GUIDELINES FOR USING PANTOPRAZOLE HUSM

Upper GIT bleed

Mucosal break lesion

Treatment

Prophylatic/suspected

Upper GIT bleed confirm

IV Pantoprazole 40 mg BD

Chronic Acute

T. Pantoprazole 40 mg BD –6/52 IV Pantoprazole 80 mg stat then IV Pantoprazole 80 mg/hour for 72 hour then IV Pantoprazole 40 mg BD for 7/7 then T. Pantoprazole 40 mg BD –6/52

OGDS

Maintenance T. Pantoprazole 40 mg OD - 3-6/12 therapy

If not properly heal

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FLOW CHART USAGE OF PPI IN HUSM ENDOSCOPY MEETING ON 4/10/07

Bleeding cases (Non variceal bleed) 1st Endoscopic procedure, then 2nd Proton pump inhibitor, then 3rd Mucosal protective therapy, then 4th I/V Somatostatin analog 25 mg/hr 1 kg, then 5th Surgival intervention PPI 1st line I/V Pantoprazole 80 mg stat, then I/V Pantoprazole 8 mg/hr for 3 – 5/7, then I/V Pantoprazole 40 mg BD Follow-up by t.Pantoprazole 40 mg BD – 8 – 12/52 and to repeat endoscopy if rebleed or after complete treatment. I/V Esomeprazole can be used as second choice. Mucosal break lesion (Prophylaxis) 1st line I/V Esomeprazole 40 mg BD or 2nd line I/V Pantoprazole 40 mg BD or 3rd line I/V Ranitidine or Tablet 4th line Mucosal protection agent (Sulcalfate) Peptic Ulser disease (PUD) 1st line Tab. Lansoprazole 30 mg OD/BD, then 2nd line Tab. Esomeprazole 40 mg OD/BD, then 3rd line Tab. Pantoprazole 40 mg OD/BD, then 4th line Tab. Rabeprazole 20 mg OD/BD, then 5th line Tab. Omeprazole 40 mg OD/BD, then 6th line Tab. Ranitidine 150 mg OD/BD, then 7th line Tab. Cimetidine 300 g OD

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In cases of PUD (No. OGDS) (No. PPI test)

with T. Ganaton 50 mg BD/TDS 1st line T. Lansoprazole 30 mg OD/BD 2nd line T. Esomeprazole 40 mg OD/BD If not improve after 2/52 refer results endoscopy investigation (Gastro/Surgical) In cases of no OGDS for PPI test 1st line T. Lansoprazole 30 mg BD – 2/52 then decision OR 2nd line T. Esomeprazole 40 mg BD – 2/52 then decision. In Cases of Biliary gastritis/recurrent GERD/GERD (Gastrooesophageal disease)

1) T. Ganaton 50 mg BD/TDS with } 1st line T. Esomeprazole 40 mg BD/TDS }

2) T. Ganaton 50 mg BD/TDS with } 2 nd line T. Rabeprazole 20 mg BD }

In Cases of PUD with normal OGDS/NERD (non erosive gastritis) T. Ganaton 50 mg BD/TDS WITH 1st line Esomeprazole 40 mg OD/BD 2 nd line T. Lansoprazole 30 mg OD/BDs 3 rd line T. Pantoprazole 40 mg OD/BD 4th line T. Rabeprazole 20 mg OD/BD

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LIPID LOWERING THERAPY USM GUIDELINES

Indications for use

1. Coronary heart disease (CHD) 2. CHD disease equivalent

a) Diabetes Mellitus b) Carotid artery disease c) Peripheral artery disease d) Abdominal aortic aneurysm

3. Familial hyperlipidaemia (or total chol > 8, LDL chol > 6) 4. CHD high risk individuals

a) Individuals with 2 or more risk factors 5. CHD low risk

a) Individuals with less than 2 risk factors 6. If asymptomatic but total cholesterol ≥ 5.0 mmol/l, LDL cholesterol ≥ 3.0

mmol/l and total CVD risk of projected CVD risk at 60 years of age is ≥ 5%. 7. Others

a) Individuals with chronic renal disease (Creatinine > 133 umol/L or GFR < 60 ml/min/1.73 m2)

b) Metabolic syndrome Drug Dose range LDL reduction Cost for 1/12 rx

( mg ) RM Pravastatin 10 - 40 19 – 40 % Simvastatin 10 - 80 28 - 48 % Lovastatin 20 - 80 29 – 48 % Atorvastatin 10 - 80 38 – 54 % Rosuvastatin 10 - 40 52 – 63 %

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Indications 1-4

• Aggressive lipid lowering therapy required • High dose and high potency drug required • Suggestion

1. Coronary heart disease (CHD) 2. CHD disease equivalent i) Diabetes Mellitus ii) Carotid artery disease iii) Peripheral artery disease iv) Abdominal aortic aneurysm 3. Familial hyperlipidaemia (or total chol > 8, LDL, chol >6) 4. CHD high risk individuals- Individuals with 2 or more

Check FLP Start atorvastatin

10 – 20 mg od TLC

Check FLP after 3/12

Total C > 4.5 or Total C < 4.5 or LDL > 2.5 LDL < 2.5

Intensification of Rx Continue medication or consider de-escalation of Rx ie change to Simvastatin or Pravastatin as per indicated

Increase dose of Atovarstatin or change to Rosuvastatin

TLC

TLC = Therapeutic lifestyle changes

5

Indications 5-7:

• Lipid lowering therapy can be step wise intensification • Suggestions

6

1. CHD low risk a) Individuals with less than 2 risk factors

2. If asymptomatic but total cholesterol ≥ 5.0 mmol/l, LDL cholesterol ≥ 3.0 mmol/l and total CVD risk of projected CVD risk at 60 years of age is ≥ 5 %.

3. Others a) Individuals with chronic renal disease

(Creatinine > 1.33 umol/L or GFR < 60 ml/min/1.73 m2) b) Metabolic syndrome

Total chol

Risk score: 10 year risk for CV death

Total risk <5 % Total risk ≥ 5 %

TLC FLP Includes:

T chol/ LDL/HDLTotal chol < 5.0 LDL chol < 3.0

F/ up 5 yearly

TLC for 3/12

FLP Includes :

T chol/LDL/HDL

Total chol ,5.0 LDL chol < 3.0

Total chol > 5.0 LDL chol > 3.0

Continue TLC Continue TLC

Reassess risk yearly Start drug therapy

If risk ≥ 5 % and Total chol < 4.5 and LDL chol < 2 5

TLC = Therapeutic lifestyle changes

Consider drug therapy

Drug therapy indicated

Total chol 5.0 – 5.9 Total chol 6.0 – 6.9 Total chol 7.0 LDL chol 2.5 – 3.5 LDL chol 3.5- 4.5 LDL chol 4.5

Pravastatin or Simvastatin or Atorvatatin or

rosuvastatin simvastatin atorvastatin If targets not achieved : Total chol > 4.5 or LDL > 2.5 CHECK COMPLIANCE TO TLC AND DRUG THERAPY

Consider intensifying treatment

Combination therapy Simvastatin Ezetimide Atorvastatin

Or Or Atorvastatin Rosuvastatin

Or And or Rosuvastatin Ezetimibe

And or Fibrates etc

Prepared by Dr Tee Meng Hun & AP Dr Zulkurnai Yusof, Med Dept

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Indication of Using Amlodipine (and ± Felodipine) in HUSM (suggestion) 1. Introduction Calcium channel blockers work by blocking the initial calcium influx into myocytes and vascular smooth muscle cells. Amlodipine and felodipine are long acting second generation dihydropyridine that have vascular smooth muscle relaxing activity with no or minimal negative inotropic effects. They have a greater selectivity for vascular smooth muscle compared to the myocardium. They vasodilate coronary arteries reduce coronary resistance, increase coronary blood flow and may enhance the development of coronary collaterals. 2.Indication of using calcium channel blocker (CCB) 2a. The use of CCB as anti-ischemic agent -calcium channel blocker has been shown to exert anti-angina properties in various ways such as reduction in heart rate, reduction in contractility, reduction in afterload and direct vasodilatation. -calcium channel blocker should be considered if there are contraindications or adverse reactions to either beta blockers of nitrates or if symptoms are not well controlled with a combination of these agents. 2b.The use in acute coronary syndrome (ACS) patients. - The potential benefits of either amlodipine or felodipine in acute MI has not been examined directly. - Amlodipine is often used in patients with acute MI when hypertension is not adequately controlled by other therapy of proven benefit (beta blockers and ACE inhibitors ). - Study in stable coronary heart disease (PREVENT trial) found no or little benefit of amlodipine but also has no harm. - Therefore amlodipine is not indicated as first line therapy on ACS patients unlike ACE inhibitors and beta blockers. 2c. The use of CCB in patients with heart failure - The potential benefit of either amlodipine or felodipine in acute MI has not been examined directly. However, clinical trial that have evaluated these drugs in heart failure (V- HeFT III and the PRAISE trials) found no or little benefit but also no harm. - In patient with heart failure, amlodipine in at a drug choice as compared to ACE inhibitors, beta blockers and aldosterone antagonist.

8

2d.The use of CCB in hypertension patients. - Although recommendations for initiating medical therapy in essential hypertension have been proposed, there is no uniform agreement on which antihypertensive agent should be given as initial therapy. A variety of different classes of drugs can be used in this setting. These include the thiazide diuretics, beta blockers, angiotensin converting enzyme (ACE) inhibitors, angiotensin II receptor blockers and calcium channel blockers. - There have been limited data as to whether different antihypertensive drugs have variable effects upon patient outcomes, particularly cardiovascular morbidity and mortality. However, an increasing number of trials have provided evidence that at the same level of blood pressure control, most antihypertensive drugs provide the same degree of cardiovascular protection provided there are no other compelling indications. - The choice of drug should be based on the patient’s individual risk profile and the tolerability of the drugs. - “First-line” drugs should have the following properties : 1. reduce long-term morbidity and mortality 2. high efficacy of once-daily administration 3. no adverse effects on concomitant risk factor 4. good tolerability - based on JNC VII guidelines, hypertensive naïve patient should receive diuretics as first line drug. 2e. The use of CCB in anti-arrythmic agents -the use of amlodipine as anti- arrythmic agents therapy was not well studied unlike verapamil and diltiazem, therefore it is not recommended as anti-arrythmic therapy. 2f. The use of CCB in patients with renal disease/nephropathy - Hypertension is common in chronic renal disease and is risk factor for progression of renal damage, and reduction of blood pressure (BP) is an efficient way of preventing or slowing the progression of this damage. BP – lowering effects are common to all antihypertensive drugs, but intra-renal effects differ between classes and between individual drugs within certain classes. Angiotensin – converting enzyme (ACE) inhibitors and angiotensin receptors blockers (ARB) have beneficial effects on proteinuria and declining renal function that appear to be mediated by factors additional to their effects on BP. These RAS inhibitors are recommended as first-line antihypertensive approach in patients with chronic kidney disease. - Calcium channel antagonist are highly a heterogenous class of compounds, and it appears that some agents are more suitable for use in patients with chronic renal disease than others. Most common calcium channel blockers are nondihydropyridine group like verapamil and diltiazem. - Dihydropyridine calcium channel blockers (eg nifedipine and amlodipine) may worsen proteinuria and accelerate the progression of disease in patients with nondiabetic or diabetic nephropathy.

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2g. The use of CCB in peripheral vascular disease (PVD) patient.

- Unlike verapamil, the use of amlodipine and felodipine in treating peripheral vascular disease patients are not well studied. Therefore, it is not recommended to use these drugs to treat PVD patients.

2h. The use of CCB in Pulmonary Artery Hypertension patients.

- The oral vasodilators of choice are the calcium channel blockers nifedipine and diltiazem. Verapamil is not recommended, since it tends to posses significant negative inotropic properties.

- Amlodipine has been a useful alternative for patients who are intolerant of the other agents (eg. Because of edema, bradycardia, tachycardia, or hypotension)

- The use of Felodipine in pulmonary artery hypertension is not well studied. 3. Advantages of Amlodipine (and felodipine) above other antihypertensive. 3a.Single daily dose, therefore this will improve patient compliance. 3b. No need for renal function monitoring. 3c. Among the least side effects compared to other anti-hypertensive. 3d. In comparison between amlodipine and felodipine, on of the retrospective study has shown that amlodipine has better patient’s adherence compared to felodipine. 4. Disadvantages of CCB above other antihypertensive. 4a. The potential benefit of either amlodipine or felodipine in ACS has not been examined directly in ACS patients. A systematic analysis of all randomized calcium blocker trials in unstable angina suggests calcium channel blockers that as a class do not prevent the development of acute myocardial infarction or reduce mortality, and it also has no harm to these group of patients. 4b. Short-acting CCB (i.e. Nifedipine) has a relatively high incidence of adverse side effects, including peripheral edema (not related to heart failure), flushing, headaches, and lightheadedness, which is due to peripheral vasodilatation. 4c. There was a study (cross sectional) showed that there was a higher rate of depression among hypertensive patients who were on calcium channel blocker as compared to other anti-hypertensive. 4d. Both amlodipine and felodipine are long acting calcium channel blockers, therefore it is not recommended as first line therapy for hypertensive urgency.

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List of Tables Table 1 Comparative pharmacokinetics of selected dihydropyridine calcium channel antagonists

Nifedipine Nisoldipine Felodipine Amlodipine Diodipine >90 Oral absorption >90 >90 >90 >90

Oral bioavailability

30-50 5-15 10-25 60-65 5-15

Elimination half-life

3-5 4-10 2-8 35-50 3-15

Table-Dosing and costs of the Calcium Channel Blockers Drug Initial Dose Usual Dosage Range Cost x 30 days Verapamil - regular (Isoptia® generic) 80mg TID 80-160 mg TID $37.33-$68.15 - long acting (Isoptin SR®) 180 mg

daily 120 mg daily-240mg BID

$37.52-$99.94 (Varelan®) $32.87-$85.92

180 mg daily

120-480 mg daily

Diltiazem - regular (Cardizem®

generic) 30mg TID 30mg TID-90 mg QID $28.51- $83.61 60 mg BID 60-80 mg BID $51.63- $126.31**

- long acting (Cardizem SR

120 mg daily

120 mg-300mg daily $47.12- $95.89 ®)**

(Cardizem CD®) Felodipine (Plendil®, Renedil

5mg daily 2.5-20 mg daily $23.13-$83.61 ®)

Nifedipine - regular capsules

(Adalat10mg TID 10mg TID-30 mg QID $27.25-$89.52

®generic) 10 mg BID 10-40mg BID $37.90-$104.72** - long acting (Adalat PA®)** 30 mg daily 30-120 mg daily $37.81-$104.72

® (Adalt XL ) 5 mg daily 5-10 mg daily $46.14-$65.34 Amlodipine (Norvasc®) 10mg TID 20-40 mg TID $62.04-$117.58

®Nicardipine (Cardene ) **Base on wholesale acquisition cost Feb. 1995 of least expensive product and professional fee of $6.50 as April 1, 1995. Pharmcare no longer covers Cardizem SR and Adalat PA

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5. References

1. Antiischemic Agents in the Management of Unstable Angina and Acute Non-ST Elevation (Non-Q Wave) Myocardial Infarction. Michael Simons, MD. Up to date version 13.3

2. Calcium Channel Blockers in Acute Myocardial Infarction. Robert S

Rosenson, MD Harold L Keneddy, MD, MPH. Up to date version 13.3.

3. Calcium Channel Blockers in the Management of Stable Angina Pectoris. Joseph P. Kannam, MD. Julian M Aroesty, MD. Bernard J Gersh, MB, ChB, DPhil, FRCP. UpToDate version 13.3.

4. Choice of Therapy in Essential Hypertension: Clinical Trials. Norman M

Kaplan, MD, Burton D Rose, MD. UpToDate version 13.3.

5. Wenzel, Rene R. Renal Protection in Hypertensive Patients: Selection of Antihypertensive Therapy. (Review). Dugs. 65 (Suppl 2):29-39, 2005.

6. JNC VII guidelines. 7. Medical Management of Claudication. UpToDate version 13.3.

8. Non Diabetic Kidney Disease (Andrew S) N Engl J Med. VOl 347. No 19.

November 7, 2002. 9. Nephropathy in Patient with Type 2 Diabetes. Remuzzi et al. N Engl J Med.

Vol. 346, No. 15 April 11, 2002.

10. Adherence to Calcium Channel Blocker Therapy in Older Adults: A Comparison of Amlodipine and Felodipine. Menzin J et al. J Int Med Res. 2004 May-June; 32(3) :233-9.

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13

FLOW CHART

Diagnosis of hypertension

Initiate lifestyle modification

If still not achieve BP target (<140/90 mmHg or <130/80 mmHg for those with diabetes or chronic kidney disease)

Initiate drug of choice

Without compelling indication With compelling indication

Stage I Hypertension BP(140-159/90-99) Thiazide is a first choice. May consider ACEI/ARB/BB/CCB or combination. If CCB is used amlodipine is preferred due to good blood pressure control compared to felodipine. If cost is an issue, felodipine can be used instead of amlodipine. If patient has side-effects to amlodipine such as headache, postural hypotension, changed to felodipine is justified.

Stage 2 hypertension (SBP > 160 or DBP >100mmHg) –consider 2 drugs

Use appropriate anti-hypertensive agent

PROPOSAL

GUIDELINES ON PLAVIX PRESCRIPTION FOR CARDIOLOGY PATIENTS HUSM

ACUTE CORONARY SYNDROME

PERCUTANEOUS CORONARY INTERVENTION

(PCI)

INTRACEPT ASD CLOSURE DEVICE

CABG

• NSTEMI/UA = 9 months • Bare metal stent = 3-4 weeks

• Plavix x 3 months • No indication • STEMI = 8 days

• Drug eluting stent (DES) = 6-12 months

* Contraindication for aspirin, ticlopidine is a substitution

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PROTOCOL NOVOSEVEN OR RECOMBINANT FACTOR 7 FOR JABATAN NEUROSAINS HUSM. Level for recommendations:

1. recommended (by experts) – better than other measures (evidence based and expert opinion) 2. optional – other measures can be as good as novoseven/lacking solid evidence.

Drug name Indication Dose Amount stored Criteria

1. Polytrauma/Trauma patient in severe DIVC or coagulopathy, requires urgent/emergency life saving surgery.

1. NOVOSEVEN -1 vial (1.2 mg) but if severely deranged coagulopathy or obese, 2 or 3 vials can be given initially.

3 vials per session of use.

Non standard and require specialist approval.

Level of recommendation (0.2-0.9 mg/kg) Recommended (1) -Paediatrics also can be

given. (0.2-0.9 mg/kg) -can be repeated after

2-5 hours.(the INR and APTT should be repeated after those 2-5 hours of therapy).

2. Coagulopathy is resistant to other

therapeutic measures and requires urgent/emergency or life saving surgery.

Same

Level of recommendation Recommended (1)

15

3. Patients known to suffer from

coagulopathy disorders (eg Haemophilia) who requires urgent/emergency life saving surgery which can or can not cause post operative DIVC.( if patient developed severe coagulopathy prior to surgery, please refer to indication 1)

Same/Novoseven made available

Level of recommendation Recommended (1) Note: alternative is the haemophilic factor (8/9)

4. Warfarin/Liver diseases induced intracranial haematoma (abnormal INR) that causing neurological deficits/neurological deterioration which is supported by radiological findings.

Same

Level of recommendation Optional (2) Note 1: FFP, Vitamin K are the alternatives. Note 2: Patient who is candidate for emergency

life saving surgery, the Novoseven is the choice made available intraoperatively because of fast effect (FFPs are the alternatives intraoperatively)

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5. Patient who has within 4 hours of

intracranial haematoma causing neurological deficits/deterioration but is not a candidate for surgery yet.

Same

Level of recommendation Optional (2) Note 1: the BP-controlled management and correction of coagulopathy if presence with other measures are the alternatives.

Note 2: routine use of Novoseven for post surgical evacuation of intracranial clots for patient with persistent post operative abnormal clotting parameters is not recommended, the FFP and/or cryoprecipitate are the primary alternatives.

Note: Clinical management among cases may differ, depending on some other clinical scenarios/factors.

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FLOW CHART

(POLY) TRAUMA PATIENT 1.

IN SEVERE DIVC OR COAGULOPATHY, PLANS FOR URGENT/EMERGENCY LIFE-SAVING SURGERY (NEUROSURGERY)

GIVE NOVOSEVEN DIVC CORRECTED

SURGERY

Level of recommendation: Recommended (1)

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2. (POLY) TRAUMA OR NON TRAUMA PATIENT

IN SEVERE DIVC OR COAGULOPATHY, DIVC

IS NOT CORRECTED BY OTHER MEANS AND REQUIRED URGENT/EMERGENCY OR LIFE SAVING SURGERY.

GIVE NOVOSEVEN DIVC OR COAGULOPATHY CORRECTED SURGERY Level of recommendation: Recommended (1)

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3. KNOWN COAGULOPATHY (Eg Haemophiliac) PATIENT

WITH/WITHOUT TRAUMA

PLAN FOR EMERGENCY LIFE SAVING SURGERY (CRANIOTOMY/CRANIECTOMY)

NOVOSEVEN MADE AVAILABLE

SURGERY NOVOSEVEN GIVEN IF COAGULOPATHY WORSENING. - novoseven should be given earlier, if severe coagulopathy occurs prior to

surgery and patient requires life saving surgery (see flow chart 1) Level of recommendation: Recommended (1)

Note: alternatives is the haemophiliac factor (8/9)

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4. WARFARIN/LIVER DISEASES INDUCES INTRACRANIAL HAEMATOMAS (ABNORMAL INR) THAT CAUSING NEUROLOGICAL DEFICITS/DETERIORATION

IMAGING BRAIN: SIGNIFICANT HAEMATOMA/S WITH RADIOLOGICAL FEATURES OF RAISED INTRACRANIAL PRESSURE AND/OR CLINICAL EVIDENCE OF RAISED INTRACRANIAL PRESSURE.

GIVE NOVOSEVEN 5.

Level of recommendation: Optional (2) Note 1: FFP, Vitamin K are the alternatives. Note 2: Patient who is a candidate for emergency life saving surgery, the Novoseven is the choice made available intraoperatively because of fast effect (FFPs are the alternatives)

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5. PATIENTS WITHIN 4 HOURS OF DEVELOPING INTRACRANIAL HAEMATOMA/S WITH NEUROLOGICAL DEFICITS/DETERIORATION.

IMAGING BRAIN: SIGNIFICANT HAEMATOMA/S WITH VOLUME 30 MLS OR ABOVE BELIEVES CAUSING NEUROLOGICAL

DEFICITS/DETERIORATION

NOVOSEVEN CAN BE GIVEN TO HALT THE PROGRESSION OF DEFICITS/DETERIORATION IN CONSERVATIVELY TREATED PATIENT WHO IS NOT YET A SURGICAL CANDIDATE.

-ROUTINE USE IS NOT RECOMMENDED.

Level of recommendation: Optional (2) Note 1: the BP-controlled managemant and correction of coagulopathy if presence with other measures are the alternatives. Note 2: routine use of Novoseven for post surgical evacuation of intracranial clots for patient with persistent post operative abnormal clotting parameters are not recommended, the FFP, Cryoprecipitate are the primary alternatives.

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ABSOLUTE CONTRAINDICATION

1. Known allergy to Novoseven. 2. Allergy to mouse, hamster and bovine proteins.

RELATIVE CONTRAINDICATIONS 1. Known thrombotic tendencies. 2. Prosthetic heart valves requiring warfarin. 3. Recent angioplasty, stent insertion, MI thrombotic CVA, PE or DVT. COMPLICATIONS 1. Thromboembolic events 2. Anaphylaxis

23

24

References:

1. Malaysian Society of Anaesthesiologist : Novoseven recommendations 2006. 2. Mayer FA, Rincon F: Ultra-early hemostatic therapy for acute intracerebral haemorrhage. Semin Hematol.2006 Jan; 43 (1 Supp): S70-6. 3. Neurosurgery : Coagulopathy in Neurosurgery and recombinant Factor 7: series articles: Jun 2006 4. DeLoughery T.G : Management of bleeding emergencies : when use recombinant activated Factor VII: Expert Opinion ; a

review article.Pharmacotherapy 7(1): 2006.

5. Novoseven Product cataloge 2006. THIS PROTOCOL MEANT TO CLINICAL DOCTORS IN NEUROSCIENCES OR ALLIED NEUROSCIENCES. ACCURATE INTERPRETATION /UNDERSTANDING MAY REQUIRE EXPERT EXPLAINATIONS. Prepared by Dr Zamzuri Idris Date: 29/10/2006

GUIDELINES FOR OUTPATIENT TREATMENT OF CHRONIC ASTHMA DEPARTMENT OF MEDICINE HOSPITAL USM

CLASSIFICATION BY SEVERITY1

CLASSIFY SEVERITY Clinical Feature Before Treatment

Symptoms Nocturnal

Symptoms FEV or PEF 1

STEP 4 Continuous Limited physical activity

Frequent ≤ 60% predicted Variability > 30% Severe

Persistent STEP 3 Daily > 1 time a week 60-80% predicted

Moderate Persistent

attack affect activity Variability > 30%

STEP 2 > 1 time a week > 2 times a month ≥ 80% predicted Mild Persistent but < 1 time a day Variability 20-30%

STEP 1 < 1 time a week Asymptomatic

≤ 2 times a month ≥ 80% predicted Intermittent Variability < 20%

and normal PEF between attacks

TREATMENT

STEP 1- Salbutamol Inhaler as required STEP 2- Move to step 2 if symptoms as above or failure of step 1 T. Montelukast 10 mg daily2

Does the patient has: Yes Salbutamol inhaler as required

STEP 3- Move to step 3 if symptoms as above or failure of step 2 STEP 4 – move to step 4 if step 3 fails

Allergic rhinitis? Definite aspirin allergy?

No Exercise induced asthma? Budesonide MDI/Turbuhaler 100-800ug BD Beclomethasone MDI 50-500 ug BD/TDS Ciclesonide MDI 160 ug OD/BD Salbutamol MDI as required Start steroid at high dose, taper down later1

Treatment options: Formoterol/ Budesonide 4.5/160Turbuhaler (Symbicort®) 1 inh BD or Salmeterol/ Fluticasone 50/250 Accuhaler (Seretide®) 1 inhalation BD Salbutamol inhaler as required

Consider Symbicort® if patient is educated because

• the dose can be adjusted according to the patients need i.e. 1 inhalation BD when symptomatic and 1 inhalation daily if stable3

• Symbicort® may be used as rescue medication

25

STEP 4 – Move to step 4 if step 3 fails

Treatment options: Plus Formoterol/ Budesonide

Montelukast 10 mg daily 4.5/160Turbuhaler (Symbicort®) 1 inh BD or

KIV Salmeterol/ Fluticasone 50/250 Accuhaler (Seretide®) 1 inhalation BD Theophyline SR 250 mg BDSalbutamol inhaler as required

Still symptomatic Add Prednisolone 5-10 mg OD Please note:

• Do reversibility test if diagnosis of asthma is questionable • Do spirometry as baseline before starting any treatment • Do spirometry before any change of treatment regime • Discuss with chest physician before starting daily prednisolone

References:

1. Global Initiative For Asthma 2002. www.ginaasthma.com 2. Mastalertz L, et al. Clin Exp Allergyu 2002 Sep;32(9):1360-5 3. Aalbers R, et al. Curr Med Res Opin 2004;20:225-240

Prepared by: Dr. Che Wan Aminud-din Hashim Respiratory Physician Department of Medicine

Version 1 Nov 2006

26

GUIDELINES FOR USING INFLUENZA VACCINE Indication: Patients with the following criteria:-

1. Moderate to severe Chronic Obstructive Pulmonary Disease (Defined by GOLD guideline, HUSM guideline)

2. Asthma with recurrent exacerbation due to flu / URTI 3. Moderate to severe bronchiectasis with recurrent exacerbation 4. Any other chronic lung disease eg. Post-tuberculosis infection, insterstitial

lung disease, etc with recurrent secondary infection. Management Plan: Influenza vaccine will be administered as yearly basis. Prepared by: Dr. Che Wan Aminud-din b Hashim Repiratory Physician HUSM

27

FLOW CHART PENGGUNAAN DRUG UNTUK RAWATAN ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD)

• METHYLPHENIDATE IR (IMMEDIATE RELEASE) • METHYLPHENIDATE SR (SLOW RELEASE) • METHYLPHENIDATE LA (LONG ACTING) • METHYLPHENIDATE (EXTENDED RELEASE) OR CONCERTA • ATOMOXETINE (STRATERA)

Pesakit dirujuk ke klinik

Diagnosa ADHD ‘Pure ADHD’ ‘ADHD with comorbidities’

Adult ADHD Disediakan oleh: Dr Mohd Jamil Yaacob, Klinik Psikiatri Kanak-kanak & Remaja.

Umur di atas 6 tahun Umur di bawah 6 tahun

IR Methylphenidate (dly-tds) Methyphenidate (dly-bd)

Methyphenidate LA (single dose) Concerta (single dose)

Behavior modification

Epilepsy

Tics

Gilles de la Tourette

Complicated Pervasive SR Development Disorders

Severe untoward events due to methyllphenidate

Atomoxetine (Stratera)

28

Lampiran A DEPARTMENTAL POLICY ON THE USE OF ANTIPSYCHOTIC DRUGS AND REQUEST FOR NON-STANDARD DRUGS

1. The typical or conventional antipsychotics are encouraged as the first line, especially for unproductive and chronic patients who had not benefited much from their improvement. However, if patients developed side-effect with the conventional drugs, changing to atypical antipsychotic is recommended.

2. The use of atypical antipsychotic drugs in Malaysia and throughout the world is increasing from year to year. In order to cut the cost, risperidone the cheapest atypical antipsychotic is recommended as the first line. However, exception to the rule is when patients clinical features are more favors for other available antipsychotics. In dealing with psychogeriatric cases that are sensitive to drug side-effect, Quatiapine may be considered as first line.

3. The used of atypical antipsychotic in poor compliance patients is discouraged: typical antipsychotics or depot preparation of typical group such Fluphenazine Decanoate and Flupentixol Decanoate should be strongly considered.

4. All the available drugs in the formulary must be tried with adequate dose (at a lower dose if patients developed side-effects) and duration before considering for non-standard drug. The request (LP) will be rejected if it does not follow the standard procedure.

5. Not all the non-standard antipsychotics could be requested through L.P, the list of non-standard drugs approved by the department will be circulated from time to time. If patients need non-standard drug which is not approved by the department, drug company should supplied to the patients or they should bought by their own.

6. An additional form which contained information such as the detail of drugs used (dose, duration and side-effect), benefit from the patient improvement and socioeconomic background of the patients family must be attached to the standard LP form when applying for non-standard drug.

7. The staffs from pharmacy department may counter-check patients folder when they are doubtful about the accurateness of the information given in the LP form. The request could not be processed if the information given was misleading.

8. The pharmacy department will give the feedback to the treating doctor whether the application for the non-standard drug is approved or not.

29

Lampiran B

FLOW CHART OF USING ATYPICAL ANTIPSYCHOTICS FOR GENERAL

PSYCHIATRIC PATIENTS

Risperidone No side-effect Developed intolerated Required dosage >4 mg daily Side-effect <4 mg daily Continued Olanzapine/ Olanzapine/ Continued the drug Aripiprazole Aripiprazole the drug Side-effect Poor response LP Quatiapine Clozapine/ drug combinations Note: try to keep maintaining dose of olanzapine and aripiprazole not exceeding 15 mg daily; otherwise review the diagnosis and medication to minimize the dose.

30

GUIDELINE ON THE USE OF ANTIPSYCHOTICS

A. SCHIZOPHRENIA AND RELATED DISORDERS (NON-EFFECTIVE PSYCHOSES)

1. UNPRODUCTIVE PATIENTS

Used typical antipsychotics as a first line

Developed moderate to severe side-effect

Developed mild side-effects

Continued the drug

Change to risperidone

* Unproductive means the patients could not contribute to the socio-economic development of the family, community or nation even after they improved; e.g, jobless patients. It is not cost-effectiveness of giving expensive drugs to these groups of patients.

31

2. PRODUCTIVE PATIENTS

Used risperidone as first line

No side-effect Developed intolerable side-effect in the dose < 3 mg daily

Required dosage >3 mg daily

Continued the drug Changed to olanzapine or other atypical antipsychotics

Change to olanzapine or increased the dose

* Examples of productive patients are students, government servants, self-employer and active house-wives.

32

B. AFFECTIVE DISORDERS Used olanzapine as first line for new cases Poor compliance or

developed side-effect Good compliance or

responding well

Change to other drug Continued the drug

OLD CASES

1. unproductive patients on atypical antipsychortics, especially involved olanzapine, try to change to typical drugs if it does not compromise with efficacy of the treatment and side-effects.

2. Any patient, who has evidence of poor drug compliance regardless of the diagnosis, should change to a cheaper drug, e.g conventional antipsychotics.

33

ALZHIMER’S DISEASE TREATMENT STRATEGY

Mild to moderate cases a) F.D.A. Approval drugs (cholinestherase inhibitors) 1) Donepezil 5-10mg/day

2) Rivastigmine 6-12mg/day 3) Galantamine 16-24mg/day b) Use Supported by Clinical Trials

1) Seligeline 5mg BD. 2) Vit. E 2000I.U./day

Moderate to severe cases a) NMDA. Antagonist- Memantine 10-20mg/day

b) Combination of cholinestherase inhibitors + N.M.D.A. Antagonist

34

PARKINSON DISEASE 1 Defer use of Levodopa if age below

60 2 Seligeline

Early stage with minimal symptoms-sign

3 Amantadine 4 Dopamine Receptor Agonists Ropinerol Pramipexol Peribedil 5 Anti-cholinergics

1 Add small titrating dose of Levodopa- dopa de carboxylase

Moderate motor symptoms interfering with activities

Inhibitor Combination (L-Dopa-Carbidopa) – Madopar (L-Dopa-Benzeraside)-Sinement

1 Add on Dopamine Receptor agonist and reduce dose of

Levodopa 2 Add on COMT Inhibitor Ento

Severe Symptoms-Motor Capone (COMTAN) Complications of L. Dopa 3 Starton STALLEVO a

combination of Levodopa- carbidopa Entocaps

4 Adjunctivies – Amantadine Anti- Cholinergics

Very advanced motor 1 Consider Surgical Treatment Complications of Levodopa Therapy Deep Brain Stimulation

35

FLOW CHART FOR TREATMENT HEPATITIS B IN TREATMENT NAÏVE PATIENTS

HBSAg positive

HBeAg status

Positive HBeAg Negative HBeAg Is ALT Elevated Is ALT Elevated

NO YES YES NO

ALT more than 2x normal

ALT less 2x normal

No treatment. ALT less 2x normal

ALT more than 2x normal Monitor ALT

every 1-3 months.

HBVDNA (PCR) Quantitative >log

HBVDNA (PCR) Quantitative >log

105 104

Liver Biopsy Ishak Score >2.0 Liver Biopsy

Ishak Score >2.0

Oral therapy 18 months (minimum) Oral therapy Minimum duration 2 years

First choice: 1. Entecavir 0.5 mg OD 2. Adefovir 10 mg OD 3. Telbivudine 600 mg OD

American/Europian/Asia Pasific Guidelines no longer use lamivudine as first line due to high viral resistance of 25% at 1 year, 45% at 2 years and 65% resistance at 3 years treatment duration.

Second choice: 1. Lamivudine 100mg Od

2. Interferon Alpha (injection)

End points of treatment 1. ALT Normalisation 2. HBeAg Seroconversion/ HBeAntibody 3. HBVDNA (PCR) supression

36

FLOW CHART OF CHRONIC VIRAL HEPATITIS B PRE CORE MUTANT HBEAG NEGATIVE

HBSAg POSITIVE MORE THAN 6 MONTHS

LIVER ENZYME ALT > 2 × NORMAL

HBVDNA (PCR) QUANTITATIVE

HBVDNA > 10,000 COPIES/ML

LIVER BIOPSY HPE BIOPSY SCORE > 2 ISHAR SCORE

THERAPY FOR MINIMUM 18 MONTHS

1. LAMIVUDINE 100 MG OD 2. TELBIVUDINE 600 MG OD

HBVDNA (PCR) QUANTITATIVE

MONITORED AT 24, 48, 72 WEEKS

THERAPY STOPPED AFTER MINIMUM 18 MONTHS IF HBVDNA (PCR) UNDETECTABLE

Prepared by: Dr. Amry A. Rahim Physician / Clinical Specialist Gastroenterology / Hepatology HUSM

37

FLOW CHART FOR GENITAL ULCER SYNDROME Patient complains of GENITAL ULCER or SORE

Take history and examine INVESTIGATIONS NEEDED:-

1. Dark ground microscopy for syphilis (IF AVAILABLE) 2. Gramstain for haemophilus ducreyi 3. Tzanck’s smear 4. VDRL, TPHA

5. HIV Ab. Multiple superficial erosions or vesicular lesions

Ulser present? PRESENT?

• Treat for SYPHILIS and CHANCROID • Health Education • Educate for behaviour change • Educate for behaviour change • Partner management YES • TCA x 2 weeks and review

results of inv. • Follow-up regime

For confirmed syphilis √ 2 weeks for results √ monthly x 3 visits √ 3 monthly x 3 visits √ 3 monthly x 2 visits • Genitial herpes management

• 3 months repeat HIV Ab. And • Educate for behaviour change VDRL/TPHA if initial results were negative • TCA x 2 weeks and review results

Treatment Protocol For Genital Ulcer Syndrome

TREATMENT FOR SYPHILIS AND CHANCROID

1ST FIRST CHOICE: IM BenzathinePenicillin 2.4 million units weekly x 2 (once a week x 2 weeks) PLUS Azythromycin 1.0 gm single oral dose

2nd SECOND CHOICE: IM Benzathine Penicilin 2.4 million units weekly x 2 (once a week x 2 weeks) PLUS Cotrimoxazole 2 tablets orally twice daily x 7 days

3rd THIRD CHOICE: IM Benzathine Penicillin 2.4 million units weekly x 2 (once a week x 2 weeks) PLUS IM Ceftriaxone 250mg single dose

Note: If patient develops allergic reaction to the 1st dose of IM Benzathine Penicillin, DO NOT give the second dose. If patient is allergic to Penicillin, use EITHER Doxycycline 100mg orally bd x 15 days OR Erythromycin ES 800 mg bd x 15 days.

38

FLOW CHART FOR VAGINAL DISCHARGE SYNDROME

Patient complains of VAGINAL DISCHARGE

Take history and do physical examination

INVESTIGATION NEEDED:- • Vaginal swab √ Wet mount for trichomonas vaginalis

√ Gram stain for candidia albicans and clue cells • Cervical swab

√ Gram stain for gonococci and pus cells √ Culture for gonococci ( using Amies charcoal transport media ) • VDRL, TPHA, and HIV ab.

YES Patient has LOWER ABDOMINAL PAIN?

NO

Refer to NEAREST Hospital

• Treat for VAGINITIS

Treatment Protocol For Vaginal Discharge Syndrome (Cervicitis And Vaginitis) 1st FIRST CHOICE: Azithromycin 1 gm single oral dose 2nd SECOND CHOICE: IM Ceftriaxone 250 mg single dose

+ Doxycycline 100 mg bd x 10 –14 days

3rd THIRD CHOICE: IM Ceftriaxone 250 mg single dose +

Erythromycin ES 800 mg bd x 10 – 14 days PLUS Metronidazole 2 gm STAT PLUS Nystatin pessaries 100,000 units daily x 14 days On follow-up: If no improvement or not effective to continue Metronidazole 400 mg bd x 7 days OR TREATMENT FOR VAGINITIS ONLY

RISK FACTORS NO • Educate for behaviour change 1. Less than 21 years old RISK ASSESSMENT

2. Single • Partner has symptoms OR • Follow up for 2 weeks for results

3. Recent partner ( less than 3 monts) • Risk factor positive

4. Multiple partners YES

• Treat for CERVICITIS and Vaginitis • Educate for behaviour change • Partner management • Follow- up ---2 weeks for result

3 months to repeat VDRL, TPHA & HIV Ab, IF INITIAL TEST WERE NEGATIVE

Treatment for Vaginal Discharge Syndrome ( Cervicitis)

Treatment for Vaginal Discharge Syndrome ( Cervicitis)

39

40

Discharge PRESENT?

Traetment for CHLAMYDIA

FLOW CHART FOR URETHRAL DISCHARGE SYNDROME IN MEN Treatment Protocol for Urethral Discharge Syndrome 1st CHOICE: Azithromycin 1gm orally single dose 2nd CHOICE: IM Ceftriaxone 250mg single dose + Erythromycin ES800mg orally bd x 10-14 days 3rd CHOICE: IM Ceftriaxone 250mg single dose + Erythromycin ES 800mg orally bd x 10-14 days IM Spectinomycin 2gm STAT + Doxycycline 100mg orally bd x 10-14 days OR IM Spectinomycin 2gm STAT + Erythromycin ES 800 mg orally bd x 10-14 days

Patient complains of Urethal Discharge/Dysuria or irritation

Take history and examine (milk URETHRA if necessary)

INVESTIGATIONS NEEDED:- - Urethral smear

√ Gram stain for gonococci & pus cells √ Culture for gonococci (use AMIE’S charcoal transport media)

- 2 glass urine test - VDRL,TPHA & HIV Ab

1. Do 2 glass test 2. result POSITIVE? ULCER PRESENT?

• Treat for GONORRHEA and CHLAMYDIA

• Educate for behaviour change • Partner management • Follow-up

If Patient is allergic to penicillin and azithromycin is not available

Treatment for Gonorhea and Chlamvdia

√ Two weeks for result √ Three months to repeat VDRL, TPHA & HIV Ab.

REFER TO Appropriate flow chart

Health Education Follow-up for 2 weeks

Yes

No

Yes

No

No

Yes

TREATMENT PLAN

OUTPATIENT TREATMENT OF CAP

YES

YES

DIAGNOSIS

NO

PRIMARY CARE OF EMERGENCY DEPT VISIT

Patient presents w/ symptoms suggestive of community-acquired pneumonia (CAP)

Does history, physical Exam & chest x-ray

confirm CAP ?

SITE OF CARE DECISION Does patient have any of the

core adverse prognistic factors?

ALTERNATIVE DIAGNOSIS

Treat patient appropriately

NO

Yes, 2 core adverse prognostic factors are present

No core adverse prognostic factors are present

EVALUATION Does patient have

preexisting adverse prognostic factors?

CLINICAL DECISION Should patient be admitted to

hospital? Base decision on clinical judgement, additional adverse

prognostic factors, the patient’s social circumstances & patient

preferences

OUTPATIENT TREATMENT Non-pharmacological

• Patient education Avoid smoking Adequate hydration &

nutrition Pharmacotherapy

• Symptomatic therapy Analgesics for pleuritic

pain • Antibiotics therapy

NO

Yes, 1 core adverse prognostic factors are present

HOSPITAL ADMISSION

YES

41

42

TREATMENT PLAN (CONT’D)

EMPIRIC OUTPATIENT CAP ANTIBIOTIC THERAPY

EMPIRIC ORAL ANTIBIOTICS Local epidemiologic patterns need to be considered to target the antimicrobial therapy against the likely pathogens Previously healthy individual Any one of the following :

• High-dose Amoxycillin • Doxycycline • Macrolide – Erythromycin

Preferred agent in many guidelines Comorbidity is present (DM, renal insufficiency, CHF, alcohol abuse, COPD) Any one of the following :

• Advanced macrolide - Azithromycin • Beta-lactam or beta lactam-beta-lactamase inhibitor • Quinolone

Patient has multiple medical condirions , has COPD & received antibiotics or oral steriods in the last 3 months or any other risk factors for Gram –ve organisms • Macrolide (Azithromycin) + beta lactam or beta-lactam (beta – lactamase inhibitor) • Quinolone (alone)

Suspected aspiration pneumonia Any one of the following :

• Beta-lactam, beta-lactamase inhibitor w/ or w/o macrolide (Azithromycin) • (Clindamycin or metronidazole w/ quinolone)

FOLLOW UP • Follow up will depend on initial severity assessment • Recommended follow up in 48-72 hr • If patient fails to improve consider the following :

Chest X-ray Hospital admission

• Possible reasons for failure to improve Host factors associated w/ a delayed response Inadequate antimicrobial selection (eg. Resistant organism or bacteria not covered by initial antibiotic therapy) Metastatic infections (eg. Meningitis, endocarditis, empysema etc) Noninfections illness

FLOW CHART OF USING SULPERAZONE IN ICU

ICU Patient

Ventilated/NonVentilated Nosocomial Infection

Non Acinetobacter Acinetobacter

Non-Drug Multi Resistance

Multi-Drug Resistance (MDR) Quinolones or

3rd Generation or

4th Generation or

Carbapename Sulperazone Unasyn

±Aminoglycoside ±Aminoglycoside

Responding Non-Responding Within 24-48 Hr or Suspicious of MDR

Continue Treatment

43

GUIDELINES FOR USING NOVOMIX 30 FLEXPEN HOSPITAL UNIVERSITI SAINS MALAYSIA

PRE-MIXED INSULIN

NovoMix 30 Mixtard 30 Penfill FlexPen

OAD’s failures

Patients on Mixtard (switch to)

OAD’s failure 1. elderly 2. hypoglycaemic prone 1. frequent hypoglycaemia 3. fasting (ramadhan) or puasa sunat)

2. poor control 3. post prandial hyperglyacemic 4 fasting (ramadhan) or puasa

44

FLOWCHART FOR USE OF GLUCOPHAGE XR

Type 2 Diabetes Mellitus

Metformin (immediate release) BID/TID

Poor compliance or Gastro-intestinal side-effects

Metformin (extended release) (Glucophage XR) once daily

45

FLOWCHART FOR USE OF INSULIN DETEMIR

Insulin requiring diabetes mellitus

NPH insulin

Hypoglycemia

Insulin Detemir/Glargine

46

ALGORITHM FOR THE MANAGEMENT OF POSTMENOPAUSAL OSTEOPOROSIS

Clinical Assessment

Patients with risk General measures: Patients with prior factor but no - Calcium intake (B) incidental low

fracture - Physical activity (B) trauma fracture In the elderly: - Vitamin D + calcium (A) - Prevention of falls (B) BMD measurement

T score: T score: T score:

≥ -1 <-1 to > -2.5 ≤ -2.5

NORMAL OSTEOPENIA* OSTEOPOROSIS OSTEOPOROSIS (BMD if available)

Monitor If multiple risk factor present (C) Treatment options: Treatment options:

-Strontium ranelate -Strontium ranelate -SERMs/ - Bishosphonate (A) -Bishosphonates (A) -SERMs (A) -Activated vitamin D (A) -Activated vitamin D (A) -Calcitonin (A)

-rPTH**(A) Reassess with BMD after 2 years (A) NO YES

Follow up with BMD if available If BMD

deteriorates Reassess Treatment options: BMD yearly (C) - Strontium ranelate - SERMs (A) - Alendronate (A) - HRT (A)

47

ZOLENDRONIC ACID PRESCRIPTION FLOW CHART

Bone Metastasis –Confirmed By Bone Scan Primary By:

1) Breast Carcinoma 2) Nasopharyngeal Carcinoma 3) Lung Carcinoma (NSCLC) 4) Prostate Carcinoma

Symptoms of Pain

Severe Hypercalcaemia Mild To Moderate Pain Severe pain. Scale > 7/10

1st

1st Line IV Zolendronic Acid 4 mg over 15 minutes every 4 weeks for 6 months.

Palliative Intension. To stop and reduce bone metastases/damage especially when bone involvement is wide spread

+/- Hypercalcaemia

2nd Line IV Zolendronic Acid 4 mg over 15 minutes every 4 weeks for 6 months

Further pain +/- Hypercalcaemia

Line IV Pamidronate 90 mg Over 2 hours every 4/52 For 6 months

48

FLOW CHART FOR USING IMATINIB IN CHRONIC MYELOID LEUKEMIA (CML), PH+ ACUTE LYMPHOBLASTIC LEUKEMIA (ALL)

Patients with Ph+CML (all phases)

Begin imatinib at 400mg daily

Assess response at 3, 6, 12, 18 months as per European Leukemia Net guidelines

Poor / No response

Suboptimal response

Good response

Continue imatinib 400 mg daily

Stop imatinib Increase imatinib to 600-800 mg daily Consider alternative

treatment

Poor / No response

Good response

Stop imatinib Continue imatinib 600-800 mg daily Consider alternative

treatment

NB 1. Chronic phase CML patients responding to imatinib should continue

treatment indefinitely until disease progression (expected rate of progression 1-5 %/year)

2. In accelerated, blast phase CML and Ph+ALL imatinib is usually used

as induction +/- chemotherapy prior to more definitive treatment like stem cell with an anticipated duration of imatinib use of 4-8 weeks.

49

Lampiran1 Dr. Shamsul Kamaruljan

ARCOXIA PRESCRIPTION FLOW CHART

*Prescription: Maximum only for 3/52 Dose: 60mg, 90mg and 120mg (Depends on severity of the pain and condition of the pain)

1st line: T. Celebrex 200-400mg dly T. Meloxicam 7.5mg bd T. Tramadol 50-100mg tds Oral opiods e.g. T. DF118, Oral morphine

1st line: NSAIDS e.g Voltaren, Mefenamic acid, Ibuprofen

History of Gastritis

Acute/chronic pain

YesNo

Pain not relieved

Pain not relieved

2nd line: 2nd

T. Celebrex 200-400mg dly T. Meloxicam 7.5mg bd Oral opiods e.g. T.DF118, Oral morphine

line: T. Arcoxia 60-120mg dly T. Oxycontin 10-40mg bd

Pain not relieved

3rd line: T. Arcoxia 60-120mg dly T. Oxycontin 10-40mg bd

50

Lampiran 2 Setelah diubahsuai oleh Jabatan Ortopedik

OUTPATIENT PAIN PRESCRIPTION FLOW CHART

Acute/chronic pain History of Gastritis *COX2 Prescription for acute pain: Maximun only for 3/52 Arcoxia Dose: 60mg (OA), 90mg (RA) and 120mg (Acute pain e.g. gouty arthritis) (Depends on severity of the pain and condition of the pain) 3rd line is same in both pathways

1st line: AC: T. Celebrex 200-400mg dly AC Gouty arthritis : T Arcoxia 120mg daily CHR: T. Meloxicam 7.5mg dly T Celebrex 200mg dly

1st line: AC: Voltaren, Mefenamic acid, Ibuprofen CHR: Feldene, Neprosyn

YesNo

Pain not relieved

Pain not relieved

2nd line: 2nd

AC: Oral opiods e.g. T.DF118, T. Arcoxia 120mg dly CHR: T. Celebrex 200 dly T. Meloxicam 7.5mg dly

line: Oral opiods e.g. T.DF118, T. Arcoxia 60-120mg dly

Pain not relieved

3rd

3rd line: Oral morphine T. Oxycontin 10-40mg bd

line: Oral morphine T. Oxycontin 10-40mg bd

AC – acute CHR - chronic

51

FLOWCHART OF PATIENTS DIAGNOSED WITH BACTERIAL CONJUNCTIVITIS

Bacterial Conjunctivitis

1st line:

Gutt. Chloramphenicol

Perform Culture and Sensitivity test Not resolved

2nd line:

Gutt. Ciprofloxacin (Ciloxan)

Not resolved

3rd line:

Gutt. Moxifloxacin (Vigamox)

52

FLOWCHART OF PATIENTS DIAGNOSED WITH BACTERIAL KERATITIS

Bacterial Keratitis

1st line:

Gutt. Ciprofloxacin (Ciloxan)

Perform Cornea Scrapping/ Culture Not resolved and Sensitivity test

2nd line: Gutt. Moxifloxacin

(Vigamox)

53

FLOWCHART OF PATIENTS REQUIRING PRE AND POST CATARACT SURGERY ANTIBIOTIC PROPHYLAXIS

Cataract Surgery

Prophylaxis

Pre–op prophylaxis: • Gutt. Moxifloxacin 0.5 % (Vigamox) 1 drop every 15 minutes 1

hour prior to surgery. • 5 % Povidone – iodine ( 1 drop ) on the ocular surface.

Intra-cameral injection:

• 1mg in 0.1 mL cefuroxime* or • 0.1 mL Gutt. Moxifloxacin 0.5% (Vigamox)1 - at the end of surgery *Dilution is required as standard ceruroxime injection is 100 mg/mL.

Post–op prophylaxis:

• Gutt. Moxifloxacin 0.5% (Vigamox) 3-4 times daily for 1 month.

Reference: 1) CRG Espiritu et. al. Safety of Prophylactic Intracameral Moxifloxacin 0.5%

Opthalmic Solution in Cataract Surgery Patients. J Cataract Refract Surg 2007: 33: 63-68

54

FLOW CHART FOR USING OLOPATADINE 0.1% AND SODIUM

CROMOGLYCATE

i. Kegunan ubat tersebut adalah untuk rawatan kes “Allergic conjunctivitis” terutama “Vernal Allergic conjunctivitis” di kalangan kanak-kanak dan remaja.

ii. Kerana mempunyai kesan kedua-dua iaitu “mast cell stabilizer” dan “anti histamines”

iii. Ubat titis sodium cromoglycate yang dahulu digunakan untuk kes di atas, akan dikurangkan kegunaannya.

“Flow chart” penggunaan kedua-dua drug bagi membezakan kes-kes tersebut seperti berikut; Pesakit

Pesakit “Allergic conjunctivitis” terutama “Vernal Allergic

conjunctivitis”

Selainnya

Ubat titis Sodium Cromoglycate 2%

Ubat titis Olopatadine

55

TREATMENT ALGORITHM OF ALLERGIC RHINITIS (AR)

Diagnosis of AR

Allergen Avoidance Drug Therapy (Antihistamines) Intermittent Symptoms Persistent Symptoms

Moderate - Severe

Moderate - Severe

Mild Mild

*

Xyzal * (Bachert C et al. J. Allergy Clin. Immunol 2004; 114: 838-844) The XPERT, Xyzal in Persistent Allergic Rhinitis Trial – Published RCT data. Indication approved by FDA / DCA.

Xyzal Xyzal *Xyzal Xyzal

1st & 2nd generation antihistaminics

1st & 2nd generation antihistaminics (No clinical data

available to support this indication

56

FLOW CHART OF THALASSAEMIA PATIENT WITH IRON OVERLOAD

DIAGNOSIS OF THALASSAEMIA ON REGULAR BLOOD TRANSFUSION

REGULAR 3-4 MONTHLY FOLLOW-UP IN PAEDIATRIC HAEMATOLOGY

CLINIC

REGULAR 3-4 WEEKLY FOLLOW-UP IN THALASSAEMIA DAY CARE UNIT

FOR BLOOD TRANSFUSION

3 MONTHLY MONITORING SERUM FERRITIN LEVEL

EVIDENCE OF IRON OVERLOAD, SERUM FERRITIN > 1000 MCG/L

INTRODUCE TO SUBCUTANEOUS DESFERAL (deferoxamine) WITH

TRAINING AND MONITORING

ASSESSMENT OF COMPLIANCE TO DESFERAL (Growth, Se Ferritin, yearly

echo of heart)

POOR COMPLIANCE GOOD COMPLIANCE TO DESFERAL TO DESFERAL Se Ferritin Se Ferritin < 2500mcg/L > 2500mcg/L CONTINUE DESFERAL

DEFERASIROX DEFERIPRONE

57

INTERFERON BETA-1B FLOWCHART

Multiple Sclerosis

1) Remitting and Relapsing type.

2) Clinically Isolated syndrome with MRI evidence of multiple

plaques.

DIAGNOSIS ESTABLISHED AS PER Mc DONALD CRITERIA

TREAT THE ACUTE EPISODE WITH I.V METHYL PREDNISOLONE

THEN CONSIDER THE THERAPEUTIC OPTION OF STARTING BETA-

INTERFERON THERAPY.

(Beta interferon is the only evidence based treatment for the above condition, to reduce the risk of relapses and slow down the disease progression).

58