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F E B R U A R Y , 2 0 1 7 - N E W S L E T T E R N O . 8 - V O L U M E 2 - I S S U E 1

T H E N A T I O N A L I N S T I T U T E O F C H E S T D I S E A S E S

N I C D N E W S L E T T E R

I N S I D E T H I S I S S U E :

M A N A G E M E N T

O F C O P D

A C U T E

E X A C E R B A T I O N

1

T A V A N I C /

D I F L U C A N

I N T E R A C T I O N

2

N I T R O N A L

D O S E 2

T U B E R C U L O S I S

T R E A T M E N T

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O U R

A C T I V I T I E S

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N E W S L E T T E R T E A M

Guest of Honor

Dr. Salah Reda

Chief Editors

Dr. Lobna Samy

Dr. Sarah El-Greeny

Dr. Manar Mostafa

Dr. Nora Said

Dr. Omima Zein

Supervised by:

Dr.Hend M.Kamel

Head of Pharmacies

A COPD exacerbation can be defined as an acute worsening in the patient’s baseline status (increase in dyspnea, cough, and/or sputum production), necessitating a change

in medications. General criteria for diagnosis of an acute exacerbation are based on clinical presentation, including an acute change of symptoms that is beyond normal day-to-day variation. Arterial blood gas should be measured, Pulse oximetry can be used to determine the need for supplemental oxygen and Spirometry is not accurate during an exacerbation and is not recommended.

Pharmacologic treatment The three classes of medication most commonly used for COPD exacerbation are Bronchodilators, Corticosteroids and Antibiotics. Bronchodilators: Inhaled bronchodilators (inhaled SABAs with or without short-acting anticholinergics) are the preferred treatment of COPD exacerbations (level of evidence C). Usual doses of Salbutamol are 2.5 mg (0.5 ml of farcolin) via nebulizer every 1–4 hours as needed or 4–8 puffs by Metered dose inhaler (Vental) with holding chamber every 1–4 hours as needed.

Short-acting anticholinergics (ipratropium bromide) are generally added for acute

exacerbation with the dose of 0.5 mg every 20 minutes for three doses; then as needed.

Corticosteroids: Systemic corticosteroids should be used in most exacerbations. OCS dose for outpatient treatment: 40 mg of oral prednisone (equivilant to 6 mg dexamethasone) once daily for 5 days is recommended in the GOLD guidelines, but insufficient data are available to provide strong conclusions about the optimal duration. Higher daily doses or oral prednisone or prednisolone may be used e.g. 50–60 mg daily (equivilant to 7.5 to 9 mg dexamethasone). Antibiotics: Antibiotics should be given if all three cardinal symptoms (increased dyspnea, increased sputum volume, and increased sputum purulence) are present. Recommended duration of antibiotic treatment is usually 5–10 days. Usual initial antibiotics for uncomplicated COPD include: azithromycin, clarithromycin, doxycycline, trimethoprim/sulfamethoxazole, and amoxicillin, with or without clavulanate. In complicated COPD with risk factors: Amoxicillin/clavulanate, levofloxacin, moxifloxacin. Risk factors: Comorbid diseases, severe COPD (FEV1 less than 50% of predicted), more than 3 exacerbations/year, antibiotic use in past 3 months

If at risk of Pseudomonas infection: High-dose of levofloxacin or ciprofloxacin (750 mg). If exacerbation does not respond to initial antibiotic, obtain sputum culture.

References: GOLD 2017, Paul marino

Treatment settings: The goal of treatment for COPD exacerbation is to minimize the negative impact of current exacerbation and prevent the development of subsequent events.

N I T R O N A L D O S E ( N I T R O G L Y C E R I N 1 M G / M L V I A L S O L U T I O N F O R

I N F U S I O N

Manufacturer's labeling: 5 mcg/minute, increase by 5 mcg/minute every 3 to 5 minutes to 20 mcg/minute. If no response at 20 mcg/minute, may increase by 10 to 20 mcg/minute every 3 to 5 minutes (generally accepted

maximum dose: 400 mcg/minute)

Unresponsive congestive heart failure The normal dose range is 10-100 micrograms / minute administered as a continuous intravenous infusion with frequent monitoring of blood pressure and heart rate. (0.6-6 mg/hr) Refractory unstable angina pectoris An initial infusion rate of 10-15 micrograms / minute is recommended; this may be increased cautiously in increments of 5-10 micrograms until either relief of angina is achieved, headache prevents further increase in dose.

(0.6-0.9 mg/hr)

Lowering blood pressure during surgery: Initial dose: 5 mcg/min IV infusion. Increase by 5 mcg/minute every 3-5 minutes to 20 mcg/minute. If no response at 20 mcg/minute increase by 10 mcg/minute every 3-5 minutes. (maximum of 200 mcg/minute), (1.2-12 mg/hr). Onset: 2 to 5 minutes. Duration: 5 to 10 minutes.

Hemodynamic and antianginal tolerance often develop within 24 to 48 hours

of continuous nitrate administration. Nitrate-free interval (10 to 12 hours/day)

is recommended to avoid tolerance development; gradually decrease dose in

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References: lexi,emc,drugs,pamphlet

S E R I O U S R I S K S O F S U S T A I N E D V E N T R I C U L A R T A C H Y C A R D I A A N D

F R E Q U E N T P R E M A T U R E V E N T R I C U L A R C O M P L E X E S A S S O C I A T E D

W I T H C O - A M I N I S T R A T I O N O F T A V A N I C / D I F U L C A N

Case Report: A yellow card concerning a male patient who developed sustained ventricular tachycardia and frequent premature ventricular complexes after administration of Tavanic 500 mg as treatment of Pneumonia and Diflucan IV drip as treatment of Candidiasis.

Recommendations for Health Care Givers:

1– Levofloxacin infusion time of at least 30 minutes for 250 mg or 60 minutes for 500 mg. The infusion must be halted immediately if tachycardia or decrease in blood pressure develop. 2-Diflucan Intravenous infusion should be administrated at a rate not exceeding 200mg/hr. 3-Caution should be taken when using fluoroquinolones or fluconazole in patients with: -Known risk factors for prolongation of the QT interval. -Uncorrected electrolyte imbalance (e.g. hypokalemia, hypomagnesemia). -Concomitant use of drugs that are known to prolong the QT interval (e.g. Class IA and III antiarrhythmics, tricyclic antidepressants, macrolides, antipsychotics). -Cardiac disease (e.g. heart failure, myocardial infarction), elderly and women.

4-Diflucan co-administration of other medicinal products known to prolong the QT interval and which are metabolised via the cytochrome P450 (CYP) 3A4 are contraindicated.

References: Egyptian Pharmacovigilance Center

THE Anti-tuberculosis drugs are:

T U B E R C U L O I S S E R I E S - T R E A T M E N T

Page 3 T H E N A T I O N A L I N S T I T U T E O F C H E S T D I S E A S E S

References: 1-Crofton and Douglas's Respiratory Diseases 2012 2-Fishman Pulmnonary Diseases and Disorders 2015 3-National TB Program 4-CDC 5-WHO annual report (2015)

As we continue in publishing the “TB series” in our newsletter, this is the Third topic.

Regimen and dose for latent TB Patients who are not infected with HIV: (a) Isoniazid (INH) 300 mg/day or 900 mg twice a week for 6–9 months (9 months preferred) (b) Rifampin (RIF) + Isoniazid (INH) for 4 months

Prepared by:

Dr. Salah Reda (MSc of chest diseases, NICD)

T reating tuberculosis (TB) disease benefits not only the individual patient but the community as a whole. Adequate dosing and duration of treatment is important for cure.

Therapy for active TB infection Listed below are the basic preferred regimens for the treatment of drug-susceptible TB

Adjunctive treatment Pyridoxine (Vitamin B6) The use of Pyridoxine is recommended for peripheral neuropathy most commonly caused by Isoniazid. Dose of Pyridoxine: 25 mg daily If patient develops peripheral neuropathy at any stage during TB treatment, the dose can be increased to 50 – 75mg (up to maximum of 200mg) until the symptoms subside, then reduce to 25mg daily.

Relapses, defined as recurrent tuberculosis caused by the

same strains was identified at baseline, are thought to be due to failure of chemotherapy to sterilize the host tissues, Failure is definefed as continuously or recurrently positive cultures after 4 months of treatment in a patient receiving appropriate chemotherapy. Default ,defined as A patient whose treatment was interrupted for 2 consecutive months or more.

Treatment for Extra pulmonary TB

Six months treatment is as effective in extra-

pulmonary as in pulmonary disease. In some instances of severe or complicated disease (meningitis, TB bones/joints, miliary TB) treatment may need to be

extended to 9 months (or 12 months in bone TB).

The intensive phase remains 2 months and the

continuation phase is prolonged to 7 months.

2(RHZE)/ 7(HR).

Steroids The use of corticosteroids is recommended in extra-pulmonary tuberculosis, particularly for TB meningitis, serous membrane and Lymph node TB (mediastinal LN with possibility of tracheal compression). High dose steroid treatment for 2-4 weeks then taper off gradually over several weeks depending on clinical progress is recommended. The response to treatment is assessed clinically.

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O U R A C T I V I T I E S : E X T E R N A L L E C T U R E S B Y O U R P H A R M A C I S T S

From our new important activities in 2016 & 2017 is participation in the training program of Hospital

Pharmacists that was organized by The Pharmacy inspection of Specialized Medical Centers cooperating with the

Central Administration of Pharmaceutical Affairs.

Our Head of Clinical Pharmacy Department, Dr. Lobna Samy, has participated with a lecture about

“Drug Intercations” and Our Head of Drug Information Center, Dr. Sarah El-Greeny, with a lecture about

“Effective Communication with Healthcare team”.

The training program served almost 140 Pharmacist from different hospitals on a national level for two

weeks and the feedback was really satisfying.

The National Institute of Chest Diseases — Clinical Pharmacy Department — Drug Information Center