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PHARMACY BULLETIN

النشرة الصيدليه

 

المحتويات

أخلاقيات مهنة الصيدلة

ISSUE NO.1** العدد الأول

ISUUE NO. 2 ** العدد الثاني

ISSUE NO. 3 ** العدد الثالث

ISSUE NO. 4 ** العدد الرابع

ISSUE NO. 5 ** العدد الخامس

ISSUE NO. 6** العدد السادس

ISSUE NO.7 ** العدد السابع

Chemical and biological agents

 

أسس أخلاقيات مهنة الصيدله التي أقرها إجتماع الإتحاد ألدولي في سيدني باستراليا في سبتمبر 1988 م

* على الصيدلي العامل في مجال خدمة الصحه والأفراد إحترام قواعد المهنه وتقدير حياة الأنسان

* على الصيدلي أن يكون عادلا في معاملة جميع المرضى دون تمييز

* على الصيدلي تحديث معلوماته المهنيه باستمرار ومتابعة الجديد في علم الصيدله

*على الصيدلي إحترام أسرار مهنته وان لا يبوح بأي معلومات عن المريض الا بإذنه أو في الحالات النادرة التي تحتم فيها مصلحة المريض البوح ببعض المعلومات عنه

* على الصيدلي تنفيذ المهام الصيدليه بحرص وتركيز

* على الصيدلي أن لا يقلل من شأن مهنته ولو جزئيا ، وان يقاوم بشدة كل محاولة المساس بأستقلال مهنته

* على الصيدلي إجتناب أي فعل يسيء الى مهنته أو يقلل من شأنها وان كان لا يمت للمهنه بصله واضعا في إعتباره ما للصيدله من مكان واحترام

* على الصيدلي إحترام أخلاقيات مهنة الصيدله ونظام مزاولة المهنة المحلي

* على الصيدلي إحترام حق المريض في حرية الأختيار ضمن الحدود الشرعيه

* على الصيدلي أن يتأكد أن المبلغ الذي يتقاضاه مقابل خدماته عادل ومعقول وأن يرفض الإشتراك في أي عمل من شأنه تعريض المريض للخطر لأن ذلك مخالف لأخلاقيات المهنه

* على الصيدلي أن يتأكد أن كل ما ينشره من معلومات ذات علاقه بمهنته صحيحه وموثوقه ومتمشيه مع آداب وأخلاقيات المهنــــــــه

* على الصيدلي الأحتفاظ بعلاقات يسودها جو الثقه مع الجهات الإداريه التابع لها

* على الصيدلي مساعدة الجهات الصحيه في جهودها لحماية الصحه بتقديم النصح وتكريس جهوده للرفع من مستوى المعايير الصحيه

* على الصيدلي أن يقوم بدوره كموجه للصحه العامه

* على الصيدلي أن يشارك في أنشطة الجمعيات المهنيه المحليه والعالميه والتي تهدف الى تحسين ظروف العمل والرفع من مستوى المهنه

* من حق الصيدلي الإمتناع عن صرف وبيع وتموين الدواء إذا رأى أن مصلحة المريض تقتضي ذلك ، وأذا كان الدواء مكتوبا بوصفه طبيه فعلى الصيدلي تقديم المشورة للطبيب الواصف

 

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ISUUE NO. 1

العدد الأول

DRUG-DRUG INTERACTION

WARFARIN-ACETAMINOPHIN

DANGEROUS INTERACTION

Warfarin is commonly used to prevent clotting in cardiovascular

diseases Warfarin has many drug interaction ,which may affect .

is activity and leading to serious side effects. Patients on warfarin

therapy easily may ingest acetaminophin ( paracetamol ) to relief

pain . Acetaminophin is without bleeding side effects like aspirin ,

but if acetaminophin is administered with warfarin it may increase

its bleeding effect .

In a prospective case control study , 289 outpatients 9 mean age 70 years on warfarin therapy for at least one month

( target INR of 2.0-3.0 ) were

followed within 24 hrs. of the reported INR . Case patients were identified and controls were randomly selected from patients with

acetaminophen , even a regular dose of

warfarin can result in dangerous hemorrhaging .

although the average weekly warfarin dose was similar between the two groups ,

the INRs were higher in the case group whom was ingesting gr-

eater amounts of acetaminophin on weekly basis . The risk for elevated

INRs with concurrent acetaminophen therapy was dose dependent .

The authors concluded that acetaminophen is under recognized cause

of over-anticoagulation in outpatients taking warfarin . Although the

authors do not propose a mechanism of action , they encourage clinic-

ians to query patients about their use of acetaminophen and monitor

INRs closely in patients who take high chronic doses .

Editorial comments : we also encourage all colleages in pharmacies to discuss this drug interaction with their patients

especially in older population. Patient education is one of patient's rights and will lead to stop purchasing similar drugs from groceries .

Ref. DPIC newsletter vol. 18 may-jun 1999 .

********************************************************************************************

PHARMACIST QUISTION ???

Q. All of the following drugs are contraindicated in breastfeeding except :

A) Cyclophosphamide

B) Ergotamine

C) Bromocriptin

D) Doxorubicin

E) Digoxin

F) Lithium

ANSWER :

Select the correct answer and clik for checking.

( A ) * ( B ) * ( C )

( D ) * ( E ) * ( F )

*

*

*

*

*

*

*

*

*

*

*

**

 

 

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ISSUE NO. 2 العدد الثاني

RIFT VALLEY FEVER

حمى الوادي المتصدع

Overview

Rift Valley Fever (RVF) is a zoonosis (a disease which primarily affects animals, but occasionally causes disease in humans). RVF may cause severe disease in both animals and humans, leading to a high morbidity and mortality, and exacting substantial economic costs from loss of livestock. Since 1930, when the virus was first isolated during an investigation into an epidemic amongst sheep on a farm in the Rift Valley of Kenya, there have been damaging outbreaks in sub-Saharan and North Africa. In 1997-98, there was been a major outbreak in Kenya and Somalia, and reports of disease from Mauritania. A wide variety of mosquitoes are possible vectors for the RVF virus (cf.: greater detail below). There is, therefore, a potential for epizootics (epidemics amongst animals) and associated human epidemics consequent on the introduction of the virus into a new area. This has often been demonstrated in the past and remains a concern.

The Virus, the Reservoirs, and the Vectors

The virus which causes RVF is a member of the Phlebovirus genus, one of the 5 genera in the family Bunyaviridae. It is primarily spread amongst animals by the bite of infected mosquitoes. A variety of mosquitoes may act as vector for transmission of the RVF virus; in different regions a different species of mosquito may prove to be the predominant vector. In addition, the various vector species play differing roles in sustaining transmission of the virus. Aedes mosquitoes may acquire the virus from feeding on infected animals, and are capable of trans-ovarial transmission (transmission of the virus from infected female mosquitoes to offspring via eggs), so new generations of mosquitoes may hatch, already infected, from their eggs. This provides a durable mechanism for maintaining the virus in nature, as the eggs of these mosquitoes may survive for periods up to several years in dry conditions. During periods of inundation of larval habitats by rainfall, for example, in the rainy season, the eggs will hatch, and the mosquito population will increase and spread the virus to the animals on which they feed. Previously uninfected mosquitoes will feed on infected, viraemic (virus circulating in the bloodstream), animals and thus amplify and perpetuate the outbreak by transmitting the virus to the animals on which they subsequently feed. Many types of animals may be infected with RVF, and disease may be severe in many domesticated animals including cattle, sheep, camels and goats, although sheep appear to be more susceptible than cattle and goats are less susceptible. Exotic breeds, more recently introduced into an endemic area, fare worse than breeds long adapted to local conditions. Animals of different ages also differ in their susceptibility to severe illness: over 90% of lambs infected with RVF die, whereas mortality amongst adult sheep can be as low as 10%. The abortion rate amongst pregnant, infected ewes is almost 100%. An epizootic of RVF is usually first manifested as a wave of unexplained abortion amongst livestock. This may be considered the sentinel event, heralding the epidemic to follow.

Transmission to Humans

During epizootics, people may become infected with RVF either by being bitten by infected mosquitoes, or through contact with the blood, body fluids or organs of infected animals. Such contact may occur while involved in the care or slaughtering of infected animals, or, possibly, from the ingestion of raw milk. The virus may infect by entering either through inoculation (e.g., if the skin is broken, or through a wound from an infected knife), or it may be inhaled as an aerosol. The aerosol mode of transmission has also led to infection in laboratory workers.

Clinical Features

The incubation period (interval from infection to onset of symptoms) of RVF varies from two to six days. There then follows an influenza-like illness, with sudden onset of fever, headache, myalgia (muscle pain) and backache. Some patients also develop neck stiffness, photophobia (the patient finds exposure to light uncomfortable) and vomiting, and in these patients the disease may be mistaken for meningitis in the early stages. The symptoms of RVF usually last from four to seven days, after which time the immune response to infection becomes detectable with the appearance of IgM and IgG antibodies, and the disappearance of circulating virus from the bloodstream.

A small proportion of patients develops a much more severe disease, and this generally appears as one of several recognizable syndromes. The fever and other symptoms described above may appear in association with eye disease, which characteristically manifests itself in retinal lesions. When the lesions are in the macula, some degree of permanent visual loss will result. Another syndrome manifests itself with acute neurological disease, as meningoencephalitis (inflammation of the brain and of the tissue surrounding it). The onset of these two syndromes is usually one to three weeks after the first symptoms. RVF may also manifest itself as haemorrhagic fever. Two to four days after the onset of illness, the patient shows evidence of severe liver disease, with jaundice and haemorrhagic phenomena, such as vomiting blood, passing blood in the faeces, developing a purpuric rash (a rash caused by bleeding in the skin), and bleeding from the gums. Patients with the RVF-haemorrhagic fever syndrome may remain viraemic for up to 10 days. The proportion of patients developing these three types of complications is about 0.5-2% for eye disease, and less than 1% for meningoencephalitis and for the haemorrhagic fever syndrome. Most fatalities occur in patients who have developed one of these complications. The case-fatality rate for patients developing haemorrhagic disease is high – approximately 50%, whereas death in those with only ocular disease or meningoencephalitis is uncommon. The total case fatality rate has varied widely in the various documented epidemics, but, overall, is less than 1%.

Diagnosis and Treatment

The diagnosis of acute RVF may be reached by several approaches. Serological tests such as enzyme-linked immunoassay (the "ELISA" or "EIA" methods) may demonstrate the presence of specific IgM antibodies to the virus. The virus itself may be detected in blood or tissues by a variety of techniques including virus culture, antigen detection tests, and PCR, a molecular method for detecting the viral genome.

The antiviral drug ribavirin has been shown to inhibit viral growth in experimental systems, but has not been evaluated in the clinical setting. Most human cases of RVF are relatively mild and of short duration, so will not require any specific treatment. For the more severe cases, the mainstay of treatment is general supportive therapy.

Prevention and Control

Rift Valley fever can be prevented by a sustained program of animal vaccination. Both live, attenuated, and killed vaccines have been developed for veterinary use. The live vaccine requires only one dose and produces long-lived immunity, but the presently-available vaccine may cause abortion if given to pregnant animals. The killed vaccines do not cause these unwanted effects, but multiple doses must be given to produce protective immunity. This may prove problematic in endemic areas. An inactivated vaccine has been developed for human use. This vaccine is not licensed and is not commercially available but has been used experimentally to protect veterinary and laboratory personnel at high risk of exposure to RVF. Other candidate vaccines are under investigation.

The risk of transmission from infected blood or tissues exists for people working with infected animals or people during an outbreak. Gloves and other appropriate protective clothing should be worn, and care taken when handling sick animals or their tissues. Healthcare workers looking after patients with suspected or confirmed RVF should employ universal precautions when taking and processing specimens from patients. Hospitalized patients should be nursed using barrier techniques. As noted above, laboratory workers are at risk, so samples taken for diagnosis from suspected cases (human and animal) of RVF should be handled by trained staff and processed in suitably equipped laboratories.

Other approaches to the control of disease involve protection from and control of the mosquito vectors. Personal protection is important and effective. Where appropriate individuals should wear protective clothing, such as long shirts and trousers, use bednets and insect repellent, and avoid outdoor activity at peak biting times of the vector species. Measures to control mosquitoes during outbreaks, e.g., use of insecticides, are effective if conditions allow access to mosquito breeding sites.

New systems which monitor the variations in climatic conditions are being applied to give advance warning of impending outbreaks by signalling the events which may predictably lead to increases in mosquito numbers. These will allow authorities to implement measures to avert the threatened epidemic.

WHO's Role

In response to the 1997-98 outbreak in northeastern Kenya and southern Somalia, WHO scientists and doctors led an international team which investigated the origins and epidemiology of the outbreak. Members of the team from WHO's headquarters and African Regional (AFRO) offices, its Kenyan and Somalian country offices, and several collaborating centres. For investigation, analysis and isolation of the virus, collaborating centres in Kenya (the Kenya Medical Research Institute), South Africa (the National Institute of Virology) and the USA (the Centers for Disease Control and Prevention) played key roles. 

حمى الوادي المتصدع

تعريف الحالة المشتبه بها :

هي حالة تعاني من الآتي : -

أ- حمى غير معروفة السبب ( درجة الحرارة أكثر من 5 و 38 درجة مئوية ) لفترة تزيد عن 48 ساعة مع ارتفاع في وظائف الكبد لأكثر من ثلاث أضعاف المعدل الطبيعي أو مع ظهور يرقان .

أو :

ب- حمى غير معروفة السبب ( درجة الحرارة أكثر من 5 و 38 درجة مئوية ) لفترة تزيد عن 48 ساعة مصحوبة باجهاض ، نزف تحت الجلد أو نزيف ( على سبيل المثال مكان الوخز ، من الجهاز الهضمي ، زيادة نزف في الدورة الشهرية ) .

أو :-

فقد مفاجىء للبصر غير معروف السبب .

أو :-

حمى غير معروفة السبب ( درجة الحرارة أكثر من 5و38 درجة مئوية ) لفترة تزيد عن 48 ساعة ومصحوبة بدوار ، ارتباك ، فقدان احساس المكان والزمان ، نسيان ، نعاس أو نوم غير سوي ، هلوسة ، إرتجاف ، تشنجات ، أو غيبوبة

أو:-

وفاة غير معروفة السبب مع وجود تاريخ مرضي لحمى .

* طريقة نقل العدوى :

1* لدغة بعض أنواع البعوض الناقل للمرض الكيولكس والأيدس .

2* ملامسة افرازات الحيوانات المصابة بالمرض .

3* إستنشاق الرذاذ المتطاير من أنسجة الحيوانات المصابة أو أجنتها أثناء عمل الفحص التشريحي البيطري لها .

* فترة الحضانة :-

فترة حضانة المرض 2-7 أيام .

* فترة أنتقال العدوى :

لا تنتقل العدوى مباشرة من الأنسان المريض الى السليم والبعوضة المصابة تصبح ناقلة للفيروس طيلة حياتها .

* القابلية للعدوى :

القابلية عامة - والعدوى البسيطة غير المشخصة يمكن أن تكون عامة - والعدوى تعطي مناعة ضد المرض .

* طريقة المكافحة :

أ- الإجراءات الوقائية :

1* اتخاذ الإجراءات المعروفة لاتقاء العدوى من لدغ البعوض

2* إتخاذ الإحتياطات اللازمة لوقاية الجسم من ملامسة دم الذبائح وأنسجتها

3* مكافحة المرض وسط الحيوانات الأليفة

ب- المكافحة في المريض والمخالطين والبيئة :

1* الإبلاغ الفوري عن الحالات

2* العزل واتخاذ الإجراءات التحوطية نحو الدم وسوائل الجسم

3* عمل إستقصاء جيد للحالات والمخالطين لاكتشاف الحالات البسيطة بينهم ولمعرفة مصدر العدوى المحتمل .

4* مكافحة البعوض حول أماكن ظهور الحالات .

5* التوعية الصحية بطرق العدوى والمكافحة .

* علاج المرض :

لا يوجد علاج نوعي للمرض ويتم علاج الأعراض والمضاعفات .

 

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ISSUE NO. 3 العدد الثالث
GUIDLINES FOR THE MANAGEMENT OF SNAKE BITE

 

PATIENT WITH SUSPECTED SNAKE BITE

1 snake brought and positively identified as poisonous or fang marks were clear ( CLICK )
2 snake was brought and positively as non-poisonous,or no fang marks,no severe local pain, none of the expected local and systemic manifestation were detected . Observe for 4 - 8 hours to exclude misidentification . Give anti- tetanic serum and tetanus toxoid ( CLICK ) .

 

 

 

 

 

 

 

Did you notice any clinical manifestation ? . YES or NO .

 

 

 

 

 

 

 

Did you notice any clinical manifestation ?. YES or NO

 

 

 

 

 

 

 

DETERMINE IF SNAKE IS

HAEMATOXIC OR NEUROTOXIC

 

 

 

 

 

 

 

 

Discharge The Patient

 

 

 

 

 

 

 

 

Give anti-tetanic serum and tetanus toxoid. Observe 24 hours .

Did you notice any clinical manifestation ? YES or NO

 

 

 

 

 

 

 

DETERMINE IF SNAKE IS

HAEMATOXIC OR NEUROTOXIC

 

 

 

 

 

 

 

Discharge The Patient

 

 

 

 

 

 

 

HAEMOTOXIC
Horned Viper

Cerastes Cerasts

Carpet Viper

Echis Coloratus

Saw Scaled Viper

Echis Carinatus

Puff Ader

Bitis Arietans

Labaratory Procedure and Expected Result if Snake is Haemotoxic
LAB TEST EXPECTED RESULT
PT & APPT

FIBRIN DEGRADATION PROD.

FIBRINOGEN

LEUKOCYTE

RBC

HEAMATOCRITE

PLATELET

Hb

high *

high *

low *

high

low

low

low

low

* These parameters are not significantly changed in the case of  B.arietans bite , however blood platelets are significantly reduced.

Expected Local and Systemic Manifestation if Snake is Haemotoxic :

  • spontaneous systemic bleeding
  • local swelling involving more than half the bitten limb
  • extensive blistering or bruising
  • marked thrombocytopenia ( > 50 000/mm3 )
  • hypotension and shock , abnormal ECG , etc.
  • prolonged clotting time
  • haematuria

GIVE  POLYVALENT SNAKE ANTIVNOME

50 ml ( 5* 10 ml ampoles) to be diluted in 250 ml normal saline infused i.v over 30 -60 minutes.some dose can be repeated every 4 - 6 hours until definite improvment take place. Children must be giventhe same dose as adults.

 

 

NEUROTOXIC
arabian cobra

naja haje arabicus

black desertcobra

walterinnesia aegyptia

mole viper

atractaspis

* mole viper atractaspis

  mainly cardiotoxic causing coronaryvasoconstriction and AV block

IF SNAKE IS POSITIVELY IDENTIFIED AS ARABIAN COBRA OR WALTERINNESIA AEGYPTIA

assist respiration

for patients who show severe neurotoxic symptom , application tensilon test ( edrophonium ) is necessary and manage according to the result .

IS BIVALENT ANTIVENOM AVAILABLE AT YOUR HOSPITAL?

YES: Give bivalent antivenom

NO: Double the dose of polyvalent antivenom and give as bivalent antivenom

EXPECTED LOCAL AND SYSTEMIC MANIFESTATION IF SNAKE IS NEUROTOXIC :

  • ptosis , external ophthalmoplegia
  • prograssive paralysis of face , plate , jaws, tongue, vocal cords ,neck muscles and muscles of deglutition
  • impaired conciousness
  • progressive respiratory failure

GIVE BIVALENT SNAKE ANTIVENOM

50 ml ( 5* 10 ml ampoles) to be diluted in 250 ml normal saline infused i.v over 30 -60 minutes.more antivenome should be given if sever signs persist after 1 -2 hours. dose can be repeated every 4 - 6 hours until definite improvment take place. Children must be giventhe same dose as adults.

* please note that the antivenom dose isbased mainly on titration of the symptoms until clinical manifestation disappears.

 

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ISSUE NO. 4 العدد الرابع
GUIDLINES FOR THE MANAGEMENT OF SCORPION STING

 

CONFIRMED SCORPION STING

1 ADULT ( CLICK )
2 CHILDREN ( CLICK ) .

 

 

 

 

 

 

 

 

Did you notice any clinical manifestation ? . YES or NO .

 

 

 

 

 

 

 

 

 

At the onset of the systemic manifestation proceed as follows :

 

 

 

 

 

 

 

 

 

Observe for 8 hours . Did you notice any systemic manifestation

YES or NO

 

 

 

 

 

 

 

 

Discharge The Patient

 

 

 

 

 

 

 

 

GIVE SCORPION ANTIVENOM

*A. crassicauda

*L.quinquestriatus

The two most dangerouse scorpions in saudi arabia and two of the most toxic in the world .

Labaratory Procedure and Expected Result

Some or all of these changes can be seen in the victims

LAB TEST EXPECTED RESULT
WBC

BLOOD GLUCOSE.

CPK

LDH

AMYLASE

Na & Ca

K

BLOOD GASES

ECG

X-ray

high

high

high

high

high

low

high

acidosis

changes

changes

* Cause of death : cardiac failure , circulatory collapse , or respiratory failure .

POLY VALENT SCORPION ANTIVENOM

Give 5*1 ampoules polyvalent scorpion antivenom diluted in a 20 - 50 ml half normal salin, i.v . over aperiod of 20 minutes . If systemic manifestation still exists , the same dose is to be repated every 2 hours up to 4 doses , then keep under observation for atleast 24 hours , sfter recovery.

* please note that the antivenom dose isbased mainly on titration of the symptoms until clinical manifestation disappears.

ADJUNCTIVE THERAPY TO SUPPORT VITAL FUNCTION

* sever pain :

0.5 ml ( max.) of 1% xylocain , infiltrated at the site of the sting .

* vomiting :

chloropramazine 0.5 - 1 mg/kg i.m. repeated if necessary

* convulsion :

diazepam i.v slowly

* pulmonary oedema :

O2 , furosemide and fluid restriction .

* dyspnea :

IPPV

* hyperthermia :

acetaminophen suppository

* hypertension :

hydralazine or nifedipin

* acidosis :

correct blood gases and electrolytes

* shock :

c.v.p line with 0.5 normal saline to keep value at 8-12 cm H2O and maintain blood pressure at a level to perfuse vital organs .( systolic B.P. between 60-70 mm Hg in children ) .

* CONTRAINDICATED DRUGS ( Don't Use ) :

Barbiturates , Morphine or Pethidine , Beta Blockers

* REFERNCE :

NATIONAL ANTIVENOM & VACCINE PRODUCTION CENTER

* For further information :

National Guard Health Affairs

Tel : 252-0252 ext. 5626/ 5655 fax: 252-0188

e-mail : navpc@ngha.org

 

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ISSUE NO. 5 العدد الخامس

Phenylpropanolamin may cause Hemorrhagic Stroke

 

Food And Drug Administration (FDA) is taking steps to remove phenylpropanolaminePPA from all drug products and has requested that all drug companies discontinue marketing products containing PPA .

FDA issued a public health advisory concerning the risk of hemorrhagic stroke( stroke is characterized by either bleeding in the brain because of ruptured vessel or impaired blood flow to a part of the brain when a vessel is blocked by a clot ) associated with PPA .

 which is an Active ingredient used in many (OTC) preparations cough and cold medications as a decongestant , the Ministry Of Health has taken steps to stop marketing of  the following  21 preparations that contain this Substance:          

1-Pholrine pediatric syrup .           (Misr medical services)

2-Tutssal pediatric syrup.                (AlJazirah)

3-Tussal expectorant .                      (AlJazirah)

4- Tussal B.T. syrup.                        (AlJazirah)

5-Tussal plane syrup.                       (AlJazirah)

6-Conta- flu tab.                               (Smith&Kline Beecham)

 7-Noflu tab.                                       (Cairo comp.)

8-Rubitiussin C.F syrup.                

(A.H Robins)        

9-Dimetapp Extan tab. (A.H Robins)

10-Dimetapp syrup.           (A.H Robins)             

11-Escornade syrup. (Smith Becham)

12-Escornade cap. (Smith Becham)

13-Contrasal S.F adult syrup.         (AlHikma)

14-Contrasal expectorant syrup .   (AlHikma)

15-Contrasal B.T. syrup.                 (AlHikma)

16-Contrasal P.J pediatric syrup.   (AlHikma)

17-Contrsal P.J adult syrup.           (AlHikma)

18-Kidi Kold syrup.                         (AlHikma)

19-RhinoTussal syrup.                       (Mack)

20-Rhinopront syrup.                       (Mack)

21-Corcidine D. tab .                        (Schering)

Antimicrobial Agents Associated With Photosensitivity :

 

Amantadin , azithromycin , ciprofl-oxacin , clofazimin , dapsone , dox-

ycycline , erythromycin ethyl succ-

inate , griseofulvin , norfloxacin ,

ofloxacin , pyrazinamide , sulfon-

amide , tetracyclines , trimethoprim

Drugs And  Breastfeeding

 

Research in the United state , Canada , Europe , and other developed countries among predominantly middle-class population , provides strong evidence that human-milk feeding decreases the incidence and/or severity of diarrhea , lower respiratory infection , otitis media , bacterial meningitis , botulism , urinary tract infection , and necrotizing enterocolitis , There are a number of studies that show a possible protective effect of human-milk feeding against sudden infant death syndrome , insulin-dependant diabetes mellitus , crohn's disease , ulcerative colitis , lymphoma , allergic diseases and other chronic digestive disease .

 

The following questions and options should be considered when prescribing drug therapy to lactating women (1) Is the drug therapy really necessary? Consultation between the pediatrician and the mother's physician can be most useful . (2) Use the safest drug , for example , acetaminophen rather than aspirin for analgesia . (3) If there is a possibility that  a drug maypresent arisk to the infant , consideration should be given to measurement of blood concentrations in the nursing infant. (4) Drug exposure to the nursing infant may be minimized by having the mother takes the medication just after she has breastfed the infant and/or just befor the infant is due to have a lengthy sleep period.

 

Drugs Contraindicated during breastfeeding :

 

Bromocriptin  , Cyclophosphamide

Cyclosporine , Doxorubicin

ALL DRUGS OF ABUSE INCLUDING:

Amphetamine , Cocaine , Heroin

 Ergotamine , lithium , methotrexate ,

Radiopharmaceuticals , lysergic acid diethylamide ( LSD) , phencyclidine ,

Drug listed as compatible* with breastfeeding by American Academy of Pediatrics ( AAP) :

 Acetaminophen , Captopril ,

Acyclovir , Atropine , Baclofen ,

Caffeine , Carbamazepine ,

Cephalosporins , Cimetidine ,

Clindamycin , Digoxin , Diltiazem,

Enalapril , Erythromycin , Ethosuximide , Hydralazine , Ibuprofen ,

Minoxidil , Naproxin , Methyldopa,

Nifedipin , Penicillin , Phenytoin ,

Prednisolone , Propoxyphene , proPylthiouracil , Pseudoephedrine ,

Quinidine , Quinine , Rifamicin ,

 Senna , Spironolacton , Tolbuta mide, Trimethoprim , Valproic acid , Verapamil , Warfarin .

 * Compatibility does not indicatethat a drug is risk-free in breastfeeding dyads ; it suggests only that in most situation , there is sufficient evedence to imply safety .

Additional drugs having significant evidence* for safety in breastfeeding dyads

 Albuterol inhalers , Amantadine , Azathioprine , Azithromycin , Beclomethasone inhaler , Cholestyramine , Clomipramine , Cromolyn sodium ,

Famotidine , Fluconazole , HeptitisA vaccin , Influenza vaccin , Insulin ,Fluvoxamin , Heparin , Ipratropium inhaler , Levothyroxine , Lortadine , Metoclopramide , Nortriptyline , Nystatin , Omeprazole , Ondansetron , Ranitidine , Sulfamethoxazole .

 

* Case report data , pharmacokineetic properties , andlor pediatric use data .

BACK العودة للقائمه الرئيسيه

 

ISUUE NO. 6 العدد السادس

REDUCING NSAID INDUCED G.I

ULCERATION IS POSSIBLE

 

The widespread use of NSAIDS , including aspirin, attests to the efficacy of these agents for relieving pain, inflammation and fever . However , it is now well recognized that a significant disadvantage of NSAIDS use is an increased risk of gastroduodenal ulcers.

Strategies to minimize these events include: avoiding NSAIDS , using the lowest effective dose , avoiding certain concomitant medications (e.g. corticosteroids ) or use of one of the new generation of highly selective cyclo-oxygenase type 2 (cox-2) inhibitor NSAIDS . For patients who are at high risk of developing adverse gastric events (e.g. the elderly and those with a prior history of ulcer) , pharmacological prophylaxis may be appropriate and possiblycost effective.

The prostaglandin misoprostol and proton pump inhibitor omeprazole are the most promising agents for prevention of gastroduodenal ulcers.

The annual death rate among patients with rheumatoid and osteoarthritis due to serious adverse consequences of gastroduodenal ulceration ( perforation and haemorrhage ) has been estimated to be as high as 16500 in US alone .Overall, the relative risk for severe gastroduodenal complications is approximately 3 to 10 times greater for NSAIDS users than non-users depending on the NSAID being used.

Even low dose aspirin increases the relative risk of ulcer haemorrhage or perforation 2 to 4 fold. 

Many strategies for damage prevention : a topical effect and a systemic effect.  

The first step in preventing NSAID-induced gastroduodenal ulceration is to carefully asses the need for NSAID Therapy. Wherever possible , non NSAID analgesic (e.g. paracetamol should be used .If treatment with NSAID is necessary the lowest possible effective dose should be as there is evidence to suggest that the development of ulcers is dose related.                        

High gastric acidity contributes to  NSAIDS injury in the stomach and duodenal bulb.                                   

Increasing the gastric mucosal PH can prevent G.I damage , presumably by increasing the time for mucosal repair. The proton pump inhibitor, omeprazol (losec) has been shown to reduce ulcer rate by up to 80 % compared with no treatment.                                           

 Misoprostol provides cytoprotetion

Intragastric prostaglandins exert various protective effects including :stimulating the section of bicarbonate and mucous, increasing the resistance of the surface epithilium to injury and preserving intravascular blood flow. Co-administration of an exogenous prostaglandin such as misoprostol with NSAIDS would be expected to be beneficial.     

Chemoprophylaxis for high risk patients

 Various risk factors have been identified which predispose to the development of a serious gastrointestinal event. Probably the most important of these advanced age (<60 years ) . It has been suggested that for patient < 1 risk factor consideration should be given to the administration. Of preventive treatment, either misoprostol or omeprazole. Other anti-ulcer agents such as histamin H2 antagonists was limited to protection against duodenal ulcers in a large comparative trial with omeprazole and sucralfate has been shown to be ineffective.

Ref. www.medscape.com ( drug&ther perspect 2000)

 

PHARMACIST SAVE LIVES LIKE SUPERMAN

 

Every day pharmacists save the lives of patients by many ways like to check wrong prescription ( names and doses , side effects) and drug interactions that some time doctor cannot judge.                

 For example a urologist prescribed Viagra for patient. Dr. asked the patient if he was on nitrates patient did not know that imdur is a nitrates pharmacist noticed that patient was using imdur that was a nitrate which has sever interaction with viagra so he saved the patient from fatal interaction.                  

 

One patient came to pharmacy with a prescription and the doctor prescribed for him danol . When the pharmacist checked the diagnosis was peptic ulcer   

 ( danol is the drug which is used for different diagnosis ). The pharmacist discussed with the doctor . Actually he wanted to write denol which is used for peptic ulcer , by mistake of alphabet he wrote this drug (i.e. A & E ) .                    

So pharmacist saved the life of patient from fatal action of the drug .

Some times pharmacist detect serious illness that required hospitalization , one lady came for cough syrup. Pharmacist detected that patient has sever illness and he informed her doctor who admitted her in hospital and was diagnosed as a case of CHF.

One mother came with child for laxative , but child was feeling abdominal pain , so, pharmacist sent him to doctor where he was operated for acute appendicitis.

 In U.S.A 100,000 people die every year because of medication errors that is 3rd leading cause of death after heart disease and cancer. Another 100,000patients become worse because of medication errors.

So , Pharmacist should check the drug , dose , side effects , and interaction. So , all prescriptions should be passed through pharmacists who are  super hero or super heroins of the pharmacy

 

 PEANUTS ALLERGY MAY BE TRIGGED BY BREAST FEEDING some moms should avoid peanuts products while nursing

mother to her It is proved that some proteins from peanuts can be transmitted through lactating baby by breast feeding.

These proteins cause allergic reaction in babies who are exposed to peanuts allergy. So children should not be exposed to peanuts until after age of 3 if parents or other family member , have a history of Br. Asthma , allergies or eczema such mother should not include peanut in their diet if they are on breast feeding .  

 

BACK العودة للقائمه الرئيسيه

 

ISSUUE NO. 7 العدد السابع
PRUDENT VANCOMYCIN USE

 

    There have been several reports of the rapid increase in the incidence of infection and colonization with vancomycin resistant enterococci (VRE) which have become world wide problem.

    Several  factors have been associated with VRE and these include:

A.     Prior exposure to vancomycin and multi-antimicrobial therapy.

B.     Severe underlying disease or immunosuppression.

C.     VRE gastrointestinal colonization.

D.    Transmission of microorganisms from patient to patient either via direct contact or indirectly via hands of personnel  or contaminated patient care equipment or environmental surfaces.

E.     Prolonged hospital stay.

F.      Physical location in the hospital.

 

   There is the growing concern that if vancomycin is not use cautiously, the vancomycin resistant genes present in VRE may be transferred to other gram-positive microorganisms such  as staphylococcus aureus.

   The following are some of the recommended measures by the US hospital  infection control practices advisory committee (HICPAC) for the prudent vancomycin use.

  A. Situations in which the use of vancomycin is appropriate or acceptable:

1. Serious infection with beta-lactam-resistant gram-positive organisms.

 

2. Infections with gram-positive organisms in patient with serious allergy to beta-lactam antimicrobial agents.

3. When antibiotic-associated colitis(AAC) fails to respond to metronidazole therapy or if AAC is severe and potentially life-threatening.

4. Prophylaxis, as recommended by the American Heart Association, for endocarditis in certain situations.

      5. Prophylaxis for major surgical procedures          involving implantation of prosthetic materials or devices at institutions with high rates of infections due to methicillin resistant Staphylococcus  aureus (MRSA) or methicillin-resistant S. epidermidis (prophylaxis should be discontinued after maximum of two doses).    

B. Situations in which the use of vancomycin should be discouraged:

1. Routine surgical prophylaxis other than in a patient with life-threatening allergy to beta-lactam antimicrobial agents.

2. Empiric therapy for a febrile  neutropenic patient, unless there is strong evidence that patient has an infection due to gram-positive microorganisms, and prevalence of infections due to MRSA in the hospital is substantial.

3. Treatment in response to a single blood culture for coagulase- negative staphylococcus, if other blood cultures drawn in the same time

frame are negative.

4. Continued empiric use for presumed infections in patients whose culture are negative for beta-lactam resistant gram-positive microorganisms.

 5. System or local prophylaxis for infection or colonization of indwelling central or peripheral catheters.

 6. Selective decontamination of the digestive tract.

 7. Eradication of MRSA colonization.

 8. Primary treatment of AAC.

 9. Routine prophylaxis of low birth-weight infants.

10. Routine prophylaxis for patients on continuous ambulatory peritoneal dialysis or hemodialysis.

11. Treatment of infections due to beta-lactam-sensitive gram-positive microorganisms in patients with renal failure (for dosing convenience)

12. Use of vancomycin solution for topical application or irrigation.

 

Reference: Hospital Infection Control practices advisory committee    (HICPAC)

 

PHENYLPROPANOLAMINE (PPA)

IN THE NEWS AGAIN

 

   The Pharmacy Bulletin of March 2001 highlighted the issue of Phenylpropanolamine

(PPA) causing Haemorrhagic stroke and the recommendation of food and drug administration (FDA) regarding the use of pharmaceutical preparation containing PPA.

However, recent studies both in the U.K & U.S.A. on causing haemorrhagic stroke have been associated with factors such as smoking status, hypertension, race and level of education.

 

  The committee on safety of medicines (CSM) of the medicines control agency (MCA) reports that the evidence of the link between PPA  and haemorrhagic stroke was weak and that the benefits of PPA as used in the U.K still outweigh the risks.

 

However it warns that:

 

1. Patient with hypertension, hyperthyrodism heart disease or those taking mono-amine oxidase inhibitors should not receive PPA products.

 

2. All patients should not exceed the stated dose.

ONE ALPHA DROPS (alphacalcidol)

ACCIDENTAL OVERDOSE .

   

Alfacalcidol is indicated  in all  conditions  where there is a disturbance of calcium metabolism due to 1- alpha hydroxylation.  These include renal osteodystrophy, hyperparathyroidism

(with bone disease),  neonatalhypocalcaemia, hypoparathyroidism, and vitamin D- dependent rickets.

    There have been