HOSPITAL KUALA KUBU BHARU PHARMACY BULLETIN

HOSPITAL KUALA KUBU BHARU
PHARMACY BULLETIN
2nd edition /Dec2015
HIGHLIGHTS:

For further enquiries, please

Measles (Page 1—4)
Pertussis (Page 5—7)
contact us at :
CURRENT ISSUE (PAGE 8-11)
DRUG INFORMATION
SERVICES (DIS)

Medication safety

Look A Like
Pharmacy Department,

Sound A like
Hospital Kuala Kubu Bharu,

High Alert Medication In HKKB
44000 Kuala Kubu Bharu,
Selangor
PHARMACY EDUCATION (PAGE 12-13)

03-60641333 ext 279
What’s In The ADA’s Diabetes Guideline
2015?
EDITORIAL BOARD
CONTRIBUTORS:
ADVISOR : Ratna Suny Mohamed Esa
CHIEF EDITOR : Noor Haslina Zainor Abidin
EDITOR : Ainur Fadlina Mohd Nadzir
Nur Shazwani Mokhtar
1)
Mohamad Shafawie Mohamad Sidik
2)
Muhammad Ashraf b Abd Nasir
3)
Vanitha A/P Hong Wee Liang
BY : MUHAMMAD ASHRAF B ABD NASIR
MEASLES
Nowadays, measles mainly affects children and is
regarded as an important reason of childhood
morbidity and mortality in developing countries. It can
cause
severe
complications,
particularly
in
malnourished children and people with reduced
immunity.
TRANSMISSION
Measles virus, the causative agent, is a single-stranded negative-sense RNA virus
belonging to the family Paramyxoviridae, genus Morbillivirus. Measles virus is
efficiently transmitted by aerosol entering the respiratory tract or by direct contact
with respiratory secretions, causing a systemic infection. This disease can also be
transmitted through sexual intercourse. After an incubation period of 8–12 days,
measles signs and symptoms will begin to show.
SIGNS & SYMPTOMS

Fever

Cough

Coryza  common cold

Conjunctivitis

Sore throat

Headache

Abdominal pain

Photophobia from
iridocyclitis

Rash  first noted on the face and neck which
increases in number for 2 or 3 days, especially
on the trunk and face.

Koplik’s spots  bluish-white, slightly raised
lesions, appears on the buccal mucosa,
usually opposite the first
molar, and occasionally
on the soft palate,
conjunctiva, and vaginal
mucosa
1
DIAGNOSIS
Although the diagnosis of measles is usually determined from the classic clinical
picture, laboratory identification and confirmation of the diagnosis are necessary
for public health and outbreak control. Laboratory confirmation is achieved by
means of the following:

Serologic testing for measles-specific IgM or IgG titers

Isolation of the virus

Reverse-transcriptase polymerase chain reaction (RT-PCR) evaluation
COMPLICATIONS
Complications from measles have been reported in every organ system (refer
table 1). It usually happens among very young infant or immunocompromised
patient. Many of these complications are caused by disruption of epithelial
surfaces and immunosuppression.
2
TREATMENT



There is no specific antiviral treatment for measles.
Complications  May require antibiotic treatment.
Other treatments  Focus on management of signs and symptoms.
People with low levels of vitamin A are more likely to have a more severe case of
measles. The WHO recommends vitamin A supplementation for all children
diagnosed with measles :
Age
Dose
< 6 months
50,000 IU/day PO for 2 doses
6-11 months
100,000 IU/day PO for 2 doses
> 1 year
200,000 IU/day PO for 2 doses
Children with clinical signs of vitamin A deficiency : The first 2 doses as
appropriate for age, then a third age-specific dose given 2-4 weeks later
IMMUNIZATION PROGRAM
In Malaysia, measles is mainly prevented by the measles, mumps and rubella
(MMR) combination vaccine. In some countries, the measles, mumps, rubella and
varicella (MMRV) combination vaccine has been used in the vaccination
program. Almost all people who have 2 doses of a measles-containing vaccine will
be protected against measles.
Table 2. Measles vaccine and MMR vaccine program in Malaysia
3
ANTI-VACCINE ISSUES
The measles vaccine has almost eliminated measles in the
United States of America. The cases have declined from an
estimated 5 million a year to virtual disappearance.
However, the latest issues regarding MMR vaccine
contribution in the development of autism in children has
once again give arise to the once forgotten disease. In 2011, the number of people
with measles in the United States was higher than usual. There were 220 people
reported to have measles. That’s more than any year since 1996. The same trend was
also observed in Malaysia during 2011, when there were 1603 confirmed cases of
measles, compared to 2010 with only 74 people with measles.
The suggestion that MMR vaccine might lead to autism had its origins in research by
Andrew Wakefield, a gastroenterologist, in the United Kingdom. In 1998, Wakefield
and colleagues published an article in The Lancet claiming that the measles vaccine
virus in MMR caused inflammatory bowel disease, allowing harmful proteins to enter
the bloodstream and damage the brain. When the finding could not be reproduced by
other researchers, the validity of this finding was later called into question. Moreover,
the findings were further discredited when an investigation found that Wakefield did
not disclose he was being funded for his research by lawyers seeking
evidence to use against vaccine manufacturers.
Furthermore, large studies of children done in the United States, the
United Kingdom, and Denmark found no link between MMR vaccine
and autism. In a nutshell, people who choose not to vaccinate their
children actually make a choice for other children and put them at
risk.
Andrew Wakefield;
The man behind the
anti-vaccine uproar
REFERENCES

Morens, D. M., & Taubenberger, J. K., (2015). A forgotten epidemic that changed medicine: measles
in the US Army, 1917–18.

Measles; Prevention and Control in Malaysia, Handbook for Healthcare Personnel


PAEDIATRIC PROTOCOLS For Malaysian Hospitals, 3rd Edition
de Vries, R.D., Mesman, A. W., Geijtenbeek,T. B. H., Duprex, W. P., and de Swart, R. L. (2012).
The pathogenesis of measles.

Selena, S. P., (2015). Measles Practice Essentials, Background, Pathophysiology. Medscape

MMR vaccine does not cause autism. Examine the evidence! (2015) Technical content reviewed
by the Centers for Disease Control and Prevention
4
BY : VANITHA A/P HONG WEE LIANG
Pertussis, an acute infectious disease commonly known as whooping cough, is very contagious. It is
caused by a type of bacteria called Bordetella pertussis. These bacteria attach to the cilia (tiny, hairlike extensions) that line part of the upper respiratory system, produce toxins that paralyze the cilia,
and cause inflammation of the respiratory tract, which interferes with the clearing of pulmonary
secretions.
Pertussis occur mainly in infants and children, and only found in humans. Transmission of pertussis can
occur through direct face-to-face contact, through sharing
Bordetella pertussis
of a confined space, or through contact with oral, nasal, or a fastidious, gram-negative bacterium,
respiratory secretions from an infected source. The
aerobic , coccobacillus capsulate of the
incubation period of the disease is 5 to 10 days (maximum is
up to 21 days). The infectious period is at the beginning of genus Bordetella
the catarrhal period which is prior to cough onset and up to
21 days after the cough started. Pertussis can cause violent
and rapid coughing, over and over, until the air is gone
from the lungs and patient forced to inhale with a loud
"whooping" sound. This extreme coughing can cause
vomiting and exhaustion.
CLINICAL MANIFESTATIONS
The clinical course of the illness is divided into three stages: catarrhal, paroxysmal and convalescent.
Pertussis has an insidious onset with catarrhal symptoms that are indistinguishable from those of
minor respiratory tract infections. The cough, which is initially intermittent, becomes paroxysmal. In
typical cases paroxysms terminate with inspiratory whoop and can be followed by posttussive
vomiting. Paroxysms of cough, which may occur more at night, usually increase in frequency and
severity as the illness progresses and typically persists for 2 to 6 weeks or more. After paroxysms sub-
side, a nonparoxysmal cough can continue for 2 to 6 weeks or longer.
5
The spread of pertussis can be limited by decreasing the
infectivity of the patient and by protecting close
contacts. Symptoms may be lessened if antimicrobial
treatment is started early in the course of illness during
the first 1 to 2 weeks, prior to paroxysmal coughing. If
treatment begins later in the course of illness, it may
not decrease symptoms but will shorten the period of
infectivity. When patient is on antibiotics, the infectious
period is at the onset of cough until the 5th day of the
14 days of recommended antibiotic treatment.

Patients with pertussis are
infectious from the beginning of
the catarrhal stage through the
third week after the onset of paroxysms (multiple, rapid coughs)
or until 5 days after the start of
effective antimicrobial treatment

Treat persons aged >1 year within 3 weeks of cough onset and infants aged <1 year and
pregnant women (especially near
term) within 6 weeks of cough
onset
The need for antibiotic prophylaxis is particularly
important in the following high risk groups:
i. infants
ii. non-immunized children
iii. immunocompromised individuals
iv. pregnant women
v. individuals with chronic respiratory illness, including asthmatics
ANTIMICROBIAL AGENTS FOR TREATMENT AND PROPHYLAXIS OF PERTUSSIS
Antibiotic
Infant < 6months
Erythromycin
< 30 days of age : not
preferred (associated with infantile hypertrophic pyloric
stenosis)
≥ 6 months & children
40-50 mg/kg/day in 4
divided doses for 14 days
(maximum 2g/day)
Adult
2g/day in 4
divided doses for 14
days
Use if azithromycin unavailable : 40-50mg/kg/day in 4 divided doses for 14 days.
Clarithromycin
For those unable to
tolerate erythromycin.
Not recommended
during pregnancy
Azithromycin
For those unable to
tolerate erythromycin
Not recommended for use in
infants < 1 month of age
15 mg/kg/day divided into 1g/day in 2 divided
2 doses for 7 days.
doses for a minimum of 7 days
Maximum 1g/day
Preferred antibiotic in infant < 10mg/kg/day on the 1st
1 month of age.
day, then 5mg/kg once
10mg/kg in a single dose for 5 daily for next 5 days.
days.
Maximum 500mg
500mg on the 1st
day then 250mg
once daily next 5
days.
Should not be used for < 2
8/40 mg per kg/day divid- 320mg/1600mg
Trimethoprimed into two doses for 14 per day in 2 divided
Sulfamethoxazole month (risk of kernicterus)
doses, for 14 days
(TMP-SMZ)
> 2 months : TMP 8mg/kg/day, days
SMZ 40mg/kg/day in 2 divided doses for 14 days
6
CONTROL OF PERTUSSIS CONTACTS
Minimum Period of Isolation of Patient

Suspected cases should be removed from the
presence of young children and infants, especially
non-immunized infants, until the patients have
received at least 5 days of a minimum 14-day
course of antibiotics.

Suspected cases who do not receive antibiotics
should be isolated for 3 weeks.
Vaccination does not
provide life-long
protection. It provides
high level of protection
Minimum Period of isolation of Contacts

If contact is symptomatic  use the same restriction as for cases

If contact is an asymptomatic (healthcare worker not receiving prophylaxis)  exclude from
workplace for 21 day after last exposure or if unknown, for 21 days after the onset of the last case
setting

If the contact is asymptomatic (not a health care worker) and exposed within the 21 days 
patient should receive antibiotic prophylaxis but no isolation is generally required
Quarantine
Inadequately immunized household contacts less than 7 years of age should be excluded from schools,
day care centers and public gatherings for 21 days after last exposure or until the cases and contacts
have received 5 days of a minimum 14 - day course of appropriate antibiotics.
References :
1. Ministry of Health Malaysia. Case Investigation and Outbreak Management for Healthcare Personnel: Pertuss
sis. Diseaase Control Division Department of Public Health. 2010. 1st Edition.
2. Centres for Disease Control and Prevention. Pertussis. Last updated: 2015 April 28
3. Joseph J Bocka et al. Pertussis Treatment and Management. Medscape
7
CURRENT ISSUE: MEDICATION SAFETY
LOOK A LIKE MEDICATION
Allopurinol 300 mg
Atenolol 100 mg
Cloxacillin 500 mg
Rifampicin 300 mg
Omeprazole 20 mg
Cefuroxime 250 mg
Activated
Charcoal 250 mg
Neurobion (Vit B1,
B6, 12)
Isoniazid 100 mg
Baclofen 10 mg
Syr Paracetamol
120 mg/5 ml
Syr
Chlorpheniramine
2 mg/ 5 ml
Medroxyprogesterone
5 mg
Carbimazole 5 mg
Baclofen 10 mg
8
LOOK A LIKE MEDICATION
Phytomenadione
10mg/ml
Phytomenadione
1mg/ml
Dopamine
40mg/ml
Noradrenaline
1mg/ml
Metochlopramide
5mg/ml
Amiodarone
50mg/ml
Acetylcysteine
200mg/ml
Sodium Bicarbonate
8.4%
Ampicillin 500mg
Benzylpenicillin 1MU
Ampicillin 1g +
sulbactam 500mg
Amoxycillin 1g +
clavulanate 200mg
Adrenaline
1mg/ml
Fluphenazine
25mg/ml
Haloperidol
5mg/ml
Atropine
1mg/ml
Hyoscine
20mg/ml
9
SOUND A LIKE MEDICATION
TABLET
Alprazolam
Clonazepam
Amlodipine
Carbamazepine
Enalapril
Gliclazide
Glucophage XR
Losartan
Madopar
Promethazine
Zantac (Ranitidine)
Midazolam
Lorazepam
Felodipine
Chlorpromazine
Perindopril
Glibenclamide
Glucovance
Valsartan
Methyldopa
Prochloperazine
Xanax (Alprazolam)
I NJECTION
Benzylpenicillin
Noradrenaline
Dobutamine
Duloxetine
Humulin
Lanoxin (Digoxin)
Nalbuphine
Benzathine penicillin
Adrenaline
Dopamine
Fluoxetine
Humalog
Naloxone
Naloxone
OTHERS
Clotrimazole
Chloramphenicol eye drop
Cotrimoxazole
Chloramphenicol ear drop
10
LIST OF HIGH ALERT
MEDICATIONS HKKB
A
L






Inj. Adenosine 6mg/2ml
Inj. Adrenaline 1mg/ml
Inj. Amiodarone 150mg/3ml
Antivenom Cobra
Antivenom Polyvalent
Tab. Acarbose 100mg



M

C

Chloral Hydrate Sodium
200mg/5ml




Inj. Dextrose Anhydrous 50% w/
v
Inj. Diazepam 10mg/2ml
Inj. Digoxin 0.5mg/2ml
Inj. Dobutamine 250mg/20ml
Inj. Dopamine 40mg/ml

D







Inj. Fondaprinux 2.5mg/0.5mg


Inj. Oxytocin 10iu / ml
Inj. Oxytocin 5iu and Ergometrine 0.5mg



Inj. Pethidine 100mg/2ml
Inj. Potassium Chloride 10% w/v
Inj. Promethazine 50mg/2ml

Inj. Streptokinase 500 000iu /
0.5ml
P
G
Inj. Glyceryl Trinitrate
50mg/10ml
 Inj. Gentamicin 80mg / 2ml
 Tab. Glibenclamide 5mg
 Tab. Gliclazide 80mg
Inj. Noradrenaline 4mg/4ml
Inj Nalbuphine 10mg / ml
O
Inj. Enoxaparin 60mg/0.6ml
F
Inj. Magnesium Sulphate
2.47g/5ml
Inj. Midazolam 5mg/ml
Inj Midazolam 15mg/3ml
Inj. Morphine Sulphate 10mg/
ml
Tab. Metformin 500mg
N
E

Inj. Labetalol 25mg/5ml
Inj. Lignocaine 100mg/5ml
Inj Lignocaine (LA)

S
V
H

Inj. Heparin 5000iu/ml

Inj. Verapamil 2.5mg / ml
W
I

Insulin

Tab. Warfarin 1mg,2mg,5mg
11
BY : MOHAMAD SHAFAWIE B MOHAMAD SIDIK
Type 1
Due to β-cell destruction
Type 2
Due to progressive insulin secretory defect on the
background of insulin resistance
GDM
Diagnosed in 2nd or 3rd trimester of pregnancy
that is not clearly overt diabetes
Specific
Due to other causes such as monogenic diabetes
syndromes, exocrine pancreas related problems
CLASSIFICATION
CRITERIA DIAGNOSIS FOR DIABETES




HbA1c ≥ 6.5% @
Fasting plasma glucose ≥ 7.0mmol/l (fasting defined as no caloric intake at least 8H) @
2H-Plasma glucose ≥ 11.1mmol/l (OGTT) @
Patient with classic symptom of hyperglycemia and RBS ≥ 11.1mmol/l

TEST performed at 24-28 weeks of gestation with not previously
diagnose with overt diabetes

75g OGTT performed at fasting (fast overnight at least 8 hour)

Measured plasma glucose at fasting, at 1H and at 2H
*GDM are diagnosed in any of the following are met or exceed :
TESTING
FOR GDM
1. Fasting  5.1 mmol/L
2. At 1 Hour  10 mmol/L
3. At 2 Hour  8.5mmol/L
TWO STEP STRATEGY : 24-28 week of gestation w/o overt diabetes
Step1:
1) 50g Glucose Load Test non fasting performed
2) Measure plasma glucose at 1H
3) If plasma glucose at 1H ≥ 7.8 mmol/l, proceed with second step
Step2:
1) 100g OGTT during fasting and measured at fasting, 1H, 2H and 3H
*GDM are diagnosed in any of the following are met or exceed :
1. Fasting

5.8 mmol/L
2. At 1 Hour  10.6 mmol/L
3. At 2 Hour  9.2 mmol/L
4. At 3 Hour  8.0 mmol/
12
PREDIABETES INDICATOR




Indicate risk of diabetes
Impaired Fasting Glucose  Fasting plasma glucose 5.6 – 6.9 mmol/l @
Impaired Glucose Tolerance  2H plasma glucose 7.8 – 11.0 mmol/L @
HbA1c  5.7 – 6.4%
HbA1c TARGET FOR DIABETES PATIENT
More Stringent Target <6.5%



Short diabetes duration

Long life expectancy
No significant CVD/vascular
complication
7%
Less Stringent Target <8%
Most
adults





Severe hypoglycemia history
Limited life expectancy
Advanced microvascular or macrovascular
complication
Extensive co morbidities
Long term diabetes in whom general
HbA1c target difficult to attain
RELATIONSHIP BETWEEN HbA1c AND MEAN PLASMA GLUCOSE
HbA1c (%)
mg/dL
mmol/L
6
126
7.0
7
154
8.6
8
183
10.2
9
212
11.8
10
240
13.4
11
269
14.9
12
298
16.5
NEW CLASS OF DRUG FOR T2DM
INVESTIGATIONAL AGENT FOR T1DM
SGLT 2 INHIBITOR


METFORMIN

INCRETIN
REFERENCE :
1. ADA STANDARDS OF MEDICAL CARE IN DIABETES 2015
13