the growing-up years. That is, children will re-tain positive attitudes about eating and about

food, learn to behave appropriately during meals, pick and choose from foods that par-ents make available during meals, eat as much or as little as they need and learn to enjoy the food that parents eat.

References:

1. Sherry B, et al. J Am Diet Assoc 2004;104:215-221.

2. Galloway AT, et al. Appetite 2006;46:318-323

3. Fisher JO, et al. J Am Diet Assoc 2002;102:58-64.

4. Wardle J, et al. J Am Diet Assoc 2005;105(2):227-232.

5. Satter EM. The Satter Feeding Dynamics Model of child overweight

definition, prevention and intervention. In: O’Donahue W, Moore BA,

Scott B, eds. Pediatric and Adolescent Obesity Treatment: A Comprehensive

Handbook. New York: Taylor and Francis; 2007:287-314.

6. Satter EM. J Am Diet Assoc 1986;86:352-356.

Stage Parents' responsibility Child's responsibility

Infancy l Responsible for the what*

Parents choose breast- or formula-feeding, help the child be calm and organized, then feed smoothly, paying attention to the cues coming from the child about timing, tempo, frequency and amount

Responsible for how much (and every-thing else)

Older babies making transition to family food

l Responsible for the what*l Is becoming responsible for when and

where the child is fed

Parents guide the child's transition from nipple feeding through semi-solids, then thick and lumpy food, to finger food at family meals based on what the child can do, not on how old he/she is.

Responsible for how much and whether to eat the foods offered by the parent.

Toddlers through adolescents l Responsible for what*, when, where

Fundamental to parent's responsibility is trusting children to decide how much and whether to eat. If parents do their job in feeding, children will do their jobs in eating.

Responsible for how much and whether

©2013 www.EllynSatterInstitute.org * Here, what refers to the type of food being consumed

PTAPR-13/001

PT IMPACT Rottapharm Viartril-S.pdf 1 2/28/13 2:08 PM


Just like learning to walk, children need help in learning to eat well. Establishing patterns of set meal and snack times, eat-

ing as a family or even positive encourage-ment about the food can help children to en-joy foods that are good for them. However, it is important to establish these patterns very much earlier on during childhood as it has been shown that older children (usually ages 5 onwards) may have developed entrenched habits that are difficult to change.

Fundamental to building positive eating at-titudes in children, parents need to be clear on their’s and the child’s role in the feeding-eat-

ing relationship. Essentially, parents’ feeding jobs are to:l choose and prepare the foodl provide regular meals and snacksl make eating times pleasantlshow children what they have to learn

about food and mealtime behaviorlbe considerate of children’s food inexperi-

ence without catering to likes and dislikeslnot let children have food or beverages

(except for water) between meal and snack times

l let children grow up to build bodies that are right for them

Tips to positive eating attitudes in early childhood


At the same time, parents need to be aware and trust their children with the following eat-ing principles:lchildren will eatlthey will eat the amount they needlthey will learn to eat the food their parents

eatlthey will grow predictablylthey will learn to behave well at mealtimes

The following are some tips that are useful for parents to establish positive eating behav-iors in children.

1. Having set meal times. Having definite times for main meals and snacks helps children to develop feelings of hunger or satiety. This can be established from almost-toddlers onwards when children are able to sit at the family table for meals.

It is important that during meals, parent(s) or caregivers (grandparents/nannies) sit with the child and eat with him/her - not just feed the child. Resist using distraction methods (e.g. toys or TV programs) to entice children to eat. Children need to associate that meal times are meant to be taken at the family table. Re-ducing background noise, like switching off the TV, also helps children to concentrate on their food during mealtimes.

Just like adults, children can get hungry in between meals. Sit-down snacks are perfect solutions for the child who did not eat much during earlier meals and parents worry that he/she might be starving before the next meal, or the one who ate well but happened to think of cookies and starts begging.

Bear in mind that snacks are little meals and therefore should be nutritious (not junk food) and not regarded as just any food hand-outs. As with main meals, sit to snack so that children can concentrate on eating and not walk around or eat while doing other activi-ties. Time snacks in such a way that children

have time to get hungry again before the next meal.

2. Selecting healthy food Meals for children should be prepared with fresh food. As much as possible, avoid over-cooking as this will reduce the amount of nu-trients and vitamins in food. Healthy cooking tips and eating habits to prevent lifestyle dis-eases in adulthood apply for children as well. Therefore it is prudent to start instilling those healthy eating habits early.

Young children are notoriously fussy when it comes to eating vegetables and can refuse feeding even at the slightest hint of vegetables. Certainly, telling children to “eat those carrots because they’re good for you” is not going to work as it may cause them to further dislike and avoid vegetables. The trick is to eat with them. Research has shown that parents who ate more fruits and vegetables have children who ate more fruits and vegetables as well. In contrast, parents with low intake of fruits and vegetables, tend to use greater pressure to get their children to eat those vegetables which re-sult in lower fruit, vegetables and micronutri-ent intake in their children.

3. Eating as a family. It is true that children mimic what their par-ents do. Although many parents are conscious


of this, many do not realize that it applies to every aspect of life, right down to fostering good eating habits in children. Therefore, watching others eat during mealtimes is an important part of teaching children to eat.

Family meals let everyone in the family go to the table hungry and eat until they get enough. By setting time aside to eat as a fam-ily, every member gets to pay attention to the meal – enjoy it when it is time to eat and for-get about it between times. This actually helps both parents and children to eat the amount they need and avoid overeating. At the same time, by allowing children to watch their par-ents eat, children also begin to learn to eat and enjoy a variety of food.

Family meals benefit both parents and chil-dren. Research has shown that adults who have regular meals eat better, are healthier and slimmer. Similarly, children and teenag-ers who have family meals eat better, feel bet-ter about themselves, socialize better and do better in school. As the saying goes, the family who eats together stays together holds true. Family meal times are more about raising healthy, happy children and fostering closer family ties.

Many modern families largely consist of dual-income families, making a three-family meal schedule almost impossible. As much as possible, parents should plan to have at least one meal together (for e.g. dinner) as a family. Among young working Malaysian parents, the responsibility of feeding children often lies on the shoulders of grandparents or nannies. Therefore it is important to encourage these caregivers to eat with the child or if this is not feasible, to sit and talk to them as they eat.

4. Responding to the child’s hunger signal. The important point here is to be sensitive to

the information or cues that the child is giving when he/she is hungry. Every child has a differ-ent way to indicate they are hungry, so be obser-vant. Successful feeding happens when parents and caregivers allow children to determine the timing, amount, preference, pacing and eating capability. The role of parents is to be there to guide their children instead of controlling them, set limits and be good role models. This includes talking about food in a positive way and prac-ticing healthy eating behaviors.

Parent are encouraged to be patient at meal-times as well. The key thing is to make meal-times enjoyable. So expect children to spill – just be prepared and keep a towel handy. Similarly, be patient when introducing new food items to children. It helps to introduce new food when the child feels good or if they are hungry. Some children may need repeated attempts before they finally accept the new food. Typical failures in feeding children stem from parents not being able to wait until their child feels hungry to feed them or lacking the patience to wait until the next mealtime to feed the child again.

Diagnosing feeding difficulties in early childhoodAny problem that negatively affects the pro-cess of parents or caregivers feeding children is considered a feeding difficulty. Feeding difficulties in young children are often over-looked and, therefore, underdiagnosed. In reality, the prevalence of feeding difficulties worldwide is high – one in every four children experiences some form of common feeding difficulties, which goes up as high as 80% in developmentally delayed children.1

Dangers of untreated feeding difficultiesIt is a misconception to view early childhood


feeding difficulties as a passing phase which the child will grow out of eventually. Experts are beginning to recognize that a wide range of causes contribute to feeding difficulties, ranging from physiological factors such as ap-petites and genetics, to psychological issues such as struggle for autonomy and the level of affection or adverse interactions between par-ent and child.

Feeding difficulties, if untreated, has ex-tensive deleterious implications. Research has shown that ‘picky eaters’ may not get the daily requirement of vitamin C and E intake; and have lower intake of protein, energy, fat as well as fruits and vegetables.2 Moreover, approximately 10% of children with feeding difficulties were below the fifth percentile for weight gain at age 30 months compared to less than 5% seen in children with no feeding difficulties.3

Feeding difficulties can lead to emotional and cognitive limitations as well. Not only do children with feeding difficulties experience significantly more negative touching and significantly less affectionate touching than children without feeding disorders,4 they are also more likely to have delays in their men-tal developmental index (MDI) relative to healthy eaters.5 Furthermore, feeding difficul-ties reflect impaired parent-child interactions where such children are far more likely to be subjected to excessive parental anxiety, and have behavioral problems including anxiety, depression, somatic complaints and even de-linquency.

IMFeDTM: A useful tool for healthcare pro-fessionals to diagnose feeding difficultiesMost feeding difficulties tend to develop in the second year of life, during children’s tran-sition to self-feeding. Although all parents are

naturally concerned when their children are not eating well, most may not be conscious of their key role in the feeding process to model eating behavior and establish feeding practic-es in their children. This is where healthcare professionals play the pivotal role in guiding parental behaviors and interactions with their children.

The continuum of feeding difficulties rang-es from picky eating to autism. Any of these behaviors i.e. feeding difficulty due to an or-ganic disease, infantile anorexia, food aller-gies, food aversion, food selectivity, food re-fusal, selective eating, colic, fear of feeding, post-traumatic feeding disorders, and even parental misperception all fall somewhere on this scale. Up until recently, accurate diagno-sis of feeding difficulties was hampered not only by the wide diversity of this disorder but also a lack of standardized definition and ter-minologies to describe feeding difficulties.

IMFeDTM (Identification and Manage-ment of Feeding Difficulties) is a new and easy-to-use diagnostic tool to help healthcare professionals in accurately identifying and managing children with feeding difficulties. Recently made available in Malaysia, IM-FeDTM stratifies children with feeding diffi-culties into a classification system created by Professor Dr Irene Chatoor and Professor Dr

IMFeDTM: Six commonly encountered feeding difficulties in children

Highly selective intake

Poor appetite that is a parental misperception

Poor appetite in a child who is fundamentally vigorous

Fear of feeding

Poor appetite due to organic disease

Poor appetite in a child who is apathetic and withdrawn


Benny Kerzner, two distinguished experts on feeding difficulties from the George Washing-ton University, USA.

Using the IMFeDTM tool, healthcare pro-fessionals can make use of the information on feeding difficulties encountered by parents in their children and classify them according to the following categories:

The IMFeDTM is more than just a diagnos-tic tool. It also provides comprehensive treat-ment and management strategies to guide healthcare professionals and parents in the care of children with feeding difficulties. Essentially, the IMFeDTM consists of the fol-lowing elements: lA patient questionnaire to gather informa-

tion about a child’s feeding patterns.lThe IMFeDTM interactive diagnosis tool,

which allow healthcare professionals to match the conditions described by parents in the patient questionnaire to the six com-mon types of feeding difficulties.

lParental guidance sheets which consists of growth charts and brochures for health-care professionals to recommend as inter-ventions for conditions that can be man-aged at home.

l Suggested management plans to health-care professionals for those conditions where physician management is the only option.

References:

1. Manikam R, et al. J Clin Gastroenterol 2000;30(1):34-46.

2. Galloway AT, et al. J Am Diet Assoc 2005;105:541-548.

3. Wright CM, et al. Pediatrics 2007;120:e1069-e1075.

4. Feldman R, et al. J Am Acad Chil Adolesc Psychiatr 2004;43:1089-1097.

5. Chatoor I, et al. Pediatrics 2004;113:e440-e447.

The IMFeDTM Malaysia Program currently offers training

workshops for healthcare professionals who are interested

to learn more about IMFeDTM. Conducted by a panel of local

experienced specialists, these workshops provide in-depth

training as well as the latest clinical updates on identification

and management of feeding difficulties in children. Health-

care professionals who are interested to learn more about

the IMFeDTM diagnostic toolkit or the IMFeDTM workshops

should contact their nearest Abbott Nutrition representative.

Spotlight | Pharmacy Today | August 2013 24

Advice on ingredients not to be sneezed at

Spotlight

Consumers are taking a more active role in selecting cough and cold products, but pharmacists still have an impor-

tant role in making sure the product is right for individuals and their symptoms.

To recommend the right treatment, the pharmacist should first find out the main symptoms of their cold, such as whether they

have a dry or a chesty cough, if they are tak-ing other medications and how long they have been sick.

New Zealand’s Amcal Bayside Pharmacy manager Emma Batey said that over the last few years there has been a trend toward peo-ple requesting cough and cold products that come in a day-and-night formula.

Trends in the cough and cold category include requests for night-and-day formulations, as well as a move to prevention rather than treatment, as Pharmacy Today New Zealand finds out

It is important to talk to people about cough and cold medicines to avoid contraindications or overdosing


“It helps them get through the day and also helps them sleep at night, so it’s quite a good choice.”

Night-time formulas often contain an anti-histamine to help people breathe through the nose.

However, it is important to have a conver-sation with people about these products as there may be a more suitable and effective op-tion, Ms Batey said.

Decongestants can increase blood pres-sure, so they may not be suitable for people with blood pressure issues or those who are taking blood pressure medication.

It is very rare that such products would have an adverse effect on these people, but pharmacists should always take it into ac-count, Ms Batey said.

People with blood pressure problems could instead use a nasal spray and take ibuprofen.

Natural health products containing horse-radish, garlic, vitamin C or zinc can help treat a chesty cough.

Pharmacists should keep an eye on ingredientsPharmacists should be aware of the active in-gredients cold treatments contain.

Some cough syrups contain full-dose paracetamol, so the person should not be tak-ing any other paracetamol on top of this.

“If you are giving many of those kinds of products that have multiple ingredients in them, like a decongestant and maybe some kind of cough suppressant and paracetamol, then you’d always want to let them know.”

Most people aren’t aware of how much paracetamol is contained in some cough products, Ms Batey said.

Lozenges mainly for relief, rather than treatmentMost lozenges soothe the throat, but they

do not treat the root cause of the pain, she said.

On the other hand, there is at least one type of lozenge on the market which contains anti-inflam-matory properties.

Natural lozenges, such as the honey-based variety, are safe to take regularly and can ease pain and irritation.

A throat spray or a gargle is a better recom-mendation for treating sore throats, Ms Batey said.

Pharmacybrands says category continues to growNew Zealand’s pharmacy retail group Phar-macybrands has just completed a review of its cough and cold category, which shows sales are positive and within the three top-selling categories.

This success story is helped by “innova-tive new product development and collabora-tive supplier engagement,” Pharmacybrands group merchandise manager Craig Tomilson said in a statement.

The cough and cold category is a market-ing priority for Pharmacybrands and suppli-ers, Mr Tomilson said.

Natural health product sales are increas-ing, particularly as a method of cough and cold prevention.

Pharmacybrands also continues to train staff on the category to ensure customers re-ceive the best advice.

“Market-leading brands and vendors con-tinue to drive consumer awareness in ‘cough and cold’ and this, combined with the real-ity that only in a pharmacy can a consumer have a real consultation with a health pro-fessional, ensures they are directed towards the right product for their unique situation,” Mr Tomilson said.


Natural products popular for prevention of coldsThere is also a growing trend toward people taking preventative measures before they get a cold, Ms Batey said.

“You tend to see a lot of people coming in for natural health products as a preventative and looking for something they can take all throughout winter to help keep their immune system up and to prevent infections.”

People can take immune-boosting prod-ucts containing natural ingredients such as echinacea, zinc and olive leaf preparations.

Kaeo Chemist in New Zealand stocks cough and cold medicines and natural health product options, but owner Viv Bath said she is about to undertake her own review of the

category due to poor sales of some products, particularly natural products.

“We’ve been writing off more of the stuff than we’ve been selling,” Ms Bath said.

As the pharmacy is located in a lower so-cioeconomic area, it is important not to over-stock expensive products.

Pharmacy staff do not tend to discuss nat-ural health options unless people specifically request them as they tend to be more expen-sive, Ms Bath said.

Instead, staff often suggest products such as saline nose drops, which help with congestion.

Pharmacists should provide people with general advice, such as the importance of bed rest and increasing fluid intake, alongside recommending products.

New Zealand in the grip of whooping cough outbreak

New Zealanders who were plagued by a persistent cough for more than a few weeks last winter may have

been suffering from whooping cough without knowing it.

The country has been in the grip of a whooping cough outbreak since 2011, result-ing in hundreds of hospitalizations and two deaths.

But many adults could have contracted the illness – also known as 100-Day Cough or per-tussis – and mistakenly believed it was just a ‘normal’ nagging cough.

The number of whooping cough cases has been rising rapidly, according to public health surveillance records from the Institute of En-


vironmental Science and Research Ltd (ESR).

The director of Auckland University’s Im-munisation Advisory Centre (IMAC) Nikki Turner said it can be difficult to diagnose whooping cough amid the many coughs and colds which break out during winter.

The distinctive noise from which whoop-ing cough derives its name is not always evi-dent, and pharmacists may need to question a patient to identify the ailment.

“It’s sometimes hard to recognize. It tends to come in bouts. People may go red in the face and some people vomit or feel nauseous. Anyone with a cough for more than two weeks – 10% to 20% of those will be whoop-ing cough. A huge number of people in the community are carrying it without realizing,” Dr Turner said.

Vaccinations first line of defenseSince January, the government’s drug-fund-ing agency Pharmac has offered free whoop-ing cough vaccinations for women between weeks 28 and 38 of pregnancy, and Dr Turner is keen to see pharmacists play a role in mak-

ing people more aware of it.“Many pregnant women are unaware of

pertussis vaccinations in pregnancy. It would be fantastic to let people know this is going to offer some protection to unborn babies and for pharmacists to be aware there is a lot of pertussis around and the importance of vac-cinating on time.”

If pharmacists suspect someone has whooping cough, they should refer the per-son to a GP, Dr Turner added.

All babies and children in New Zealand are eligible for free immunizations against whooping cough at six weeks, three months and five months old. All children also receive free boosters at four and 11 years of age.

Pharmacists may become even more in-volved in the fight against the disease by ad-ministering a combined whooping cough, diphtheria and tetanus jab to adults if a bid for reclassification gets the nod.

A request by Pharmacybrands to reclassify the single-dose booster-vaccine, Tdap, was met favorably at a Medicines Reclassification Committee Meeting last October.

The committee was due to reconsider the submission at its April meeting now that Phar-macybrands has supplied more detailed infor-mation on patient selection and how a phar-macist would find out whether a patient has had the primary vaccination, Dtap, already.

If reclassified, Tdap will remain prescrip-tion only, except when given to someone over 18, by a pharmacist who has completed the Immunisation Advisory Centre vaccinator course.

A total of 5,938 pertussis notifications were reported

last year compared with 1,996 cases in 2011.

Between 1 January and 5 March this year, 1,039 per-

tussis cases were notified. Seventy-nine (7.6%) of the

notified cases were aged less than one year and 60

people were hospitalized. The areas most affected

are Canterbury and Waikato District Health Boards

(DHBs).


Avoid honey in babies under one

When treating children with colds, it is important that pharmacists base advice on the children’s ages, not

just their symptoms, to ensure they use the safest and the most effective methods.

New Zealand’s Urban Pharmacy owner Tae Wu said parents are increasingly anxious about their children using cough and cold medications, and often request natural health products to boost their immunity.

Staff at the Papakura pharmacy will often recommend products containing echinacea and honey.

New Zealand’s Best Practice Advocacy Centre (BPAC) states on its website that hon-ey should be used only by children over the age of one due to its rare association with in-fant botulism.

It can be stressful and emotional for par-ents when their child has a cold, particularly if the child is young, Mr Wu said. A pharma-cist can provide parents with advice, but also remind them they can go to a GP for a second opinion if they wish, he said.

Kaeo Chemist owner Viv Bath is reluctant to recommend cough suppressant medica-tions for young children as this can prevent them from clearing mucus from the system.

Instead, Ms Bath recommends saline drops as a nasal decongestant for children over the age of two, and honey-based products for children over the age of one.

Treatment options for children under the age of two are limited, Ms Bath said.

Pharmacy staff spend a lot of time explain-ing to parents that the pharmacy stocks mini-mal cold treatments for children under the age of six due to guidelines produced by New Zealand’s Medicines and Medical Devices Safety Authority (Medsafe).

Medsafe’s 2010 guidelines state that cough

and cold products containing the follow-ing ingredients should only be used in chil-dren over the age of six: brompheniramine, chlorpheniramine, diphenhydramine, pro-methazine, tripoldine, dextromethorphan, pholcodine, guaifenesin, ipecacuanha, phen-ylephrine or pseudoephedrine. The best treat-ment option for this age group is paracetamol liquid or ibuprofen liquid, which clear “stuffy noses,” Ms Bath said.

Paracetamol also treats the pain and fever as-sociated with a cold. Ibuprofen can help with headaches, earaches, and muscle and joint pain.

Medsafe advises that preparations contain-ing only bromhexine – mucolytic – or intra-nasal decongestants, such as oxymetazoline and xylometazoline, remain restricted to use in children aged over two years.

It is important to keep a close eye on young children with a cold, particularly babies, as they can deteriorate extremely quickly, Mr Wu said. Parents should also monitor their babies – if an infant is particularly grumpy and unsettled, it is best to consult a GP to rule out any other health conditions.

If the child has a stiff neck and spots on the skin which remain visible when pushed down on, the parent should take the child to the GP to rule out meningitis.


Pharmacy Update brings you updates on disease management and advances in pharmacotherapy based on reports from symposia, conferences and interviews, as well as latest clinical data. This month’s updates are made possible through unrestricted educational grants from MSD.

Improving CV health in T2DM patients with newer agents • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •P30

Pharmacy UPDATE

Smart Rx. Every Time.

www.MIMS.com

30 Pharmacy Update

Improving CV health in T2DM patients with newer agents

Patients with type 2 diabetes mellitus (T2DM) generally have a two- to four-fold increased risk of cardio-

vascular (CV) disease compared to non-diabetics, as well as a higher mortality risk. Therefore, it is important to keep patients to target, and this is possible with newer antidiabetic agents, says an expert.

CV events account for approximate-ly 70 percent of deaths in older patients with T2DM [National diabetes fact sheet, 2011, www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf Accessed on 26 June]

There has been much controversy sur-rounding the effects of antidiabetic medi-cations on CV disease risk, Professor Dato’ Dr. Mafauzy Mohamed, a senior consul-tant endocrinologist and director of the Health Campus, Universiti Sains Malaysia, Kelantan, told Medical Tribune. Observa-tional studies have found sulfonylureas to increase CV risk, but this has not been replicated in randomized controlled trials. Sulfonylureas are thought to increase CV risk due to their effect on the heart’s sul-fonylurea receptors, which affect ischemic preconditioning. Gliclazide, which does not bind to the heart’s sulfonylurea recep-tors, appears to have lower CV risks com-pared to other sulfonylureas, he said. (Eur Heart J 2011;32(15):1900-8)

The glitazone class of medications have been found to increase the risk of heart fail-ure. Rosiglitazone, in particular, has also been noted to increase the risk of myocar-dial ischemia. It is thought that the possi-ble reasons could be fluid retention, heart

failure, weight gain and a slight increase in LDL-cholesterol concentration, he said. However, in randomized studies such as the Diabetes Reduction Assessment with Ramipril and Rosiglitazone Medication (DREAM) trial, A Diabetes Outcome Pro-gression Trial (ADOPT) trial and Rosigli-tazone Evaluated for Cardiovascular Out-comes in oral agent combination therapy for type 2 Diabetes (RECORD) trial, rosi-glitazone was not found to significantly in-crease major adverse cardiac events except in the case of heart failure. The signal for increased risk of myocardial ischemia or myocardial infarction actually came from meta-analyses, he said.

The findings from this study are

consistent with previous reports

which found that sitagliptin does

not increase CV risk compared to

other treatments and placebo

‘‘

31 Pharmacy Update

This conflicting data have led to con-cern on the part of doctors to treat T2DM patients, fearing that medicating patients may increase CV events. The only medi-cation that has been shown to reduce CV disease in obese T2DM patients is metfor-min, as shown in the UK Prospective Dia-betes Study (UKPDS). (Br J Clin Pharmacol 1999;48(5):643-8)

Dipeptidylpeptidase-4 (DPP-4) inhibi-tors are a newer class of antihyperglycemic therapy that improve glycemic control by inhibiting the inactivation of the incretin hormones, glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic poly-peptide. Sitagliptin (Januvia®, Merck Sharp & Dohme), was the first agent approved in this class of antihyperglycemic agents. To date, DPP-4 inhibitors (sitagliptin, saxa-gliptin, vildagliptin, linagliptin, and alo-gliptin) have not been shown to be associat-ed with an increased risk of cardiovascular events. (Cardiovasc Diabetol 2013;12:3. doi: 10.1186/1475-2840-12-3)

The findings from this study are con-

sistent with previous reports which found that sitagliptin does not increase CV risk compared to other treatments and placebo. Taking DPP-4 inhibitors typically leads to weight loss, in addition to a very low risk of hypoglycemia, he said.

A meta-analysis of DPP-4 inhibitor trials has not shown an increased risk of CV dis-ease. There are ongoing long-term random-ized, double-blind control trials looking at CV events in patients on DPP-4 inhibitors (such as the Sitagliptin Cardiovascular Outcome Study (TECOS) and Cardiovas-cular Outcome Study of Linagliptin versus Glimepiride in Patients with Type 2 Dia-betes (CAROLINA)). GLP-1 has also been shown that it may have a beneficial effect on the heart.

Data so far showed that sitagliptin does not appear to increase the risk of CV disease, as observed from the vari-ous short term trials. It can be used safe-ly when prescribed according to the ap-proved indications and patient conditions, he added.

Clinical Pharmacy | Pharmacy Today | August 2013 32

Acne can be managed

Clinical Pharmacy

By Dr Hew Yin Keat MB BCH BAO Malaysia Aesthetic Clinic Kuala Lumpur

Epidemiology and demographicsAcne vulgaris (common acne) is the most com-mon skin disease. It is a chronic condition in which there is a blockage or inflammation of hair follicles and the accompanying sebaceous glands.

Acne can appear as skin-colored bumps (comedones), pustules, nodules or cysts. It is usually first seen in the teenage years when there is a spike in the levels of hormones es-sential for the development of secondary sexu-al characteristics, in particular testosterone and other androgens in both males and females. Testosterone and other androgens increase the production of sebum from the sebaceous glands and this initiates the cycle of acne for-mation.

The prevalence of acne is estimated to be about 80% in teenagers. In adults between the ages of 30 and 50, it may be as high as 20%. It af-fects both men and women. While it is usually more severe in men, it is frequently more per-sistent in women. Up to 60% of affected people seek treatment for acne, often with products bought over the counter. It is estimated that about 30% of teenagers have acne that ideally requires medical treatment.

Beginning with the increase in sebum pro-duction, many other factors then come into play, resulting in the formation of different de-

grees of severity of the disease. There is a genet-ic predisposition for acne as there is a tendency for severe, scarring acne to run in families. Ex-ternal factors include the use of inappropriate make-up or skincare, certain medications that may have a direct or indirect androgenic effect, the rupturing of microcomedones by excessive mechanical pressure or manipulation, and en-vironmental factors like heat and humidity.

Although there is a general assumption that acne may also be affected by lifestyle changes, there is a lack of good quality evidence from randomized controlled trials (RCTs) on the effects of dietary interventions, hygiene mea-sures or exposure to sunlight. As such, we have to be cautious in drawing firm conclu-sions from them.

Studies which found no relationship be-tween acne and chocolate or sugar consump-tion had small sample sizes and were of lim-ited quality. One study using self-assessment questionnaires found a correlation between poor dietary habits and acne before exams. However, the confounding factor of stress was not taken into account and the methodology was poor.

A study of adolescents in Singapore showed a statistically significant correlation between stress levels and the severity of acne. Another study showed a link between a high glycemic

Recognised byAcademy of Pharmacy

Earn 1CPD pointevery month


index and load diet and worsening acne, and an improvement was seen on modifying the diet.

There is also a study linking consumption of milk and dairy products with the severity of acne. Dairy products may be made from the milk of lactating dairy cows injected with hor-mones used to boost milk production, which could possibly be converted by the human body into metabolites with androgenic prop-erties.

PathogenesisDuring puberty, there is increased testosterone production, which stimulates the sebaceous glands to produce more sebum, which leads to seborrhea (greasy skin). In people who are prone to acne, there is (1) abnormal follicular hyperkeratinization, which results in the for-mation of a plug of keratin (dead skin cells) and sebum at the follicle – a microcomedo results. These microcomedo, as the name suggests, are microscopic and invisible to the naked eye. As the plug size increases and (2) a buildup of se-bum develops behind it, they become visible as comedones or whiteheads. Some of these rupture and the plug is expelled to form open comedones or blackheads. (3) Bacterial coloni-zation of the comedones can ensue, typically with the naturally occurring commensal Pro-pionibacterium acnes and to a lesser extent P. granulosum. (4) Inflammation and pus forma-tion then occurs due to an immune reaction to chemotactic chemicals released by the coloniz-ing bacteria, resulting in an acne lesion or pus-tule.

Clinical profileAcne usually occurs on areas of skin where the concentration of sebaceous glands is densest. It principally affects the face (99% of people), the back (60%) and the chest (15%).

The acne lesions can be either inflammato-ry or non-inflammatory, or a mixture of both.

Non-inflammatory lesions are open (white-heads) and closed comedones (blackheads). Inflammatory lesions are papules, pustules, nodules (deep pustular lesions) and cysts.

The skin of people with acne can be:lOily, with faint shiny sheen at the forehead,

nose and chin.lThickened, due to poor natural exfoliation.lDull, due to uneven texture as a result of

acne lesions.

Differential diagnosisAcne vulgaris is rarely misdiagnosed, but there are conditions that mimic the signs of acne. These are:lRosacea: It is a condition most often con-

fused with acne. It usually appears in older people and has a central face distribution. Its main symptom is facial flushing. There is also an absence of comedones, nodules and scarring.

lGram negative folliculitislPerioral dermatitislAcneiform drug eruptionslEosinophilic pustular folliculitisl Milia: These are small keratin cysts that

may be confused with whiteheads. They are mostly found around the eyes.

ComplicationsThe development of complications is a cru-cial aspect of why acne cannot be trivialized. It needs to be treated seriously and, in some cases, attempted to be resolved as quickly as possible.

Besides the disfiguring marks of acne on the face leading to poor self-esteem and reduced quality of life, the following complications can also occur:lHyperpigmentation: This occurs as post-in-

flammatory hyperpigmentation at almost every pustular lesion. Whilst an inflam-matory lesion usually lasts about a week, these red or brown spots may only resolve


in three months to two years, adding to the patient’s sense of disfigurement. Fortunate-ly, these spots almost always resolve, but some can last indefinitely unless treated.

lScarring: Acne vulgaris can cause exten-sive and permanent scarring. Scarring is al-ready present in up to 90% of people who visit a dermatologist, but is usually mild and only visible on scrutiny or magnifica-tion. However, it has been estimated that up to 20% of those with acne have signifi-cant scarring (socially noticeable). Scarring can be either atrophic (sunken) or hyper-trophic (raised), but it is usually the former that occurs.

lPsychological problems: The appearance of acne on the most vis-ible part of a person can cause significant psychological problems, including anxiety and depression. This can make the patient suffer from embarrassment and avoid so-cial interaction, thus reducing quality of life. Studies have shown patients to have decreased self-esteem, social withdrawal and anger. Younger people with acne can often be subject to bullying and stigmatiza-tion by their peers, who might believe the condition is due to avoidable lifestyle fac-tors. Suicide has been reported as a conse-quence of the distress caused by acne.

AssessmentAcne can be classified as mild, moderate or se-vere.lMild acne predominantly consists of non-

inflammatory comedones.lModerate acne consists of a mixture of

non-inflammatory comedones and inflam-matory papules and pustules.

lSevere acne is characterized by nodules and cysts, as well as a preponderance of in-flammatory papules and pustules.

lScarring indicates previous episodes of se-vere acne and its presence warrants more

aggressive treatment to prevent further scarring.

lAcne congloblata and fulminans are se-vere variants that require immediate re-ferral.

ManagementMany guidelines are available to the clinician for the management of acne. The most compre-hensive, logical and peer-reviewed guidance is contained within the treatment algorithm pub-lished by the Global Alliance to Improve Out-comes in Acne, authored by a panel of interna-tional dermatologists. This algorithm is shown in the table below.

MedicinesTopical therapiesPatients with mild acne usually require topical treatment alone. Those with more extensive acne should be prescribed topi-cal agents in conjunction with appropriate oral therapy. Many topical preparations are available, and the choice of preparation will depend on the type of lesions seen on clini-cal examination.

Patients with mixed lesions should be prescribed therapy that is active against microcomedones, comedones and inflam-matory lesions from the outset. No single topical agent can affect all the etiological factors implicated in acne pathogenesis, and a combination of preparations may be needed for a successful outcome.

Response to topical agents can be slow, and it is important that patients have realistic ex-pectations of their response to therapy. Patients should also be informed that topical therapy should be applied to all areas of skin within the active site and not just to the visible lesions, as normal skin in an acne-prone site is likely to have many evolving microcomedones. The table below summarizes the actions of topical agents on each etiological factor.


Topical retinoidsRetinoic (vitamin A) acid is available in the form of tretinoin gel or cream (0.01-0.025%) and its isomer, isotretinoin gel (0.05%). A third-generation retinoid-like drug, adapalene (gel or cream; 0.1%), also licensed for mild-to-mod-erate acne, has a significant and rapid anti-in-flammatory action and is better tolerated than its predecessors.

Vitamin A and other retinoids reduce ab-normal growth and development of keratino-cytes within the pilosebaceous unit. Reversal of the hyperkeratinization within the follicu-lar canal, as well as the induction of acceler-ated proliferation of the follicular epithelium, helps to ‘unplug’ the follicle. This, in turn, in-hibits development of microcomedo and non-inflammatory lesions, resulting in less anaero-bic conditions, a reduction in P. acnes growth and a microenvironment less favorable for the development of inflammation. In addition, the newer retinoids reduce the rupture of comedo-nes into the surrounding skin, also resulting in less inflammation.

All topical retinoids can produce irritant dermatitis, but this is less problematic with second- and third-generation agents and with cream formulations rather than gels. Patients should be warned that they may experience an initial flare of inflammatory lesions at the start of treatment. Due to potential photosensitiv-ity, topical retinoids are best applied at night and patients should not expose themselves to excessive ultraviolet light. The link between retinoids and teratogenicity is well established, but significant systemic absorption of topical retinoids has not been demonstrated. Recom-mendations are, however, that female patients should be advised to avoid pregnancy and discontinue use immediately should they con-ceive while on treatment.

Benzoyl peroxideBenzoyl peroxide (BPO) is a powerful antimi-

crobial agent that destroys both surface and ductal bacterial organisms and yeasts. Its li-pophilic properties permit penetration of the pilosebaceous duct, and its efficacy is largely against superficial inflammatory lesions. Once applied to the skin, BPO decomposes to release free oxygen radicals, which have potent bac-tericidal activity in the sebaceous follicles and anti-inflammatory action. It also has effects on non-inflammatory lesions by reducing fol-licular hyperkeratosis to some degree. BPO, as with topical retinoids, has no effect on sebum production.

Azelaic acidAzelaic acid is available as a 20% cream for acne. It has effects on comedogenesis by par-tially normalizing the disturbed terminal dif-ferentiation of keratinocytes in the follicular infundibulum. A direct anti-inflammatory ef-fect has been demonstrated, and it has been used successfully to treat post-inflammatory hyperpigmentation resulting from deep-seat-ed nodular inflammatory lesions. However, it is ineffective at suppressing sebum produc-tion, and the previously reported impact of azelaic acid on the function and population density of P. acnes has recently been chal-lenged. Azelaic acid cream is a generally well-tolerated preparation that can cause cutane-ous irritation, but this is usually less severe than with BPO or topical retinoids.

Topical antibioticsTopical antibiotics are beneficial for reducing inflammatory lesions through diminution of skin surface and follicular P. acnes. They exert their direct anti-inflammatory actions via an antioxidant effect on leukocyte chemotaxis, and suppress pro-inflammatory free fatty ac-ids and surface lipids. Topical antibiotics also have some effect on non-inflamed lesions by reducing perifollicular lymphocytes, which are involved in comedogenesis.


Increasing worldwide emergence of anti-bacterial resistance to P. acnes is an impor-tant consideration. Resistance is most prob-lematic with topical erythromycin, with 47% of patients in UK primary care harboring resistant strains of P. acnes, closely followed by clindamycin (41%) and tetracycline (18%).

There has been some correlation demon-strated between poor response and the pres-ence of antibiotic-resistant P. acnes. It is now recommended that topical antibiotics should not be used as monotherapy and should only be continued until such a time as visible clin-ical improvement ceases.

Mild Moderate Severe

Comedonal Papular/Pustular Papular/Pustular Nodular Nodular/ Conglobate

First Choice Topical Retinoid Topical Retinoid+ Topical Antimicrobial

Oral Antibiotic+ Topical Retinoid ± BPO

Oral Antibiotic+ Topical Retinoid ± BPO

Oral Isotretinoin

Alternatives Azelaic Acid or Salicylic Acid

Alt Topical Antimicrobial Agent + Alt. Topical RetinoidOr Azelaic Acid

Alt Oral Antibiotic+ Alt. Topical Retinoid ± BPO

Oral Isotretinoinor Alt. Oral Antibiotic+ Alt. Topical Retinoid± BPO/Azelaic Acid

High-dose oral Antibiotic+Topical Retinoid+BPO

Alternatives for Females

See first choice See first choice Oral Anti-Androgen+ Topical Retinoid/Azelaic Acid ± BPO

Oral Anti-Androgen+ Topical Retinoid/Azelaic Acid ± BPO

High-dose Oral Anti-Androgen+ Topical Retinoid

Maintenance Therapy

Topical Retinoid Topical Retinoid ± BPO

*BPO: benzoyl peroxide Source: J Am Acad Dermatol 2003;49:S1-37.

Table 1: Acne treatment algorithm

Therapies Sebum production

Hyper-keratinization

Inflammation Reduction in Propionibacterium acnes

Topical therapies

Retinoids – ++ + –

Benzyl peroxide – + ++ +++

Antibiotics – + ++ +++

Azelaic acid – + + +/–

Nicotinamide – + + +/–

Systemic therapies

Antibiotics – +++ +++

Hormonal therapy ++ ++ Indirect Indirect

Retinoids +++ ++ ++ ++

Adapted from Layton AM. Int J Clin Pract 2006;60(1):64–72

Table 2: A review on the treatment of acne vulgaris


NicotinamideTopical nicotinamide is available as a 4% gel to be used twice daily. It has anti-inflammatory actions. Double-blind studies have shown it to be more effective than the vehicle alone in older patients with acne, although consider-able improvement was noted with placebo. It has been demonstrated to be as effective as 1% clindamycin gel, and has the benefit over anti-microbials of not inducing P. acnes resistance, which may be of interest in patients requiring long-term maintenance therapy.

Systemic antibioticsAntibiotics were the first effective treatment for acne. They are the most widely prescribed agents and are indicated for severe inflamma-tory acne, extensive truncal acne and moderate facial acne not responding to topical therapies. Acne does not represent a classical bacterial infection and antibiotics act largely through exerting effects that are independent of their anti-bacterial actions, mainly through anti-inflammatory mechanisms. They reduce the numbers of P. acnes, Staphylococcus epidermis and pro-inflammatory mediators (e.g. TNF-α, IL-1 and IL-6) in the microcomedo, and modu-late the host response to these stimuli.

Systemic antibiotics should be prescribed in an adequate dosage, and the frequency and duration only continued for as long as they are deemed to be working. Patients with acne are often treated with multiple antibiotics and, as a consequence, their flora is exposed to a sig-nificant selective pressure for resistance devel-opment. Rotational antibiotics should, there-fore, be avoided, and if combining topical and systemic antibiotics, the same chemical type should be used to avoid the emergence of re-sistant strains of P. acnes to different classes of antibiotics.

Based on efficacy and safety data, and pop-ulation levels of bacterial resistance, tetracy-clines are recommended as the first-line an-

tibiotic of choice. Oxytetracycline (1 g/day) is frequently associated with poor compliance as it must be taken 30 minutes before food and not with milk to ensure adequate absorption. Second-generation tetracyclines are less likely to be affected by food and can be taken once daily. This aids adherence. Doxycycline (100–200 mg/day) should be used in preference to minocycline owing to its side effects. Tetracy-clines are contraindicated in children less than 12 years of age (age varies according to na-tional licenses) as they can discolor dentition. In pregnancy, they can result in the inhibition of fetal skeletal growth and should be avoided.

Trimethoprim (200 to 300 mg/day) has a similar efficacy to tetracycline, but does not have a license for acne and is reserved as a third-line antimicrobial agent for cases where there is proven resistance to other agents. It may also be used in young patients in whom tetracyclines are contraindicated. As it is used as a treatment for potentially serious cutane-ous and systemic infections, such as those caused by methicillin-resistant Staphylococcus aureus, it is advisable to limit its use to selected cases only.

There are documented cases of acne improv-ing with other classes of antibiotics, including oral azithromycin, cephalosporins and fluoro-quinolones. However, like trimethoprim, they are commonly used to treat a variety of sys-temic infections and, as such, their use should be restricted and discouraged in acne.

The question of duration of antibiotics in acne treatment has not been adequately re-searched, and any published recommenda-tions are not supported by strong scientific evidence. A total of three weeks is the reported minimum period before any obvious improve-ment is likely to be noted, and a minimum of three months, extending to six months with topical therapy, is required to achieve maxi-mum benefit.

A number of publications have proposed


how antibiotics should best be administered in order to achieve maximal therapeutic re-sponse, while avoiding resistance. The most comprehensive recommendations published by the Global Alliance to Improve Outcomes in Acne are as follows:

Avoidance of oral or topical antibiotics as monotherapy – combination regimens from the onset of therapy should expedite response and reduce the duration of antibiotic courses, therefore:lCombine an antimicrobial with a topical

retinoid or a benzoyl peroxide-containing product.

lLimit the use of antibiotics to short periods and discontinue use when no further or significant improvement occurs.

lAvoid combined oral and topical antibiot-ics – if required, stay within the same class

lDo not use antimicrobials as maintenance therapy – opt for a topical retinoid, with BPO added for antimicrobial effect if needed.

lAvoid switching antibiotics without ad-equate justification – when possible, utilize the original antibiotic for relapses. [Source: J Am Acad Dermatol 2009;60(5):S1-50]

Female patients should also be warned about the potential decreased efficacy of oral contra-ceptive and be advised to take supplementary birth control precautions if oral antibiotics are to be incorporated into a regimen containing the contraceptive pill.

However, with the exception of rifampicin-containing drugs, scientific evidence to sup-port the notion that commonly prescribed anti-biotics reduce blood concentrations and/or the effectiveness of oral contraceptives is lacking.

Hormonal therapiesHormonal influences play an important role in the pathogenesis of acne. Increased sebum production due to androgens acting at the se-baceous follicle is a pre-requisite for acne in all

patients. Prior to puberty, the adrenal glands produce increasing amounts of dehydroepi-androsterone sulfate (DHEAS), which can be metabolized into more potent androgens in the skin, driving enlargement of the sebaceous gland and increased sebum production.

Both males and females have acne that is re-lated to increased sensitivity of the sebaceous gland to androgens. In women, aberrant ex-cess production of androgens from the ovary may also cause acne, and should be excluded in females with acne that is persistent, of late onset or associated with hirsutism.

Hormone manipulation is, therefore, an ad-ditional resource in the treatment of female patients with acne. Hormonal investigations and treatments are indicated when acne is re-calcitrant and standard treatments have failed, as well as when oral isotretinoin is inappropri-ate, not available or when rapid relapse has occurred after repeated courses. They are also desirable when menstrual control and/or con-traception are required alongside acne therapy.

All available treatments share the common goal of opposing the effects of androgens on the sebaceous gland and, to a lesser extent, the follicular keratinocyte. This can be accom-plished with the use of estrogens, androgen receptor blockers (cyproterone acetate, chlor-madinone acetate, spironolactone, drospire-none, desogestrel and flutamide) or agents de-


signed to inhibit the endogenous production of androgens by the ovary (e.g. oral contracep-tives, cyproterone acetate and gonadotrophin-releasing agonists) or adrenal gland (e.g. low-dose glucocorticoids).

IsotretinoinOral isotretinoin is a synthetic vitamin A ana-log used for patients with moderate-or-severe recalcitrant acne, provided there are no con-traindications. It is the only treatment that has an effect on all four major pathogenic factors involved in acne and is, therefore, considered the most clinically effective anti-acne therapy available.

Isotretinoin decreases the size and secretion of the sebaceous gland, normalizes follicular keratinization and prevents comedogenesis, inhibits the growth of surface and ductal P. acnes via changes of the follicular milieu, and has anti-inflammatory effects.

During treatment, isotretinoin reduces se-bum production by 90% or greater (within six weeks) and P. acnes populations decrease sub-stantially. However, both sebum and P. acnes levels increase upon cessation of treatment, al-beit to a lesser extent.

The most significant adverse event associ-ated with the administration of isotretinoin is teratogenicity. A Pregnancy Prevention Pro-gram has been advocated for all females of child-bearing potential. Educational aspects advise that both the patient and prescriber should understand the implications of terato-genicity – the patient should accept detailed counseling from the prescriber before and dur-ing treatment and sign a consent form prior to initiation.

Adverse psychiatric events, including mood changes, depression and suicidal ide-ation, have been reported in acne patients taking isotretinoin. Epidemiological studies performed by the US FDA found little or no in-crease in psychiatric disease including depres-

sion and suicide over the background preva-lence in the adolescent population. However, clinicians should be aware of a potential rare idiosyncratic reaction in some young, vulnera-ble patients, which could lead to mood chang-es and depressive symptoms during treatment with isotretinoin.

CosmeceuticalsCosmeceuticals are products that may have little pharmaceutical activity and minimal potential side effects, and would be pre-scribed for what would be considered to be traditionally cosmetic indications. Raymond Reed, a founding member of the US Society of Cosmetic Chemists, first coined the term ‘cosmeceutical’ in 1961. In 1971, Albert Kling-man reactivated interest in cosmeceuticals by developing a formula to improve the appear-ance of UV damaged and wrinkled skin us-ing retinoic acid. They are applied topically as cosmetics, but contain ingredients that in-fluence the skin’s biological function. Cosme-ceuticals improve appearance, but they do so by delivering nutrients necessary for healthy skin.

As acne is also a disease process that can greatly affect appearance, there has been growing interest in recent years in the role of cosmeceuticals for the treatment of acne. These can come in the form of lHygiene and cleansing productslTopical sebum-controlling agentslCorneolyticslTopical anti-inflammatory agentslMoisturizerslPhotoprotective agentslShaving productslCamouflage products

Besides their role as functional cosmetics, they can potentially minimize the common side ef-fects of the usual acne therapies like systemic retinoids or topical benzoyl peroxide, retinoids


To answer the quiz for your CPD points, please go to www.mims-cpd.com.my

and antibiotics. These therapies often cause stratum corneum barrier dysfunction which leads to skin irritation and inflammation and, hence, poor patient adherence and compli-ance. When correctly prescribed, these cosme-ceuticals may have a synergistic effect.

An example of a range of cosmeceutical products intended for acne patients is Papu-lex® which is topically applied and contains non-prescription pharmaceutical agents. They contain ingredients that address most of the pathophysiological processes involved in the formation of acne. These ingredients are:lAnti-bacterial adhesion substance – an EU-

patented film-forming substance made from natural materials that inhibits bacte-rial adhesion to the corneocytes

lNicotinamide – shown to have anti-inflam-matory properties and also to reduce acne lesions

lZinc PCA – reduces sebum secretion.

DiscussionIn order for the treatment and management of acne to be successful, the following factors should be taken into consideration:lClassification of disease severitylAppropriate selection of medicationslLength of therapylPotential adverse effectslCosmetic approach lPatient compliance

Acne is a very common disease that typically affects adolescents and young adults, an age when people are more impatient, emotional and self-conscious. This makes the treatment of acne rather difficult without a good under-standing between the physician or pharmacist and the patient.

It is essential that the conditions leading to the disease and the course of it be properly explained to the patient in a clear and under-standable manner so as to recruit the coopera-tion of the typically young patient. Much of the success of the therapy and management rests on the shoulders of the patient, as correct ap-plication of the topical treatments prescribed can make the difference between a good or poor outcome.

Initial adherence is not enough as treatment has to be sustained typically for months be-fore a significant improvement is seen. Regu-lar follow-ups and assessments, and possibly a change in the strategy of management, may be required depending on the course of the disease. Adverse reactions to the use of topical treatments may have to be addressed so as to sustain the cooperation of the patient.

The following may be used to promote ad-herence of the patient:lPhysician/pharmacist-patient counseling

and educationl Demonstration of medication administrationlImproving and understanding patient

compliancelAssess quality of life based on treatment

outcomeslEvaluating possibility of psychiatric mor-

biditylUse of medication reminders, self-moni-

toring with diaries, support groups and telephone follow-up

lUse of available resources and educational tools.

With enough care and attention to the above, the management of acne could possibly be more straightforward, rewarding and certainly very attainable.

Publisher : Ben Yeo

Contributing Editors : Saras Ramiya, Leonard Yap, Pank Jit Sin, Malvinderjit Kaur Dhillon (Malaysia)

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Pharmacy Today is published 11 times a year by MIMS Medica. Pharmacy Today is on controlled circulation publication to pharmacists in Malaysia. It is also available on subscription to members of allied professions. The price per annum is US$48 (surface mail) and US$60 (overseas airmail); back issues at US$5 per copy. Editorial matter published herein has been prepared by professional editorial staff. Articles ending with PTNZ have been adapted from Pharmacy Today New Zealand. Views expressed are not necessarily those of MIMS Medica. Although great effort has been made in compiling and checking the information given in this publication to ensure that it is accurate, the authors, the publisher and their servants or agents shall not be responsible or in any way liable for the continued currency of the information or for any errors, omissions or inaccuracies in this pub-lication whether arising from negligence or otherwise howsoever, or for any consequences arising therefrom. The inclusion or exclusion of any product does not mean that the publisher advocates or rejects its use either generally or in any particular field or fields. The information contained within should not be relied upon solely for final treatment decisions.

© 2013 MIMS Medica. All rights reserved. No part of this publication may be reproduced in any language, stored in or introduced into a retrieval system, or transmitted, in any form or by any means (electronic, mechanical, pho-tocopying, recording or otherwise), without the written consent of the copyright owner. Permission to reprint must be obtained from the publisher. Advertisements are subject to editorial acceptance and have no influence on editorial content or presentation. MIMS Medica does not guarantee, directly or indirectly, the quality or effica-cy of any product or service described in the advertise-ments or other material which is commercial in nature. Printed in Malaysia by KHL Printing Co Sdn Bhd. Lot 10 & 12, Jalan Modal 23/2, Seksyen 23, Kawasan MIEL, Fasa 8, 40000 Shah Alam, Selangor Darul Ehsan. PP17931/12/2013(033147) ISSN 1170-1927

Editorial Advisory Board

Dato’ Eisah A. Rahman Pharmaceutical Services Division, Ministry of Health

Datuk Nancy Ho President, Malaysian Pharmaceutical Society

Yip Sook Ying Secretary, Malaysian Pharmaceutical Society

Assoc Prof Dr Mohamad Haniki Nik Mohamed Malaysian Academy of Pharmacy

Prof Dr P.T. Thomas Universiti Kebangsaan Malaysia

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