Pharmacy

Newsletter Vol. 27 Nov-Dec 2014

Self-medication: Don’t take med-ications blindly

Drug Comparison:

Streptokinase-Alteplase-Tenectaplase

Complimentary Medicine:

Body Walking

Drug Doping

In Sport

CO

NTE

NTS

Focus

Diluents for Injectable Drugs

Topic of Current Interest

Drug Doping in Sports

Complementary medicine

Body Walking

Drug Comparison

Streptokinase vs Alteplase vs

Tenectaplase

Drug Profile

Propiverine

Counselling

Dengue: The use of papaya leaves

Drug Safety

Self-medication: Don’t take medications blindly

Activities/ Announcement

Promosi: Sahabat Farmasi

EDITORIAL BOARD

PN. SAIDATUL RAIHAN BT IBRAHIM

PN. NOORAZLINDA YAACOB

PN. AFZAN RAIHAN IZZATI HAMZAH

EDITOR:

WOON SU ANN

CONTRIBUTOR:

TANG KAH WONG

MUNAWWARAH BINTI MD KAILANI

NUR FARAHIN BINTI ABDUL JABAR

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3-4

5-6

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9-10

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Many drugs used in sterile products, especially antibiotics, come in a dry powder form. It is extremely important that the correct diluent be selected and the appropriate calculations be performed to ensure correct concentrations and stability of the finished product. Diluent is a clinically inactive ingredient/liquid used to

dilute or reconstitute a medication. It is also used to convert a dry form of a substance to a liq-

uid form. It is typically inserted with a syringe through the rubber stopper of the medication

vial for injectable drugs.

Some medications are very unstable in liquid form. Therefore, they are supplied in a dry

form to which an inactive diluent is added just before use. The information about the specific

type and amount of diluent to be added to achieve specific concentrations is provided on the

product label. Selecting the correct diluents (liquid or solution) is important in reconstituting a

medication. Incorrect diluents used can affect the medication’s stability, efficacy and safety.

Use of the incorrect diluent may result in loss of potency of the medication, an unwanted

chemical interaction, or a shorter period of stability of the reconstituted medication. The infor-

mation regarding the correct diluent to be used is clearly written on the product label. To en-

sure that the ingredients are compatible or incompatible with the diluent, the pharmacist or

pharmacy technician should check the reference books available in the pharmacy or may con-

sult the product information leaflet.

Diluents for Injectable Drugs By: Tang Kah Wong

Normal Saline Normal saline is a term commonly used interchangeably with 0.9% sodium chloride

(NaCl) injection.

It is the concentration of sodium chloride within the human blood stream.

It is isotonic, as are most injectable formulations. By diluting with normal saline, the

tonicity of the solution is unaltered. However, it is now known that rapid infu-

sion of NS can cause metabolic acidosis.

Dextrose 5% Dextrose is a form of glucose (sugar). Dextrose 5% in water is injected into a vein

through an IV to replace lost fluids and provide carbohydrates to the body.

It may be used as a diluent (liquid) for preparing injectable medication in an IV bag.

The difference between Dextrose with others diluent that is that sugar is a rapidly

regulated and metabolized compound in the bloodstream. As the sugar is me-

tabolized, or is removed from circulation by the liver making it into glycogen,

what remains is free water, which is hypotonic and therefore tends to cross

membranes out of the vascular space until osmotic equalibrium is reachieved.

Sterile Water for

Injection

Sterile Water for Injection USP is a clear, colorless, odorless liquid. It is sterile, hypotonic, nonpyrogenic, and contains no bacteriostatic or antimicrobi-

al agents.

It is a suitable diluent for intravascular injection after first having been made ap-

proximately isotonic by the addition of suitable solute. However, The solutions

can cause fluid and/or solute overload resulting in dilution of serum electrolyte

concentrations, overhydration, congested states or pulmonary edema.

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So, which is the best diluent?

The choice between water for injection , dextrose 5% and 0.9% sodium chloride (normal

saline) as a diluent is a matter of debate. Normal saline is most commonly used among these

three diluents. Water for injection is hypotonic; using it as a diluent will potentially produce a hy-

potonic solution, where can cause hypotonic of cells and hemolytic.

On the other hand, dextrose 5% can becomes hypotonic too after the sugar is metabolized

by body and only free water left . It also can decrease sodium and potassium level causing hypo-

natremia and hypokalemia. Moreover, prolonged use of sugar water can cause high blood sugar

(hyperglycemia). Monitoring is needed blood glucose levels carefully when using dextrose IVs,

especially if the patient is diabetic.

There no doubt normal saline is most recommended as most of the drug can be diluted

with it. Secondly, Normal saline is isotonic, as are most injectable formulations. By diluting with

normal saline, the tonicity of the solution is unaltered. Unfortunately, risk of hypernatremia and

hyperchloremic metabolic acidosis has been reported. The chloride content of isotonic saline is

particularly high relative to plasma (154 mEq/L versus 103 mEq/L, respectively). Chloride ions

can cause decrease bicarbonate ions which act as buffering agent. Without these ions, acidosis

of body will occur , this is known as hyperchloremic metabolic acidosis.

In conclusion, all pharmaceutical company and profession recommended dextrose 5% and

normal saline as a diluent, but mostly there recommended normal saline. Most importantly, be-

fore choose a good diluent drug compatibility with diluent should be considered as well as patient

condition (diabetes and fluid restriction patient ) too.

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Stimulant Stimulate and incite the central nervous system, relieve physical and psycolog-iccal fatigue Eg. Bromantan, Cocaine, Ephedrine

Narcotics Relieve pain and discomfort which could arise from muscle strain Eg. Methadone, morphine

Beta 2 agonist Use when precise coordination is crucial (shooting and diving) All beta 2 agonist except formoterol

Peptide hormones and similar substances Increase performance ability, accelerate metabolism, increase resilience and stress resistance Eg Insulin, corticotrophin, erythropoietin

Diuretic Use as masking substance to conceal other doping substance taken

Glucocorticosteriod Relieve inflammation Eg.Prednisolone, dexamethasone, hydro-cortisone

Aromatase inhibitors Increase one’s own testosterone secre-tion Prohibited in male only Eg. Tamoxifen, clomiphen, cyclofenil

Anabolic steroid Increase muscle strength, resil-ience, help quickly restore after strenuous physical exercise, accelerates nearly all biosyn-thetic processes, especially protein generation. Eg. Nandrolone stanozolol, stenbolone, testosterone

Cannobinoid Improve concentration of attention and determination Eg. Derivatives of cannabis sativa

Types of Drug Prohibited in Sports

Doping is now a global problem that follows international sporting events worldwide. International

sports federations, led by the International Olympic Committee, have for the past half century at-

tempted to stop the spread of this problem, with little effect.

The use of banned performance-enhancing drugs in sports is commonly referred to as doping,

particularly by the organizations that regulate sporting competitions. The reasons for the ban are

mainly the health risks of performance-enhancing drugs, the equality of opportunity for athletes,

and the exemplary effect of drug-free sport for the public.

By: Woon Su Ann

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Urine

Testing

When called for a drugs test the athlete is entitled to have

a representative (such as their coach or team doctor)

present to verify that the testing occurred in accordance

to guidelines. A sample is provided (in view of an official

of the same gender) and split into two bottles and sealed

by the athlete. A code number will be attached to the bot-

tle and recorded on the relevant paperwork to ensure the

correct result is given to the athlete whilst retaining their

anonymity.

Following the sampling procedure the athlete must com-

plete a medical declaration which states all medicines,

drugs and substances taken over the last week. It is im-

portant that the athlete records everything, from over-the-

counter medicines, to supplements and prescribed drugs.

If any of these substances are on the prohibited list the

athlete must hold a Therapeutic Use Exemption (TUE).

The competitor, representative and official all check the

form before the official and athletete sign it and both par-

ties are given a copy.

The samples are then sent to a registered laboratory (if

there is not one on site) where sample A is tested using

gas chromatography (which uses separation techniques

to divide the contents of the sample) and mass spec-

trometry (which provides the exact molecular specifica-

tion of the compounds). If a positive result is found with

sample A, the athlete is notified before sample B is also

tested. The athlete or their representative is entitled to

be present at the unsealing and testing of the second

sample. If this too is positive, the relevant sporting or-

ganisations are notified whose responsibility it is to de-

cide what penalties or bans are to be imposed.

Blood Testing

Blood testing is used in the detection of drugs such

as EPO and artificial oxygen carriers by testing the

haematocrit or blood count. Over time a "blood profile" of

an athlete can be built up to help determine average

readings for each individual. This can help with blood

doping tests in the future. The same anonymity and rep-

resentative procedures apply as for urine sampling.

Again the athlete is asked to select and check the testing

and collection equipment before a phlebotomist (an indi-

vidual trained to draw blood) collects two samples of

blood directly into bottles A and B. The bottles stay in the

possession of the athlete (who is always accompa-

nied by an official) until they are sealed in the sample

collection kit. Samples are sent to a lab for testing.

The same procedure applies as in urine testing,

where if the A sample is positive, the B sample is then

tested. Another positive result means the appropriate

governing bodies are notified.

The World Anti-Doping Agency (WADA) was established in 1999 to promote, coordinate, and monitor at the interna-tional level to fight against doping in sport in all its forms. The Agency is composed and funded equally by the Sports Movement and Governments of the world. WADA works to ensure that athletes benefit from the same anti-doping pro-tocols and protections, no matter the nationality, the sport, or the country where tested. The ultimate goal is safe and fair competition worldwide for clean sport.

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Body walking is a therapeutic massage to promote healing

within the body. The therapist use ischemic pressure that is

able to exponentially increase the therapeutic affect by uti-

lizing pinpointed pressure with various foot positions and

pressure. The result is surprisingly relaxing and rejuvinating

for the client, and easier on the therapist’s body.

Roots in Asia

What is Body Walking?

Traditional Ashiatsu massage is based

in Traditional Chinese Medicine. It is per-

formed in both China and Japan by practition-

ers who have been trained to take a whole-

body approach towellness. In addition to

offering massage to their clients, these practi-

tioners may also assess diet, prescribe herbs,

and use other treatment modalities to address

the client's health problems.

By: Nur Farahin Abdul Jabar

BODY

WALKING

This modality has its roots in Asia, but today, sev-

eral different versions of Ashiatsu massage are

practiced around the world. Learning to perform

Ashiatsu massage requires some advanced train-

ing, because indifferent technique could cause

damage to the client's back.

Ashiatsu Massage

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In traditional Ashiatsu, the client lies on the floor in loose, com-

fortable clothing while the practitioner walks across his or her

back, using the feet to target specific pressure points. A bar for

support may or may not be used, depending on the practitioner.

This form is also sometimes called barefoot Shiatsu, referencing

the fact that the therapist is shoeless, and that the principles of

Shiatsu, a massage technique which focuses on pressure points,

are utilized in the massage.

Advantages

History

Walking massage takes less time to perform but is

more effective. Masseuses working with their hands

often develop repetitive strain injuries, tendonitis, and

other problems. These problems do not occur with

walking massage. Walking massage utilizes gravity as a

helper, with the massage therapist using the whole

body as a tool, rather than just the arms. This can re-

duce work-related injuries for the massage therapist.

How is body walking performed?

The ancient systems employed walking massage to apply

deeper pressure with less effort. In the late 1990s, mas-

sage therapist Ruthie Hardee developed a version of

Ashiatsu known as Ashiatsu Oriental Bar Therapy. She

utilizes traditional Asian techniques, but focuses on use

of massage as a relaxation tool, as opposed to a medical

treatment. While Ashiatsu Oriental Bar Therapy certainly

can address muscle pain and tension, the practitioner

does not have the training and skills of someone who

practices Traditional Chinese Medicine.

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Streptokinase Tenecteplase Alteplase

Indications Acute myocardial infarction, ar-

terial thrombosis, arteriovenous

cannula occlusion clearance,

deep venous thrombosis, pul-

monary embolism

Acute myocardial infarction Acute myocardial infarction, cere-

brovascular accident(acute & is-

chemic), pulmonary embolism, cen-

tral venous catheter occlusion

Dose Acute myocardial infarction (IV):

1500000 IU infused over 60

min

Acute myocardial infarction

(intracoronary): 20000 IU

bolus, then 2000 to 4000

IU / min for 10 to 90 min

Arterial thrombosis: loading

dose 250000 IU IV over 30

min, then 100000 IU / hr for

24hr

Arteriovenous cannula occlusion

clearance: instill 250000 IU /

2ml into each occluded limb

of the catheter

Deep vein thrombosis: loading

dose 250000 IU IV over 30

min, then 100000 IU / hr for

72hr

Pulmonary embolism: : loading

dose 250000 IU IV over 30

min, then 100000 IU / hr for

24hr (72hr if concurrent DVT

is suspected)

Acute myocardial infarction:

administer IV bolus over

5sec,

weight < 60kg: 30mg,

weight 60-69kg: 35mg,

weight 70-79kg: 40mg,

weight 80-89kg: 45mg,

weight > 90kg: 50mg

Acute myocardial infarction

(accelerated infusion): weight >

67kg: give 15mg IV bolus, 50mg

over 30min, then 35mg over

60min.

Acute myocardial infarction

(accelerated infusion): weight ≤

67kg: 15mg IV bolus, then

0.75mg/kg over 30min, then

0.5mg/kg over 60min.

Acute myocardial infarction (3hr

infusion): weight < 65kg,

1.25mg/kg IV administered over

3hr, give 60% in the first hour

(10% of which to be given as

bolus), give remaining 40% over

the next 2hr

Acute myocardial infarction (3hr

infusion): weight ≥ 65kg, 60mg

in the first hour (6-10mg of

which to be given as bolus),

20mg over the second hour, and

20mg over the third hour

Cerebrovascular accident: 0.9mg/kg

IV (not to exceed 90mg total

dose), infused over 60min with

10% of the total dose give as an

initial bolus over 1min

Pulmonary embolism: 100mg IV in-

fused over 2hr

Cost RM 901.80/ vial (1 vial =

1500000 IU)

RM 3630.00/ vial (1 vial =

10000 IU or 50mg)

RM 5106.35/ 2 vials (1 vial = 50mg)

Comparison between Streptokinase, Tenecteplase & Alteplase

By: Munawwarah Md Kailani

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Pharma-

cokinetic

(ADME)

Onset & duration: the effect of

hyperfibrinolytic effect disap-

pears within a few hours,

however the effect on coag-

ulation may persist for up to

12 to 24hr after discontinua-

tion of streptokinase

Absorption (Bioavailability): not

absorbed orally and rectally

Distribution: volume of distribu-

tion is 5.68L

Excretion: by renal, with rate of

7.08L/hr

Elimination half-life: 18min due

to the action of antibodies,

or 83min which is operative

in the absence of antibodies

Onset & duration: the time to

reperfusion approximately

11min

Metabolism: mainly in liver, but

extent unknown, and some in

plasma

Excretion: total body clearance is

99 to 119ml/min, and plasma

clearance is approximately

105ml/min

Elimination half-life: 20 to 24min

Onset & duration: time to

initial response is

30min and time to peak

response approximate-

ly 60min

Distribution: volume of dis-

tribution is 8.1L

Metabolism: metabolized at

liver, with the metabo-

lites degraded to con-

stituent amino acids

Excretion: total body clear-

ance is 380 to 570ml/

min

Elimination half-life: 26.5 to

46min

Pharma-

codyna-

mic

Streptokinase and plasminogen

form a complex, exposing plas-

minogen-activating site, and

then, cleavage of peptide bond

converts plasminogen to plas-

min. In treatment of acute MI,

streptokinase prevents primary

or secondary thrombus for-

mation in microcirculation sur-

rounding the necrotic area.

Tenecteplase binds to fibrin rich

clots and cleaves the Arg/Val

bond in plasminogen to form

plasmin. Plasmin in turn de-

grades the fibrin matrix of the

thrombus, thereby exerting its

thrombolytic action. This helps

eliminate blood clots or arterial

blockages that cause myocardial

infarction.

Alteplase binds to fibrin in

a thrombus and converts

the entrapped plasminogen

to plasmin. It also produces

limited conversion of plas-

minogen in the absence of

fibrin.

Mecha-

nism of

Action

Streptokinase forms a highly

specific 1:1 enzymatic complex

with plasminogen which con-

verts inactive plasminogen mol-

ecules into active plasmin. Plas-

min degrades fibrin clots as well

as fibrinogen and other plasma

proteins. This in turn leads to

the degradation of blood clots.

Genetically engineered variant of

alteplase with multiple point mu-

tations of tPA molecule resulting

in longer plasma half-life, en-

hanced fibrin specificity & in-

creased resistance to inactivation

by plasminogen activator inhibitor

1 (PAI-1) compared to alteplase.

Promotes thrombolysis by con-

verting plasminogen to plasmin

which degrades fibrin & fibrino-

gen

Recombinant human tissue

-type plasminogen activa-

tor (t-PA), produces local

fibrinolysis. . Promotes

thrombolysis by converting

plasminogen to plasmin

which degrades fibrin &

fibrinogen

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Propiverine By: Tang Kah Wong

Propiverine hydrochloride is used to treat people who have urinary problems caused by an overac-tive bladder or by spinal cord injuries. It works by pre-venting spasms of the bladder muscle. This can help to reduce the episodes of urinary incontinence or reduce the feeling of urgency that bladder spasms can cause.

Dose:

Adult: 15mg 2 to 3 times daily, increase to 4 times daily if required.

Max dose: 60mg .

Children more than 5 years old: 0.2 –0.4 mg/kg per day in 2 divided doses.

(MOH Drug Formulary (Blue Book)

Before you take Propiverine

Do not take Propiverine if you are allergic (hypersensitive) to propiverine hydrochloride or to any of the other ingredients content inside the drug.

Do not take Propiverine if you suffer from any of the following conditions:

obstruction of the bowel obstruction to the bladder outlet (difficulty in passing urine) myasthenia gravis (a disease causing muscle weakness) a loss of function of the muscles controlling your bowel movements (intestinal atony) severe inflammation of the bowel (ulcerative colitis) that may lead to diarrhoea containing blood and mucus and stomach pains toxic megacolon (a condition involving enlargement of the bowel) increased pressure in the eye moderate or severe liver disease fast and irregular heart beat (arrhythmia) you are pregnant or breast-feeding

Mictonorm® 15 mg Coated

Tablets

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Possible side effects

Drug interaction

The following medicines as they may interact with Propeverine:

Other precautions

Any sudden wheeziness, difficulty in breathing or dizziness, swelling of the eye-lids, face, lips or throat

Peeling and blistering of the skin, mouth, eyes and genitals

Rash affecting your whole body.

antidepressants (e.g. imipramine, clomipramine and amitriptyline), sleeping tablets (e.g. benzodiazepines), anticholinergics taken by mouth or injection (usually used to treat asthma, stomach cramps, eye problems or urinary incontinence), amantadine (used to treat flu), neuroleptics (eg. promazine, olanzapine, quetiapine) (drugs used to treat psy-

chotic disorders like schizophrenia or anxiety), beta stimulants (drugs used to treat asthma), isoniazide (a treatment for tuberculosis)

metoclopramide (used to treat nausea and vomiting)

Taking Propervine with food and drink The tablets should be swallowed whole before meals. Pregnancy and breast-feeding Do not take Propervine if you are pregnant, likely to become

pregnant or are breast-feeding. Driving and using machines Propervine can sometimes cause sleepiness and blurred vision. You should not drive or operate machinery if you suffer from

sleepiness and blurred vision

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The Use of Papaya

Leaves in Dengue Fever

By: Munawwarah Md Kailani

Dengue is the most common arthropod-

borne viral illness in humans. It is transmitted

by mosquitoes of the genus Aedes, which are

widely distributed in subtropical and tropical are-

as of the world. It is afebrile illness that affects

all ages with symptoms appearing 3-14 days

after the infective bite. Symptoms range from

mild fever, to incapacitating high fever, with se-

vere headache, pain behind eyes, muscle and

join pain, rash. Severe dengue, also known as

dengue haemorrhagic fever (DHF) is a specific

syndrome that mainly affects children. It causes

abdominal pain, bleeding and circulatory col-

lapse (shock). Since dengue fever is caused by

a virus, there is no specific medicine or antibiotic

to treat it. For a typical dengue fever, the treat-

ment is directed toward relief of the symptoms.

With the recent dengue outbreak, the use

of papaya (carica papaya) leaves as natural

remedy for dengue has become more popular.

According to the recent newspaper articles, the

Institute for Medical Research (IMR) will soon

release pamphlets on the correct use of papaya

leaf extract in the treatment of dengue. This is

based on the clinical studies that showed the

use of papaya leaves may increase blood plate-

let count and assist in the recovery of those with

less severe complications. Animal studies sug-

gest that papaya leaf extracts have potential

therapeutic effects on disease process, which

results in destabilization of biological mem-

branes as they inhibit haemolysis in vitro and

may cause elevated platelet and red blood cell

counts. There is a trial from Malaysia demon-

strated significantly higher platelet count after 40

to 48 hours of first dose of papaya leaves’ juice.

According to the Evidence-Based Com-

plementary and Alternative Medicine Volume

2013, consumption of Carica papaya leaf juice

induced rapid increase in platelet count in pa-

tients with grade one and two dengue fever and

the fatal dengue haemorrhagic fever. A random-

ised controlled trial that was carried out by IMR

and Hospital Tengku Ampuan Rahimah found

out patient that were administered with 50gm of

fresh Carica papaya juice for 3 consecutive

days showed a significant increase in platelet

count compared to those who received standard

management.

Basically the methods to prepare the

juice were already shared widely in the internet

and social media. The most commonly used

method is to prepare 2 pieces of raw papaya

leaves, then clean the leaves and pound and

squeeze with a filter cloth. You will only get one

tablespoon of juice per leaf, so take two table

spoons of papaya leaf juice once a day. The leaf

cannot be boiled, cooked or rinsed with hot wa-

ter, because it will lose its strength. Only the

leafy part of the papaya plant is being used, not

the stem or sap. The juice is very bitter and you

have to swallow it.

However, the role of Carica papaya leaf

juice cannot be scientifically substantiated

based on a few positive preliminary reports. Alt-

hough herbal products are assumed to be safe

because they are natural, this assumption can-

not be valued more than just conventional wis-

dom. The science must provide evidence to dis-

pel myths and focus efforts on more evidence-

based management of dengue fever using pa-

paya leaf juice.

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Self medication is an act of consuming drugs without the ad-

vice of healthcare professionals. It also includes taking more

than the prescribed dosage, consuming medicine for a longer

duration than required, consuming medication prescribed for

a prior illness, sharing medicine among family members or

switching from Western to herbal medicines without consult-

ing a doctor. Shallow Self-

Diagnosis

What is self medication?

According to a study done in Malaysia, aimed to explore the

awareness and attitude among urban population towards self

medication, it was found that 83.9% of participants consumed

OTC medications, most commonly were supplements and vita-

mins, followed by painkillers, flu/cough remedies and sore throat

products. Easy access, convenience and time saving were the

most frequent reasons for self-medication.

Most people do it because they want to eliminate the cost and time of seeing a doctor. Others assume their condition is too mild for a doctor’s intervention and some believe they have ac-quired enough information to self-diagnose and self-medicate.

Common illnesses which lead to self-medication include head-

ache, flu, cough, joint pain, constipation and flatulence. Men-

strual pain, stomach discomfort and food poisoning are also

often self-medicated and painkillers and antibiotics are the two

drugs which are most commonly misused.

By: Nur Farahin Abdul Jabar

In Malaysia

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Bermula dari: 26 Nov 2012

Fungsi: Menyediakan medium perantara yang merapatkan jurang antara Cawangan Penguat-kuasa Farmasi Negeri Melaka dengan masyara-kat.

Facebook: Sahabat Farmasi

Misi:

Menyampaikan informasi terkini mengenai penguatkuasaan farmasi dan penggunaan ubat-ubatan.

Menjamin keselamatan masyarakat dari segi ubat-ubatan.

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Tarikh: 20 November 2014

Lokasi: Auditorium Sri Baiduri

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