Inside this issue:

Is Your Make-up Killing You?

1 - 3

G6PD Deficiency 4 - 5

Comparison:

Symbicort 160/4.5 & Symbicort 320/9

6 - 7

Home Medication Review (HMR)

8 -9

Changes of Insulin Brand: Insugen ®

10

Truth @ Myths:

Vaccination

11-12

Achievement of PKDMT

13

New Staff in PKDMT

14

ISSUE 1 YEAR 2017

PKD MELAKA TENGAH

Editorial Board Advisor: Dr. Rusdi bin Abd. Rahman Chief Editor: Halisah binti Kasdi Editor: Chew Poh Chiong Contributors: Tan Jien Lee

Nur Farahin Binti Abdul

Jabar

Adillah Binti Ahmad

Tan Chen Jie

By Chan Mei Sze

A cosmetic is a preparation applied on the external parts of the human body to enhance or change a person’s appearance. Cosmetics are readily available today in the form of creams, lipstick, perfumes, eye shad-ows, nail polishes, hair sprays etc.

Makeup has been around for centuries. The first known people who used cosmetics for beauty were the Egyptians. Cosmetics were so important to the Egyptians that even in their tombs, archaeologists have found makeup and ointments.

What’s Cosmetics?

The History of Cosmetics

Ancient Egyptians may have been the first users of killer cosmetics. To beautify their eyes, the Ancient Egyptians used black and green paints. The green paint was derived from malachite powder (green copper ore) and was used because it would make eyes appear larger. The black paint was derived from powdered galena (lead sulphite) and kohl (manganese, lead or copper). Today we know that lead can cause brain damage and miscarriages.

From Mercury makeup to lead eyeliner, killer cosmetics for over decades

Lead in your lipstick? Mercury in your face cream? Recent headlines about toxic ingredients hiding in beauty products are enough to make even the vainest among us want to go back to the good old days of rubbing cherries on our lips to make them red.

Women in many countries use cosmetics products in pursuit of beauty. In 2013, Malaysian spent about US$407 million on cosmetics and toiletries products and this demand was mainly met by im-ports. Cosmetics are required to be effective, long-lasting, stable and safe to human use. Yet, hazard-ous ingredients such as inorganic mercury compounds, hydroquinone, and steroid were found in the cosmetics and toiletries from stuff manufactured all over the world. Cosmetics are often applied to large areas of the skin, left on for long hours, and used repeatedly everyday. Hence, cosmetics that contain hazardous ingredients pose significant risk to users.

Introduction

PHARMACY BULLETIN

Mercury containing cream is extremely efficient in skin whitening. It is used by large fractions of the population, primarily women in Asia, Africa and Latin America in pursuit of “fair skinned beauty”. Mercury absorbed extremely efficient into the skin leading to severe health issues that are very harmful even if you do not apply them to your skin. Due to its absorption efficiency, the exposure to even small amount of it may cause serious health threat.

Mercury targeting growing brain, hence foetuses are most susceptible to mercury. Methylmercury exposure in the during pregnancy can affects in baby's growing brain, nervous system and kidney. The primary health effect of mercury is im-paired neurological development. Therefore, cognitive thinking, memory, atten-tion, language, and fine motor and visual spatial skills may be affected in children who were exposed to methylmercury as foetuses. Pregnant women using these mercury containing creams can have harmful health effects on developing foetus.

Cases of kidney damage caused by long term used of mercury containing skin-lightening products reported in China, Hong Kong and UK. In those cases, once the source of mercury exposure was identified and the women stopped using the harmful products, their kidney function gradually returned to normal. Unfortunate-ly, most women who use skin-lightening products are unlikely to be seen by a medical professional who could detect such kidney damage at an ear-ly stage and eliminate their mercury exposure before more serious disease develops.

Page 2

Not Just a Pretty Face: The Ugly Side of the Beauty Industry

M E R C U R Y

Figure 1 : Over-pigmented skin caused by mercury

containing creams

Figure 2 : Ammoniated mercury can cause rashes and

allergic reactions

Signs and Symptoms of Mercury

toxicity

Tremors

Irritability

Changes in vision

Memory problems

Numbness and tingling in hands, feet or around the mouth

Hydroquinone is used to lighten the dark patches of skin caused by pregnancy, birth control pills, hormone medicine, or injury to the skin. Skin whitening products use active ingredients, hydroquinone can reduce skin protection from UV ray which in turns increase the risk of skin cancer.

All skin care preparations like creams, lotions, gels, soaps, etc con-taining hydroquinone, steroids and hormonal preparations should be registered by the Pharmacy and Poisons Board of the Ministry of Health for medical use due to its long term adverse effect.

Hydroquinone use can cause severe skin redness, burning or sting-ing; severe skin dryness or cracking. Long term use of Hydroqui-none may also leads to ochronosis. When ochronosis occurs, the skin becomes considerably darker and thicker than normal.

Hydroquinone has been use as skin whitener for decades, however, with all the harm it may be doing, it is advisable to make the safe decision and pick safer alternatives that are available in the market.

Hydroquinone

Figure 3

Reaction due to susceptible to UV ray after hydroquinone use

Figure 4

Long term use of Hydroquinone may also leads to ochronosis

Lead is an element that occurs naturally in the earth. Traces amounts of lead may occur in the foods we eat and the water we drink. Metals are often used in mineral dyes, which give lipstick its colour. Over the years, there have been reports alleging dangerous levels of lead in lipstick. Though metal content varied widely from brand to brand, research showed that women who apply lipstick two to three times daily can ingest approximately 20 percent of the daily amount that's considered safe in drinking water or more of toxic metal (aluminum, cadmium, chromium, and manganese).

Elevated lead levels in adults can lead to a host of health problems from miscarriages to seizures. Lead exposure among children can lead to permanent brain damage. While Cadmium, for example, is a carcinogen.

However, lipstick, as a product intended for topical use with limited absorption, is ingested only in very small quantities. We do not consider the lead levels we found in the lipsticks to be a safety concern. But the amount of lead in cosmetics should be con-trolled by public health authorities to ensure its safe to be used.

Lead, Cadmium, Cromium contamination

REFERENCES:

1. Olumide, Y.M., Odunowo, B.D., and Odiase, A.O. (1991) Regional dermatoses in the African. Part 1. Facial hypermelanosis. International Journal of Dermatology 30(3):186-189.

2. Li, S.J., et al. (2010) Mercury-induced membranous nephropathy: clinical and pathological features. Clinical Journal of the American Society of Nephrology 5(3):439-444.

3. Tang, H.L., et al. (2006) Minimal change disease following exposure to mercury-containing skin lightening cream. Hong Kong Medical Journal 12(4):316-318.

4. Oliveira, D.B., et al. (1987) Membranous nephropathy caused by mercury-containing skin lightening cream. Postgraduate Medical Journal 63(738):303- 304.

5. Bracchi, P. (2007, January 12). Dying to be whiter: The black women who risk their lives for lighter skin. Retrieved July 23, 2008, from http://www.dailymail.co.uk/femail/article-428541/Dying-whiter-The-black-women-risk-lives-lighter-skin.html - See more at: http://www.safecosmetics.org/get-the-facts/chemicals-of-concern/hydroquinone/#sthash.1Ho4n8dI.dpuf

6. Sivern, M., 2013,Which 20 Lipsticks Contain the Most Lead? Mother Jones, http://www.motherjones.com/environment/2013/05/study-lead-metals-lipstick-top-20

7. Walter, P., et al., 1999, Making make-up in Ancient Egypt, Nature 397, 483-484.

CONCLUSION

While many skin-lightening products are safe, there are still products on the market which are unlabelled, mislabeled, counterfeit, or not labelled in a language the user can read. Therefore, consumers do not know what is actually in the product they are using. Despite national bans, however, recent tests show mercury-containing skin lighteners are still sold in developed countries. There is urgent need for more effective government actions in all countries to restrict the sale and production of hazardous containing cosmetics. Non-governmental and government organizations should work in to develop and disseminate effective consumer education materials. Effective public education campaigns on hazard-ous ingredients in cosmetics in order to educate consumers of all cultures and continents to the hazards hidden in these products.

Page 3

Glucose-6-phosphate dehydrogenase (G6PD) is an enzyme that is in-volved in the normal processing of carbohydrates and it also protects red blood cells from the effects of potentially harmful molecules called reactive oxygen species.

What is G6PD?

G6PD DEFICIENCY

G6PD deficiency is a hereditary abnormality in the activity of an erythrocyte (red blood cell) enzyme. G6PD deficient individuals had mutations in the G6PD gene that causes reduction in the amount of G6PD enzyme or alter its structure. G6PD enzyme can no longer play its protective role in these individuals. As a result, reactive oxygen species can accumulate and cause red blood cells break down prematurely. This destruction of red blood cells is called hemolysis. The most common medical problem associated with G6PD deficiency is hemolytic anemia. This type of anemia leads to paleness, yellowing of the skin and whites of the eyes (jaundice), dark urine, fatigue, shortness of breath, and a rapid heart rate.

G6PD deficiency

The defect is sex-linked, transmitted from mother (usually a healthy carrier) to son (or daughter, who would be a healthy carrier too). This is due to the fact that the structure of G6PD is carried on the X chromosome. In females, only one of the two X chromosomes in each cell is active; consequently, fe-male heterozygotes for G6PD deficiency have two populations of red cells; deficient cells and normal cells.

By: Teoh Sook Yee

Page 4

In people with G6PD deficiency, hemolytic anemia is most often triggered by several factors as shown in the figure. These triggering factors can increase the levels of reactive oxygen species. When this happens, red blood cells of G6PD-deficient patients cannot overcome the oxidative stress, subsequently causing red blood cells to be de-stroyed faster than the body can replace them.

1. Fava beans and other legumes

2. Ascorbic acid

3. Artificial blue dyes

4. Menthol or menthol-containing foods

5. Soy-containing products

6. Foods containing sulfites

Foods that need to be avoided:

Page 5

Medications associated with G6PD Name Risk Level Avoid/Use Cautiously/Safe for use

Acetylsalicylic acid High Avoid

Ascorbic Acid Low Use Cautiously

Benzhexol - Use Cautiously

Chloramphenicol High Avoid

Chloroquine High Avoid

Ciprofloxacin High Avoid

Colchicine Low Use Cautiously

Dapsone High Avoid

Diphenhydramine Low Use Cautiously

Dopamine Low -

Dorzolamide High Avoid

Frusemide - Avoid

Glibenclamide High -

Isoniazid Low Use Cautiously

Levofloxacin High Avoid

Methyltioninium Chloride (methylene blue) High Avoid

Moxifloxacin High Avoid

Nitrofurantoin High Avoid

Norfloxacin Low -

Ofloxacin High Avoid

Paracetamol Low Use Cautiously

Phenytoin Low Use Cautiously

Phytomenadione (Vitamin K1) Low Use Cautiously

Primaquine High Avoid

Probenecid - Avoid

Quinine - Avoid

Quinidine - Avoid

Streptomycin Low Use Cautiously

Sulfamethoxazole High Avoid

Sulfasalazine, Salazosulfapyridine (salazopyrin) High Avoid

Trimethoprim Low -

References:

1. Jeff Bubp, PharmD, Marilyn Jen, and Karl Matuszewski, MS, PharmD. Caring for Glucose-6-Phosphate Dehydrogenase (G6PD)–Deficient Patients: Implications for Pharmacy. P T. 2015 Sep; 40(9): 572–574.

2. McMillan DC, Schey KL, Meier GP, Jollow DJ. Chemical analysis and hemolytic activity of the fava bean aglycon divicine. Chem Res Toxicol. 1993;6(4):439–444.

3. Beutler E. Glucose-6-phosphate dehydrogenase deficiency: a historical perspective. Blood. 2008;111(1):16–24.

4. Youngster I, Arcavi L, Schechmaster R, et al. Medications and glucose-6-phosphate dehdrogenase deficiency: an evidence-based review. Drug Saf. 2010;33(9):713–726.

5. https://ghr.nlm.nih.gov

6. http://www.g6pd.org

Symbicort 160/4.5 (Budesonide 160 mcg/ Formoterol 4.5 mcg)

Symbicort 320/9 (Budesonide 320 mcg / Formoterol 9 mcg )

Mode of

Action

Budesonide - has a dose-dependent anti-inflammatory action in the airways, resulting in re-

duced symptoms and fewer asthma exacerbations.

Formoterol - is a selective beta2-adrenergic agonist that when inhaled results in rapid and

long-acting relaxation of bronchial smooth muscle in patients with reversible airways obstruc-

tion. Onset of bronchodilating effect within 1-3 minutes. The duration of effect is at least 12

hours after a single dose.

Dosage Asthma Maintenance therapy

Adults (18 Years and Older):

1-2 inhalations twice daily (maximum of 4 in-halations twice daily)

Adolescents (12-17 Years):

1-2 inhalations twice daily.

Children (6-11 years) 1 inhalation bd,

<6 yr Not recommended.

COPD:

Adults (18 Years and Older):

2 inhalations twice daily.

Asthma Maintenance therapy

Adults (18 Years and Older):

1 inhalation twice daily (maximum of 2 inhala-tions twice daily).

Adolescents (12-17 Years):

1 inhalation twice daily.

Children Under 12 Years: Not recommended.

COPD:

Adults (18 Years and Older):

1 inhalation twice daily.

Symbicort Maintenance and Reliever Therapy (SMART)

Adults (18 Years and Older):

Reliever Therapy (in Addition to Maintenance Therapy):

1 additional inhalation as needed in response to symptoms (Total daily dose of up to 12 in-halations could be used for a limited period).

Patients using more than 8 inhalations daily should be reassessed and their maintenance therapy should be reconsidered.

Children & Adolescents <18 Years:

SMART is not recommended

SMART is not recommended.

Should be used as Symbicort maintenance therapy ONLY.

Prescriber Category

A/KK (Consultant/Specialists/Family Physician Specialists)

A/KK (Consultant/Specialists/Family Physician Specialists) — Not in PKDMT formulary

Price RM 124.90 (60 doses/can);

RM 213.20 ( 120 doses/ can)

RM 213.20 (60 doses/ can)

DRUG COMPARISON

Page 6

By Goh Shi Yu

Twist Unscrew and

remove the cover. Hold

the Turbuhaler upright

and TWIST the grip.

Click Twist the gr ip back in

the other direction until you

hear a CLICK. Your Turbuha-

ler is now loaded with a dose of

medicine. The dose is a tiny

amount of fine powder.

Breathe out BREATHE

OUT as much as you feel

comfortable. Do not blow

into the Turbuhaler.

Breathe in Place the mouth-

piece in your mouth and

form a seal with your lips.

BREATHE IN deeply. Do

not chew or bite on the

mothpiece .

Instructions for Use/Handling Symbicort Turbuhaler

How to Prepare A New Inhaler For Use:

1. Unscrew and lift off the cover. A rattling sound is heard when you unscrew the cover.

2. Hold the inhaler upright with the red grip downwards. Do not hold the mouthpiece when you turn the grip. Turn

the grip as far as it will go in one direction and then back again as far as it will go. It does not matter which way you

turn first. During this procedure you will hear a click.

3. Perform step above twice. The inhaler is now prepared for use and you should not repeat the above procedure

again. To take a dose, please continue according to the instructions as follows.

How to Use Symbicort Turbuhaler:

5. Remove the inhaler from your mouth, before breathing out.

6. If more than one dose has been prescribed, repeat steps 2-4.

7. Replace the cover by screwing it back on tightly.

8. Rinse your mouth out with water after morning and evening doses. Do not swallow.

Counselling Points

Do not remove the mouthpiece or twist it unnecessarily.

If the patient by mistake perform the loading procedure more than once before taking your dose, you

will still only receive one dose.

The sound heard if you shake the inhaler is not produced by the medication but by a drying agent.

Cleaning: Wipe the outside of the mouthpiece regularly (once a week) with a dry tissue.

How Will The Patient Know When To Replace The Inhaler?

For the last 10 doses, the background of the indicator is red. When the zero reaches the middle of the window, it

is time for you to discard the inhaler.

Page 7

INTRODUCTION

Home Medication Review (HMR) is a patient-focused process which advocates the optimal and quality use of medication at the patient’s home. It involves systematic assessment of the patient’s medication in order to iden-tify and meet the medication-related needs as well as to identify, resolve and prevent drug related problems [1].

This service is a continuation of patient’s care from health facilities to their home. It is a comprehensive activity which involves clarification of the indication for use and administration details of all prescription and non-prescription medicines (including nutritional supplements, vitamins, herbal/complementary medicine and other remedies) and assessment of medication storage at home.

Despite the Ministry of Health (MOH) spending billions of Ringgit in purchasing medications, many patients fail to achieve the targeted goal of treatment. Under-utilization of medications and treatment non-adherence may be the contributing factors towards failure in achieving treatment goals. A survey done by the Pharmaceuti-cal Services Division, MOH on medication returned by patients to the various pharmacy healthcare facilities showed that the value of returned medications amounted to RM 200,000 in 2008 and RM 700,000 in 2009. Therefore, it is timely to incorporate HMR into the current healthcare system as HMR can be vital in improving health outcomes and reducing expenditures [2].

PHARMACIST INVOLVEMENT

HMR is conducted by 4 qualified pharmacists from different Klinik Kesihatan (2 pharmacists each team). As a start, HMR visit will be limited to one patient every month or every 2 month, whereby there will be a minimum of one or two patients per visit.

Involving Pharmacists in the implementation of HMR services will ensure better therapeutic outcomes in the overall management of the patients. Pharmacist will be responsible for provision of information and advising patients or caregivers with regard to medications and therapeutic devices. In addition, the pharmacist will moni-tor and advocate patient’s awareness about adherence, safety and quality use of medications and provide advice on proper storage conditions as well as disposal of unused medicines.

OBJECTIVE

To improve health outcomes and quality of life of the patient by emphasizing the quality use of medication, through appropriate, safe, judicious and proper use of medicines in the home setting.

Page 8

By Nur Syahirah Binti Abd Raof

References

1. Home medication review protocol 1st edition 2011 MOH

2. National health and morbidity servey, 2006

Page 9

Patient Inclusion Criteria Patient Exclusion Criteria

Patient suffering from chronic illness and taking 5 or more medications for long term therapy.

Patient who is taking more than 12 doses of medications daily.

Patients suspected of non-adherence or not managing well with medication-related therapeutic devices (such as in-halers or insulin pen).

Patients who are managing their own medication but at risk due to language difficulties, impaired insight, confu-sion/dementia or any other cognitive difficulties (such as geriatric patients).

Patients who have defaulted treatment or fail to refill their medications especially chronic illness.

Symptoms requiring pharmaceutical intervention such as occurrence of adverse drug reaction or sub therapeutic response toward treatment.

Non-MOH patients

Patients who are homeless or do not have a proper place to stay.

Foreign workers, non-permanent residents.

Name INSUGEN –30/70 INSUGEN-N INSUGEN-R

Type of Insulin Short-acting Insulin (30%)

Intermediate-acting Insulin (70%)

Intermediate-acting Insulin Short-acting Insulin

Onset of Action Within 30 minutes Within 60 minutes to 90 minutes

Within 30 minutes

Maximum Peak Effect

Between 2 to 8 hours Within 4 to 8 hours Between 2 to 4 hours

Shelf Life 20C to 80C - till expiry date

Room Temperature – 6 weeks

20C to 80C - till expiry date

Room Temperature – 6 weeks

20C to 80C - till expiry date

Room Temperature – 6 weeks

Biosimilar Insuman Comb 30

Humulin 30/70

Insuman Basal

Humulin N

Insuman Rapid

Humulin R

INSULIN PEN: INSUPEN PRO

Only available in Green

Return plunger rod by gripping the pen body in one hand and gently pushing back the

plunger rod

If injection stops during the injection and 0 is not indicated - the cartridge does

not have enough insulin left. Administer balance doses with a new insulin

cartridge. DO NOT FORCE the injection button down.

By Nurul Nabihah Binti Mohamed Noor

Page 10

VACCINATION

Page 11

By Chew Poh Chiong

References

1. Immunization Schedule from Ministry of Health Malaysia, 2015

2. Case Investigation and Outbreak Disease Control Division, Department of Public Health, Ministry of Health, 2010, 1st Edition

3. What are some of the myths – and facts – about vaccination? (2013). WHO. http://www.who.int/features/qa/84/en/

4. U.S. Department of Health and Human Services

5. http://www.nhs.uk

6. http://www.vaccines.gov/

Page 12

Page 13

JOHAN

Kategori Produk Anugerah Inovasi

Jabatan Kesihatan Negeri Melaka 2017

Nama Produk : Smart NP Sharp Bin

ACHIEVEMENT OF PKDMT

JOHAN

Kategori Oral Konvensyen Quality Assurance (QA) 2017

Jabatan Kesihatan Negeri Melaka 2017

Tajuk Projek:

Increasing Number of Follow-up DMTAC Patients in PKD Melaka Tengah

LAW SHY KEE

PEGAWAI FARMASI UF44

KK PERINGGIT

MUHAMMAD ABDUL WAFI

PEGAWAI FARMASI UF44

KK PERINGGIT

CHOO HUAN TING

PEGAWAI FARMASI UF44

KK PERINGGIT

MASTRIA BINTI MOHAMED

PEGAWAI FARMASI UF41

KK PERINGGIT

SITI MASLIZAH BINTI SETO

PEGAWAI FARMASI UF44

KK AYER KEROH

GOH SHI YU

PEGAWAI FARMASI UF41

KK AYER KEROH

THAMAIYANTI A/P

PADMANATHAN

PEN. PEG. FARMASI U32

KK AYER KEROH

MUHAMMAD LUKMAN

PEN. PEG. FARMASI U29

KK AYER KEROH

CHE KU ADILA BT. CHE KU

ABDUL RAHIM

PEN. PEG. FARMASI U29

KK SUNGAI UDANG

NURUL NABIHAH BINTI

MOHAMED NOR

PEGAWAI FARMASI UF41

KK TENGKERA

ADILLAH BINTI AHMAD

PEGAWAI FARMASI UF44

KK AYER MOLEK

THANARUPINI A/P

GIAMASROW

PEGAWAI FARMASI UF41

KK CHENG

JESSNIE KHUNG MEI INN

PEGAWAI FARMASI UF41

KK SERI TANJUNG

RACHEL ELSPETH MATHEWS

PEGAWAI FARMASI UF41

KK JALAN GEREJA

Page 14