Vol. 7 No. 1 (2021): Malaysian Journal of Pharmacy


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Published: 30 June 2021

In this issue:

  • Antifungal Treatment of Mucormycosis Associated with COVID-19
  • Clinical Pharmacist in a COVID-19 Hospital- A Malaysian Experience
  • Warfarin – Fenofibrate Interaction: Hospital Kuala Lumpur Experience
  • Monotherapy with Lopinavir/Ritonavir or in Combination with Interferon Beta-1b in Patients with Non-severe COVID-19 Disease: A Clinical Case Series
  • Impact of Medication Reconciliation by Clinical Pharmacist during Hospital Admission of Patients with Chronic Kidney Disease (CKD) Stage IV-V in Hospital Raub, Pahang
  • Pharmacy Value-Added Services: Experience in a Malaysian Public Hospital
  • Analgesic Dosing Behaviours in Patients with Chronic, Non- Cancer Pain: Does it Affect the Pain Control?
  • Utilization Review of Anti-peptic Ulcer Drugs at an Outpatient Pharmacy Setting of a Private Hospital in Malaysia
  • The Effect of Pharmacist’s Interventions on Anaemia Management among Continuous Ambulatory Peritoneal Dialysis Patients in Terengganu Tertiary Hospital
  • PROCEEDINGS of MPS-NATIONAL PHARMACISTS CONVENTION 2021

Antifungal Treatment of Mucormycosis Associated with COVID-19

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    Abstract

    Mucormycosis is an angioinvasive fungal infection due to fungi of the order Mucorales. The prognosis from mucormycosis can be poor despite early diagnosis and aggressive therapy. The systematic review and meta-analysis by Muthu and colleagues [1] investigated the rate of mortality in patients with pulmonary mucormycosis. While there had been a significant decrease in the mortality rate over time, the recent (2010-2020) rate of mortality is still substantial, in which about one in two patients (49.8%; 95% confidence interval 43.2% to 56.3%) with pulmonary mucormycosis died from the disease. Yet, patients originated from the lower-middle-income countries had a higher mortality rate, in which about three in four patients (71.5%; 95% confidence interval 58.7% to 84.3%) with pulmonary mucormycosis died from the disease. Indeed, there has been a recent surge in the occurrence of mucormycosis in lower-middle-income countries, especially in India. As raised by Szarpak [2], the increased incidence with a fairly severe course of mycormycosis was reported in patients with a history of coronavirus disease 2019 (COVID-19) and received systemic corticosteroid therapy.

    Clinical Pharmacist in a COVID-19 Hospital- A Malaysian Experience

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      Abstract

      The coronavirus disease 2019 (COVID-19) pandemic has hugely affected healthcare services, particularly pharmacy services in a COVID-19 hospital. Before the COVID-19 outbreak, clinical pharmacists routinely reviewed patients’ medications upon ward admission, actively participated in ward rounds and partook in transitional care activities focusing on medication reconciliation and patient education in the wards. However, in order to limit contact with COVID patients, hospital pharmacy department reacted promptly by establishing remote clinical pharmacy services in order to sustain the quality of inpatient pharmaceutical care. This commentary describes the challenges faced by clinical pharmacists in a Malaysian hospital as we continue to provide clinical pharmacy services amidst the new norm.

      Warfarin – Fenofibrate Interaction: Hospital Kuala Lumpur Experience

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        Abstract

        Case reports in western populations reported that fenofibrate enhances the anticoagulatory effect of warfarin. We are reporting ten cases of warfarin-fenofibrate interaction among Malaysian patients’ cases that were managed at the anticoagulation clinic of Hospital Kuala Lumpur. Patients taking warfarin and micronized fenofibrate 145mg daily concurrently between the year 2014 to 2018 were identified in May 2018. Ten active patients were included, and the relevant data were retrieved retrospectively. All patients received warfarin for stroke prevention in atrial fibrillation (AF), with a target international normalised ratio (INR) of 2 to 3. No dose adjustment was done upon initiation of fenofibrate. Warfarin doses were adjusted to achieve the targeted range but fenofibrate was not discontinued. Eight patients had INR levels above the target range when INR being reassessed between 20 to 62 days after initiation of fenofibrate. Their weekly warfarin doses were between 17.5mg-46.5mg. Baseline INR ranged between 1.6 -3.1. Percentage of dose reduction ranged between 5%-60%. Four of the patients were on other concurrent interacting medications such as statin and levothyroxine. Only one patient, whose case was with an INR 3.1 before initiation of fenofibrate, required admission for hematoma (INR 12). Two patients had INR within the target range, and INR were assessed at 14 and 21 days after fenofibrate initiation. Their weekly warfarin doses were between 24.5mg and 26.5mg while baseline INR was 2.8 and 1.9 respectively. Interaction between fenofibrate and warfarin may increase INR among Malaysian patients, thus close monitoring of INR is warranted. Empirical warfarin dose reduction may be considered upon initiation of this drug combination for patients with AF. The next INR reassessment date should be arranged not later than three weeks after initiation of fenofibrate.

        Monotherapy with Lopinavir/Ritonavir or in Combination with Interferon Beta-1b in Patients with Non-severe COVID-19 Disease: A Clinical Case Series

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          Abstract

          The outbreak of Coronavirus Disease 2019 (COVID-19), caused by severe acute respiratory syndrome (SARS) coronavirus (SARS-CoV-2), has infected and killed millions of people worldwide. It has substantially increased the burden on healthcare system. However, the optimal approach to treatment of COVID-19 is uncertain. “Off-label” use of lopinavir/ritonavir (LPV/r) and interferons, particularly interferon beta (IFN-β), were the most suggested at the early stage. Although the United States National Institutes of Health’s (NIH) COVID-19 guidelines do not recommend the use of both medications for the treatment of COVID-19 in hospitalized patients, their roles in patients with non-severe disease are still unclear. Macau, a famous city for tourism, had 46 COVID-19 confirmed cases as of 2020. In this retrospective review, we summarized clinical and laboratory features of 39 COVID-19 patients admitted in the Centro Hospitalar Conde de São Januário (CHCSJ), of whom all did not receive oxygen therapy or ventilatory support during hospitalization. Of note, 12 (30.8%) of them were asymptomatic. The most common symptoms were fever and cough upon admission. They were all treated with LPV/r ± IFN-β-1b plus supportive care. The mean length of hospitalization was 26.6 (SD ± 12.6) days with LPV/r monotherapy, whereas 27.8 (SD ± 10.1) days with LPV/r/IFN-β-1b combination therapy (p=0.65). The percentage of 28-day negative results for polymerase chain reaction (PCR) test were 67.9% (19 of 28) with monotherapy and 63.6% (7 of 11) with combination therapy (p=0.80). No fatal case was reported and all patients discharged successfully. No beneficial clinical outcome was observed with the addition of IFN-β-1b to LPV/r-based therapy. Further studies are warranted to confirm these findings.

          Impact of Medication Reconciliation by Clinical Pharmacist during Hospital Admission of Patients with Chronic Kidney Disease (CKD) Stage IV-V in Hospital Raub, Pahang

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            Abstract

            Medication errors are more likely to occur during patient’s transition of care. There was very little information about impact of medication reconciliation activities done for patients with chronic kidney disease (CKD) Stage IV-V during admission stage in Malaysian Primary Hospitals. The objective of this study is to evaluate the impact of clinical pharmacist’s medication reconciliation activities during hospital admission of patients with CKD stage IV-V. This cross-sectional study was carried out in two multidisciplinary wards (male & female ward) in Hospital Raub, Pahang over 12 months with ethical approval. A clinical pharmacist was assigned to enroll potential study subjects in both wards. Patients over 18 years old who had previous history of CKD Stage IV-V were included in the study after obtaining informed consent. Medication reconciliation was carried out by the clinical pharmacist within 24 working hours during the admission of study subjects. All detected medication discrepancies were further classified as “intended” or “unintended” after discussion with the prescribing medical officer. The Severity Level of each unintended medication discrepancy was rated by a visiting medical specialist. Twelve patients with CKD stage V were recruited to the study. A total of 49 medication discrepancies were identified and most (89.8%) were found to be unintended. The most common unintended medication discrepancy identified was omission error. Most of the unintended medication discrepancies (59.1%) was rated as “No potential harm”, while 40.9% were rated as “Potential for monitoring and/or Intervention to preclude harm”. None of the unintended medication discrepancy was rated as “Potential harm”. In conclusion, medication discrepancies were common during admission of patients with late-stage chronic kidney disease in a primary hospital. Medication reconciliation performed by clinical pharmacist during admission has a potential role in preventing potential harms that may arise from unintentional medication discrepancies.

            Pharmacy Value-Added Services: Experience in a Malaysian Public Hospital

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              Abstract

              The Pharmacy value-added services (PVAS) has been implemented in Malaysian public hospitals to facilitate the collection of follow-up medications. In specific, PVAS include Integrated Drug Dispensing System, Medicine by Post, Drive-Through Pharmacy, and many more. While past studies examined the satisfaction towards PVAS and its impact on patients’ waiting time, little explored the awareness and the experience of patients towards each type of PVAS. This study aims to explore the patient’s awareness on PVAS, adoption of PVAS, their satisfaction towards PVAS, and willingness to adopt PVAS. This was a cross-sectional study conducted in January 2020. We invited the eligible patients or their family members to participate in the study. Respondents recruited at the Outpatient Pharmacy Department of Miri Hospital using convenient sampling. A questionnaire in the Malay language was developed and content validated to gather information on the demographic data, awareness on PVAS, adoption of PVAS, satisfaction towards PVAS, and willingness to adopt PVAS. A list of PVAS was included for the respondents to select the types they were aware of and used before. Results were presented as frequencies, percentages, mean and standard deviation. A total of 398 respondents participated in the study. Majority of the respondents (70.1%) were aware that PVAS offered in Miri Hospital. However, about a third of the respondents (31.4%) had experience using PVAS. The most commonly used PVAS was Appointment Card Dispensing System (49.6%) and that with the least usage was Local Partial Medication Supply Service (2.4%). The Drive-Through Pharmacy has the greatest satisfaction score, 4.40 (SD=0.70), whereas Call-and-Collect Service was the least satisfied, 3.88 (SD=0.91). Majority of the respondents (86.2%), specifically 95.8% of the experienced PVAS user and 90.1% of inexperienced group, were willing to adopt PVAS to collect their follow-up medications. The Drive-thru Pharmacy, which has the greatest awareness and satisfaction yet low usage, should be further promoted for greater adoption. Besides, such PVAS should be expanded to other healthcare facilities.

              Analgesic Dosing Behaviours in Patients with Chronic, Non- Cancer Pain: Does it Affect the Pain Control?

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                Abstract

                Chronic pain has a significant impact on sufferers’ quality of life. Furthermore, treatment inadequacies are often reported in the literatures. This study aims to investigate the prevalence of the different dosing behaviors in analgesics use in chronic, non-cancer pain and their correlation to pain control. This is a cross-sectional study and a convenience sampling method was applied. Brief Pain Inventory- Short Form and Pain Management Index was computed to assess pain control. Statistical analysis was performed with Pearson chi-square test and alpha value was set at 0.05. A total of 127 patients were analyzed. 70.9% of the patients reported inadequate pain control with their prescribed analgesic(s). 88.2% patients only took oral analgesics whenever they felt the pain while 11.8% patients took around-the-clock despite the absence of pain. Among them, 11.8-34.7% of patients did not follow their prescriber’s instruction for oral and topical analgesic use respectively. However, no statistically significant result was found between the dosing behaviors and pain control (p>0.95). It was also reported that 98% of patients were not aware of the maximum daily dose of their prescribed analgesic(s). The prevalence of ‘as needed’ dosing is higher than around-the-clock dosing in the management of chronic, non-cancer pain, with deviation from the prescribed instructions between 11.8-34.7%. However, those differences were not significantly associated with the pain control.

                Utilization Review of Anti-peptic Ulcer Drugs at an Outpatient Pharmacy Setting of a Private Hospital in Malaysia

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                  Abstract

                  Anti-peptic ulcer drugs (APUDs) such as proton pump inhibitors (PPI), H2 receptor antagonists (H2A), antacids are widely prescribed. This study is aimed to describe the utilisation pattern of APUDs based on WHO Defined Daily Dose (DDD) and identify most commonly used APUD in the selected hospital. A retrospective study was carried out in outpatient of the selected hospital for year 2017. Sample size was calculated using Raosoft. DDD of APUDs and direct drug cost were calculated. Data were collected through electronic medical record by retrieving patients’ registration number. Inclusion criteria were patients above 18 years old and APUDs prescribed for gastrointestinal related indications. A total of 160 prescriptions were randomly selected for data analysis. Based on the DDD calculated, Rabeprazole 20mg was most prescribed drug among PPI (n=33), while Maalox is most prescribed drug among the antacids (n=23). Based on the DDD calculated, Pantoprazole 20mg recorded highest rates per user per day about 1.26 DDD / user / day while antacids, Actal reported highest usage rate with 7.11 DDD / user / day. Besides, there are 5.4 days supplied per user for this drug. Dexlansoprazole 60mg is the most expensive drug among all the PPI listed in hospital formulary. It has 18.5 days supplied/user, which is the second shortest duration of treatment among all the other PPIs. In contrast, omeprazole 20mg is the lowest cost PPI but the duration supplied per user is longer resulting in higher total cost of therapy. In conclusion, PPIs were the most commonly prescribed.