Buletin Hospital Pontian 2.2017

Issue 2/2017 October 2017

Pharmacy Bulletin

INSIDE THIS ISSUE: PAGE 2
What is: POM? (Patient’s Own PAGE 3-4
Medications) PAGE 5
PAGE 6-7
Disease: STROKE PAGE 8

Update on Fondaparinux 2.5mg PAGE 9-11
Injection

List of Emergency Drug in Hospital
Pontian

Cost-Saving Measures, New & Delist
Medications in Hospital Pontian
Formulary

LASA (Look alike Sound alike)

Pharmacy Activities PAGE 12-17

Advisor: EDITORIAL BOARD Members:
Ms. Ng See Leau Co-editors: Ho Sek Wen
Pang Tser Wan Norafiqahassyirah
Chief Editor: Muhamad Aizuddin Fadhilah
Siti Nur Ain Samian Teepa Anushia Dewi Hairulnisah
Nur Ain Syafika Nur Awatif Fatini
Yong Li Xin
Ng Wan Ling
Aedy Zulhelmi
Nur ‘Aina

Pusat Maklumat Ubat,
Unit Farmasi, Hospital Pontian
Jalan Alsagoff 82000 Pontian, JohorTakzim
Tel:07-6873333 ext: 515/513

PHARMACY RX BULLETIN

PATIENT’S OWN MEDICATION (POM)

[POMs Policy and Guideline] Patient’s own medicines (POMs) policy and Some of the hospitals in Johor had started to
guideline is one of the initiatives implemented use this policy and guideline after its imple-
in 2016 to reduce medicines wastage in Minis- mentation such as Hospital Sultanah Aminah,
try of Health (MOH) facilities. This policy and Hospital Sultan Ismail, Hospital Sultanah Fat-
guideline as a guidance on management of imah Muar, Hospital Segamat, and Hospital
POMs during administration of patients in Sultanah Nora Ismail Batu Pahat
wards at MOH facilities.

What is POMs?

POMs are medicines that have been prescribed or brought by the patient individually and taken to the hospital while requir-
ing treatment in the ward. Patients need to take their medicines to the hospital so that health personnel can identify the prop-
er medical history to ensure patient care continuity. Complementary medicines including traditional medicines and supple-
ments are excluded from POMs due to the difficulty in identifying the content and its indications.

Procedure POMs: CP 1 Form Dangerous drug/ Psychotropic
Drug/ Medicine not in hospital
 Receiving of POMs: All the POMs formulary/ KKM Formulary
should be given to Pharmacist during
ward round. These POMs will be val- POMs in category of dangerous drug
ued and medicine that have been should be keep in locked cabinet and
checked will be recorded in CP1 form handled under poison act and psycho-
and kept together in patient fail. tropic drug. These medicine have to keep
in transparent bag and labeled and each
 Labeling of POMs: Continuing medi- receiving or usage have to record.
cines are label again using the generic
name to avoid medication error. POMs that not in hospital formulary /
KKM formulary need to be saved and
 Storing of POMs: The POMs will be handled based on procedure of each facil-
kept according to the type of medicine. ities.
The cold item will be stored at fridge
and dangerous drug inside the locked POMs Supplying during Unused POMS
cabinet. Discharge
 Stopped/ Withhold POMs:
 Prescription POMs: POMs that want POMs list need to be screened
to be used at ward will be prescribed by pharmacist whether should Tied and save inside container with
by Doctor and marked with ‘POM’. be continued or not together label, POMs from MOH facilities that
with prescription. If POMs not be used in ward need to return to
 Supplying : Prescription labeled with need to be continued, the quan- pharmacy, POMs that buy by patients
POM do not supply by Inpatient phar- tity of medicine will be added will be return to them during discharge.
macy but use POMs in ward while the according to the duration on the
prescription without labeled POM will prescription. Stopped POMs  Damaged and expired Medicines
be supply by pharmacy. need to be return to inpatient
and that will be informed to pa- These medicines need to return to phar-
 Administration of POMs: Staff nurs- tients. macy for disposal. POMs under Danger-
es will refer to medication chart before ous Drug / Psychotropic Drug will be
administration and to ensure patients disposed according Dangerous Drug Act
get their medicine. 1952 .

Rujukan:

Bahagian Perkhidmatan Farmasi. (2017). Polisi dan Garis Panduan Patient's Own Medicines (POMs). [online] Available at:
https://www.pharmacy.gov.my/v2/ms/dokumen/polisi-garis-panduan-patients-own-medicines-poms.html [Accessed 11 Oct. 2017].

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WHAT IS STROKE?

 Clinical syndrome characterized by rapidly developing clinical symptoms and/or signs of focal, and
at times global, loss of cerebral function, with symptoms lasting more than 24 hours or leading to
death, with no apparent cause other than that of vascular origin.

TRANSIENT ISCHEMIC ATTACK (TIA)

 Same, but with symptoms lasting less than 24 hours and which is thought to be due to inadequate
cerebral or ocular blood supply as a result of arterial thrombosis or embolism.

TYPES OF STROKES MANAGEMENT

Non-pharmacological tips:
 Monitoring of glucose level
 Smoking cessation
 Avoid heavy alcohol

consumption

PRIMARY SECONDARY
PREVENTION PREVENTION

Ischemic stroke : 87% incidences  Achieve target BP  Single antiplatelet :
from all stroke cases control level  Aspirin 75 – 325mg OD
 Clopidogrel 75mg OD
EVIDENCE BASED TCM  Tight glycaemic  Ticlopidine 250mg BD
FOR STROKE PATIENT control in DM
patient Double antiplatelets (not
Ginkgo Evidence for the benefit of (Hb A1c<6%) recommended)
Biloba (GB) GB after acute ischemic  Aspirin + clopidogrel is
stroke appears promising,  Statin therapy in
Tocopherol but not sufficient to warrant high risk group not superior to either
(Vitamin E) clinical routine use. [6] (those with CVD, one drug alone. Has
occlusive arterial higher bleeding risk.
Reduce risk of ischemic
stroke by 10% disease or DM)  Warfarin in AF patient
 Aspirin therapy  ACEI or ARB
BUT  Avoid oestrogen  Statin therapy
Increase risk of
hemorrhagic stroke by 22% based HRT in
Caution against widespread post menopausal
use. [5] women

Targeted especially in high risk individuals:
 Age : Risk of stroke increases with age. Doubles

after age of 55.
 Gender : More prevalent in men
 Family history of stroke.

Turmeric Has neuroprotective effect,
however, futher study must
be conducted. [4]

Ginseng Has neuroprotective effect
proven by in vitro or in vivo
studies on rats/mice. 3
However, futher study must
be conducted. [3]

MULTIDISCIPLINARY
APPROACH

Management and rehabilitation of stroke patient is handled by Stroke Medication Therapy
a multidisciplinary team which comprises of physician, Adherence Clinic (SMTAC)
Pharmaceutical Services Division
PHARMACIST, nurses, dietitian, physiotherapist, occupational launched SMTAC Protocol in 2013
therapist, and speech & language therapist. Each one of them as a guide for pharmacists to provide
assist in the recovery of a stroke patient in many significant care for stroke patients with aim:

ways. 1. To maximize the benefits of
Pharmacists can make a difference by playing a major role medication
especially in identifying the pharmaceutical care issues that
2. To minimize adverse
arise and offering solution to them. effect/complications from
medication.
PHARMACEUTICAL CARE ISSUES
RELATED TO STROKE PATIENT 3. To improve patient’s
adherence.
1. Patient has swallowing difficulty or on enteral feeding
(eg. Ryle’s tube feeding), thus medication has to be 4. To increase patient’s
administered via enteral tube. However, some arising understanding towards illness.
concerns have to be taken into account such as some
medication cannot be crushed for example enteric- 5. To increase patient’s
coated tablet. Other than that, drug-enteral feed understanding towards
interaction and drug-enteral tube interaction have to medication
be considered for drug such as phenytoin.
6. To enhance awareness on risk
2. Patient has impaired/restricted mobility thus cannot factors & prevention of
administer insulin injection by himself/herself. recurrent stroke

3. Stroke patient cannot administer inhaler device 7. To educate patient on healthy
himself/herself. Inhaler devices such as Seretide lifestyle & risk factor
Accuhaler is not suitable for immobile stroke patient and management.
should be changed to other alternatives.
This service is being offered at
4. Caretaker/family members have limited knowledge on Hospital Sultanah Nur Zahirah,
patient’s medication Terengganu & Hospital Sultanah
Bahiyah, Kedah.
5. Financial difficulties especially now patient is unable to
go to work.

6. Difficulty to go for follow-up at Klinik Kesihatan due to
immobility/bed-ridden.

REFERENCES

1. CPG on the Management of Ischaemic Stroke (2012)

2. Protocol Medication Therapy Adherence Clinic, Ward & HMR : Neurology (Stroke) (2013).

3. Rastogi, V., Santiago-Moreno, J., & Doré, S. (2014). Ginseng: a promising neuroprotective strategy in stroke. Frontiers in Cellular

Neuroscience

4. Cole, G. M., Teter, B., & Frautschy, S. A. (2007). Neuroprotective Effect of Curcumin . Advances in Experimental Medicine and

Biology, 595, 197–212.

5. Schürks Markus, Glynn Robert J, Rist Pamela M, Tzourio Christophe, Kurth Tobias. (2010). Effects of vitamin E on stroke subtypes:

meta-analysis of randomised controlled trials BMJ; 341 :c5702

6. Zeng, X., Liu, M., Yang, Y., Li, Y., and Asplund, K. (2005) Ginkgo Biloba for Acute Ischaemic Stroke (Cochrane Review). (Issue

4)The Cochrane Library. John Wiley & Sons, Ltd, Chichester, UK

7. Abdul Aziz, A. F., Mohd Nordin, N. A., Abd Aziz, N., Abdullah, S., Sulong, S., & Aljunid, S. M. (2014). Care for post-stroke patients

at Malaysian public health centres: self-reported practices of family medicine specialists. BMC Family Practice, 15, 40.

8. Abdul Aziz, A. F., Mohd Nordin, N. A., Ali, M. F., Abd Aziz, N. A., Sulong, S., & Aljunid, S. M. (2017). The integrated care pathway

for post stroke patients (iCaPPS): a shared care approach between stakeholders in areas with limited access to specialist stroke 4

care services. BMC Health Services Research, 17, 35.
9. Wiliams N. T. (2008). Medication Administration Through Enteral Feeding Tubes. Am J Health Syst Pharm.

UPDATE ON INJECTION FONDAPARINUX 2.5MG IN HOSPITAL PONTIAN

Antithrombotic (synthetic pentasaccharide) that selectively binds to antithrombin III (ATIII) that cause an an-
tithrombin III-mediated selective inhibition of Factor Xa → potentiating neutralization of Factor Xa → disrupts blood coag-
ulation cascade, which inhibits thrombin formation and thrombus development

INDICATION Prevention of Venous Treatment of unstable angina or non-ST segment Treatment of ST segment elevation my-
Thromboembolic Events (VTE) elevation myocardial infarction (UA/NSTEMI) ocardial infarction (STEMI)

DOSE 2.5mg once daily (SC) 2.5mg once daily (SC) 2.5mg once daily (IV of first dose then SC
for next)

DURATION 6-14 days (bed rest at least 4 days) Up to 8 days or until hospital discharge Up to 8 days or until hospital discharge

INDCATION OF FONDAPARINUX Treatment of unstable angina or non-ST segment Treatment of ST segment elevation myocardial
infarction (STEMI)
IN HOSPITAL PONTIAN elevation myocardial infarction (UA/NSTEMI) 2.5mg once daily (SC)

DOSE 2.5mg once daily (SC) Supplied FOR 3 days

DURATION Supplied FOR 3 days

HOW TO USE?? ② ② Plunger ③ Finger-grip ④ Security sleeve

① ① Needle
shield

Remove needle Pull it in straight line away REMINDER!!! ⑥
shield by twisting it
from the syringe’s body ⑤ DO NOT expel the air
③ bubble from the syringe
④ before injection!

Inject ALL the content by Release the plunger

Gently pinch cleaned Hold syringe firmly pressing down the plunger
skin to make fold by the finger grip as far as it goes

CONTRAINDICATION CATEGORY
Pregnancy : B (FDA) ; C (AUS)
 Known hypersensitivity to fondaparinux or any
of the excipient Prescriber : A*

 Active clinically significant bleeding

 Active bacterial endocarditis

 Severe renal impairment (creatinine clearance
<30mL/min)

PRECAUTION

 MUST NOT ADMINISTERED
INTRAMUSCULARLY!!!

 Bleeding
 Spinal/epidural anaesthesia/spinal puncture
 Elderly patients
 Low body weight patients
 Renal / Hepatic impairment
 Thrombocytopenia
 PCI and risk of guiding catheter thrombus

References: Arixtra Fondaparinux Sodium product leaflet
MOH Medicines Formulary 2014
Lexicomp Drug Information Handbook 23rd Edition Fondaparinux Form used in Hospital Pontian 5

LIST OF EMERGENCY DRUGS IN HOSPITAL PONTIAN

(UPDATED 24 JAN 2017)

Antidote/Antitoxin Category Indication Stock Availability
Activated Charcoal A GI Decontamination Available in Pharmacy

50g Granules B Bite by snakes causing 1 vials
(Available in Pharmacy)
Antivenom hematotoxicity
Hemato Polyvalent* 2 vials
(Malayan pit viper, White-lipped (Floor Sock A&E)

green pit viper and Siamese
Russell’s viper)

Bite by snakes causing 3 vials

Antivenom B neurotoxicity (Available in Pharmacy)
Neuro Polyvalent*
(Cobra, Banded Krait, Malayan 2 vials
Antivenom
Sea Snake* Krait) (Floor Sock A&E)

1 vials

B Sea snake bite (Available in Pharmacy)
1 vials

(Floor Sock A&E)

Atropine Sulphate B Organophosphate poisoning Emergency Trolley
1mg/ml Injection (insecticide poisoning)

Calcium Gluconate 10% B Hydrofluoric acid poisoning Emergency Trolley
Injection (10ml /amp)

Desferrioxamine B A Chronic iron toxicity or overload Available in Pharmacy
Methanesulphonate

0.5g Injection

Diazepam 5mg/ml Injection B Organophosphate poisoning Dangerous Drug
(insecticide poisoning) /Psychotropic Cabinet
Ethyl Alcohol 96% v/v BP
Undenatured (for internal - Treatment of methanol or ethylene Available in Pharmacy
glycol poisoning
and external use)
B Benzodiazepine poisoning Emergency Trolley
Flumazenil 0.5mg/5ml
Injection

Glucagon (Lyophilised) B Calcium channel blocker poisoning Available in Pharmacy
1mg/ml Injection Beta blocker poisoning

*Quantity of drugs available for STAT dose only. Kindly refer patient to nearest specialist
hospital if further treatment is required.

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Antidote/Antitoxin Category Indication Stock Available

Leucovorin Calcium Methotrexate overdose, methanol
(Calcium Folinate) A poisoning and trimethoprim Available in Pharmacy

50mg Injection toxicity

N-Acetylcysteine 200mg/ml A* Paracetamol poisoning Available in Pharmacy
Injection (NAC) B
(2g/amp) B Opioid poisoning (pead) Emergency Trolley
B Opioid poisoning (Ward Pead only)
Naloxone HCl 0.02mg/ml
Injection Emergency Trolley

Naloxone HCl 0.4mg/ml Reversal of non-depolarising Available in Pharmacy
Injection neuromuscular blockade

Neostigmine
Methylsulphate 2.5mg/ml

Injection

Octreotide 0.05mg/ml A Sulphonylurea poisoning Available in Pharmacy
Injection

Pralidoxime Chloride B Organophosphate poisoning Available in Pharmacy
25mg/ml (insecticide poisoning)

(500mg/amp)

Protamine Sulphate B Heparin overdose Available in Pharmacy
10mg/ml Injection

Acceleration of excretion in drug

Sodium Bicarbonate 8.4% intoxication

(1mmol/ml) Injection B (where excretion of the drug into Emergency Trolley

(10ml/amp) the urine is accelerated by

elevated urine pH)

Vitamin K1 10mg/ml B Overdose of anticoagulants Floor Stock
Injection (warfarin)

References
• Micromedex Solutions
• IPCSPesticide_ok.pdf (Sound Management of Pesticides and Diagnosis and Treatment of Pesticide Poisoning, WHO, 2006)
• Retrieved from https://www.atsdr.cdc.gov/mhmi/mmg11.pdf [Hydrogen Fluoride (HF), CAS 7664-39-3; UN 1052 (anhydrous), UN 1790

(solution)]
• Retrieved from www.pharmacy.gov.my/intranet on Dec 26, 2016
• Retrieved from http://reference.medscape.com/drug/alcohol-ethyl-ethanol-343730 on Dec 26, 2016
• Retrieved from http://www.globalrph.com/glucagon_dilution.htmon Dec 26, 2016
• Retrieved from http://www.snake-antivenin.com/hematotoxic-polyvalent-snake-antivenom-asian-snakes-malayan-pit-viper-green-pit-viper-

russell-viper.html on Dec 24, 2016
• Retrieved from http://www.snake-antivenin.com/neurotoxic-polyvalent-snake-antivenom-cobra-king-cobra-banded-krait-malayan-krait-

venom.html on Dec 24, 2016
• Sea Snake (antivenom) leaflet
• Retrieved from https://www.cdhb.health.nz/Hospitals-Services/Health-Professionals/Neonatal-Clinical-Resources/Neonatal-Drug-Information-

Sheets/Documents/Sodium%20Bicarbonate.pdf on Jan 5, 2017

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COST-SAVING MEASURES, NEW AND
DELIST MEDICATIONS IN HOSPITAL

PONTIAN

Cost-saving New Medication Medication Delist from
measures in HDP added in HDP HDP Formulary
Formulary
• The use of PPI’s Cap • Syrup Ampicillin
Omperazole is change • Cap Amoxicillin 125mg/5ml
to Tab Pantoprazole 500mg
• Tab Bacampicillin
• The use of Tab • Cap Cloxacillin 500mg 400mg
Calcium Lactate is
change to Tab Calcium • Syrup Paracetamol • Beclomethasone
Carbonate 250mg/5ml Dipropionate
100mcg/dose inhaler
• Calamine lotion is • S/C Fondaparinux
only prescribed to 2.5mg/ml • Tab Terbutaline 2.5mg
patient that has large
affected skin area • Iron (III) hydroxide • Tab Theophylline
while Calamine cream sucrose complex 125mg
is precribed to patient 20mg/ml solution for
with small affected injection • Human Albumin 25%
skin area
• Ketoprofen Patch
• Syrup Ampicillin
125mg/5ml is change
to Syrup Amoxicillin
125mg/5ml

Rujukan: Mesyuarat Jawatankuasa Ubat dan Terapeutik Hospital Pontian Bil 1/2017

8

LOOK-ALIKE DRUG IN HOSPITAL PONTIAN

Drug Name T. Paracetamol 500mg T. Magnesium Trisilicate BP

Drug
Picture

Drug Name Syrup Diphenhydramine Syrup Diphenhydramine
HCl 14mg/5mL (Adult) HCl 7mg/5mL (Paed)
Drug
Picture

Drug Name T. Telmisartan 40mg T. telmisartan 80mg

Drug
Picture

Drug Name T. B Complex T. Folic Acid 5mg

Drug
Picture

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Drug Name T. Calcium Lactate 300mg T. Ferrous Fumarate 200g

Drug
Picture

Drug Name IV Midazolam 5mg/mL IV Midazolam 15mg/3mL

Drug
Picture

Drug Name IV Hydrocortisone 100mg IV Streptomycin 1g

Drug
Picture

Drug Name IV IV Morphine IV IV
Pethidine 10mg/mL Haloperidol Phytomenadi-
Drug 50mg/mL one 1mg/mL
Picture 5mg/mL

10

SOUND-ALIKE DRUG IN HOSPITAL PONTIAN

aMILoride amLODIPine

amLODIPine felodipine

chlorproMAZINE carBAMAZepine

cycloSPORINE cycloSERINE

DOBUTamine DOPamine

hydrALAZINE hydrOXYzine

Madopar Methyldopa

Co-trimoxazole Clotrimazole

carBIMazole Co-trimoxazole

ENALApril PERINDOpril

Glucophage XR Glucovance

gliCLAzide gliBENclamide

LOsartan Valsartan

cloZAPine OLANZapine

Isosorbide Dinitrate Isosorbide Mononitrate

lamiVUDine lamoTRIgine

clonazePAM LORazepam

Aminophylline Amitriptyline

Azithromycin Erythromycin

Acriflavine Acyclovir

ESOMEprazole Omeprazole

Note : 1) List includes drugs available in Hospital Pontian and drugs which are kept for SPUB purposes.
2) List will be updated from time to time when new guideline released by ISMP and/or MOH. List should also be updated when new
drugs available in Hospital Pontian.

References: 1) FDA and ISMP Lists of Look-Alike Drug Names with Recommended Tall Man Letters (updated 2016)
2) GUIDE ON HANDLING LOOK ALIKE, SOUND ALIKE MEDICATIONS First Edition (2012). Pharmaceutical Services Divisyen
MOH Malaysia
3) Medication Safety Newsletter, MOH, (Dis 2015)

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PHARMACY BULETIN

PHARMACY ACTIVITIES

RAMADHAN IFTAR & FAREWELL CEREMONY PF JUSTINE

Date: 13 June 2017
Place: Pharmacy Ward Supply

PHARMACY BOOTH AT HOSPITAL PONTIAN HARI RAYA AIDILFITRI

Date: 25 June 2017
Place: Unit Sajian Hospital Pontian

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“KENALI UBAT ANDA” TALK AND EXHIBITION AT SCHOOL

Date: 21 Sept 2017
Place: Sek.Men. Keb. Benut

KUA TALK BY PF YONG

“KENALI UBAT ANDA” EXHIBITION AT COMMUNITY

Date: 29 Sept 2017
Place: Surau Taman Sri Aman Pontian

13

JOHOR PHARMACY NETBALL TOURNAMENT Date: 30 Sept 2017
Place: SJKC Tah Tong Pontian

Date: 12 Oct & 9 Nov 2017 FAREWELL PARTY
Place: Pharmacy Ward Supply

FAREWELL PARTY PPK EN. MUSTAPHA

FAREWELL PARTY PF TEEPA

HOME MEDICATION REVIEW (KUA)

Date: 10 Nov 2017
Place: Patient's Home (Parit Semerah)

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ANTIBIOTIC AWARENESS WEEK

ANTIBIOTIC AWARENESS TALK TO HOSPITAL
PONTIAN STAFFS AT DEWAN SRI TANJUNG

SIGNING OF ANTIBIOTIC PLEDGE BY DR. ZAINAL
(PENGARAH HOSPITAL PONTIAN)

ANTIBIOTIC AWARENESS AND “KENALI UBAT
ANDA” EXHIBITION

SIGNING OF ANTIBIOTIC PLEDGE BY PHARMACISTS AND
PHARMACIST’S ASSISTANTS

MEDICATION SAFETY TALK SIGNING OF ANTIBIOTIC PLEDGE BY MEDICAL OFFICERS, MATRONS,
AT DEWAN SRI TANJUNG SISTERS AND SENIOR MEDICAL ASSISTANTS

15

FAREWELL TO PF JUSTINE AND PF TEEPA

THANK YOU FOR YOUR SERVICE
PN SALMAH AND EN MUSTAFA

16

WELCOMING NEW STAFFS

Muhammad Hakim Aedy Zulhelmi
PF UF41 PF UF41

Ng Wan Ling Fadhilah
PF UF41 PRP UF41

Nurul Awatif Fatini Hairulnisah
PRP UF41 PRP UF41

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