hialid - side effectsenews.mims.com/landingpages/pt/pdf/pharmacy_today... · choose hialid for...

September/October 2013

Enhancing capacity and capability for a modern pharmacy sector

Forum

Unity hits the sweet spot on diabetes management

News

Children prefer mini tablets over syrup: study

Up to 70% of people with dry eyes have corneal damages1

HIALID® is clinically proven to prolong tear break-up time for long-lasting hydration and to promote faster healing of the cornea.

Choose Hialid for better control of dry eye.

HIALID®

ophthalmic solutionManufactured by:Santen Pharmaceutical Co.,Ltd.4-20 Ofukacho, Kita-ku, Osaka, 530-8552, Japan

Distributed by:LF Asia Distribution 279 Jalan Ahmad Ibrahim, #03-01, Singapore 639938

Reference 1. Santen Internal Data (2004)

News | Pharmacy Today | September/October 2013 2

Children prefer mini tablets over syrup: study

By Rajesh Kumar

Children prefer to take their medica-tions in the form of uncoated mini tablets rather than syrup, a study

involving more than 300 infants and pre-school children has suggested.

Liquid formulations are most frequently used for young children because tablets are widely considered to be not appropriate, at least up to the age of 6 years. However, use of syrup has major disadvantages, such as chemi-cal, physical, or microbial instability, taste is-sues, lack of controlled release properties, lim-ited number of safe excipients, and unreliable dosing because of incomplete swallowing, said the researchers in Germany.

To evaluate the acceptability of 2mm tablets as an alternative to syrup and coated tablets of the same size in young children, they re-cruited 306 pediatric patients aged 6 months to 5 years (51 children in each of the six age groups) at the University Children’s Hos-pital in Duesseldorf, Germany for the open, cross-over study. [J Pediatr 2013; doi: 10.1016/j.jpeds.2013.07.014]

All the children were randomized to re-ceive three formulations without active phar-maceutical ingredients, one after the other, and their reactions noted. The acceptability of uncoated 2mm tablets was superior to syrup and the children were able to swallow uncoat-ed mini-tablets better than the syrup. Only two of the 306 children, both in age group 6 months to 1 year, coughed because of the coated mini-tablet. But this did not have any clinical relevance.

“Mini-tablets are a valuable alternative

to syrup for children 6 months to 6 years of age and are more acceptable compared with liquid formulation,” said the research-ers, Professor Joerg Breitkreutz, director of the Institute of Pharmaceutics and Biophar-maceutics at Heinrich-Heine-University Duesseldorf in Duesseldorf, Germany, and colleagues.

“Regulatory bodies such as the (US) Food and Drug Administration and European Medicines Agency (EMA) are encouraged to take our data into account for guideline updates and future drug approval processes.”

In an earlier exploratory study by the same team, uncoated mini tablet did not show infe-riority, when compared with glucose syrup, in 60 children aged 6 months to 6 years. [Arch Dis Child 2012; 97: 283–286]

“The current study is a confirmatory study of the same design, but also includes coated mini tablets as a third sample, which has to be swallowed entirely. The data confirms the outcome of the exploratory study and shows even more pronounced superiority of the mini tablets, surprisingly both coated and un-

In the study, children aged 6 months to 6 years were able to swallow mini tablets better than the syrup.


coated, compared to syrup,” said Breitkreutz. Yet another study from a different group

including the Dutch Regulatory Agency showed similar preference for bigger (4mm) tablets. [Arch Dis Child 2013;98:725–731]

“All these studies will shift the paradigm on the acceptability of pediatric medicines from liquid to solid dosage forms, in my opin-ion,” Breitkreutz said in an email interview with Pharmacy Today.

“This was called for by the WHO a few years ago and has now been scientifically proven.”

The lack of approved medicines and ad-equate drug formulations for children led to global regulatory initiatives. According to the European Regulation on Pediatric Medi-cines, suitable dosage forms for children, par-ticularly small children, have to be developed by pharmaceutical companies as part of their pediatric investigation plan. However, until

now there has been a lack of valid scientific data on the most suitable pediatric dosage forms for safe administration of medicines to small children.

The WHO recommends the use of solid multi-particulates, but the EMA had previ-ously questioned general applicability of solid dosage forms to children aged below 2 years. The latest evidence should help progress the debate on this issue.

Dr. Low Kah Tzay, pediatrician and neona-tologist at the Anson International Pediatric & Child Development Clinic in Singapore said the study is indeed significant. However, a follow up study needs to determine the ideal shape of the tablets and choking hazards in younger children, said Low.

“Another consideration is the dosage regi-men. Tablets are less flexible than liquid prep-aration for the dosage in children which are calculated according to their body weight.”

Forum | Pharmacy Today | September/October 2013 4

Singapore government is ramping up the capacity and capability of the country’s pharmacy workforce.

The National University of Singapore’s De-partment of Pharmacy is currently the lone academic institution for training pharmacists. More than a decade ago, NUS had about 40 pharmacy students every year. In 2012, this number rose to 180. We are hoping to eventu-ally increase this number to 240 students ev-

ery year.But it is not just the numbers that we are

interested in. We are also working to enhance the capabilities of our pharmacist workforce. For instance, trainee pharmacists in Singa-pore need to undergo a one-year pre-registra-tion training with a center accredited by the Singapore Pharmacy Council after finishing their four-year degree in pharmacy. We are planning to change this model.

Enhancing capacity and capability for a modern pharmacy sector Excerpts from an interview with Assistant Professor Lita Chew, Chief Pharmacist, Ministry of Health, Singapore.

Lita Chew


After spending 3 months of their training at the NUS, pharmacists may soon be able to complete the rest in the different streams of pharmacy profession – be it in patient care, regulatory field or in the drug industry.

Simultaneously, we are trying to open up the whole pharmacy sector for pre-registra-tion training. Ten industry players (those not involved in direct patient care) have recently started taking pre-registration trainees. We started a pilot last year with 10 percent of the pre-registration pharmacists to go through this new model. This is being increased to 30 percent of the NUS pre-registration pharma-cists this year.

Curriculum at the NUS is also being re-shaped to fit into the new way we need to train future pharmacists. The Ministry of Health (MOH) recently reviewed post-gradu-ate training and education. The review looked at providing support in terms of scholarships, funding and residency training, etc. That will help to further develop pharmacists who are already working in patient care and offer them a clear path to career progression.

Career plan for pharmacy techniciansWe are also looking into the career struc-

ture and development plan for our pharmacy technician workforce, so they are able to take on more expanded roles as part of the chang-ing professional landscape.

The technicians are generally graduates of the Certified Pharmacy Technician Course or-ganized by the Pharmaceutical Society of Sin-gapore (PSS) who have gained qualifications under the Workforce Skills Qualifications (WSQ) framework.

We also have technicians who are gradu-ates of the pharmaceutical science diploma at polytechnics. Foreign pharmacy degree hold-

ers whose qualifications are not recognized for registration as pharmacists in Singapore also work as pharmacy technicians. Currently, technicians’ development pathways are main-ly left to the organizations on the ground, and are not are very attractive. A career structure and clear development plan will hopefully change that. Technicians can certainly take on more responsibilities.

That aside, there is perception that phar-macists working in primary health care do not get to play a significant role in primary health care and, as a consequence, their skills are not being fully utilized.

I would like to correct that perception. When you think of primary health care , you also have to consider pharmacists who are working in public sector polyclinics and at-tached community pharmacies. They have been playing a key role in not just dispens-ing, advice and medicines reconciliation, but also in a truly collaborative model of primary health care delivery.

The Agency for Integrated Care (AIC) and PSS are also running programs wherein com-munity pharmacists are involved in review-ing medications in nursing homes. Com-munity pharmacists are also active in health promotion. One example is the Health Pro-motion Board’s (HPB) Health Ambassadors program that pharmacists have long been involved in through PSS.

Community pharmacy’s enhanced roleMedication management services, health

screening efforts etc. are the other areas where community pharmacists deliver better care to patients in the community. Unity Pharmacy’s Sweet Spot program in collaboration with the NUS (featured in this issue) is one such ex-ample.


If you look at our medicines classification system: we have pharmacy only medicines and general sale medicines. These are avail-able to pharmacists to manage patients with minor ailments such as cough and cold, cuts and bruises and minor fungal infections. To diagnose these and to be able recommend medications appropriate for the condition, along with necessary advice on how to take those medicines, is right up their alley.

Pharmacists are very cognizant of not just the twin challenges of our ageing population and an explosion in the numbers of those with chronic diseases, but also the rising health care costs and public expectations. We can certainly do more.

From an acute care perspective, many pharmacists are already participating in team

based care, wherein they collaborate with physicians to deliver a specific care to a tar-geted group of patients. We have pharmacists in hospitals and polyclinics running outpa-tient clinics for chronic diseases.

We are in the process of creating a nation-al pharmacy landscape architecture, so that the medication related information can flow across the sector.

Hopefully, we will soon have a blueprint that pharmacy stakeholders can look at and say this is the way things need to be done. It will tell us what capabilities we need to build, and eventually help us to link with other systems that the MOH has envisioned such as national electronic health records, to create a truly modern and dynamic pharma-cy sector in Singapore.


Unity hits the sweet spot on diabetes management

By Rajash Kumar

Unity Pharmacy’s clinical advisory program on hypertension, diabetes and hyperlipidemia is expanding to

a fourth site at Tampines in East Singapore.The community pharmacist-led free ser-

vice called “Sweet Spot” is the result of col-laboration between the National University of Singapore (NUS) Department of Pharmacy and NTUC Unity Healthcare Co-Op Ltd.

Already available at Ang Mo Kio Hub, J Cube and Singapore Post Centre pharmacies, the service aims to empower patients with diabetes, hypertension and dyslipidemia to gain better control of their condition. They can drop by at a participating pharmacy ev-ery month for health advice and counseling, offered in a dedicated counseling area.

“We focus on patients who are diagnosed with type 2 diabetes without any acute condi-tions, and are unable to see their doctors reg-ularly. Most of these patients are our walk-in customers. Some have also signed up for the program after learning about it at our atrium events,” said program coordinator consultant pharmacist Mr. Parry Zhang.

In a typical session with patients, pharma-cists check for medication adherence, effec-tiveness of drug therapy and identify medica-tion related problems, as appropriate.

“In addition, we go through their daily blood sugar readings with them, help them identify factors which cause their blood sugar to spike too high or dive too low, coach them on adopting a healthier lifestyle and set goals

with them,” said Zhang.“Blood pressure is monitored at every ses-

sion and Point of Care testing for HbA1c and lipid profiles is performed when they are not available for a patient.”

The Sweet Spot program is funded by NUS Academy of GxP Excellence (NUSAGE) and the Alice Lim Grant. It provides participating patients with glucometer, strips and lancets for self-monitoring of blood glucose daily. At the end of the 6 month program, the patients can keep the glucometer. Should they want to exit the program halfway, eg after 3 months, the program does not make them pay for any-

Pharmacists go over vitals with diabetic patients at Unity Pharmacy's Sweet Spot locations.


thing except return the glucometer. All the pharmacists leading the clinical ser-

vice have gone through an inter-professional diabetes training workshop led by Dr. Joyce Lee, clinical pharmacist and assistant profes-sor at the NUS Department of Pharmacy.

Lee has been instrumental in setting up similar pharmacist-led clinical services at the National Healthcare Group polyclinics and Tan Tock Seng hospital. Upon completing the workshop and attaining the certification, the pharmacists worked with Dr. Lee in small groups for hands-on techniques and case dis-cussions.

“Our goal is to support the doctors and healthcare teams in institutions by serving as a bridge to ensure that these patients are cared for in between their follow up visits with their health providers, which can be as long as 3 to 6 months for most, and to add value to the chronic disease management process ,” said Lee.

The program was first trialed in 2011 to demonstrate the added-value of community pharmacists in improving patient care. Its

benefits include continued improvements or maintenance of the patients’ condition until their next visit to their doctors and reduced delay in care. The long term benefits may in-clude reduced costs and lowered risk for com-plications related to chronic diseases.

In a recent pilot study that evaluated the effectiveness of the program, it was found that 76 percent of the 100 patients attained improvement and maintenance of their dia-betes goals, with up to 1.95 percent reduction in HbA1c at 6 months.

“Uncontrolled blood pressure and choles-terol levels prior to joining us had also im-proved in 60 percent and 70 percent of pa-tients respectively. It was also found that the overall medication adherence and patient quality of life scores were already trending up positively 3 months into the program,” said Zhang.

“Through this program, we aim to educate and empower patients to better understand and care for their own chronic diseases, with ease of getting professional help at Unity Pharmacies.”


By Elvira Manzano

Senior Minister of State for Health Dr. Amy Khor has called on pharmacists to take a more active role in the health care

team and align their practices with the vision of Healthcare 2020 to improve care and health system outcomes.

In her opening remarks at the 23rd Singa-pore Pharmacy Congress, the minister said the aging and growing population and the changing lifestyles of Singaporeans pose sig-nificant challenges to the nation’s health care system. This is in addition to the rising tide of chronic diseases, polypharmacy complica-tions and higher hospital admissions.

Due to this shift in health care burden, strategies to advocate healthy lifestyle are critical for prevention of disease and hospi-tal admissions and effective management of chronic diseases, she said.

“We need a transformation in health care delivery and a remodelling of practice across the acute, intermediate and long-term care sectors. Pharmacists will play a vital role in this transformation.”

Pharmacists are well-positioned to drive and support healthcare changes, given their expertise in medication management and disease prevention, she added.

Khor went on to acknowledge the en-hanced roles pharmacists play to optimize patient care and outcomes. She specifically mentioned the pharmacists of Khoo Teck Puat Hospital who had to visit patients with recurrent admissions at home to help them manage potential drug-related conditions, as part of Alexandra Health System’s “Ageing-

Pharmacists vital to meeting health care challenges: minister

in-Place” program. She also cited the Phar-maceutical Society of Singapore for its City for All Ages project, which involves teaching the public and the elderly about safe medica-tion use.

“All these initiatives increase the acces-sibility of pharmacists to the public, where you can be seen as their trusted healthcare partners. Pharmacists have taken on expand-ed practice roles, from managing patients in pharmacists-led ambulatory clinics and pro-viding medication therapy management to providing therapeutic consultation and pa-tient monitoring.”

She also noted pharmacists’ increasing in-volvement in translational research, particu-larly pharmacy researchers from the Singa-pore General Hospital

“I encourage more pharmacists to rise up to the challenge of creating breakthroughs and discovering new evidence that would im-pact practice and improve patient outcomes.”

Pharmacists will have to collaborate more closely and effectively within and beyond the community to provide patient-centric and holistic care, she said.

“While we increase our capacity in antici-pation of increasing patient load by increas-ing the number of beds and building more hospitals, what is more important is to keep the public and patients healthy at home and away from hospitals.”

The annual congress was attended by lo-cal delegates and speakers and focused on the theme transforming pharmacy practice towards new horizons in health care.


Child-resistant packaging essential in some drugs

Child-proof packaging can prevent accidental ingestion and serious toxicity from some drugs.

By Laura Dobberstein

Even a single pill of medications such as buprenorphine can be life-threatening in the hands of children. But child-re-

sistant packaging can reduce unintended ac-cess to these drugs, a recent large retrospec-tive study has highlighted.

“Unintentional poisonings among chil-dren are an important public health prob-lem,” wrote Dr. Eric Lavonas of the Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, in Denver, Colorado, US and colleagues.

The researchers found that out of 2,380 children under the age of 6 unintentionally exposed to buprenorphine, 587 required treatment in the hospital intensive care unit and 4 died. The most common side effects included lethargy, respiratory depression, small pupils and vomiting.

Ninety-five percent of exposures occurred when the drug was ingested in tablet form. In 30.5 percent of cases where a root cause was identified, the children had access to the drug because it was stored in sight. Children were also prone to finding the drug in an adult’s bag or purse (8.1 percent) and stored in a con-tainer other than the original package (5.5 percent).

Other causes of exposure included a child finding buprenorphine in wallets, purses, couches, automobiles, parents’ pockets, floors, hotel rooms, cups, cigarette packag-es, eyeglass cases, cellophane, tissue paper, breath mint containers and trash cans. The average age of the children in the study was 2 years with 74.5 percent of the children fall-ing between the ages of 1 and 3. [J Pediatr.

2013;doi: 10.1016/j.jpeds.2013.06.058] Lavonas and team recommended all po-

tent medications that can cause fatality in one dose be issued in single dose, child re-sistant packaging, like a blister pack or foil pouch. The authors believe that this method is more beneficial than education, citing that 15.7 percent of cases involved medications prescribed for someone other than the pri-mary caregiver of the child.

“Whenever young children are visiting or supervised by grandparents or other adults who have dangerous medications, addition-


By Rajesh Kumar

Many women with symptoms of uri-nary tract infections chose to avoid antibiotics when advised by their

GP and gave their bodies a chance to heal naturally.

As a result, 20 out of 28 women with symptoms of uncomplicated urinary tract infections who had not used antibiotics for a week reported improvement or cure, a small study showed. [BMC Family Practice 2013; ePub ahead of print]

Antibiotic-resistant bacteria are a big problem and the incidence of ‘superbugs’, which are resistant to several antibiotics, is on the rise the world over. Excessive use of antibiotics increases the chances of disease causing bacteria developing resistance to an-tibiotics.

Pharmacists are aware that antibiotics do not work on viruses, and for many minor

bacterial infections. But this small study sug-gested that the body’s own immune system may be capable of fighting off minor infec-tions on its own.

The study involved 20 general practices in and around Amsterdam, the Netherlands. Healthy, non-pregnant women who contact-ed their GP at these practices with painful and/or frequent urination for no longer than 7 days registered their symptoms and gave urine samples for urinalysis and culture.

GPs asked all patients if they were willing to delay antibiotic treatment, without know-ing the result of the culture at that moment. After 7 days, patients reported if their symp-toms had improved and whether they had used any antibiotics.

Thirty seven percent (n=51) of the 137 women who were asked by their GP to delay antibiotic treatment agreed to do so. After one week, 55 percent (28/51) of these women had not used antibiotics, of whom 71 percent

Getting better without antibiotics?

al steps should be taken to reduce the risk of unintentional exposure,” said Lavonas and colleagues.

“Child resistant packaging helps, but no pill bottles are truly childproof,” Dr. Ron Kirschner, medical director at the Nebraska Regional Poison Center in Omaha, Nebraska, US, told Pharmacy Today. In addition to child resistant packaging, Kirschner advocated caretaker education and storing medication in places where children cannot gain access, like a locked cabinet or box.

“As we live in a more heavily medicated society, families have more pills around for

kids to get into, but there are a relatively small number that are really dangerous,” said Kirschner.

He listed long acting opioids, extended release forms of opioid analgesics, calcium channel blockers, some oral agents for dia-betes and a number of psychotropic drugs as those most associated with serious toxic-ity when adult doses are ingested by small children. Kirschner advised that anyone who accidentally ingests the wrong medica-tion should be put in touch with a healthcare professional to determine whether further action is necessary.


(20/28) reported clinical improvement or cure. None of the participating women de-veloped kidney inflammation, which can be a side effect of untreated urinary infection.

“Women may be more receptive to the idea of delaying treatment than is commonly assumed by many clinicians. Given proper

observations to simply doing nothing, or giv-ing pain medication instead of an antibiotic, is an effective treatment…which will reduce the risk of developing antibiotic-resistant bacteria,” said Dr. Bart Knottnerus from the academic medical center of the University of Amsterdam, the Netherlands.

By Rajesh Kumar

Certain drugs can delay wound heal-ing, according to research.

Principal drugs implicated are cy-totoxic antineoplastic and immunosuppres-sive agents, corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs), and anti-coagulants. [Prescrire Int. 2013; 22:94-98]

“In practice, when wound healing is de-layed, it is best to keep in mind that a drug may be the cause, and to consider withdraw-ing any drug or drugs known to have this ef-fect, in order to allow the wounds to heal,” said the researchers. Pharmacists may keep this in mind when coming across patients with slow healing wounds and refer them to the prescriber.

Healing of surgical and traumatic wounds mainly involves the clotting process, inflam-mation, cell proliferation and tissue remodel-ing. And healing time depends on the depth of the wound. In order to identify drugs that can slow the healing process, researchers re-viewed comparative clinical trials, epidemio-logical studies and detailed case reports, us-ing the standard Prescrire methodology and came up with the above list.

Delayed healing of surgical or traumatic wounds was associated with persistent bleed-ing, increased wound seepage and, in some cases, failed wound closure.

“Delayed wound healing can have severe and sometimes life-threatening consequences, including deep-seated infection, prolonged hospitalization, repeat surgery to join or re-join the wound edges, and delayed functional recovery of a transplanted organ,” said the re-searchers.

Delayed healing may also be due to failure of one or several steps in the healing process, caused by metabolic, cardiovascular, infec-tious or immunological disorders.

Some drugs can delay wound healing

Delayed wound healing can have severe outcomes such as longer hospital-ization and repeat surgery.

Feature | Pharmacy Today | September/October 2013 13

Dry eye syndrome is a common prob-lem affecting millions of people worldwide. It affects the young and

the elderly alike, especially those who wear contact lenses or work in an air-conditioned or windy environment.

Those who spend long hours working in front of computers or playing video games or take medications such as antihistamines for run-ny nose can also be susceptible to the condition.

Most of us rarely take notice, but the sur-face of the eye is constantly being moistened by a thin film of tear with each blink, keeping the eyes wet, protecting them against infec-

Feature

tion and assisting in healing of injuries. Dry eyes refer to a symptom caused either

by an increased evaporation of this tear film or an inadequate production of tear film on the cornea or conjunctiva, said optometrist Ms. Koe Hui Shan of the Eagle Eye Centre, Singapore.

According to the Singapore National Eye Centre (SNEC), when the quality or quantity of tear is abnormal, it results in damage of the ocular surface, irritation of the eyes or visual disturbances. A condition of the eyelid called Meibomian gland disease can also lead to dry eyes.

Dry eyes: causes, diagnosis and solutionAwareness and early treatment of dry eyes are the key to preventing complications.


If the patient does not have any pre-exist-ing disease, eye injuries or has not had any eye operation (e.g. refractive correction LASIK) done, the main cause of dry eyes may simply be due to aging, since tear production can de-crease with age, added Koe.

The Singapore Optometric Association (SOA) describes the most common symptoms associated with dry eyes as itch, feeling of sand or other foreign object in eyes, burning sensa-tion, mucous discharge and transient blurring of vision that is relieved by repeated blinking.

Severe dry eyes cases may lead to pathologi-cal changes in the cornea if left untreated. Doc-tors usually examine the eyes using a slit lamp first to check for any existing damage. It will also allow the doctor to look at the quality and the break up time of the tear film, said Koe.

Common treatment for the dry eye syn-drome includes ocular lubricant ointments and gels, artificial tears, cyclosporine eye drops, oral supplements, meibomien gland disease (MGD) therapy and nonpharmaco-logical treatments/procedures.

“If the dry eyes are caused by a pre-exist-ing eyelids disease, doctors may prescribe lids cleaning agents as well. In some cases, Ome-ga 3 fatty acids may also be prescribed,” said Koe, adding that usually there are no contra-indications to the commonly used medicines for dry eyes.

Pharmacists may also want to check with patients if they are used to prolonged con-tact lens wear or prolonged work in front of the computer, which will reduce the patient’s blinking rate. Changing these habits could help reduce the severity of the condition.

When dry eye symptoms become so severe that frequent instillation of artificial tears or lubricants does not provide adequate relief, occlusion of the lacrimal puncta (where tears drain out from the eye) or eyelid surgery may be necessary, according to the SOA.

Awareness and early treatment of the dry eyes is the key. If patient experiences pain, itchiness, redness or has worsening condition even after trying all, refer him/ her to a spe-cialist, added Koe.

Eye drops can be tricky to apply. Pharmacy staff can offer the following advice to make the process as simple as possible:• Wash hands first.• Shake the container, then open.• Pull down the lower eyelid gently to form a pocket. Tilt the head back slightly and look up.• Hold the bottle between thumb and index finger, and squeeze it gently to release the

recommended number of drops.• Do not touch the eye with the dropper tip.• Try not to blink as this draws the drop into the tear duct.• Close eye and press gently over the corner of the eye for a few minutes to stop the eye

drop draining through the tear duct.• Remove excess drops with a clean tissue.• Wait 10 minutes before adding other eye products to the eyes.

Advice for applying eye drops


Dry eyes extract a high cost from government, patientsBy Rajesh Kumar

Dry eye syndrome (DES) seems to impose a huge economic burden in Singapore.

At the Singapore National Eye Centre (SNEC) alone, the average total cost of dry eye treatments per year was estimated to be US$1,515,085 while patients spent around US$23 for each episode, said the researchers Dr. Samanthila Waduthantri of the Singapore Eye Research Institute, and colleagues in a study. [PLoS ONE 2013;doi:10.1371/journal.pone.0037711]

Ocular lubricants accounted for a large pro-portion of the pharmacological expenditure and number of units purchased on certain categories of treatment such as meibomien gland disease (MGD) therapy, preservative free lubricants and cyclosporine eye drops were shown to increase significantly over a 2 year period, the researchers observed.

They retrieved retrospective data on the type and cost of dry eye treatment in SNEC from pharmacy and clinic inventory databas-es from 2008 to 2009. According to the type of treatment, data were sorted into seven groups; MGD treatment, preservative free lubricant eye drops, preserved lubricant eye drops, lu-bricant ointments and gels, cyclosporine eye drops, oral supplements and nonpharmaco-logical treatments/procedures.

Each recorded entry was considered as one patient episode (PE). Cost data from 54,052 patients were available for analysis. Total number of recorded PEs was 132,758. To-tal annual expenditure on dry eye treatment for year 2008 and 2009 were US$1,509,372.20 and US$1,520,797.80 respectively. Total ex-penditure per PE in year 2008 and 2009 were

US$22.11 and US$23.59 respectively.From 2008 to 2009, the researchers noted a

0.8 percent increase in total annual expenditure and 6.69 percent increase in expenditure per PE. Pharmacological treatment was attributed to 99.2 percent of the total expenditure with lu-bricants accounting for 79.3 percent of the total pharmacological treatment expenditure.

Total number of units purchased in preser-vative free lubricants, cyclosporine eye drops and MGD therapy increased significantly, whereas number of units purchased in pre-served lubricants and ointments/gels reduced significantly from 2008 to 2009.

“Our study demonstrates that DES impos-es a direct burden to the health care expendi-ture…given the limitations of the availability of socio-economic data in our data sources, true costs of DES, borne by both the patient and the government, are likely to be much higher,” said the researchers.

Outcome of this study can be used in con-junction with clinical trials, and quality of life studies to determine the cost effectiveness of the dry eye treatment, they said, adding that it should help increase awareness of clinicians and policymakers on the importance of pursuing cheaper and effective novel treatment modali-ties “and improving the existing public health-care systems to reduce the financial burden of DES on both patients and healthcare systems.”

Researchers said the overall expenditure on DES seemed lower compared to studies that included physician consultation charg-es, which suggested that national healthcare costs may be reduced if stable patients could be managed by primary healthcare practitio-ners including GPs, optometrists, pharma-cists or if they self-medicated.


Glaucoma patients who often forget to ap-ply their eye drops can now use a smart phone app to remind them to do so.

Called MyEyeDrops, the app was launched by the Singapore National Eye Centre (SNEC) in February and is believed to be the first free app of its kind available on the App Store and Google Play.

The app displays different eye drops with accompanying photos to help glaucoma pa-tients or their caregivers set up and manage different lists of medication. Users can then set up “appointments” on the go to remind them to apply their eye drops at the right time.

The app also allows users to set up medica-tion lists and appointment reminders for dif-ferent people, a convenient feature for those who are taking care of more than one patient. Video clips are included to educate users on proper eye care and inform them about com-mon eye conditions.

Avoiding complicationsA study of 344 glaucoma patients in 2011

found that 70 per cent of them tend to forget to apply their medication. This can increase the risk of complications, said Dr. Daniel Su, consultant at the SNEC Glaucoma service and co-project leader of the MyEyeDrops app.

The eye drops are meant to relieve eye pres-sure, which is higher in glaucoma patients. “If eye pressure remains elevated, it may dam-age the optic nerve and this can lead to blind-ness,” said Su. “So, it is important for patients to apply their eye drops regularly. Not apply-ing the medication can cause eye pressure to

stay high and the risk of blindness remains, or is even increased.”

About half of all glaucoma patients need more than one type of eye drops, so the app’s ability to track the different medica-tion will be a big help to patients and their caregivers, said Dr. Jocelyn Chua, consul-tant at the SNEC Glaucoma service and project co-leader. Glaucoma patient Mdm Daisy Tan, 66, found the app very useful. The retiree sometimes forgets to apply her eye drops. There are also times when she cannot remember which eye she applied the medication to. “The app acts as my medical diary,” she said. “I can record details of my eye pressure. It also keeps me updated on my medical appointments.”

MyEyeDrops was developed by SNEC and Integrated Health Information Systems (IHiS) - the IT arm of the Ministry of Health (MOH)- and was co-funded by SNEC and MOH. MyEyeDrops draws on lHiS and Sing-Heath’s experience in developing mobile apps for chronic diseases such as diabetes, rheumatoid arthritis and renal conditions.

New app helps glaucoma patients track their medication

Launched by the Singapore National Eye Centre, MyEyeDrops is available for free from the App Store and Google Play. It comes with videos and pic-tures to teach users about proper eye care and common eye conditions.

Phot

os a

nd t

ext

cour

tesy

: Sin

gapo

re H

ealth

, a

bi-m

onth

ly p

ublic

atio

n of

SG

H a

nd S

ing-

Hea

lth a

cade

mic

hea

lthca

re cl

uste

r.


Eye drops for glaucoma patients can pro-duce side effects which mimic the symp-toms of heart disease, depression and

even impotence and pharmacists and physicians need to watch out for the connection.

Beta-blocker eye drops are often used for glaucoma patients and their side effects can make people short of breath, lower their pulse and make them bradycardiac. The drops can also give patients vivid nightmares and in-duce erectile dysfunction (ED) or impotence in men.

In absence of adequate communication between ophthalmologists, GPs and phar-macists, the patient could end up getting prolonged and unnecessary treatment for these conditions on the basis of symptoms alone, said Helen Danesh-Meyer, associate professor of ophthalmology at Auckland University’s School of Medicine in Auckland, New Zealand.

One of her patients had a pacemaker put in due to his cardiac symptoms; while there have been others who ended up getting un-necessary treatment for their symptoms of depression and impotence, when all they needed to do was to change their eye drops.

Danesh-Meyer said better communication is needed between eye specialists, GPs and pharmacists as patients can skip mentioning their eye drops when asked if they are on any other medication.

“It’s our job to write to our patients’ GP and make sure they know what eye drops their pa-tients are on and sometimes remind them of the side effects as well. Right now (such com-munication) varies from doctor to doctor,” she said.

Eye drops can be systemically absorbed after administration and can, therefore, cause systemic adverse effects associated with a particular medicine, said Mr. Tony Fraser, business manager for BPAC, an indepen-dent organisation promoting best practice in medicine in New Zealand.

“Beta-blockers and carbonic anhydrase inhibitors may cause erectile dysfunction. Therefore, systemically absorbed eye drops may cause ED. Application of gentle pres-sure to the tear duct after instilling drops may reduce systemic absorption and mini-mise the risk of adverse effects,” he said in a written statement.

Danesh-Meyer said the best course of action for pharmacists would be to contact the ophthalmologist and/or GP and dis-cuss with them the side effect they might be concerned about.

“There are several classes of medications which the patient can be swapped to, and there are options of laser surgery which may be appropriate for the patient as well,” she said.

Impotence can be a side effect of eye drops

Patients tend to forget mentioning eye drops when asked if they are taking any medicines.


New research into how a diet of low glycaemic index foods impacts on the development of macular degen-

eration has begun at Westmead Hospital in Sydney, Australia.

Professor of Ophthalmology at the Univer-sity of Sydney, Dr. Paul Mitchell, is heading the trial over the next three years and will look at the effects this diet has on people showing signs of macular degeneration, the Australian reported.

Professor Mitchell received a research grant from the Macular Degeneration Foundation of Australia to conduct the research. He aims to gain a deeper understanding of the risk fac-tors for macular degeneration and will build on his research from the Blue Mountains Eye Study, which showed supplements contain-ing antioxidants, zinc and fish oils could

reduce the onset and effects of the disease.Professor Mitchell plans to study the im-

pact the eye disease has on quality of life and any links between modifiable risk factors such as nutrition and smoking, and genetic predisposition.

In a report published last year, Eyes on the

Future, Professor Mitchell found signs a low GI diet has the potential to reduce the risk of developing macular degeneration, but more research was needed.

Foods with a lower GI include fruits, vege-tables, wholegrain breads and pasta, milk and yoghurt. The Glycaemic Index is a way of scor-ing different foods according to how quickly the carbohydrates are absorbed in the blood-stream. Low GI carbohydrates break down slowly, releasing glucose more gradually.

Research tests low-GI diet for eye disease

Food with low glycemic index can potentially reduce the risk of eye disease.

READ JPOG ANYTIME, ANYWHERE. Download the digital edition today at www.jpog.com

Pharmacy Today | September/October 2013 19

China investing billions in biomedical R&DBy Rajesh Kumar

China is transforming itself from a manufacturing base to an innovation hub, investing US$160 billion in bio-

medical research and development (R&D) activities, according to the US-based Lux Re-search.

Fifteen new drug innovation centers and super clusters are being developed around the country’s five major provinces and pharma-ceutical-related patent filings have already wit-nessed an exponential growth, the report said.

“Rising income levels and a shifting de-mographical landscape are creating a faster growing market space for innovative biomed-ical products in China,” said Mr. Kevin Pang, research director for Lux and a contributor to the report titled, Mapping the Chinese Biomedi-cal R&D Landscape.

“While the Chinese domestic market pro-vides ample room for all players now, Chi-nese pharmaceutical companies will natural-ly look outside to lucrative markets in North America and Japan over time,” Pang added.

Lux Research analysts examined the state of China’s biomedical sector, with particular atten-tion to its R&D and found that the country may overtake Japan to become the second-largest R&D spender in the world, behind the US.

BusinessBiomedical research has emerged as a fo-

cus area in the country, with funding shifting from traditional basic research to greater em-phasis on commercialization. The Major New Drug Innovation Program (MNDIP), started in 2009, has emerged as a source of innova-tion in China, producing over 3,000 patents and 12 products.

“With funding of over $4.5 billion by 2012, China has set ambitious goals of developing 30 new innovative drugs and powering 200 drugs to sales over RMB 100 million,” the re-port said.

Oncology has received the most attention – 56 of the 127 MNDIP projects seek to de-velop drugs for cancer, now the leading cause of death in China. Biologics outweigh small molecule drugs by a large margin – 34 for de-veloping biologics versus only 22 for develop-ing small molecule drugs.

The authors said Chinese pharmaceutical’s rapid growth has been aided by changes in patent and related laws since 1992 when the nation joined the TRIPS (Trade-Related as-pects of Intellectual Property Rights) agree-ment.

A latest revision has made biomedical pat-ent protection truly enforceable, and is likely to act as a stimulus to further innovation, they said.

Pharmacy Today | September/October 2013 20

FDA approval for Singapore’s mini ECG device

By Rajesh Kumar

A Singapore-based company has re-ceived the US Food & Drugs Ad-ministration (FDA) approval for its

small, smart phone-enabled electrocardio-gram (ECG) device.

The development will help EPI Mobile Health Solutions gain market access to the world’s largest pharmaceutical and medi-cal device market. The company claims its product, EPI Mini, is the world’s first, pat-ented ECG function integrated with a mobile phone.

The device collects ECG readings through the user’s fingertips. The data is then sent to their smart phone via bluetooth and is then automatically sent to EPI’s 24-hour health concierge service, which sends an interpre-tation of the results back to the user via text message.

The device is intended for use by adults with cardiovascular disease, who are con-sidered high risk for possible cardiovascu-lar events or are concerned about their heart function and rhythm.

Users who sign up for a subscription ser-vice can also store and track their ECG data in a virtual health record they can access online. Up to five different users can be registered on a single device.

EPI Mini’s predecessor, EPI Life, gained Health Science Authority of Singapore (HSA) clearance last year and has since been on sale. EPI Life is a mobile phone with EPI Mini in-tegrated into it. It’s larger and weighs more than the mini and takes up to 30 seconds to read a user’s heart rate.

US-based AliveCor’s Heart Monitor and Cardiac Design’s ECG Check app, which are similar mobile phone based systems, had also earlier received the FDA clearance.

An authoritative tool featuring a comprehensive list of health

topics in easy-to-read format and patient-friendly tone, to

aid patient counselling sessions at retail pharmacies.

6 Shenton Way, #15-08 OUE Downtown 2, Singapore 068809Tel: (65) 6290 7400 Fax: (65) 6290 7401

The newest drug information support from MIMS

Counselling GuideFor Pharmacists

Singapore Edition of MIMS Pharmacy 2014Interested in getting your personal copy of MIMS Pharmacy?

Contact us at [email protected] today.

PRINT

ONLINE

MOBILE

INTEGRATED

2 n d E d i t i o n 2 0 1 3 / 2 0 1 4SINGAPORE

w w w . m i m s . c o m

SI N

GA

PO

RE

20

13

/ 20

14

ISSN 2335-6731

Schwabe Flash Ad_Tebonin.ai 1 7/18/2013 2:35:53 PM

MPG2013-SG_010813.pdf 1

8/1/13 12:19 PM

MPG-SG209x282_1013hr.pdf 1 10/9/13 2:56 PM

Clinical Pharmacy | Pharmacy Today | September/October 2013 22

Naomi Adam, MSc (Med), Category 1 Accredited Education Provider (Royal Australian College of General Practitioners)

IntroductionAsthma is an atopic disease characterized

by reversible airway obstruction, reduction in lung function and bronchial hyper-reactiv-ity. The main symptoms include dry cough, expiratory wheezing, chest tightness and dyspnea, which are intermittently triggered by allergens, infections and airway irritants. Also a consequence of atopy, allergic rhini-tis (AR) features the classical symptoms of sneezing, rhinorrhea and nasal obstruction. [Ital J Pediatrics 2012;38:60] Both of these con-ditions have significant impact upon quality of life and severely limit an individual’s abil-ity to perform normal daily activities. The difficulty in breathing, whether due to nasal inflammation, bronchial inflammation, or a combination of both is particularly distress-ing.

The link between asthma and allergic

rhinitis is well recognized and a united air-ways disease theory has been proposed to explain the association. The two conditions frequently co-exist, and have several shared pathophysiological features. Both are due to an immune response to a foreign substance or allergen. It appears that the same inflam-matory mechanisms are at work in both the upper and lower respiratory tracts. [Ital J Pe-diatrics 2012;38:60]

Ciclesonide Mode of action and pharmacology

The primary mode of action of cortico-steroids such as ciclesonide is suppression of inflammation. These drugs have a wide range of effects on cells (eg, mast cells, eo-sinophils, neutrophils, macrophages, and lymphocytes) and mediators (eg, hista-mines, eicosanoids, leukotrienes, and cyto-kines) associated with allergic inflamma-tion. In cell culture studies, ciclesonide has been shown to inhibit the expression of in-tercellular adhesion molecule (ICAM)-1,

Ciclesonide: Novel corticosteroid for the treatment of asthma and allergic rhinitis

Drug Profile

The link between asthma and allergic rhinitis, which often co-exist, is well recognized. Both are due to an immune response to a foreign substance or allergen resulting in inflammation. Clinical trials have demonstrated the benefits of ciclesonide, a new-generation corticosteroid which suppresses inflammation, in the treatment of patients with asthma and allergic rhinitis.


granulocyte-macrophage colony stimulating factor (GM-CSF), and interleukin (IL)-8 by human bronchial epithelial cells stimulated with IL-4 and tumor necrosis factor (TNF)-α. [Pulm Pharmacol Ther 2006;19:210-217] Fur-thermore, ciclesonide inhibits the prolifera-tion of fibroblasts [Immunol Lett 2007;112:39-46] as well as T-cell migration and cytokine production after allergen challenge. [Int Arch Allergy Immunol 2008;145:111-121]

Ciclesonide is a new-generation cortico-steroid that has been optimized for topical use. It is a pro-drug that is activated locally in the airway mucosa by carboxylesterase and cholinesterase enzymes. This activa-tion appears to be selective to the nose and lung, compared with the oropharynx, which has important implications for avoidance of steroid-related oropharyngeal and laryngeal side effects (eg, hoarseness, candidiasis). [J Asthma Allergy 2008;1:49-54]

The active metabolite – desisobutyryl-ciclesonide – can reversibly form fatty acid conjugates (mostly with oleic acid). These lipid-conjugates are retained locally and can serve as a pool for slow release of the drug. If ciclesonide does enter the systemic circula-tion, there is very high protein binding and first-pass metabolism [Clin Pharmacokinet 2004;43:479-486], which inactivates the drug and helps to minimize systemic side effects.

Clinical efficacyCiclesonide has demonstrated efficacy in

allergic rhinitis, in both the seasonal (SAR) and year-round perennial (PAR) forms. In 701 patients with moderate SAR, ciclesonide 100 μg or 200 μg for 4 weeks was associated with a dose-related and significant reduc-tion in nasal symptom score (comprised of nasal congestion, nasal itching, sneezing and

runny nose). [Ann Allergy Asthma Immunol 2006;97:657-663] Similarly, in PAR the efficacy of ciclesonide 200 μg relative to placebo was demonstrated in 471 patients with a signifi-cant reduction in symptom score. [Ann Aller-gy Asthma Immunol 2007;98:175-181] Impor-tantly, symptom control is maintained over a full 24-hour period in SAR [J Allergy Clin Im-munol 2006;118:1142-1148] and PAR [Ann Al-lergy Asthma Immunol 2007;98:175-181], and there is no evidence of tachyphylaxis when used over 1 year. [Ann Allergy Asthma Immu-nol 2007;99:69-76] Furthermore, ciclesonide provides functional improvements, as dem-onstrated by a placebo-controlled study uti-lizing anterior rhinomanometry to measure nasal airflow. [J Clin Pharmacol 1999;39:1062-1069]

The clinical trials program to study cicle-sonide in asthma has been extensive. A num-ber of placebo-controlled investigations have definitively shown the beneficial effect of ciclesonide upon lung function, number of asthma exacerbations and systemic steroid use. [Clin Med Ther 2009;1:1437-1449] There are also many published studies of cicle-sonide versus active comparators – mostly budesonide and the widely used flutica-sone propionate – across the spectrum of asthma severity. Most of these trials show equivalence, while some suggest that cicle-sonide has superior efficacy. [Clin Med Ther 2009;1:1437-1449]

Formulation and dosingFor the treatment of allergic rhinitis, cicle-

sonide is formulated as a nasal spray. In SAR in adults and children aged 6 years and older, the recommended and maximum dose is 200 μg/day, which is two sprays per nostril. The dose recommendation is the same for PAR,


however it should only be used in adults and children aged 12 years and up.

In the treatment of asthma for adults and adolescents aged 12 years and up, the rec-ommended dose of ciclesonide is 100–800 μg/day (and for children aged 6–11 years, 100–200 μg/day), adjusted according to indi-vidual response. The medication is adminis-tered from a metered-dose inhaler (MDI) in one or two puffs, and a spacer device may be used if required. The MDI used to deliver ciclesonide contains the active ingredient in a hydrofluoroalkane (HFA) solution. This produces a comparatively small particle size (approximately 1.1 μm in diameter), which leads to high lung deposition and distri-bution to the small airways. [J Aerosol Med 2006;19:117-126]Adverse reactions

Historically, corticosteroids have been as-sociated with concerns regarding their sys-temic effects such as growth inhibition in-duced by hypothalamus-pituitary-adrenal (HPA) axis suppression and decreased bone mineral density. However, the pharmacolog-ical properties of ciclesonide (as well as the HFA formation in the case of asthma treat-ment) contribute to a noticeably enhanced safety profile. Monitoring of cortisol levels has shown that ciclesonide has no clinical-ly meaningful effect upon the HPA axis or growth when used for either AR [J Investig Allergol Clin Immunol 2012;22:1-12] or asth-ma. [J Asthma Allergy 2009:2:25-32]

The majority of adverse effects (AEs) seen with intranasal or inhaled ciclesonide are lo-cal. With intranasal use, the prescribing in-formation states that the most common AEs (≥2 percent) are nasal discomfort, headache

and epistaxis. There have been rare cases of ulcerations, and nasal septal perforations. (ciclesonide nasal aerosol) Prescribing Infor-mation Common AEs (≥1 percent) with in-haled ciclesonide for asthma are paradoxical bronchospasm and dysphonia. (ciclesonide inhalation aerosol) Prescribing Information Place within treatment guidelines

The use of intranasal and inhaled cortico-steroids is recommended in several interna-tional treatment guidelines for AR and asth-ma, respectively. For example, the Joint Task Force on Practice Parameters (representing the American Academy of Allergy, Asthma & Immunology, the American College of Allergy, Asthma and Immunology, and the Joint Council of Allergy, Asthma and Immu-nology) states that intranasal corticosteroids are the most effective medication class for controlling symptoms of AR. There is level A evidence that intranasal corticosteroids are more effective than combination therapy with an antihistamine and leukotriene (LT) antagonist in the treatment of SAR. These guidelines also note that unlike most other intranasal corticosteroid formulations, there is no alcohol or benzalkonium chloride in the commercially available preparation of cicle-sonide. [J Allergy Clin Immunol 2008;122:S1-S84] Similarly, the National Institute for Health and Care Excellence (NICE) guide-lines note that intranasal corticosteroids are more effective than an oral antihistamine, and the preferred treatment modality when the predominant AR symptoms are sneez-ing or nasal discharge. Intranasal cortico-steroids are also recommended when the predominant symptom is nasal blockage or when nasal polyps are present. [National


Considerations in acute wound care By Laura Dobberstein

The need for wound care is expected to grow in Southeast Asia over the next decade due to a rise in obesity

and diabetes, rising health care costs, aging population and an increase in surgical inter-ventions.

With clinical pharmacists now running outpatient clinics for chronic diseases and playing a key role in aged care, it is impera-tive they keep abreast with the latest concepts in acute care of wounds in patients who have diabetes, have had falls or have suffered cuts and other injuries.

According to Dr. Lynn Teo, consultant dermatologist at The Dermatology Practice at Mount Elizabeth Novena Hospital in Sin-gapore, these concepts are often not accu-rately used.

The wound process “It is important to understand what hap-

pens to the wound after an acute wound pro-cess,” Teo told pharmacists at the 23rd Singa-pore Pharmacy Congress recently.

Institute for Health and Care Excellence. Al-lergic rhinitis. http://cks.nice.org.uk/allergic-rhinitis#!scenariorecommendation:1]

Asthma guidelines also underline the importance of inhaled corticosteroids as a treatment option. The Global Initiative for Asthma Guide for Asthma Management and Prevention outlines a five-step approach to asthma control. Step one is control of asth-ma attacks with rapid-acting β2-agonist as needed. If this is insufficient, steps two to five are based on the regular use of an in-haled corticosteroid preventer medication, with additional therapies as needed. [Glob-al Initiative for Asthma. Pocket guide for

asthma management and prevention. 2012.] The Scottish Intercollegiate Guidelines Net-work follow a similar scheme, and state that inhaled corticosteroids (ICS) are the recom-mended preventer drug for adults and chil-dren for achieving overall treatment goals. ICS should be considered for patients who have experienced exacerbations of asthma in the previous 2 years, use inhaled β2-agonists three times a week or more, are symptomatic three times a week or more, or wake due to asthma symptoms 1 night a week or more. [Scottish Intercollegiate Network. British guideline for the management of asthma. 2012.]

Conditions like diabetes and COPD can complicate a healing wound.


During hemostasis, the first of four phases in wound healing, the bleeding of a wound is sealed through platelet aggregation, fibrin clot formation and coagulation. An acute inflammatory response initiated by local migration of neutrophils and macrophages helps prevent microbial overgrowth.

In the next phase, proliferation, dam-aged soft tissue is replaced with healthy new granulation tissue and matrix material. Through the last two phases, maturation and remodeling, the type III collagen formed by fibroblasts is converted to type I collagen to enhance the strength and integrity of the soft tissue. Cells that are no longer needed are re-moved by apoptosis.

“The first two phases occur within 2 days of wounding. The third and fourth states go on for 3 to 6 months,” explained Teo.

She advised that health care professionals begin treatment by checking that their pa-tients are otherwise healthy. Conditions like diabetes, incorrectly functioning thyroid, COPD and insufficient nutritional intake can complicate a healing wound.

Steps in wound careThe first step to wound care is to control

the bleeding. Wounds that contain a large amount of exudates may benefit from eleva-tion of the affected area, application of direct pressure and calcium alginate wound dress-ing. These dressings, such as Kaltostat and Algisite M, promote hemostasis by exchang-ing calcium ions with sodium ions in the wound fluid that initiate clotting.

The calcium alginate is packed into the wound where it may swell up to 20 times its weight. These dressings are comfortable to use, simple and historically effective, said Teo.

She advocated that doctors ask the patient how wounds were caused in order to iden-tify potential candidates for tetanus vaccina-tion. Tetanus-prone wounds include com-pound fractures, deep penetrating wounds, wounds containing foreign bodies like wood splinters, wounds complicated by pyogenic infections, wounds with extensive tissue damage and any wound obviously contam-inated with soil, dust or horse manure, es-pecially if topical disinfection is delayed for more than 4 hours.

Cuts and abrasions should be cleaned to remove any embedded debris when pos-sible. This can often be done with warmed cleansing solution or under a running tap for very soiled wounds. Antiseptic solution may be required if the patient’s immune status is a concern.

The decision on how to close the wound can depend on the likelihood of infection. Deep wounds may need primary closure through suture adhesives, staples or strips. Delayed primary closure occurs when the wound closure is delayed for about 3 to 5 days and is ideal for delayed presentations or wound infection.

If there are no signs of infection, a doc-tor may decide to remove devitalized tis-sue and apply a delayed closure. A natural unaided healing process is called a second-ary intention closure and are best for areas with low infection rates like the scalp, said Teo.

She stressed the importance of using moist dressings to avoid further damage during redressing. Dry dressings may cause further damage by sticking to the wound bed. An-other benefit of keeping a wound moist is that accelerates the healing process.

In dry wounds, a scab forms a barrier to


migration and spreading of epidermal cells that slows healing. Wounds kept moist aid the epidermal cells in migration, allow great-er access for inflammatory cells to meet po-tential pathogens and the dressing itself pro-vides a barrier to contamination.

Dry wounds are more prone to scarring than moist wounds. However, dry wounds are necessary for ischemic wounds as keep-ing these wounds moist may lead to sub-sequent infection and further breakdown of the wound bed. Moist dressings exist on the market in varying degrees of wetness from hydroactive gel, meant for bleeding wounds, to gelling foam dressing, designed for wounds with heavy exudation.

Pitfalls and mythsPatients should seek advice for chronic

or distal wounds, said Teo. Chronic wounds may be a sign of other conditions like lep-rosy, diabetes or a vasculitic ulcer.

Common misconceptions concerning those with healing wounds are that they should avoid soy sauce and seafood. Teo says patients should feel free to eat both of these foods. Contrary to popular myths, soy sauce will not cause the wound to turn darker and seafood will not cause pus in fresh wounds, although those with allergies to these foods will still want to avoid them.

Anti-scarring remedies may help reduce scarring once wounds have fully healed.

FOR NEW & OLD SCARS:• Softens and flattens raised scars

• Relieves itching and discomfort of scars

• Reduces redness and discoloration

• Prevents abnormal and excessive scar formation

Further information available upon requestQuality innovations by:

NEW!

The novel formulation for PREVENTION & Treatment of STRETCH MARKS

www.strataderm.com www.stratamark.net


Clinical pharmacists play key role in lymphoma care

By Radha Chitale

Clinical pharmacists are frequently tasked with follow up or supportive care management for cancer patients.

For cases of lymphoma at the National Cancer Centre Singapore (NCCS), for exam-ple, they can be responsible for preventing and managing side effects of chemotherapy, drug-drug interactions and drug-herb inter-actions, in the case of more than 50 percent of NCCS patients who use complementary and alternative medicines (CAM). [J Oncol Pharm Pract. doi: 10.1177/1078155212449031]

A review on inpatient interventions by clinical pharmacists over 1 year at the NCCS revealed that over one-fifth of interventions were rated “highly impactful and [promoted] desirable outcomes including cost savings

and prescribing.” Ninety-seven percent of the suggested in-

terventions were okayed by an oncologist. Interventions considered the best among the oncologists surveyed were those promoting cost-effective prescribing, than those that re-solved drug-related problems. Fewer of those interventions that would positively affect workflow were scored high.

“Data obtained from this study strongly jus-tify the clinical pharmacy services offered to lymphoma patients on the team,” the research-ers said. “It has also demonstrated that the in-puts by clinical pharmacists are highly valuable and have major contributions to patient care.”

Specific areas in which clinical pharmacists can assist patients with lymphoma include ju-dicious use of prophylactic granulocyte-colo-ny sti-mulating factors (G-CSF) to keep febrile

Conditions like diabetes and COPD can complicate a healing wound.


neutropenia at bay. Febrile neutropenia can occur as a result

of the immunosuppressive chemotherapy patients require. Therefore, keeping it at bay allows oncologists to maintain optimal che-motherapy levels without the risk of treat-ment-related complications.

Optimized use of antiemetics, tumor lysis prevention, and drug monitoring are also key areas for clinical pharmacist intervention in

order to prevent toxicity and maintain treat-ment efficacy.

“Moving forward, clinical pharmacy spe-cialists need to constantly expand their roles on the lymphoma team in order to satisfy the evolving demands of healthcare…a multi-disciplinary team-care approach must be ad-opted to assume responsibility and account-ability in drug therapy management,” the researchers concluded.

Smart Rx. Every Time.

www.MIMS.com

Pharmacy Today provides

the latest information for

community, hospital and

industrial pharmacists,

pharmacy staff, pharmacy

students, government

agencies and the

pharmaceutical industry.

The only n ewspaper i n s i ngapore TargeTing pharmacy profess ionals

For more information on sponsorship opportunities, please contact: [email protected]

For pharmacy news, views and editorial matters, contact: [email protected]

The leading pharmacy publication in New Zealand, Malaysia and the Philippines is now in SiNgaPore!

PT-SG-Filler209x282FINAL_0813.indd 1 8/6/13 4:16 PM

After Hours | Pharmacy Today | September/October 2013 31

Japan’s Cultural Heart

K Y O T OMonika Stiehl

The curtain rises. Dressed in a light blue kimono covered all over with white flowers, the Maiko stands stock-still,

with head held low, turning her back to the audience. Then the music starts. In accor-dance with the smooth tones of the Koto, the Japanese harp, the Maiko gently begins moving, first elegantly her fingers and arms, then turning to face the audience, raising the head. The face covered with white make-up, the lips painted flaming red and the coal-black hair artistically towered, she looks like a piece of art.

We are in Kyoto, the cultural heart of Ja-pan, watching the Kyomai, the so-called tra-ditional Kyoto Style Dance, performed by a Maiko, an apprentice Geisha. Her dance tells the melancholic story of the life of Mai-kos and Geishas in ancient Japan. Kyoto is the ancestral home of traditional Japanese performances not only of the Kyomai, but also the Chado, a Japanese tea ceremony, the Kyogen, an ancient comic theater and the Bunraku, a traditional puppet play.

Kyoto is rich in cultural heritage. One of

the many UNESCO world heritage sites in the city is the Kinkaku-ji temple (or Golden Pavilion). It shimmers in the adjacent lake and is one of the most visited tourist spots in Kyoto. As is the Kiyomizu-dera temple, an ancient Buddhist shrine founded in 798. Its present buildings were constructed in 1633. There is not a single nail used in the entire structure. It takes its name from the mirac-ulous waterfall within the complex, which runs off the nearby hills. The name Kiyo-mizu means clear or pure water. Visitors can drink the water, which is believed to have wish-granting powers. The temple complex includes several other shrines. Among them the Jishu Shrine, dedicated to Okuninushi, a god of love and ‘good matches.’ Jishu Shrine possesses a pair of ‘love stones’ placed 6 meters apart. You can try to walk between them and it’s said that you will find love or true love when you are able to reach the other stone with your eyes closed. There are always lots of young ladies and men trying their luck.

The Ginkaka-ji temple (or Silver Pavillion) charms with its beautiful Japanese garden. An essential element is the impressive Zen

After Hours | Pharmacy Today | September/October 2013 32

sand garden. The meticulously raked sand is said to visualize the waves of the ocean and a carefully built pile symbolizes Mount Fuji.

A relaxing stroll down Tetsugaku-no-michi (or the so-called Philosopher’s way), a pleasant stone path through the northern part of Kyoto’s Higashiyama district, which is lined by hundreds of cherry blossom trees, comes highly recommended.

Approximately 2 kilometers long, the path begins near the Ginkaku-ji temple and follows a small canal. The path gets its name from one of Japan’s most famous and influential philosophers of the 20th century – Nishida Kitaro – who is said to have prac-ticed meditation while walking along it each day to Kyoto University.

After all this mental food, a visit to Nishi-ki market will provoke your appetite for real food. Known as ‘Kyoto’s Kitchen’, this tradi-tional food-market is vibrant, full of activity and Japanese delicacies such as prawns with teriyaki mayonnaise and stuffed octopus heads served on a stick.

Kyoto has often been described as the most Japanese part of Japan. Here at Nishiki, one gets the impression that this might well be true.

Useful tips for visiting KyotoVisiting Kyoto requires some well thought

out pre-planning, especially if you only have limited time. The city has an abundance of amazing pagodas, temples and shrines to see – more than 1,800 altogether. No wonder Kyoto has a reputation for being Japan’s cul-tural heart. You will also find graceful Gei-shas and Maikos gliding around the corners of the narrow streets of Gion, dressed in tra-ditional Kimonos. You can join traditional Japanese ceremonies like the Chado, the tea ceremony, or the Kyomai, the Kyoto Style Dance performanced by Maikos or Geishas, which will make you feel like you are in an-cient Japan. And after that, food markets full of Japanese specialities will bring you sud-denly back to the present.

MIMS.com now comes with a brand new look and mobile app!Along with a redesign that helps enhance ease of access to crucial clinical

information, MIMS.com can now be accessed through a FREE mobile application, available on the iTunes store.

With MIMS available across multiple platforms and devices, you can

now easily and conveniently find the most up-to-date and relevant drug

information anytime, anywhere.

CONNECT WITH MIMS:

www.mims.com MIMS mobile/tablet app facebook.com/mimscom

Journal of Paediatrics, Obstetrics & Gynaecology

MIMScomNew290x406_1013SG.indd 1 10/9/13 3:35 PM

Publisher : Ben Yeo

Managing Editor : Greg Town

Senior Editor : Rajesh Kumar

Contributing Editors : Radha Chitale, Elvira Manzano, Grace Ling

Publication Manager : Jason Bernstein

Business Managers : Carrie Ong, Josephine Cheong, Melanie Nyam

Designers : Lisa Low, Agnes Chieng, Sam Shum

Production : Jenny Lim

Circulation Executive : Christine Chok

Accounting Manager : Minty Kwan

Advertising Coordinator : Angeline Chua

Published by : MIMS Pte Ltd 6 Shenton Way Tower 2, #15-08 Singapore 068809 Tel: (65) 6290 7400 Fax: (65) 6290 7401 Email: [email protected]

Pharmacy Today is published 6 times a year by MIMS Pte Ltd. Pharmacy Today is on controlled circulation publication to pharmacists in Singapore. It is also available on subscription to members of allied profes-sions. The price per annum is US$48 (surface mail) and US$60 (overseas airmail); back issues at US$5 per copy. Editorial matter published herein has been prepared by professional editorial staff. Articles ending with PTNZ have been adapted from Pharmacy Today New Zealand. Views expressed are not necessarily those of MIMS Pte Ltd. Although great effort has been made in compiling and checking the information given in this publication to ensure that it is accurate, the authors, the publisher and their agents shall not be responsible or in any way liable for the continued currency of the information or for any errors, omissions or inaccuracies in this publication whether arising from negligence or otherwise howsoever, or for any consequences arising therefrom. The inclusion or exclusion of any product does not mean that the publisher advocates or rejects its use either generally or in any particular field or fields. The information contained within should not be relied upon solely for final treatment decisions.

© 2013 MIMS Pte Ltd. All rights reserved. No part of this publication may be reproduced in any language, stored in or introduced into a retrieval system, or transmitted, in any form or by any means (electronic, mechanical, photocopying, recording or otherwise), without the written consent of the copyright owner. Permission to reprint must be obtained from the publisher. Advertisements are subject to editorial acceptance and have no influence on editorial content or presen-tation. MIMS Pte Ltd does not guarantee, directly or indirectly, the quality or efficacy of any product or service described in the advertisements or other material which is commercial in nature.

Printed by KHL Printing Co Pte Ltd, 57 Loyang Drive, Singapore 508968

PP17931/12/2013(033147) ISSN 1170-1927

Editorial Advisory Board

Associate Professor Head of Department of Pharmacy, Faculty of Chui Wai Keung Science, National University of Singapore

Ms. Lita Chew Chief Pharmacist, the Government of Singapore and Registrar, Singapore Pharmacy Council

hialid - side effectsenews.mims.com/landingpages/pt/pdf/pharmacy_today... · choose hialid for...

Documents