J a b a ta n Fa r m a si Ho sp i ta l K u a l a K r a i

E di s i F e br ua r i 2 0 1 4

B ULETIN FARMASI
INSIDE THIS ISSUE:

R E N A L I M PA I R E D ,
1 3 4

DOES

I T MAT TE R ?

Renal Impaired Nephrotoxic Drug List Drug-Renal Dose Adjustment 5S Activities Parenteral Nutrition MIMS Gateway Product Adulteration Current Research in CKD Pharmacist Research Creativity Activities

6 8 9 11 12

What is renal impaired? Renal impaired failure of renal function whether it is rapidly occur, acute kidney injury or gradually takes time to occur, chronic renal injury. An acute renal failure occur usually during and after hospitalization that on most fa v o r a b l e c o n d i t i o n a r e completely reversible. A chronic renal failure (CRF) is a failure thats take time and gradually will decrease kidney ability to do its normal function. CRF can be categorized into stages based on patient glomerular filtration rate (GFR). Stages of CRF Stage 1 : GFR +90 Normal renal function but urine finding and structural finding point to kidney disease. Stage 2 : GFR 60-89 Mildly reduce kidney function with stage 1 findings.

13 14 15

A patient with renal failure that shows water retention in the body.

Stage 3 : GFR 30-59 Moderately reduce kidney function. Stage 4 : GFR 15-29 Severely reduce kidney function.

Stage 5 : GFR <15 or on dialysis Very severe or end stage renal failure.

N E P H RO T OX I C , W H AT I S I T ?
Some drugs or certain substance can cause toxic effect to kidney by altered intraglomerular hemodynamic, tubular cell toxicity, inflammation, crystal nephropathy, rhabdomyolysis, and thrombotic microangiopathy. 1 There are various drugs that can cause nephrotoxic whether as single agent or as synergistic toxic effect. See pages 2 and 3 listing for nephrotoxic drugs.

Reference Medscape & National Kidney Foundation

ADVISOR: AZMI B ABAS

MUHAMMAD AFFIQ CHIEF EDITOR: DIR RATHNA MASNI KAMARUDDIN

ERIC PEA NAI HUI

ABDUL AZIZ NUR DIYANA CHE ISMAIL

NURUL AZERAH IDRIS ILHAM LIYANA

TUAN FAUZIAH TN ROSLLI FATEN KHALILAH

ADIBAH JAMDIN NURUL FAUZANIY

W.NOR AZIRA BT ABDULLAH

NOR IZZATI

ROSNANI AB RAHMAN

ABIDAH ISMAIL

WAN NORSHAHADAH MD HASHIMIE MAT HASSAN

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Drugs Associated with Nephrotoxicity DRUG CLASS/DRUG(S)

Analgesics Acetaminophen, aspirin Nonsteroidal anti-inflammatory drugs Antidepressants/mood stabilizers Amitriptyline (Elavil*), fluoxetine (Prozac) Rhabdomyolysis Antihistamines Diphenhydramine (Benadryl), doxylamine Rhabdomyolysis (Unisom) Antimicrobials Acyclovir (Zovirax) Acute interstitial nephritis, crystal nephropathy Tubular cell toxicity Chronic interstitial nephritis Acute interstitial nephritis, altered intraglomerular hemodynamics, chronic interPATHOPHYSIOLOGIC MECHANISM OF RENAL INJURY

Aminoglycosides Amphotericin B (Fungizone*; deoxycholic acid formulation more so than the lipid Tubular cell toxicity formulation) Acute interstitial nephritis, glomeruloneBeta lactams (penicillins, cephalosporins) phritis (ampicillin, penicillin) Quinolones Rifampin (Rifadin) Sulfonamides Vancomycin (Vancocin) Antiretrovirals Adefovir (Hepsera), cidofovir (Vistide), tenofovir (Viread) Indinavir (Crixivan) Benzodiazepines Calcineurin inhibitors Cyclosporine (Neoral) Cardiovascular agents Cardiovascular agents Angiotensin-converting enzyme inhibitors, angiotensin receptor blockers Clopidogrel (Plavix), ticlopidine (Ticlid) Statins Chemotherapeutics Cisplatin (Platinol) Interferon-alfa (Intron A) Methotrexate Mitomycin-C (Mutamycin) Diuretics Loops, thiazides Drugs of abuse Cocaine, heroin, ketamine (Ketalar), methadone, methamphetamine Herbals Chinese herbals with aristocholic acid Proton pump inhibitors Lansoprazole (Prevacid), omeprazole Others Others Allopurinol (Zyloprim) Haloperidol (Haldol) Pamidronate (Aredia) Phenytoin (Dilantin) Quinine (Qualaquin) Ranitidine (Zantac) Tubular cell toxicity Acute interstitial nephritis, crystal nephropathy Rhabdomyolysis Altered intraglomerular hemodynamics, chronic interstitial nephritis, thrombotic microangiopathy Altered intraglomerular hemodynamics Thrombotic microangiopathy Rhabdomyolysis Chronic interstitial nephritis, tubular cell toxicity Glomerulonephritis Crystal nephropathy Thrombotic microangiopathy Acute interstitial nephritis Rhabdomyolysis Chronic interstitial nephritis Acute interstitial nephritis Acute interstitial nephritis Rhabdomyolysis Glomerulonephritis Acute interstitial nephritis Thrombotic microangiopathy Reference Am Fam Physician. 2008 Sep Acute interstitial nephritis Acute interstitial nephritis, crystal Acute interstitial nephritis Acute interstitial nephritis, crystal nephropathy Acute interstitial nephritis

Chemotherapeutics

Diuretics Drugs of abuse

Herbals Proton pump inhibitors

DRUGS THAT NEEDS RENAL DOSE ADJUSTMENTS

One fine day in Bikini Bottom...

SpongeBob, do you know that not all drugs are safe in patient with renal impairment ? Really? So, how do you treat them doc? They sure need treatment.. Hey Squidward, do you have kidneys?? Huh, do I care??

Well, they call it renal dose adjustment. Meaning we have to reduce the dose or frequency because patients ability to eliminate the drugs or its metabolites is diminished. For example, CEFOTAXIME (Normal range: IV 1-2g q6-8h) Clcr 10-50 ml/min : q8-12h Clcr <10 ml/min : q24h CEFTAZIDIME (Normal range: IV 1-2g q8-12h ) Clcr 31-50ml/min : 1g q12h Clcr 16-30 ml/min : 1g q24h Clcr 6-15 ml/min : 500mg q24h Clcr <5 ml/min : 500mg q48h
Usual dosage Aminoglycosides Amikacin 5-7.5mg/kg/dose q8h

Hey you.. Give me back my kidneys!!

Renal dose adjustments Clcr>60 ml/min : q8h Clcr 40-60 ml/min : q12h Clcr 20-40 ml/min : q24h Conventional: Clcr>60 ml/min : administer q8h Clcr 40-60 ml/min : administer q12h Clcr 20-40 ml/min : administer q24h Clcr<20 ml/min : Loading dose, then monitor level

Gentamicin

Conventional: 1-2.5mg/kg/dose q8-12h Once daily: 4-7mg/kg/dose once daily

Meropenem

IV: 0.5-1g q8h

Clcr 26-50 ml/min : the usual dose q12h Clcr 10-25 ml/min : Half the usual dose q12h Clcr<10 ml/min : Half the usual dose q12h Clcr>50 ml/min : q8-12h Clcr 20-49 ml/min: q24h Clcr<10 ml/min : will need longer interval, determine by serum concentrations Reference Micromedex 2013 & Handbook Of Medication Dosing in Renal Failure for Healthcare Professional First Edition

Vancomycin

1g or 10-15mg/kg/dose q12h

Diclofenac Celecoxib Naproxen

Meloxicam

Piroxicam Hey Patrick, doctor said these NSAIDs are not recomended for severe renal impairment

Mefenamic acid

What about an ice cream??? Ketoprofen

Meow. For alternative, we can use ibuprofen, paracetamol, aspirin and opioids like tramadol

Spongebob me boy, what about allopurinol and ranitidine, are they safe for me??

Wow I feel like a doctor already

If you have renal impairment then the dose should be adjusted.. ALLOPURINOL : -CrCL 10 to 20 mL/min, 200 mg daily -CrCL 3 to 10 mL/min, 100 mg daily -CrCL less than 3 mL/min, 100 mg at extended intervals greater than every 24 hours RANITIDINE : -CrCl less than 50 mL/min, -150 mg ORALLY every 24 hours -IV 50mg every 18-24 hours

THEY TOOK MY KIDNEYS!!!

Relax Plankton, it was just an immunization.

I wonder is it kidney or brain in his head. 5 Reference Micromedex 2013 & Handbook Of Medication Dosing in Renal Failure for Healthcare Professional First Edition

Gotong Royong Perdana

Pelupusan Dokumen
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PARENTERAL NUTRITION
Defined as the therapeutic intravenous administration of major nutrients to a patient when oral or enteral nutrition is inadequate due to poor tolerance, poor absorption or refusal to eat,impossible due to bowel obstruction or undesirable because of deep coma or necessity for bowel rest.

Routes of Administration
Peripheral Route Central Route

Solution <900 mosm Short term support (< 2 weeks) Caloric need limited to
2000kcal/day

Solution >900 mosm Long term support (> 10 days) Caloric need can exceed
2000kcal/day

Most common problem:

thrombophlebitis

Most common problem: catheter

sepsis

Complications

Suggested Nutrient Intake for Adult Patients Critically ill patients Stable patients 0.8 to 1.0g/kg/d Not >7g/kg/d 1g/kg/d 30 to 35kcal/kg/d 30 to 40ml/kg/d Protein Carbohydrate Lipid Total calories Fluid 1.2 to 1.5g/kg/d 3-5g/kg/d 1g/kg/d 22 to 30kcal/kg/d Minimum needed to deliver adequate macronutrients

Refeeding syndrome, expansion of extracellular volume, catheter leak, venous thrombosis

Reference A Practical Guide To Nutrition Support In Adults And Children University Malaya Medical Centre

www.mimsgateway.com.my
Drug Knowledge Database for KKM. A powerful and flexible MIMS search engine enables quick access to MIMS drug information, decision support tools, useful learning and information resources, third party databases and even MOH CPGs.

Use the Quick Links to browse for clinical resources such as product images, drug interaction checker, drug allergy checker, drugs information, decision support modules, MIMS news journals, and etc.

Use the Search Box to do a quick keyword search. (brand/generic name of the drug)

Kindly contact DIS Pharmacy at ext 1344 for email address and password before log in. Thanks!

The search result is displayed as formulary details of MOH Drug Formulary (Blue Book),

Useful clinical tool to assist in differential diagnosis decision, clinical calculators, Msian CPG, and MIMS Disease Charts.

Knowledge is power. Information is liberating. Education is the premise of progress, in every society, in every family. ~KOFI ANAN~
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2013 PRODUCT ADULTERATION ISSUE

Cases of ADR in HKK(2013): Up to 17 adverse drug reaction (ADR) cases have been detected as at November 2013. These include but not limited to drugs such as Cloxacillin capsule, BCG vaccine, Acarbose tablet, Unasyn (ampicillin+sulbactam) injection and Gemfibrozil capsule.
All products listed are no longer allowed to be imported/manufactured/distributed/sold in this country and the Authority has directed that all stocks of these products to be withdrawn from the market.

These products were found to contain chemicals, including pesticides that are not allowed in the schedule of natural products (traditional). The use of natural products adulterated with chemicals such as those detected can cause serious adverse events. Meanwhile, the cosmetic products listed have been found to contain banned substances, including unauthorized scheduled poison in cosmetic products.

NO.

PRODUCT NAME

CATEGORY TRADITIONAL PRODUCT COSMETIC

LICENSEE

MANUFACTURER

POISON/CHEMICAL DETECTED TADALAFIL

STA-LIONS

TOGETHER LINK ENTERPRISE. OWI LAB (M) SDN. BHD. NOBLE ASPECT SDN. BHD. CHEE SING (LABUAN) SDN. BHD. EUROPE COSMECEUTICAL INDUSTRIES SDN BHD AURAQU ENTERPRISE AURAQU ENTERPRISE SF INFINITY RESOURCES SF INFINITY RESOURCES HARESH ENTERPRISES SDN BHD

DZ TRADE (MALAYSIA) SDN. BHD. OWI LAB (M) SDN. BHD.

AVEANA NIGHT REVIVAL CREAM BLEMISHED SKIN AMPOULES GOLDEN HORSE B&W CREAM GH902-1 CELLNEX ANTISENSITIVE ESSENCE TREATMENT NATURAL 99 NIGHT CREAM NATURAL 99 DAY CREAM SF BEAUTY NIGHT CREAM (FACIAL) SF BEAUTYDAY CREAM (FACIAL) ACRENA PURE HERBAL PAPAYA SOAP

TRETINOIN

COSMETIC

NOBLE ASPECT SDN. BHD. CHIN SAN CHEMICAL WORKS, TAIWAN CENTRE DE RECHERCHES BIOCOSMETIQUES S.A., SWITZERLAND

AZELAIC ACID

COSMETIC

MERCURY

COSMETIC

BETAMETHASONE

COSMETIC

CV RAJA KOSMETIK, INDONESIa CV RAJA KOSMETIK, INDONESIA YAMNI INDUSTREIS SDN. BHD. YAMNI INDUSTREIS SDN. BHD. RE-X PRODUCTS CO. LTD. THAILAND

MERCURY

COSMETIC

MERCURY

COSMETIC

MERCURY

COSMETIC

MERCURY

DO YOU KNOW?

10

COSMETIC

TRETINOIN

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Now ALL professional staff can report ADR cases. And everything is at your fingertips! Simply log on to http://portal.bpfk.gov.my

CURRENT RESEARCH IN CHRONIC KIDNEY DISEASE

IMPORTANCE OF RENAL DOSE ADJUSTMENT

THE IMPACT OF INPATIENT COLLABORATIVE CLINICAL PHARMACY RENAL DOSING SERVICE ON DOSAGE ADJUSTMENT IN PATIENTS WITH CHRONIC KIDNEY DISEASE
Objectives: To evaluate the impact of an inpatient collaborative renal dosing service by pharmacists participating in clinical rounds on dosage adjustment according to renal function, adverse drug events, and drug costs. Out of 388 dosing recommendations given by the pharmacist, the prescribers accepted a total of 212 recommendations (54.6%). The most commonly accepted interventions were with ranitidine, ceftazidime, ampicillin/sulbactam, amoxicillin/clavulanate, metoclopramide, digoxin, atenolol, chlorothiazide, and amikacin. In the pre-intervention group, 64 (21.3%) patients had suspected adverse drug event with a total of 73 events. The number significantly decreased in the intervention group to 49 events in 48 ( 16.0%) patients (p-value <0.05). The intervention caused savings in drug cost of RM 7760. Conclusion : The inpatient collaborative clinical pharmacy dosing service can increase the proportion of drugs adjusted to renal function. This can save drug costs and has the potential to prevent adverse drug events.

ROWA JAMAL ABDULHAFEZ KHATIB (AL-RAMAHI), JUNE 2009

CHOISE OF ANTI-HYPERTENSIVE AGENTS

MANAGEMENT OF CHRONIC KIDNEY DISEASE

ACEI or ARB afford significant renal protection, in addition to that attributable to blood pressure lowering, and should be used as firstline agents in all patients with diabetes (with or without evidence of albuminuria), in nondiabetic kidney disease with proteinuria (random urine protein to creatinine ratio > 100 mg/mmol)and in those with heart failure. ACEIs and ARBs may have additional beneficial effects in progressive CKD, by inhibiting the actions of angiotensin II on glomerular permeability and tubulo-interstitial fibrosis. Several targets for anti-fibrotic agents have been validated in cellular and animal studies, but progress in translating these results to clinical practice has been disappointing. Nevertheless, drugs targeting the pathways of TGF, connective tissue growth factor, plateletderived growth factor, Ki-Ras and NF-KB are all possible future therapeutic agents. The ONTARGET study suggests that combination therapy should be used with caution, especially in patients with vascular disease, owing to the greater risk of hypotensive symptoms, syncope and renal dysfunction. Moreover, the CO-OPERATE study, which appeared to support dual therapy, has now been withdrawn after the results of an academic investigation indicated serious concerns surrounding this publication. In addition, an international, double-blinded, randomized, controlled trial is ongoing to assess the effect of combination reninangiotensin system blockade on CKD in diabetics. Owing to the risks of serious adverse effects, dual blockade with an ACEI and an ARB should only be initiated under specialist supervision.

Family Medicine Specialists Association of Malaysia ,JANUARY 2012

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EFFECT OF ERYTHROPOIETIN ON BLOOD PRESSURE AMONG HAEMODIALYSIS PATIENTS IN HOSPITAL KUALA KRAI ABSTRACT 1st place

KNOWLEDGE, ATTITUDE & PRACTICE (KAP) ON DRUGS FOR MINERAL & BONE DISORDER (MBD) IN HEMODIALYSIS PATIENTS IN HOSPITAL KUALA KRAI

ABSTRACT

4th place

Background: Anaemia is among the most important complications of chronic kidney disease. Erythropoietin (EPO) may improve anaemia, but it cause hypertension in these patients. Our aim is to investigate the effect of erythropoietin on blood pressure among patients undergoing haemodialysis in Haemodialysis Unit (HDU), Hospital Kuala Krai (HKK). We also investigate the effect of two different doses of EPO on blood pressure and factors affecting the incremental of blood pressure. Methodology: A cross-sectional study was used. Haemodialysis patients on EPO-alpha (Eprex) therapy were involved in this study. BP was measured on 0, 15, and 30 minutes after EPO injection. Paired t test was used to analyse the difference of mean MAP at 0, 15, and 30 minutes. Result: Total of 36 patients were evaluated. 32 patients showed incremental of MAP (>4mmHg) after 30 minutes of EPO injection. There were significant different of mean MAP at 0 & 15 minutes and at 15 & 30 minutes after injection. Patient received higher dose (4000IU/dose) showed higher incremental of MAP compared to patients received 2000IU/dose (p<0.05). In addition, demographic factors have no significant effect on BP during EPO therapy. Conclusion: EPO showed significant incremental of MAP in majority of haemodialysis patient in HKK. By : Izzati, Pea Na Hui, Shahadah

Background: Mineral and bone disorder (MBD) is one of the complications that arise from Chronic Kidney Disease. Awareness regarding KAP in patient is important for patients compliance towards medications. This cross sectional study was conducted with the aim to know the level of knowledge, attitude and practice regarding drugs for MBD in patients of HDU of HKK from May-August 2013 to optimize the treatment regime. Methodology: KAP validated questionnaire was used for this purpose. 41 patients were group into good knowledge (score>70%), good attitude (score >3) and good practice (score >7) for each category. Data was analyzed using SPSS version 17.0 Result: Majority of patients (95 %) had good knowledge and 36.6 % had good attitude. However, only 7.3 % had good practice. There were significant associations between educational level and concomitant disease with attitude (p <0.05). There were weak positive associations found between knowledge and attitude (r= 0.157), knowledge and practice (r=0.196), as well as attitude and practice (r=0.143). Conclusion: Results revealed good knowledge with moderate attitude but poor practices toward drugs for MBD. By : Affiq, Fauzaniy, Abidah

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TAHAP KEFAHAMAN DAN KEPATUHAN YANG RENDAH TERHADAP UBAT-UBATAN ANTIDIABETIK DI KALANGAN PESAKIT DIABETES MELLITUS DI KLINIK PAKAR PERUBATAN HOSPITAL KUALA KRAI Nurul Azerah Idris, Tuan Fauziah Tuan Roslli Adibah Jamdin, Nik Norazwana Nik Mohd Salleh, Dir Rathna Masni Kamaruddin Unit Farmasi, Hospital Kuala Krai PENGENALAN DAN MASALAH KUALITI Tahap kefahaman dan kepatuhan terhadap ubat-ubatan antidiabetik di kalangan pesakit Diabetes Mellitus (DM) di Klinik Pakar Perubatan Hospital Kuala Krai adalah rendah berdasarkan hasil kajian retrospektif Diabetes Mellitus Therapy Adherance Clinic (DMTAC). Kajian ini dilakukan untuk mengenalpasti faktor-faktor berlakunya masalah tersebut seterusnya mengambil tindakan pemulihan untuk meningkatkan tahap kefahaman dan kepatuhan terhadap ubat-ubatan antidiabetik PENGUKURAN UNTUK PENAMBAHBAIKAN Sasaran projek adalah sebanyak 80% pesakit faham tentang rawatan dan patuh terhadap ubatan antidiabetik. PROSES PENGUMPULAN MAKLUMAT Kajian prospektif ini dijalankan bermula 1/4/2013 hingga 30/4/2013 (pre-pemulihan) dan 1/8/2013 hingga 31/8/2013 (post-pemulihan) melibatkan semua pesakit DMTAC berumur 18 tahun dan ke atas.Tahap kefahaman dinilai berdasarkan Modified Morisky Scale manakalan tahap kefahaman adalah berdasarkan borang kaji selidik. ANALISA DAN INTERPRETASI Hasil kajian prepemulihan mendapati sebanyak 75% pesakit DM tidak faham dan sebanyak 60% tidak patuh pada ubatan antidiabetik. Faktor- faktor penyebab berlakunya masalah yang telah dikenalpasti adalah 1. kurang pengetahuan tentang penyakit dan rawatan, 2. pengambilan ubat di rumah tidak dipantau, 3. keliru dengan bentuk fizikal ubat dan 4.persepsi negatif pesakit mengenai rawatan antidiabetik. STRATEGI PERUBAHAN Sebagai strategi penambahbaikan, kumpulan telah mengadakan sesi pendidikan pesakit secara individu dan berkumpulan berdasarkan Protokol DMTAC dengan bantuan Conversation Map, Drug Album , Drug Board dan Risalah Maklumat DM dan Antidiabetik. Pesakit juga digalakkan membawa ahli keluarga semasa kaunseling. KESAN PERUBAHAN Selepas tindakan pemulihan dijalankan pada 1/5/13-31/8/13, didapati tahap kefahaman dan kepatuhan telah meningkat kepada 83 % dan 75 %, masing-masing. LANGKAH SETERUSNYA Memastikan DMTAC dijalankan mengikut protokol. Menggalakkan penglibatan ahli keluarga dalam sesi kaunseling.Memperluaskan penggunaan risalah dan membekalkan kepada setiap pesakit.

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BBQ Session

Lucky Draw

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Bawa bola pingpong guna sudu

Tiup belon paling besar

Puzzle

Kutip ubat guna chopstick

Setinggi-tinggi terima kasih : En Azmi Abas, Cik Norazwana, Pn hatijah, En Teoh Khe Lee, En Zin, En Hashimie, Cik Adibah, Cik Diyana, Cik Fauziah, Cik Rosnani, Cik Azira Pn Ma, Pn Da, Pn Esah, Pn Wani, En Lauji, En Mokhtar, En Lan En Affiq, En Aziz, En Eric & semua yang terlibat menjayakan Farmasi Family Day.

Bawa belon guna kepala

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SEPTEMBER & OCTOBER

NOVEMBER & DECEMBER

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JOM CARI PERKATAAN TERSEMBUNYI...

Try to fill in all of the empty boxes so that:

Each row contains the number. Each column contains the number. Each square 2 by 2 box contains the number.

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