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MEDICINES THAT USE IN NORMAL SPONTANEOUS DELIVERY (NSD) IN THE PHILIPPINE SETTING

by tacio
I just want to blog about the medicines that are continuously used during and after childbirth in the Philippines.
These medicines are given to mothers to facilitate their labors and sometimes help them not to feel the pain. The
medicines are classified according to the action that they provide. First is the antibiotic. The commonly antibiotic
used is the Ampicillin sodium 250mg, 500mg or 1g vial, usually a loading dose of 2g is necessary to fight infection
during labor. In most fatal cases, Cefuroxime sodium 750mg or 1.5g vial has been given to prevent multiplication of
harmful infections and the risk of death. The loading dose for this drug is 1.5g. The second classifications are the
oxytocics, these drugs help to contract the uterine and accelerate the expulsion of the infant from the womb. Drugs
such as Oxytocin and Methylergometrine maleate are drugs capable to perform such activity. Oxytocin can be
obtained in 10 iu in 1ml, and Methylergometrine maleate 200mcg/ml. The doses that can be given to the patient are
depending on the physician's order and/or the gravity of the patient's case. The last drugs' classification is the
sedative-hypnotics and analgesics. In these categories the laboring mothers will not feel any pain during the
operation because of the pain relieving action of Nabuphine HCl 10mg/1ml amp. During also the procedure
Midazolam 5mg/ml, 10mg/2ml or 15mg/3ml amp is being injected to the patient to sedate her, so that she will not
be aware to what is happening. The doses also depend of the doctor's order and the gravity of the patient's case.
Also Promethazine HCl 25mg/ml amp is always given to augment the action of the Midazolam. The Intravenous fluid
that necessarily to sustain the mothers' hydration and that the drugs will be supplied to the patient is 5% Dextrose
in Lactated Ringer's Solution (D5LRS 1L). The medicines introduced in this article are based on the prescription
orders of the OB-Gyne doctors in the Mandaluyong City Medical Center (MCMC), and may vary depending on the
doctor's orders and hospital that the laboring mother is admitted. Moreover, this article does not generalize that the
drugs herein are the official medicines used for childbirth. For more information and questions you may leave your
queries in the comments so that it will be answered. MEDICINES THAT USED IN NORMAL SPONTANEOUS DELIVERY
(NSD) IN THE PHILIPPINE SETTING I just want to blog about the medicines that are continuously used during and
after childbirth in the Philippines. These medicines are given to mothers to facilitate their labors and sometimes help
them not to feel the pain. The medicines are classified according to the action that they provide. First is the
antibiotic. The commonly antibiotic used is the Ampicillin sodium 250mg, 500mg or 1g vial, usually a loading dose of
2g is necessary to fight infection during labor. In most fatal cases, Cefuroxime sodium 750mg or 1.5g vial has been

given to prevent multiplication of harmful infections and the risk of death. The loading dose for this drug is 1.5g. The
second classifications are the oxytocics, these drugs help to contract the uterine and accelerate the expulsion of the
infant from the womb. Drugs such as Oxytocin and Methylergometrine maleate are drugs capable to perform such
activity. Oxytocin can be obtained in 10 iu in 1ml, and Methylergometrine maleate 200mcg/ml. The doses that can
be given to the patient are depending on the physician's order and/or the gravity of the patient's case. The last
drugs' classification is the sedative-hypnotics and analgesics. In these categories the laboring mothers will not feel
any pain during the operation because of the pain relieving action of Nabuphine HCl 10mg/1ml amp. During also the
procedure Midazolam 5mg/ml, 10mg/2ml or 15mg/3ml amp is being injected to the patient to sedate her, so that
she will not be aware to what is happening. The doses also depend of the doctor's order and the gravity of the
patient's case. Also Promethazine HCl 25mg/ml amp is always given to augment the action of the Midazolam. The
Intravenous fluid that necessarily to sustain the mothers' hydration and that the drugs will be supplied to the patient
is 5% Dextrose in Lactated Ringer's Solution (D5LRS 1L). The medicines introduced in this article are based on the
prescription orders of the OB-Gyne doctors in the Mandaluyong City Medical Center (MCMC), and may vary
depending on the doctor's orders and hospital that the laboring mother is admitted. Moreover, this article does not
generalize that the drugs herein are the official medicines used for childbirth

Pharmacy Question:

Pharmacology Category:
1.Which of the following agents is classified as a selective direct-acting beta-2 agonist?
a. Proprnolol
b. Methoxamine
c. Isoxsuphrine
d. Prazosin
e. Ephedrine

2. In terms of mechanism of action, which of the following drugs most closely resembles that of Clonidine?
a. Phenylephrine
b.Reserpine
c.Guaethidine
d.Methyldopa

e. Amlodipine

3. A given adrenergic agent induces uterine relaxation and bronchial smooth muscle relaxation. These effects can be
attributed to:
a. Alpha-1 stimulation
b. Alpha-2 stimulation
c. Beta-1 inhibition
d. Beta-1 stimulation
e. Beta-2 stimulation

4. What is the dominant adrenergic receptor in the heart?


a. Dopamine-1
b. Alpha-1
c. Alpha-2
d. Beta-1
e. Beta-2

5. Which of the following inotropic agents is most useful for patients with acute heart failure complicated by acute
reduction in creatinine clearance?
a. Epinephrine
b. Norepinephrine
c. Dopamine
d. Dobutamine
e. Digitalis
ANSWER TO THE QUESTION
These are the answers to the questions yesterday:
1. c. - Isoxsuphrine (Duvadilan), a tocolytic agent.
2. d. - Methyldopa, which is converted in the brain to alpha-methylnorepinephrine.
3. e. - Beta-2 stimulation
4. d. - Beta-1
5. c. - Dopamine apart from stimulating beta-1 receptors, stimulates D1 receptors causing increased renal blood flow
and glomerular filtration. This may be useful in patients with acute renal insufficiency.

METHYLERGOMETRINE MALEATE NOW AN ETHICAL DRUG


Yes guys! What you have read is true, yet, the memorandum letter has not distributed, but exactly last year it was
removed from the list of dangerous drugs in the Philippines. I had called twice the Philippine Drug Enforcement
Agency (PDEA) to confirm this issue and it was confirmed that Methylergometrine maleate, in any brand, whether in
a form of 125mcg tab or 200mcg/ml amp is now an official ethical drug. In addition to their confirmation, the
informer told me that the drug can now be dispensed with or without S2 no. written on the prescription. Moreover, I
asked him if I should write on the dangerous drug book, but the reply was not necessarily up to now. I had also a
chance to verify it from the FDA Philippines through their officer. The officer told me that the issue is true and valid. I
will guarantee you to post the memorandum letter if I have the copy already.

Nalbuphine
INCLUSION OF NALBUPHINE HYDROCHLORIDE IN THE LIST OF DANGEROUS DRUGS
Here is a copy of the Board Regulation No. 1 from Dangerous Drugs Board through Philippine Drug Enforcement
Agency (PDEA), which stated the reasons why Nalbuphine HCl 10mg/ml amp was included in the List of Dangerous
Drugs.

Questions A-02
Pharmaceutical Calculation Category:
1. You have a vial of magnesium sulfate solution with concentration of 4.06 mEq/ml. Express this concentration as
mg/ml and mOsmol/liter. Molecular weight of magnesium sulfate is 120.

2. Extra strength Alka-Seltzer effervescent tablets contain 1,985 mg Sodium bicarbonate per tablet. How many
millimoles of sodium bicarbonate are obtained in each tablet? Molecular weight of Sodium bicarbonate is 84.
3.Half normal saline is 0.45% sodium chloride. Express this concentration in mEq/ml.
4. Calculate the NaCl equivalent for glycerin, a non-electrolyte with a MW of 92.
5. Zinc sulfate is a 2-ion electrolyte, dissociating 40% in weak solutions. Calculate its dissociation factor.
Questions-Answers:
Pharmaceutical Calculation Category:
1. You have a vial of magnesium sulfate solution with concentration of 4.06 mEq/ml. Express this concentration as
mg/ml and mOsmol/liter. Molecular weight of magnesium sulfate is 120.
Solution to the Answers:
A) 4.06mEq/1ml x 120mg/2mEq = 243.6 mg/ml
B) 243.6mg/1ml x 2mOsmol/120mg x 1,000ml/1L = 4,060mOsmol/L
2. Extra strength Alka-Seltzer effervescent tablets contain 1,985 mg Sodium bicarbonate per tablet. How many
millimoles of sodium bicarbonate are obtained in each tablet? Molecular weight of Sodium bicarbonate is 84.
Solution to the Answers:
1,985mg/1tablet x 1mmol/84mg = 23.63mmol/tablet
3.Half normal saline is 0.45% sodium chloride. Express this concentration in mEq/ml.
Solution to the Answers:
0.45g/100ml x 1,000mg/1g x 1mEq/58.5g = 0.077mEq/ ml

4. Calculate the NaCl equivalent for glycerin, a non-electrolyte with a MW of 92.


Solution to the Answers:
i factor for sodium chloride = 1.8
i factor for glycerin = 1.0
58.5/1.8 x 1.0/92 = 0.3533
5. Zinc sulfate is a 2-ion electrolyte, dissociating 40% in weak solutions. Calculate its dissociation factor.
Solution to the Answers:
On the basis of 40% dissociation, 100 particles of zinc sulfate yield:
40 zinc ions
40 sulfate ions
60 undissociated particles
140 total particles

QUESTIONS A-03
Pharmacology Category:
1. In synaptic neurotransmission, which of the following ions plays a significant role in neurotransmitter release?
a. Sodium

b. Potassium
c. Magnesium
d. Calcium
e. Chloride
2. The primary mechanism of neurotransmitter release is accomplished by what process?
a. Diffusion
b. Carrier-mediated
c. Active transport
d. Facilitated transport
e. Exocytosis
3. What is the amino acid precursor in the synthesis of catecholamines?
a. Phenylalanin
b. Glycerine
c. Tyrosine
d. tryptamine
e. Glutamic acid

4. In the biosynthesis of Norepinephrine, what step is considered as rate-limiting?


a. Active uptake of tyrosine
b. Conversion of tyrosine to dihydroxyphenylalanine
c. Conversion of DOPA to Dopamine
d. Uptake of Dopamine in presynaptic storage vesicles
e. Conversion of Norepinephrine to Epinephrine
5. Which of the following substances exert a negative feedback control on Tyrosine Hydroxylase which serves as the
mechanism for moment-to-moment regulation of the rate of catecholamine synthesis?
a. Dopamine
b. Acetylcholine
c. DOPA
d. Epinephrine
e. Norepinephrine
ANSWERS A-03
Pharmacology Category:
Here are the answers to the questions last January 6, 2012.
1. D. Calcium
2. E. The primary mechanism of neurotransmitter release is exocytosis.

3. C. Tyrosine is the amino acid precursor in the synthesis of catecholamines.


4. B. In the biosynthesis of Norepinephrine, the rate-limiting step is the conversion of tyrosine to
dihydroxyphenylalanine by the enzyme Tyrosine Hydroxylase.
5. E. Norepinephrine

UNBEATABLE BRANDS
Drugs are automatically known through their brand names. Brand name goes always with its generic name. Generic
name has been used universally to recognize the identity of the drug, and utilized by health professionals to
distinguish the drug pertained, if the prescription order of the doctor is contained in brand name only. The trend in
world market today is that brand names are usually bought, because medical professionals prescribed them, of their
known efficacy and short term regimen.

In the Philippines setting, the law enforces and implements that all medical doctors must prescribe generic drugs to
their patients, with or without brand names, especially those who are destined in hospital, due to the fact that all
patients are incapable to purchase high cost drugs. Drugstores revamped their strategy by increasing generic drug
products in their establishments, rather than that of branded drugs. Having this changed, consumers can afford
already the medicines they needed by purchasing generic drug products. But their was a controversy regarding
generic drugs. Generic drugs are mostly manufactured by not known and local manufacturers. For this reason, a
possibility that the production of the drugs is undetermined and overlooked. The cGMP is also questionable whether
is observed or followed. Inefficacy, substandard and low quality products are the main intrigues to the generic drugs.
The reason why most of the time the ailment cannot be cured, long term medication usage and hospitalization, and
the most terrifying is to get worsen.

But there are products that are choice of the most of physicians. They were chose because of the effect they provide
and facilitate activity such as surgical operation, childbirth and recuperation. Enumerated below are the trusted
brands of medicines that have bioequivalent generic products, but still prescribed by physicians (unofficial):

1. Sensorcaine (Astrazeneca)
2. Nubain amps (Invida)
3. Methergin amps (Novatis)
4. Syntocinon amps (Novartis)
5. Diazepam (Roche)
6. Midazolam amps (Roche)
7.Ponstan (Pfizer)

8. Xylocaine (Astrazeneca)
9. Serc (Solvay Pharma)
10. Ventolin products (GlaxosmithKline)

These drugs are unbeatable and widely used in every hospital in the country.

QUESTIONS A-04
Questions:
1.Any anxious, unintended, and undesired effects of a drug that occurs at doses used in human for prophylaxis,
diagnosis or therapy:
A. Adverse Drug Event
B. Allergy

C. Hypersensitivity
D. Adverse Drug Reaction
E. idiosyncracy
2. Study of the use of and effects of drugs in a large number of people:
A. Pharmacoepidemiology
B. Pharmacovigilance
C. Pharmacoinformatics
D. Pharmcogenetics
E. Pharmacogenomics

3. Which of the following diuretics should be used as initial therapy for most patients with hypertension, either alone
or in combination?
A. thiazide diuretics
B. loop diuretics
C. potassium-sparing diuretics
D. osmotic diuretics
E. Both A and B
4. A clinical syndrome characterized by discomfort in the chest, jaw, shoulder, back or arm:

A. Atrial fibrillation
B. Angina pectoris
C. Myocardial infarction
D. Deep vein thrombosis
E. Ischemic heart disease
5. Which of the least nephrotoxic aminoglycoside?
A. Streptomycin
B. Tobramycin
C. Neomycin
D. Amikacin
E. Netilmicin
ANSWERS A-04
Answers to the Questions:
1. D. Adverse Drug Reaction, Definition.
The term adverse drug event is used to describe an injury resulting from administration of drug.
2. B. Pharmacovigilance, definition.
3. A. Thiazide-type diuretics should be used as initial therapy for most patients with hypertension. They can be used
either alone or in combination with other anti-hypertensive drug classes which have demonstrated to be beneficial in

randomized controlled outcome trials ( E.g. ACE inhibitors, aldosterone receptor blockers, beta blockers, and calcium
channel blockers).
4. B. Angina is usually a marker for underlying heart disease. It is a symptom of myocardial ischemia that
fibroproliferative response. The functional status of the vascular endothelium also contributes to plaque formation.
5. A. Mild renal dysfunction develops in up to 25% of patients receiving aminoglycosides for several days or more.
This is due to the accumulation of these drugs in the proximal tubule. Streptomycin remains to be the least
nephrotoxic aminoglycoside.

BFAD Strengthening Law (RA 9711)


Bureau of Food and Drugs (BFAD) which recently changed its name into Food and Drug Administration has already
strengthened its enforcement through the new Republic Act No 9711. The synopsis of this new law is to
strengthening and rationalizing the food and drugs (BFAD) by establishing adequate testing laboratories and field
offices, upgrading its equipment, augmenting its human resource complement, giving authority to retain its income,
renaming it the Food and Drug Administration (FDA), amending certain sections of Republic Act No. 3720, as
amended and appropriating funds thereof. It also goes with its Implementing Rules and Regulations (IRR) to make it
possible to enforce and consummate the new law. To show the whole Law and IRR..

Distributors on the Go!


Pharmaceutical world is so dynamic, it means that this business is so active and that everyone needs medicines to
outwit diseases. Such business is also undergone series of transfer for medicines to reach the consumer. Because of
that brokers are involved, and retailers are importing their products through them. Distribution is the proper term to
define the outreach of the medicine products to the drugstores and outlets. In the Philippines, distributors are very
alive and an expand of them are near unaccountable. Most of them distribute generic drug products and locally
made drugs. But what pharmaceutical company distributor is flagging away in distributing and wholesaling branded
drug, and trusted by major international pharmaceutical companies?

It seems there is only one to be selected. As a pharmacist and purchaser, I have top five major distributors selected,
whereas, I usually place an order and procure. They are:
1. Zuellig Pharma
2. Metro Drug, Inc
3. GB Distributors, Inc
4. RBC-MDC Pharmacy
5. Apollo Plus Distributor
Zuellig Pharma has been the top most choice, because it provides most of the extensive branded products that are
marketable and physician-prescribed in the market today. Zuellig Pharma can be easily reached through their
salesmen, phone calls, internet transactions and SMS. It is also the leading distributor that distributes and supplies
branded drug products for small business drugstores and top drugstores - such as Mercury Drugstores, Watsons,
South Star Drugstore - in the country. I found them so complete, because I can say that almost all major branded
drug products are solely offered through it and cannot be sought in other distributors, unless you go directly to the
principal company to purchase

Drug Companies' Stratagem


Have you noticed why some drugs are sold out in the market? How does this happen even the company is not
known and not famous? What strategies they are taking to sell out their products? I could give some reasons why
some drug products are salable, but in fact it should not be.
1. Discounts, freebies and deals are the regular and casual preference of saleability. The higher discounts the drug
company gives the lower will be the retail price of the products, same as to deals. Deals are dependable to the
number of free products that will be added to the regular order. The highest that a drug company can bid is 1+1 or

buy one take one; moreover, freebies has been used to attract costumers, because of the free item that within the
product such as toys, samples and etc. But these kind of transactions are price dependent and more on pushing in
the part of drugstores, due to its commonality in the all business.
2. Incentives, rebates, box retrieval and food treat. These is a form of simple bribery to the drugstore's personnel to
ensure drugs' movement and turn-over. A lot of small drugstores are engaged into this business.
3. Sponsoring and donating. Some drug companies sponsor and donate money, goods, fixtures and training to
drugstores. In return the drugstore should push and sell the products of sponsoring company that serve as gratitude
to have they shared.
4. Engaged to agreement and contract. The drug company will enter into agreement and sign a contract with
drugstore to assure that their products will be sold and pushed, in return the drug company will guarantee the
drugstore that a certain amount of the profit will be given to them. This is modified form of rebate. 10-30 percent is
the usual range of rebate.
2. Favoring and gaining the physician's trust. This is the main reason why drugs are being patronized and bought by
the consumers. Doctors are big factor. They have the power to prescribe what drug brands they want their patients
to take. Patients are confident to what the doctor prescribes and tells, so they are following the drug order written in
their prescription. Obviously, the medical representatives are always gaining and favoring physicians, so that they
will prescribe their handled drugs. Some agreed with rebates and incentives. Some ask for sponsorship to their
conventions and seminars. And the most expensive drug company can provide is to sponsoring their trip to abroad
with free plane fare, allowance and hotel accommodations that are all fully paid by drug company. What could a
physician ask for when all these things are provided to him. However, the drug company is not crazy to spend lots of
money. The company is looking forward that its products will be moved in the market with fast turn-overs to get
back the loss and profit on it. They are relying to the physician's promise to prescribe their drugs. If not possible the
physician will be liable for breaching the agreement.
I know a drug company who hit its target profit last year, because of all the above mentioned strategies were
applied. The drug company's investments hit PHP 400M+. I may conclude that strategies are important to drug

companies to sell their products in the market. Physicians and drugstores should be prioritized. These things are
normal in pharmacy business, but they have also limitations.

Yellow Prescription

Yellow Prescription is used to purchase dangerous drugs. Should be filled out completely by the doctor and should
present with duplicate when trying to buy medicines in drugstore. Dispensing dangerous drugs are very critical.
Pharmacist must know the expiration date of the the S2 license of the doctor, and the S2 and license no. should be
genuine.

StandardOperatingProcedure(SOP)forPharmacy
Standard Operating Procedure (SOP) is a documentation that describes how to perform various routine operations. It contains a step by step
instructions.

In pharmacy settings various activities are performed everyday, each task should be under a standardized process that everybody must follow.
Personnel must submit themselves to these procedures to have organized and synchronicity in the work place. Food and Drug Administration
(FDA) has imposed it as a requirement to every pharmacy workplace to have and make its own SOP. They are requiring the following tasks of
SOP - Product Complaints, Product Recalls, Procurement of Stocks, Good Dispensing Practice, Good Storage Practice, Cold Chain Management,
Disposal of Expired, Damaged, Returned or Rejected Products. The pharmacist/s, individual who can knowledgeably review the procedures or

somebody higher up in the hierarchy of the department are the ones who can create, review and approve the SOP. All businesses that falls under
pharmacy, either manufacturing, distributing, trading, laboratories or drugstores are mandated to make their own SOP.
Here's an illustration of SOP that should be followed when creating it for your drugstore. Hope it can help you.