Heparin belongs to the class of medications called anticoagulants. In general, it works by decreasing the clotting ability of the blood1 . Unfractionated heparin (UFH) has been a significant lifesaver in which it has many advantages to offer; include rapid onset of action, the ability to inhibit multiple coagulant proteins, ease of monitoring and better reversibility profile as compared to the newer anticoagulants whether oral or parenteral2 . Such advantages are expected to keep UFH and its derivatives, the lowmolecular-weight heparins (LMWHs), at the therapeutic forefront for a number of indications such as prophylaxis or treatment of deep vein thrombosis (DVT), treatment of acute pulmonary embolism (PE) and in cases where alternative therapies are currently lacking (cardiac surgery), unsuitable (mechanical valves), or untested (cancer associated thrombosis and antiphospholipid antibody syndrome)2 . Heparin-induced thrombocytopenia (HIT) is considered the most common form of drug-induced thrombocytopenia as well as one of the pronounced causes of thrombocytopenia in hospitalized patients. Next to bleeding, HIT is the most significant nonhemorrhagic adverse effect associated with heparin therapy2,3 . Two clinical forms of HIT are generally recognized. Type I (heparin-associated thrombocytopenia) occurs in up to 30% of patients receiving heparin. It is a non–immune-mediated reaction often presenting early to exposure (within one to two days) with an asymptomatic, mild-tomoderate transient decline in the platelet count (rarely below 100,000/mcL) with few complications. Resolution is often spontaneous without discontinuation of therapy. On the other hand, Type II (heparin-induced thrombocytopenia) is the more severe immune-mediated reaction3 . LMWH has been studied in many to have lower incidence of HIT as compared to UFH 4,5 . The cause of HIT is unknown. It is hypothesised that sensitisation of the antiheparin/platelet factor 4 antibody leads to production of procoagulant platelet-derived microparticles and thrombin generation, with the potential for development of the clinical manifestations that are characteristic of HIT— thrombocytopenia and venous or arterial thrombosis6 . The diagnosis of HIT is based on both clinical and serological findings. HIT antibody seroconversion, along with thrombocytopenia or other clinical manifestations, such as skin lesions at heparin injections sites or acute systemic reactions (fever, chills, cardiorespiratory distress) after intravenous (IV) bolus administration, are necessary to confirm a positive diagnosis of HIT6 . References: 1. https://medlineplus.gov/druginfo/meds/a682826.html. 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. 1/2018 Edition AS-S A Y D A L I AH We RXpert Clinically, HIT should be first suspected when a patient is4 :- a) receiving heparin, typically for 5 to 14 days; b) experiencing an unexplained drop in the platelet count, usually a decline of 50% or more from baseline; c) having a marked thrombocytopenia with a single administration of heparin. To ease the diagnosis of HIT, a scoring system has been developed; the Pretest Probability of HIT (The Four T’s Table)6 . In view of treatment, strongly suspected (or confirmed) HIT (wit or without thrombosis) is recommend to discontinue all heparin (UFH or LMWH) and administer a nonheparin anticoagulant such as Lepirudin, Argatroban, Bivalirudin or Fondaparinux. HIT can occur early or late and should be considered in any patient with recent exposure to any type of heparin (UFH or LMWH) and with significant reductions in platelet counts or thrombosis. Without appropriate treatment, 10% to 20% of patients face losing a limb, and 20% to 30% die as a result of the devastating thrombotic complications. Other complications include DVT, PE, myocardial infarction, cerebrovascular accidents, skin necrosis, and end-organ damage6 . Hence, early identification in order to provide proper management has continued to become challenges in clinical setting. References (Cont): 4.Lori-Ann Linkins. Heparin induced thrombocytopenia. BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.g7566 5. Junqueira DR1, Perini E, Penholati RR, Carvalho MG. Unfractionated heparin versus low molecular weight heparin for avoiding heparin-induced thrombocytopenia in postoperative patients. Cochrane Database Syst Rev. 2012 Sep 12;(9):CD007557. doi: 10.1002/14651858.CD007557.pub2. 6. Lori-Ann Linkins. Heparin induced thrombocytopenia. BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.g7566 HEPARIN-INDUCED THROMBOCYTOPENIA الصيدليه A Bulletin of Pharmacy Department, IIUM Medical Center. By: Nor Ilyani Mohamed Nazar RPh., Ph.D. Figure 1: Pathogenesis of heparin-induced thrombocytopenia.3 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.
A prescription is a legal instruction from a prescriber to a dispenser. Every country 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 entitled to write it. In Malaysia, every prescription is regulated under Poison Act 1952 Section 21(2). All prescriptions which arrive to the pharmacy will undergo screening and validating process. A good prescription should have the following information:- It is strongly recommended to use the generic (nonproprietary) name to facilitates understanding on specific medication information. The dose of the drug indicates how many milligrams each tablet, suppository, or milliliter of fluid needed for an individual patient. Internationally recognized abbreviations should be used (g for gram or ml for millilitre). In order to avoid any misunderstanding, the name of the drugs 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 under 12 years of age, the body weight must also clearly be stated. In manual prescription, a poor handwriting can easily lead to errors. Hence, it is a legal duty of the prescriber to uphold the principles of safe prescribing such as to write legibly in order to prevent any error during prescription writing and further increase the risk of medication errors delivered to the patients. PHARMACY DEPARTMENT Assalamualaikum w.b.t., A hearty congratulations to the committee members of As - Saydaliah bulletin. I would like to take this opportunity to express my heartfelt thanks to all pharmacy staff and IIUMMC in general for a great team work. 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 educate and share knowledge to patients and other healthcare providers. 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 pharmaceutical care. Once again, I would like to congratulate and thank everyone who has contributed and involved in making this bulletin a success. A Word From Chief Editor Mon - Sun : 7am - 11pm. Minimal strength: 1 - 2pm and 5 - 11pm Friday break : 12.15 - 2.45pm Contact No : 09-59102591 Operation Hour INPATIENT PHARMACY: OUTPATIENT PHARMACY: Mon - Thu : 8am - 5.30pm Fri : 8am - 1pm then 2.45 - 5.30pm Minimal strength : 1 - 2pm and 5pm onwards on weekdays and Friday 12.15 - 1pm. Contact No : 09 - 5912577 PRODUCTION (TPN & CDR): Mon - Fri : 8am - 5pm . Closed on weekends. Contact No : 09-59102544 EMERGENCY PHARMACY: Mon - Sun : 11pm - 7am Contact No : 09-5911233 MEDICAL STORE: Mon - Thu : 8am - 5pm Friday : 8am - 12.15pm then 2.45 - 5pm Contact No : 09-5912648 COLUMNIST: EDITOR: Mdm Che Rokiah bt Ismail CHIEF EDITOR: Asst. Prof. Dr. Norny Syafinaz Ab Rahman Asst. Prof. Dr. Nor Ilyani Mohamed Nazar ADVISORS: As - Saydaliah Edition 1/2018 EDITORIAL BOARD Ms. Fatin Azzyati bt Pakururazi Ms. Habibah Kamaruzaman Ms. Nurul Hazimah Abdul Aziz Ms.Nur Munirah Zainol Abidin Mr. Zulfikri Abdul Hamid Ms. Mery Hu Wei Ying Dr. Nor Ilyani Mohamed Nazar SATELLITE PHARMACY: Mon - Thu : 10am - 4pm. Break : 1 - 2pm. Friday : 10am - 12.15pm then 2.45 - 4pm. Contact No : 09-5911047 By: Habibah Kamaruzaman Pharmacist, RPh. 13493 DRUG ACT: WHAT IS A GOOD PRESCRIPTION? Patient Details Prescription Details 1.Name 2.Address & contact number (if manually written without tracking system) 3.Identification Number (I.C.,Registration No.) 1.Drug regimen (name of preparation, drug, dose, frequency, administration and duration). 2.Prescriber’s signature and stamp 3.Prescriber’s name and address 4.Date of prescribing Che Rokiah Binti Ismail, RPh. 1930 Chief Pharmacist. الصيدليه Compiled by: Mery Hu Wei Ying Pharmacist, RPh. 12610
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 properties. Generally, medications that should not be crushed/cut fall into one of these categories: MEDICATION EDUCATION Do and Don’ts in Tablet Administration Type of Oral Medication Example Sustained- release / Control-release tablet Suffixes: CC, CD, CR, ER, Retard, SR, XL, XR Oxycodone MR 10mg Tab. Tamsulosin 4mg Tab. Doxasozin XL 4mg Tab. Enteric-coated tablet Pantoprazole Tab. Omeprazole Tab. Combination tablet of 2 or more active ingredient Irbesartan/Hydrochlorothiazide Tab. Amlodipine/Valsartan/Hydrochlorothiazed Tab. Reminder: Some tablet which has scored can be divided into halves to ease administration but not necessarily can be crushed. Do ask your Pharmacist yah! MEDICATION HIGHLIGHTS ENOXAPARIN: A PORCINE-BASED ANTICOAGULANT FROM AN ISLAMIC PERSPECTIVE Enoxaparin (trade name: Clexane) is a low molecular weight heparin (LMWH) that does not need an activated partial thromboplastin time (aPPT) monitoring and able to deliver predictable therapeutic effect. According to Merli and Groce (2010), FDA has approved Enoxaparin injection for vein thromboembolism (VTE) prophylaxis, treatments of deep vein thrombosis (DVT) and acute coronary syndromes (ACS). Undoubtedly, Enoxaparin has a potential and many advantages as an anticoagulant agent. However, the former is a porcine-based drug which derived from swine’s intestine. In Islam, the questions of permissible (halal) and forbidden (haram) constitute as one of the core principles and philosophy of Islamic Law. Due to this, it is not surprising that majority of the academic discourse on halal and haram concentrates on foods and beverages. Nevertheless, the issue has been recently extrapolated to medicinal/ pharmaceutical products as well and attracts serious attention among patients, practitioners and scholars. Muslims are expected to keep their bodies healthy physically and mentally in order to perform their obligations toward Allah SWT. When inflicted with a disease or illness, they are required to seek for treatment and its cure. Referring to one of the hadiths, the Prophet Muhammad SAW has urged his followers : “Ask Allah for forgiveness and health, for after being granted certainty, one is given nothing better than health”. (Related in Tirmidhi) Thus, the use of medicine for curing illnesses and diseases is generally legalized and recognized in Islam. Allah SWT has mentioned in the Quran : “Allah has only forbidden you dead meat and blood and the flesh of swine and that on which any other name has been invoked besides that of Allah…but if one is forced by necessity, without wilful disobedience nor transgressing due limits, then is he guiltless. For Allah is Oftforgiving, Most Merciful” (Al-Baqarah: 173). These generally ascribed principles assert that these substances such as intoxicants (al-khamr), swine and impure things could not be consumed at all costs, yet there are certain situations that heed the need of using substances such as in the case of emergency or out of the extreme necessity for survival (darurah). In explaining this, the jurists have roused debates and discussions concerning the meaning of the term and its application in real life situations. On top of that, Enoxaparin injection comes in prefilled syringe of several different doses i.e. 20mg, 40mg and 60mg which is administered by subcutaneous injection. Due to this simplicity of administration, it has an advantage to reduce hospital stay of patients who are indicated for Enoxaparin injection. Patients could opt to have their injection at home as outpatient basis provided that they have been counselled for injection technique by the pharmacist prior to discharge. Thus, in order to be in-line with the concept of shariah-compliance hospital; the Pharmacy Department is in the process of implementation of written informed- consent in the case of non-halal pharmaceuticals use in this hospital. This is very much consistent with the mission and vision of IIUMMC to be a leading centre of excellence and innovation for healthcare education, training and research. The implementation shall also serves as a written document of consent to reduce risk of medico legal cases as well as a medium of education to patient and advocates the right to refuse a treatment by a patient (except in emergency situations). By: Zulfikri Abdul Hamid Pharmacist, RPh. 13491 As - Saydaliah Edition 1/2018 الصيدليهBy: Nur Munirah Zainol Abidin Pharmacist, RPh. 13501
As - Saydaliah Edition 1/2018 الصيدليه Compiled by: Nurul Hazimah Abdul Aziz Pharmacist, RPh. 13504