AS-S A Y D A L I AH الصيدليه
A Bulletin of Pharmacy Department, IIUM Medical Center. 1/2018 Edition
HEPARIN-INDUCED THROMBOCYTOPENIA Clinically, HIT should be first sus-
pected when a patient is4:-
By: Nor Ilyani Mohamed Nazar RPh., Ph.D.
a) receiving heparin, typically for 5
Heparin belongs to the class of medications called anticoagulants. In general, it works by to 14 days; b) experiencing an
unexplained drop in the platelet
decreasing the clotting ability of the blood1. Unfractionated heparin (UFH) has been a significant count, usually a decline of 50% or
lifesaver in which it has many advantages to offer; include rapid onset of action, the ability to more from baseline; c) having a
inhibit multiple coagulant proteins, ease of monitoring and better reversibility profile as com- marked thrombocytopenia with a
pared to the newer anticoagulants whether oral or parenteral2. Such advantages are expected to single administration of heparin.
keep UFH and its derivatives, the low-
molecular-weight heparins (LMWHs), To ease the diagnosis of HIT, a
at the therapeutic forefront for a num- scoring system has been devel-
ber of indications such as prophylaxis oped; the Pretest Probability of HIT
or treatment of deep vein thrombosis (The Four T’s Table)6. In view of
(DVT), treatment of acute pulmonary treatment, strongly suspected (or
embolism (PE) and in cases where confirmed) HIT (wit or without
alternative therapies are currently thrombosis) is recommend to dis-
lacking (cardiac surgery), unsuitable continue all heparin (UFH or
(mechanical valves), or untested LMWH) and administer a non-
(cancer associated thrombosis and heparin anticoagulant such as
antiphospholipid antibody syndrome)2. Lepirudin, Argatroban, Bivalirudin
Heparin-induced thrombocytopenia Figure 1: Pathogenesis of heparin-induced thrombocytopenia.3
(HIT) is considered the most common HIT can occur early or late and
form of drug-induced thrombocytope- should be considered in any patient
nia as well as one of the pronounced with recent exposure to any type of
causes of thrombocytopenia in hospi- heparin (UFH or LMWH) and with
talized patients. Next to bleeding, HIT significant reductions in platelet
is the most significant non- counts or thrombosis. Without ap-
hemorrhagic adverse effect associated propriate treatment, 10% to 20%
with heparin therapy2,3. of patients face losing a limb, and
20% to 30% die as a result of the
Two clinical forms of HIT are generally recognized. Type I (heparin-associated thrombocyto- devastating thrombotic complica-
penia) occurs in up to 30% of patients receiving heparin. It is a non–immune-mediated reaction tions. Other complications include
often presenting early to exposure (within one to two days) with an asymptomatic, mild-to- DVT, PE, myocardial infarction,
moderate transient decline in the platelet count (rarely below 100,000/mcL) with few complica- cerebrovascular accidents, skin
tions. Resolution is often spontaneous without discontinuation of therapy. On the other hand, necrosis, and end-organ damage6.
Type II (heparin-induced thrombocytopenia) is the more severe immune-mediated reac- Hence, early identification in order
tion3. LMWH has been studied in many to have lower incidence of HIT as compared to UFH 4,5. to provide proper management has
continued to become challenges in
The cause of HIT is unknown. It is hypothesised that sensitisation of the antiheparin/platelet clinical setting.
factor 4 antibody leads to production of procoagulant platelet-derived microparticles and throm- References (Cont):
4.Lori-Ann Linkins. Heparin induced thrombocytopenia.
bin generation, with the potential for development of the clinical manifestations that are charac- BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.g7566
teristic of HIT— thrombocytopenia and venous or arterial thrombosis6. The diagnosis of HIT is 5. Junqueira DR1, Perini E, Penholati RR, Carvalho MG. Unfrac-
tionated heparin versus low molecular weight heparin for avoiding
based on both clinical and serological findings. HIT antibody seroconversion, along with thrombo- heparin-induced thrombocytopenia in postoperative patients.
Cochrane Database Syst Rev. 2012 Sep 12;(9):CD007557. doi:
cytopenia or other clinical manifestations, such as skin lesions at heparin injections sites or acute 10.1002/14651858.CD007557.pub2.
6. Lori-Ann Linkins. Heparin induced thrombocytopenia.
systemic reactions (fever, chills, cardiorespiratory distress) after intravenous (IV) bolus admin- BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.g7566
istration, are necessary to confirm a positive diagnosis of HIT6.
2.Gowthami M. Arepally Heparin-induced thrombocytopenia. Blood 2017.129:2864-2872; doi: ttps://doi.org/10.1182/blood-2016-11-709873
3.Daniel A. Zinkovsky, and Marilena S. Antonopoulos. Heparin-Induced Thrombocytopenia: Overview and Treatment. P T. 2008 Nov; 33(11): 642-644, 647-651.
Disclaimer: As-Saydaliah is a newsletter of Pharmacy Department, IIUM Medical Centre, Kuantan. All efforts have been taken to ensure the correctness and accuracy
of the information published. Our department is not responsible for any claims or action as a result of unauthorized usage of any materials from this newsletter.
As - Saydaliah Edition 1/2018 الصيدليه
DRUG ACT: WHAT IS A GOOD PRESCRIPTION? EDITORIAL BOARD
A prescription is a legal instruction from a prescriber to a dispenser. Every country ADVISORS:
has its own standards for the minimum information required for a prescription, and
its own laws and regulations to define which drugs require a prescription and who is Asst. Prof. Dr. Norny Syafinaz
entitled to write it. In Malaysia, every prescription is regulated under Poison Ab Rahman
Act 1952 Section 21(2).
Asst. Prof. Dr. Nor Ilyani
All prescriptions which arrive to the pharmacy will undergo screening and validating Mohamed Nazar
process. A good prescription should have the following information:-
Patient Details Prescription Details
1.Drug regimen (name of preparation, Mdm Che Rokiah bt Ismail
1.Name drug, dose, frequency, administration
and duration). EDITOR:
2.Address & contact number (if man-
ually written without tracking system) 2.Prescriber’s signature and stamp Ms. Fatin Azzyati bt Pakururazi
3.Identification Number 3.Prescriber’s name and address COLUMNIST:
4.Date of prescribing Ms. Habibah Kamaruzaman
Ms. Nurul Hazimah Abdul Aziz
It is strongly recommended to use the generic (nonproprietary) name to facilitates Ms.Nur Munirah Zainol Abidin
understanding on specific medication information. The dose of the drug indicates Mr. Zulfikri Abdul Hamid
Ms. Mery Hu Wei Ying
how many milligrams each tablet, suppository, or milliliter of fluid needed for an in- Dr. Nor Ilyani Mohamed Nazar
dividual patient. Internationally recognized abbreviations should be used (g for gram PHARMACY DEPARTMENT
or ml for millilitre). In order to avoid any misunderstanding, the name of the drugs Operation Hour
and doses should be written in full ( Tab levothyroxin 500 micrograms/mcg/
µg). Age of the patient is crucial especially in geriatric or young children. In patient
Mon - Sun : 7am - 11pm.
under 12 years of age, the body weight must also clearly be stated. In manual pre- Minimal strength: 1 - 2pm and 5 - 11pm
Friday break : 12.15 - 2.45pm
scription, a poor handwriting can easily lead to errors. Hence, it is a legal du- Contact No : 09-59102591
ty of the prescriber to uphold the principles of safe prescribing such as to OUTPATIENT PHARMACY:
write legibly in order to prevent any error during prescription writing and further Mon - Thu : 8am - 5.30pm
Fri : 8am - 1pm then 2.45 - 5.30pm
increase the risk of medication errors delivered to the pa- By: Habibah Kamaruzaman Minimal strength : 1 - 2pm and 5pm on-
tients. Pharmacist, RPh. 13493 wards on weekdays and Friday 12.15 - 1pm.
Contact No : 09 - 5912577
A Word From Chief Editor
PRODUCTION (TPN & CDR):
Mon - Fri : 8am - 5pm . Closed on weekends.
A hearty congratulations to the committee members of As - Saydaliah Contact No : 09-59102544
bulletin. I would like to take this opportunity to express my heartfelt thanks to all EMERGENCY PHARMACY:
pharmacy staff and IIUMMC in general for a great team work. Mon - Sun : 11pm - 7am
Contact No : 09-5911233
Being one of the support clinical departments for IIUM Medical Centre has
greatly challenged us not only as medications keeper, but we are also responsible to
Mon - Thu : 8am - 5pm
educate and share knowledge to patients and other healthcare providers. Friday : 8am - 12.15pm then 2.45 - 5pm
Contact No : 09-5912648
In line with the publish of Saydalli bulletin’s first edition, I am in high hope this will
aid to improve Pharmacy Department’s services to patients focusing in
Mon - Thu : 10am - 4pm. Break : 1 - 2pm.
pharmaceutical care. Friday : 10am - 12.15pm then 2.45 - 4pm.
Contact No : 09-5911047
Once again, I would like to congratulate and
Compiled by: Mery Hu Wei Ying
thank everyone who has contributed and involved in Che Rokiah Binti Ismail, Pharmacist, RPh. 12610
making this bulletin a success. RPh. 1930
As - Saydaliah Edition 1/2018 الصيدليه
Do and Don’ts in Tablet Administration
Tablet is most common oral medication that is widely used by patients. In some cases, in order to ease
administration of tablet, most of the patients opt to crush or cut the tablet despite of swallow it wholly. However, there are
numerous medications that should not be crushed or chewed due to its specific formulations and pharmacokinetic proper-
Generally, medications that should not be crushed/cut fall into one of these categories:
Type of Oral Medication Example
Sustained- release / Control-release tablet Oxycodone MR 10mg Tab.
Suffixes: CC, CD, CR, ER, Retard, SR, XL, XR Tamsulosin 4mg Tab.
Doxasozin XL 4mg Tab.
Combination tablet of 2 or more active ingredient Omeprazole Tab.
Reminder: Some tablet which has scored can be divided into halves to ease administra-
tion but not necessarily can be crushed. Do ask your Pharmacist yah! By: Nur Munirah Zainol Abidin
Pharmacist, RPh. 13501
ENOXAPARIN: A PORCINE-BASED ANTICOAGULANT
FROM AN ISLAMIC PERSPECTIVE
Enoxaparin (trade name: Clexane) is a low molec- with a disease or illness, they are required to seek this, the jurists have roused debates and discus-
ular weight heparin (LMWH) that does not need for treatment and its cure. Referring to one of the sions concerning the meaning of the term and its
an activated partial thromboplastin time (aPPT) hadiths, the Prophet Muhammad SAW has urged application in real life situations.
monitoring and able to deliver predictable thera- his followers :
peutic effect. According to Merli and Groce On top of that, Enoxaparin injection comes in
(2010), FDA has approved Enoxaparin injection for “Ask Allah for forgiveness and health, for after prefilled syringe of several different doses i.e.
vein thromboembolism (VTE) prophylaxis, treat- being granted certainty, one is given nothing 20mg, 40mg and 60mg which is administered by
ments of deep vein thrombosis (DVT) and acute better than health”. subcutaneous injection. Due to this simplicity of
coronary syndromes (ACS). (Related in Tirmidhi) administration, it has an advantage to reduce
hospital stay of patients who are indicated for
Undoubtedly, Enoxaparin has a potential and Thus, the use of medicine for curing illnesses and Enoxaparin injection. Patients could opt to have
many advantages as an anticoagulant agent. How- diseases is generally legalized and recognized in their injection at home as outpatient basis provid-
ever, the former is a porcine-based drug which Islam. Allah SWT has mentioned in the Quran : ed that they have been counselled for injection
derived from swine’s intestine. In Islam, the technique by the pharmacist prior to discharge.
questions of permissible (halal) and forbid- “Allah has only forbidden you dead meat and
den (haram) constitute as one of the core blood and the flesh of swine and that on which Thus, in order to be in-line with the concept of
principles and philosophy of Islamic Law. any other name has been invoked besides that shariah-compliance hospital; the Pharmacy De-
of Allah…but if one is forced by necessity, with- partment is in the process of implementation
Due to this, it is not surprising that majority of the out wilful disobedience nor transgressing due of written informed- consent in the case of
academic discourse on halal and haram concen- limits, then is he guiltless. For Allah is Oft- non-halal pharmaceuticals use in this hospi-
trates on foods and beverages. Nevertheless, the forgiving, Most Merciful” (Al-Baqarah: 173). tal. This is very much consistent with the mission
issue has been recently extrapolated to medicinal/ and vision of IIUMMC to be a leading centre of
pharmaceutical products as well and attracts seri- These generally ascribed principles assert that excellence and innovation for healthcare educa-
ous attention among patients, practitioners and these substances such as intoxicants (al-khamr), tion, training and research. The implementation
scholars. swine and impure things could not be consumed shall also serves as a written document of consent
at all costs, yet there are certain situations that to reduce risk of medico legal cases as well as a
Muslims are expected to keep their bodies healthy heed the need of using substances such as in medium of education to patient and advocates the
physically and mentally in order to perform their the case of emergency or out of the extreme right to refuse a treatment by a patient (except in
obligations toward Allah SWT. When inflicted necessity for survival (darurah). In explaining emergency situations). By: Zulfikri Abdul Hamid
Pharmacist, RPh. 13491
As - Saydaliah Edition 1/2018 الصيدليه
Compiled by: Nurul Hazimah Abdul Aziz
Pharmacist, RPh. 13504