P

H

A

R

M

A

C

Y

Vol. 23 March-April 2014

WATER RATIONING:

HOW IT AFFECTS OUR HEALTH

ACUPRESSURE,

A NEW PROMISING

ALTERNATIVE

Newsletter

Pharmacy

DRUGS IN HRT:

BLEEDING & NON BLEEDING REGIMEN

MERS–CoV:

THE OUTBREAK

;

2

CO

NT

EN

TS

11-12

5-6

7-8

9-10

3-4

12-13

15

16

14

Focus MERS-CoV: The Outbreak

Topic of Current Interest Water Rationing: How It Affects Our Health

Complementary Medicine Acupressure, A New Promising Alternative

Drug Comparison Drugs in HRT: Bleeding & Non-bleeding Regimen

Drug Profile Methods of Drug Administration

Drugs in HRT: Bleeding/non-bleeding ma

Me

Counseling Indacaterol Inhaler

Drug Safety Long-term use of Pain Killers

Announcement Jamuan Perpisahan & Sambutan Hari Jadi

Laughter the Best Medicines Chocolates: Eat It The Healthy Way

EDITORIAL BOARD NURLAILA BAHARUDIN EDITOR

PN. SAIDATUL RAIHAN IBRAHIM

PN. NOORAZLINDA YAACOB

AFZAN RAIHAN IZZATI HAMZAH

CONTRIBUTOR

KOW SOO CHENG

RATHNAA A/P NADARAJAN

SUHAILA ABD RAHMAN

;

3

MERS-CoV: THE OUTBREAK

Middle East Respiratory Syndrome (MERS) is a viral respiratory illness that was first reported in Saudi Arabia in 2012. It is caused by coronavirus and was named after the place of discovery. Hence, it is known as MERS-CoV. Most people who have been confirmed to have MERS-CoV infection develop severe acute respiratory illness. They show symptoms such as fever, cough, and shortness of breath. According to Centers of Disease Control (CDC), about 30% of the infected people dies.

On the 2nd

of May 2014, the US International Health Regulation (IHR) reported the first laboratory confirmation of MERS-CoV infection in a male US citizen. He was in his 60s. He lived and worked in Riyadh, Saudi Arabia. He traveled to the US from Riyadh and landed on Chicago on 24

th of April 2014 via London

Heathrow Airport. He then travelled from Chicago to Indiana by bus. He began feeling unwell around 14

th of

April 2014. He had low-grade fever without any respiratory symptoms. On 27

th of April 2014, he developed

shortness of breath, cough, increasing fever, and mild runny nose. On 28 April 2014, he was admitted to the hospital. His chest x-ray showed infiltrates in the right lung base and he was placed in a private ward for futher investigations. Negative pressure room and airborne precautions were implemented. Full isolation (standard, contact, and airborne) precautions were implemented on 30

th of April 2014.

This is the first report of an imported case of MERS-

CoV in the United States and in the American

Region.

THE HISTORY

;

4

MERS-CoV: THE OUTBREAK

Currently, there is no specific antiviral treatment recommended for MERS-CoV infection. Individuals

with MERS can seek medical care to help relieve symptoms. For severe cases, current treatment

includes care to support vital organ functions.

Treatment

There is no vaccine available at the moment to

prevent MERS-CoV infection. CDC is discussing with partners the possibility of developing one. For

prevention, CDC routinely advises that people protect themselves from respiratory illnesses by taking these

daily preventive measures;

Wash hands often with soap and water for 20

seconds, and help young children to do the same. If soap and water are not available, use

an alcohol-based hand sanitizer.

Cover your nose and mouth with a tissue when

coughing or sneezing, throw the tissue into the trash.

Avoid touching eyes, nose and mouth with unwashed hands.

Avoid personal contact, such as kissing, or sharing cups or eating utensils, with sick people.

Clean and disinfect frequently touched surfaces such as toys and doorknobs.

Prevention

Most people confirmed to have MERS-CoV infection have had severe acute respiratory illness with symptoms of: • Fever

• Cough

• Shortness of breath

Symptoms & Complications

;

5

WATER RATIONING: How it affects our health and life?

How to manage water wisely during water rationing? Below are some

tips.

W.A.T.E.R. is a fundamental part

of our lives. It is easy to forget how we

completely depend on it. Human survival

is dependent on water. Water has been

ranked by experts as the second most

essential things in life after oxygen. But

have you ever wondered, what happens

to us if water rationing occurs? No more

plenty of water to do our routine life.

MALAYSIANS may finally have to face up

to the fact that water is now a scarce

resource, and nothing brought this home

more than the recent rationing exercise in

the Klang Valley. Although people can

breathe a sigh of relief now that full supply

has been restored after two months of

hardship starting from March 2014, the

Meteorological Department has warned that

the next dry spell could start as early as June

and last until October 2014.

;

6

During this season, many of

infections and disease can occur

because of the restricted use of clean

water. Cholera and typhoid/

paratyphoid enteric fevers can easily

spread.

1. Typhoid and paratyphoid enteric

fevers

Typhoid and paratyphoid fevers are

infections caused by bacteria which

are transmitted from faeces to

ingestion. Clean water, hygiene and

good sanitation prevent the spread of

typhoid and paratyphoid.

Contaminated water is one of the

pathways of transmission of the

disease. The disease is usually caused

by the bacteria Salmonella typhi and

Salmonella paratyphi respectively.

Typhoid fever is a bacterial infection

of the intestinal tract and

bloodstream. Symptoms can be mild

or severe and include sustained fever

as high as 39°-40° C, malaise,

anorexia, headache, constipation or

diarrhoea, rose-coloured spots on the

chest area and enlarged spleen and

liver. Most people show symptoms 1-

3 weeks after exposure. Paratyphoid

fever has similar symptoms to typhoid

fever but is generally a milder disease.

Disease Cause By

Dirty Water

2. Cholera

Epidemics of cholera, a bacterial

illness that causes severe watery

diarrhea and vomiting, are seen more

often during times of disaster, when

community infrastructure has been

destroyed or compromised. Floods,

earthquakes, and civil unrest can lead

to the breakdown of community

services.

Lack of access to improved sanitation

facilities can cause the bacteria to leak

into the water supply, thus having the

potential to infect all who drink the

water. This bacterium spreads very

easily from person to person, and in

times when fresh, clean water is not

available for drinking and hand

washing, caretakers of the sick can

infect themselves and others very

easily (Falco and Smith 2010).

;

7

What is Acupressure?

It is an ancient healing art using the fingers to gradually press key healing points stimulating the body's natural curing ability. In our body, there are acupressure points also known as acupoints that lies along meridians or channels in the body. Vital energy flows along these meridian which is also called ‘Qi’.

Utilizing the power and sensitivity of the human bare hand, acupressure therapy is effective in the relief of stress-related ailments, for self-treatment and preventive health care. Acupressure has high electrical conductivity at the surface of the skin which conducts and channels healing energy most efficiently.

How Does Acupressure work?

Back care

Acupressure effectively aids in alleviating muscular tension in all areas of the back. Self-care suggest a person lie down on a few tennis balls tied in socks due to the reason that the acupoints are stationed at either side of the spine or upper back as shown in the Figure 1.

Beauty Treatment

Slight finger pressure on the heavenly appearance points (Figure 2) in conjunction with therapeutic facial exercise relieves facial tension and enhances one’s outwards appearance.

The History of ACUPRESSURE

It was founded in Asia over 5,000

years ago.

Involves the healing energy that is Qi

or Chi.

The human body was believed to

comprise of 12 major meridians that

links up specific organs in the body,

which starts at the fingertips,

connecting to the brain and other

organs.

Yin and Yang groups make up the 12

standard meridians, also called the

Principal Meridians. There are the

Yin meridians of the arm are Lung,

Heart, and Pericardium; the Yin

Meridians of the leg are Spleen,

Kidney, and Liver. The Yang

meridians comprise of the arm are

Large Intestine, Small Intestine, and

Triple Burner; and the Yang

meridians of the leg are Stomach,

Bladder, and Gall Bladder [1, 2].

Figure 1

ACCUPRESSURE

;

8

Alleviating trauma & emotional pain

Acupressure release this muscular

tension caused by emotional stress

Figure 2: Heavenly appearance point

Figure 1: Lowerback acupressure point

Practitioners use their fingers, palms, elbow or feet or special devices to execute pressure on targeted acupoints. A typical session last up to 1 hour.

Acupressure vS Acupuncture

ACUPRESSURE ACUPUNCTURE

Healing technique does not break the skin

Uses thin, long needles in addressing health concerns

Self-performed treatment is possible Performed by trained practitioner

Discovered earlier 2500BCE China Discovered slightly later

Gradual pain relieve Faster pain relieve

Fewer side effects Skin tissue may be allergic to needle stimulation

BENEFITS AND RISK OF ACCUPRESSURE

BENEFITS RISKS

Cure stress-related ailments

Certain acupoints such as SP6 of spleen meridian is not recommended during pregnancy as it will affect the growing fetus.

Preventive healthcare

Boosting immune system

Increases circulation

Reduces pain

Develop spirituality and vibrant health

Releases tension

;

9

Oral Contraceptive

The primary function of oral contraceptives is to prevent pregnancy

and hence helping a couple to plan their family child. Below is

classification of OCP:

(i) Combined oral contraceptive (COC) This type of OCP contains estrogen and progestin

It stops ovulation, makes endometrial (lining of the

uterus) thin so that embryo implantation is unlikely to

occur and the cervical mucus thick so that it is difficult for

the sperm to swim through the mucus into the uterine

cavity.

It tends to make menses very short in duration and scanty

in amount.

It is taken around the same time everyday for 21 days

continuously, followed by a 7-day break (that's when

menses usually occurs). After the 7-day break, a new

course of pill begins.

Examples: Nordette (levonorgestrel and ethinylestradiol) and

Mercilon (ethinylestradiol and desogestrel)

(ii) Progesterone-only pills (PO)

Mini pills contain progesterone hormone only.

It prevents the ovaries from releasing an egg (ovulation),

thicken mucus at the cervix so sperm cannot enter the

uterus, and in rare cases, prevent a fertilized egg from

implanting in the uterus.

The menses will be very short and scanty. People taking

this type of OCP usually experience irregular menses.

Therefore, the mini pills are unpopular among OCP users.

However, it is considered a "milder" pill due to lesser

major side-effects.

It is taken every single day of the year without breaks in

between.

Examples: Micronor (norethindrone)

;

10

OCP AVAILABLE IN HOSPITAL MELAKA

COC Cyproterone Acetate 2 mg

& Ethinyloestradiol

0.035 mg Tablet

(Diane 35)

Androgen dependent diseases

in women

1 tablet daily for 21 days from the

first day of the cycle, followed by

7 tablet free days

COC Desogestrel 150 mcg &

Ethinylestradiol 30 mcg

Tablet

(Marvelon)

Contraception 1 tablet daily for 21 days,

subsequent courses repeated after

7 day interval (during which

withdrawal bleeding occurs)

COC Ethinylestradiol 20 mcg &

Drospirenone 3 mg Tablet

(Yaz)

i) Oral contraception

ii) Treatment of acne vulgaris

in women seeking oral

contraception.

iii) Treatment of symptoms of

premenstrual dysphoric

disorder (PMDD) in women

who choose to use an oral

contraceptive as their method

of contraception.

1 tablet daily for 28 consecutive

days starting on 1st day of

menstrual bleeding

COC

Levonorgestrel 150 mcg

and Ethinyloestradiol 30

mcg Tablet

(Rigevidon)

Contraception 1 tablet daily for 21 days from

first day of the cycle, followed by

7 tab free days

;

11

Methods of Drug Administration

The two primary channels for getting medications into the body are enteral (through the alimentary canal/gastrointestinal (GI) tract) and parenteral routes. The GI tract provides a fairly safe but relatively slow-acting site for drug absorption. Oral, sublingual, and rectal preparations are given via the GI tract. Parenteral administration theoretically includes all routes of administration other than the oral route; but in clinical usage, parenteral administration commonly includes these routes: intradermal (ID), subcutaneous (SC), intramuscular (IM), and intravenous (IV).

2 Parenteral route is usually chosen in the

emergency setting to provide a rapid onset of action and to ensure high blood levels of the drug.1 The

parenteral route also is used when the GI route would inactivate the drug and in unstable or seriously ill patients who require precise administration and monitoring.1

Intradermal or Intracutaneous

Subcutaneous

ID administration involves using a syringe to inject a

liquid drug into the dermis, the layer of skin just below

the epidermis or skin surface. The amount of

medication that can be given via this route is limited,

and systemic absorption is very slow. Generally, this

route is reserved for diagnostic skin tests, such as

allergy testing and for the Mantoux test that screens

for tuberculosis and also for local anesthesia. The

inner aspect of the forearm is the most common site

for intradermal injections because it gives good

visualization of the response to test media.

With SC administration, medications are injected into fatty, subcutaneous tissue under the skin and overlying the muscle. The rate of absorption is slower than that seen with IM and IV administration. A maximum of 2 mL of a drug can be given subcutaneously. SC injections provide a slow, sustained release of medication and a longer duration of action and are used when the total volume injected is no more than 1 mL of liquid.

Many medications, including insulin, allergy shots, heparin, and epinephrine, are given by the SC route. SC injection sites, all areas relatively distant from bones and major blood vessels, include the area over the scapula, the lateral aspects of the upper arm and thigh, and the abdomen. At least 1 inch (2.5 cm) pinched fold of skin and tissue is necessary for administering SC injections. Burned, edematous, or scarred skin should not be used as a SC injection site, nor should the area 2 inches (5 cm) in diameter around the umbilicus or belt line.. Medications administered subcutaneously should be limited to those that are highly soluble, low in volume, and nonirritating. Repeated subcutaneous injections of irritating drugs can result in tissue atrophy, the formation of sterile abscesses, and necrotic tissue.

;

12

Intramuscular

Intravenous Endotracheal

The drug is injected into muscle tissue, from which it is absorbed into the bloodstream. This method of administration has a predictable rate of absorption but is considerably slower than IV administration. IM injection is useful when drug action faster than that provided by SC injection is desired but rapid effects are not required. The onset of action usually occurs within 10 to 15 minutes after an IM injection. However, the blood flow to the injection site affects the absorption rate. The most common muscles into which drugs are administered are the deltoid and the gluteus. In general, 5 mL of fluid can be administered with an IM injection, but a maximum of 1 mL of medication can be given into the deltoid, whereas 10 mL can be given into the gluteus.

The technique for administering an IM injection is the same for both adult and pediatric patients. It is important to note that, as a rule, patients presenting with a chief complaint of chest pain should not receive medications by the IM route. IM injection of medication may cause an elevation of certain muscle enzymes that routinely circulate in the blood. An IM injection must be given into a muscle that is large enough that the needle will not accidentally injure a nearby nerve. Examples of drugs given intramuscularly include meperidine for severe pain and penicillin for bacterial infection. Some liquid drugs, such as Valium (an antianxiety drug), can never be given by IM injection because they are not water soluble and, if

injected, would form precipitate particles in the muscle tissue.

Medications are administered intravenously to obtain an immediate onset of action, to obtain the highest possible blood concentration of a drug, and to treat conditions that require the constant titration of medication. These can be in the form of an IV bolus or as a slow IV infusion,

sometimes referred to as a piggyback infusion. The rate of absorption is rapid and predictable. Of all the routes frequently employed, however, IV administration of drugs has the most potential for causing adverse reactions. Sites used for IV administration include the veins on the hand and wrist, the forearm veins that traverse the antecubital fossa, the veins on the scalp and umbilical vessels (for infants), and the superficial veins of the leg and foot when other sites cannot be used. In all but a few cases, it is essential that an IV be established before administering medications intravenously. Establishing an IV line makes the repeated administration of medications less traumatic. The IV route entirely bypassses the step of absorption because the drug is not absorbed from the tissues or stomach. Examples of drugs given intravenously include thiopental for induction of general anesthesia, diazepam to control continuous epileptic seizures, and most chemotherapy drugs.

When an IV line cannot be started, it is sometimes possible to administer emergency medications down an endotracheal tube, which permits absorption into the capillaries of the lungs and into the blood. It has been shown that this route has a rate of absorption as fast as the IV route. Drugs that can be administered endotracheally include epinephrine, lidocaine, naloxone, and atropine. When administering a medication via the endotracheal tube, the dose should be increased to 2 to 2.5 times the intravenous dose. The endotracheal route is also used to administer synthetic lung surfactant drug to treat respiratory distress syndrome in premature infants.

;

13

Long-term Use of Pain Killers

A wide range of analgesics have been used in the treatment of chronic pain. There is

considerable variation in patient responses to analgesia, both in terms of efficacy and side effect. Regardless of which analgesia is used, regular review and reassessment to determine that there is continued value from using a particular medication is important in providing ongoing good quality.

A. Non-steroidal Antiinflammatory Drugs

(NSAIDs)

Gastrointestinal (GI) adverse effects are well established risks of long term regular NSAID treatment and may include decreased appetite, nausea, vomiting, diarrhoea, constipation, heart burn and stomach pain or cramps. Other effects were varied and included oedema, dry mouth, rash, dizziness, headache, and tiredness. Meta-analyses of RCTs have shown that long term regular use of ibuprofen, diclofenac, celecoxib and etorocoxib are all associated with an increased risk of myocardial infarction and coronary heart disease although reported less with naproxen. An increased risk of heart attack and stroke with some non-selective NSAIDs, such as diclofenac, is well recognised, particularly with long-term use of high doses and in patients who are already at a high risk. Naproxen and low-dose ibuprofen (1,200mg per day or less) are considered to have the most favourable thrombotic cardiovascular safety profiles of all non-selective NSAIDs.

One of the main reasons for high drop-out rates in clinical trials of opioids is side effects (the most common are gastrointestinal and CNS side effects). Patients using oxycodone experienced more somnolence than those using other opioids.

1 Across studies, a high

percentage of patients experience dry mouth (42%), constipation (20–41%), sweating (34%), weight gain (29%), somnolence (14–29%), problems with sleep (25%), memory deficits (24%), loss of appetite (23%), nausea (17–33%), concentration deficits (19%), fatigue (19%), sexual dysfunction (18%), dizziness (12–22%), vomiting (11–15%), pruritus/dry skin (10%) and urinary retention.

3

A few serious side effects such as sedation and respiratory depression were reported. Adverse effects led to discontinuation in 11% of patients on weak opioids and 35-39% on strong opioids.

B. Opioids

C. Drugs for Neuropathic Pain

Gabapentin has a favourable side-effect profile, few clinically significant drug-drug interactions and is generally well tolerated; however, common side effects include dizziness (21%), somnolence (16%), peripheral edema (8%), and gait disturbance (9%).

1,4 Confusion, ataxia, dry mouth and weight gain is also an adverse effect.

4

In patients on pregabalin, common adverse effects reported include dizziness (8-43%), somnolence (6-30%), weight gain (5-20%), ataxia (2-21%), peripheral edema (3-19%), amblyopia (1-17%), abnormal thinking (1-10%) and diplopia (2-13%).

5 Other adverse effects seen in clinical trials include asthenia, euphoria, dry mouth, headache,

constipation, vertigo, tremor, confusion, and nausea.5 The adverse effects that most frequently led to discontinuation

in the clinical trials were dizziness and somnolence.5 It has been suggested that this drug be avoided if the patient has

a problem with weight gain.4

;

14

Chocolates: Eat It the Healthy Way

Report states that dark chocolate can aid in mood enhancement. Cocoa flavanols in dark chocolate has calming effect hence consumption of cocoa flavanol dark chocolate have more positive mood state. Chocolate contains psychopharmacological active compound namely, methylxanthines, caffeine and theobromine.

Caffeine improves alertness and motor function. Theobromine binds to adenosine receptors executing psychoactive properties. Its flavonol content has neuro-cognitive effects.

A randomised controlled trial was done on seventy-two healthy men and women aged 40-65 years. They were asked to consume a 20 g dark chocolate drink mix with either 500 mg of cocoa flavanols, 250 mg or no cocoa flavanols for 30 days. Results showed that after 30days, the group with highest flavonol consumption portrays higher level of calmness and contentedness. Hence, dark chocolate is recognized to alleviate anxiety and depression symptoms.

Chocolate Happiness Undergoing More Pleasantness (CHUMP) study compared effects of dark chocolate, milk chocolate and normal chocolate to the level of happiness. This study lasted for a month. 60 participants were elected for each group of dark chocolate, milk chocolate and normal chocolate. Results showed that chocolate consumption people given dark chocolate and milk chocolate were far happier than with normal chocolate group.

Advantages Disadvantages

Lowering of blood pressure,

natural preventer of heart disease

Mood enhancement Contain tryptophan than aids

in brain functioning which leads to excitement and renews the soul

Contains antioxidants similar to that found in teas

Its antioxidants aids in prevention of heart disease, cancer and toxin-caused cellular damage

Source of good cholesterol Its flavonoid content

improves cardiovascular health and improves blood circulation

High fat and calorie content

May input unnecessary fat to the heart

Contain minute amounts of central

nervous system stimulants specifically

caffeine hence has mild effects on

increasing alertness

Contains theobromine, a mild stimulant

known to relax smooth muscle lining of

the lungs

;

15

JAMUAN PERPISAHAN

&

SAMBUTAN HARI JADI

TARIKH:

25HB APRIL 2014 (JUMAAT)

Lowering of blood pressure,

natural preventer of heart disease

Mood enhancement Contain tryptophan than aids

in brain functioning which leads to excitement and renews the soul

Contains antioxidants similar to that found in teas

Its antioxidants aids in prevention of heart disease, cancer and toxin-caused cellular damage

Source of good cholesterol Its flavonoid content

improves cardiovascular health and improves blood circulation

High fat and calorie content

May input unnecessary fat to the heart

Contain minute amounts of central

nervous system stimulants specifically

caffeine hence has mild effects on

increasing alertness

Contains theobromine, a mild stimulant

known to relax smooth muscle lining of

the lungs

TEMPAT:

FARMASI UTAMA, FARMASI BEKALAN WAD

SAMBUTAN HARI JADI BAGI:

STAFF YANG LAHIR

PADA BULAN

MAC, APRIL & MEI

MERAIKAN:

PUAN AZURA AZLAN

ENCIK ABD AZIZ MD NOR

CIK NADIAH ABDULLAH

PUAN MARIAM ASIAH SAHID