Vol. 7 No. 2 (2021): Malaysian Journal of Pharmacy
|Published: 31 Dec 2021
In this issue:
Introduction: Problems with medication therapy are a major concern in health care because of the associated increase in morbidity, mortality and increased cost of treatment. Clinical pharmacy services are well established in developed countries such as the United States and has been reported to reduce adverse drug events, medication errors, patient’s length of stay, mortality rates and costs. Clinical pharmacists proactively ensure rational medication use, avoiding medication errors at point of prescribing. They participate in ward rounds, communicate with the team in the wards, interview patients, perform medication reconciliation, provide counselling, therapeutic drug monitoring, antibiotic stewardship, discharge screening and follow ups. Any discrepancy or problems detected will be conveyed to the relevant team member for correction. Objective: To describe and evaluate the interventions performed by clinical pharmacists in a tertiary teaching hospital in Malaysia. Method: A clinical pharmacy observational retrospective study was conducted between January and December 2019. Fourteen clinical pharmacists were assigned to respective wards in the medical, surgery and intensive care units to provide pharmaceutical care. All interventions performed in the wards were documented systematically. Result: A total of 3345 interventions were recorded. The most frequent interventions were on rational drug therapy (n = 1456, 43.5%), followed by corrections made on prescription (n = 1349, 40.3%) and changes in dosage and frequency (n = 540, 16.2%). The majority of suggestions (n = 3264, 97.6%) have been accepted. Conclusion: To our knowledge, this is the first study reporting clinical pharmacist interventions in a teaching hospital in Malaysia. The involvement of clinical pharmacist in the wards contributed to the optimisation of pharmacotherapy, safety and better patients’ outcomes. There was good inter-professional collaboration at the ward level.
Effectiveness of Pharmacist-Led Audit-and-Feedback Intervention in Promoting Appropriate Third-Generation Cephalosporin Use at a Tertiary Public Hospital in Malaysia
Objective: This study aimed to determine the effectiveness of a pharmacist-led audit-and-feedback intervention in promoting the appropriate prescribing of third-generation cephalosporins and timely culture and sensitivity (C&S) testing in patients admitted to a neurosurgical ward. Method: This quasi-experimental study was conducted from July 2019 to August 2020 in a tertiary public hospital in Malaysia. In the pre-intervention phase, seventy patients who have received treatment with third-generation cephalosporins were examined by a ward pharmacist. The use of a cephalosporin was deemed to be appropriate only if it was in line with either the National Antimicrobial Guidelines 2019 or the recommendations made by the Antimicrobial Stewardship team. The availability of C&S test performed before the first dose of cephalosporin was also studied. As an intervention, the findings were presented and discussed in a 2-hour feedback session. Subsequently, the post-intervention audit was performed in the same manner as in the pre-intervention phase. The primary outcome measures were the proportion of cases with appropriate use of cephalosporin and timely C&S testing. The variables were analysed descriptively. Pearson’s chi-square test was used to assess the differences in appropriateness of antibiotics use and C&S testing, in the pre- and post-intervention cohorts. Result: Seventy cases were studied in the pre- and another seventy in post-intervention phases. The proportion of cases with appropriate use of third-generation cephalosporin increased significantly from 77.1% (54 / 70) to 95.8% (67 / 70) following the intervention (p = 0.001). The proportion of cases with a C&S test performed timely also increased significantly from 38.6% (27 / 70) to 58.6% (41 / 70) (p = 0.018). Conclusion: The pharmacist-led audit-and-feedback intervention was effective in improving the appropriateness of the prescribing of third-generation cephalosporins and timely culture and sensitivity testing, indicating the antimicrobial stewardship strategy had produced a positive outcome.
A Qualitative Study Exploring Pharmacists’ Perspectives on the Conceptualization and Operationalization of Patient-Centred Care in the Hospital Pharmacy Setting
Objective: The objectives of this study were to determine how hospital pharmacists in a developing country interpret the term “patient-centred care (PCC)”, how it was or can be operationalized in hospital pharmacy practice, and barriers faced in delivering such care. Method: A generic qualitative approach was utilized. Semi-structured interviews were conducted with purposively sampled pharmacists from a Malaysian tertiary referral hospital until data saturation, using an interview guide informed by relevant literature. Interviews were audio-recorded and transcribed verbatim, with resultant transcripts subsequently coded and analysed using thematic analysis technique. Result: Fifteen pharmacists were interviewed. Hospital pharmacists conceptualized the basic spirit of PCC as “putting patients first”. On the operationalization of PCC in pharmacy services, one theme/viewpoint was that all processes of care that are patient-oriented, including efforts that facilitate patient convenience, improve ecosystem of care and access of care should be considered as PCC. A contrasting theme only regard pharmacy services demonstrating specific elements, such as provision of individualized therapy, holistic in nature and enable building of rapport and trust between patient and pharmacist, as being consistent with PCC principles. Improving pharmacists’ communication skills, patients’ health literacy and over-reliance on clinicians as well as resource limitations are deemed integral for successful implementation of PCC services. Conclusion: Beyond the concept of putting patients first, there was confusion on the exact concept of PCC and its subsequent operationalization in hospital pharmacy practice. Development of a pharmacy specific PCC framework to serve as a universal blueprint to guide operationalization is recommended.
Introduction: Following the outbreak of the Covid-19 pandemic in early 2020, the traditional face-to-face delivery moved to online distance learning (ODL). New to the university’s online learning environment are the first-year students. This study explores perceptions and experiences of the first-year undergraduate pharmacy students learning via the ODL mode during the Covid-19 pandemic. Objective: This study aims to gain an understanding of the students’ learning issues and concerns during ODL. Method: Students’ responses were collected and analysed using thematic analysis. Result: The findings revealed three broad themes of learning issues and concerns during ODL: (1) adapting to online distance learning mode, (2) feeling overwhelmed and increased stress, and (3) support and guidance during online learning. The results indicate the need for enhanced teaching and social presences during ODL. Conclusion: Adapting to ODL seems to take longer time than expected for the first-year pharmacy students. It appears that they struggled to manage their lives and studies in remote learning, thus requiring more support and direct instruction.
Knowledge of Malaysian University Students on Methods of Contraception, Assessed Using a Validated Instrument (Knowledge on Methods of Contraception)
Background: Sexually active woman or couple may not be aware of the different methods of contraception and this can lead to unplanned pregnancy with psychological and social effects, and with significant impact on a woman’s’ life. Objective: To develop and validate an instrument, Knowledge on Methods of Contraception (KMC) and to assess the knowledge of non-medical related university students on the methods of contraception. Method: The 25-item KMC (KMC-25) was initially administered to 130 non-medical related university students and retested after four weeks. Fifty pharmacy undergraduates were recruited for comparison. The validated KMC-25 was then completed by another 402 non-medical related university students. Result: Internal consistency of the KMC-25 was good with Cronbach’s alpha = 0.78. There was significant correlation between the test-retest total scores (p < 0.001) and no significant difference for all the items, indicating stable reliability. Flesch Reading Ease score was 49.3 which means that the KMC-25 could be easily understood by undergraduates. The KMC-25 scores between pharmacy and non-medical related students were significantly different with median (interquartile range, IQR) of 60 (50 - 68) and 26 (12 - 40), respectively (p < 0.001). Out of 402 respondents, only 34 (8.4%) scored 50% and above, and were considered to have adequate knowledge on methods of contraception. Knowledge on contraception was significantly related to various characteristics of the students. Conclusion: The present study showed that KMC-25 is a reliable and valid instrument to assess university students’ knowledge on methods of contraception. However, university students from non-medical related programs have poor knowledge and this warrants the implementation of educational programs.
Background: Medication review is emerging as one of the vital components of medication management to prevent medicine-related problems. Study demonstrated a high prevalence of potentially inappropriate medication use in private aged care facilities. There is a strong need for medication review in the private healthcare system in Malaysia to ensure pharmaceutical safety and effectiveness. This study aimed to determine the knowledge, attitude and practice of private hospital pharmacists on medication review service in Malaysia. Method: This cross-sectional study was carried out from October to November 2020 using an online questionnaire. Private hospital pharmacists in Malaysia were invited to participate in a validated 36-items questionnaire. Descriptive statistics, Mann-Whitney U test and Kruskal-Wallis H test were performed to analyse the data. Results: Survey questionnaires were completed by 104 private hospital pharmacists. 80 pharmacists (76.9%) presented with a high level of knowledge of medication review, while 92 pharmacists (88.5%) had a positive attitude. Approximately two-third (n = 68, 65.4%) was providing medication review in the pharmacy, whereas 45 of them (43.3%) did not obtain patient’s medication history at the time of admission or as early as possible. Besides, only 69 of the participants (66.3%) reconciled patient’s own medication with the prescribed medicines. Factors associated significantly with practice of medication review include age (p = 0.010) and years of experience as a private hospital pharmacist (p = 0.016). Three major perceived challenges of implementing medication review were lack of time (82.7%), insufficient training (79.8%) and lack of manpower (60.6%). Conclusion: In conclusion, private hospital pharmacists in Malaysia have high level of knowledge, a positive attitude and a fair practice regarding medication review service. Several challenges such as lack of time, insufficient training and lack of manpower might obstruct the practice of medication review service in the private hospitals.
Use of Alirocumab for the Secondary Prevention of Cardiovascular Disease in a Patient with End-stage Renal Disease on hemodialysis
Introduction: Cardiovascular diseases (CVDs) are quite prevalent globally, with atherosclerotic being a predominant CVD in Asia. Well-controlled low-density lipoprotein cholesterol (LDL-C) level is crucial in both primary and secondary prevention of these conditions, particularly in patients with chronic kidney disease (CKD). Lipid management in this setting is a major concern for physicians and patients. Here, we report the case of a man with previous hypertension, type 2 diabetes mellitus, dyslipidemia, peripheral artery disease, CKD, heart failure, and coronary artery disease post multiple stent implantations. He was initiated on rosuvastatin treatment, during which he developed rhabdomyolysis, and subsequently received regular hemodialysis. Since the patient was at a very high risk of cardiovascular events and adverse drug reactions, treatment with alirocumab (a proprotein convertase subtilisin / kexin type 9 inhibitor) was initiated for further controlling LDL-C level. Although there is a lack of evidence on the use of alirocumab in patients on hemodialysis, the drug demonstrated a favorable efficacy and safety profile in our patient.
Introduction: Antibiotic resistance is increasing worldwide. The prevalence of bacterial resistance varies in different geographical areas, and it was correlated with the utilisation of antibiotics in the general population. Objective: This study was conducted to assess public knowledge and attitudes towards antibiotic usage in Perlis, Malaysia. Method: A validated self-administered questionnaire survey was distributed among the public in three main parliament areas of Perlis using the quota sampling method from August to October 2017. The questionnaire from a previous study by Lim et al. was used and the data were analysed using SPSS version 20.0. Result: About half of the respondents (51%) were found to have good knowledge (score ≥6 out of 12), and 45.1% have a good attitude (score ≥6 out of 8). The mean knowledge score was 5.0±2.19 and the mean attitude score was 5.6±3.00. As for knowledge, most respondents still perceived those antibiotics would work on viral infections in the common cold and cough. In terms of attitude, almost three-quarters of the study population (74%) expected antibiotics to treat cough and cold while two-thirds of the respondents (65.1%) expected that taking antibiotics would improve recovery. Half of the respondents (53.6%) will stop taking antibiotics when they start feeling better. Age, education level, and employment sector were found to be significantly associated with knowledge and attitude. There was a positive correlation (r=0.581) between knowledge and attitude scores. Conclusion: This study has identified people with better knowledge would have an appropriate attitude regarding the use of antibiotics. Hence, educational programmes targeting the young generation and public who do not work in the healthcare field are significant to promote the appropriate utilisation of antibiotics among the public in Perlis.
Stability Study of an Extemporaneous Isoniazid Oral Suspension Prepared using Commercially Available Tablets with X-Temp® Oral Suspension System
Isoniazid (INH) is a hydrazine derivative that is routinely used for the treatment of pulmonary and extrapulmonary tuberculosis. It is used with other anti-tuberculosis drugs usually in regimes including rifampicin, ethambutol, and pyrazinamide. As there is no access to commercial oral solution in Malaysia, there is a requirement to prepare this product by extemporaneous compounding. This study is initiated to identify an easy-to-prepare formulation for compounding and to select product storage condition and establish beyond-use date. INH tablets were used to mix into X-Temp® Oral Suspension System to compound the 10 mg per mL and 40 mg per mL solution. For the stability studies, the finished products were packed into amber HDPE bottles and stored at refrigeration (5°C ± 3°C) or room temperature (30°C ± 2°C) for up to 90 days. The samples were evaluated by visual inspection, pH measurement, high-performance liquid chromatography (HPLC) assay at predetermined testing intervals for 90 days. The samples were submitted for microbiology testing at each time point. An HPLC method validation was also carried out to ensure that the system provides accurate, precise and reliable analytical data. The results showed that INH suspension at concentration of 10mg/mL and 40mg/mL remained unchanged in physical, chemical and microbiological evaluations for up to 90 days. The HPLC results demonstrated that all the samples retained the drug concentration within the specification. It could be suggested that INH tablet can be extemporaneously compounded in X-Temp® Oral Suspension System at a concentration of between 10mg/mL to 40mg/mL with the resulting product stable for up to 90 days when packed in HDPE bottles and stored at either refrigeration or room temperature.