Publications

Price Variation Among Registered Brands of Anti-Cancer Medicines Available in Pakistan

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    Abstract

    The current study aims to explore the number of registered anticancer medicine in Pakistan and the price variation of these single-ingredient medicines. A data-based study was conducted between March 2021 and May 2021. Pharmaguide (Mobile Version 2020 – 2021), Druginfosys.com and Medicialstore.com.pk were used to derive the price of anticancer medications sold in Pakistan. The difference in minimum and maximum costs of each formulation was calculated, and the price variations in 81 anticancer medicines belonging to 14 different categories were analysed. There were 115 formulations registered for these 81 anticancer medications. Estimations in price difference revealed that topotecan (4mg / ml) had the highest price variation, while the lowest price variation of 4.01% was observed for abiraterone acetate (250mg). Price variations among different anti-cancer brands marketed in Pakistan are noticeable and substantial, therefore necessitating action from the drug regulatory authority of Pakistan, not only to gain awareness on this issue, but also to set pricing thresholds to make the prices of anti-cancer medications more affordable. In addition, external reference pricing and reimbursement programs partially sponsored by the government or insurance companies can be a possible way to control the price variation of anti-cancer drugs.

    Beware of Triple Whammy

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      Abstract

      The term “triple whammy” refers to a drug interaction following the concurrent use of angiotensin-converting enzyme inhibitors or angiotensin-II receptor blockers, diuretics and non-steroidal anti-inflammatory drugs, the combination of which greatly increases the odds of acute kidney injury. Here, we report a case of a 66-year-old gentleman who was admitted into a tertiary care hospital for elective orthopaedic intervention. He had previously been prescribed sacubitril/valsartan and frusemide and had newly been started on celecoxib during hospitalisation. Upon the initiation of celecoxib, a mild increase in his serum creatinine was immediately observed, and this occurrence is believed to be due to the “triple whammy” combination. The combination of perindopril, frusemide and celecoxib continued to be overlooked throughout his hospitalisation. He was subsequently planned to be discharged with celecoxib on top of his existing chronic medications. However, upon discharge, the dispensing pharmacist took notice of the drug interaction and successfully intervened to withhold celecoxib.

      Hyperlipidemia Post Initiation of Nilotinib among Chronic Myeloid Leukemia Patients in a Tertiary Hospital of Malaysia

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        Abstract

        Introduction: Nilotinib is effective in patients with chronic myeloid leukemia (CML), but is also associated with hyperlipidemia, which can be a risk factor for atherosclerotic vascular events. Objective: To determine the completeness in monitoring the fasting lipid profile (FLP), changes in lipid levels before and after the initiation of nilotinib, and changes in lipid levels after statin therapy. Method: This was a retrospective cohort study that included all patients with CML in the chronic or accelerated phase, who were receiving follow up under the haematology clinic of a regional referral hospital in the state of Perak, Malaysia. Patients who had been prescribed nilotinib from the beginning of January 2010 to June 2020 were included in the study, including patients who were still on treatment as well as those who, despite having their treatment discontinued during the observation period, still followed up in the clinic. The monitoring of FLP was defined as either “complete” (with both pre-initiation and post-initiation FLP available); or “incomplete” (with either one of pre-initiation or post-initiation FLP available); or “not ordered”. An LDL level of ≥ 2.6 mmol / L was considered suboptimal. Since the changes in FLP parameters were found to not be normally distributed, the data were evaluated using the Wilcoxon test, whereby a two-tailed p-value of P < 0.05 was considered statistically significant. Result: 61 patients who met the inclusion criteria were included. The FLP test was not ordered in 16 patients, incomplete in 33 patients and complete in 11 patients (18%). Patients who had completed the test displayed a significant increase in median HDL, LDL, and total cholesterol level from 1.27 to 1.46 mmol / L (p = 0.009), 2.10 to 3.30 mmol / L (p = 0.003) and 3.90 to 5.33 mmol / L (p = 0.005) respectively after the initiation of nilotinib. Statin was prescribed to 6 patients with a baseline mean LDL of 4.77 mmol / L, whereby the mean LDL was significantly reduced by 1.82 mmol / L (p = 0.003) after treatment. Conclusion: Patients experienced a significant increase in total cholesterol and LDL levels with nilotinib. Treatment with statin has elicited a significant reduction in LDL. Only a small proportion of patients received complete FLP monitoring, which warrants attention from the health authority.

        Medication Administration via Enteral Feeding Tubes: A Survey of Nurses’ Knowledge and Practice

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          Abstract

          Introduction: Enteral feeding is a type of nutritional support for critically ill patients who are unable to tolerate oral feeding. It is vital to ensure that nurses practise proper administration techniques via enteral feeding tubes (EFT) to ensure that medications can be delivered safely and effectively. Objective: This study aims to assess the knowledge and practice of nurses on medication administration through EFT. The association between demographics and knowledge was also explored. Method: This study is a cross-sectional, self-administered, content-validated, pre-tested questionnaire survey involving all nurses who worked in the ward setting at Hospital Queen Elizabeth II from August to December 2020. Result: A total of 409 questionnaires were sent out with 252 responses received. The majority of respondents were female (n = 240, 95.6%) with a median working experience of 84 months (interquartile range of 44 months). Most nurses knew that the immediate-release dosage forms (n = 237, 94.4%) may be crushed and administered through EFT. Similarly, most nurses were aware that sublingual nitroglycerin (GTN) tablets should not be crushed (n = 232, 92.8%) and that nystatin suspension should not be administered via EFT (n = 212, 85.1%). However, about half of the nurses responded incorrectly when questioned about the particulars of EFT involving the administration of sustained-release medications (n = 152, 60.6%), soft gelatin capsules (n = 111, 44.4%) and hard gelatin capsules (n = 102, 40.6%). Meanwhile, in terms of practice, a majority of the nurses would correctly routinely flush the EFT before (n = 226, 90.4%) and after (n = 245, 98.8%) the administration of medications. However, only a small proportion of nurses (n = 43, 17.3%) demonstrated the appropriate practice of administering all medications separately all the time. Furthermore, it was also worth noting that for some specific knowledge-based questions, nurses from the intensive care setting had more correct responses when compared to those from the general ward setting (p < 0.05). Conclusion: The knowledge gap and inconsistencies in practices amongst nurses related to the use of EFT may lead to suboptimal delivery of medications, whilst potentially compromising patient outcomes. Hence, continuous educational programs should be carried out to ensure safe and effective drug administration through EFT.

          Contraceptive Intention among Postpartum Women and Willingness for Pharmacist Counselling in Negeri Sembilan, Malaysia: A Cross-Sectional Study

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            Abstract

            Introduction: Postpartum woman and child health is a public health concern as closely spaced pregnancies can lead to adverse maternal and infant outcomes. However, data regarding contraceptive intention among Malaysian postpartum women is lacking. Objective: This study aimed to determine the preferred contraceptive methods among postpartum women, the barriers to contraceptive use among non-users, and the willingness to seek contraceptive counselling provided by pharmacists, besides also aiming to explore factors associated with the intention to use contraceptives. Method: This research involved a cross-sectional study among postpartum women who delivered their babies in three main hospitals in Negeri Sembilan, Malaysia. A simple random sampling method was used to recruit study participants from September 2019 to January 2020. A face and content validated questionnaire was used for data collection. Descriptive data were presented as numbers and percentages. Pearson Chi-squared test and multiple logistic regression were used for inferential analysis. Result: The response rate was 98.8%. Of the 409 respondents, 84.8% were ≤ 35 years of age, 99.5% were married, and 79.2% were of Malay descent. More than half (62.9%) preferred using modern and non-modern contraceptive methods. The main barriers to contraceptive use were not feeling like using any contraceptive method (52%) and concerns about side effects (26.7%). Spouse education level (adj OR 2.141, 95% CI 1.267 – 3.617) and experience on previous formal contraceptive counselling (adj OR 3.642, 95% CI 2.091 – 6.343) significantly influenced the intention. The majority of respondents (82.4%) were willing to get contraceptive counselling from a pharmacist. Conclusion: The majority of the Malaysian postpartum women express interest in using both modern and non-modern contraceptive methods. Pharmacists could expand their services by advising on the appropriate choice of contraceptive methods in the future.

            Impact of an Antibiotic Stewardship Program on the Use of Carbapenem in a Malaysian Tertiary Hospital (ACTION)

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              Abstract

              Introduction: The Antimicrobial Stewardship (AMS) program had been advocated to promote the rational use of antibiotic prescribing. However, the outcome of AMS in promoting the judicious use of carbapenem, and thus, minimising resistance, has not been widely studied in Malaysia. Objective: To investigate the types of interventions made by the AMS team, their acceptance, and the impact of such interventions on carbapenem consumption as well as the resistance pattern of carbapenem-resistant Enterobacterales (CRE). Method: This was a retrospective study conducted in adult medical wards of the Kuala Lumpur General Hospital (HKL), whereby data was extracted from the AMS forms of patients and subsequently reviewed by the AMS team from January to December 2016. Result and Discussion: The mean (SD) age of 169 patients included in this study was 59.2 (10.6) years. Ertapenem was the most prescribed carbapenem (44.4%), followed by meropenem (34.3%) and imipenem/cilastatin (21.3%). The study demonstrated that only 32% of carbapenem therapy had been empirically initiated, while, 68 cases (40.2%) were classified as unjustified use. Out of these cases, 39 cases (57%) were recommended to be discontinued, 25 cases (37%) were to be de-escalated and 4 cases (6%) were set for changing/escalation. The acceptance rate was reported to be around 73.5% (50 out of 68 cases). After one year of AMS implementation, carbapenem consumption (as shown by the defined daily dose/1000 inpatient bed-days) reduced by 33.7%. Similarly, a notable decrease in CRE cases (33.3%) was observed following a year of AMS initiation. Conclusion: AMS-guided interventions were able to demonstrate a reduction in carbapenem consumption as well as CRE rates in the medical wards.

              Qualitative Analysis on Interprofessional Collaboration in the Management of Paediatric Bronchial Asthma: Challenges and Suggestions for Improvement

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                Abstract

                Introduction: Multi-disciplinary healthcare providers need to move beyond task-based responsibility towards a more collaborative approach. Chronic childhood diseases such as bronchial asthma demands effective multidisciplinary team collaboration to improve patient care. Objective: We aimed to examine the interprofessional collaboration between physicians and pharmacists in the management of paediatric bronchial asthm, to explore the views and experiences of both pharmacists and physicians on the important aspects of Paediatric Respiratory Medication Therapy Adherence Clinic (PRMTAC) and patient-centeredness, and to identify barriers against interprofessional shared decision-making in the management of paediatrics bronchial asthma. Method: The study involved a face-to-face interview involving paediatric medical officers and pharmacists involved with PRMTAC. The semi-structured interview included four pharmacists and three paediatric resident physicians from Hospital Tuanku Fauziah, Perlis, Malaysia. A full audio recording was used for detailed data retrieval and verbatim transcription. The session was deemed completed once all the probed questions had reached a thematic conclusion. Result and Discussion: Three main themes emerged: (I) The relevance and necessity of PRMTAC service to complement paediatric outpatient bronchial asthma management, (II) the lack of communication between pharmacist-physician in outpatient bronchial asthma management, and (III) recommendations for a combined clinic in the management of outpatient paediatric bronchial asthma. PRMTAC services were rated as highly relevant in the management of outpatient bronchial asthma among all study respondents, irrespective of profession. The detailed assessment of medication compliance and technical demonstration provided by PRMTAC services were deemed fundamental in holistic patient care. The current clinical scenario demonstrates that the pharmacist and paediatric medical team work independently and in parallel, rather than collaboratively. Such workflow challenges in-tandem decision-making with regards to patient-focused medication. The lack of interaction also impedes sharing of ideas and new knowledge that could benefit both parties in relation to the management of outpatient bronchial asthma. A combined clinic was unanimously suggested to remedy this. Conclusion: Proper planning with regard to allocation of support systems and mobilisation of human resources needs to be instituted to realise the implementation of a nationwide combined clinic in the management of paediatric bronchial asthma.

                Baclofen Prescribing Practice and Its Appropriateness in an Outpatient Setting of a Tertiary Hospital

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                  Abstract

                  Introduction:  Reports of baclofen toxicity in patients with severe renal impairment have raised concerns regarding prescribing practice of the drug in the outpatient department. The aim of this study is to determine the incidence of inappropriate prescribing of baclofen and its prescribing pattern. Method: This was a retrospective, observational study of prescriptions from July to December 2014 in an outpatient clinic of a public hospital in Malaysia. All prescriptions containing baclofen were selected and records of these patients were retrieved and reviewed. Where available, results of serum creatinine were also collected. Appropriateness of baclofen use was determined by 3 independent doctors based on labelled indication of baclofen. Result: Out of 65,922 prescriptions screened, 691 (1.1%) prescriptions which contained baclofen and whose records could be retrieved were included in the analysis. Most of the prescriptions were for pain (78.2%) and contained at least one pain medication. Baclofen was prescribed concomitantly with NSAIDs, antihypertensives and oral hyperglycaemic agents in 535 (77.4%), 49 (7.1%) and 25 (3.6%) cases respectively. Two patients had kidney failure. The overall proportion of inappropriate use of baclofen was high (n = 641, 92.7%). Although the trend of baclofen use reduced drastically after September 2014, possibly due to stricter prescribing practices that was enforced in the department, the proportion of its inappropriate use remained high. Conclusion: Inappropriate use of baclofen is prevalent. Rigorous interventions such as trainings should be carried out to avoid future preventable overdoses or toxicities.

                  Trends in the Utilization of Psychotropic Drugs in Serdang Hospital

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                    Abstract

                    Introduction: The prevalence of mental health issues in Malaysia has tripled from 10.7 % in 1996 to 29.2 % in 2015. This was reflected by an increasing usage of psychotropic drugs over the past two decades. Thus, this study was carried out to explore the utilization trends of psychotropic drugs prescribed in Serdang Hospital. Method: This observational retrospective quantitative study was conducted using 11-year data from January 2008 to December 2018. Dispensing data was obtained using the electronic hospital information system (eHIS) in Serdang Hospital. Defined daily doses per 1000 populations per year metric (DDDs / 1000 / year) were used to compare the popularity of psychotropic classes and individual drugs. A comparison of the frequency and distribution of the drugs over time was made using Microsoft Office Excel 2013. Result: Total utilization of psychotropic drugs increased markedly by 859.2 % (from 75.9 to 727.8 DDDs / 1000 / year) from 2008 to 2018. Antidepressants were the most frequently dispensed class, with a significant increase by 1828.6 % (from 20 to 385.9 DDDs / 1000 / year). On the other hand, attention deficit hyperactivity disorder (ADHD) medication was the least dispensed class, from no usage in 2008 to 4.3 DDDs / 1000 / year in 2018. In 2018, out of 27 psychotropic drugs, sertraline (26.4 %) was the most frequently dispensed drug with 192.3 DDDs/1000/year. Conversely, clobazam (0.2 %) was the least dispensed drug with 1.2 DDDs / 1000 / year. Conclusion: Psychotropic drug utilization in Serdang Hospital increased markedly over the study period. All six classes contributed to the increment. Appropriate use of psychotropic drugs should be investigated in future.

                    Assessment of Vancomycin Pharmacokinetic Parameters among Malaysian Adult Patients in Penang with Different Kidney Functions

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                      Abstract

                      Introduction:  Vancomycin is indicated for highly resistant gram-positive systemic infections. The targeted trough and 24-hour area under the concentration-time curve (AUC24) level of vancomycin must be achieved for efficacy and safety. Local population-based pharmacokinetic parameters including the elimination rate constant (Ke), half-life (t1/2), volume of distribution (Vd) and vancomycin clearance (Clvanco) can allow better vancomycin dosing determination. Objective: This study aims to determine the pharmacokinetic parameters in the Malaysian adult patients in Penang based on different kidney functions. Method: This was a retrospective, single-centered study conducted in the Clinical Pharmacokinetics Department, Penang General Hospital from 1 January 2016 to 31 December 2017. This study included adult patients who had been treated with intravenous vancomycin under therapeutic drug monitoring. The patients’ personalised vancomycin pharmacokinetic parameters were determined using a series of pharmacokinetic equations. Result: From the recruited 26 patients, 73.1% were male and 46.2% were above 50 years old. A total of 34.6% patients had the actual body weight / ideal body weight ratio of more than 1.0. The median total daily dose was 34.72 mg / kg. The median for Cmax (peak serum concentration) was 26.0 mg /L while Cmin (trough serum concentration) was 14.20 mg / L. The median for AUC24 is 412.08 mg*hr / L. The overall median for Ke and t1/2 were 0.091 hr-1 and 7.62 hours, respectively. The median Vd was 0.90 L / kg. It was found that with increasing creatinine clearance, the Ke and Vd increased while the t1/2 decreased. Conclusion: The vancomycin pharmacokinetic data from this study varied according to different degree of creatinine clearances.