Edition 01/2014 Pharmacy Bulletin PEJABAT KESIHATAN DAERAH , MELAKA Inside this issue: MTAC EVENTS 2 Medication Therapy Adherence Clinic (MTAC) is an ambulatory care service by certified pharmacists in MEDICATION 4 ERROR REPORTING collaboration with physicians with the aim of empowering patients in disease control. It was introduced in 2004 as part NITROGLYCERIN 6 of the Clinical Pharmacy Services of the Ambulatory Clinic PRODUCT System, emphasizing on medication management to NEW DRUG IN PKDJ 8 improve quality, safety and cost-effectiveness of patient care. INSUMAN 10 This year, Klinik Kesihatan (KK)Selandar, KK Jasin and SUPPLEMENTS 12 KK have started conducting diabetes MTAC (DMTAC). KK will begin in October 2014. STAFF UPDATES 13 DMTAC’s aim is to help diabetic patients improve their POSITIVE THINKING 14 medication adherence level and glycemic control. The patients enrolled in this clinic will be followed up for a minimum of eight (8) visits where they will receive a EDITORIAL BOARD number of services including medication adherence ADVISOR : assessment, medication counseling, and diabetes education Chan Bee Leng by pharmacists. Apart from that, pharmacists will also assess EDITOR: patients and address their needs as well as scheduling Lio Ee Lee appointments for them. Any pharmaceutical related issues and changes will be noted in both the MTAC review and the patient’s case notes. Patients will be discharged provided he completed all the necessary education modules and showed excellent diabetes control.

CONTRIBUTORS : - Anida Hamzah - Nur Nadiah Marzuki - Ng Sin Yee - Erwany Md Dewa - Amreet Kaur Gill - Teh Wan Yuan - Loh Tze Min - Tan Siong Guan - Mohd Solleh Rahim - Noridarabiaton Ali Akbar - Ku Yee Kun Events Page 2 KK SELANDAR - METHADONE PROGRAMME

On 29th April 2014, a methadone programme was organized by Klinik Kesihatan Selandar. The event was held in Dewan Parameswara from 8.00 am to 1.00pm. The objectives of the programe include:

• To strengthen the bond between patients and staffs • To reinforce the inclusion and exclusion criteria and to highlight the essential rules • To give vivid explanation to the methadone clients regarding the order to stop supplying takeamway doses • To introduce the Methadone 1 (M1M) service to all the clients as an approach to encourage DOT.

At the end of the session, several prizes were given away to those who won the lucky draw and a special reward was presented to the best methadone client in Klinik Kesihatan Selandar for Year 2014. Before adjournment, a Q&A session was dedicated for the clients to share related issues and clarify their doubts regarding the MMT programme. The programme ended successfully with co-operation from the medical officers, pharmacists, medical assistants, staff nurses as well as the methadone clients.

Events Page 3 Quality Use of Medicine-Consumer (QUM-C ) Jan - June 2014

BIL BIL AKTIVITI TARIKH MASA TEMPAT PESERTA 1 Pameran QUMC 13/1/2014 8.30-12.30 KK Merlimau 55 2 Pameran QUMC 13/1/2014 2.30-4.30 KK Umbai 40 3 SMK Dato Abd 60 Pameran QUMC 23/4/2014 8.00-12.00 Rahman Yaakub

4 40 Ceramah & Pameran KK Selandar QUMC 29/4/2014 8.00-12.00 5 Pameran QUMC 43 Inside Story Headline Sempena Karnival 24/5/2014 8.00-5.00 Pendidikan & Kerjaya MINI Stadium Jasin

6 Pameran QUMC 100 Sempena Program Kesihatan Cegah Kanser 25/5/2014 8.00-1.00 Japerun Servik &Payudara

7 Pameran&Ceramah 35 Sempena Program Nafas 20/6/2014 8.00-12.00 Baru Bermula Ramadhan KK Umbai

8 Pameran & Ceramah QUMC Sek Keb Tehel 200 sempena Program Doktor 21/6/2014 8.00-1.00 Muda

9 Balai raya Kg. Alai 77 Pameran & Ceramah QUMC 22/6/2014 8.00-12.00 Medication Error Reporting Page 4 Online

What is a medication error? A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient or consumer. Such an event may be related to professional practices, healthcare products, procedures and systems including prescribing, order communication, product labelling, packaging and nomenclature, compounding, dispensing, distribution, administration, education, monitoring and use. Although many medication errors may not cause grave harm to patients, some medications are known to carry a higher risk of harm than other medications. Errors in the administration of these medications can have catastrophic clinical outcomes.

Medication Error Reporting Page 5 Online Below are strategies that can be implemented by the facility in order to reduce the medication errors. • Allergy card • Streptokinase card • Splenectomy card • General vaccination card • High Alert Medication Labeling • Unit Dose • Medication Therapy Adherence Cilinic (MTAC) • Medication Reconciliation / Pharmacist Discharge Planning • Medication Counselling • Medication History Taking • Tallman Lettering • Standard Medication Abbreviation • Medication Generic Name Example of prescription with non-standard abbreviation:

The ‘MTF’ abbreviation is non-standard and cannot be used to prescribe a Metformin. The prescription can be mistakenly filled with MTX, which is the standard abbreviation of Methotrexate. In Malaysia, medication error reporting is at the moment on a voluntary basis.All the error detected can be reported online via http://mers.moh.gov.my/MERS. The main objective of medication reporting is to minimise the reoccurrence of errors and ultimately to improve patient safety.

Reference:

Guideline on Medication Error Reporting. MoH. 1st ed. July 2009. Type of Nitroglycerin Products Page 6

Nitroglycerin is a vasodilator, a medicine that opens blood vessels to improve blood flow. It is used to treat angina, a type of chest pain or discomfort Quick-acting Nitroglycerin that happens when there is Nitroglycerin comes in not enough blood flowing quick-acting forms and A) Tablet long-acting forms. The different types of nitroglycerin tablets to the heart. To improve include sublingual and buccal tablets. Be- blood flow to the heart, 1) Quick-acting forms: fore using any type of nitroglycerin, pa- nitroglycerin opens up (dilates) • · The tablets are placed under the tongue tients should sit down, because it may the arteries in the heart (sublingual) or between cause fainting or dizziness. The doctor may (coronary arteries), which the cheek and gum instruct the patient to take a dose before improves symptoms and (buccal). any physical activity that may cause angina reduces how hard the heart • · The spray is used on or under the tongue or as soon as the patient first notices symp- has to work. Quick-acting toms. Some people may be instructed to forms of nitroglycerin are used • 2) Long-acting forms: take a second dose after five minutes if the to relieve angina or used just • · Extended-release tablet first dose does not alleviate chest pain. A before activities that typically • · Skin patches third dose may be taken five minutes after cause angina. Long-acting the second if needed. In the event that three forms of nitroglycerin are used nitroglycerin tablets are ineffective at re- to prevent angina from happen- lieving symptoms, patients will need to call ing. They are not used to stop for an ambulancefive minutes following sudden symptoms of angina. the third dose. Buccal nitroglycerin tablets

should be placed in the mouth between the gum and the cheek and allowed to dissolve completely. Patients must avoid chewing or swallowing these tablets. Page 7

Fig. 1 GTN Spray. Fig. 2 GTN patch

B) Spray Long-acting Nitroglycerin Those who have difficulty with nitroglyc- A) Extended-release Tablet erin tablets may take the drug in a spray. Extended-release tablet of glyceryl trinitrate are used to prevent Patients should avoid shaking the con- the chest pain caused by angina pectoris. Angina occurs when tainer. After removing the cap, it should be there is an inadequate supply of oxygen for the work the heart is held upright and placed very close to the performing. The tablets will reduce the heart's work and will patient’s open mouth. He may then press release the medicine slowly giving protection over several the button once to release one dose. The hours. Extended-release tablets are not suitable for treating an medicine should not be inhaled and pa- attack that has already star ted as the tablets will take too long to tients must avoid spitting or drinking for start working. One example of extended-release tablets available five to 10 minutes. To treat an angina at- in market is Sustac® Tablet. tack, use 1 to 2 sprays on or under the B) Skin Patches tongue as directed by your doctor. Sit qui- Apply one patch every 24 hours. It is usual to apply the patches etly after using a dose. A spray may be re- to your chest or upper arm, but this may vary depending upon peated every 3 to 5 minutes as directed by which brand of patches you have been given. Use a different your doctor. area of skin each time you apply a patch. When you use GTN all the time, your body becomes used to it and then it has much less Do not use more than 3 sprays in 15 min- of an effect. To overcome this tolerance, you may remove the utes unless your doctor tells you otherwise. patch before you go to bed, to leave your blood free of nitrate in If chest pain continues after a total of 3 the early hours when you are asleep. sprays, seek medical attention at once, References: unless your doctor gives you different in- 1) Glyceryl Trinitrate for Angina. Available online: structions. If you use nitroglycerin spray to http://www.patient.co.uk/medicine/glyceryl-trinitrate-for-angina prevent angina caused by physical activity, 2) Nitroglycerin. MedlinePlus, National Institute of Health. Available online : http://www.nlm.nih.gov/medlineplus/druginfo/meds/a601086.html use it 5 to 10 minutes before activity. 3) Nitroglycerin Spray. Available online: http://www.drugs.com/cdi/nitroglycerin-spray.html New Drugs in PKDJ Page 8

1. GLICLAZIDE 60MG MODIFIED RELEASE TABLET

INDICATION As monotherapy or in combination with other oral anti-diabetic agents in type 2 diabetes when

• Dietary measure

• Physical exercise

• Weight Loss

2. BENZOYL PEROXIDE GEL BP 5%

INDICATION

• Mild to moderate acne vulgaris New Drugs in PKDJ Page 9

3. INSUMAN COMB (biphasic) INSUMAN BASAL (intermediate acting)

INSUMAN RAPID (short acting)

INDICATION Same indication as insulin from Novo Nodisk

4. INSULIN GLARGINE 300IU/3ML INJECTION INDICATION Diabete mellitus type 1 in adult and child over 6 years Diabetes mellitus type 2 in adult COMPARISON BETWEEN Page 10 INSUMAN AND NOVO NORDISK INSULIN

Product Novo Nordisk Insulin

Recombinant human in- √ √ sulin

NPH Insulatard Insuman® Basal Type of Intermediate insulin Insulin

Regular Actrapid Insuman ® Rapid

Insulin

NPH Mixtard Insuman ® Comb 30 Premixed

Insulin

Page 11

Product Novo Nordisk Insulin

NPH In- 1 hour before bedtime 45-60 min before meal; termediate can be once (evening or

Insulin bedtime) or twice-daily

(plus in the morning) Time of admini- Regular 30 min before meal 15-20min before meal stration Insulin NPH Pre- 30 min before meal 30-45 min before meal

mixed In- (twice daily) (twice daily)

sulin

Method of admini- Subcutaneously. Subcutaneously.

stration

Insulin Pen Novopen 4 ALLSTAR™

Re-suspension Insulatard and Mixtard Insuman® Basal and need to be resuspended Insuman® Comb 30

before injection. need to be resuspended before injection. Insuman® Basal and Insuman® Comb 30 Cartridges have three metal bullets that allow an efficient mixing procedure

Supplements Page 12

A dietary supplement is intended to provide nutrients that may otherwise not be consumed in sufficient quantities. Supplements as generally understood include vitamins , minerals , fiber, fatty acids, or amino acids , among other substances. They are marketed in dose form as pills, tablets, capsules, or liquid in measured doses.

No. Products Supported goal 1. Amino acids powder / capsules Increase energy

2. Fish oils soft gels Health & Wellness with omega 3 essential fatty acid Support healthy heart function , joint flexibility, cell production

3. Garlic tablet Improve immune system , fight germs of all sort , and reduce the risk for heart disease

4. Gingko Biloba An Herb Improve blood circulation, which might help in brain , eyes, ears, and legs function better

5. Alfafa Complex High in protein , calcium, and miner- als. Also use in herbal medicine to stimu- late appetite and improve digestion problems

6. Lecithin Capsules Lecithin is a source of choline, an essential nutrient Benefit in acne , in improving liver function , and in lowering cholesterol

7. Vitamin B Complex Health & Wellness Help to metabolize protein, fats, and carbohydrates into energy

8. Vitamin C Tablet Health & Wellness Improve immune system , Supporting the body natural antioxi- dant

New staff in PKDJ Page 13

Pharmacist

Noridarabiaton Ali Akbar Teoh Sook Yee (PF U41, KK Kemendor) (PF U44, KK Selandar)

Pharmacy Assistant

Nor Liza Bt Rabbu Qurratu' Aini Bt Kaber ( PPF U29, KK Umbai) ( PPF U29, KK Kemendor)

Nor Haniza Bt Khairudin Tham Ngan Yin ( PPF U29, KK Umbai) ( PPF U36, KK Jasin) Page 14