Volume 2 | Issue 2 | July-Dec 2019 A BULLETIN OF PHARMACY DEPARTMENT | DRUG & POISON INFORMATION SERVICES Pharmacists are always traditionally impressed as the ‘drug dispenser’. Although pharmacists represent a traditional health profession with ancient roots, they are often viewed with considerable ambiguity and uncertainty by those outsides of the profession. Little do they know that the pharmacist profession is experiencing significant growth and development in terms of services; where the beneficiary ranges from doctors to patients. To a varying degree, pharmacists had progressed toward a more patient-oriented practice and adapting the concept of clinical pharmacy. The pharmacist’s role from behind the counter has evolved in the past decades; emerging into clinical involvement to ensure the quality usage of medication and maximising patient care. This marked the beginning of a period of rapid transition that was characterised by expansion and integration of professional functions, as well as increased professional diversity and closer interaction with physicians and other health care professionals. World Pharmacist Day was first celebrated in 2014 after a council meeting threw at the International Pharmaceutical Federation Congress in Istanbul, Turkey. After that, 25th September was coined as the day to promote and advocate the role of the pharmacist and their contribution to society. This year, the Pharmacy Department of IIUM Medical Centre delightfully held its very first world pharmacist day event jointly with the other coorganisers – the Kulliyyah of Pharmacy IIUM Kuantan Campus, IIUM Pharmacy Students Society (IPhA), Jabatan Kesihatan Negeri Pahang (JKNP) & Malaysia Pharmaceutical Society (MPS) Pahang. (continue to page 3) IIUM MEDICAL CENTRE الصيدليه TRIPLE WHAMMY EFFECT (page 6) THE ANDALUSIAN APOTHECARY: IBNU AL-BAYTAR (page 4) PHARMACO – MEDICOLEGAL (page 10) P
EDITORIAL BOARD TABLE OF CONTENTS COVER STORY PHARMACIST’S WORLD World Pharmacist Day 2019: “Safe and Effective Medicine For All" Medication Safety: Triple Wharmmy Effect Medication Education: Ticagrelor HEALTH SECTION TRIPLE WHAMMY EFFECT: Three simultaneous compounded effects that often overlooked! / p8 PHARMACIST IN FOCUS: The Andalusian Apothecary - Ibnu al-Baytar / p10 PHARMACO - MEDICOLEGAL: A brief summary / p12 ADVISOR CHIEF EDITOR COLUMNIST Asst. Prof. Dr. Ilyani Mohamed Nazar Asst. Prof. Dr. Norny Syafinaz Ab. Rahman Che Rokiah Ismail Tan Boon Yuan Mohd Amirul Arif Yaakub Geethaavacini A/P Gobi Raja Muhammad Azrai Bin Rozali Nurul Hidayah Binti Suhaimi Ahmad Farhan Ismail Fatin Azzyati Pakururazi EDITOR ASSISTANT EDITOR Norhasila Bt Hassim Page 1 Page 8 Page 4 Page 10 Page 12 Page 2 Page 2 Pharmacy Law: Pharmaco - Medicolegal Pharmacist in Focus: The Andalusian Apothecary – Ibnu al-Baytar © The Pharmacy Department, IIUM Medical Centre. Copyright and other intellectual property rights in this material belongs to the Pharmacy Department, IIUMMC and all rights are reserved. The IIUMMC authorises healthcare organisations to reproduce this material for educational and non-commercial use only. DRUG & POISON INFORMATION SERVICES (DIS) PHARMACY DEPARTMENT, IIUM MEDICAL CENTRE. Phone: +609-5911630/2558 Email: [email protected]
PAGE 3 As-Saydaliah الصيدليه Booth Exhibition and Activities Several pharmaceutical-related bodies were invited to exhibit their respective interests. These include KOP, IPhA, JKNP, AADK and others. The exhibitions were to introduce the pharmaceutical industry in Malaysia and to increase community awareness of medicines. Other than exhibition, interactive games and colouring contest were also in place for kids. Career Pathway Talk Students, particularly those in their senior year, were specially invited to attend a sharing session by the honourable speakers. They were Assoc. Prof. Dr. Mohamad Haniki Nik Mohamed (Head of Internationalisation and Global Network, Kulliyah of Pharmacy, IIUM), Mr. Zulfikri Bin Abdul Hamid (Pharmacist IIUMMC), and Mr. Aziz Bin Jamaludin (Chairperson of MPS Pahang). The audience was exposed with the current updates on the pharmacist profession from the teaching & learning field, retail and also a hospital. With the current progression, we believe that the pharmaceutical industry will continue to advance and serve more people in the future. Health Monitoring & Medication Counselling Pharmacist professional activities also cover counselling and monitoring of patients at the time of dispensing of prescription and non-prescription drugs. Within the health care team, the pharmacist is the key member who provides ongoing drug therapy monitoring. Thus, this session which consists of observing blood glucose level, blood pressure level, and the BMI range; help in detecting potential compliance issue or adverse outcome. The interpreted results from the session will guide the attending pharmacist in giving the best and appropriate advice to the patient. Bryan Tan Boon Yuan, he newly joined the pharmacy department as inpatient pharmacist. Striving to be better and stronger each day. Email: [email protected] In addition to the appreciation, we aimed to improve the awareness and understanding of the importance of health and medications. The event was officiated by IIUMMC hospital director, Assoc. Prof. Dato’ Dr. Mohamed Saufi Bin Awang. Booths and activities were then started to receive their visitors not long after the ceremony. Variety of programme and activities endeavoured, given the availability towards attendees from different age groups.
PAGE 4 As-Saydaliah الصيدليه His Magnum Opus Ibnu al-Baytar’s largest and widely used book, Kitab al-Jami fi Adwiya al-Mufrada (كتاب الجامع لمفردات األدوية واألغذية) or Book on Simple Medicaments and Foods) is one of the most significant treaties of botany encompassing therapeutic plants. It stood the test of time, being regarded as a guide and hold a high status among botanist up to 18th century. The treatise comprises on estimated 1400 different items which in majority covers on medicinal plants. Ibnu al-Bayṭār’s (1197–1248) real name is Ḍiyāʾ Al-Dīn Abū Muḥammad ʿAbdllāh Ibn Aḥmad al-Mālaqī. His title, "Ibnu al-Baytar" is derived from the Arabic word which means "son of the veterinarian". Ibnu al- Baytar’s father is a veterinarian. Ibnu al-Baytar was born in the city of Malaga, Andalusia (modern-day Spain). He received his education and started collecting plants in and around Andalusia under the teachings of Abu al-Abbas Ahmad al-Nabati. Al-Nabātī, a prominent botanist in Seville was responsible for developing a new scientific method, introducing empirical and experimental techniques in the testing, description and identification of numerous materia medica, and separating unverified reports from those supported by actual tests and observations. Such an approach was thus adopted by Ibnu al-Bayṭār. He left Spain in 1219 on a plant collecting expedition and travelled as far as the northern coast of Africa and parts of Asia. The major regions he visited include Anatolia, Buqia, Constantinople, Tunis, Tripoli, Barqa and Adalia. His apex achievement was during the rule of Malik al-Kamil, the Egyptian ruler in which he was appointed as a Chief Herbalist in 1224. The position was well utilised to further his reach in his botanical enthusiasm by collecting more herbal samples in the Middle East, Greece, Spain and Turkey. Besides that, he also critically studied relevant works of literature from various cultures and nations he visited and as a result, had successfully mustered more than 150 manuscripts. He died in Damascus in 1248. Two sample pages from Ibn al-Baytar’s treatise Jâmi mufradat al-adwiya wa-‘l-aghdiya. Suleymaniye Library, Ayasofya, MS 3748. Pharmacist in Focus
PAGE 5 As-Saydaliah الصيدليه Contributions Ibnu al-Baytar was a great botanist and pharmacist of his time. He received numerous credits for his introduction of new scientific methods in experiments. Besides that, Ibnu Al-Baitar was the first who specifies the timing of medicines, which one to be taken during the night and which were to be made during the day. Ibnu al-Baytar wrote a second monumental work, Kitab Al-Mughni fi alAdwiyah Mufrada (Book of Drug and Nutrition). The book subdivides into 20 chapters; dealing with the cure of head diseases, treatment of ear diseases, cosmetics, antidotes, and fevers. In this work, he also makes observations on smallpox: “As soon as the pustules appear on a child, he must be treated at the sole of the feet with henna, which then will prevent the disease from spreading to the eyes. I have many times observed this” References: 1) Al Khattabi, M.A. “Atteb wa al atibba fi al Andalus al Islamia” Dar Al Gharb al Islami 1988 2 vols. 2) Prof. Nil Sari (Istanbul University, Cerrahpasha Medical School) (06 June,2007). “Hindiba: A Drug for Cancer Treatment in Muslim Heritage”. FSTCLimited. Archived from the original on 2008-01-22. 3) A. Whipple: The Role, op. cit., p.34. 4) Acharya, Deepak; Anshu, Shrivastava (2008). Indegious Herbal Medicine; Tribal Formulation and Traditional Herbal Practices. Jaipur, india: Aavishkar Publishers. ISBN 81-7910-252-1. 5) Addelson, Barbara (December 2003). “Natural Science Institute in Botany and Ecology for Elementary Teachers”. Botanical Garden s Conservation International. The Cactus Family. Pentland, Oregon: Timber Press. ISBN 978-088192-498-5. Amirul Arif Yaakub is one of the junior pharmacists under the wing of Inpatient Pharmacy. He is an enthusiast for outdoor activitieslike hiking and paintball. Email: [email protected] Having a meticulous personality, he took great care in selecting the plants to later be recognised as medicines. Two magnificent examples of his contributions are essential oils and Hindiba. Essential oils are known to be versatile, from curing distresses to refreshing rooms at home. They are also widely commercial; added to potpourri, burned as incense or simply use as soaps and candles. He had mentioned not only how essential oils were made but what kinds of oils were of true therapeutic value, other than fragrant purpose. Specific to his books, he also paid attention to orange water and rosewater. Hindiba was patented in 1977 by Nil Sari, Hanzade Dogan, and John K. Snyder after its benefit in the treatment of neoplastic disorders was discovered. Remarkably, Ibnu alBaytar was a man ahead of his time. He found the anticancer properties of Hindiba and documented the findings in his manuscripts. Statue of Ibn al-Bayṭār in Benalmádena Costa, Spain. Legacy Ibnu al-Baytar’s name was mentioned in many established manuscript across the world. One of them is Encyclopedia Londinensis (1810), printed in London. It says, “This learned physician and botanist is spoken of as one of the great ornaments of his country, and of the age in which he lived.” As a modern health practitioner, we can take this prodigy of pharmacy and his life achievements to further esteem ourselves in pursuing the best of our speciality. Ibnu Al-Baytar, among other prominent figures in the field, had shown to the later generations that if man embodies the spirit of keen observation and sheer enthusiasm in his life, the whole world will be his home and sanctuary.
PAGE 6 As-Saydaliah الصيدليه Perindopril, frusemide, and diclofenac. Sounds familiar? These are some of the common drugs being prescribed to or being used by many patients for the management of hypertension, heart failure, and arthritis. The aforementioned drugs belong to groups called angiotensinconverting enzyme inhibitors (ACE-i), diuretics, and non-steroidal antiinflammatory drug (NSAID), respectively. Although each belongs to different groups, they share one common ground: they have the potential to decrease renal function. Individually, they pose a relatively small risk of Acute Kidney Injury (AKI), but in combination, the risk increases substantially (refer Figure 1). To understand how this happens, we need to review the pharmacological effects of these drugs on the kidneys. ACE-i plays a vital role in improving blood pressure and cardiovascular diseases, but the exact mechanism is still being explored. One theory state that the triple whammy effect acts on the kidney by causing vasodilation of the efferent renal arteriole, which in turn reducing the glomerular filtration. This is the reason why serum creatinine (Scr) will increase after administration of ACE-i. Diuretics, on the other hand, promote diuresis that can lead to hypovolemia (loss of extracellular fluid). The effect of ACE-i and diuretics increase the risk of AKI and thus, the supply to the glomeruli is further diminished. If NSAID is added into this equation, the risk will be much higher. NSAID multiplying the effect by blocking cyclooxygenase 2 (COX-2) enzyme that will prevent prostacyclin synthesis. Consequently, it can lead to afferent arteriolar vasoconstriction (refer Figure 2). Figure 1 Medication Safety Three simultaneous compounded effects that often overlooked!
PAGE 7 As-Saydaliah الصيدليه In the case of such incidence occurs, discontinuation of all the offending agents is warranted. Upon patient stabilisation, necessary drugs which lead to such incidence can be slowly reintroduced back. Drugs such as ACE-i, ARBs and/or diuretics are often vital in disease management. Meanwhile, NSAID at this point should be considered as contraindicated since it can provoke another AKI. “Double whammy” which consist of combination or either ACE-i or ARB and diuretics does not lead to AKI as seen in triple whammy effect. Only the addition of NSAID can make it happen. If the management of pain is needed, consider weak to moderate opioid. In the era of discovery, new drugs are being discovered for therapeutic purposes. This also comes at the cost of increased drugspatients interactions. Whether beneficial or harmful, one can never know until it genuinely manifests itself. Therefore, we as healthcare professionals must exercise our roles in making sure patients receive the best healthcare management without compromising their safety. Muhammad Azrai bin Rozali is the pharmacist in charge of Inpatient Pharmacy. He likes to learn new things and welcome every new challenges ahead as opportunities to become better. He can be contacted via [email protected] The term triple whammy (three simultaneous deleterious blows with compounded effect) was first coined by Merlin C Thomas. In his case report1 , Thomas mentioned the incidence of two elderly women admitted to the hospital due to AKI. Upon further investigation, it was found that both patients were taking either perindopril, indomethacin, and furosemide as part of their routine medications. The aforesaid medications were known to be responsible for the AKI, and after discontinuation, the AKI resolve. Numerous studies also have reported the same findings 2-4 , although most were only retrospective studies. Older age, advanced kidney disease, heart failure, and liver disease are among factors that further increase the likelihood of triple whammy incidence. The clinical presentation of the triple whammy effect includes reduced urine output, dry mucous membrane, tachycardia, orthostatic hypotension, and lethargy. An increase in serum creatinine of 26.5 μmol/L or more in 48 hours or an increase in serum creatinine to at least 1.5 times baseline within a 7-day period strongly suggests triple whammy effect if the “culprits” are present. Figure 2 References: 1. Thomas, Merlin. (2000). Diuretics, ACE inhibitors and NSAIDs: the triple whammy. The Medical journal of Australia. 172. 184-5. 10.5694/j.1326-5377.2000.tb125548.x. 2. https://bpac.org.nz/2018/triple-whammy.aspx 3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1884747/ 4. https://www.pharmacytimes.com/publications/issue/2013/april2013/diuretics-aceis-arbs-and-nsaids-a-nephrotoxiccombination
PAGE 8 As-Saydaliah الصيدليه Antimicrobial resistance amongst microorganisms that commonly cause infections in healthcare settings is a growing problem worldwide. Antimicrobial resistance occurs as a direct result of antibiotic treatment and is driven by the increasing consumption of antimicrobials. Infections with multidrugresistant bacteria are more difficult to treat and are associated with poorer outcomes for patients and increased costs to the health care system. A research suggest that Ticagrelor - an antiplatelet agent - may represent a new class of antibiotics that works against multidrug-resistant staphylococci or enterococci. It also possess bactericidal activity against antibiotic-resistant gram-positive bacteria that pose a threat to human health, including MRSA. The findings were published online on May 8 in a research letter in JAMA Cardiology. The antibacterial properties of ticagrelor do not seem to be related to its antiplatelet activity and are not seen with other antiplatelet agents, such as clopidogrel or prasugrel. Instead, they appear to be mediated through a different, novel mechanism. This new mechanism potentially opens the door to a new class of antibiotics, which are urgently needed, as more bacteria are becoming resistant to current drugs. The researchers say their findings warrant further investigation, including randomised clinical trials comparing the protective activity of ticagrelor with that of other antiplatelet drugs against gram-positive bacterial infection in patients with cardiovascular disease. They suggest that a dual antiplatelet and antibacterial effect of ticagrelor might make it superior to other P2Y12 inhibitor antiplatelet Medication Education
PAGE 9 As-Saydaliah الصيدليه agents in patients with cardiovascular disease who are at risk for gram-positive bacterial infections, such as infective endocarditis. They also indicate that the drug could be used in polymer coatings of implanted cardiac devices to lower the risk for infection. It was noted that because the antibacterial mechanism appears to be distinct from the antiplatelet activity, there is potential for a range of new ticagrelor-derived antibiotics, devoid of antiplatelet activity, for use against multidrugresistantstaphylococci or enterococci. Lower Infection-Related Deaths The researchers conducted their studies after noticing that among patients with acute coronary syndrome and pulmonary infections who were receiving intensive care, survival appeared more likely with ticagrelor than other antiplatelet agent2 . Ticagrelor reversibly inhibits the platelet adenosine diphosphate P2Y12 receptor. It is approved for prevention of cardiovascular events in patients with atherosclerotic cardiovascular disease and shows evidence of superior clinical performance compared with other P2Y12 inhibitors. According to Lars Wallentin et al., (2009) report findings from a post hoc analysis of the Comparison of Ticagrelor and Clopidogrel in Patients with ACS in (PLATO) trial revealed that patients treated with ticagrelor had a lower risk of infection-related death than those treated with clopidogrel bisulfate. More recently, in the Targeting Platelet-Leukocyte Aggregates in Pneumonia with Ticagrelor by Travis R. Sexton et al. (2018) in (XANTHIPPE) study, ticagrelor was associated with improved lung function in patients hospitalized for pneumonia1 . According to Patrezio Lancelotti et al., (2019), although bactericidal concentrations are not reached systemically in patients receiving typical dosages for treating cardiovascular disease, antibacterial activity at infection sites may still be achieved through local, possibly platelet-driven, drug accumulation. MRSA is a huge problem, with few drugs available to treat it, but in the lab, ticagrelor killed MRSA more rapidly than vancomycin2 . It also showed good activity against Enterococcus, which can cause infective endocarditis or infections of cardiac devices and is often highly resistant to antibiotics that can be very difficult to treat. The study report that ticagrelor and its metabolite, AR-C124910, demonstrated bactericidal activity against all gram-positive strains tested, including the drug-resistant strains glycopeptide intermediate S aureus (GISA), Methicillin- Resistant Staphylococcus epidermidis (MRSE), MRSA, and vancomycinresistant E faecalis (VRE) 2 . However, the most suitable dose of ticagrelor for the antibacterial action is too high comparing to its antiplatelet action2 . Hence, “patient would have a high bleeding risk. In order to obtain the antibacterial effect without the bleeding, we have changed the ticagrelor molecule slightly so it loses its antiplatelet effect but keeps the antibacterial action3 .” References: 1) Travis R.Sexton, Guoying Zhang, , Tracy E. Macaulay, Leigh A. Callahan, Richard Charnigo, Olga A. Vsevolozhskaya, ZhenyuLi, Susan Smyth.(2018). Ticagrelor Reduces Thromboinflammatory Markers in Patients With Pneumonia. JACC: Basic to Translational Science. Volume 3, Issue 4, August 2018, Pages 435-449. 2) Patrizio Lancellotti, Lucia Musumeci, Nicolas Jacques, Laurence Servais, Eric Goffin, Bernard Pirotte, and Cécile Oury.(2019). Antibacterial Activity of Ticagrelor in Conventional Antiplatelet Dosages Against Antibiotic-Resistant Gram-Positive Bacteria. JAMA Cardiology. 2019 May 8 : e191189. 3) Medscape Medical News. Ticagrelor: A new Antibiotic. May (2019) Nurul Hidayah Suhaimi is an inpatient pharmacist. She loves sewing and listening to music during her leisure time. She can be contacted via email at [email protected]
PHARMACO –L On the 31st of July 2019, I had an opportunity to attend the Pharmacolegal Conference at Kuala Lumpur, organized by the MySeminars. Among all those topics that were discussed on that day, the one that caught most of our attention was the forum discussion held at the end of the session. pharmacolegal cases reported annually. It is best for us as pharmacist to look out because at times, simple everyday work can be over looked and taken for granted. For instance, let’s say it was a normal busy day in pharmacy and one of the pharmacist dispensed a cough syrup (with narcotic agent) which might cause drowsiness, without informing the patient about its side effect. After consuming the medication, patient was driving and experienced the drowsiness which caused a motor vehicle accident. As a pharmacist who dispensed the medication, he/she can be held liable for the accident. This kind of small things can lead to a pharmacolegal case on us. So how do we prevent such thing? The answer is simply, by doing our job as it is. When we are screening the medication and found out something wrong with the medication, dose, and frequency or with the prescription itself, PLEASE do call and confirm with the prescriber. Because prescriber are normal humans who are subjected to fatigue due to unpredicted working hours and excessive workload too. To add on to it, we have no authorization to change anything in the prescription without being asked to do so by the prescriber themselves. Wherever possible, it is important for us to jot down the intervention and with which prescriber we have spoken to. Most importantly, every time during dispensing and counselling the patient about their medication, we need to make sure the patient knows all the important side effects and what to be expected when they consume the medication. This is not only to legally safe ourselves incase anything happen but as a healthcare professional who plays an important role in a person’s health care management, we do have our own responsibility to give only the best to our patient. PAGE 10 As-Saydaliah الصيدليه Geethaavacini Gobi Raja is an outpatient pharmacist in IIUMMC. She loves baking and traveling during her free time. Geethaa can be contacted through email: [email protected] So as pharmacist, one of our expertise would mainly be on dispensing and counseling of medication to the patient but are we doing it correctly and safely? Can our words be used against us when there is any problem arises? Whose mistake would it be when an inappropriate medication was prescribed by the physician and dispensed by a pharmacist? Or are we also liable when patient experience any side effects which we failed to address and inform them? We might not have thought about all this but would you believe if someone says there are hundreds of thousands of medicolegal and A brief summary PHARMACO - MEDICOLEGAL