tag:blogger.com,1999:blog-86001059663530987512024-03-29T21:42:45.149+08:00Rx NoteAncora Imparo - I'm still learning!Soon Senghttp://www.blogger.com/profile/12198523062740513134noreply@blogger.comBlogger565125tag:blogger.com,1999:blog-8600105966353098751.post-61165745745729406612024-03-29T21:38:00.001+08:002024-03-29T21:42:13.108+08:00Licensing Officer and Drug Enforcement Officer<h2>Introduction</h2><p></p><p><a href="https://pharmacy.moh.gov.my/en/documents/amendment-acts-enforced-pharmaceutical-services-division-ministry-health-malaysia.html">Poisons (Amendment) Act 2022</a> is officially commenced on 1 January 2023, except section 21.</p><p></p><ul><li>The maximum fine for general penalties should not exceeding RM50000 or by imprisonment for a term not exceeding 5 years or both.</li></ul><p></p><div><p><br /></p><p><br /></p><h2>Licensing Officer</h2><p>"Licensing Officer" means a person appointed to be a Licensing Officer under section 26 of <a href="https://mypharmacistnote.blogspot.com/2020/10/poisons-act-1952.html">Poisons Act 1952</a> and includes the Director General of Health.</p><p><b>Section 26</b> Issue or cancel previously issued licenses.</p><p></p><ul><li><b>Type A - Pharmacist's Poisons License</b></li><ul><li>To import, store and deal generally by wholesale and retail or by wholesale only or by retail only, subject to Poisons Act 1952</li></ul><li><b>Type B - Wholesaler's Poisons License</b></li><ul><li>Issued to any person whom the Licensing Officer may consider to be a fit and proper person to hold such licence, or issued to a responsible officer of a company incorporated under the Companies Act 1965 [Act 125] to import, store and sell by wholesale such poisons (excluding Group A Poisons).</li></ul><li><b>Type D - Retailer's License for Part II Poisons</b></li><ul><li>Issued to any person whom the Licensing Officer may consider to be a fit and proper person to hold such licence, to store and sell by retail such Part II Poisons as may be specified.</li></ul><li><b>Type E - Sodium Hydroxide</b></li><ul><li>Issued to any person who in the course of his business uses Sodium Hydroxide in such substantial quantity that the Licensing Officer deems it appropriate to issue to him a licence to import, store and use Sodium Hydroxide.</li></ul></ul><p><b>Section 27 Register of Licences: </b>Every licence issued shall be numbered consecutively in respect of each type and of the year in which it was issued, commencing each year with the number one.</p><p></p><ul><li>In the event of the cancellation of any license, the date of such cancellation shall be noted in the register.</li></ul><p></p><p></p><p><b>Section 31</b> Authorize in writing any registered pharmacist in the public service to exercise the powers of a drug enforcement officer.</p><p></p><p><b>NOTE:</b> To identify if a poison is Part I or Part II, please refer <a href="https://pharmacy.moh.gov.my/en/documents/poisons-act-1952-and-regulations.html">First Schedule of the Poison List</a>. Also, <a href="https://mypharmacistnote.blogspot.com/2020/10/poisons-act-1952.html">Group A, Group B, Group C and Group D poisons</a> are under Part I.</p><p><br /></p><p><br /></p><h2>Drug Enforcement Officer</h2><p>"Drug Enforcement Officer" means any registered pharmacist in the public service duly authorized in writing by the Licensing Officer under <a href="https://mypharmacistnote.blogspot.com/2020/10/poisons-act-1952.html">Poisons Act 1952</a> subsection 31(1).</p><p></p><ul><li><b>Section 31A </b>Powers of enforcement, inspection and investigation</li><li><b>Section 31B</b> Search and seizure</li><li><b>Section 31C</b> Power to access premises and land</li><li><b>Section 31D</b> Power to require information and documents</li><li><b>Section 31E</b> Access to recorded information, computerized data, etc.</li><li><b>Section 31F</b> No cost or damages arising from entry, search or seizure to be recoverable</li></ul><p></p><p><b>Section 32A </b>With the written consent of the Public Prosecutor, compound any offence committed by any person under <a href="https://mypharmacistnote.blogspot.com/2020/10/poisons-act-1952.html">Poisons Act 1952</a> and its regulations.</p><p><br /></p><p><br /></p><h2>External Links</h2><ul><li><a href="https://codeblue.galencentre.org/2022/07/21/parliament-passes-poisons-amendment-bill-after-three-year-delay/">Parliament Passes Poisons Amendment Bill After Three-Year Delay, 2022</a><br /></li><li><a href="https://pharmacy.moh.gov.my/en/documents/poisons-act-1952-and-regulations.html">Poisons Act 1952 and Regulations</a></li><li><a href="https://pharmacy.moh.gov.my/en/content/pharmacy-enforcement-division.html">Pharmacy Enforcement Division</a><br /></li></ul></div>Soon Senghttp://www.blogger.com/profile/12198523062740513134noreply@blogger.com0tag:blogger.com,1999:blog-8600105966353098751.post-66975347248348469852024-03-28T16:41:00.001+08:002024-03-28T16:41:52.021+08:00Dangerous Drugs Act 1952 and Regulations<h2>Introduction</h2><p>Apart from <a href="https://mypharmacistnote.blogspot.com/2020/10/poisons-act-1952.html">Poisons Act 1952 and Regulations</a>, we should also have a fair understanding on <a href="https://pharmacy.moh.gov.my/en/documents/dangerous-drugs-act-1952-and-regulations.html">Dangerous Drugs Act 1952 and Regulations</a> to be well prepared for <a href="https://mypharmacistnote.blogspot.com/2020/12/qualifying-examination-to-practice.html">Qualifying Examination to Practice Pharmacy</a>.</p><p>Today, we are going to have a refresh on legislation requirements in dispensing Dangerous Drugs:</p><p></p><p></p><ul><li>Dangerous Drugs</li><li>Restriction of Application of Regulations</li><li>Possession</li><li>Control of Import and Export</li><li>Storage</li><li>Prescription</li><li>Keeping of Records</li></ul><p></p><p><br /></p><p><br /></p><h2><b>Dangerous Drugs</b></h2><p>Dangerous Drugs means any drug or substance which is for the time being comprised in the <a href="https://pharmacy.moh.gov.my/en/documents/dangerous-drugs-act-1952-and-regulations.html">First Schedule</a>. Some examples are:</p><div><ul><li>Cannabis</li><li>Amphetamine</li><li>Cocaine*</li><li>Codeine*</li><li>Dihydromorphine</li><li>Diphenoxylate*</li><li>Fentanyl</li><li>Heroin</li><li>Hydrocodone</li><li>Hydromorphone</li><li>Ketamine</li><li>Methadone</li><li>Morphine</li><li>Oxycodone</li><li>Oxymorphone</li><li>Pethidine</li><li>Pholcodine*</li><li>Piminodine</li><li>Remifentanil</li></ul><p>* All products registered under the Control of Drugs and Cosmetics Regulations 1984 will be a <a href="https://mypharmacistnote.blogspot.com/2020/10/poisons-act-1952.html">Group C Poison under Poisons Act 1952</a>.</p><p><br /></p><p><br /></p><h2><b>Restriction of Application of Regulations</b></h2><p><b>Regulation 25</b> - Nothing in these Regulations, except Paragraph (8) of <b>Regulation 15</b> and <b>Regulation 16 </b>of these Regulations, shall apply to a product containing any drug specified in the <a href="https://pharmacy.moh.gov.my/en/documents/dangerous-drugs-act-1952-and-regulations.html">Third Schedule</a>.</p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiYl2585SypuKPKkJHMleRrCBR8_NMhMmuxFoEAkM43NvUHNPML2-1q1cUSa9irMe4bMtkc5npj8bnojc2s8icjwxOEawg_SXiI8Lhl71qwX64ZErtdd86olWVptrOMYVohjeXvR0M72yc/s615/Capture.PNG" style="margin-left: 1em; margin-right: 1em;"><img alt="Third Schedule of Dangerous Drugs Act 1952" border="0" data-original-height="548" data-original-width="615" height="285" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiYl2585SypuKPKkJHMleRrCBR8_NMhMmuxFoEAkM43NvUHNPML2-1q1cUSa9irMe4bMtkc5npj8bnojc2s8icjwxOEawg_SXiI8Lhl71qwX64ZErtdd86olWVptrOMYVohjeXvR0M72yc/w320-h285/Capture.PNG" title="Third Schedule of Dangerous Drugs Act 1952" width="320" /></a></div><div><b>NOTE:</b> </div><div><ul><li>The products in no. 1 of the <a href="https://pharmacy.moh.gov.my/en/documents/dangerous-drugs-act-1952-and-regulations.html">Third Schedule</a> will be regulated as dispensed medicines under <a href="https://mypharmacistnote.blogspot.com/2020/10/poisons-act-1952.html">Poisons Act 1952 and Regulations</a>.</li><li>The products in no. 2 of the <a href="https://pharmacy.moh.gov.my/en/documents/dangerous-drugs-act-1952-and-regulations.html">Third Schedule</a> will be regulated under <a href="https://mypharmacistnote.blogspot.com/2020/11/poisons-psychotropic-substances.html">Poisons (Psychotropic Substance) Regulations 1989</a>.</li><li>Hence, morphine powder is regulated under Dangerous Drugs Act 1952 and Regulations, but morphine sulphate 10 mg tablet is regulated under <a href="https://mypharmacistnote.blogspot.com/2020/11/poisons-psychotropic-substances.html">Poisons (Psychotropic Substances) Regulations 1989</a>.</li></ul></div><p><br /></p><p><br /></p></div><h2><b>Possession</b></h2><p>Under <b>Regulation 6</b>, a person shall not be in possession of a drug or preparation unless it is <b>lawfully supplied</b> by a registered medical practitioner/veterinary surgeon or on a prescription.</p><p>Under <b>Regulation 7</b>, the supplier (either a qualified medical practitioner or licensed pharmacist), <b>shall not deliver it to a person who purports to be sent by or on behalf of the recipient, unless</b> that person either:</p><div><ul><li>Is a person authorized under these Regulations to be possession of that drug or preparation; or</li><li>Produces to the supplier a statement in writing signed by the recipient to the effect that he is authorized by the recipient to receive the drug or preparation in question on behalf of the recipient and the supplier is reasonably satisfied that the document is a genuine document.</li></ul><p><br /></p><p><br /></p></div><h2><b>Control of Import and Export</b></h2><p>Under <b>Section 4 and Section 5</b>, no person shall import to Malaysia or export from Malaysia any raw opium, coca leaves, poppy-straw or cannabis except under and in accordance with the authorization of the Minister.</p><p>Refer <b>Section 19 and Section 20</b> for export and import of dangerous drug respectively</p><p></p><ul><li>“Export authorization” means an authorization issued by a competent authority in a country from which a dangerous drug is exported;</li><li>“Import authorization” means a licence, issued by a competent authority in a country into which it is intended to import dangerous drugs.</li></ul><p></p><div><br /></div><p><br /></p><h2><b>Storage</b></h2><p>As stated in <b>Regulation 9(2)</b> of <a href="https://pharmacy.moh.gov.my/en/documents/dangerous-drugs-act-1952-and-regulations.html">Dangerous Drugs Regulations 1952</a>, every drug or preparation shall be kept in a locked receptacle which can only be opened by authorized registered pharmacist or some assistant of his being a registered pharmacist.</p><p><br /></p><p><br /></p><h2><b>Prescription</b></h2><div>As stated in <b>Regulation 11 </b>of <a href="https://pharmacy.moh.gov.my/en/documents/dangerous-drugs-act-1952-and-regulations.html">Dangerous Drugs Regulations 1952</a>, the prescription to supply Dangerous Drug must:</div><div><ul><li>be in writing and signed by the registered medical practitioner/dentist/veterinary surgeon giving it with his usual signature and dated by him;</li><li>specify the address of the registered medical practitioner/dentist/veterinary surgeon giving it</li><li>specify the name and address of the person for whose treatment it is given or, if it is given by a veterinary surgeon, of the person to whom the article prescribed is to be delivered;</li><li>have written thereon, if given by a dentist, the words "for local dental treatment only", and if given by a veterinary surgeon, the words "for animal treatment only"; and</li><li>specify, if prescribes a preparation containing or compounded of preparations all of which are contained in the British Pharmacopoeia or the British Pharmaceutical Codex, the total amount of the preparation or of the each preparation, as the case may be, and in any other case the total amount of the drug to be supplied.</li></ul><p><b>Regulation 12 </b>states that the person dispensing a prescription shall, at the time of dispensing it,</p></div><div><ul><li>Mark thereon the date on which it is dispensed and in the case of a prescription which may be dispensed a second or <b>third time</b>, the date of each occasion on which it is dispensed, and</li><li><b>Shall retain it and keep it on the premises where it is dispensed</b> and so as to be all times available for inspection.</li></ul><div><br /></div></div><div><br /></div><h2><b>Keeping of Records</b></h2><div>Under <b>Regulation 15</b>, every person authorized to supply drugs or preparations shall comply with the following provisions:</div><div><ul><li>A Register in the form that set out in the <a href="https://pharmacy.moh.gov.my/en/documents/dangerous-drugs-act-1952-and-regulations.html">Second Schedule</a>, in the <b>national language or in English</b></li><li>A <b>separate Register </b>or a separate part of the Register with respect to each of the drugs</li><li>The required entry must be made <b>on the day in which the drug or preparation is received by or supplied by him, </b>or, if that is not reasonably practicable, on the day next following the said day</li><li><b>No cancellation, obliteration </b>shall be made of an entry in the Register and any correction of an entry must be made by way of a marginal note or a footnote which must be specify the date on which the correction is made</li></ul><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjOre42vBfMk4us1MarxeD7VMZbZ724FLfKjkxoiVOuTZBug0kmUnzCk8m7cqt-BTd0qJqjP7AARTx8uyucllnZRuhunnZwfyZ23s5s3E2MWVOKkEevyUR3FI2pV1RqOIULYmFhA2DF6eA/s598/Capture+2.PNG" style="margin-left: 1em; margin-right: 1em;"><img alt="Form of Register" border="0" data-original-height="598" data-original-width="495" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjOre42vBfMk4us1MarxeD7VMZbZ724FLfKjkxoiVOuTZBug0kmUnzCk8m7cqt-BTd0qJqjP7AARTx8uyucllnZRuhunnZwfyZ23s5s3E2MWVOKkEevyUR3FI2pV1RqOIULYmFhA2DF6eA/w265-h320/Capture+2.PNG" title="Form of Register" width="265" /></a></div><p>For the purpose of this Regulation, "a proper reference" means a reference which is entered in the Register under the same date as that on which the <b>entry in the day-book or in the Prescription Book</b> was made and is otherwise such as to enable that entry to be easily identified.</p><p>Under <b>Regulation 16</b>, <b>all registers, records, book, prescriptions, signed orders</b> and other documents shall be kept for a period of <b>2 years from the data on which the last entry is made.</b></p><p><br /></p><p><br /></p></div><h2><b>Summary</b></h2><div><a href="https://pharmacy.moh.gov.my/en/documents/dangerous-drugs-act-1952-and-regulations.html">Dangerous Drugs Act 1952 and Regulations</a> also regulates the importation, exportation, manufacture, sale and use of opium and of certain dangerous drugs.</div><p></p>Soon Senghttp://www.blogger.com/profile/12198523062740513134noreply@blogger.com0tag:blogger.com,1999:blog-8600105966353098751.post-73298705267690811352024-03-28T16:41:00.000+08:002024-03-28T16:41:19.131+08:00Poisons (Psychotropic Substances) Regulations 1989<h2>Introduction</h2><p>Today, we are going to have a small discussion on application of <a href="https://pharmacy.moh.gov.my/en/documents/poisons-act-1952-and-regulations.html">Poisons (Psychotropic Substances) Regulations 1989</a> under <a href="https://mypharmacistnote.blogspot.com/2020/10/poisons-act-1952.html">Poisons Act 1952</a> in community or hospital pharmacy setting.</p><p></p><ul><li>Psychotropic Substance</li><li>Posession</li><li>Control of Import and Export</li><li>Prescription</li><li>Register</li><li>Storage</li><li>Disposal</li></ul><p></p><p><br /></p><p><br /></p><p></p><h2><b>Psychotropic Substance</b></h2><p>Psychotropic Substance is anything found in <a href="https://pharmacy.moh.gov.my/en/documents/poisons-act-1952-and-regulations.html">Third Schedule</a> of the <a href="https://mypharmacistnote.blogspot.com/2020/10/poisons-act-1952.html">Poisons Act 1952</a>. Some examples are:</p><p></p><p></p><ul><li>Buprenorphine</li><li>Clobazam</li><li>Clotiazepam</li><li>Diazepam</li><li>Methylphenidate</li><li>Phentermine</li><li>Zolpidem</li><li>Any product which is registered under the <a href="https://mypharmacistnote.blogspot.com/2020/12/sale-of-drugs-act-1952-and-regulations.html">Control of Drugs and Cosmetics Regulations 1984</a> and contains any of the following substances</li><ul><li>Alfentanil</li><li>Dihydrocodeine</li><li>Fentanyl</li><li>Ketamine</li><li>Methadone</li><li>Morphine</li><li>Oxycodone</li><li>Pethidine</li><li>Sulfentanil</li></ul></ul><p></p><p><b>NOTE:</b> Morphine powder is regulated under <a href="https://mypharmacistnote.blogspot.com/2020/11/dangerous-drugs-act-1952-and-regulations.html">Dangerous Drugs Act 1952 and Regulations</a>, but morphine sulphate 10 mg tablet is regulated under Poisons (Psychotropic Substances) Regulations 1989.</p><p><b><br /></b></p><p><b><br /></b></p><p></p><h2><b>Possession</b></h2><p>Under <b>Regulation 3</b>, a person shall not be in possession of a drug or preparation unless it is <b>lawfully supplied</b> by a registered medical practitioner, registered dentist Division I, veterinary surgeon or on a prescription.</p><p></p><ul><li>Also, the following persons or class of persons shall be authorised to be in possession of psychotropic susbtance</li><ul><li>A licensed pharmacist</li><li>A registered medical practitioner</li><li>A registered dentist Division I</li><li>A veterinary surgeon</li><li>The holder of a permit issued under regulation 15</li><li>A person employed in any hospital at which human ailments are treated and for the time being in charge of any ward, operating theatre or of other sections of such hospital who possesses psychotropic substance for use in such ward, operating theatre or sections</li><li>A person concerned with scientific education or research or chemical analysis in a department, university or institution wholly maintained by the Government or approved by the Director General of Health</li><li>A pharmacist in the public service</li><li>An officer of Customs, police officer or an officer of the Postal Department when acting in the course of his duty as such</li><li>A <a href="https://mypharmacistnote.blogspot.com/2023/01/licensing-officer-and-drug-enforcement.html">Drug Enforcement Officer</a></li><li>A person engaged in the delivery of any psychotropic substance from a lawful supplier to a person authorised to have it in his possession, for such period as in the circumstances of the case is reasonably sufficient to enable the delivery to the recipient to be effected</li><li>A person acting on behalf of the class of the persons lawfully supplied with such psycotropic substance (patient)</li><li>A person possessing psychotropic substance for administration to a patient or animal in accordance with the direction of a registered medical practitioner, registered dentist Division I or a veterinary surgeon, as the case may be.</li></ul></ul><p></p><p><br /></p><p><br /></p><h2>Control of Import and Export</h2><p>Under <b>Regulation 4</b>, no person shall import or import any psychotropic unless</p><p></p><ul><li>He has in his possession a valid and subsiting import or export authorisation relating to such psycotrophic substnace; and</li><li>Such import or export is in accordance with the terms and conditions specified in the import or export authorisation.</li></ul><p></p><p>The provision of Regulation 4 shall not apply to</p><p></p><ul><li>Any person arriving in or leaving Malaysia who carries as part of his personal luggage and solely for his personal use or for the use of his family, a prepared or packaged medicine containing any psychotropic substance, not exceeding such quantities as may be reasonably required for one month's use by one person, which has been lawfully supplied to such person by or on the prescription of a qualified medical practitioner; or</li><li>The international carriage by ships, aircrafts or other forms of international public transport entering or leaving Malaysia of such limited quantities of any psychotropic substance as may be required during their journey or voyage for first aid purposes or emergency cases.</li></ul><p></p><p><br /></p><p><b><br /></b></p><h2><b>Prescription</b></h2><p>As stated in <b>Regulation 11(2) </b>of <a href="https://pharmacy.moh.gov.my/en/documents/poisons-act-1952-and-regulations.html">Poisons (Psychotropic Substances) Regulations 1989</a>, every prescription for any psychotropic substance prescribed by a registered medical practitioner, registered dentist Division I or veterinary surgeon shall:</p><p></p><p></p><ul><li>be writing, signed and dated by the prescriber</li><li>state the full name, address and telephone number of the prescriber</li><li>state the age, full name and address of the patient or, in the case of a prescription by a veterinary surgeon, the full name and address of the person to whom such psychotropic substance is to be delivered</li><li>indicate the total amount of psychotropic substance to be supplied and the dose</li><li>specify the number of times (<b>not exceeding 3)</b> the psychotropic substance may be supplied, and if supplied more than once, at what intervals.</li></ul><p>On top of the requirement above, under <b>Regulation 11(3)</b>, <b>no person shall sell or supply</b> any psychotropic substance on a prescription which is presented to him <b>more than 90 days after date of the prescription</b>.</p><p>At the time of selling or supplying the psychotropic substance on a prescription, the licensed pharmacist shall endorse upon the face of the prescription above the signature of the prescriber, his name and address and the date on which such psychotropic substance was sold or supplied.</p><p>Every prescription of the sale or supply of psychotropic substance shall be kept for a period of <b>at least 2 years </b>from the date of sale or supply.</p><p><br /></p><p><br /></p><h2><b>Emergency Supply</b></h2><p>As stated in <b>Regulation 11(6) </b>of <a href="https://pharmacy.moh.gov.my/en/documents/poisons-act-1952-and-regulations.html">Poisons (Psychotropic Substances) Regulations 1989</a>, if it shall appear to the seller or supplier that any psychotropic substance is required urgently in cases of emergency and that it is impossible without unreasonable delay to obtain a prescription complying with the requirements, it shall be lawful for the pharmacist to sell or supply such psychotropic substance without a prescription, after <b>making an entry to that effect in his prescription register for psychotropic substance, upon the verbal or telephoned instructions</b> of a registered medical practitioner, registered dentist Division I or veterinary surgeon, <b>personally known to him.</b></p><p>In every such case, the seller or supplier</p><p></p><ul><li>Shall take all necessary steps to obtain, and the prescriber shall deliver, a <b>prescription as required within one day of the date of such sale or supply;</b></li><li><b>Shall not sell or supply more than one day's supply </b>of such psychotropic substance; and</li><li>Shall take such reasonable steps to ascertain the authenticity of the person who gave the instructions.</li></ul><p></p><p><br /></p><p><br /></p><h2><b>Register</b></h2><p>Records under <a href="https://pharmacy.moh.gov.my/en/documents/poisons-act-1952-and-regulations.html">Poisons (Psychotropic Substances) Regulations 1989</a></p><div><ul><li><b>Regulation 19 - Prescription Register for Psychotropic Substance</b></li><ul><li>The date on which the psychotropic substance was sold or supplied or administered and the serial number of the entry in such register</li><li>The name and strength of the psychotropic substance and the quantity sold or supplied or administered</li><li>The name, identity card number, passport number or any other legal identification document and address of the patient, or where the prescriber is a veterinary surgeon or the prescription relates to animal treatment, the name and address of the recipient</li></ul><li><b>Regulation 20 - Supply Register for Psychotropic Substance</b></li><ul><li>The full name and address of the prospective purchaser or recipient, the date of the sale or supply, the name, strength and quantity of the psychotropic substance sold or supplied and the purposes for which it is stated to be required</li><li>The prospective purchaser or recipient has affixed his signature to the entry or has forwarded to the seller or supplier a written order in respect of such sale or supply signed by such person</li></ul><li><b>Regulation 21 - Production Register for Psychotropic Substance</b></li><ul><li>The date of which the psychotropic substance was used for manufacture and the amount used</li><li>The pharmaceutical dosage form of the psychotropic substance manufactured and the quantity of psychotropic substance found in each unit of the pharmaceutical dosage form</li><li>The theoretical yield of the psychotropic substance in pharmaceutical dosage form manufactured and the batch number assigned to it</li><li>The actual yield of the psychotropic substance in pharmaceutical dosage form manufactured</li><li>The total units of the psychotropic substance in pharmaceutical dosage form sampled for the purpose of quality control</li><li>The total units of the psychotropic substance in pharmaceutical dosage form transferred for the purpose of sale or supply</li></ul><li><b>Regulation 21A - Register of Psychotropic Substance Received, Delivered or Administered</b></li></ul><div>Under <b>Regulation 22</b>, every person </div></div><div><div><ul><li>Shall use a <b>separate register or a separate part of the register</b> with respect to each type of psychotropic substance</li><li>Shall <b>enter in the register</b></li><ul><li>every quantity of psychotropic substance received, delivered or
administered, as the case may be, by him whether for the purpose of sale, supply, administration
or any other purpose,</li><li>the total stock of such psychotropic substance in his possession,</li><li>the name
and address of the supplier or the recipient of such psychotropic substance, and</li><li>the date on
which such psychotropic substance was received, delivered or administered by him or the
reference number of the patient or client such psychotropic substance was administered to</li></ul><li><b>Shall not make any cancellation, obliteration</b> or alteration of an entry in any register, and any correction of an entry must be made by way of a marginal note or a footnote which must specify the date on which the correction is made.</li></ul><div><div>Under <b>Regulation 23</b>, every register required shall be</div><div><ul><li>be in the form of a bound book or in the form which has the written approval of the Licensing Officer subject to the terms and conditions as he may impose</li><li>be preserved for a <b>period of 2 years </b>from the date of the last entry</li></ul></div></div></div></div><div><br /></div><div><br /></div><h2><b>Storage</b></h2><div><p>Any room, cabinet, safe or receptacle used to store any psychotropic substance <b>shall be locked</b> and unlocked by the person authorized to possess such psychotropic substance, and the keys to such room cabinet, cabinet, safe or receptacle shall be kept by him only.</p><p><br /></p><p><br /></p></div><h2><b>Disposal</b></h2><p>No person shall dispose of the psychotropic substance in his possession except in the presence and in accordance with the instructions of a <b>Drug Enforcement Officer.</b></p><p></p><ul><li>The true particulars of the date of disposal and the quantity shall be entered in the register to which it relates and shall be acknowledged by the Drug Enforcement Officer.</li></ul><p></p><p></p>Soon Senghttp://www.blogger.com/profile/12198523062740513134noreply@blogger.com0tag:blogger.com,1999:blog-8600105966353098751.post-86059036120000671582024-03-20T23:23:00.000+08:002024-03-20T23:23:33.426+08:00Lexicomp Drug Information Handbook<h2>Introduction</h2><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhFS63JWmCpRN3Ytoj9aUPPxaiEJ2y1F4h-SmNbjGB4RQ5EgD4hXbTKegUQ7rqsMF5ijiWUz5ryZvc3ZJPrQSoQ2gn2cRlPoAD9j6P7Kk7jNM9v9HCU3thPCjhUumBk2446l66nB0IQtORG-WiJtIGbVtvilsumK-Y-NhizN5F6UAbHmKt0N3rcWtVp/s420/TH_31DIH_300.jpg" style="margin-left: 1em; margin-right: 1em;"><img alt="Lexicomp Drug Information Handbook" border="0" data-original-height="420" data-original-width="300" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhFS63JWmCpRN3Ytoj9aUPPxaiEJ2y1F4h-SmNbjGB4RQ5EgD4hXbTKegUQ7rqsMF5ijiWUz5ryZvc3ZJPrQSoQ2gn2cRlPoAD9j6P7Kk7jNM9v9HCU3thPCjhUumBk2446l66nB0IQtORG-WiJtIGbVtvilsumK-Y-NhizN5F6UAbHmKt0N3rcWtVp/w143-h200/TH_31DIH_300.jpg" title="Lexicomp Drug Information Handbook" width="143" /></a></div><p></p><p>Undoubtedly, <a href="https://www.wolterskluwer.com/en/solutions/lexicomp">Lexicomp Drug Information Handbook</a> is a great reference to have.</p><p></p><ul><li>The 32nd edition has 1444 drug monographs, each offering up to 32 fields of information specific to a particular medication.</li></ul><p></p><p><b>The same drug information content can be found at <a href="https://mypharmacistnote.blogspot.com/2020/10/uptodate-dynamed-and-bmj-best-practice.html">UpToDate</a>, but with missing information</b> in</p><p></p><ul><li>Storage/stability</li><li>Preparation for Administration</li><li>Extemporaneously Prepared</li></ul><p></p><p><br /></p><p><br /></p><div><h2>Mobile Application: UpToDate Lexidrug (formerly Lexicomp)</h2></div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEir5AhD4svCsNYhUu34bs_7AbHbgwS7g8Si8TySBoxTVF3i4uin1B_DVZf4Uc4XX9XLBH4yCZ16fFKQGDVxc4FFvAByw9_nOrsrLdomA-a8aQVHcZyX3JVXLi1qb9Tt3T5ifm056dW477W1E1st0sGFVIMKN_9E-EaONT3XeBLtBkD5TpBXS5NcTpNuZVg/s712/Lexicomp.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img alt="Lexicomp" border="0" data-original-height="318" data-original-width="712" height="143" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEir5AhD4svCsNYhUu34bs_7AbHbgwS7g8Si8TySBoxTVF3i4uin1B_DVZf4Uc4XX9XLBH4yCZ16fFKQGDVxc4FFvAByw9_nOrsrLdomA-a8aQVHcZyX3JVXLi1qb9Tt3T5ifm056dW477W1E1st0sGFVIMKN_9E-EaONT3XeBLtBkD5TpBXS5NcTpNuZVg/w320-h143/Lexicomp.png" title="Lexicomp" width="320" /></a></div><p>In response to the industry's call for unified solutions, Lexicomp is renamed to UpToDate Lexidrug starting March 2024.</p><p></p><ul><li>Its mobile application provides a faster drug information searching and more intuitive <a href="https://mypharmacistnote.blogspot.com/2020/11/drug-interactions.html">drug interaction</a> checker.</li></ul><p></p><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhZUwtIcyDcFmy4JtMZ-_d4mHPTxqAsEIsl9qaVTKxhtFirLlED_0p1wtIx5lRVJjpegd_KoPyM36FPqGJFtTe5l9uh_RdIHQmmX2kqM3jUOwAtOEkFaRRq-wRCqE9VLfwoB8NspH2Mk17Bg-EQ0Ee806JiBaRZdraznoAuI9Kh6uj8otfAaIv1SNZMvu4/s1440/UpToDate%20Lexidrug%20Main.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img alt="UpToDate Lexidrug" border="0" data-original-height="1440" data-original-width="664" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhZUwtIcyDcFmy4JtMZ-_d4mHPTxqAsEIsl9qaVTKxhtFirLlED_0p1wtIx5lRVJjpegd_KoPyM36FPqGJFtTe5l9uh_RdIHQmmX2kqM3jUOwAtOEkFaRRq-wRCqE9VLfwoB8NspH2Mk17Bg-EQ0Ee806JiBaRZdraznoAuI9Kh6uj8otfAaIv1SNZMvu4/w148-h320/UpToDate%20Lexidrug%20Main.png" title="UpToDate Lexidrug" width="148" /></a></div></div></div><p>Handy Tips</p><div><ol><li>When viewing drug monographs, you should use the <b>"JUMP" button on the top right corner</b> for faster navigation.<br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgul7Rq8gapPjYvYCYOa209L4iIi-DGXzp7kGCAmPzVxaGkfaO0YHaCFwOL27h_ko95uQlWS5H2fqsfKUJPIdbKvQBV2tLxLryqPbbcgqFRw8dMfE0kEko9TUC2T18Fv0kmzdjBXpTq8HfzFoMKcolCjfPLnT3a9YMrLbYAwGcjpvZOlBjrKlWvfTS_EuU/s1440/UpToDate%20Lexidrug.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img alt="UpToDate Lexidrug" border="0" data-original-height="1440" data-original-width="664" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgul7Rq8gapPjYvYCYOa209L4iIi-DGXzp7kGCAmPzVxaGkfaO0YHaCFwOL27h_ko95uQlWS5H2fqsfKUJPIdbKvQBV2tLxLryqPbbcgqFRw8dMfE0kEko9TUC2T18Fv0kmzdjBXpTq8HfzFoMKcolCjfPLnT3a9YMrLbYAwGcjpvZOlBjrKlWvfTS_EuU/w148-h320/UpToDate%20Lexidrug.png" title="UpToDate Lexidrug" width="148" /></a></div></li><li>In the <i>Text Size</i> menu under <i>Preferences</i>, you may <b>adjust the text size of drug monograph</b> to have a better overall visual experience.</li><li>In the <i>Settings</i> menu under <i>Preferences</i>, you <b>may opt for auto-updates through WiFi and Data or WiFi only.</b></li></ol></div><p><br /></p><p><br /></p><div><h2>Useful Features</h2><p><b>Extensive brand name search</b></p><p></p><ul><li>Covers international <b><a href="https://mypharmacistnote.blogspot.com/2020/10/brand-name-search.html">brand</a></b> names too.</li></ul><p><b>Extensive dosing information</b></p><p></p><ul><li>Covers dosing in paediatric, older adult and <a href="https://mypharmacistnote.blogspot.com/2021/04/dosing-in-obese.html">obese</a> patients.</li><li>Covers dosing in altered <a href="https://mypharmacistnote.blogspot.com/2023/09/chronic-kidney-disease.html">kidney function</a> and <a href="https://mypharmacistnote.blogspot.com/2022/01/prescribing-in-hepatic-impairment.html">hepatic impairment</a> too.</li></ul><p></p><p><b>Adverse Reactions (Significant): Considerations</b></p><p></p><ul><li>Useful for <a href="https://mypharmacistnote.blogspot.com/2020/10/medication-counselling.html">medication counselling</a>.</li></ul><p></p><p><b>Lexi-Interact covers both <a href="https://mypharmacistnote.blogspot.com/2020/11/drug-interactions.html">drug interaction</a> and <a href="https://mypharmacistnote.blogspot.com/2021/02/drug-allergy.html">drug allergy</a> checker.</b></p><p></p><ul><li>You may still able to add drugs that is not available in United States.</li></ul></div>Soon Senghttp://www.blogger.com/profile/12198523062740513134noreply@blogger.com0tag:blogger.com,1999:blog-8600105966353098751.post-41213978426324641332024-03-09T19:09:00.001+08:002024-03-09T21:19:38.313+08:00Lipid-Lowering Drugs<h2>Introduction</h2><p>Lipids, including cholesterol and triglycerides, are transported in the plasma as lipoproteins, of which there are 4 classes.</p><p></p><ul><li><b>Chylomicrons</b> transport triglycerides and cholesterol from the gastrointestinal tract to the tissues, where triglyceride is split by lipoprotein lipase, releasing free fatty acids and glycerol which are taken up in muscle and adipose tissue. Chylomicron remnants are taken up in the liver, where cholesterol is stored, secreted in bile, oxidised to bile acids or converted into VLDLs.</li><li><b>Very-low-density lipoproteins (VLDLs)</b> transport cholesterol and newly synthesised triglycerides to the tissues, where triglycerides are removed as before, leaving LDLs.</li><li><b>Intermediate-density and low-density lipoprotein (LDL)</b> particles with a large component of cholesterol; some cholesterol is taken up by the tissue and some by the liver, by endocytosis via specific LDL receptors.</li><li><b>High-density lipoprotein (HDL)</b> particles absorb cholesterol derived from cell breakdown in tissues (including arteries) and transfer it to VLDL and LDL particles via cholesterol ester transport protein (CETP).</li></ul><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhx-_8Vre4a0dFV9c8M7uf9hhR6hwwMjnt4nwVbC9PQbHGIQS35L6cQqEuG2Xhx63PRGRMfSLID2ClXh50lEBYZ9IAYnr2ap2bofK2N5C6rxS6II-1vsyS6kPDHhVOybEcFCWV2W2qBaGHtXoMVZKkl7Q2mkRT78enu6Q8G_asCXkDj9MqL2b6vlVgg/s1375/Lipid%20Lowering%20Drugs.png" style="margin-left: 1em; margin-right: 1em;"><img alt="Lipid-Lowering Drugs" border="0" data-original-height="1375" data-original-width="1368" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhx-_8Vre4a0dFV9c8M7uf9hhR6hwwMjnt4nwVbC9PQbHGIQS35L6cQqEuG2Xhx63PRGRMfSLID2ClXh50lEBYZ9IAYnr2ap2bofK2N5C6rxS6II-1vsyS6kPDHhVOybEcFCWV2W2qBaGHtXoMVZKkl7Q2mkRT78enu6Q8G_asCXkDj9MqL2b6vlVgg/w318-h320/Lipid%20Lowering%20Drugs.png" title="Lipid-Lowering Drugs" width="318" /></a></div><p>In addition to dietary measures and correction of other modifiable cardiovascular risk factors, the main agents used clinically to decrease plasma lipoprotein concentrations are</p><p></p><ul><li><a href="https://mypharmacistnote.blogspot.com/2020/12/statins.html">Statins</a></li><li>Fibrates</li><li>Inhibitors of cholesterol absorption</li><li>Nicotinic acid or its derivatives</li><li>PCSK9 inhibitors</li><li>Small interfering RNA (siRNA) PCSK-9 inhibitors</li></ul><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgvydeLHHekXW9yQ9DlFo38htDlN0UOUJVp4H8AnY11MuqZFaGEGth5XWg5-Ugg9jGHvbg4r1HomHbZR810q2ZODmp0ao08pD3E9dNs--bs2KV4Z-0R-P91eRKFIyoDozZfxW-AcMQ2aHNED4E0E4BRZdP-TyaQWrElkLQPeyng1Xeds4u2PAbyFd8p/s999/Effects%20of%20Lipid%20Lowering%20Therapy.png" style="margin-left: 1em; margin-right: 1em;"><img alt="Effects of Lipid Lowering Therapy" border="0" data-original-height="610" data-original-width="999" height="195" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgvydeLHHekXW9yQ9DlFo38htDlN0UOUJVp4H8AnY11MuqZFaGEGth5XWg5-Ugg9jGHvbg4r1HomHbZR810q2ZODmp0ao08pD3E9dNs--bs2KV4Z-0R-P91eRKFIyoDozZfxW-AcMQ2aHNED4E0E4BRZdP-TyaQWrElkLQPeyng1Xeds4u2PAbyFd8p/w320-h195/Effects%20of%20Lipid%20Lowering%20Therapy.png" title="Effects of Lipid Lowering Therapy" width="320" /></a></div><p><br /></p><p><br /></p><h2>Statins</h2><p><a href="https://mypharmacistnote.blogspot.com/2020/12/statins.html">Click here to learn more.</a></p><p><br /></p><p><br /></p><h2>Fibrates</h2><p>Fibrates are thought to act by binding to peroxisome proliferator-activated receptor α (PPARα) on hepatocytes. This then leads to changes in the expression of genes involved in lipoprotein metabolism.</p><p></p><ul><li>Consequently, fibrates <b>reduce triglyceride and, to a lesser extent, LDL-C levels, while increasing HDL-C.</b></li><li>Fibrates take 2-5 days to have measurable effect on VLDL-C, with their optimum effect present after 4 weeks.</li><li>Members include bezafibrate, ciprofibrate, fenofibrate and gemfibrozil.</li></ul><p></p><p>Fibrates are mainly used in those whose <b>serum-triglyceride concentration is greater than 10 mmol/litre</b> or in those who cannot tolerate a statin (specialist use).</p><p></p><ul><li>Fenofibrate has a uricosuric effect, which can reduce uric acid concentrations by about 25%.</li></ul><p></p><p>Fibrates are known to significantly increase the effect of anticoagulants, while concurrent use with a statin is associated with an increased risk of myositis and, rarely, rhabdomyolysis.</p><p></p><ul><li>The risk with gemfibrozil is 15 times higher when compared to fenofibrate because it interferes with statin glucuronidation.</li><li>The combination of statins and gemfibrozil is discouraged. The myopathy risk is minimal with pravastatin combination.</li><li><b>Fibrates should preferably be taken in the morning and statins in the evening to minimize peak dose concentrations and decrease the risk of myopathy.</b></li></ul><p></p><p><br /></p><p><br /></p><h2>Inhibitors of Cholesterol Absorption</h2><p>In the past, bile acid-binding resins (e.g. cholestyramine, colestipol) were the only agents available to reduce cholesterol absorption and hence, lower plasma cholesterol.</p><p><b>Ezetimibe is a more potent drug than resins</b> (a daily dose of 10 mg) and can be used as supplementary treatment to statins in patients with severe <a href="https://mypharmacistnote.blogspot.com/2020/12/dyslipidemia.html">dyslipidaemia</a>.</p><p></p><ul><li>It is not recommended in patients with moderate to severe hepatic impairment.</li></ul><p></p><p><br /></p><p><br /></p><h2>PCSK9 Inhibitors</h2><p>PCSK9 is synthesised in inactive form by many tissues, including brain and liver.</p><p></p><ul><li>When activated, it binds to LDL receptors and promotes their lysosomal degradation following LDL uptake into hepatocyte cytoplasm. This prevents the recycling of LDL receptors to surface membrane, which diminishes their ability to sequester LDL.</li></ul><p></p><p>Two monoclonal antibody PCSK9 inhibitors, alirocumab and evolocumab, have recently been licensed.</p><p></p><ul><li>Both drugs are administered by<b> subcutaneous injection</b> and <b>require storage in a refrigerator.</b></li></ul><p></p><p><b>More data are needed to assess the long-term safety of PCSK9 inhibitors</b>, including neurocognitive and immunogenic effects as well as long-term consequences of very low LDL.</p><p></p><p><br /></p><p><br /></p><h2>Small Interfering RNA (siRNA) PCSK-9 Inhibitors</h2><p>Inclisiran is a long-acting, synthetic siRNA molecule that binds to an RNA-induced silencing complex (RISC), thereby inhibiting the translation of PCSK9 messenger RNA (mRNA) causing a marked reduction in LDL-C levels.</p><p></p><ul><li>Inclisiran is administered subcutaneously.</li><li>Inclisiran should not be used in combination with PCSK-9 inhibitors since there is no evidence of additive LDL lowering.</li></ul><p></p><p><br /></p><p><br /></p><h2>External Links</h2><div><ul><li><a href="http://library.lol/main/5716611BF130884200DA965EDFD23A58">Rang & Dale’s Pharmacology, 2019</a></li><li><a href="http://library.lol/main/B6C662D4E838288AEE7E875A82CC5877">Clinical Pharmacy and Therapeutics, 2018</a></li><li><a href="https://www.malaysianheart.org/?p=highlights&a=1941">Clinical Practice Guideline on Management of Dyslipidemia, 2023</a></li></ul></div>Soon Senghttp://www.blogger.com/profile/12198523062740513134noreply@blogger.com0tag:blogger.com,1999:blog-8600105966353098751.post-59617124481392206402024-03-09T19:08:00.002+08:002024-03-09T20:28:59.770+08:00Statins<h2>Introduction</h2><p>Statins are widely recognized as the <b>first-line <a href="https://mypharmacistnote.blogspot.com/2023/06/lipid-lowering-drugs.html">lipid-modifying therapy</a></b> for reducing cardiovascular risk due to consistent results of numerous randomized primary and secondary prevention clinical trials.</p><p></p><ul><li>They achieve this by <b>inhibiting the hydroxymethylglutaryl coenzyme A reductase (HMG-CoA reductase),</b> which catalyses the first committed step of cholesterol synthesis in the liver.</li></ul><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi7ApFNxnJ82MMDlONf87kmyJpyAmTgvE5m7x1TH5vY6UTGMam2-UJlb7IvW66EjVVlzFS24yoMQDD-49_G6VlJ5zblPJOKFKFhZkPJiCOOylgIiUam42BYXcpDaiq4DQU87vCJiJc2NuOa7bfLzmafHQxUOjq_0QTwej5acJO0OajYnxQU_L7tYtcQ/s578/statins.png" style="margin-left: 1em; margin-right: 1em;"><img alt="Cholesterol Synthesis in the Liver" border="0" data-original-height="406" data-original-width="578" height="225" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi7ApFNxnJ82MMDlONf87kmyJpyAmTgvE5m7x1TH5vY6UTGMam2-UJlb7IvW66EjVVlzFS24yoMQDD-49_G6VlJ5zblPJOKFKFhZkPJiCOOylgIiUam42BYXcpDaiq4DQU87vCJiJc2NuOa7bfLzmafHQxUOjq_0QTwej5acJO0OajYnxQU_L7tYtcQ/w320-h225/statins.png" title="Cholesterol Synthesis in the Liver" width="320" /></a></div><ul><li><b>Statins are hepatoselective with extensive <a href="https://mypharmacistnote.blogspot.com/2021/12/drug-metabolism.html">first-pass metabolism</a></b>, which is advantageous because the liver is the main site of cholesterol synthesis, with extrahepatic sites synthesising essential cholesterol.</li></ul><p></p><p><b>NOTE:</b> There is growing interest in their potential <i>pleiotropic effects</i>, which are actions unrelated or indirectly related to their effect on plasma LDL levels, such as anti-infammatory and antioxidant effects.</p><p><br /></p><p><br /></p><h2>Administration Time</h2><p>When advising patients on statin use, it is commonly recommended to take statins at night.</p><div><ul><li>However, <a href="https://pubmed.ncbi.nlm.nih.gov/29771699/">this statement may not apply universally to all statins</a> available on the market.</li><li>It serves as a simplified way of remembering the dosing time and subsequently, improving patient adherence.</li></ul><b>Shorter-acting statins, like pravastatin and simvastatin, may be slightly more effective if taken at bedtime</b> due to increased cholesterol production overnight when the stomach is relatively empty.<br /><ul><li>On the other hands,<b> long-acting statins, such as rosuvastatin and atorvastatin, can be taken at any time of the day</b> due to their extended duration of action.</li></ul><p><br /></p><p><br /></p><h2>Statin Choices</h2><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjS4ZZasG7BV7RW_H4Oen7lMigbhJkEK2ItsX7SshpB0PU7ac9Yajwe_ed2xn2yhzMFIWC4D3Lu5XL__a5N0nWlqivh3mlXxemSXcNovOcD7PGs9834yHVU4srD4wo1EGFKqRabDhfEugU/s498/Untitled+2.png" style="margin-left: 1em; margin-right: 1em;"><img alt="Relative Potency of Statins" border="0" data-original-height="480" data-original-width="498" height="308" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjS4ZZasG7BV7RW_H4Oen7lMigbhJkEK2ItsX7SshpB0PU7ac9Yajwe_ed2xn2yhzMFIWC4D3Lu5XL__a5N0nWlqivh3mlXxemSXcNovOcD7PGs9834yHVU4srD4wo1EGFKqRabDhfEugU/w320-h308/Untitled+2.png" title="Relative Potency of Statins" width="320" /></a></div><p>The selection of the most appropriate statin is still a subject of debate.</p><p></p><ul><li>Atorvastatin is currently favoured due to its low cost, safety profile and evidence of efficacy.</li><li>Rosuvastatin, the most potent statin available, is normally reserved for individuals who have not responded adequately to their first-line statin or failure to tolerate other statins.</li></ul><p></p><p><b>The degree of LDL-C reduction seen with the different statins is dose-dependent.</b></p><p></p><ul><li>High-intensity statin therapy produces a greater percentage LDL-C reduction and thus reduces CV events more than moderate-intensity statin therapy.</li><li>Lower-intensity statin therapy has also been shown to reduce CV events, but to a lesser degree.</li><li>Also, there is <b>considerable inter-individual variation</b> in LDL-C reduction with the same dose of drug.</li></ul><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiqf5slMQLgIfAMr1R0pKS9nAfsbqct_dZQyCgRZMYo3fFqB46eKBjplAKJ7iSJ2ac7MhK3-aAy7IGnhKpytjunwBc0lh6K9O6LqX6_IrDy4FUodCuKhT-xQohLNyZgv7FrtKUT4rPXkJ9EYf8auWWz0ObIT7IS6Uzkw66MIYFruThoUALig9I8uyZQNGM/s928/Intensity%20of%20Statin%20Therapy.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="539" data-original-width="928" height="186" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiqf5slMQLgIfAMr1R0pKS9nAfsbqct_dZQyCgRZMYo3fFqB46eKBjplAKJ7iSJ2ac7MhK3-aAy7IGnhKpytjunwBc0lh6K9O6LqX6_IrDy4FUodCuKhT-xQohLNyZgv7FrtKUT4rPXkJ9EYf8auWWz0ObIT7IS6Uzkw66MIYFruThoUALig9I8uyZQNGM/s320/Intensity%20of%20Statin%20Therapy.png" width="320" /></a></div><p><b>NOTE:</b> The FDA recommends rosuvastatin dosage reductions in Asian patients to maximum 20 mg daily because pharmacokinetic studies have demonstrated an approximate two-fold increase in median exposure to rosuvastatin in Asian subjects when compared to Caucasian controls.</p><p><br /></p><p><br /></p><h2>Adverse effects</h2><p>Many side effects appear mild and transient.</p><p></p><ul><li><b>The commonest include gastrointestinal symptoms, altered liver function tests and muscle aches</b>.</li></ul><p></p><p>Although rare, myopathy, characterized by unexplained muscle soreness or weakness, can occur with any statin and may lead to myoglobinuria secondary to rhabdomyolysis.</p><p></p><ul><li><b>Patients should seek medical advice once experiencing any muscle pain, tenderness or weakness.</b></li></ul><p></p><p><b>NOTE:</b> Muscle toxicity can occur with all statins, but the likelihood increases with higher doses (especially with <a href="https://www.medscape.com/viewarticle/744242">high-dosage 80 mg/day simvastatin</a>) and in certain patients. </p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiEIWGj-c77_Paej4BjBUJf0l-HsW3nJu-dJkZVHkQAGyKvv3humu9JmaSI6KlEqdPNrddl6kX225uL5uq6rXod2jd8mgcHVi7WoSAlVE3jeLRw9KSVCY-QcLk1EgRIRTn2quL2b3OO_WpBTIFCs1Ub9GsWcHFfZvE8WTnFbDaaP_42kPiQZscSL8x9E3w/s1810/Statin%20Myopathy.png" style="margin-left: 1em; margin-right: 1em;"><img alt="Statin Myopathy" border="0" data-original-height="1810" data-original-width="1279" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiEIWGj-c77_Paej4BjBUJf0l-HsW3nJu-dJkZVHkQAGyKvv3humu9JmaSI6KlEqdPNrddl6kX225uL5uq6rXod2jd8mgcHVi7WoSAlVE3jeLRw9KSVCY-QcLk1EgRIRTn2quL2b3OO_WpBTIFCs1Ub9GsWcHFfZvE8WTnFbDaaP_42kPiQZscSL8x9E3w/w226-h320/Statin%20Myopathy.png" title="Statin Myopathy" width="226" /></a></div><p><br /></p><p><br /></p><h2>Pregnancy</h2><p>Statin therapy should be <b>avoided in pregnancy and lactation </b>unless there is strong clinical indication.</p><p></p><ul><li>It should not be prescribed to women of childbearing potential unless adequate contraception is taken.</li></ul><p></p><p><br /></p><p><br /></p><h2>Stopping Statins?</h2><p>A common scenario encountered when dispensing statins is patients discontinuing their medication out of fear or side effects or the belief that their cholesterol levels are not significantly elevated.</p><p></p><ul><li><b>If LDL-C targets have been achieved, the same dose of statin should be maintained.</b></li><li>Also, <b>maximum tolerated doses of statins are recommended for patients who have experienced <a href="https://mypharmacistnote.blogspot.com/2021/12/acute-coronary-syndrome.html">acute coronary syndrome</a></b> to prevent major adverse cardiovascular events (MACEs), regardless of their cholesterol levels.</li></ul><p></p><p><br /></p><p><br /></p><h2>Co-enzyme Q10 Supplementation</h2><p>A <a href="https://pubmed.ncbi.nlm.nih.gov/26192349/">meta-analysis of 6 RCTs</a> demonstrated that <b>statin treatment is associated with significant reductions in plasma CoQ10 concentrations.</b></p><p></p><ul><li>Although CoQ10 deficiency has been associated with various conditions and disorders, the consequences of reduced CoQ10 levels in individuals following statin treatment remain unclear.</li></ul><p></p><p>As CoQ10 deficiency has been associated with myopathies, multiple studies have investigated whether CoQ10 supplementation can improve muscle symptoms associated with statin use.</p><p></p><ul><li>To date, there have been <b><a href="https://www.nps.org.au/news/can-co-enzyme-q10-supplementation-prevent-or-treat-statin-associated-muscle-symptoms">mixed results across trials on the effect of CoQ10 supplementation on muscle symptoms in patients in taking statins</a>.</b></li></ul><p></p><p>However, if a patient chooses to take CoQ10, this supplement should be used with caution in those taking oral anticoagulants such as warfarin due to potential for interactions, and international normalised ratio (INR) should be monitored.</p><p><b><br /></b></p><p><b><br /></b></p><h2>Drug Interactions</h2><p>It is essential to be aware of potential drug interactions with statins, particularly with simvastatin.</p><div><p style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjJZCa1vHB5xsCkfqT8PtN0M0r8aQHLvRaQrZGJTeTPMdm7RQXNNwhhhMbwwiMnPfybCaGHvwt8BqtGqytPe2LihAjAd7Z5hALqpa3TYPTiowRv1-oaqDrF4CTECNnY5Ruv-F1oO69c8tM/s493/Untitled+3.png" style="margin-left: 1em; margin-right: 1em;"><img alt="Drug Interactions Involving Statins" border="0" data-original-height="493" data-original-width="393" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjJZCa1vHB5xsCkfqT8PtN0M0r8aQHLvRaQrZGJTeTPMdm7RQXNNwhhhMbwwiMnPfybCaGHvwt8BqtGqytPe2LihAjAd7Z5hALqpa3TYPTiowRv1-oaqDrF4CTECNnY5Ruv-F1oO69c8tM/w255-h320/Untitled+3.png" title="Drug Interactions Involving Statins" width="255" /></a></p></div></div><p style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEixVI0aXLg8LhLJ0YTCFPDtFzcg4uJ3a9BBN92VmdBGLQpCt_0Lo4okDntcU89nIjHcyuUoSGtHTjBJo75hbDyb-FKgh2giOogDle-mjmPXIvl8SyHwoU9KiaORt6K1ddDjwD0KYbmH2hA/s573/Untitled+4.png" style="margin-left: 1em; margin-right: 1em;"><img alt="Drug Interactions with Simvastatin" border="0" data-original-height="531" data-original-width="573" height="296" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEixVI0aXLg8LhLJ0YTCFPDtFzcg4uJ3a9BBN92VmdBGLQpCt_0Lo4okDntcU89nIjHcyuUoSGtHTjBJo75hbDyb-FKgh2giOogDle-mjmPXIvl8SyHwoU9KiaORt6K1ddDjwD0KYbmH2hA/w320-h296/Untitled+4.png" title="Drug Interactions with Simvastatin" width="320" /></a></p><div class="separator" style="clear: both; text-align: left;"><p><br /></p><p><br /></p><h2>External Links</h2><div><ul><li><a href="https://www.medscape.com/viewarticle/744242">FDA Restricts Use of Simvastatin 80 mg, 2011</a><br /></li><li><a href="https://pubmed.ncbi.nlm.nih.gov/26192349/">Statin therapy and plasma coenzyme Q10 concentrations--A systematic review and meta-analysis of placebo-controlled trials, 2015</a><br /></li><li><a href="https://pubmed.ncbi.nlm.nih.gov/29771699/">The optimal time of day for statin administration: a review of current evidence, 2018</a><br /></li><li><a href="https://pubmed.ncbi.nlm.nih.gov/28385543/">Rosuvastatin pharmacokinetics in Asian and White subjects wild-type for both OATP1B1 and BCRP under control and inhibited conditions, 2017</a></li><li><a href="https://www.nps.org.au/news/can-co-enzyme-q10-supplementation-prevent-or-treat-statin-associated-muscle-symptoms">Can co-enzyme Q10 supplementation prevent or treat statin-associated muscle symptoms?, 2021</a><br /></li></ul></div></div>Soon Senghttp://www.blogger.com/profile/12198523062740513134noreply@blogger.com0tag:blogger.com,1999:blog-8600105966353098751.post-30096269410394327942024-03-09T19:03:00.001+08:002024-03-09T19:45:21.792+08:00Dyslipidemia<h2>Introduction</h2><p><b>Cardiovascular disease (CVD) has been the leading cause of death in Malaysia</b> for over a decade.</p><p></p><ul><li>CVD includes coronary heart disease (CHD), cerebrovascular disease (strokes) and peripheral arterial disease (PAD).</li><li>The common cardiovascular risk factors include dyslipidemia, <a href="https://mypharmacistnote.blogspot.com/2020/12/hypertension.html">hypertension</a>, <a href="https://mypharmacistnote.blogspot.com/2020/12/diabetes-mellitus.html">diabetes mellitus</a>, <a href="https://mypharmacistnote.blogspot.com/2021/06/smoking-cessation.html">smoking</a> and <a href="https://mypharmacistnote.blogspot.com/2021/06/obesity.html">overweight/obesity</a></li></ul><div>Commonly used cut off values for dyslipidemia are</div><div><ul><li>Total cholesterol (TC) > 5.2 mmol/L</li><li>High density lipoprotein cholesterol (HDL-C) <1.0 mmol/L (males) or <1.2 mmol/L (females)</li><li>Triglycerides (TG) >1.7 mmol/L</li><li>Low density lipoprotein cholesterol (LDL-C) levels - will depend on the patient's CV risk</li></ul><p><b>Low-density lipoprotein cholesterol (LDL-C) is an important causal risk factor for atherosclerotic cardiovascular disease (ASCVD).</b></p><p></p><ul><li>Higher lifelong exposure to LDL-C lead to acute coronary syndromes earlier in life.</li></ul><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh9b6sglGMXhVM4bcdGK0IubzGzWmgwRE-Ag7p1R2hIBfPZWXYVwLVNJTrRBItr9vHK5klU2pQN8B5zclnToKQjg0DXuwcSIKRdoHTSqHyoHdoi_WEFPYRVvFBt27102netaslu3BCsSCpLtm-pdY-HSbgCeKDYY0dDqGwba03ndIOAXruy50TUbCsXAIM/s1156/Dyslipidemia%20to%20ACS.png" style="margin-left: 1em; margin-right: 1em;"><img alt="Dyslipidemia to CVD" border="0" data-original-height="584" data-original-width="1156" height="162" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh9b6sglGMXhVM4bcdGK0IubzGzWmgwRE-Ag7p1R2hIBfPZWXYVwLVNJTrRBItr9vHK5klU2pQN8B5zclnToKQjg0DXuwcSIKRdoHTSqHyoHdoi_WEFPYRVvFBt27102netaslu3BCsSCpLtm-pdY-HSbgCeKDYY0dDqGwba03ndIOAXruy50TUbCsXAIM/w320-h162/Dyslipidemia%20to%20ACS.png" title="Dyslipidemia to CVD" width="320" /></a></div><p><br /></p><p><br /></p><h2>Measurement of Lipids</h2><p>A standard lipid profile includes measurement of plasma or serum TC, LDL-C, HDL-C and TG.</p><p><b>LDL-C is usually calculated by the Freidewald equation which is not valid in the presence of elevated TG (TG >4.5 mmol/L).</b></p><div><ul><li>Fredeiwald equation: LDL-C (mmol/L) = TC - HDL-C - TG/2.2</li></ul><p><b>Do we need to fast before lipid measurement?</b></p><p></p><ul><li><a href="https://pubmed.ncbi.nlm.nih.gov/10886474/">Non-fasting lipid testing is acceptable. </a>The difference in the values between a fasting and non-fasting sample is small and has been shown to have no impact on CV risk estimation even in diabetics.</li></ul><p><br /></p><p><br /></p><h2>Management</h2><p>All individual should be risk stratified.</p><ul><li>Patients with <b>established CVD, CKD and diabetes fall into the very high and high risk categories.</b></li><li><b>All other individuals</b> should be risk stratified at the outset using the <b>Framingham General CVD risk score</b> to determine if they are at High, Intermediate (Moderate) or Low Risk.</li><li>The intensity of risk factor reduction and target lipid levels will depend on their CV risk.</li></ul><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjeeD4dHarrP7koUloru_KoIbM5xNd_d4bmqhFpoBZn2R0tuRQfl3dpCm_Dc6GHsiicBkqFRpC0h5upl7KbP_o6EoCw8XK3oRbmXfTFtngLqIMAIsMiE9g-jW1h84VYGUGJn6JXUZ5Pb-pEz71SjfZpVsGOBiXXzAIl17C4osZOLrVivjcV7Ap_xmutLWQ/s2639/Dyslipidemia%20Target.png" style="margin-left: 1em; margin-right: 1em;"><img alt="Dyslipidemia Targets" border="0" data-original-height="2639" data-original-width="1859" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjeeD4dHarrP7koUloru_KoIbM5xNd_d4bmqhFpoBZn2R0tuRQfl3dpCm_Dc6GHsiicBkqFRpC0h5upl7KbP_o6EoCw8XK3oRbmXfTFtngLqIMAIsMiE9g-jW1h84VYGUGJn6JXUZ5Pb-pEz71SjfZpVsGOBiXXzAIl17C4osZOLrVivjcV7Ap_xmutLWQ/w225-h320/Dyslipidemia%20Target.png" title="Dyslipidemia Targets" width="225" /></a></div><p><b>LDL-C is the primary target of therapy.</b></p><p></p><p></p><p></p><p></p><ul><li>Numerous randomized clinical trials have consistently shown that reducing TC and LDL-C reduces vascular risk and prevents CVD.</li><li><a href="https://www.ahajournals.org/doi/full/10.1161/CIRCOUTCOMES.121.008552">Every 1 mmol/L LDL-C reduction is associated with ~20% reduction of CV events.</a></li></ul><p>Non-HDL Cholesterol may be considered as a secondary target when treating individuals with</p><div><ul><li>Combined hyperlipidemias</li><li>Diabetes</li><li>Metabolic syndrome</li><li>Chronic kidney disease</li></ul><p>In patients with high triglyceride >4.5 mmol/L, when the LDL-C cannot be calculated, non-HDL-C level becomes the primary target of therapy and can be calculated from a non-fasting serum.</p><p><b>NOTE:</b> The targets for non-HDL-C are 0.8 mmol/L higher than the corresponding LDL-C goal.</p></div></div><p><span>The lipid targets are similar to </span><a href="https://academic.oup.com/eurheartj/article/41/1/111/5556353">ESC/EAS Guidelines for the Management of Dyslipidemias 2019</a><span>.</span></p><p style="clear: both; text-align: center;"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgnQhiWD2bGxlxsUB6D6FwUIxGk8fKW8o70uPD6LQehc5u_kKjv3kTh5zCf9fiu3qJackDGF9hWFHtszybzJGOEnxP2FS9BuYiSeVlimYP-976EFtaLcSL7FlmaJcSwKQG0IzLBfcu7VF0AxEolbPhfkqPBGMESTeWtvn7o2vrCUhBmoFxAx6Uc_s8LRLw/s2093/ESC%20Lipid%20Target%202019.png" style="margin-left: 1em; margin-right: 1em;"><img alt="ESC Lipid Targets 2019" border="0" data-original-height="1265" data-original-width="2093" height="193" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgnQhiWD2bGxlxsUB6D6FwUIxGk8fKW8o70uPD6LQehc5u_kKjv3kTh5zCf9fiu3qJackDGF9hWFHtszybzJGOEnxP2FS9BuYiSeVlimYP-976EFtaLcSL7FlmaJcSwKQG0IzLBfcu7VF0AxEolbPhfkqPBGMESTeWtvn7o2vrCUhBmoFxAx6Uc_s8LRLw/w320-h193/ESC%20Lipid%20Target%202019.png" title="ESC Lipid Targets 2019" width="320" /></a></div><p></p><p>Based on <a href="https://www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000677">ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease, 2019</a>, <b>maximally tolerated statin therapy is recommended as primary prevention in patients 20 to 75 years of age with an LDL-C level of 190 mg/dL (4.9 mmol/L) or higher.</b></p></div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi79BEDXinIfdAHAqYCbUBq3L-WdByhyphenhyphenC_PCnQHqCzDlasG0_UbUbYd1amdvSFbEUOwnei97rRBINz0ADvFGucCQ223TWwXm3oAvMjyd9TO1mTaXk6JZ3_nkp7AO6FXJ88otOnGZY6ERDsdU9vnUKf7EjsjDsJDndWfjj5M3FD3ECG73YfY45F9XLwd6Ng/s1099/AHA%20Lipid%20Target%202019.png" style="margin-left: 1em; margin-right: 1em;"><img alt="AHA Lipid Targets 2019" border="0" data-original-height="913" data-original-width="1099" height="266" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi79BEDXinIfdAHAqYCbUBq3L-WdByhyphenhyphenC_PCnQHqCzDlasG0_UbUbYd1amdvSFbEUOwnei97rRBINz0ADvFGucCQ223TWwXm3oAvMjyd9TO1mTaXk6JZ3_nkp7AO6FXJ88otOnGZY6ERDsdU9vnUKf7EjsjDsJDndWfjj5M3FD3ECG73YfY45F9XLwd6Ng/w320-h266/AHA%20Lipid%20Target%202019.png" title="AHA Lipid Targets 2019" width="320" /></a></div><p>Dyslipidemia in specific conditions</p><p></p><ul style="text-align: left;"><li>For patients with <b>hypertension</b>, initiate statins for primary prevention if <b>LDL-C >3.4 mmol/L</b>. Assess CV risk using the FRS-General CVD risk score in all other patients.</li><li>All persons with <b>diabetes</b> <b>above the age of 40 </b>should be treated with a statin regardless of baseline LDL-C level.</li></ul><p></p><p><br /></p><p><br /></p></div><h2>Therapeutic lifestyle changes (TLC)</h2><p>Therapeutic lifestyle changes (TLC) are a critical component of health promotion and CV risk reduction efforts <b>both prior to and after commencement of lipid-lowering therapies in all individuals</b>.</p><div><b>Healthy diet</b></div><div><ul><li>Primarily fruits and vegetables</li><li>Minimally processed foods.</li><li>Low added sugar and salt in beverages and foods</li><li>Limit trans unsaturated fatty acid intake to <1% of total energy intake.</li></ul><b>Regular exercise</b><br /><ul><li> ≥150 minutes a week of moderate aerobic or 75 minutes a week of vigorous aerobic exercise</li></ul><p><b><a href="https://mypharmacistnote.blogspot.com/2021/06/smoking-cessation.html">Avoidance of tobacco smoking</a></b> (including passive smoking)</p><p><b>Alcohol restriction</b></p><p>Maintenance of an ideal weight of <b>BMI 20-23.5 kg/m<sup>2</sup></b><b> </b>and waist circumference <90 cm (men), <90 cm (women).</p><p><b><br /></b></p><p><b><br /></b></p><h2>Pharmacological Treatment</h2><p><b>LDL-C reduction with <a href="https://mypharmacistnote.blogspot.com/2020/12/statins.html">statin</a> treatment remains the cornerstone of lipid lowering therapy to reduce CVD risk.</b></p><div><ul><li>The amount of CV risk reduction seen will depend on the absolute risk of the individual and the degree of LDL-lowering that is achieved.</li><li>An achieved on-treatment LDL-C level of <1.6 mmol/L appears to significantly slow down progression of atherosclerosis.</li><li>Statins also have moderate effect in lowering TC and in elevating HDL-C.</li></ul></div><p>If the <b>LDL-target level is not achieved</b> with the maximum tolerated dose of a statin, consider</p><div><ul><li>Ezetimibe and/or</li><li><a href="https://pubmed.ncbi.nlm.nih.gov/24373748/">PCSK 9 inhibitors</a>, e.g. alirocumab and evolocumab subcutaneous injection or</li><li>Inclisran</li></ul><p>If the <b>triglyceride target is not achieved</b> with the maximum tolerated dose of a statin, consider</p><ul><li>Adding fenofibrate</li></ul><p></p></div><div><p><b>NOTE:</b> Gemfibrozil should not be used in combination with <a href="https://mypharmacistnote.blogspot.com/2020/12/statins.html">statins</a> due to the myopathy risk.</p></div><p><b><br /></b></p><p><b><br /></b></p><h2><b>Complementary Supplements</b></h2><p><b>Beta-Glucan</b></p><div><ul><li><a href="https://pubmed.ncbi.nlm.nih.gov/25411276/">Meta-analysis of randomised controlled trials</a> found <b>≥3 g/day of oat beta-glucan may decrease LDL by 0.25 mmol/L and total cholesterol by 0.30 mmol/L</b> without changing HDL cholesterol or triglycerides.</li><li>Also, clinical trials find <a href="https://pubmed.ncbi.nlm.nih.gov/36435335/">oats decrease blood pressure</a> and may be <a href="https://pubmed.ncbi.nlm.nih.gov/26690472/">beneficial in glucose control</a>.</li><li>On the other hand, yeast-derived beta-glucan, with a different types of linkages between the glucose molecules, better known for its ability to enhance the immune function.</li></ul></div><p><b>Fish Oil</b></p><p></p><ul><li>The American Heart Association (AHA) recommends a minimum of 2 fatty fish servings per week. Clinical trials suggest <b>fish oil supplementation of omega-3 fatty acids 1 g/day in coronary heart disease, </b>and when <b>triglycerides are elevated, a minimum of omega-3 fatty acids 2 g/day, up to a maximum of 4 g/day. </b>Fish oil supplements contain varying ratios of EPA and DHA.</li><li>Fish oil supplements have been reported to cause inconsistent but significant increases in LDL-C.</li><li>High doses of fish oil (>3 g/day omega-3 fatty acids) may increase the risk of bleeding with anticoagulant and antiplatelet agents.</li></ul><p></p><p><b>Garlic</b></p><p></p><p></p><p></p><p></p><ul><li><a href="https://pubmed.ncbi.nlm.nih.gov/23590705/">Garlic preparations may reduce total serum cholesterol and LDL</a><span> </span>in individuals with hyperlipidaemia when used for longer than 2 months. No improvement in HDL or triglycerides levels.</li><li>A<span> </span><a href="https://pubmed.ncbi.nlm.nih.gov/32010325/">2020 meta-analysis</a> of 12 trials and 553 hypertensive participants showed that garlic supplements lower systolic blood pressure by an average of 8.3±1.9 mm Hg and diastolic blood pressure by 5.5±1.9 mm Hg.</li></ul><p><b>Plant Sterols</b></p><p></p><ul><li><a href="https://www.heartfoundation.org.au/getmedia/b466322b-c4ea-400b-b1ae-cffa98ec60df/Heart_Foundation_Summary_of_Evidence_Phytosterol_Stanol_enriched_foods_2009.pdf">The Australian Heart Foundation</a> concludes a daily intake of <b>plant sterols around 2 g/day may reduce LDL by approximately 10%, </b>but has little effect on HDL or triglycerides.</li></ul><p></p><p><b>Coenzyme Q10</b></p><p></p><ul><li>Several reviews have found CoQ10 supplementation may help replenish plasma/serum CoQ10 levels reduced by statin therapies with a daily dose of ≥100 mg/day.</li><li><a href="https://www.nice.org.uk/guidance/ng238">NICE guidance on cardiovascular disease: risk assessment and reduction, including lipid modification</a>, does not support the use of coenzyme Q10 supplements as a strategy to improve adherence to <a href="https://mypharmacistnote.blogspot.com/2020/12/statins.html">statin</a> therapy due to insufficient evidence.</li></ul><p></p><p><br /></p><p><br /></p></div><h2>Summary</h2><p>Despite dyslipidemia being a major risk factor for CVD, there is some unmet needs in dyslipidemia management.</p><p></p><ul><li>Lack of awareness of updated LDL-C target.</li><li>Inability to reach treatment goals.</li><li>Treatment adherence, including patient reluctance to high-intensity lipid-lowering therapies and concern about statin-related adverse effects.</li></ul><p></p><p><br /></p><p><br /></p><h2>External Links</h2><p></p><ul><li><a href="https://www.malaysianheart.org/?p=highlights&a=1941">Clinical Practice Guideline on Management of Dyslipidemia, 2023</a></li><li><a href="https://academic.oup.com/eurheartj/article/41/1/111/5556353">ESC/EAS Guidelines for the Management of Dyslipidemias, 2019</a></li><li><a href="https://www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000677">ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease, 2019</a><br /></li><li><a href="https://academic.oup.com/eurheartj/article/42/34/3227/6358713">ESC Guidelines on cardiovascular disease prevention in clinical practice, 2021</a><br /></li><li><a href="https://pubmed.ncbi.nlm.nih.gov/10886474/">Blood cholesterol screening influence of fasting state on cholesterol results and management decisions, 2000</a><br /></li><li><a href="https://pubmed.ncbi.nlm.nih.gov/23590705/">Effect of garlic on serum lipids: an updated meta-analysis, 2013</a><br /></li><li><a href="https://pubmed.ncbi.nlm.nih.gov/25411276/">Cholesterol-lowering effects of oat β-glucan: a meta-analysis of randomized controlled trials, 2014</a><br /></li><li><a href="https://pubmed.ncbi.nlm.nih.gov/24373748/">PCSK9: From discovery to therapeutic applications, 2014</a><br /></li><li><a href="https://pubmed.ncbi.nlm.nih.gov/26690472/">The Metabolic Effects of Oats Intake in Patients with Type 2 Diabetes: A Systematic Review and Meta-Analysis, 2015</a><br /></li><li><a href="https://pubmed.ncbi.nlm.nih.gov/30580575/">Statin Safety and Associated Adverse Events: A Scientific Statement From the American Heart Association, 2019</a><br /></li><li><a href="https://pubmed.ncbi.nlm.nih.gov/32010325/">Garlic lowers blood pressure in hypertensive subjects, improves arterial stiffness and gut microbiota: A review and meta-analysis, 2020</a><br /></li><li><a href="https://pubmed.ncbi.nlm.nih.gov/33296453/">A Systematic Review and Meta-Analysis of Randomized Controlled Trials on the Effects of Oats and Oat Processing on Postprandial Blood Glucose and Insulin Responses, 2021</a><br /></li><li><a href="https://www.ahajournals.org/doi/full/10.1161/CIRCOUTCOMES.121.008552">Compounding Benefits of Cholesterol-Lowering Therapy for the Reduction of Major Cardiovascular Events: Systematic Review and Meta-Analysis, 2022</a><br /></li><li><a href="https://pubmed.ncbi.nlm.nih.gov/36435335/">Effect of oat consumption on blood pressure: a systematic review and meta-analysis of randomized controlled trials, 2022</a><br /></li><li><a href="https://www.sps.nhs.uk/articles/using-coenzyme-q10-supplements-for-statin-induced-muscle-symptoms/">Using coenzyme Q10 supplements for statin-induced muscle symptoms, 2022</a><br /></li></ul><p></p>Soon Senghttp://www.blogger.com/profile/12198523062740513134noreply@blogger.com0tag:blogger.com,1999:blog-8600105966353098751.post-84443794263198066572024-03-09T10:58:00.000+08:002024-03-09T10:58:10.391+08:00Medication Induced Ophthalmic Issues<h2>Introduction</h2><p>Medications can cause ocular adverse effects.</p><p></p><ul><li>Most disappear once the drug is discontinued (such as blurry vision from an anticholinergic).</li><li>In other cases, the damage can be permanent (such as vision loss with a PDE-5 inhibitor).</li></ul><p></p><p><br /></p><p><br /></p><h2>Common Drugs Known to Cause Vision Changes or Damage</h2><p><b>Eye inflammation</b></p><p><i>Bisphosphonates (e.g. alendronate)</i> - conjunctivitis, episcleritis, scleritis, keratitis or uveitis</p><p><b>Retinal changes/retinopathy</b></p><p><i>Chloroquine</i></p><p><i>Hydroxychloroquine</i></p><p><b>Optic neuropathy</b></p><p><i>Amiodarone</i> (plus corneal deposits)</p><p><i>Ethambutol</i></p><p><i>Linezolid</i></p><p><b>Intraoperative floppy iris syndrome (IFIS); causes difficulty in cataract surgery</b></p><p><i>Alpha-blockers (e.g. tamsulosin)</i></p><p><b>Colour discrimination</b></p><p><i>Digoxin</i> (with toxicity) - yellow/green vision</p><p><i>PDE-5 inhibitors (e.g. sildenafil)</i> - greenish tinge around objects</p><p><i>Voriconazole</i> - Colour vision changes</p><p><b>Vision loss/abnormal vision</b></p><p><i>Clomiphene</i> - blurred vision, reduced visual acuity, phosphenes (flash in the visual field), scintillating scotomas (spots in the visual field), blindness</p><p><i>Digoxin</i> (with toxicity) - blurriness, halos</p><p><i>PDE-5 inhibitors</i> - vision loss (one or both eyes; can be permanent)</p><p><i>Gabapentin</i> - nystagmus, diplopia and visual field defects</p><p><i>Isotretinoin</i> - reduced night vision (can be permanent), dryness, irritation</p><p><i>Topiramate</i> - visual field defects</p><p><i>Vigabatrin</i> - permanent vision loss (high risk)</p><p><i>Voriconazole</i> - abnormal vision, photophobia</p><p><b>Cataract formation</b></p><p><i>Allopurinol</i> - long-term use</p><p><i>Corticosteroids</i> - also raises intraocular pressure</p><p><br /></p><p><br /></p><h2>Summary</h2><p>Patients must be instructed to report visual changes immediately; in most cases, the damage is reversible if the medication is stopped quickly.</p><p><br /></p><p><br /></p><h2>External Links</h2><p></p><ul><li><a href="https://www.reviewofophthalmology.com/article/systemic-drugs-with-ocular-side-effects">Systemic Drugs with Ocular Side Effects, 2011</a><br /></li><li><a href="https://pubmed.ncbi.nlm.nih.gov/34421178/">The ocular adverse effects of oral drugs, 2021</a><br /></li><li><a href="https://www.npra.gov.my/index.php/en/component/content/article/449-english/safety-alerts-main/safety-alerts-2023/1527547-clomiphene-risk-of-serious-visual-disturbances-potentially-leading-to-blindness.html?Itemid=1391">Clomiphene: Risk of Serious Visual Disturbances Potentially Leading to Blindness, 2023</a><br /></li></ul><p></p>Soon Senghttp://www.blogger.com/profile/12198523062740513134noreply@blogger.com0tag:blogger.com,1999:blog-8600105966353098751.post-56541552518250948032024-03-09T10:47:00.000+08:002024-03-09T10:47:53.457+08:00Metformin: Risk of Vitamin B12 Deficiency<h2>Drug Safety Update</h2><p>Vitamin B12, also referred to as cobalamin, is a water-soluble vitamin that is naturally present in foods or animal origin such as meat, dairy and eggs. Vitamin B12 deficiency is defined as a reduced serum B12 level of ≤300 pg/mL (221 pmol/L).</p><div><ul><li>Vitamin B12 deficiency can be asymptomatic or associated with <b>haematologic (such as megaloblastic anaemia), neurologic (such as peripheral neuropathy), and psychiatric disorders (such as impaired memory and irritability)</b> that can usually be reversed by early diagnosis and treatment.</li></ul><p><b>Vitamin B12 deficiency is now regarded as a common <a href="https://mypharmacistnote.blogspot.com/2021/03/adverse-drug-reactions.html">adverse drug reaction</a></b> and may affect up to 1 in 10 people who take <a href="https://mypharmacistnote.blogspot.com/2023/06/oral-glucose-lowering-drugs.html">metformin</a>.</p><p></p><ul><li>Several oversea studies have shown that the occurrence of vitamin B12 deficiency is common among patients on <a href="https://mypharmacistnote.blogspot.com/2023/06/oral-glucose-lowering-drugs.html">metformin</a> (<b>ranging from 4.3% to 30%)</b>.</li><li><b>The risk increases with a higher dose, longer treatment duration</b> and in patients with risk factors for vitamin B12 deficiency.</li><li>In a <a href="https://pubmed.ncbi.nlm.nih.gov/33442187/">local study by Krishnan et al. (2020)</a>, non-Malay race (Chinese or Indian) was associated with an approximately four-fold increased risk, whereas the duration of metformin use of more than five years conferred a greater than two-fold increased risk for vitamin B12 deficiency.</li></ul><p><br /></p><p><br /></p><h2>Recommendations</h2><p><b>Perform serum vitamin B12 level tests when metformin-induced vitamin B12 deficiency is suspected.</b></p><p></p><ul><li>Consider periodic vitamin B12 monitoring in patients with risk factors.</li></ul><p></p><p><b>Educate patients </b>on <a href="https://mypharmacistnote.blogspot.com/2023/06/oral-glucose-lowering-drugs.html">metformin</a> therapy to seek medical attention if they develop signs and symptoms suggestive of low vitamin B12 level, including new or worsening symptoms of extreme tiredness, a sore and red tongue, pins and needles sensation, or pale or yellow skin.</p><p>Treat vitamin B12 deficiency promptly in accordance with the latest clinical guidelines and continue metformin therapy for as long as it is tolerated and not contraindicated.</p><p><br /></p><p><br /></p><h2><b>External Links</b></h2><p></p><ul><li><a href="https://www.npra.gov.my/index.php/en/component/content/article/435-english/safety-alerts-main/safety-alerts-2022/1527398-metformin-risk-of-vitamin-b12-deficiency.html?Itemid=1391">NPRA - Metformin: Risk of Vitamin B12 Deficiency, 2022</a><br /></li><li><a href="https://www.npra.gov.my/index.php/en/component/content/article/454-english/safety-alerts-main/safety-alerts-2024/1527576-updated-metformin-risk-of-vitamin-b12-deficiency.html?Itemid=1391">[Updated] Metformin: Risk of Vitamin B12 Deficiency, 2024</a><br /></li><li><a href="https://www.gov.uk/drug-safety-update/metformin-and-reduced-vitamin-b12-levels-new-advice-for-monitoring-patients-at-risk#">MHRA - Metformin and reduced vitamin B12 levels: new advice for monitoring patients at risk</a><br /></li><li><a href="https://pubmed.ncbi.nlm.nih.gov/31725641/">Association between metformin dose and vitamin B12 deficiency in patients with type 2 diabetes, 2019</a><br /></li><li><a href="https://asean-endocrinejournal.org/index.php/JAFES/article/view/803">Prevalence of Vitamin B12 Deficiency and its Associated Factors among Patients with Type 2 Diabetes Mellitus on Metformin from a District in Malaysia, 2020</a><br /></li></ul><p></p></div>Soon Senghttp://www.blogger.com/profile/12198523062740513134noreply@blogger.com2tag:blogger.com,1999:blog-8600105966353098751.post-13640235918331058092024-03-05T23:50:00.000+08:002024-03-05T23:50:07.034+08:00Motion Sickness<h2>Introduction</h2>Moving vehicles like boats, airplanes, cars and amusement park rides can all trigger motion sickness.<br /><p></p><ul><li>Motion sickness is thought to be caused by a <b>conflict of messages</b> to the brain, where the vomiting centre receives information from the eyes, the GI tract and the vestibular system in the ear.</li><li>Children less than 2 years old are typically resistant to motion sickness; the incidence peaks at approximately 9 years of age and then decreases throughout adulthood.</li></ul><p></p><p>Symptoms of motion sickness include <b>nausea and sometimes vomiting, pallor and cold sweats</b>.</p><p><br /></p><p><br /></p><h2>Environmental Modifications</h2><p></p><p>Looking at the <b>horizon or a distant, stationary object.</b></p><p><b>Avoidance of reading or looking at a screen</b> while in a moving environment, as this can increase conflict between vestibular and visual cues.</p><p><b>Selecting seats where motion is the least.</b></p><ul><li>In a boat, lower deck and midship cabins are recommended.</li><li>In a car, the front seat is recommended.</li><li>In a plane, a seat over the front edge of the wing is recommended.</li><li>If travelling by train or bus, forward facing seats are recommended.</li></ul><p></p><p></p><p><br /></p><p><br /></p><h2>OTC Medications</h2><p>Treatment of acute motion sickness is often ineffective, and therefore an <b>emphasis should be placed on prevention</b>.</p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiqI-REfBwDuTwNqBemzZB1zpSN5LA3Fz0xwtSmwVwgQtA9kUGoDIZQCAMxhef184ocAzfwsFWToV9RPly31h_VMDVnzZkWtIiFa1brnztDV2AOPfYDqpxtJsD4vvRA1OxT1fabITjevZ4xNimAI6IOLUIi4vU2dOrTgGbgxi3YXLGSr62EyVh12eID/s1054/dosage.png" style="margin-left: 1em; margin-right: 1em;"><img alt="Drugs for Motion Sickness" border="0" data-original-height="270" data-original-width="1054" height="83" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiqI-REfBwDuTwNqBemzZB1zpSN5LA3Fz0xwtSmwVwgQtA9kUGoDIZQCAMxhef184ocAzfwsFWToV9RPly31h_VMDVnzZkWtIiFa1brnztDV2AOPfYDqpxtJsD4vvRA1OxT1fabITjevZ4xNimAI6IOLUIi4vU2dOrTgGbgxi3YXLGSr62EyVh12eID/w320-h83/dosage.png" title="Drugs for Motion Sickness" width="320" /></a></div><p>Medications are helpful in the prevention of motion sickness but are often sedating. The most commonly used options are</p><p></p><ul><li><b>Hyoscine (Scopolamine) hydrobromide </b>- Antimuscarinic agent</li><ul><li>The <b>most effective drug</b> for the prevention of motion sickness.</li><li>It is <b>NOT</b> the same as hyoscine butylbromide, which is used to reduce intestinal motility and relieve the pain of gastrointestinal smooth muscle spasm.</li><li>A scopolamine 1.5 mg patch can be applied behind the ear at least 4 hours before travel to help prevent nausea and vomiting caused by motion sickness. It remains effective for up to 72 hours.</li></ul><li><b>Older, sedative <a href="https://mypharmacistnote.blogspot.com/2021/02/antihistamines.html">antihistamines</a></b></li><ul><li>The older, sedative antihistamines <b>also have appreciable antimuscarinic activity</b>, which contributes towards their use as antiemetics.</li><li>Examples include <b>dimenhydrinate, meclizine, cyclizine, cinnarizine, promethazine.</b></li><li>The "old antihistamine" chlorpheniramine lacks antimuscarinic activity, hence is not an antiemetic.</li><li>Oral medications must be taken 30-60 minutes prior to the needed effect.</li></ul></ul><p><b>Side effects</b> of hyoscine hydrobromide and sedating antihistamines are <b>mainly related to anticholinergic effects</b> and include sedation, blurred vision, dry mouth and, in older adults, confusion and urinary retention.</p><p><b>NOTE:</b> Nonsedating antihistamines do not appear to be effective for the treatment of motion sickness.</p><p><br /></p><p><br /></p><h2>Complementary and Alternative Treatments</h2><p><b>Ginger </b>has been used for many years for travel sickness. Clinical trials have produced conflicting findings in travel sickness.</p><p><b>Acupressure bands </b>are typically applied to both wrists prophylactically, but evidence of effectiveness is equivocal.</p><p><br /></p><p><br /></p><h2>External Links</h2><p></p><ul><li><a href="https://pubmed.ncbi.nlm.nih.gov/2339974/">Acupressure and motion sickness, 1990</a><br /></li><li><a href="https://pubmed.ncbi.nlm.nih.gov/7945125/">A comparison of the efficacy of cinnarizine with scopolamine in the treatment of seasickness, 1994</a><br /></li><li><a href="https://pubmed.ncbi.nlm.nih.gov/11452572/">Acupressure relieves the symptoms of motion sickness and reduces abnormal gastric activity, 2001</a><br /></li><li><a href="https://pubmed.ncbi.nlm.nih.gov/16194058/">Zingiberis rhizoma: a comprehensive review on the ginger effect and efficacy profiles, 2005</a><br /></li><li><a href="https://pubmed.ncbi.nlm.nih.gov/21678338/">Scopolamine (hyoscine) for preventing and treating motion sickness, 2011</a><br /></li></ul><p></p>Soon Senghttp://www.blogger.com/profile/12198523062740513134noreply@blogger.com0tag:blogger.com,1999:blog-8600105966353098751.post-48282059733263677702024-03-05T00:14:00.000+08:002024-03-05T00:14:24.501+08:00Migraine<h2>Introduction</h2><p>Migraine is a common <b>primary headache </b>disorder or unclear aetiology.</p><p></p><ul><li>It occurs more commonly in women than in men.</li><li>It is <b>recurrent </b>in nature and classically presents as moderate-to-severe head pain lasting <b>4-72 hours</b>.</li></ul>It is typically <b>unilateral </b>with a pulsating quality, accompanied by nausea, vomiting, photophobia, and/or phonophobia, and may be <b>preceded by aura that consists of sensory, motor or language symptoms.</b><br /><ul><li>Visual auras (accounts for ~90% of auras experienced) can take many forms, such as scotomas (blind spots), fortification spectra (zigzag lines) or flashing and flickering lights.</li><li><b>Photophobia and phonophobia</b> often mean that patients will seek out a <b>dark quiet room </b>to relieve their symptoms.</li></ul><p><b>NOTE: </b>Headache is not a disease state or condition but rather a symptom, of which there are many causes.</p><p><br /></p><p><br /></p><h2><b>Potential Trigger Factors</b></h2><p>Triggers and strategies to reduce migraine attacks</p><p></p><ul><li><b>Stress</b></li><ul><li>Maintain regular sleep pattern.</li><li>Perform regular exercise.</li><li>Modify work environment.</li><li>Do relaxation techniques, such as yoga.</li></ul><li><b>Diet</b> - Any food can be potential trigger, but food that is implicated include cheese, citrus fruit, chocolate.</li><ul><li>Maintain a food diary. If an attack occurs within 6 hours of food ingestion and is reproducible, it is likely that it is a trigger for migraine.</li><li>Eat regularly and do not skip meals.</li><li>Detecting triggers is complicated because they appear to be cumulative, jointly contributing to a threshold above which attacks are initiated.</li></ul></ul><p>In some women, the drop in oestrogen levels just before <b><a href="https://mypharmacistnote.blogspot.com/2021/11/primary-dysmenorrhoea.html">menstruation</a> </b>is a trigger for migraine, with symptoms generally occurring from 2 days before the start of bleeding up until 3 days after.</p><p><br /></p><p><br /></p><h2>Treatment</h2><p>For <b>mild-to-moderate migraine attacks</b>, consider simple <b>oral analgesics such as <a href="https://mypharmacistnote.blogspot.com/2020/10/paracetamol.html">paracetamol</a> or </b><b><a href="https://mypharmacistnote.blogspot.com/2020/10/nsaids.html">NSAID</a></b><b>.</b></p><div><ul><li>When the response to a nonopioid analgesic is suboptimal, consider adding an antiemetic (especially metoclopramide) - the antiemetic can improve treatment response by increasing drug absorption.</li><li>In general, trial one nonopioid analgesic for a couple of migraine attacks. If this is not effective, change to a different nonopioid analgesic or a triptan.</li></ul></div><p>For <b>moderate-to-severe migraine attacks, </b>consider <b>sumatriptan 50-100 mg orally or other triptans</b> if sumatriptan not effective.</p><div><ul><li>Triptans should be taken at the first sign of a migraine for best efficacy.</li><li><a href="https://pubmed.ncbi.nlm.nih.gov/16426262/">Patients who do not respond well to one triptan may respond to another.</a></li><li>Based on limited evidence, it is still recommended that triptans be avoided in patients with hemiplegic migraine, basilar migraine, ischemic stroke, ischemic heart disease, Prinzmetal's angina and uncontrolled hypertension.</li><li>Combination with monoamine oxidase inhibitors is relatively contraindicated with triptans because of the risk of <a href="https://mypharmacistnote.blogspot.com/2022/11/serotonin-syndrome.html">serotonin syndrome</a>. Triptans should not be used within 24 hours of the of ergotamine preparations or a different triptan medication.</li></ul><p>The <b>combined use of a triptan and a <a href="https://mypharmacistnote.blogspot.com/2020/10/nsaids.html">NSAID</a></b> to treat acute migraine appears to be more effective than using either drug class alone.</p><p></p><ul><li><a href="https://pubmed.ncbi.nlm.nih.gov/17405970/">The best-studied combination is sumatriptan with naproxen.</a></li></ul><p></p><p>A variety of ergotamine preparations, alone and in combination with caffeine and other analgesics, have been used for the abortive treatment of migraine.</p></div><div><div><ul><li><b>Most place-controlled trials of oral ergotamine alone <a href="https://pubmed.ncbi.nlm.nih.gov/12558771/">have failed to show efficacy in the relief of migraine</a>.</b></li><li>Ergotamine tartrate <b>may be associated with significant side effects</b>, and may worsen the nausea and vomiting associated with migraine. In addition, vascular occlusion and rebound headaches have been reported with oral doses exceeding 6 tablets per 24 hours or 10 tablets per week. Years of use also may be associated with <a href="https://pubmed.ncbi.nlm.nih.gov/1596047/">valvular heart disease</a>.</li><li>Ergots should be <a href="https://pubmed.ncbi.nlm.nih.gov/9665056/">avoided in patients with coronary artery disease</a> because they cause sustained coronary artery constriction, peripheral vascular disease, hypertension, and liver or renal disease.</li><li>In addition, ergotamine overuse has been associated with an increased risk of cerebrovascular, cardiovascular, and peripheral ischemic complications, particularly among those using cardiovascular drugs.</li><li>They also should not be used in patients who have hemiplegic migraine, migraine with brainstem aura, and migraine with prolonged aura because they may reduce cerebral blood flow.</li></ul></div><p>For those with contraindications to or who do not tolerate triptans (e.g. coronary artery disease), a <b>calcitonin gene-related peptide (CGRP) antagonist or lasmiditan may be effective.</b></p><p></p><ul><li>CGRP antagonists</li><ul><li>Examples: Ubrogepant, rimegepant, zavegepant</li><li>Long-term data are needed to better define safety and tolerability.</li></ul><li>Lasmiditan</li><ul><li>The most common adverse event is dose-dependent dizziness.</li><li>Patients should not drive a motor vehicle, operate machinery or engage in potentially hazardous activities for at least 8 hours after each dose of lasmiditan.</li></ul></ul><p></p><div><p><b>Frequent analgesic use can cause medication overuse headache.</b></p></div><div><ul><li>Limit nonopioid analgesic use to less than 15 days per month, and limit triptan use (or drugs that contain opioid analgesic) to less than 10 days per month.</li></ul></div><p><br /></p><p><br /></p></div><h2>Prophylaxis</h2><p>Consider migraine prophylaxis in patients who</p><p></p><ul><li>Experience migraine attacks that reduce quality of life due to high frequency, severity or duration.</li><li>Experience attacks ≥4-5 days/month, even with no reported disability.</li><li>Cannot take acute therapies due to contraindications, adverse events or inadequate response.</li><li>Prefer prophylaxis, depending on physician judgement and type of migraine.</li></ul><p></p><p>The choice of treatment depends on factors such as patient preference, adverse effects, drug interactions, medication cost and other co-morbidities.</p><div><ul><li>For patients with hypertension who are nonsmokers and ≤60 years of age, reasonable options include metoprolol, propranolol or timolol in the absence of contraindications to beta blockers.</li><li>For patients with hypertension who are smokers or are >60 years of age, options include verapamil or flunarizine.</li><li>For patients with <a href="https://mypharmacistnote.blogspot.com/2021/06/depression.html">depression</a> or mood disorder, reasonable options include amitriptyline or venlafaxine.</li><li>For patients with <a href="https://mypharmacistnote.blogspot.com/2021/07/epilepsy.html">epilepsy</a>, reasonable options include valproate or topiramate.</li><li>For patients with <a href="https://mypharmacistnote.blogspot.com/2021/05/insomnia.html">insomnia</a>, amitriptyline is a reasonable option.</li><li>For patients with <a href="https://mypharmacistnote.blogspot.com/2024/03/raynaud-phenomenon.html">Raynaud phenomenon</a>, reasonable options include verapamil or flunarizine.</li><li>Pizotifen may cause drowsiness (may be preferred in patients with <a href="https://mypharmacistnote.blogspot.com/2021/05/insomnia.html">insomnia</a>) and weight gain.</li><li>Valproate should not be used for females of childbearing potential, because it is teratogenic and is associated with an increased risk of congenital anomalies.</li><li>If patients have not benefited from ≥3 trials of oral migraine prophylaxis treatment, may consider CGRP monoclonal antibodies (high cost and lack long-term safety and efficacy data).</li></ul></div><div><div style="text-align: center;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg5iOgm75fyu0OVD5Re-UzrCYHPlCGm3gZfhWNi_WtLczNpID5jm4b-5J7ZSzMWYx1Ct9-AXAMuklnc9yaZV7UAd-5cZ6skwP9zHL_txeJPO3kldsz1qN_pj_zAl1aRV9LiBhzSgelG-CbCoybwovs4DFIX0WolkTQMeLPyOF_i7UBYGFf0AI-5tgi8Ilg/s1640/Migraine%20Prophylaxis.png" style="margin-left: 1em; margin-right: 1em;"><img alt="Migraine Prophylaxis" border="0" data-original-height="1640" data-original-width="1276" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg5iOgm75fyu0OVD5Re-UzrCYHPlCGm3gZfhWNi_WtLczNpID5jm4b-5J7ZSzMWYx1Ct9-AXAMuklnc9yaZV7UAd-5cZ6skwP9zHL_txeJPO3kldsz1qN_pj_zAl1aRV9LiBhzSgelG-CbCoybwovs4DFIX0WolkTQMeLPyOF_i7UBYGFf0AI-5tgi8Ilg/w249-h320/Migraine%20Prophylaxis.png" title="Migraine Prophylaxis" width="249" /></a></div></div><p>Start at low dose and slowly titrate up to achieve desired effect.</p><p></p><ul><li>Trial a prophylactic drug for migraine for at least 8 to 12 weeks to assess its efficacy.</li><li>A good response to treatment is defined as a 50% reduction in the severity and frequency of migraine attacks.</li></ul><p></p></div><div><p>A review of ongoing prophylaxis should be considered after 6-12 months; treatment can be gradually withdrawn in many patients.</p><p><br /></p><p><br /></p><h2>Supplements</h2><p><b>Feverfew</b> has been the <a href="https://mypharmacistnote.blogspot.com/2020/10/about-herbs.html">herbal remedy</a> most studied for the prevention of migraine, but evidence regarding <a href="https://pubmed.ncbi.nlm.nih.gov/25892430/">benefit is conflicting</a>.</p><p>There is only <a href="https://pubmed.ncbi.nlm.nih.gov/25533715/">limited evidence supporting <b>magnesium</b> supplementation for migraine prevention in adults</a>.</p><p>In a small, randomized controlled trial of 42 patients with migraine, <b>CoQ10</b> was effective for migraine prevention; <a href="https://pubmed.ncbi.nlm.nih.gov/15728298/">significantly more patients treated with CoQ10 (100 mg three times daily) experienced a ≥50 percent reduction in attack frequency at three months than patients treated with placebo (47.6 versus 14.4 percent)</a>.</p><p><br /></p><p><br /></p></div><h2>External Links</h2><div><ul><li><a href="https://www.uptodate.com/contents/acute-treatment-of-migraine-in-adults">UpToDate - Acute treatment of migraine in adults</a><br /></li><li><a href="https://www.uptodate.com/contents/preventive-treatment-of-episodic-migraine-in-adults">UpToDate - Preventive treatment of episodic migraine in adults</a><br /></li><li><a href="https://www.dynamed.com/management/migraine-treatment-of-acute-attack-in-adults">DynaMed - Migraine - Treatment of Acute Attack in Adults</a><br /></li><li><a href="https://pubmed.ncbi.nlm.nih.gov/1653139/">A randomized, double-blind comparison of sumatriptan and Cafergot in the acute treatment of migraine. The Multinational Oral Sumatriptan and Cafergot Comparative Study Group, 1991</a></li><li><a href="https://pubmed.ncbi.nlm.nih.gov/9665056/">Coronary side-effect potential of current and prospective antimigraine drugs, 1998</a><br /></li><li><a href="https://pubmed.ncbi.nlm.nih.gov/17405970/">Sumatriptan-naproxen for acute treatment of migraine: a randomized trial, 2007</a><br /></li><li><a href="https://pubmed.ncbi.nlm.nih.gov/25892430/">Feverfew for preventing migraine, 2015</a><br /></li><li><a href="https://pubmed.ncbi.nlm.nih.gov/25533715/">An evidence-based review of oral magnesium supplementation in the preventive treatment of migraine, 2015</a><br /></li></ul></div><p></p>Soon Senghttp://www.blogger.com/profile/12198523062740513134noreply@blogger.com0tag:blogger.com,1999:blog-8600105966353098751.post-74529834981723017112024-03-04T22:01:00.001+08:002024-03-04T22:01:16.016+08:00Nocturnal Enuresis<h2>Introduction</h2><p>Enuresis is urinary incontinence while sleeping (at night or during naps).</p><p></p><ul><li>By definition, it is not considered abnormal until 5 years of age and must occur at least twice weekly for ≥3 consecutive months.</li></ul><p></p><p>In other words, nocturnal enuresis, or bed-wetting, is a normal part of a child's development and is not generally treated before age 5 years.</p><p><br /></p><p><br /></p><h2>Management</h2><p><b>Offer reassurance</b> that most enuresis resolves over time.</p><p></p><ul><li>15% per year among children >6 years old.</li></ul><p></p><p><b>Behavioural treatments are used first.</b></p><p></p><ul><li>Fluid restriction in hours prior to bedtime.</li><li>Elimination of products that cause diuresis or bladder irritation such as caffeinated beverages.</li><li>Maintain normal fluid intake during the day.</li><li>Advise scheduled urinations during the daytime (4-7 times per day) and voiding just prior to bedtime.</li><li>Enuresis alarm in motivated and compliant family.</li></ul><p>For patients beginning at age 6 years, <b>offer desmopressin </b>(0.2-0.4 mg tablet or 0.12-0.24 mg sublingual tablet) orally<b> 1 hour prior to bedtime</b> for enuresis alone or in combination with an alarm in nonresponsive patients.</p><p></p><ul><li>Desmopressin is more rapidly effective than alarms and requires a shorter time commitment and less caregiver supervision, but has a higher relapse rate.</li><li>Stop desmopressin treatment for 1 week every 3 months to assess for resolution of enuresis.</li><li>Medication may be used for up to 6 months.</li></ul><p></p><p><b>NOTE:</b> Bladder training exercises (such as attempting to hold the urine during the day for a set time period) are not recommended.</p><p><br /></p><p><br /></p><h2>Using An Enuresis Alarm</h2><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj7wYwho2bCuJ5ecI6JqcylLvwuNhPdl8qj1qWDAvCBfI9k4U-AmiAf1M9tX99BIUTyBkS1PFuFGOxIK7y15Du9IH9eHmanJJsUsjKHcn1Dwwp1ktcr32EbAqBMZHux3S8R8ChDqo4tL_suUsphCCW79idGNOA7Gnb2-gCy7jIFR0GqxxEndK8t5PTbxMs/s686/Enuresisalarm.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img alt="Enuresis Alarm" border="0" data-original-height="686" data-original-width="503" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj7wYwho2bCuJ5ecI6JqcylLvwuNhPdl8qj1qWDAvCBfI9k4U-AmiAf1M9tX99BIUTyBkS1PFuFGOxIK7y15Du9IH9eHmanJJsUsjKHcn1Dwwp1ktcr32EbAqBMZHux3S8R8ChDqo4tL_suUsphCCW79idGNOA7Gnb2-gCy7jIFR0GqxxEndK8t5PTbxMs/w147-h200/Enuresisalarm.jpg" title="Enuresis Alarm" width="147" /></a></div><p>Enuresis alarms are activated when a sensor, placed in the undergarments or on a bed pad, detects moisture. The arousal device is usually an auditory alarm and/or a vibrating belt or pager.</p><p>Instructions</p><p></p><ul><li>The alarm should be demonstrated to the child and family before use.</li><li>It must be used every night.</li><li>The family and child should be instructed that the child is in charge of the alarm.</li><li>Each night before they go to sleep, the child should test the alarm; with the sound (or vibration) in mind, the child should imagine in detail, for one to two minutes, the sequence of events that occur when the alarm sounds (or vibrates) during sleep.</li></ul>The sequence is as follows:<p></p><p></p><ul><li>The child turns off the alarm, gets up, and finishes voiding in the toilet (only the child should turn off the alarm). The child's being fully awake and cognizant of what is happening is critical to the success of alarm therapy. However, at the initiation of alarm therapy, it may be necessary for the caregivers to wake the child when the alarm sounds.</li><li>The child returns to the bedroom.</li><li>The child changes the bedding (with caregiver supervision) and clothing. Changes of bedding and clothing should be kept near the bed.</li><li>The child wipes down the sensor with a wet cloth and then a dry cloth (or replaces the sensor if it is disposable).</li><li>The child resets the alarm and returns to sleep.</li></ul><p></p><p>A diary should be kept of wet and dry nights.</p><p></p><ul><li>Positive reinforcement should be provided for successful completion of the above sequence of events, waking and getting out bed to void, and for dry nights.</li><li>Penalties (e.g., the removal of a reward) for wetting episodes appear to be counterproductive.</li></ul><p></p><p><br /></p><p><br /></p><h2>External Links</h2><div><ul><li><a href="https://www.dynamed.com/condition/enuresis">DynaMed - Enuresis</a><br /></li><li><a href="https://www.uptodate.com/contents/nocturnal-enuresis-in-children-management">UpToDate - Nocturnal Enuresis in Children: Management</a><br /></li></ul></div>Soon Senghttp://www.blogger.com/profile/12198523062740513134noreply@blogger.com0tag:blogger.com,1999:blog-8600105966353098751.post-48522937855982302852024-03-04T20:57:00.000+08:002024-03-04T20:57:36.715+08:00Benign Prostatic Hyperplasia<h2>Introduction</h2><p>The prevalence of benign prostatic hyperplasia (BPH) <b>increases with age</b>, affecting approximately 42% of men between the ages of 51 and 60 years and 82% of men between the ages of 71 and 80 years.</p><p>The signs and symptoms of BPH are mainly LUTS (lower tract urinary symptoms), which include</p><p></p><ul><li><b>Storage symptoms</b>: frequency, urgency, nocturia and incontinence</li><li><b>Voiding symptoms: </b>weak stream, dribbling, dysuria, straining</li></ul><p>Symptoms can significantly impact quality of life.</p><p><br /></p><p><br /></p><h2>Treatment Principles</h2><p>The severity of reported BPH symptoms guides selection of treatment.</p><p></p><ul><li>Validated severity and bother scores exist, such as the <a href="https://pubmed.ncbi.nlm.nih.gov/1279218/">American Urological Association Symptom Index (AUA-SI)</a>, BPH Impact Index, or <a href="https://pubmed.ncbi.nlm.nih.gov/11446839/">International Prostate Symptom Score (IPSS)</a>, to quantitatively grade the severity and bother of LUTS.</li></ul><p></p><p><br /></p><p><br /></p><h2>Nonpharmacological Management</h2><div><p>Offer <b>watchful waiting </b>for men with LUTS due to BPH which are not significantly bothered by their symptoms.</p><p>Suggest <b>limiting fluid intake in evening, avoiding excess alcohol, avoiding caffeine and increasing physical activity.</b></p><p>Consider <b>altering medications that may be aggravating symptoms</b>, if appropriate.</p><ul><li>E.g. Anticholinergic drugs, diuretics, testosterone replacement</li></ul><p></p><p><br /></p><p><br /></p></div><h2>Pharmacological Management</h2><p><b><span class="fontstyle0">α</span>-Adrenergic Blockers</b></p><div><ul><li>Works by reducing smooth muscle contractions in the urethra and surrounding tissues.</li><ul><li><b>Nonspecific α-adrenergic blockers (e.g. doxazosin and <a href="https://mypharmacistnote.blogspot.com/2020/10/terazosin-in-ureteral-calculi-expulsion.html">terazosin</a>) also lower blood pressure significantly.</b></li><li>Newer agents such as tamsulosin, silodosin and alfuzosin are more α<sub>1</sub>-selective and may have less associated hypotension.</li></ul><li><span class="fontstyle0">Can improve symptoms within 48 hours (full effect in 4-6 weeks) and also improve urinary flow rates.<br /></span></li><li><span class="fontstyle0"><b>Intraoperative floppy iris syndrome is a concern</b> with α-blockers, especially tamsulosin. This increases the technical difficulty of <a href="https://mypharmacistnote.blogspot.com/2021/11/cataract.html">cataract</a> surgery and increases the incidence of complications such as posterior capsule rupture, iris trauma and vitreous loss.</span><br /></li><li>Other adverse effects include retrograde ejaculation, erectile dysfunction, nasal congestion, hypotension, dizziness and tachycardia.</li></ul><p><b>5α-Reductase Inhibitors</b></p></div><ul><li>5α-reductase inhibitors (e.g. dutasteride and finasteride) do not immediately reduce LUTS and should be reserved for use in men with <b>large prostate volume (more than 40 g)</b>. At least 6 months of therapy is usually needed for clinical benefit. Prostate size may be reduced by about 25% during this interval.</li><li>The most common adverse effects are <b>erectile dysfunction, decreased libido, decreased ejaculate and decreased semen count.</b></li><li>Usage of 5α-reductase inhibitors may be associated with a delayed diagnosis of prostate cancer and a more advanced histological stage of cancer at the time of diagnosis.<br /></li></ul><p>The <a href="https://www.eu-openscience.europeanurology.com/article/S15699056(06)001485/fulltext">MTOPS trial</a> and <a href="https://www.futuremedicine.com/doi/abs/10.2217/ahe.12.61?journalCode=ahe">CombAT trial</a> found that <b>combination therapy with an alpha blocker and 5-alpha reductase inhibitor</b> provided a greater improvement in LUTS compared to monotherapy.</p><p><b>Phosphodiesterase Type 5 Inhibitors</b></p><div><ul><li>May be considered for patients with <b>comorbid BPH and <a href="https://mypharmacistnote.blogspot.com/2023/07/erectile-dysfunction.html">erectile dysfunction</a></b>.<br /></li><ul><li>Tadalafil 5 mg once daily.</li></ul><li><b>Reported adverse effects with PDE5 inhibitors are relatively rare</b>, with the more commonly reported effects consisting of headache, flushing, dyspepsia, nasal congestion, back pain, myalgias, and sinusitis.</li><li>They should be <b>avoided in patients receiving nitrates for ischaemic heart disease or those with poor cardiac function.</b></li></ul></div><p><b>Anticholinergic (antimuscarinic) Agents</b></p><ul><li>An appropriate and effective treatment alternative for management of LUTS secondary to BPH in men<b> without an elevated postvoid residual</b> and when LUTS are <b>predominantly storage symptoms </b>(frequency, urgency, and incontinence).</li><li>Examples are tolterodine, oxybutynin, darifenacin, solifenacin and trospium.</li></ul><p><b>Beta-3 Agonist</b></p><div><ul><li>Mirabegron may be used in men with mainly <b>bladder storage symptoms </b>(frequency, urgency, and incontinence).</li></ul></div><p><br /></p><p><br /></p><h2>Surgery</h2><p>Surgery is preferred in men with <b>severe symptoms and in those with moderate symptoms who have not adequately responded to medical options.</b></p><p></p><ul><li>The options range from minimally invasive therapies (e.g. prostatic urethral lift, transurethral needle ablation) to the more invasive transurethral resection of the prostate, and enucleation prostatectomy in select cases.</li></ul><p></p><p><br /></p><p><br /></p><h2>Supplements</h2><p>There is conflicting evidence about the efficacy of <b>saw palmetto plant extract</b> (<i>Serenoa repens</i>) in relieving LUTS.</p><div><ul><li><a href="https://pubmed.ncbi.nlm.nih.gov/12137626/">Serenoa repens for benign prostatic hyperplasia, 2002</a><br /></li><li><a href="https://pubmed.ncbi.nlm.nih.gov/22551330/">Serenoa repens monotherapy for benign prostatic hyperplasia (BPH): an updated Cochrane systematic review, 2012</a><br /></li></ul></div><p>Though the exact mechanism(s) by which saw palmetto works is uncertain, available evidence supports a possible additive or synergistic effect with 5α-reductase inhibitors, which impair the conversion of testosterone to dihydrotestosterone (DHT).</p><p>Pygeum, pumpkin seed (beta-sitosterol) and rye pollen are other natural products that have shown some improvement in BPH symptoms.</p><p><br /></p><p><br /></p><h2>External Links</h2><p></p><ul><li><a href="https://pubmed.ncbi.nlm.nih.gov/11446839/">Reliability and validity of the International Prostate Symptom Score in a Malaysian population, 2001</a><br /></li><li><a href="https://www.eu-openscience.europeanurology.com/article/S15699056(06)001485/fulltext">The MTOPS Study: New Findings, New Insights, and Clinical Implications for the Management of BPH, 2006</a><br /></li><li><a href="https://pubmed.ncbi.nlm.nih.gov/22297243/">Monotherapy with tadalafil or tamsulosin similarly improved lower urinary tract symptoms suggestive of benign prostatic hyperplasia in an international, randomised, parallel, placebo-controlled clinical trial, 2012</a><br /></li><li><a href="https://www.futuremedicine.com/doi/abs/10.2217/ahe.12.61?journalCode=ahe">Combination treatment with tamsulosin and dutasteride for benign prostatic hyperplasia, 2012</a><br /></li><li><a href="https://pubmed.ncbi.nlm.nih.gov/26965560/">Efficacy and Safety of Mirabegron Add-on Therapy to Solifenacin in Incontinent Overactive Bladder Patients with an Inadequate Response to Initial 4-Week Solifenacin Monotherapy: A Randomised Double-blind Multicentre Phase 3B Study (BESIDE), 2016</a><br /></li><li><a href="https://www.nps.org.au/australian-prescriber/articles/drugs-for-benign-prostatic-hypertrophy">Drugs for benign prostatic hypertrophy, 2018</a><br /></li></ul><p></p>Soon Senghttp://www.blogger.com/profile/12198523062740513134noreply@blogger.com2tag:blogger.com,1999:blog-8600105966353098751.post-36398062802858529642024-03-04T20:37:00.000+08:002024-03-04T20:37:21.223+08:00Nutritional Supplementation in Pregnancy<h2>Introduction</h2><p>Pregnancy, typically lasts 37-40 weeks, is a critical period of rapid foetal growth and development as well as maternal physiological change.</p><p></p><ul><li>Nutrient requirements are increased to provide for the optimal growth and development of the foetus and to support maternal health.</li><li>An additional of 340 to 450 kcal/day for pregnant women in second or third trimester.</li></ul><p></p><p><br /></p><p><br /></p><h2>Lifestyle Modifications</h2><p>When treating pregnant patients, lifestyle modifications should always be considered first.<br /></p><ul><li><b>Avoid alcohol</b> and other known or potentially harmful substances (e.g. smoking, illicit drug and mercury)</li><ul><li>Avoid fish containing high levels of mercury (shark, billfish, tuna, swordfish).</li></ul><li><b>Limit caffeine intake to less than 200-300 mg per day.</b></li><ul><li>Be mindful of other forms of caffeine in black tea, coke, energy drinks and gym supplements.</li></ul><li><b>Teratogenic drugs should be discontinued prior to pregnancy, if possible.</b></li></ul><p><br /></p><p><br /></p><h2>Preconception Care with Folic Acid</h2><p><b>Folic acid is recommended in all women of childbearing age.</b> It is important in preventing neural tube defects, such as spina bifida and anencephaly, which occurs during the early stages of pregnancy and also aids in red blood cell formation.</p><p></p><ul><li>Folic acid 400-500 mcg daily for at least 4 weeks prior to pregnancy and for the first 12 weeks of gestation.</li><li>Folate requirements increase to 600 mcg daily on the fourth to ninth of pregnancy.</li></ul><p></p><p><b>NOTE:</b> A higher dose of folic acid (5 mg daily until 12 weeks of gestation) is recommended for high-risk women (e.g. previous history of neural tube defects, anticonvulsant medication, gestational diabetes mellitus).</p><p><br /></p><p><br /></p><h2>Calcium and Vitamin D Supplementation</h2><p>The baby's skeleton requires adequate calcium and vitamin D. If deficient in calcium, the mother's bone health will be sacrificed to provide for the baby.</p><ul><li><b>Maintain adequate intake of calcium (total of 1000-1300 mg elemental calcium per day).</b></li><ul><li>Apart from foetal bone development, calcium supplementation during pregnancy, especially for women with low dietary calcium intake, may reduce the incidence of hypertensive disorders (including <a href="https://mypharmacistnote.blogspot.com/2021/11/hypertensive-disorders-in-pregnancy.html">pre-eclampsia</a>) and preterm labour.</li></ul><li><b>Maintain adequate vitamin D intake (around 600 IU or 15 mcg)</b></li><ul><li>Reduces risk of <a href="https://mypharmacistnote.blogspot.com/2021/11/hypertensive-disorders-in-pregnancy.html">pre-eclampsia</a>, pre-term birth, small-for-gestational-age birth and gestational diabetes.</li><li>Do not take cod liver oil or any supplements containing vitamin A (retinol).</li></ul></ul><p><br /></p><p><br /></p><h2>Iron Supplementation</h2><div>Iron is required for foetal brain growth and development and prevention of <a href="https://mypharmacistnote.blogspot.com/2021/08/anaemia.html">anaemia</a>.</div><ul><li><b>Maintain adequate intake of iron (about 27 mg of iron per day).</b></li><li>Supplementation is recommended for those with established deficiency and those at risk of deficiency (including vegetarians, women with a multiples).</li></ul>Although iron supplementation can worsen <a href="https://mypharmacistnote.blogspot.com/2021/06/morning-sickness.html">morning sickness</a>, women with <a href="https://mypharmacistnote.blogspot.com/2021/08/iron-deficiency-anaemia.html">iron-deficiency anaemia</a> should not stop taking iron supplements without consulting a doctor.<p><br /></p><p><br /></p><p></p><h2>Iodine Supplementation</h2><p>Iodine is essential for production of maternal thyroid hormone, foetal brain and CNS development.</p><p></p><ul><li>Maintain adequate iodine intake (250 mcg).</li></ul><p></p><p><b><br /></b></p><p><br /></p><h2>External Links</h2><ul><li><a href="https://www.uptodate.com/contents/nutrition-in-pregnancy-dietary-requirements-and-supplements">UpToDate - Nutrition in pregnancy: Dietary requirements and supplements</a><br /></li><li><a href="https://www.nhs.uk/pregnancy/keeping-well/vitamins-supplements-and-nutrition/">NHS UK - Vitamins, supplements and nutrition in pregnancy</a><br /></li><li><a href="https://www.acog.org/womens-health/faqs/nutrition-during-pregnancy">ACOG - Nutrition During Pregnancy</a><br /></li><li><a href="https://www.blackmoresinstitute.org/education/condition-information-sheets">Blackmore Institute - Condition Information Sheet</a><br /></li><li><a href="https://pubmed.ncbi.nlm.nih.gov/21364848/">Omega-3 Fatty Acids and Pregnancy, 2010</a><br /></li><li><a href="https://pubmed.ncbi.nlm.nih.gov/25707780/">Iodine intake in pregnancy—even a little excess is too much, 2015</a><br /></li><li><a href="https://pubmed.ncbi.nlm.nih.gov/31925443/">Safety and efficacy of supplements in pregnancy, 2020</a><br /></li><li><a href="https://www.sciencedirect.com/science/article/pii/S0261561419330274">Vitamin D supplementation and incident preeclampsia: A systematic review and meta-analysis of randomized clinical trials, 2019</a><br /></li></ul><p></p>Soon Senghttp://www.blogger.com/profile/12198523062740513134noreply@blogger.com2tag:blogger.com,1999:blog-8600105966353098751.post-12444403363129677752024-03-04T20:01:00.000+08:002024-03-04T20:01:19.588+08:00Cushing Syndrome<h2>Introduction</h2><p>Cushing syndrome refers to the signs and symptoms that result from excess cortisol.</p><p></p><ul><li>Initial screening tests for Cushing syndrome include the 1 mg <a href="https://mypharmacistnote.blogspot.com/2022/07/dexamethasone-suppression-test.html">overnight dexamethasone suppression test</a>, and measurements of free cortisol (24-hour urinary cortisol and late-night salivary cortisol).</li></ul><p><br /></p><p><br /></p><h2>Symptoms</h2><p></p><p>Symptoms include central obesity, facial puffiness or roundness, peripheral oedema, thinning of the skin, and weakness, as well as complications such as <a href="https://mypharmacistnote.blogspot.com/2020/12/diabetes-mellitus.html">diabetes</a>, <a href="https://mypharmacistnote.blogspot.com/2020/12/hypertension.html">elevated blood pressure</a>, <a href="https://mypharmacistnote.blogspot.com/2020/12/dyslipidemia.html">dyslipidaemia</a> and <a href="https://mypharmacistnote.blogspot.com/2021/08/osteoporosis.html">osteoporosis</a>.</p><ul><li>In children, cortisol excess can also cause growth failure and delay of maturation (except in children with coincident androgen excess).</li></ul><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbXQ2uaqiqgKWHiJmJGS322IlFiwR5Q_fDEgRXLW0crqdghtfleBnk6JUtIR2paDdbYXQXfrW2iVo0o4RMSqCGaKadBBFzkRY-VGtbTNq4ZI3iJf25ruuhGbdeoda3VZRYZyVgZQc1R0NgZg5j68k1yRDL3N0MVRUrtD7K8jIh2_5wQHkSnrDwgxEsqQw/s995/Cushing%20Syndrome.png" style="margin-left: 1em; margin-right: 1em;"><img alt="Cushing Syndrome" border="0" data-original-height="995" data-original-width="794" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbXQ2uaqiqgKWHiJmJGS322IlFiwR5Q_fDEgRXLW0crqdghtfleBnk6JUtIR2paDdbYXQXfrW2iVo0o4RMSqCGaKadBBFzkRY-VGtbTNq4ZI3iJf25ruuhGbdeoda3VZRYZyVgZQc1R0NgZg5j68k1yRDL3N0MVRUrtD7K8jIh2_5wQHkSnrDwgxEsqQw/w255-h320/Cushing%20Syndrome.png" title="Cushing Syndrome" width="255" /></a></div><p><br /></p><p><br /></p><h2>Management</h2><p>Treatment should be directed, whenever possible, at the primary cause of the syndrome.</p><p>Cushing syndrome can be caused by</p><p></p><p></p><p></p><p></p><p></p><ul><li>Exogenous administration of glucocorticoids</li><li>Endogenous production of cortisol by an adrenal adenoma or carcinoma</li><li>Bilateral nodular adrenal hyperplasia (rare)</li><li>Overstimulation of both adrenal glands by excess adrenocorticotrophic hormone (ACTH) production from a pituitary adenoma (Cushing disease) or an ectopic ACTH-producing tumour.</li></ul>Soon Senghttp://www.blogger.com/profile/12198523062740513134noreply@blogger.com0tag:blogger.com,1999:blog-8600105966353098751.post-45313318646363748482024-03-04T18:39:00.003+08:002024-03-04T18:42:08.110+08:00Ascites<h2>Introduction</h2><p>Ascites is a <b>pathologic accumulation of fluid in the peritoneal cavity most often caused by cirrhosis</b>, but other causes include malignancy, <a href="https://mypharmacistnote.blogspot.com/2022/12/nephrotic-syndrome.html">nephrotic syndrome</a>, <a href="https://mypharmacistnote.blogspot.com/2021/09/heart-failure.html">heart failure</a>, malnutrition and infections such as peritoneal tuberculosis.</p><p></p><ul><li>It can lead to the development of spontaneous bacterial peritonitis (SBP) and hepatorenal syndrome (HRS).</li></ul>The serum-ascites albumin gradient correlates directly with portal pressures.<p></p><ul><li>A SAAG gradient ≥ 1.1 g/dL suggests portal hypertension, most likely due to cirrhosis. Other causes include venous congestion such as from right sided heart failure.</li><li>A SAAG gradient < 1.1 g/dL suggests other causes of ascites such as peritoneal carcinomatosis, chronic peritoneal infection, nephrotic syndrome, pancreatic ascites, and protein-losing enteropathy.</li></ul><p><b>NOTE:</b> Treat ascites with a SAAG gradient of <1.1 g/dL by addressing the underlying aetiology as diuretics are often ineffective and may lead to volume depletion.</p><p><br /></p><p><br /></p><h2>Management</h2><p>There are many treatment approaches to managing ascites, which are chosen based on the severity.</p><p></p><ul><li>A small volume of ascitic fluid detected on imaging is considered mild ascites and is generally not treated.</li><li>All patients with cirrhosis and ascites should be considered for liver transplantation, with expedited evaluation if there is worsening renal dysfunction or rapid liver decompensation.</li></ul><b>Patients with symptomatic ascites (i.e. causing abdominal discomfort or distension) due to portal hypertension should</b><p></p><p></p><ul><li><b>Restrict dietary sodium intake to <2 grams/day</b></li><ul><li>Reducing added salt and improved awareness of high sodium content in many pre-packaged and canned foodstuffs.</li></ul><li>Adequate protein and energy intake - to manage malnutrition</li><li><b>Cease alcohol intake</b></li><li>Avoid sodium retaining medications (including <a href="https://mypharmacistnote.blogspot.com/2020/10/nsaids.html">NSAIDs</a>, ACE inhibitors)</li><li>Use <a href="https://mypharmacistnote.blogspot.com/2020/10/antihypertensives.html">diuretics</a> to increase fluid loss</li><li>Fluid restriction is not indicated unless there is severe hyponatremia (serum sodium <120 mEq/L).</li></ul>Diuretic therapy for ascites can be initiated with either <b>spironolactone monotherapy or with a combination of frusemide and spironolactone</b>.<p></p><p></p><ul><li>When used in combination, a ratio of 100 mg spironolactone to 40 mg frusemide (up to spironolactone 400 mg/day and frusemide 160 mg/day) should be used to maintain potassium balance.</li><li>Consider withholding furosemide if there is hypokalaemia and decreasing dose of spironolactone if there is hyperkalaemia.</li><li>Consider withholding diuretics if renal insufficiency develops.</li></ul><p></p><p>In severe cases, abdominal paracentesis is needed to directly remove ascitic fluid.</p><p></p><ul><li><b>Large volume of paracentesis (removal of >5 L over 1-6 hours) is associated with significant fluid shifts and the addition of albumin (6-8 grams per liter of fluid removed or 50 gram total) is recommended</b> at the time of or soon after the procedure to avoid postparacentesis complications (e.g. hypovolemia, hyponatremia, kidney impairment.</li></ul><p></p><p><br /></p><p><br /></p><h2>External Links</h2><p></p><ul><li><a href="https://www.uptodate.com/contents/ascites-in-adults-with-cirrhosis-initial-therapy">UpToDate - Ascites in adults with cirrhosis: Initial therapy</a><br /></li><li><a href="https://www.dynamed.com/condition/ascites">DynaMed - Ascites</a><br /></li></ul><p></p>Soon Senghttp://www.blogger.com/profile/12198523062740513134noreply@blogger.com0tag:blogger.com,1999:blog-8600105966353098751.post-63202110584461734542024-03-04T15:12:00.005+08:002024-03-04T17:06:59.423+08:00Endometriosis<h2>Introduction</h2><p>Endometriosis is a common gynaecologic condition that affects females during their reproductive years, defined as the <b>growth of endometrial tissue outside the uterus</b>.</p><p></p><ul><li>Clinically, endometriosis can cause several symptoms with the most common being <a href="https://mypharmacistnote.blogspot.com/2021/11/primary-dysmenorrhoea.html">dysmenorrhea</a>, chronic pelvic pain, dyspareunia and infertility.</li><li>However, a patient can remain asymptomatic.</li></ul><p></p><p><br /></p><p><br /></p><h2>Management</h2><p>Medical management of endometriosis-related pain is non-specific and aimed at alleviating symptoms.</p><p>First-line treatment options include</p><p></p><ul><li><b><a href="https://mypharmacistnote.blogspot.com/2020/10/paracetamol.html">Paracetamol</a> or<a href="https://mypharmacistnote.blogspot.com/2020/10/nsaids.html"> NSAIDs</a></b></li><ul><li>A 3-month trial with or without hormonal therapies is recommended.</li></ul><li>Continuous administration of <b><a href="https://mypharmacistnote.blogspot.com/2021/07/combined-oral-contraceptives.html">combined hormonal contraceptives</a> or progestin alone </b>(e.g. dienogest, norethisterone and medroxyprogesterone).</li><ul><li>Oral progestogens are indicated if there is a contraindication to oestrogens and long-acting progestogens.</li><li>Patient acceptability of oral progestogens is poor due to the adverse effects such as breast tenderness, irregular bleeding and headaches. The usual length of treatment is 3 to 6 months, but longer or repeat courses are common. Their long-term use is limited by the risk of hypoestrogenism (affecting bone and possibly cardiovascular health).</li></ul></ul><p></p><p>For women with endometriosis-related pain refractory to initial treatment with oral contraceptives and NSAIDs, consider</p><p></p><ul><li>Empiric treatment with a 3-month course of <b>GnRH agonist (e.g. leuprolide IM injection, triptorelin IM injection, goserelin implant, nafarelin nasal spray) with hormone therapy</b></li><ul><li>GnRH agonists may cause hypoestrogenic adverse effects (e.g. hot flushes, vaginal dryness, decreased bone mineral density), which limit their duration of use to 6 months.</li><li>Oestrogen and progestogen replacement (with doses typically used for combined menopausal hormone therapy) reduce these adverse effects, allowing GnRH agonist use for up to 2 years.</li><li>Use GnRH agonists with caution in young people, particularly adolescents, because GnRH agonists may limit peak bone mass.</li></ul><li>Levonorgestrel-releasing intrauterine device (IUD)</li><li><b>Danazol</b></li><ul><li>Is reserved for use by specialists when other treatments are not tolerated.</li><li>It has significant adverse effects (e.g. hirsutism, acne, voice change, liver toxicity, dyslipidaemia, a small increase in the risk of ovarian cancer), and treatment duration is limited to 6 to 9 months.</li><li>An effective nonhormonal method of <a href="https://mypharmacistnote.blogspot.com/2021/07/contraception.html">contraception</a> must be used concurrently during treatment with danazol.</li></ul><li>Aromatase inhibitors, e.g. letrozole, anastrozole - <a href="https://mypharmacistnote.blogspot.com/2020/11/off-label-use.html">Off-label use</a></li></ul><p></p><p><b>Surgical management of endometriosis is indicated for treatment of severe pain or infertility.</b></p><p></p><ul><li>It involves laparoscopic removal or destruction of endometriotic tissue, or hysterectomy.</li></ul><p></p><p><br /></p><p><br /></p><h2>External Links</h2><p></p><ul><li><a href="https://tgldcdp.tg.org.au/">Therapeutic Guidelines - Endometriosis</a><br /></li><li><a href="https://pubmed.ncbi.nlm.nih.gov/20567196/">Practice bulletin no. 114: management of endometriosis, 2010</a><br /></li><li><a href="https://pubmed.ncbi.nlm.nih.gov/29787038/">NICE Endometriosis: diagnosis and management, 2017</a><br /></li></ul><p></p>Soon Senghttp://www.blogger.com/profile/12198523062740513134noreply@blogger.com0tag:blogger.com,1999:blog-8600105966353098751.post-49837123791514387562024-03-04T14:20:00.003+08:002024-03-04T14:20:22.966+08:00Raynaud Phenomenon<h2>Introduction</h2><p>Raynaud phenomenon is a common condition that is <b>triggered by exposure to cold and/or stress</b>, leading to vasospasm in the extremities (most commonly in the fingers and/or toes).</p><p></p><ul><li>The vasospasm causes the skin to turn white and then blue, which is followed by painful swelling when the affected areas warm and can result in amputation in severe cases.</li></ul><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiu_R_TwjSnCSoQ031zNYeAsv0D4NqnQEUXaAdANiuwEOt34nw7EGOsAXr94IL7yeDZq1SYQOUtdZecdZnnu8OfB3wzQKDSUs9QbJx_ROxlezpVerbwyQixEBYRFkk4DFg_vuxm26AGHqSkQtr7l3ZibZLCgkI6WjDdl_plITBiaH0iWqGLCdJB1U39WJE/s720/Raynaud%20Phenomenon.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img alt="Raynaud Phenomenon" border="0" data-original-height="720" data-original-width="648" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiu_R_TwjSnCSoQ031zNYeAsv0D4NqnQEUXaAdANiuwEOt34nw7EGOsAXr94IL7yeDZq1SYQOUtdZecdZnnu8OfB3wzQKDSUs9QbJx_ROxlezpVerbwyQixEBYRFkk4DFg_vuxm26AGHqSkQtr7l3ZibZLCgkI6WjDdl_plITBiaH0iWqGLCdJB1U39WJE/w288-h320/Raynaud%20Phenomenon.png" title="Raynaud Phenomenon" width="288" /></a></div><p><b>NOTE:</b> Raynaud phenomenon can be a primary condition or can occur secondary to a connective tissue disease (e.g. systemic sclerosis) or other disease (e.g. arthrosclerosis, malignancy)</p><br /><p style="text-align: center;"><br /></p><h2>Management</h2><p>For patients with uncomplicated Raynaud phenomenon (no progression to digital ulceration or critical ischemia), lifestyle changes are effective to control attacks.</p><p></p><ul><li>Avoid cold exposure, e.g. the use of gloves and warm clothing</li><li><a href="https://mypharmacistnote.blogspot.com/2021/06/smoking-cessation.html">Smoking cessation</a></li><li>Avoid vasoconstricting drugs, e.g. pseudoephedrine, phenylephrine, methylphenidate, beta blockers</li></ul><p></p><p>In more severely affected patients, particularly those with an underlying connective tissue disease, <b>vasodilators drugs may be used</b> to reduce vasospasm.</p><p></p><ul><li>For first line therapy, use a dihydropyridine calcium channel blocker (e.g. nifedipine)</li><li>Second-line therapy includes</li><ul><li>Intravenous prostanoids, e.g. iloprost</li><li>Phosphodiesterase-5 inhibitor, e.g. sildenafil</li><li>Topical glyceryl trinitrate (transdermal patches or ointment)</li><li><a href="https://pubmed.ncbi.nlm.nih.gov/10616013/">Angiotensin II receptor blockers, e.g. losartan</a></li><li><a href="https://pubmed.ncbi.nlm.nih.gov/3731684/">Alpha blockers, e.g. prazosin</a></li><li><a href="https://pubmed.ncbi.nlm.nih.gov/11561116/">Selective serotonin reuptake inhibitors (SSRIs), e.g. fluoxetine</a></li></ul></ul><p></p><p><br /></p><p><br /></p><h2>External Links</h2><p></p><ul><li><a href="https://www.uptodate.com/contents/treatment-of-raynaud-phenomenon-initial-management">UpToDate - Treatment of Raynaud phenomenon: Initial management</a><br /></li><li><a href="https://www.dynamed.com/condition/raynaud-phenomenon">DynaMed - Raynaud Phenomenon</a><br /></li></ul><p></p>Soon Senghttp://www.blogger.com/profile/12198523062740513134noreply@blogger.com0tag:blogger.com,1999:blog-8600105966353098751.post-19169371499113722602024-03-04T12:57:00.002+08:002024-03-04T13:43:27.891+08:00Myasthenia Gravis<h2>Introduction</h2><p>Myasthenia gravis is an autoimmune disease that attacks the connections between nerves and muscles, resulting in weakness in skeletal muscles (e.g. muscles that control the eyes, face, neck and limbs).</p><p></p><ul><li>In most cases, the <b>immune system targets the acetylcholine (ACh) receptor</b> (less commonly the muscle-specific tyrosine kinase MuSK).</li><li>Most often in females aged 10 to 30 years and males aged 50 to 70 years.</li></ul><p>Symptoms often include changes to the eyes/vision [e.g., double vision (diplopia), drooping eyelid (ptosis)], problems with chewing/swallowing and weakness in the neck and jaw.</p><p><br /></p><p><br /></p><h2>Management</h2><p><b>Cholinesterase inhibitors (specifically pyridostigmine) are the mainstay of treatment in myasthenia gravis, especially in ocular disease or mild generalized disease.</b></p><p></p><ul><li>Time the doses for when the patient is most fatigued (e.g. 30 to 45 minutes before meals when the patient has bulbar weakness).</li><li>Cholinergic effects can occur, e.g. salivation, lacrimation, excessive urination, diarrhoea.</li></ul><p>For more severe disease or when acetylcholinesterase inhibitors are inadequate, the next step is <b>immunosuppressive medication.</b></p><p></p><ul><li>Oral corticosteroids (e.g. prednisolone) should be the first-choice drug.</li><ul><li>May also be used to provide short-term benefit.</li><li>An uncommon effect of starting a high corticosteroid dose is that symptoms can get worse in the first 3 to 7 days, but this is transient.</li></ul><li>Azathioprine, cyclosporine or mycophenolate mofetil may be effective but have risks of severe adverse effects.</li></ul><p></p><p>Biologics that can be considered for generalized myasthenia gravis include</p><p></p><ul><li>Eculizumab</li><li>Ravulizumab</li><li>Zilucoplan</li><li>Efgartigimod</li><li>Rozanolixizumab</li><li>Rituximab (off-label second-line option)</li></ul><p></p><p>Some severe cases require treatment with <b>plasmapheresis or intravenous immunoglobulin (IVIG), or even thymectomy</b> (removal of the thymus gland - recommended for patients with thymoma)<b>.</b></p><p><br /></p><p><br /></p><h2>Drugs to Avoid or Use with Caution</h2><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiBpD4Nsrf7e-eLInxO-oIuoduQ3cw53Qih4jllIT5WTzGqpS69OVE75wgCPG3n6GqwWSjgCM3imtamqHCT_eEQVN8G_6mqnzXDI7CteoH3qi6N3qqoz1JftUBeE808vhIY24x3JhkZ6MrLL0oz4Fgjsei95QAi1NgM_C4WK7KF5J-TT9NmvrQYEasxNBQ/s1405/Drugs%20to%20Avoid%20in%20Myasthenia%20Gravis.png" style="margin-left: 1em; margin-right: 1em;"><img alt="Drugs to avoid or use with caution in patients with myasthenia gravis" border="0" data-original-height="1405" data-original-width="1233" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiBpD4Nsrf7e-eLInxO-oIuoduQ3cw53Qih4jllIT5WTzGqpS69OVE75wgCPG3n6GqwWSjgCM3imtamqHCT_eEQVN8G_6mqnzXDI7CteoH3qi6N3qqoz1JftUBeE808vhIY24x3JhkZ6MrLL0oz4Fgjsei95QAi1NgM_C4WK7KF5J-TT9NmvrQYEasxNBQ/w281-h320/Drugs%20to%20Avoid%20in%20Myasthenia%20Gravis.png" title="Drugs to avoid or use with caution in patients with myasthenia gravis" width="281" /></a></div><p><br /></p><p><br /></p><h2>External Links</h2><p></p><ul><li><a href="https://tgldcdp.tg.org.au/">Therapeutic Guidelines - Myasthenia gravis, including ocular myasthenia</a></li><li><a href="https://www.dynamed.com/condition/myasthenia-gravis">DynaMed - Myasthenia Gravis</a><br /></li></ul><p></p><p></p><p></p>Soon Senghttp://www.blogger.com/profile/12198523062740513134noreply@blogger.com0tag:blogger.com,1999:blog-8600105966353098751.post-55142241087468794392024-02-29T23:41:00.009+08:002024-02-29T23:46:30.007+08:00Systemic Lupus Erythematosus<h2>Introduction</h2><p>Systemic lupus erythematosus (SLE or commonly referred to as lupus) is <b>an autoimmune disease </b>associated with autoantibody production, primarily affects young women, with a female-to-male ratio of 10:1.</p><p></p><ul><li>The disease predominantly occurs in people age 15-45 years and it is more common in women of African-American and Asian descent.</li></ul><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiF9v8nUN00ZRT2k4mLt_IfTHr8mlMhi_xWx4CY3zTojPo29BsojO3hLWrcqe9_lRxu5eU6TrfA5yzxiU3c_6EHoeikimgGL3veSEgQc_fclj5zi15tocgnYLc9_A_9iHqIMkJSp2DiSbVJuuvj1MZ9T_4cw_8kcUNjLA4efaop86YFLP07odl6dJpIr50/s800/Lupus%20Malar%20Rash.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img alt="Lupus Butterfly Rash" border="0" data-original-height="800" data-original-width="632" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiF9v8nUN00ZRT2k4mLt_IfTHr8mlMhi_xWx4CY3zTojPo29BsojO3hLWrcqe9_lRxu5eU6TrfA5yzxiU3c_6EHoeikimgGL3veSEgQc_fclj5zi15tocgnYLc9_A_9iHqIMkJSp2DiSbVJuuvj1MZ9T_4cw_8kcUNjLA4efaop86YFLP07odl6dJpIr50/w158-h200/Lupus%20Malar%20Rash.jpg" title="Lupus Butterfly Rash" width="158" /></a></div><p><br /></p><p><br /></p><h2>Symptoms</h2><p>Systemic lupus erythematosus can involve almost any organ and may present in different ways.</p><p></p><ul><li>Fatigue is common, but does not help distinguish SLE from other diseases.</li><li>Arthritis and cutaneous manifestations [e.g. malar rash ("butterfly rash") and photosensitivity] are most common, but renal, hematologic and neurologic manifestations contribute largely to morbidity and mortality.</li></ul><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjB1DB2hv-BGFmJwnPgxLJfZbGepf5kHAvjvusYxV3W6pdtrLKBJss2Cg7uOlSmYIzKM6W8kDUA53-X6q_E9r57cLeTom3PVi1aBvp5n26-U9edFVobVFK_7Lp9HxQV2PdOFJ3n4LT68lq9ufOeJp7qIzl1oG3IitVtdrB8Fyq2IURplBU7jwkxZq4WkMw/s1193/SLE.png" style="margin-left: 1em; margin-right: 1em;"><img alt="SLE Signs and Symptoms" border="0" data-original-height="452" data-original-width="1193" height="121" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjB1DB2hv-BGFmJwnPgxLJfZbGepf5kHAvjvusYxV3W6pdtrLKBJss2Cg7uOlSmYIzKM6W8kDUA53-X6q_E9r57cLeTom3PVi1aBvp5n26-U9edFVobVFK_7Lp9HxQV2PdOFJ3n4LT68lq9ufOeJp7qIzl1oG3IitVtdrB8Fyq2IURplBU7jwkxZq4WkMw/w320-h121/SLE.png" title="SLE Signs and Symptoms" width="320" /></a></div><p><br /></p><p><br /></p><h2>Triggering Factors</h2><p>Factors such as sunlight, certain drugs and viral infection are known to trigger SLE, but the underlying cause is not fully understood.</p><p>Drugs that include lupus include</p><p></p><ul><li>Methimazole</li><li>Propylthiouracil</li><li>Methyldopa</li><li>Minocycline</li><li>Procainamide</li><li>Hydralazine</li><li>Anti-TNF agents</li><li>Terbinafine</li><li>Isoniazid</li><li>Quinidine</li></ul><p></p><p><b>NOTE:</b> Drug-induced lupus erythematosus (DILE) usually resolves within weeks after drug discontinuation.</p><p><br /></p><p><br /></p><h2>Management</h2><p>Ideally, the goal should be remission, but complete remission with the absence of clinical activity and no use of glucocorticoids or immunosuppressive therapy is rare.</p><p></p><ul><li><b>Mild symptoms can be managed with <a href="https://mypharmacistnote.blogspot.com/2020/10/nsaids.html">NSAIDs</a></b> with or without other analgesics.</li><li><b>Hydroxychloroquine</b></li><ul><li>is recommended for all patients with SLE and is the cornerstone of therapy.</li><li>Due to the risk of <a href="https://mypharmacistnote.blogspot.com/2023/12/medication-induced-ophthalmic-issues.html">retinal toxicity</a>, most patients should not receive a daily dose >5 mg/kg/day using actual body weight or 400 mg, whichever is lower.</li></ul><li><b>Corticosteroids</b></li><ul><li>Are used to most forms of SLE and up to 57-86% of patients receive continuous or chronic therapy.</li><li>Chronic use of any dose is associated with cardiovascular complications, psychological disturbances, <a href="https://mypharmacistnote.blogspot.com/2021/06/glaucoma.html">glaucoma</a>, <a href="https://mypharmacistnote.blogspot.com/2021/11/cataract.html">cataracts</a>, hyperglycaemia, weight gain, avascular necrosis of bone, and <a href="https://mypharmacistnote.blogspot.com/2021/08/osteoporosis.html">osteoporosis</a>.</li><li>Hence, if glucocorticoid use is required, treatment should be minimized and tapered as soon as possible. Moreover, initiation of immunomodulatory agents may also aid in tapering.</li></ul><li>In patients who are not responding to hydroxychloroquine (alone or in combination with glucocorticoids) or patients who are unable to reduce oral prednisolone dose (or equivalent) ≤7.5 mg/day, consider the addition of</li><ul><li><b>Immunosuppressive agents</b>, such as methotrexate, azathioprine, mycophenolate mofetil, cyclophosphamide.</li><li><b>Biologics</b>, such as anifrolumab, belimumab, rituximab.</li></ul></ul><p></p><p>Lifestyle modifications</p><p></p><ul><li>Rest and proper exercise to manage the fatigue.</li><li><b>Weight control.</b></li><li><b><a href="https://mypharmacistnote.blogspot.com/2021/06/smoking-cessation.html">Smoking cessation</a></b> is encouraged since tobacco smoke can exacerbate SLE and diminish the effectiveness of antimalarials and belimumab.</li><li>Since <a href="https://mypharmacistnote.blogspot.com/2021/08/drug-induced-photosenstivity.html">photosensitivity</a> is common in SLE, <b><a href="https://mypharmacistnote.blogspot.com/2020/10/sunscreen-spf.html">sunscreens and sun protection/avoidance</a> are recommended.</b></li></ul><p></p><p><br /></p><p><br /></p><h2>External Links</h2><p></p><ul><li><a href="https://www.uptodate.com/contents/overview-of-the-management-and-prognosis-of-systemic-lupus-erythematosus-in-adults">UpToDate - Overview of the management and prognosis of systemic lupus erythematosus in adults</a><br /></li><li><a href="https://www.dynamed.com/condition/systemic-lupus-erythematosus-sle-in-adults">DynaMed - Systemic Lupus Erythematosus (SLE) in Adults</a><br /></li><li><a href="https://ard.bmj.com/content/83/1/15">EULAR recommendations for the management of systemic lupus erythematosus: 2023 update</a></li></ul><p></p><p></p>Soon Senghttp://www.blogger.com/profile/12198523062740513134noreply@blogger.com0tag:blogger.com,1999:blog-8600105966353098751.post-50423755839729036692024-02-28T20:33:00.000+08:002024-03-08T23:22:32.530+08:00Teaching<h2>Introduction</h2><p>The third <a href="https://www.who.int/">World Health Organization</a> Consultative Group on the Role of the Pharmacist held in 1997 proposed the concept of "<a href="https://www.jyoungpharm.org/sites/default/files/10.5530_jyp.2014.2.1.pdf">Seven-Star Pharmacist</a>".</p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEijmB7Gb5LqYgsan3UY1ds3UV2P7AzJ6jFIUf0ux6Md9ccuy6dSPFqHm3NpEy8Ble2xt_T4AxdU9Kd49Vb4P5_N7Sj8MKkm_te0kbh8fRoI079qUmYtRmdlJFzn_P4Cjhm1cEC3lT1JRglZIN-7dG6YD_mg-78FyLml3jMc9CQYDNEpQcF3cjvm-o1u/s683/7star.png" style="margin-left: 1em; margin-right: 1em;"><img alt="WHO Seven-Star Pharmacist" border="0" data-original-height="417" data-original-width="683" height="195" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEijmB7Gb5LqYgsan3UY1ds3UV2P7AzJ6jFIUf0ux6Md9ccuy6dSPFqHm3NpEy8Ble2xt_T4AxdU9Kd49Vb4P5_N7Sj8MKkm_te0kbh8fRoI079qUmYtRmdlJFzn_P4Cjhm1cEC3lT1JRglZIN-7dG6YD_mg-78FyLml3jMc9CQYDNEpQcF3cjvm-o1u/w320-h195/7star.png" title="WHO Seven-Star Pharmacist" width="320" /></a></div><p>One of the pharmacist's key responsibilities is to assist with the <b>education and training of future generations of pharmacists and the public</b>.</p><p></p><ul><li>My English teacher's words still ring true: "The more you use what I teach, the more it becomes your own." This sentiment deeply resonates with my passion for knowledge sharing.</li></ul><p></p>While figuring on how to be a good preceptor, I also wish to forget this single obligation because <b>it is exhausting yet not rewarding and demotivating</b>.<br /><ul><li>Not many provisional registered pharmacists enjoyed being bombarded by numerous medical questions daily.</li><li>On the other hand, preceptors often lack dedicated recognition for their efforts. To illustrate, preceptors cannot even earn a single penny when they take the effort to guide you the proper way.</li></ul><p><b>NOTE:</b> Isn't life too fake if we all practice <a href="https://www.google.com/amp/s/www.rightattitudes.com/2008/02/20/sandwich-feedback-technique/amp/">sandwich feedback technique</a>?</p><p style="text-align: center;"><img alt="Sandwich Feedback Technique" border="0" data-original-height="479" data-original-width="931" height="165" src="https://blogger.googleusercontent.com/img/a/AVvXsEjjMSA0CPcMHzUXr9MbxPXxykXSWL6RTrzfYbytmlFEinB3FCe4e8iViZjqoIuiuOX6bRZ4r3BCuUmEZQzHzEU-LjdbSaPV0StfJztvH4UHAdBCzRF2k3HKHscTJPTIDdRO2BtUsrIRUlXMmfj-4bcOw07nDZVX6kobi6omjNRn-bxNnaH5d9WwnLJs=w320-h165" title="Sandwich Feedback Technique" width="320" /></p><p><br /></p><p><br /></p><h2>Experience Sharing</h2><p>I believe, our method of teaching is mostly modelled based on <b>past experience</b> (that is how I was trained when I was once a provisional registered pharmacist) and <b>how we think it should be</b>.<br /></p><p></p><ul><li>Hence, I often tell fresh fully registered pharmacists, "starting from this moment, you can show how you would guide fresh provisional registered pharmacist differently from previous personal experience".</li></ul><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj8fnpplr-whLLeGk45RIV8y3F_vQw2nZSX-zFZWqglEXuEg9xPloa3yk4aEmVGsPV0bzhegv3KWvoxj7_EsjOHETm1vEpyNvmJD4uqiC8IMv2bDCTqX5dKVA-JuxUuECicZoUo2A5LCc0t7Iafmr2pkQ2KNjf0kctltVb0ntrBnY8ZNW2K4nfG837O/s800/1635057197636.jpg" style="margin-left: 1em; margin-right: 1em;"><img alt="Be the Senior You Needed When You Were A Junior" border="0" data-original-height="640" data-original-width="800" height="256" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj8fnpplr-whLLeGk45RIV8y3F_vQw2nZSX-zFZWqglEXuEg9xPloa3yk4aEmVGsPV0bzhegv3KWvoxj7_EsjOHETm1vEpyNvmJD4uqiC8IMv2bDCTqX5dKVA-JuxUuECicZoUo2A5LCc0t7Iafmr2pkQ2KNjf0kctltVb0ntrBnY8ZNW2K4nfG837O/w320-h256/1635057197636.jpg" title="Be the Senior You Needed When You Were A Junior" width="320" /></a></div><p>From my personal experience, teaching should not focus only on developing a detailed syllabus, but to <b>consider their personal goals of the rotation.</b></p><p></p><ul><li>When I was fresh in this pharmacy profession, I was too ambitious. I aimed to pass down all my knowledge and experience to provisional registered pharmacists in rotation, and at the same time, I was expecting them to be on the active learning mode.</li><li>However, very soon, I realised it is a mission impossible.</li><li><b>You can easily demand yourself to put extra effort in self-learning, but practically not possible to force anyone to learn more.</b></li><li>Meanwhile, I often ponder on the times when I demand high performance standard from provisional registered pharmacists, am I being too strict or overexpecting again? Or should I be the everyone else, focusing on the works at hand only? Why should I be frustrated due to disappointment?</li></ul><p></p><p>Nonetheless, I realise, when we become more senior, we start to build up more patience to guide them, perhaps because we have seen worse cases where things could go wrong.</p><p></p><ul><li>More importantly, we also reach the same conclusion that <b>it is your own responsibility to make sure that you learn from what you do.</b></li></ul><p></p><p><br /></p><p><br /></p><h2>Cycles of Training</h2><p><a href="https://mypharmacistnote.blogspot.com/2020/10/provisional-registered-pharmacist.html">Provisionally registered pharmacists</a> may not see their experience as part of a larger training cycle. However, for each batch of fresh pharmacy graduates, we slowly guide them from scratch, aiming for them to be proficient by the year's end.</p><p></p><ul><li>Supervisors may find it frustrating to train provisional registered pharmacists from novice to competent, only to have them leave and the cycle begin anew with the next batch.</li><li>Often, <b>the same mistakes are repeated by different people of the same or different batch</b>. To a certain extent, the frustration has built up and the enthusiasm has lost.</li></ul><p></p><p>As you progress in your pharmacy career and become a senior pharmacist yourself, you gain a deeper understanding of why senior pharmacists set expectations and make demands of new graduates.</p><p></p><ul><li>Looking back on our provisional registered pharmacist journey, are we really the best students that our senior pharmacists expecting?</li><li>Or rather, we did numerous silly mistakes or do not have adequate knowledge and experience in the first year.</li></ul><p></p><p><b>Everyone is learning on their own pace and picking up the skills and confidence </b>along the journey<b>.</b></p><p></p><ul><li>However, this is just an excuse if you are not actively learning new things for self-improvement.</li><li>You shall not blame as if seniors know more because they have more working experience (<b>BUT</b> they also put in extra efforts to learn up).</li></ul><p></p><p><br /></p><p><br /></p><h2>Mutualism</h2><p>As human beings, it is important to <b>mutual respect for another other</b>.</p><p></p><ul><li>We should not harbour thoughts of superiority or consider ourselves better than others.</li><li>Gone are the days where we were the fresh ones, and the juniors will also grow older and may become your colleagues.</li></ul><p></p><p>Most importantly, we should not perceive juniors as not giving their best effort, as they too face significant stress in completing their tasks.</p><p></p><ul><li><b>They have other commitments in life as well.</b></li></ul><p></p><p>Let us not forget the ultimate goal of mutualism. <b>Senior pharmacists can share their experiences with junior pharmacists, while the juniors can provide updates on current medical knowledge.</b></p><p></p><ul><li>It is always interesting to explore an issue from a <a href="https://mypharmacistnote.blogspot.com/2022/09/perspectives.html">different perspective</a>.</li></ul><p></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhxQ7cusHLL6COH_zs-puQfdQ3ycBi8LzFDeJ0amwvkSYZETs4KBOudP0843BoaB00_q0vBJ3oPrscbrCWwHtOkcYFL0VrNvpxZDMkyvixCwVX0nrRHdQR2TM1wGmN6TTHznlrRGgEFxCxUH_bxv3sJngmiCO1Y1vbpsSxzluYA1M8yMNg3XZPnnJ4v/s3840/1725151-Phil-Collins-Quote-In-learning-you-will-teach-and-in-teaching-you.jpg" style="margin-left: 1em; margin-right: 1em;"><img alt="In Learning You Will Teach and In Teaching You Will Learn" border="0" data-original-height="2160" data-original-width="3840" height="180" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhxQ7cusHLL6COH_zs-puQfdQ3ycBi8LzFDeJ0amwvkSYZETs4KBOudP0843BoaB00_q0vBJ3oPrscbrCWwHtOkcYFL0VrNvpxZDMkyvixCwVX0nrRHdQR2TM1wGmN6TTHznlrRGgEFxCxUH_bxv3sJngmiCO1Y1vbpsSxzluYA1M8yMNg3XZPnnJ4v/w320-h180/1725151-Phil-Collins-Quote-In-learning-you-will-teach-and-in-teaching-you.jpg" title="In Learning You Will Teach and In Teaching You Will Learn" width="320" /></a></div><p><br /></p><p><br /></p><h2>Summary</h2><p><b>To teach is to have passion</b> and dedication for others, a selfless giving of your time and commitment.</p><p></p><ul><li>Believe me, it is not an easy task to undertake the teaching role.</li><li>Some pharmacists may have vast knowledge and expertise in certain clinical areas, but they may have forgotten the challenges they face as provisional registered pharmacists, which can make it difficult for them to communicate effectively with provisional registered pharmacists at their level.</li></ul><p></p><p>But, remember this: <b>Every fresh pharmacy graduate is like a blank cake.</b></p><p></p><ul><li>It is unlikely that any preceptors can transform them into biscuits, as they are inherently cakes.</li><li>What we do is decorate them through provisional registered training, enabling them to better cope with future challenges.</li></ul><p></p><p><b>NOTE:</b> It is sometimes funny to think that though we may learn a topic in detail (steps by steps, down to molecular level), but then we are summarizing the information to give an overall description when explaining in lay man to a patient.</p><p><br /></p><p><br /></p><h2>External Links</h2><p></p><ul><li><a href="https://www.jyoungpharm.org/sites/default/files/10.5530_jyp.2014.2.1.pdf">Seven-Star Pharmacist Concept by WHO, 2014</a></li><li><a href="https://www.tldrpharmacy.com/content/what-kind-of-preceptor-are-you">What Kind of Preceptor Are You?, 2021</a><br /></li></ul><p></p>Soon Senghttp://www.blogger.com/profile/12198523062740513134noreply@blogger.com0tag:blogger.com,1999:blog-8600105966353098751.post-24944600133512023512024-02-24T10:28:00.000+08:002024-02-24T10:28:23.255+08:00Artificial Intelligence<h2>Introduction</h2><p>Artificial intelligence has been both feared and embraced as an essential component of technology.</p><p></p><ul><li>While some have worried that AI could eventually lead to the extinction of humanity, others have been fascinated by the possibilities it presents.</li></ul><p></p><p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/k64P4l2Wmeg" title="YouTube video player" width="560"></iframe></p><p><br /></p><p><br /></p><h2>AI Chatbots</h2><p>Recently, there have been exciting developments in the field of AI, including the launch of conversational AI models such as <a href="https://chat.openai.com/">ChatGPT</a> by OpenAI, <a href="https://copilot.microsoft.com/">Microsoft Copilot</a> and <a href="https://gemini.google.com/app">Gemini</a>. These tools can generate plausible-sounding yet precise answers to a wide range of questions.</p><p></p><ul><li>In fact, <a href="https://chat.openai.com/">ChatGPT</a> may pass <a href="https://www.thestar.com.my/tech/tech-news/2023/01/26/chatgpt-bot-passes-us-law-school-exam">law school</a>, <a href="https://www.medscape.com/viewarticle/987549">medical school</a>, or <a href="https://www.independent.co.uk/tech/chatgpt-mba-exam-wharton-professor-b2267919.html">MBA</a> exam.</li><li>However, the rise of AI also raises concerns about job displacement and the potential for cheating in education.</li></ul><p></p><p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/Fn8jDanbf0c" title="YouTube video player" width="560"></iframe></p><p>Despite its impressive capabilities, <a href="https://chat.openai.com/">ChatGPT</a> will not <a href="https://www.livemint.com/opinion/columns/will-chatgpt-replace-google-asour-go-to-web-search-platform-11671733523981.html">replace Google Search</a>, because</p><div><ul><li>Life is complicated and conflicting in nature, saturated with grey areas.</li><li>Humans like to hear a second opinion.</li><li>Since ChatGPT was trained on a diverse range of text data (with no accuracy check in place), the answers from ChatGPT are not perfect and should not be relied on as the sole source of information.</li></ul></div><p><br /></p><p><br /></p><h2>ChatGPT vs Microsoft Copilot vs Gemini</h2><p>Although <a href="https://chat.openai.com/">ChatGPT</a> by OpenAI, <a href="https://copilot.microsoft.com/">Microsoft Copilot</a> and <a href="https://gemini.google.com/app">Gemini</a> by Google are all large language models that are trained on a massive dataset of text and code and answers your questions in an informative way, each performs differently.</p><p><b>ChatGPT by OpenAI</b></p><p></p><ul><li>Strengths</li><ul><li>Free unlimited access for ChatGPT-3.5 model.</li><li>Can generate creative text formats.</li><li>Capable of learning from prior exchanges.</li></ul><li>Weaknesses</li><ul><li>Verbose in response.</li><li>Free version is confined to 2021 training data.</li><li>Answers can be incorrect although sound logical and professional.</li></ul></ul><p></p><p><b>Microsoft Copilot (previously known </b><b>as "Bing Chat")</b></p><p></p><ul><li>Strengths</li><ul><li>Based on GPT-4 model, but information is more precise than ChatGPT.</li><li>Content can be generated in 3 different conversation styles: Creative, Balanced and Precise.</li><li>The information is often linked to relevant websites.</li><li>Can also <a href="https://www.theverge.com/2023/10/3/23901963/bing-chat-dall-e-3-openai-image-generator">generate images using the DALL-E 3 AI Image Generator</a>.</li></ul><li>Weaknesses</li><ul><li>Limited to 30 images per day for image creation, although <a href="https://mspoweruser.com/microsoft-lifts-free-copilot-daily-limit-rolling-out-amidst-buzz-over-paid-copilot-pro-plan/">the previous maximum of 300 chats per day has been lifted</a>.</li></ul></ul><p></p><p><b>Gemini by Google (previously known as "Google Bard")</b></p><p></p><ul><li>Strengths</li><ul><li>Can be helpful in synthesizing insights.</li><li>Good at suggesting article improvements.</li><li>Users able to see up to 3 different drafted answers per user prompt.</li><li>Able to interact with information from your Gmail, Docs and Drive.</li><li>Able to create images but not as excellent as Microsoft Copilot.</li></ul><li>Weaknesses</li><ul><li>Does not have the ability to access information from an external website.</li></ul></ul><p></p><p>All in all, AI chat is a powerful language tool that is able to rewrite contents based on the data that it has been trained on, but lacking actual intelligence or critical thinking.</p><p><br /></p><p><br /></p><h2>Her</h2><div><p>There is much debate about whether humans can develop an emotional connection with artificial intelligence. While it may seem unlikely at first, it is possible that AI could eventually become sophisticated enough to understand our feelings and interact with us on a personal level.</p><p></p><ul><li>In today's world,<b> many people feel isolated and lacking in social support.</b> AI could provide a listening ear and a sense of companionship by attentively listening our rants each day and providing daily motivation.</li><li>With their constant availability, they can always be there for us whenever needed.</li></ul><p></p></div><p></p><p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/dJTU48_yghs" title="YouTube video player" width="560"></iframe></p><p><br /></p><p><br /></p><h2>Summary</h2><p>The world is changing rapidly.</p><p></p><ul><li>To stay ahead of the curve, we should actively embrace artificial intelligence and its potential.</li></ul><p>Personally, I have leveraged AI chatbots to enhance the grammar and flow of my articles.</p><p></p><ul><li>However, it is crucial to remember that <b>these tools primarily remixes existing information and lack the capacity to generate truly original ideas or concepts.</b></li></ul><p></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhQ0cbehD-WdPaTLALbJCEbnJaS4o-wDB1l6gm7GSdSc1XqkUN7r11EmSAYTJAKV1pqIwFw238mACqbM6HtdnRGjQPVHjy7rPwBZUTB3gEeHp_477V5I7qgPkITntF_ueLO0gulkIaZYdMOWSXuvRR1AVjUfcs8fuUHnyZIxtheX15vRD7DxP_Bv0l0QX8/s958/960x0.webp" style="margin-left: 1em; margin-right: 1em;"><img alt="Embracing Artificial Intelligence" border="0" data-original-height="638" data-original-width="958" height="213" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhQ0cbehD-WdPaTLALbJCEbnJaS4o-wDB1l6gm7GSdSc1XqkUN7r11EmSAYTJAKV1pqIwFw238mACqbM6HtdnRGjQPVHjy7rPwBZUTB3gEeHp_477V5I7qgPkITntF_ueLO0gulkIaZYdMOWSXuvRR1AVjUfcs8fuUHnyZIxtheX15vRD7DxP_Bv0l0QX8/w320-h213/960x0.webp" title="Embracing Artificial Intelligence" width="320" /></a></div><p><br /></p><p><br /></p><h2>External Links</h2><ul><li><a href="https://www.thestar.com.my/tech/tech-news/2023/01/26/chatgpt-bot-passes-us-law-school-exam">ChatGPT bot passes US law school exam, 2023</a><br /></li><li><a href="https://www.independent.co.uk/tech/chatgpt-mba-exam-wharton-professor-b2267919.html">Concerns mount as ChatGPT passes MBA exam given by Wharton professor, 2023</a></li><li><a href="https://www.zdnet.com/article/what-is-chatgpt-and-why-does-it-matter-heres-everything-you-need-to-know/">What is ChatGPT and why does it matter? Here's what you need to know, 2023</a><br /></li><li><a href="https://searchengineland.com/microsoft-bing-search-chatgpt-392789">The new Bing: Microsoft unveils its ChatGPT-like, AI-powered search engine, 2023</a><br /></li><li><a href="https://www.theverge.com/2023/5/10/23718066/google-bard-ai-features-waitlist-dark-mode-visual-search-io">Google drops waitlist for AI chatbot Bard and announces oodles of new features, 11 May 2023</a><br /></li><li><a href="https://www.digitalnewsasia.com/business/ramsay-sime-darby-health-care-collaborates-annaliseai-and-aws-deploy-ai-tool-clinicians">Ramsay Sime Darby Health Care collaborates with Annalise.ai and AWS to deploy AI tool for clinicians, 28 July 2023</a><br /></li><li><a href="https://www.microsoft.com/en-us/bing/do-more-with-ai/image-creator-improvements-dall-e-3?form=MA13KP">Bing Image Creator improvements with DALL-E 3, 21 Nov 2023</a><br /></li><li><a href="https://www.zdnet.com/google-amp/article/what-is-copilot-formerly-bing-chat-heres-everything-you-need-to-know/">What is Copilot (formerly Bing Chat)? Here's everything you need to know, 2024</a><br /></li><li><a href="https://mspoweruser.com/microsoft-lifts-free-copilot-daily-limit-rolling-out-amidst-buzz-over-paid-copilot-pro-plan/">Microsoft lifts free Copilot daily limit, rolling out amidst buzz over paid Copilot Pro plan, 2024</a><br /></li></ul>Soon Senghttp://www.blogger.com/profile/12198523062740513134noreply@blogger.com0tag:blogger.com,1999:blog-8600105966353098751.post-77455354153255275952024-02-21T23:02:00.001+08:002024-03-15T22:37:35.078+08:00In-Use Shelf-Life<h2>Introduction</h2><p><a href="https://www.fda.gov/drugs/pharmaceutical-quality-resources/expiration-dates-questions-and-answers">Drug expiration dates</a> reflect the time period during which the product is known to remain stable when it is stored according to its labelled storage conditions.</p><p>Nonetheless, at work, many patients may ask you, how long more you can keep using a solution or cream once opened. Or sometimes, is it still fine to keep using an expired medication?</p><p><b>The old adage that "all good things come to an end" applies this situation very well.</b></p><p></p><ul><li>Medications last longer (up to expiry date) when they are stored unopened.</li><li>Using expired medications may cause harm or it has lost its effectiveness over time.</li></ul><p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/1mcS27CUja8?si=5LfQT_FUg-a--_qZ" title="YouTube video player" width="560"></iframe><br /></p><p><br /></p><p><br /></p><h2>Antibiotic Suspension</h2><p>Please refer to products leaflet since the recommendation is brand specific.</p><p><b>Amoxicillin 200 mg and Clavulanate 28 mg per 5 ml Syrup</b></p><ul><li><i>Augmentin</i> - The dry powder should be stored in unopened containers in a dry place at below 25°C. Reconstituted suspension should be stored in a refrigerator (2-8°C) and used within 7 days.</li><li><i>Clamovid BID</i><b> </b>- Refrigerate and use within 7 days after reconstitution.</li><li><i>Fleming</i><b> </b>- The dry powder should be stored below 30°C in unopened container in a dry place. Reconstituted suspensions should be stored in a refrigerator (2-8°C) and used within 7 days.</li></ul><p><b>Amoxicillin Trihydrate 125 mg/5 ml and 250 mg/5ml Syrup</b></p><ul><li><i>Betamox</i><b> - </b>Store below 30°C. Protect from light. After reconstitution, store between 2-8°C and to be used within 7 days after mixing.</li><li><i>Dyna Amoxycillin</i><b> </b>- Keep refrigerated and to be used within 7 days of mixing.</li></ul><p><b>Ampicillin Sodium and Sulbactam Sodium 250 mg/5 ml Suspension</b></p><ul><li><i>Unasyn</i><b> - </b>Store below 30°C. The reconstituted oral suspension must be stored under refrigeration and discarded after 14 days.</li></ul><p><b>Ampicillin Trihydrate 125 mg/5 ml Suspension</b></p><ul><li><i>Ampicilla</i><b> </b>- Once reconstituted, refrigerate and use within 7 days.</li><li><i>Dyna Ampicillin</i> - Keep refrigerated (2-8°C) after reconstitution. To be used within 7 days of mixing.</li></ul><p><b>Azithromycin 200 mg/5 ml Granules</b></p><ul><li><i>Binozyt</i><b> </b>- The prepared suspension can be kept at up to 30°C for 5 days.</li><li><i>Imexa</i><b> </b>- For both powder and reconstituted suspension, keep container well closed, store below 30°C and protect from light. Use within 5 days after reconstitution.</li><li><i>Kidimac</i><b> - </b>Before reconstitution, store below 30°C. After reconstitution, store the suspension at 25°C to 30°C. Reconstituted suspension should be used within 10 days. Discard the reconstituted suspension if more than 10 days. Do not freeze.</li><li><i>Zithrolide</i><b> - </b>Dry powder (unopen bottle), store below 30°C. Once reconstituted with water, store in refrigerator at 2-8°C. Once reconstituted with water, the suspension has a shelf life of 5 days.</li><li><i>Zithromax</i> - Store below 30°C for the powder and the reconstituted suspension. Shelf-life is 5 days for the reconstituted product.</li><li><i>Zynomax</i><b> </b>- Store below 30°C for powder reconstituted suspension. The reconstituted suspension form lasts up to 5 days.</li></ul><p><b>Cefuroxime Axetil 125 mg/5 ml Suspension</b></p><ul><li><i>Axcel</i><b> </b>- Store below 30°C. Protect from light. After reconstitution, refrigerate between 2-8°C and use within 10 days.</li><li><i>Zinnat</i> - The unreconstituted suspension should be stored below 30°C. The reconstituted suspension when refrigerated between 2 and 8°C can be kept for up to 10 days.</li></ul><div><b>Cephalexin 125 mg/5 ml Syrup</b></div><ul><li><i>Axcel</i><b> </b>- Store below 30°C until reconstituted. After reconstitution, refrigerate between 2°C to 8°C and use within 7 days.</li><li><i>Dynalexin Dry Syrup</i><b> </b>- Store in a dry place below 25°C. Protect from light. Keep refrigerated after reconstitution. To be used within 7 days of mixing.</li><li><i>MPI</i><b> - </b>Before mixing, store in a cool, dry place (15-25°C). Avoid moisture and heat. After mixing, store in refrigerator (2-8°C) and use within 5 days.</li><li><i>Uphalexin</i><b> - </b>Store below 30°C, until reconstituted. After reconstitution, refrigerate between 2°C to 8°C and use within 7 days.</li></ul><p><b>Clarithromycin 125 mg/5 ml and 250 mg/5 ml Granules</b></p><ul><li><i>Klacid</i><b> </b>- Store at room temperature (below 30°C) in a well-closed container. Do not refrigerate the reconstituted suspension; store at room temperature.</li></ul><p><b>Cloxacillin Sodium 125 mg/5 ml Suspension</b></p><ul><li><i>Cloxacilla</i><b> </b>- Powder for dry syrup, need no refrigeration until reconstituted. Once reconstituted, refrigerate and use within 7 days.</li><li><i>Oxacil</i><b> </b>- Store in a dry place below 30˚C. Protect from light. Store in the refrigerator after reconstitution. Discard 7 days after reconstitution. Consume within 12 months after opening the pouch.</li></ul><p><b>Erythromycin Ethylsuccinate 200 mg/5 ml Suspension</b></p><ul><li><i>Ericin</i><b> - </b>Keep in refrigerated after reconstituted (2-8°C) and use reconstituted suspension within 7 days.</li></ul><p><b>Erythromycin Ethylsuccinate 400 mg/5 ml Suspension</b></p><ul><li><i>Eryson </i>- Discard 7 days after reconstitution. Store tightly closed in refrigerator after reconstitution.</li></ul><p><br /></p><p><br /></p><h2>Antiviral Suspension</h2><p><b>Abacavir 20 mg/ml Oral Solution</b></p><p></p><ul><li><i>Ziagen</i> - Discard oral solution 2 months after first opening.</li></ul><p></p><p><b>Lamivudine 10 mg/ml Oral Solution</b></p><p></p><ul><li><i>3TC</i> - Store at or below 30°C. Discard one month after first opening.</li></ul><p></p><div><p><b>Lopinavir 80 mg and Ritonavir 20 mg per ml Oral Solution</b></p><p></p><ul><li><i>Kaletra</i><b> - </b>Store Kaletra oral solution at 2-8°C until dispensed. For patient use, refrigerated Kaletra oral solution remains stable until the expiration date printed on the label. If stored at room temperature up to 25°C, oral solution should be used within 2 months.</li></ul><p></p><p><b>Oseltamivir 60 mg/5 ml Powder for Oral Suspension</b></p><p></p><ul><li><i>Fluhalt</i> - Before mixing, store below 30˚C, protected from moisture. Store the prepared suspension under refrigeration (2-8˚C) and use within 14 days.</li></ul><p></p><p><b>Nevirapine 50 mg/5 ml Oral Suspension</b></p><p></p><ul><li><i>Nevirex</i> - Do not store above 30°C. The product should be used within 2 months of opening.</li></ul><p></p><p><b>Zidovudine 10 mg/ml Syrup</b></p><p></p><ul><li><i>Retrovir</i> - Discard 1 month after first opening.</li></ul><p></p><p><br /></p><p><br /></p><div><h2>Ear Drops</h2><p>Unless mentioned otherwise, discard 28 days after opening.</p><p><b>Ear Wax Softener</b></p><ul><li><i>Cerumol</i> - Discard the drop 6 months after opening.</li></ul><p><b>Chloramphenicol 5% Ear Drop</b></p><ul><li><i>Enclor</i> - Store at 2°C-8°C. Protect from light and freezing. Discard after 30 days from date of opening.</li></ul><p><b>Dexamethasone Sodium Phosphate 0.1% and Neomycin Sulphate 0.5% Eye/Ear Drop</b></p><ul><li><i>Neo-Deca</i><b> </b>- Discard 4 weeks after opening.</li></ul><p><b>Gentamicin 0.3% Eye/Ear Drop</b></p><ul><li><i>Beagenta</i> - Do not use 1 month after first opening.</li></ul><p><b>Gentamicin Sulphate 0.3% and Betamethasone 0.1% Eye/Ear Drop</b></p><ul><li><i>Betagen</i><b> </b>- The bottle should be disposed of 4 weeks after opening.</li></ul><p><b>Ofloxacin 0.3% Otic Solution</b></p></div><div><ul><li><i>Tarivid</i><b> </b>- This product exhibits good stability for 4 months at room temperature (25°C) after opening.</li></ul></div><p><br /></p><p><br /></p><h2>Eye Drops and Ointments</h2><p>Unless mentioned otherwise, with preservative: Discard 28 days after opening. Without preservative: Discard after each use.<br /></p><p><b>Artificial Tears/Eye Lubricant Ophthalmic Gel</b></p><ul><li><i>GenTeal Gel</i><b> - </b>Once the tube has been opened, discard any remaining product after 3 months.</li><li><i>Hylo Gel</i> - Can be used for 6 months after opening.</li><li><i>Refresh Liquigel</i><b> </b>- Discard 1 month after opening.</li><li>Systane Gel Drops - Discard any remaining solution 3 months after first opening.</li><li><i>Vismed Gel Multi</i><b> </b>- Can be used up to 3 months after first use.</li></ul><p><b>Artificial Tears/Eye Lubricant Ophthalmic Solution</b></p><ul><li><i>Eye Glo Moist</i><b> </b>- Discard contents 4 weeks after opening.</li><li><i>GenTeal</i><b> - </b>Once the bottle is opened, discard any remaining solution after 3 months.</li><li><i>Hialid 0.1%</i><b> </b>- Discard contents 1 month after opening.</li><li><i>Hylo Comod</i><b> </b>- Can be used for 6 months after opening.</li><li><i>Optavid</i><b> </b>- Discard the contents 28 days after first opening.</li><li><i>Optavid Advance</i><b> - </b>Discard the contents 28 days after first opening.</li><li><i>Optive</i><b> </b>- Discard 90 days after opening.</li><li><i>Optive Advanced</i><b> </b>- Discard 90 days after opening.</li><li><i>Optive Fusion</i><b> </b>- Discard 90 days after opening.</li><li><i>Optrex Refreshing</i> - Discard 3 months after first opening.</li><li><i>Refresh Tears</i> - Discard 1 month after opening.</li><li><i>Systane Balance</i> - Discard any remaining product 6 months after first opening.</li><li><i>Systane Complete</i> - Discard any remaining emulsion 3 months after first opening.</li><li><i>Systane Hydration</i> - Discard any remaining solution 3 months after first opening.</li><li><i>Systane Ultra</i> - Discard any remaining solution 6 months after first opening.</li><li><i>Systane Ultra UD (Preservative Free)</i><b> </b>- Discard any remaining solution after use. Do not save solution in an opened vial.</li><li><i>Tears Naturale II</i><b> </b>- Discard 6 months after opening.</li><li><i>Tears Naturale Free</i><b> - </b>Discard remaining contents after use. Do not save solution in an opened vial.</li><li><i>Vismed Multi</i><b> </b>- Can be used up to 3 months after first use.</li></ul><p><b>Artificial Tears/Eye Lubricant Ophthalmic Ointment</b></p><ul><li><i>Duratears Lubricanting Eye Ointment</i> - Discard one month after first opening.</li><li><i>Lacri-Lube Lubricating Eye Ointment (Preservative Free)</i><b> </b>- Discard unused contents 6 months after opening.</li></ul><p><b>Atropine Sulphate 1% Eye Drop</b></p><ul><li><i>Isopto*-Atropine</i><b> </b>- Discard 1 month after opening.</li></ul><p><b>Betaxolol 0.25% Eye Suspension</b></p><ul><li><i>Betoptic-S</i><b> </b>- Discard 4 weeks after first opening.</li></ul><p><b>Bimatoprost 0.01% Ophthalmic Solution</b></p><ul><li><i>Lumigan</i><b> </b>- Discard unused content 4 weeks after opening.</li></ul><p><b>Bimatoprost 0.03% and Timolol 0.5% Eye Drop</b></p><ul><li><i>Ganfort</i><b> </b>- Discard unused contents 4 weeks after opening.</li><li><i>Ganfort PF</i><b> </b>- Store below 30°C. Use once only and discard residue. Once the pouch is opened, use within 10 days.</li></ul><p><b>Brimonidine Tartrate 0.1% Ophthalmic Solution</b></p><ul><li><i>Alphagan P</i><b> - </b>Discard unused contents 28 days after opening.</li></ul><p><b>Brimonidine Tartrate 0.15% Ophthalmic Solution</b></p><ul><li><i>Iobrim</i><b> </b>- Shelf life after first opening: 28 days</li></ul><p><b>Brimonidine 0.2% and Timolol 0.5% Eye Drop</b></p><ul><li><i>Combigan</i><b> </b>- Discard unused contents 4 weeks after opening.</li><li><i>Brimolol</i><b> </b>- Discard unused contents 4 weeks after opening.</li></ul><p><b>Brinzolamide 1% and Brimonidine Tartrate 0.2% Ophthalmic Suspension</b></p><ul><li><i>Simbrinza</i><b> </b>- Discard 1 month after first opening.</li></ul><p><b>Brinzolamide 1% and Timolol 0.5% Eye Suspension</b></p><ul><li><i>Azarga</i><b> - </b>Discard 4 weeks after first opening.</li></ul><p><b>Brinzolamide 1% Ophthalmic Suspension</b></p><ul><li><i>Azopt</i><b> - </b>Discard 4 weeks after first opening.</li></ul><p><b>Chloramphenicol 0.5% Eye Drop</b></p><ul><li><i>Nicol</i><b> </b>- Store between 2-8°C. Protect from light. Discard contents 4 weeks after opening.</li><li><i>Xepanicol</i><b> - </b>Store in refrigerator between 2-8°C. Do not freeze. Discard eye drops 4 weeks after the first opening.</li></ul><p><b>Chloramphenicol 1% Eye Ointment</b></p><ul><li><i>Chlorop</i><b> </b>- Discard contents 4 weeks after opening.</li><li><i>Kloraxin</i><b>- </b>Discard 4 weeks from the date of opening the tube.</li></ul><p><b>Ciclosporin 0.05% Ophthalmic Emulsion</b></p><ul><li><i>Restasis</i><b> - </b>Discard after each use.</li></ul><p><b>Ciclosporin 0.1% Ophthalmic Emulsion</b></p><ul><li><i>Ikervis</i><b> - </b>Discard any remaining emulsion immediately after use.</li></ul><p><b>Ciprofloxacin HCl 0.3% Ophthalmic Solution</b></p><ul><li><i>Cipmax</i><b> </b>- Not to be used 1 month after opening.</li><li><i>Cipofain</i><b> - </b>Discard 28 days after first opening.</li></ul><p><b>Cyclopentolate 1% Eye Drop</b></p><ul><li><i>Cyclogyl</i><b> - </b>Discard 1 month after opening.</li></ul><p><b>Dexamethasone 0.1%, Neomycin Sulphate 3500 IU/g and Polymyxin B Sulphate 6000 IU/g Eye Ointment</b></p><ul><li><i>Maxitrol </i>- Discard 1 month after opening.</li></ul><p><b>Dexamethasone 0.1%, Neomycin Sulphate 3500 IU/ml and Polymyxin B Sulphate 6000 IU/ml Ophthalmic Suspension</b></p><ul><li><i>Maxitrol </i>- Discard 1 month after opening.</li></ul><div><b>Dexamethasone Sodium Phosphate 0.1% and Neomycin Sulphate 0.5% Eye/Ear Drop</b></div><ul><li><i>Neo-Deca</i><b> </b>- Discard 4 weeks after opening.</li></ul><p><b>Dexamethasone Sodium Phosphate 0.1% Eye Drop</b></p><ul><li><i>Maxidex</i><b> </b>- Discard 1 month after opening.</li></ul><p><b>Diquafosol Sodium 3% Ophthalmic Solution</b></p><ul><li><i>Diquas</i><b> </b>- After opening, use within one month.</li></ul><p><b>Dorzolamide 2% and Timolol 0.5% Eye Drop</b></p><ul><li><i>Cosopt</i><b> - </b>Discard 1 month after first opening.</li><li><i>Cosopt-S</i><b> </b>- Should be used no longer than 1 month after first opening the pouch. Discard any unused single dose containers after that time.</li><li><i>Ocudor-T</i><b> </b>- After opening, store below 25˚C, and discard after 28 days after first opening.</li><li><i>Zolamidol</i><b> </b>- Use the solution within 28 days after opening the vial.</li></ul><p><b>Dorzolamide HCl 2% Ophthalmic Solution</b></p><ul><li><i>Lamisopt</i><b> </b>- Use within 4 weeks of opening.</li><li><i>Ocudor</i><b> </b>- Use the solution within 28 days.</li><li><i>Trusopt</i><b> - </b>Discard 1 month after opening.</li></ul><p><b>Ectoin 2% Eye Drop</b></p><ul><li><i>Hydrelo Allergy</i><b> </b>- Discard 12 hours after opening.</li></ul><p><b>Epinastine HCl 0.5 mg/ml Ophthalmic Solution</b></p><ul><li><i>Relestat</i><b> - </b>Throw away the bottle 28 days after you first opened it.</li></ul><p><b>Fusidic Acid 1% Eye Drop</b></p><ul><li><i>Fucithalmic</i><b> </b>- Discard after 28 days from opening.</li></ul><p><b>Fluorometholone 0.1% Ophthalmic Suspension</b></p><ul><li><i>FML Liquifilm</i><b> </b>- Discard unused contents 4 weeks after opening.</li></ul><p><b>Gatifloxacin 0.5% Ophthalmic Solution</b></p><ul><li><i>Zymaxid</i><b> - </b>Discard 28 days after opening.</li></ul><p><b>Gentamicin 0.3% Eye Drop</b></p><ul><li><i>Bactigen</i> - Use the solution within 1 month after opening the vial.</li></ul><p><b>Gentamicin 0.3% Eye/Ear Drop</b></p><ul><li><i>Baegenta</i><b> </b>- Do not use 1 month after first opening.</li></ul><p><b>Gentamicin Sulphate 0.3% and Betamethasone 0.1% Eye/Ear Drop</b></p><ul><li><i>Betagen</i><b> </b>- The bottle should be disposed of 4 weeks after opening.</li></ul><p><b>Ketorolac 0.5% Eye Drops</b></p><ul><li><i>Acular</i><b> - </b>Discard unused contents 28 days after opening.</li></ul><p><b>Ketotifen 0.025% Eye Drop</b></p><ul><li><i>Tofen</i><b> </b>- After first opening, the content should be used within 28 days.</li></ul><p><b>Latanoprost 0.005% and Timolol Maleate 0.5% Eye Drop</b></p><ul><li><i>Xalacom</i> - Prior to opening, store at 2-8°C. After opening, may store up to 25°C for 4 weeks.</li></ul><p><b>Latanoprost 0.005% Eye Drop</b></p><p></p><ul><li><i>Avetaprost </i>- Store in a refrigerator (2°C to 8°C). Protect from light. After opening the bottle, do not store above 25°C and use within 4 weeks.</li><li><i>Latanost</i> - Store in a refrigerator (2°C to 8°C). Protect from light. After opening the bottle, do not store above 25°C and use within 4 weeks.</li><li><i>OptaProst </i>- Before opening, store below 30°C, protect from light. After opening, store below 30°C, protect from light and use within 4 weeks.</li><li><i>Latanost</i> - Store in a refrigerator (2°C to 8°C). Protect
from light. After opening the bottle, do not store above 25°C and use within 4
weeks.</li><li><i>Xalatan</i> - Prior to opening, store at 2-8°C. After opening, may store up to 25°C for 4 weeks.</li></ul><p></p><p><b>Levofloxacin 1.5% Ophthalmic Solution</b></p><ul><li><i>Cravit</i><b> </b>- After first opening, to be used within 1 month.</li></ul><p><b>Moxifloxacin 0.5% Ophthalmic Solution</b></p><ul><li><i>Vigamox</i><b> </b>- Discard 28 days after opening.</li></ul><p><b>Nepafenac 0.1% Ophthalmic Solution</b></p><ul><li><i>Nevanac</i><b> </b>- Discard 28 days after opening.</li></ul><p><b>Olopatadine HCl 0.1% Ophthalmic Solution</b></p><ul><li><i>Olodin </i>- Discard contents 28 days after opening the bottle.</li><li><i>Olopan </i>- Use within 4 weeks after first opening the bottle.</li><li><i>Patanol</i><b> - </b>Discard 4 weeks after first opening.</li></ul><p><b>Olopatadine HCl 0.2% Ophthalmic Solution</b></p><ul><li><i>Pataday</i><b> </b>- Discard 28 days after opening.</li><li><i>Patasyn </i>- Discard 28 days after opening.</li></ul><p><b>Omidenepag Isopropyl 0.002% Ophthalmic Solution</b></p><ul><li><i>Eybelis</i><b> - </b>After opening of bottle, use within 1 month.</li></ul><p><b>Pilocarpine 2% Eye Drop</b></p><ul><li><i>Isopto* Carpine</i><b> - </b>Discard 1 month after opening.</li></ul><p><b>Ripasudil HCl Hydrate 0.4% Ophthalmic Solution</b></p><ul><li><i>Glanatec</i><b> - </b>Discard 4 weeks after first opening.</li></ul><p><b>Sodium Chloride 0.9% Eye Drop</b></p><ul><li><i>Rinz</i><b> </b>- Discard 4 weeks after first opening of bottle.</li></ul><p><b>Sodium Cromoglycate 2% Eye Drop</b></p><ul><li><i>Allergo-Comod</i> - To be used within 12 weeks after opening.</li><li><i>Allergocrom</i><b> </b>- To be used within 4 weeks after opening.</li></ul><p><b>Sodium Hyaluronate 0.5 mg/ml and Ectoine 20 mg/ml Eye Drop</b></p><ul><li><i>Hylo Dual</i><b> </b>- Can be used for 6 months after opening.</li></ul><p><b>Sodium Hyaluronate 2 mg/ml and Ectoine 20 mg/ml Eye Drop</b></p><ul><li><i>Hylo Dual Intense</i><b> </b>- Can be used for 6 months after opening.</li></ul><p><b>Tetrahydrozoline 0.05% Eye Drop</b></p><ul><li><i>Allersine</i><b> </b>- Do not use 1 month after first opening.</li></ul><p><b>Prednisolone Acetate 1% Ophthalmic Suspension</b></p><ul><li><i>Econopred* Plus</i><b> </b>- Discard one month after opening.</li><li><i>Pred Forte</i><b> </b>- Discard unused contents 4 weeks after opening.</li></ul><p><b>Proparacaine HCI 0.5% Ophthalmic Drops</b></p><ul><li><i>Alcaine</i><b> </b>- Store refrigerated between 2-8°C. Discard 4 weeks after first opening.</li></ul><p><b>Tafluprost 0.0015% and Timolol 0.5% Ophthalmic Solution</b></p><ul><li><i>Tapcom-S</i><b> - </b>Store in a refrigerator (2-8°C). After opening the foil pouch: do not store above 25°C and protect from light. Use within 28 days.</li></ul><p><b>Tafluprost 0.0015% Ophthalmic Solution</b></p><ul><li><i>Taflotan</i><b> </b>- After opening, to be used within 1 month.</li><li><i>Taflotan S</i><b> </b>- Store in a refrigerator (2-8°C) and protect from light. After opening the aluminum foil pouch: Stored below 25°C and protect from light. Use within one month.</li></ul><p><b>Timolol 0.5% Eye Drop</b></p><ul><li><i>Iotim</i><b> </b>- Use the solution within 1 month after opening the vial.</li><li><i>Timo-Comod</i> - To be used within 12 weeks after opening.</li><li><i>Timoptol-XE</i><b> </b>- Discard 1 month after opening.</li></ul><p><b>Tobramycin 0.3% and Dexamethasone 0.1% Ophthalmic Suspension</b></p><ul><li><i>TobraDex</i><b>- </b>Discard 4 weeks after opening.</li></ul><p><b>Tobramycin 0.3% and Dexamethasone 0.1% Ophthalmic Ointment</b></p><ul><li><i>TobraDex</i><b>- </b>Discard 4 weeks after opening.</li></ul><p><b>Tobramycin 0.3% Ophthalmic Ointment</b></p><ul><li><i>Tobrex</i><b> - </b>Discard 1 month after opening.</li></ul><p><b>Travoprost 0.003% Eye Drop</b></p><ul><li><i>Izba</i><b> - </b>Discard 4 weeks after opening.</li></ul><p><b>Travoprost 0.004% and Timolol 0.5% Eye Drop</b></p><ul><li><i>DuoTrav</i> - Discard 4 weeks after first opening.</li></ul><p><b>Travoprost 0.004% Eye Drop</b></p><ul><li><i>Travatan</i><b> </b>- Discard 4 weeks after first opening.</li></ul><p><b>Tropicamide 1% Eye Drop</b></p><ul><li><i>Mydriacyl</i><b> </b>- Discard 1 month after opening.</li></ul><p><br /></p><p><br /></p><h2>GLP-1 Receptor Agonists</h2><div><b>Dulaglutide 0.75 mg and 1.5 mg Solution for Injection in Pre-filled Pen</b></div><ul><li><i>Trulicity</i><b> </b>- Store at 2-8°C. Do not freeze. If needed, each single-dose pen or prefilled syringe can be kept at room temperature, not to exceed 30°C for a total of 14 days.</li></ul><p><b>Exenatide 2 mg Powder and Solvent for Prolonged-Release Suspension for Injection</b></p><ul><li><i>Bydureon</i><b> </b>- Store under refrigeration at 2-8°C; Vials/pens may be stored at ≤25°C for up to 4 weeks. Do not freeze (discard if freezing occurs).</li></ul><p><b>Liraglutide 6 mg/ml Preloaded Injector</b></p><ul><li><i>Victoza, Saxenda</i><b> </b>- Store in a refrigerator (2-8°C). After first use, can also be stored below 30°C and used within 1 month.</li></ul><p><b>Lixisenatide 10 mcg/0.2 ml and 20 mcg/0.2 ml Solution for Injection 3 ml Prefilled Pen</b></p><ul><li><i>Lyxumia</i><b> </b>- Store under refrigeration at 2-8°C. After initial use, may store at <30°C and pen should be discarded 14 days after initial use.</li></ul><div><b>Semaglutide 1.34 mg per ml Solution for Injection Pre-filled Pen</b></div><ul><li><i>Ozempic</i> - Store in a refrigerator (2-8°C). Keep away from the cooling element and do not freeze. In-use shelf life: 6 weeks. Store below 30°C or in a refrigerator (2-8°C). Keep the pen cap on when the pen is not in use in order to protect it from light. USA product leaflet suggests that after initial use, store at 2-8°C or 15-30°C for up to 56 days.</li></ul><p><b>Semaglutide 0.25 mg per 0.5 ml, 0.5 mg per 0.5 ml, 1 mg per 0.5 ml, 1.7 mg per 0.75 ml and 2.4 mg per 0.75 ml Solution for Injection Pre-filled Pen</b></p><p></p><ul><li><i>Wegovy</i> - Store at 2-8°C. If needed, prior to cap removal, the pen can be kept from 8-30°C for up to 28 days. Do not freeze; protect from light. Keep in original carton until time of administration; discard pen after use (for single use only).</li></ul><p></p><p><br /></p><p><br /></p><h2>Inhalers</h2><p><b>Beclomethasone Dipropionate 100 mcg and Formoterol Fumarate Dihydrate 6 mcg Pressurized Inhalation Solution (MDI)</b></p><ul><li><i>Foster MDI</i> - Prior to dispensing to the patient, store in a refrigerator (2-8°C) (for a maximum of 15 months). After dispensing, do not store above 30°C (for a maximum of 2 months).</li></ul><p><b>Beclomethasone Dipropionate 100 mcg and Formoterol Fumarate Dihydrate 6 mcg NEXThaler</b></p><ul><li><i>Foster NEXThaler</i><b> </b>- Do not store above 30°C. After first opening the pouch, the medicinal product should be used within 2 months.</li></ul><p><b>Beclomethasone Dipropionate 100 mcg, Formoterol Fumarate Dihydrate 6 mcg and Glycopyrronium Bromide 12.5 mcg Pressurized Inhalation Solution (MDI)</b></p><ul><li><i>Trimbow</i> - Prior to dispensing, store in a refrigerator (2-8°C), do not freeze and do not expose to temperatures higher than 50°C. After dispensing, the medicinal product may be stored for a maximum of 2 months at a temperature of up to 30°C.</li></ul><p><b>Beclomethasone Dipropionate 200 mcg/dose Inhaler (Easyhaler)</b></p><ul><li><i>Beclomet</i> - 6 months after the laminate pouch has been opened.</li></ul><p><b>Budesonide 200 mcg/dose Inhalation (Easyhaler)</b></p><ul><li><i>Giona</i> - 6 months after the laminate pouch has been opened.</li></ul><p><b>Budesonide 80 mcg and Formoterol 4.5 mcg per Actuation, Pressurized Inhalation (MDI); Budesonide 160 mcg and Formoterol 4.5 mcg per Actuation, Pressurized Inhalation (MDI)</b></p><ul><li><i>Symbicort Rapihaler</i><b> </b>- Shelf life after first opening of the foil is 3 months.</li></ul><p><b>Fluticasone Furoate 100 mcg and Vilanterol 25 mcg Inhalation (Ellipta); Fluticasone Furoate 200 mcg and Vilanterol 25 mcg Inhalation (Ellipta)</b></p><ul><li><i>Relvar</i><b> </b>- To be used within 1 month of first opening of the tray. USA and UK product leaflets suggest in-use shelf life of 6 weeks.</li></ul><p><b>Fluticasone Propionate 125 mcg and Formoterol Fumarate Dihydrate 5 mcg per actuation pressurized inhalation, suspension (MDI); Fluticasone Propionate 250 mcg and Formoterol Fumarate Dihydrate 10 mcg per actuation pressurized inhalation, suspension (MDI)</b></p><ul><li><i>Flutiform</i><b> </b>- Use within 3 months of opening the foil pouch.</li></ul><p><b>Salbutamol 200 mcg/dose Inhaler (Easyhaler)</b></p><ul><li><i>Buventol</i> - 6 months after the laminate pouch has been opened.</li></ul><p><b>Tiotropium 2.5 mcg/puff solution for inhalation (Respimat)</b></p><ul><li><i>Spiriva Respimat</i> - Discard by date is 3 months from the date the cartridge is inserted into the inhaler.</li></ul><p><b>Tiotropium 2.5 mcg and Olodaterol 2.5 mcg per actuation, inhalation (Respimat)</b></p><ul><li><i>Spiolto Respimat</i> - Discard by date is 3 months from the date the cartridge is inserted into the inhaler.</li></ul><p><b>Umeclidinium 62.5 mcg and Vilanterol 25 mcg Inhalation (Ellipta)</b></p><ul><li><i>Anoro</i><b> </b>- To be used within 6 weeks of first opening of the tray.</li></ul><p><br /></p><p><br /></p><h2>Insulins</h2><p>Unless mentioned otherwise, store at 2-8°C and once in-use, can store at room temperature for 28 days.</p><p><b>Insulin Aspart 100 IU/ml Injection (Pre-filled Pen/Penfill)</b></p><ul><li><i>Fiasp</i><b> </b>- Before opening, store in a refrigerator (2-8°C). After first opening, use within 4 weeks when stored below 30°C and do not refrigerate.</li><li><i>NovoRapid</i> - Before opening, store in a refrigerator (2-8°C). After first opening, use within 4 weeks when stored below 30°C or stored in a refrigerator (2-8°C).</li></ul><p><b>Insulin Aspart 30% and Protaminated Insulin Aspart 70% 100 IU/ml Injection (FlexPen)</b></p><ul><li><i>NovoMix 30</i> - Before opening, store in a refrigerator (2-8°C). After first opening, use within 4 weeks when stored below 30°C and do not refrigerate.</li></ul><p><b>Insulin Degludec 100 IU/ml and 200 IU/ml Injection (FlexTouch)</b></p><ul><li><i>Tresiba</i><b> </b>- Before opening, store in a refrigerator (2-8°C). After first opening, use within 8 weeks when stored below 30°C or stored in a refrigerator (2-8°C).</li></ul><p><b>Insulin Degludec 70% and Insulin Aspart 30% 100 IU/ml Injection in Pre-filled Pen</b></p><ul><li><i>Ryzodeg</i><b> </b>- Before opening, store in a refrigerator (2-8°C). After first opening, use within 4 weeks when stored below 30°C or stored in a refrigerator (2-8°C).</li></ul><p><b>Insulin Detemir 100 IU/ml Injection in Prefilled Syringe/Cartridge</b></p><ul><li><i>Levemir</i> - Before opening, store in a refrigerator (2-8°C). After first opening, use within 6 weeks when stored below 30°C or stored in a refrigerator (2-8°C).</li></ul><p><b>Insulin Glargine 100 IU and Lixisenatide 33 mcg per ml Injection (Pre-filled Pen)</b></p><ul><li><i>Soliqua 30-60</i> -<b> </b>Store in a refrigerator (2-8°C). Shelf-life after first use is 28 days when stored below 25°C and do not refrigerate.</li></ul><p><b>Insulin Glargine 100 IU and Lixisenatide 50 mcg per ml Injection (Pre-filled Pen)</b></p><ul><li><i>Soliqua 10-40</i> -<b> </b>Store in a refrigerator (2-8°C). Shelf-life after first use is 28 days when stored below 25°C and do not refrigerate.</li></ul><p><b>Insulin Glargine 300 IU/3 ml Injection (Prefilled Pen)</b></p><ul><li><i>Basalog One</i><b> </b>- Store in a refrigerator (2-8°C). The in-use shelf life is up to 28 days when kept at room temperature (up to 30°C).</li><li><i>Lantus Solostar</i><b> </b>- Store in a refrigerator (2-8°C). Once in use, pens may be stored for a maximum of 4 weeks not above 30°C, away from direct heat or direct light. Pens in use should not be refrigerated.</li></ul><p><b>Insulin Glargine 300 IU/ml Injection (Pre-filled Pen)</b></p><ul><li><i>Toujeo</i> - Store in a refrigerator (2-8°C). Shelf life after first use is 6 weeks when stored below 30°C. USA product leaflet suggests 8 weeks when stored below 30°C.</li></ul><p><b>Insulin Glulisine 100 IU/ml Solution for Injection in Pre-filled Pen 3 ml</b></p><ul><li><i>Apidra SoloStar</i><b> - </b>Store in a refrigerator (2-8°C). Once in use, pens may be stored for a maximum of 4 weeks below 25°C, away from direct heat or direct light. Pens in use should not be refrigerated.</li></ul><p><b>Insulin Lispro 100 IU/ml Injection in Prefilled Syringe/Cartridge</b></p><ul><li><i>Humalog</i><b> </b>- Store in a refrigerator (2-8°C). Once in use, pens may be used for up to 28 days when stored below 30°C. Pens in use should not be refrigerated.</li></ul><p><b>Insulin Lispro 25% and Insulin Lispro Protamine 75% 100 IU/ml Suspension for Injection in Prefilled Syringe/Cartridge</b></p><ul><li><i>Humalog Mix 25</i><b> </b>- Store in a refrigerator (2-8°C). Once in use, pens may be used for up to 28 days when stored below 30°C. Pens in use should not be refrigerated.</li></ul><p><b>Insulin Lispro 50% and Insulin Lispro Protamine 50% 100 IU/ml Suspension for Injection in Prefilled Syringe/Cartridge</b></p><ul><li><i>Humalog Mix 50</i><b> </b>- Store in a refrigerator (2-8°C). Once in use, pens may be used for up to 28 days when stored below 30°C. Pens in use should not be refrigerated.</li></ul><p><b>Insulin Recombinant Neutral Human Short-Acting 100 IU/ml Penfill and Refill</b></p><ul><li><i>Actrapid</i> - Store in a refrigerator (2-8°C). The in-use shelf life is 6 weeks when stored below 30°C.</li><li><i>Insugen-R</i> - Store in a refrigerator (2-8°C). After first opening, use within 6 weeks when stored below 30°C.</li></ul><p><b>Insulin Recombinant Synthetic Human, Intermediate-Acting 100 IU/ml Penfill and Refill</b></p><ul><li><i>Insulatard</i> - Store in a refrigerator (2-8°C). The in-use shelf life is 6 weeks when stored below 30°C.</li><li><i>Insugen-N</i> - Store in a refrigerator (2-8°C). After first opening, use within 6 weeks when stored below 30°C.</li></ul><p><b>Insulin Recombinant Synthetic Human, Premixed 100 IU/ml Penfill and Refill</b></p><ul><li><i>Mixtard</i> - Store in a refrigerator (2-8°C). The in-use shelf life is 6 weeks when stored below 30°C.</li><li><i>Insugen-30/70</i> - Store in a refrigerator (2-8°C). After first opening, use within 6 weeks when stored below 30°C.</li></ul><p><br /></p><p><br /></p><h2>Nasal Spray and Drop</h2><p><b>Azelastine HCl 137 mcg and Fluticasone Propionate 50 mcg per dose Nasal Spray</b></p><ul><li><i>Dymista</i> - Once opened, use within 6 months.</li></ul><p><b>Beclomethasone 50 mcg/dose Nasal Spray</b></p><ul><li><i>Beconase Aqueous</i><b> </b>- Discard 3 months after using the spray.</li></ul><p><b>Ciclesonide 50 mcg/dose Nasal Spray</b></p><ul><li><i>Omnaris</i> - Discard 4 months after the bottle is removed from the foil pouch.</li></ul><p><b>Fluticasone Furoate 27.5 mcg/dose Nasal Spray</b></p><ul><li><i>Avamys</i> - Used within 2 months after first opening.</li></ul><p><b>Mometasone Furoate 50 mcg Aqueous Nasal Spray</b></p><ul><li><i>Nasonex</i> - Used within 2 months of first opening.</li></ul><p><b>Oxymetazoline HCI 0.01% Nasal Drop</b></p><p></p><ul><li><i>Iliadin Baby Up to Year</i> - After opening the pack, the Iliadin decongestant nasal drop/spray should not be used longer than 6 months.</li></ul><p></p><p><b>Oxymetazoline HCl 0.025% Nasal Drop</b></p><p></p><ul><li><i>Iliadin Child 1-6 Years</i> - After opening the pack, the Iliadin decongestant nasal drop/spray should not be used longer than 6 months.</li></ul><p></p><p><b>Oxymetazoline HCl 0.05% Nasal Drop</b></p><p></p><ul><li><i>Iliadin Adult and Children 6+</i> - After opening the pack, the Iliadin decongestant nasal drop/spray should not be used longer than 6 months.</li></ul><p></p><p><b>Oxymetazoline HCl 0.05% Nasal Spray</b></p><p></p><ul><li><i>Iliadin Adults Nasal Spray</i> - After opening the pack, the Iliadin decongestant nasal drop/spray should not be used longer than 6 months.</li></ul><p></p><p><b>Triamcinolone Acetonide 55 mcg Nasal Spray</b></p><ul><li><i>Nasacort AQ</i> - Discard within 2 months after first opening.</li></ul><p><br /></p><p><br /></p><div><h2><b>PCSK9 Inhibitors</b></h2><p><b>Alirocumab 75 mg and 150 mg Injection (Prefilled Pen/Syringe)</b></p></div><div><ul><li><i>Praluent</i> - Store at 2-8°C in the outer carton. After removal for the refrigerator, solution must be used within 30 days (below 25°C) or discarded.</li></ul><p><b>Evolocumab 140 mg Injection (Pre-filled Autoinjector/Syringe)</b></p><ul><li><i>Repatha</i> - Store between 2-8°C in the original carton. May also store at room temperature in the original carton; however, under these conditions, must use within 30 days.</li></ul></div><p><br /></p><p><br /></p><div><h2>Pessary</h2></div><p><b>Gemeprost (Prostaglandin E1 Synthetic Analogue) 1 mg Pessary</b></p><div><ul><li><i>Cervagem</i><b> - </b>Gemeprost suppositories are stored in a frozen state at -10°C.Once foil is opened, any pessary not used within 12 hours should be destroyed.</li></ul><p><b>Lactobacillus acidophilus 100 million viable cells and Estriol 0.03 mg Vaginal Tablet</b></p><ul><li><i>Gynoflor</i> - Store Gynoflor vaginal tablet in a refrigerator at 2-8°C. Storage of Gynoflor at room temperature during the treatment period (1-2 weeks) does not affect its efficacy.</li></ul></div><p><br /></p><p><br /></p><h2>Rectal</h2><p><b>Hydrocortisone 0.5%, Cinchocaine HCl 0.5%, Framycetin Sulphate 1% and Aesculin 1% Ointment</b></p><ul><li><i>Proctosedyl Ointment</i><b> </b>- Store below 30°C. Discard contents 28 days after opening.</li></ul><div><b>Lignocaine, Aluminium Acetate, Zinc Oxide and Hydrocortisone Ointment</b></div><ul><li><i>Xyloproct Ointment</i><b> </b>- 2 years if stored in a refrigerator (2-8°C). 2 months if stored not above 25°C.</li></ul><div><b>Lignocaine, Aluminium Acetate, Zinc Oxide and Hydrocortisone Suppository</b></div><ul><li><i>Xyloproct Suppository</i><b> </b>- 30 months if stored in a refrigerator (2-8°C). 2 months if stored not above 25°C.</li></ul><p><br /></p><p><br /></p><div><h2>Topical Preparations</h2><p><b>Calcipotriol Monohydrate 50 mcg/g and Betamethasone Dipropionate 0.5 mg/g Cutaneous Foam</b></p><ul><li><i>Enstilar</i><b> </b>- Discard 6 months after first opening.</li></ul><p><b>Calcipotriol Monohydrate 50 mcg/g and Betamethasone Dipropionate 0.5 mg/g Gel</b></p><ul><li><i>Xamiol</i> - Discard 3 months after opening.</li></ul><p><b>Calcipotriol Hydrate 50 mcg/g and Betamethasone Dipropionate 0.5 mg/g Ointment</b></p><ul><li><i>Daivobet</i><b> - </b>After first opening of container: 12 months.</li></ul><p><b>Clindamycin 1% and Benzoyl Peroxide 5% Gel</b></p><ul><li><i>Duac</i><b> </b>- Pharmacist: Store at refrigerator (2-8°C). Patient: Store at temperatures up to 25°C. Discard after 2 months.</li></ul><p><b>Estradiol 1.53 mg/dose Transdermal Spray</b></p><ul><li><i>Lenzetto</i> - Use within 56 days of first use.</li></ul></div><div><p><br /></p><p><br /></p><h2>Miscellaneous</h2></div><p><b>Acetylcysteine 100 mg/5 ml Oral Solution</b></p><p></p><ul><li><i>Fluimucil</i><b> </b>- After opening, do not store for more than 15 days.</li></ul><p></p><p><b>Alfacalcidol 2 mcg/ml Drops</b></p><p></p><ul><li><i>One-Alpha</i> - Store at 2 to 8°C (in a refrigerator). After opening, the shelf life is 4 months when stored at 2 to 8°C (in a refrigerator).</li></ul><p></p><p><b>Benzydamine HCl 3.0 mg/ml Throat Spray</b></p><p></p><ul><li><i>MediThroat Spray 3.0 mg/ml</i> - Use within 6 months after opening.</li><li><i>Zipelor Forte Oromucosal Spray</i> - After opening, do not keep it more than 12 months.</li></ul><p></p><p><b>Ciclosporin 100 mg/ml Oral Solution</b></p><p></p><ul><li><i>Sandimmun Neoral</i> - Should be stored below 30°C, but not below 20°C for more than 1 month. After opening, Sandimmun Neoral oral solution should be used within 2 months.</li></ul><p></p><p><b>Digoxin 50 mcg/ml Elixir</b></p><p></p><ul><li><i>Lanoxin</i> - Store below 30°C. Discard any unused portion 12 days after opening.</li></ul><p></p><p><b>Distilled Witch Hazel 13% v/v in a Solution buffered with Borax and Boric Acid</b></p><p></p><ul><li><i>Optrex Multi Action Eye Wash</i><b> - </b>Discard any unused product 28 days after opening.</li></ul><p></p><p><b>Flurbiprofen 8.75 mg/dose Spray</b></p><p></p><ul><li><i>Strepsils Max Pro Direct Spray</i><b> </b>- Discard product 6 months afer opening.</li></ul><p></p><p><b>Frusemide 10 mg/ml Oral Solution</b></p><p></p><ul><li><i>Vusimide</i> - Store below 30°C. Discard opened bottle after 90 days.</li></ul><p></p><p><b>Glyceryl Trinitrate 0.5 mg Sublingual Tablet</b></p><p></p><ul><li><i>Myonit Insta - </i>Discard after 8 weeks in use.</li></ul><p></p><p><b>Glyceryl Trinitrate Aerosol Spray 400 mcg (Metered Dose)</b></p><p></p><ul><li><i>Nitrosol Spray </i>- Manufacturer's expiry date.</li></ul><p></p><p><b>Itraconazole 10 mg/ml Oral Solution</b></p><p></p><ul><li><i>Sporanox</i> - Discard 1 month after first opening the container.</li></ul><p></p><p><b>Multivitamin Drops</b></p><p></p><ul><li><i>Appeton Baby Drops</i><b> - </b>Do not use after 1 month of opening.</li></ul><p></p><p><b>Povidone Iodine 1% Mouth Wash</b></p><p></p><ul><li><i>Betadine Gargle and Mouthwash</i><b> </b>- Use within 6 months after first opening.</li></ul><p></p><p><b>Risperidone 1 mg/ml Oral Solution</b></p><p></p><ul><li><i>Risperdal</i> - Opened container: 3 months when protected from freezing.</li></ul><p></p><b>Sucroferric Oxyhydroxide 500 mg Chewable Tablet</b><p></p><ul><li><i>Velphoro</i><b> </b>- Shelf life after first opening of the bottle: 45 days.</li></ul><p></p><p><b>Zuclopenthixol 20 mg/ml Drops</b></p><p></p><ul><li><i>Clopixol</i> - Before opening, store in a refrigerator (2-8°C). After opening, store below 25°C. Use within 6 weeks.</li></ul></div><div><p><br /></p></div><p><br /></p><h2>General Recommendations</h2><p><b>The manufacturer's expiry, if shorter or the manufacturer's specificized in-use shelf-life takes precedence over the following guidelines.</b> The guidance given here should be used as aid to the pharmacist's own professional judgement on matters of stability and in-use expiry.</p><p><b>Tablets and Capsules</b></p><p></p><ul><li><i>Blister Packed/Single Unit Dose</i> - Manufacturer's expiry</li><li><i>Bulk Packs</i> - 1 year form date of opening</li></ul><p>Exceptions: Products susceptible to atmospheric moisture, GTN</p><p><b>Liquids</b></p><div><ul><li><i>Preserved Internal and External</i> - 6 months (local policy may direct 3 months for internal liquids)</li><li><i>Extemporaneously Prepared to a BP Monograph or EDS Formula</i> - 4 weeks from date of manufacture</li><li><i>Diluted Preserved Liquids</i> - 2 weeks</li><li><i>Preserved with Chloroform</i> - 2 weeks</li></ul><p><b>Creams</b></p></div><div><ul><li><i>Packed in Tubes</i> - 3 months (local policy may direct 1 month for unpreserved creams)</li><li><i>Packed in Jars/Pots</i> - 1 month</li><li><i>Diluted Commercial Preparations </i>- 2 weeks</li><li><i>Extemporaneously Prepared in a Suitable Base</i> - 4 weeks from date of manufacture</li></ul><p><b>Ointments</b></p></div><div><ul><li><i>Packed in Tubes</i> - 6 months</li><li><i>Packed in Jars/Pots</i> - 3 months</li><li><i>Diluted Commercial Preparations</i> - 4 weeks</li><li><i>Extemporaneously Prepared in a Suitable Base</i> - 8 weeks from date of manufacture</li></ul></div><p></p><p><br /></p><p><br /></p><h2>Extemporaneous Preparations</h2><p>You may refer <a href="https://mypharmacistnote.blogspot.com/2021/07/extemporaneous-preparation-with-unknown.html">here</a> for recommendations on extemporaneous preparations with unknown stability.</p><p><br /></p><p><br /></p><h2>External Links</h2><p></p><ul><li><a href="https://www.fda.gov/drugs/pharmaceutical-quality-resources/expiration-dates-questions-and-answers">FDA - Expiration Dates - Questions and Answers, 2018</a></li><li><a href="http://www.rotherhamccg.nhs.uk/Downloads/Top%20Tips%20and%20Therapeutic%20Guidelines/Rotherham%20CCG%20good%20practice%20guidance%20on%20expiry%20dates%20of%20medicines.pdf">Rotherham CCG - Good Practice Guidance on Expiry Dates of Medicines, 2016</a></li><li><a href="https://ipswichandeastsuffolkccg.nhs.uk/Portals/1/Content/Members%20Area/Clinical%20Area/Medicine%20managment/Care%20home%20information/Summary%20of%20in%20use%20shelf%20lives%20V2.pdf">Ipswich and East Suffolk CCG - Summary of In-use Shelf Lives, 2018</a></li></ul><p></p>Soon Senghttp://www.blogger.com/profile/12198523062740513134noreply@blogger.com6tag:blogger.com,1999:blog-8600105966353098751.post-43463640492833902152024-02-17T21:26:00.000+08:002024-03-17T21:33:49.488+08:00PRP Assessment<h2>Introduction</h2><p>Under the Malaysian <a href="https://mypharmacistnote.blogspot.com/2020/12/registration-of-pharmacists-act-1951.html">Registration of Pharmacists Act 1951</a>, to apply for full registration, pharmacy graduates must complete provisional registration training to the satisfaction of the Pharmacy Board for a period of not less than 1 year.</p><p>Specifically, they have to complete the <b>PRP Log Book</b> with a <b>minimum passing mark of 60%</b>.</p><div><ul><li><a href="https://pharmacy.moh.gov.my/ms/dokumen/buku-log-latihan-ahli-farmasi-provisional-prp-sektor-awam.html">Government Hospital</a><br /></li><li><a href="https://pharmacy.moh.gov.my/ms/dokumen/buku-log-latihan-ahli-farmasi-provisional-prp-klinik-kesihatan.html">Health Clinic</a><br /></li><li><a href="https://pharmacy.moh.gov.my/ms/dokumen/record-training-experience-provisionally-registered-pharmacist-prp-log-book-%e2%80%93-private-hospital.html">Private Hospital</a><br /></li><li><a href="https://pharmacy.moh.gov.my/ms/dokumen/record-training-experience-provisionally-registered-pharmacist-prp-log-book-%e2%80%93-community-pharmacy.html">Community Pharmacy</a><br /></li><li><a href="https://pharmacy.moh.gov.my/ms/dokumen/record-training-experience-provisionally-registered-pharmacist-prp-log-book-%e2%80%93-pharmaceutical.html">Pharmaceutical Industry</a><br /></li><li><a href="https://pharmacy.moh.gov.my/ms/dokumen/record-training-experience-provisionally-registered-pharmacist-prp-log-book-non-manufacturing.html">Non-manufacturing Pharmaceutical Industry</a><br /></li><li><a href="https://pharmacy.moh.gov.my/ms/dokumen/record-training-experience-provisionally-registered-pharmacist-prp-log-book-%e2%80%93-research-development.html">Research & Development (Academia)</a><br /></li></ul><p><br /></p><p><br /></p><h2>Training in Progress</h2><p>No matter which rotation a provisional registered pharmacist starts with in a hospital,<b> their preceptors will assess their individual knowledge and skills before they are confident</b> in allowing them to do anything unsupervised.</p><p></p><ul><li>Supervisors have to take responsibility for what a provisional registered pharmacist is doing under their supervision.</li></ul><p></p><p>In community pharmacy, preceptors will often work side by side on a daily basis to observe what the provisional registered pharmacist is doing.</p><p><br /></p><p><br /></p><h2>Dilemma At Government Facilities</h2><p>For many preceptors, it is often a difficult decision to give a justifying mark in provisional registered pharmacist logbook.</p><p></p><ul><li>Should the mark be solely based on <b>knowledge assessment or attitude to learn and sense of responsibility</b>?</li><li>The situation is further complicated by the fact that the provisional registered pharmacist is someone that you know and the future of him affected by the PRP Log Book marks.</li></ul><p></p><p>In terms of knowledge-oriented assessment, one may argue that it is illogical to expect new pharmacists to know everything in one year of training.</p><p></p><ul><li>Moreover, apart from knowledge, lots of important values and soft skills are equally important.</li></ul><p></p><p><br /></p><p><br /></p><h2>Intern Examination</h2><p>In contrast, intern programs in some developed countries (e.g., Australia, United Kingdom, United States) include an intern examination from the pharmacy board to ensure a minimum satisfying knowledge and quality.</p><p></p><ul><li>While passion is essential in long-term continuous professional development, <b>pharmacist competency remains the key</b>.</li><li>I still remember, years ago, lecturer used to say if you already failed the intern exam 3 times, you should consider giving up on pharmacy profession, regardless how passionate you are.</li></ul><p></p><p><br /></p><p><br /></p></div><h2>Summary</h2><p>To guarantee the highest quality of future pharmacists, <b>standardized national pharmacist licensing exam should be in place</b> on top of the PRP logbook requirements.</p><p></p><ul><li>Afterall, increasing the number of healthcare professionals without rigorous quality control will not only cast blame on the profession, but also endanger the public.</li></ul><p></p><p><br /></p><p><br /></p><h2>External Links</h2><div><ul><li><a href="https://www.pharmacycouncil.org.au/resources/intern-written-exam-guide-and-sample-paper/">Australia - Intern Written Exam guide and sample paper</a><br /></li><li><a href="https://nabp.pharmacy/programs/examinations/naplex/">North American Pharmacist Licensure Examination (NAPLEX)</a><br /></li><li><a href="https://pebc.ca/"> Pharmacy Examining Board of Canada</a><br /></li><li><a href="https://www.pharmacyregulation.org/cy/the-registration-assessment">UK - GPhC registration assessment</a><br /></li></ul></div>Soon Senghttp://www.blogger.com/profile/12198523062740513134noreply@blogger.com1tag:blogger.com,1999:blog-8600105966353098751.post-88912116291437915692024-02-15T00:22:00.003+08:002024-02-23T08:45:52.877+08:00Community Pharmacy FAQ<h2>Introduction</h2><p>Time really flies. It has been over 8 years since I graduated from university.</p><p>Reflecting my first community pharmacy placement, I cannot help but remember the mix of excitement and nervousness.</p><p></p><ul><li>Looking back, I wish I had more information about what to expect, so I am writing this post to share my experience and answer some basic questions for future community pharmacists.</li></ul><p><br /></p><p><br /></p><h2><b>What can I expect or prepare once I embarked on a community pharmacy journey?</b></h2><p>Community pharmacy operations often <b>demand long working hours.</b></p><p></p><ul><li>Moreover, pharmacists may be required to work weekends and public holidays.</li><li>Due to its fast-paced environments, pharmacists also need to multitask efficiently to handle diverse customer needs and demands.</li></ul><p></p><p>Generally, a community pharmacist plays 2 important roles.</p><p></p><p></p><ul><li><b>Management and <a href="https://mypharmacistnote.blogspot.com/2020/12/practical-inventory-control.html">inventory control</a> </b></li><ul><li>Involves ordering, receiving, storing, dispensing and disposing of medications</li></ul><li><b>Provide services to customers (sales and professional health advises)</b></li><ul><li>It is crucial to develop clear <a href="https://mypharmacistnote.blogspot.com/2021/06/communication.html">communication skill</a> to explain complex information in a way patients can understand.</li></ul></ul><p>In an overview, public comes to a pharmacy for a number of reasons.</p><p>First, he may come to <b>purchase a named medicine based on prescription or just help their relatives or friends to <a href="https://mypharmacistnote.blogspot.com/2021/11/specific-product-requests.html">purchase certain common OTC products</a>.</b></p><p></p><ul><li>In these circumstances, pharmacists may or may not need to provide a detailed <a href="https://mypharmacistnote.blogspot.com/2020/10/medication-counselling.html">medicine counselling</a> depending on the customer's needs and preferences.</li></ul><p></p><p>Second, he may come to <b><a href="https://mypharmacistnote.blogspot.com/2021/11/responding-to-symptoms.html">request advice about symptoms</a> and appropriate treatment for common conditions.</b></p><p></p><ul><li>Hence, you should be familiar with common ailments, such as <a href="https://mypharmacistnote.blogspot.com/2022/12/cold.html">common cold,</a> <a href="https://mypharmacistnote.blogspot.com/2020/10/cough.html">cough</a>, <a href="https://mypharmacistnote.blogspot.com/2021/01/styes.html">styes</a>, <a href="https://mypharmacistnote.blogspot.com/2023/01/itch-without-rash.html">skin itch without rash</a>, <a href="https://mypharmacistnote.blogspot.com/2021/02/fungal-skin-infections.html">fungal skin infection</a>, <a href="https://mypharmacistnote.blogspot.com/2021/01/onychomycosis-fungal-nail-infection.html">onychomycosis</a>, <a href="https://mypharmacistnote.blogspot.com/2020/11/constipation.html">constipation</a>, <a href="https://mypharmacistnote.blogspot.com/2020/11/diarrhoea.html">diarrhoea</a>, <a href="https://mypharmacistnote.blogspot.com/2021/02/acne.html">acne</a> and allergy.</li><li>Clinical decisions should be made upon the patient scenarios, either referral to a doctor or recommending a product.</li><li>Sometimes, lifestyle or dietary changes can be suggested as well.</li></ul><p></p><p>Certainly, customers may also look for <b>dietary supplements</b>. </p><p></p><ul><li>Learning up <a href="https://mypharmacistnote.blogspot.com/2020/10/about-herbs.html">supplements</a> is a must in community pharmacy, regardless of whether you believe in them or not.</li><li>Be familiar with the range of supplements available in the pharmacy, especially the indications and contraindications.</li><ul><li>What supplements can you suggest for <a href="https://mypharmacistnote.blogspot.com/2020/12/diabetes-mellitus.html">diabetes mellitus</a>?</li><li>Before suggesting red yeast rice for management of cholesterol, you should have checked if he is on any <a href="https://mypharmacistnote.blogspot.com/2020/12/statins.html">statins</a>.</li><li>Similarly, we should not recommend ginkgo biloba to improve blood circulation if customer is already on <a href="https://mypharmacistnote.blogspot.com/2021/08/oral-anticoagulant.html">warfarin</a>.</li><li>Both glucosamine and chondroitin may enhance the anticoagulant effects of <a href="https://mypharmacistnote.blogspot.com/2023/06/warfarin.html">warfarin</a> too.</li></ul></ul><p></p><p>Well, do you think it ends there? Actually, it does not.</p><p></p><ul><li>You may meet customers who ask you: what is the difference between the oats/<a href="https://mypharmacistnote.blogspot.com/2021/10/infant-formula.html">milk formulas</a>, which <a href="https://mypharmacistnote.blogspot.com/2020/10/emollients-moisturizers.html">moisturizer</a> is the best, does this deodorant stain the cloth, which hair shampoo is good for <a href="https://mypharmacistnote.blogspot.com/2021/06/dandruff.html">dandruff</a> and <a href="https://mypharmacistnote.blogspot.com/2021/06/alopecia.html">alopecia</a>, what is the smell of this body lotion, or what is the differences between <a href="https://mypharmacistnote.blogspot.com/2020/10/blood-pressure-monitoring.html">blood pressure machine</a>/ thermometer/ <a href="https://mypharmacistnote.blogspot.com/2021/08/blood-glucose-measurement.html">glucometer</a>.</li><li>The question list goes on. You are not just a pharmacist, but a product expert too.</li></ul><p></p><p><b>NOTE: </b>Nonetheless, your provisional registered pharmacist training experience will be hugely subjected to your preceptor.</p><p><br /></p><p><br /></p><div><h2><b>What to do if I did not know the answer to my customers question?</b></h2><p>It is okay not to know during your first week, but you should not leave the customer hanging. On the other hand, you should apologize first and find someone who can assist him or her, such as a senior pharmacist or a more experienced colleague.</p><p></p><ul><li>Afterwards, you should put effort in learning up the answer.</li><li><b>It does not matter how much you know at the start, but more importantly your motivation and effort in learning it up.</b></li><li>With times, you will gain more experiences in recommending common ailments.</li></ul><p></p><p>Regarding availability of products, you may be able to <b>check through the retail system</b> if a product is available in your system catalogue.</p><p></p><ul><li>Alternatively, you should familiarize yourself with the range of products available by <b>browsing through the shelves when it is not busy</b> and also <b>volunteer yourself to stocking up products</b>.</li><li>When you are stocking up products, you shall try to learn the various product names and then looking at the constituent ingredients of these unfamiliar products.</li><li>Never be a stationary statue at the pharmacy counter!</li></ul><p></p></div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj5i-oOgBivcZNQ1-f8jfzvb6UVGxfveA2WAL5OAND54AVbYgZIntv6VV8XLup3vXGcxdQvc8hDh9ASXVOtM9qmONKexkKkyeAZtWeid3QQE6H7lQulmQqpbUryWUeVCEEva6SxMVifZMWlgmK4jmg2T8fq9egoNNOl0DoBKOnIFYd5jWKu7ouYynJy/s1080/1654306425656.jpg" style="margin-left: 1em; margin-right: 1em;"><img alt="Eye Level is Buy Level" border="0" data-original-height="1080" data-original-width="1080" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj5i-oOgBivcZNQ1-f8jfzvb6UVGxfveA2WAL5OAND54AVbYgZIntv6VV8XLup3vXGcxdQvc8hDh9ASXVOtM9qmONKexkKkyeAZtWeid3QQE6H7lQulmQqpbUryWUeVCEEva6SxMVifZMWlgmK4jmg2T8fq9egoNNOl0DoBKOnIFYd5jWKu7ouYynJy/w320-h320/1654306425656.jpg" title="Eye Level is Buy Level" width="320" /></a></div><p><br /></p></div><div><br /></div><div><h2><b>Where can I read up information on minor ailments?</b></h2><p>Different from hospital pharmacy setting where diagnosing and prescribing is doctor's job, community pharmacists is the person responsible to <a href="https://mypharmacistnote.blogspot.com/2021/11/responding-to-symptoms.html">handle minor ailments</a>.</p><p>Few key important questions to ask should include:</p></div><div><ul><li>W - Who is the patient and what are the symptoms?</li><li>H - How long have the symptoms been present?</li><li>A - Action taken?</li><li>M - Medication being taken?</li></ul></div><p>Apart from Google, my personal recommended readings are</p><div><ul><li><a href="https://mypharmacistnote.blogspot.com/2021/02/community-pharmacy-references.html">Symptoms in the Pharmacy, 2023</a></li><li><a href="https://mypharmacistnote.blogspot.com/2021/02/community-pharmacy-references.html">Community Pharmacy: Symptoms, Diagnosis and Treatment, 2020</a></li><li><a href="https://mypharmacistnote.blogspot.com/2021/02/community-pharmacy-references.html">Handbook of Nonprescription Drugs, 2020</a></li></ul></div><div><p style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhmi034k1HVb45vSBP-D4G04UhafM1zMjcXvX0hQJoyalEMEYGWoSYxa_Ob6egwfXX_k8Rj5f7jR7gBufe6MCryqwhaf5zaIgMHrCe8R15YSo9vz6_YG_qYjDHjSrrjFFP-x2gl9fJeLcxH4oBIKQMO_1eMZQGQnUnQaf7AfzibcQ_jw77ofSeNIiPB/s450/Symptoms%20in%20the%20Pharmacy.jpg" style="margin-left: 1em; margin-right: 1em;"><img alt="Symptoms in the Pharmacy" border="0" data-original-height="450" data-original-width="299" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhmi034k1HVb45vSBP-D4G04UhafM1zMjcXvX0hQJoyalEMEYGWoSYxa_Ob6egwfXX_k8Rj5f7jR7gBufe6MCryqwhaf5zaIgMHrCe8R15YSo9vz6_YG_qYjDHjSrrjFFP-x2gl9fJeLcxH4oBIKQMO_1eMZQGQnUnQaf7AfzibcQ_jw77ofSeNIiPB/w133-h200/Symptoms%20in%20the%20Pharmacy.jpg" title="Symptoms in the Pharmacy" width="133" /></a><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgZIDK_OgR2rwMXZYXq9lsiWr0rSrRO_1SVPmhTkQCmJ1DnaCKJ_bHYzs--yBQIhqjply4hsmUbl6EW8RZFI5ULX2Mb51lHAWylbkGTeYbAnimdQo1wOgQKFgisD3uDd4OmkTjNXDCk9GN0tS_gTBMR4Zi8mwontwXd-T9uyIKykd7NZB296e0NwLMo/s500/Community%20Pharmacy%20Symptoms,%20Diagnosis%20and%20Treatment.jpg" style="margin-left: 1em; margin-right: 1em;"><img alt="Community Pharmacy: Symptoms, Diagnosis and Treatment" border="0" data-original-height="500" data-original-width="375" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgZIDK_OgR2rwMXZYXq9lsiWr0rSrRO_1SVPmhTkQCmJ1DnaCKJ_bHYzs--yBQIhqjply4hsmUbl6EW8RZFI5ULX2Mb51lHAWylbkGTeYbAnimdQo1wOgQKFgisD3uDd4OmkTjNXDCk9GN0tS_gTBMR4Zi8mwontwXd-T9uyIKykd7NZB296e0NwLMo/w150-h200/Community%20Pharmacy%20Symptoms,%20Diagnosis%20and%20Treatment.jpg" title="Community Pharmacy: Symptoms, Diagnosis and Treatment" width="150" /></a><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgVM8DF67tVIM_z3iUpzuhsSKpzJZAwcLehfdFG7QqjusoK0k9-uwrb7fAo94HHtjocgzAEAiYfXdCW4aoIoH1kSUm2sadChH092-Lffhe8d2wnY54PTt32P4qiq_fKsoKhgIMOH9KyT-w/s2048/showCoverImage.jpg" style="margin-left: 1em; margin-right: 1em;"><img alt="Handbook of Nonprescription Drugs" border="0" data-original-height="2048" data-original-width="1582" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgVM8DF67tVIM_z3iUpzuhsSKpzJZAwcLehfdFG7QqjusoK0k9-uwrb7fAo94HHtjocgzAEAiYfXdCW4aoIoH1kSUm2sadChH092-Lffhe8d2wnY54PTt32P4qiq_fKsoKhgIMOH9KyT-w/w154-h200/showCoverImage.jpg" title="Handbook of Nonprescription Drugs" width="154" /></a></p><p><b>NOTE:</b> Alternatively, you may also read family medicine medical textbooks to learn from the perspective of a physician in dealing with these common ailments.</p><p><b>Regardless how prepared you are, you may still encounter unfamiliar scenarios,</b> such as cough-induced headache or post-nasal drip.</p><p></p><ul><li>Keep calm and learn to be a competent pharmacist!</li></ul><p><br /></p><p><br /></p><p></p></div><h2><b>How should I choose which products to recommend for minor ailments?</b></h2><p></p><p>To be a great community pharmacist, you need to be very familiar with all the products sold in your pharmacy, being a drug or <a href="https://mypharmacistnote.blogspot.com/2020/10/about-herbs.html">supplement</a>.</p><p></p><ul><li>For a starter, you may stick with a particular brand range and slowly expand your selection range.</li><li>With times, you may eventually need to know all products available.</li></ul><p></p><p>On top of that, you should have some ideas on factors that could affect your product recommendation, such as patient's symptoms, medication history, age, <a href="https://mypharmacistnote.blogspot.com/2020/10/drugsandpregnancy.html">pregnancy</a>, <a href="https://mypharmacistnote.blogspot.com/2021/06/drugs-and-lactation.html">breastfeeding</a>, medication effectiveness and price.</p><p></p><ul><li>Is it the most expensive <a href="https://mypharmacistnote.blogspot.com/2021/02/antihistamines.html">antihistamine</a> best for hay fever?</li><li>What differences in terms of time onset that you can foresee if you <a href="https://mypharmacistnote.blogspot.com/2023/07/analytical-thinking-in-community.html">recommend Ravin enema instead of lactulose syrup</a>?</li><li> If a 2 year old child is experiencing <a href="https://mypharmacistnote.blogspot.com/2020/11/diarrhoea.html">diarrhoea</a>, is it safe to use <a href="https://mypharmacistnote.blogspot.com/2020/10/smecta-not-for-children-below-2-years.html">Smecta</a>?</li></ul><p></p><p>Many pharmacists limit themselves to a specified range of products that they prefer to recommend because they have experience with them, but there is no real reason for not using an alternative.</p><p></p><p></p><p></p><p></p><ul><li>In other words, you may come up with your own personal product range from which you make your own recommendations. However, you should also stay informed about new innovations.</li></ul><p><b>Regardless the final recommendation that you may make, always ask yourself, if you are the patient, will you take it?</b></p><p></p><ul><li>Product recommendation should always be on the best interests of patients, not based solely on personal bias or financial incentives.</li></ul><p></p><p><br /></p><p><b><br /></b></p><div><h2><b>Which medicines do I need a prescription for dispensing?</b></h2><p>In accordance to <a href="https://mypharmacistnote.blogspot.com/2020/10/poisons-act-1952.html">Poisons Act 1952</a>, <b>Group B Poisons need a prescription</b>, whereas <b>Group C poisons can be dispensed by a pharmacist without a prescription. </b>There are also poisons fall under the Exempt list (i.e. can be sold over the counter in community pharmacy), such as</p><p></p><ul><li>Clotrimazole preparation for external use</li><li>Paracetamol except for parenteral administration</li><li>Terbinafine preparation for external use</li><li>Vitamins except for parenteral administration</li></ul><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgRkLU0bJ2l3X8XmhL5DcuFPwBCtqhKrQ7oAunHDdj5bfex8UNS6XLDPwD0CAW02Jp-1nJJ_wGKYa9On0lunlkGxkMwsvCjFv6Yisdjsde09WnJnSLXcHATB1Q9bybNqfPhpn1_3kXx8NjBgWdNP9Z8xM4PzLQFFthd2-MnkFhj3wdGNc0jAbcJyK5Q/s2048/WHO.jpg" style="margin-left: 1em; margin-right: 1em;"><img alt="Antibiotic Resistance What Can You Do" border="0" data-original-height="2048" data-original-width="2048" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgRkLU0bJ2l3X8XmhL5DcuFPwBCtqhKrQ7oAunHDdj5bfex8UNS6XLDPwD0CAW02Jp-1nJJ_wGKYa9On0lunlkGxkMwsvCjFv6Yisdjsde09WnJnSLXcHATB1Q9bybNqfPhpn1_3kXx8NjBgWdNP9Z8xM4PzLQFFthd2-MnkFhj3wdGNc0jAbcJyK5Q/w320-h320/WHO.jpg" title="Antibiotic Resistance What Can You Do" width="320" /></a></div><p><br /></p><p><br /></p><h2><b>Where to check the brands of medicine available on the market?</b></h2><p>Generally, I will suggest to use <a href="https://quest3plus.bpfk.gov.my/pmo2/index.php">NPRA Quest 3+ Product Search</a>.</p><p></p><ul><li>A detailed discussion on brand name search is available <a href="https://mypharmacistnote.blogspot.com/2020/10/brand-name-search.html">here</a>.</li></ul><p></p><p><br /></p><p><br /></p></div><h2><b>Is it very different from what I learnt in university and real practice?</b></h2><p>University has prepared you to not only work at a community pharmacy, but also at industry or research settings. Nonetheless, at community pharmacy, I see little needs that we need to explain what is meant by cholinergic pathway to a patient.</p><p></p><ul><li>However, we should <b>apply the clinical knowledge in our daily practice</b>, for example explaining anticholinergic side effects to your customers (e.g. dry mouth, drowsiness and blurry vision).</li><li>Another example will be if a customer complaining <a href="https://mypharmacistnote.blogspot.com/2020/10/antihypertensives.html">dry cough after started on ACE inhibitor</a>, you may refer patients to doctor to review <a href="https://mypharmacistnote.blogspot.com/2020/12/hypertension.html">hypertension</a> management.</li></ul><p></p><p>In practice, there are various formulations, brand names, generic and over-the-counter products.</p><p></p><ul><li>Plus, <a href="https://mypharmacistnote.blogspot.com/2023/08/the-change-at-community-pharmacy.html">new medications and supplements are constantly entering the market</a>, demanding continuous learning and adaptation.</li></ul><p></p><p>Also, <a href="https://mypharmacistnote.blogspot.com/2023/10/business-nature-of-community-pharmacy.html">community pharmacy is a business</a> that aims to generate profit to sustain long-term growth.</p><p><br /></p><p><br /></p><div><h2><b>What is the career pathway of a community pharmacist?</b></h2><p>At private sector, employers will expect you to be more proactive in learning and making justified decisions.</p><p></p><ul><li><b>Your salary is based on your working performance (i.e. sales), not based on grading system.</b></li></ul><p>After working for few years at community pharmacy, you can either</p><p></p><ul><li>Explore other pharmacy-related job opportunities, such as production pharmacist or medical science liaison.</li><li><a href="https://mypharmacistnote.blogspot.com/2023/01/set-up-retail-pharmacy.html">Become an owner to operate your own pharmacy</a> - the ULTIMATE goal</li></ul><p></p><p><b>Remember, dreams are evolving and changing directions as we age.</b></p><p></p><ul><li>Your dreams may not be the same when you are at 20, 30, 40 or 50 years old.</li></ul><p><br /></p></div><div><p><br /></p><h2>External Links</h2><ul><li><a href="https://mpsypc.com.my/publications/prp-faq-series-community-pharmacy/">PRP FAQ Series: Community Pharmacy, 2021</a></li><li><a href="https://mpsypc.com.my/publications/govtoprivate-communitypharmacy/">#GovtoPrivate: Community Pharmacy, 2022</a><br /></li><li><a href="https://aipharm.xyz/articles/malaysia-community-pharmacies-report-2022">Malaysia Community Pharmacies Report 2022</a></li></ul></div>Soon Senghttp://www.blogger.com/profile/12198523062740513134noreply@blogger.com0