ncd drugs & immnunisation
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NCD DRUGS &
IMMUNIZATION
ANITHA D.NPHARMACIST
PHC KADAMANITTA
• It is a disease which is not infectious. Such
diseases may result from genetic or lifestyle
factors.
• A non-communicable disease is an illness that is
caused by something other than a pathogen.
• The non-communicable diseases are spread by:
heredity, surroundings and behavior.
NON COMMUNICABLE DISEASE (NCD)
• Hereditary Factors
• Improper diet
• Smoking
• Other Factors
CAUSES
Hypertension
Diabetes
Cardio Vascular Disease
Cancer
Asthma
Atherosclerosis
EXAMPLES
HypertensionThe Silent killer
Force exerted by circulating blood on the arterial walls
Maximum (systolic) pressure – pressure in the artery when
the left ventricle is contracting to force the blood into
aorta and other arteries. It is 120mm Hg
Minimum (diastolic) pressure – The left ventricle & arterial
BP decreases as blood returns to the right atria & ventricle
of the heart from the venous system. It is 80mm Hg.
The normal blood pressure is 120/80.
BLOOD PRESSURE
Hypertension is high blood pressure. Blood
pressure is the force of blood pushing
against the walls of arteries as it flows
through them.
HYPERTENSION -DEFINITION
Essential (Primary) Hypertension
Secondary Hypertension
Pseudo Hypertension
White coat Hypertension
HYPERTENSION-TYPES
No medical cause
Risk factors :
Sedentary lifestyle
Obesity ( body mass index greater than
25)
Salt ( sodium) sensitivity
Alcohol, smoking
Family history
ESSENTIAL OR PRIMARY HYPERTENSION
Chronic Kidney Diseases.
Chronic Steroid Therapy & Cushing’s Syndrome.
Drug-Induced or drug related
Pheochromocytoma
Thyroid or parathyroid Disease.
Sleep Apnea.
SECONDARY HYPERTENSION
When BP measured by cuff is falsely
elevated compared to reference standard
because of hardened calcific arterial walls.
PSEUDO HYPERTENSION
BP recording in office or clinic is high while at
home is normotensive
"white coat" hypertension appear to have no greater
risk than people with normal blood pressure
WHITECOAT HYPERTENSION
1. LIFE STYLE MODIFICATION
a) Weight reduction
b) Dietary Approach
c) Dietary Sodium restriction.
d) Moderate Alcohol consumption
e) Physical activity
MANAGEMENT
MANAGEMENT
DASHdiet
Regular exercise
Loose weight , if obese
Reduce salt and high fat diets
Avoid alcohol consumption
A. FIRST LINE AGENTS
Angiotensin converting Enzyme
Inhibitors(ACEIs)
Angiotensin Receptor Blockers(ARBs)
Calcium channel Blockers(CCBs)
Thiazide Diuretics
B. SECOND LINE AGENTS
B-Blockers
Aldosterone Antagonists
PHARMACO THERAPY
ACE stands for angiotensin converting enzyme
Used to treat high BP
40% of the dose is excreted in urine
Onset of action- 1 hour
Peak- 4-6 hours
Duration of action-atleast 24 hours
Dosage-
Initial dose- 2.5mg to 5mg/day
ACE INHIBITORSENALAPRIL MALEATE
Maintenance dose- 10mg to 40mg/day in single or
divided doses
Maximum dose- 40mg/day
Administration- with or without meals. Administer
with food if GI upset occurs.
Storage- at room temperature, away from moisture
and heat.
Pregnancy- do not use
ENALAPRIL (CONTD)
POINTS TO REMEMBER
Regular BP check up
Kidney & liver function test may be needed
Very low BP with this medication may be
associated with vomiting, diarrhea or sweating
more than usual
If surgery is required stop the medicine for a short
time
Contraindicated in angioedema
ENALAPRIL (CONTD)
Avoid drinking alcohol
Do not use potassium suplements
Avoid getting up quicky from a sitting or lying
position. Get up slowly & steadily to prevent fall.
DRUG FOOD INTERACTION
Enalapril + Alcohol – increases hypotensive effect
thereby lowers BP
ENALAPRIL (CONTD)
DRUG DRUG INTERACTIONS
Enalapril + Indomethacin- decreases hypotensive
effect of enalapril. Avoid the combination.
Enalapril+ losartan/telmisartan/olmesartan-
Increases risk of hypotension, renal impairment &
hyperkalaemia
Enalapril + Aspirin- The anti hypertensive efficacy
of enalapril may be reduced by high dose of aspirin.
ENALAPRIL (CONTD)
Enalapril + Trimethoprim- serious hyperkalemia in
association with renal impairment.
Enalapril + NSAIDs- increase BP, increase risk of renal
impairment & hyperkalemia
Enalapril + rifampicin- increase in BP.
DRUG DISEASE INTERACTIONS-
Enalapril—Renal diseaseEnalapril – Liver diseaseEnalapril – strokeEnalapril – congestive heart failure
ENALAPRIL (CONTD)
It belongs to a group of drugs called angiotensin II receptor antagonists.
DOSAGE FORM
Initial Dose : 50 mg orally once a day.
Maintenance Dose: 25mg to 100mg orally in 1 to 2 divided doses
Max dose:-100mg/day
ROUTE OF ADMINISTARTION: Oral
USES
Losartan is used to treat high blood pressure.
It is used to lower the risk of stroke in certain people with heart disease.
It is used to slow long-term kidney damage in people with type 2 diabetes who
also have high BP.
ANGIOTENSIN II RECEPTOR ANTAGONISTS
LOSARTAN
USES
Losartan is used to treat high blood pressure.
It is used to lower the risk of stroke in certain
people with heart disease.
It is used to slow long-term kidney damage
in people with type 2 diabetes who also have
high BP.
LOSARTAN(CONTD)
SPECIAL DIRECTIONS & PRECAUTIONS
Can be taken with or without food.
Monitor BP regularly
Avoid alcohol : Drinking alcohol lowers BP & increases
side effects of Losartan.
Do not use potassium supplements or salt substitutes.
Avoiding getting up too fast from sitting or lying position.
Do not use in pregnancy & Lactation.
LOSARTAN CONTD…
DRUGS-DISEASE INTERACTION
LOSARTAN DEHYDRATION,HYPONATRENIA,HEMODIALYSIS
It should be used cautiously in patients on diuretics
therapy, those on dietary salt restriction, renal dialysis.
Risk for excessive hypotension.
Losartan-Congestive Heart Failure
Can cause renal impairment 0liguria Myocardia ischemia Death
LOSARTAN CONTD…
Losartan + Diltiazem : Causes low BP, Kidney function
impairment & hyperkalemia (High blood Potassium)
Losartan + Enalapril: Low BP, Kidney function impairment
& hyperkalemia .
Losartan+ChlorpheniramineMaleate/Codeine/
Phenylephrine /Potasium Iodide
Combining these medication may significantly increase potassium levels in the blood. High levels of potassium can develop into condition known as hyperkalemia. This lead to kidney failure, muscle paralysis, irregular heart rhythm & cardiac arrest.
LOSARTAN CONTD…
Limit consumption of potassium –rich foods such as
tomatoes, potatoes, bananas, plantains , Papayas,
Pears, mangoes & potassium containing salt
substitutes.
Symptoms of Hyperkalemia
1. Nausea, Vomiting
2. Tingling of hands & feet.
3. Feeling of heaviness in the legs.
4. Weak pulse
5. irregular heart beat.
LOSARTAN CONTD…
Losartan + Codaine
Additive effect in lowering Blood Pressure
Side Effects
Headache
Dizziness
Light headedness
Fainting
changes in pulse or heart rate.
Avoid driving or operating hazardous machinery.
LOSARTAN CONTD…
Losartan + Amlodipine - May increase potassium
levels in the blood. Hyper kalemia.
Losatan + NSAID (Ibuprofen) – Increase the risk of
renal impairement & hyperkalemia.
Losatan + Indomethacin –May attenuate anti
hypertensive effect of Losartan.
Losatan +Fluconazole –Reduces the conversion of
losartan to it’s active metabolite.
LOSARTAN CONTD…
Losartan + Rifampicin- Increases the metabolism of
losartan and its active metabolite which may result in
reduced anti-HT effects.
Losartan + Levodopa –Enhanced Hypertensive effect.
Losartan + Aspirin –Aspirin in doses over 300mg daily
increases risk of renal impairment.
DRUG-FOOD INTERACTION Losartan +Alcohol – Increases Hypotensive effect.
So, there is chance for low BP.Losartan + Pottasium Salts- Increased risk of
Hyperkalaemia
LOSARTAN CONTD…
ACTION- amlodipine relaxes (widens) blood
vessels & improve blood flow.
Uses- Hypertension, chest pain (angina), other
conditions caused by coronary artery disease.
Dosage-
Initial dose – 2.5mg – 5mg orally once a day
Maintenance dose- 5mg – 10mg orally once a day
CALCIUM CHANNEL BLOCKERSAMLODIPINE
Pregnancy- not recommended.Breast feeding- not recommended.Storage- at room temperature, away from moisture,
heat & light.Administration- with or without food
POINTS TO REMEMBER
Do not stop beta blockers too quickly because serious
heart problems may be caused that cannot be
prevented by amlodipine.
AMLODIPINE (CONTD)
Use with caution in heart valve problem, CHF, Liver
diseases Get up slowly & steadily.
DRUG FOOD INTERACTION
Amlodipine + Alcohol- may lower BP & may increase
side effects of amlodipine.DRUG DISEASE INTERACTION
Amlodipine-Cardiogenic Shock/Hypotension- should not be used in patients with hypotension (Systolic Pressure less than 90mm Hg).It further depresses cardiac output & BP.
AMLODIPINE (CONTD)
DRUG DRUG INTERACTIONS
Amlodipine + Aspirin –May increase BP .If already taking
the combination & if aspirin is stopped BP may decrease.
Amlodipine +Calcium Carbonate- Decreases the effect
of Amlodipine.
Amlodipine+ Metoprolol- Additive effect in lowering BP &
Heart rate.
Amlodipine+ Ibuprofen- May increase BP.
Amlodipine+Chlorpheniramine/Codeine-Additive
effect,Lowers BP.
AMLODIPINE (CONTD)
Amlodipine+MVT with minerals-can decrease effects of
Amlodipine.
Amlodipine+ Diclofenac –may increase BP.
Amlodipine + Pheno- Pheno reduce blood levels and effect of
amlodipine.
Amlodipine+ Rifampicin/INH – lowers effect of amlodipine.
Amlodipine +Clarithromycin – may increase blood levels of
amlodipine. Serious side effects like irregular heart beat,
swelling fluid retention & heart failure.
AMLODIPINE (CONTD)
It is a class of drug called beta blockers.
ACTION : Relaxing blood vessels & slowing heart rate to
improve blood flow & decrease blood pressure.
USES : To Treat high Blood Pressure, Migraine headache ,
Heart failure & prevent heart attack.
DIETARY INSTRUCTIONS : Take low salt or low sodium
diet.
STORAGE: Store at room temperature away from excess
heat & moisture
ATENOLOL
ADMINISTRATION:
Take with a full glass of water.
Take atenolol at the same time every day.
DOSAGE :Initial dose: 50 mg orally once a day. The full effect
of this dose will usually be seen within 1 to 2 weeks. If an
optimal response is not achieved, the dosage should be
increased to 100 mg orally once a day.
Max dose- 100mg/day
DRUG FOOD INTERACTION :
Atenolol+ Alcohol = Decreases the anti-Hypertension
effect.
ATENOLOL
√ Atenolol + Orange Juice = The bio availability of atenolol is moderately
reduced by orange juice.
DRUG DRUG INTERACTION
Atenolol + Diclofenac = Diclofenac reduce the effects of atenolol
in lowering BP especially if diclofenac is used regularly to treat
arthritis.
Atenolol + Antacids/Anti diarrheal = Reduce the
absorption of atenolol.
Atenolol +NSAIDS= Increase blood pressure.
Atenolol + Indomethacin= Indomethacin reduces the anti-
Hypertension effect of atenolol.
Atenolol + Nifedipine = severe hypotension & heart
failure.
ATENOLOL
IMMUNISATION
DIABETES MELLITUS
Insulin is like a key which opens the
body cell doors to allow glucose to enter.
In the absence of enough insulin, glucose
cannot enter the cells and remains in the blood
stream in high amounts (hyperglycemia)
High blood sugar due to defective or deficient
insulin action and the resulting associated
problem is called diabetes.
Cells in the body needs glucose (sugar) for
making energy required for daily life.
The food we eat turns into glucose after
digestion .
What is Diabetes?
Diabetes mellitus is a condition in which glucose
level in the blood are much higher than normal and
hence this condition is also commonly referred to as
sugar disease.
The defect in this condition is that either the
pancreas does not produce enough insulin or it
produces sufficient insulin, but the cells of the body
are unable to use the insulin properly.
DIABETES MELLITUS
Who are prone ...?
Thirst
Polyuria
Blurring of vision
Weight loss.
DIABETES MELLITUS-SYMPTOMS
The long–term effects of diabetes mellitus include
progressive development of the specific complications of
retinopathy with potential blindness, nephropathy that
may lead to renal failure, and/or neuropathy with risk of
foot ulcers, amputation, Charcot joints, and features of
autonomic dysfunction, including sexual dysfunction.
People with diabetes are at increased risk of
cardiovascular, peripheral vascular and cerebrovascular
disease.
Diabetes Long-term Effects
Type 1 diabetes
Type 2 diabetes
Gestational diabetes
Other types of Diabetes
LADA (latent autoimmune diabetes)
MODY (maturity-onset diabetes of youth)
Secondary Diabetes Mellitus
Classification of Diabetes
Was previously called insulin-dependent diabetes
mellitus (IDDM) or juvenile-onset diabetes.
Risk factors for type 1 diabetes may include
autoimmune, genetic and environmental factors.
TYPE I DIABETES
Was previously called non-insulin-dependent diabetes
mellitus (NIDDM) or adult-onset diabetes.
It usually begins as insulin resistance, a disorder in
which the cells do not use insulin properly. As the need
for insulin rises, the pancreas gradually loses its ability
to produce insulin.
Type 2 diabetes is associated with older age, obesity,
family history of diabetes, history of gestational
diabetes, impaired glucose metabolism, physical
inactivity, and race/ethnicity.
TYPE II DIABETES
A form of glucose intolerance that is diagnosed in
some women during pregnancy.
During pregnancy, gestational diabetes requires
treatment to normalize maternal blood glucose
levels to avoid complications in the infant.
GESTATIONAL DIABETES
Patients usually aged >25 years
Initial control achieved with diet alone a diet &
oral hypoglycemic agents.
Insulin dependency occurs within months but can
take 10 yrs or more.
LADA
Mutations in any one of several transcription factors
or in the enzyme glucokinase lead to insufficient
insulin release from pancreatic ß-cells, causing
MODY.
FEATURES
Young onset of diabetes
Strong family history diabetes.
Sulfonylurea sensitivity
MODY
Within MODY, the different subtypes can essentially be
divided into 2 distinct groups: glucokinase MODY and
transcription factor MODY
Glucokinase MODY requires no treatment, while
transcription factor MODY requires low-dose
sulfonylurea therapy
MODY ( CONTD)
causes of Diabetes mellitus include:
Acromegaly,
Cushing syndrome,
Thyrotoxicosis,
Pheochromocytoma
Chronic pancreatitis,
Cancer
SECONDARY DIABETES MELLITUS
o DIET
o EXERCISE
o YOGA
o MEDICATION
o INSULIN
o ORAL ANTIDIABETICS
DIABETES MELLITUS - MANAGEMENT
Patients should be educated to practice self-care. This allows the
patient to assume responsibility and control of his / her own
diabetes management. Self-care should include:
Blood glucose monitoring
Body weight monitoring
Foot-care
Personal hygiene
Healthy lifestyle/diet or physical activity
Identify targets for control
Stop smoking
SELF CARE
Dosage Form : Tablet Dose :
Initial dose: 2.5 mg to 5mg tablet once daily.
Usual Single dose: 2.5mg to 10mg.
MAXIMUM DOSE: 20 MG/DAY
A single dose of 10mg tablet must not be exceeded. Larger daily
doses must be divided into at least two separate single doses.
Usual daily dose : 5mg to 10mg
Exceeding a total daily dose of 15mg (3tablets) is not
recommended, because high doses of up to 4 tablets are more
effective in exceptional cases.
GLIBENCLAMIDE
Route of administration : Oral
Duration of action : Usually long-term therapy.Uses : Type 2 Diabetes
Indications : Non insulin dependent Type 2 diabetes
mellitus .Whenever blood glucose levels cannot be controlled
adequately by diet, Physical exercise & weight reduction alone.
It can be given together with insulin & can be combined with
other oral antidiabics.
Uses: Action: Glibenclamide lowers the blood glucose by
stimulating the release of insulin from the pancreas, an effect
dependent upon functioning beta cells.
GLIBENCLAMIDE (CONTD)
Other mechanism include reduction of basal hepate glucose production and enhancement of peripheral insulin action at post-receptor sites.
Glibenclamide has a mild diuretic action & increase free water clearence.
Glibenclamide is nearly completely absorbed after oral administration & it is extensively bound 99%to serum proteins.
Peak concentration is reached in 2-6 hrs. Glibenclamide is completely metabolized in the liver. It is excreted as metabolites in bile & urine.
Special direction & Precautions: Daonil is to be taken before food. Do not skip
meals after the tablets have been taken. Correction of dosage must be considered
GLIBENCLAMIDE (CONTD)
Contradictions
Patients with Type I IDDM
Treatment of Diabetic Ketoacidosis.
Serious renal dysfunction.
Serious hepatic dysfunction.
Pregnant women.
Breast feeding woman.
Patients hypersensitive to Glibenclamide.
GLIBENCLAMIDE (CONTD)
Precautions Patients should be made aware of hypoglycemic &
Hyperglycemic symptoms.
Hyperglycemic Symptoms Increased urinary frequencyIntensive thirstDryness of mouth & dry skin
Hypoglycemic Symptoms Intensehunger,Nausea,Vomiting,Sweating,Tremor,Restles
sness,Speech disorder, Headaches, Loss of self –control, Loss of consciousness up to & including coma, shallow respiration & bradycardia.
GLIBENCLAMIDE (CONTD)
Regular monitoring of glucose levels in blood & urine.
Hypoglycemia can be corrected by immediate intake of carbohydrates. Eg: Glucose, Sugar, Tea, Fruit, Juice.
Patient must carry minimum 20gms of glucose with them all times.
Contradictions1) Hemolytic anemia: Treatment of patients with
Glucose-6-Phosphate dehydrogenize (G6PD) deficiency with sulphonyl urea can lead to hemolytic anemia.
2) Pregnancy : must not be taken3) Lactation : Must not be taken
GLIBENCLAMIDE (cont)
DRUG INTERACTIONS-
DRUG DRUG INTERACTIONS-
Glibenclamide+Ciprofloxacin-increases the hypoglycemic
effect of glibenclamide
Glibenclamide+NSAIDs- increases the hypoglycemic effect
Glibenclamide + fluconazole- increases serum levels of
glibenclamide
Glibenclamide + thyroid agents- decrease hypoglycemic
effect
GLIBENCLAMIDE (cont) DAONIL
Glibenclamide+ Phenytoin- decrease hypoglycemic
effect of glibenclamide
Glibenclamide + INH/ Rifampicin- Decrease
hypoglycemic effect
Glibenclamide + salicylates- increases the
hypoglycemic effect
Glibenclamide + oestrogens-decrease hypoglycemic
effect
Glibenclamide + bosentan- may increase
hepatotoxic effect of bosentan
GLIBENCLAMIDE (C ONTD)
DRUG FOOD INTERACTION
Glibenclamide + Alcohol- May cause disulfuram
like reactions
DRUG DISEASE INTERACTION
Glibenclamide- renal dysfunction
Glibenclamide- hepatic dysfunction
GLIBENCLAMIDE(CONTD)
It was discovered in Japan in 1981. It is an alpha-
glucosidase inhibitor.
Action- Voglibose delays the absorption as well as
digestion of dietary polysacharides by reversibly
inhibiting carbohydrate digestive enzyme like sucrose,
maltose etc.
It has additive effect with sulphonylurea
It diminishes weight increasing effects of
sulphonylurea
VOGLIBOSE
USES- In NIDDM patients as immunotherapy In combination with other OHAs In addition to insulin in DM patients
DOSAGE-
Maximum dosage- 0.6mg/day
Initial dosage- 0.2-0.3mg bd
ADMINISTRATION- before meals
VOGLIBOSE(CONTD)
CONTRAINDICATIONS-
Hypersensitivity to the drug
Diabetic ketoacidosis
Inflammatory bowel disease, chronic ulceration,
intestinal obstructions
Disorders of digestion or absorption
PREGNANCY/LACTATION- not to be used
STORAGE- store below 30 c
VOGLIBOSE(CONTD)
ACTION-Metformin works by suppressing glucose
production in the liver.
DOSAGE-
Initial dose- 500mg orally twice a day
Extended release- 500-2000mg/day
Maximum dose- 2500mg/day
USES-Type II diabetes, polycystic ovary syndrome
PREGNANCY/LACTATION- not to be used
METFORMIN
POINTS TO REMEMBER-
Should not be given to children younger than 10 yrs old
Extended release metformin should not be given to
children younger than 17 yrs old
In case of x-ray or CT scan using a dye, temporarily
stop metformin
ADMINISTRATION- with food
METFORMIN( CONTD)
It is an oral antidiabetic drug in the biguanide class
It works by suppressing the glucose production by liver
Drug of choice in the treatment of type 2 diabetes
Only antidiabetic drug shown to prevent cardiovascular
complictions of diabetes
Helps to reduce LDL cholesterol & triglyceride level
French physician Jean Sterne published first clinical trial of
metformin as a treatment for diabetes in 1957. He coined
the word “Glucophage”
METFORMIN
Chemical name: N,N-Dimethyl
imidodicarbonimidic diamide
As of 2010, metformin is one of the only
two oral antidiabetics in the WHO’s list of
essential medicines, the other one is
glibenclamide
METFORMIN
Metformin + metoprolol: cause hypoglycemia
Metformin + Lasix: increase the effect of metformin
which may lead to a condition called lactic acidosis
Metformin + levothyroxine: levothyroxine may interfere
with blood glucose control & reduce the effect of metformin
Metformin + cimetidine: increases plasma concentration
of metformin, thereby reducing clearance of metformin by
kidneys.
METFORMIN DRUG DRUG INTERACTION
Alcohol + metformin: may cause a
condition called lactic acidosis (serious
metabolic complication associated with
metformin accumulation in plasma usually at
levels exceeding 5mcg/ml)
symptoms-increasing sleep, weakness, slow
heart rate, stomach pain, shortness of breath
METFORMIN -ALCOHOL/FOOD INTERACTION
1. LACTIC ACIDOSIS: metformin is contraindicated
in patients with renal dysfunction. metformin
should not be administered to patients with
acute or chronic metabolic acidosis.
2. Metformin—B12 deficiency: Metformin may
interfere with vitamin B12 absorption
METFORMIN –DISEASE INTERACTION
It is a long acting sulfonylurea antidiabetic drug
Used to treat type 2 diabetes mellites
Mode of action: increase insulin production by pancreas
( It is not used in type 1 diabetes because in type 1
diabetes the pancreas is not able to produce insulin)
GLIMEPIRIDE
MAJOR INTERACTION
GLIMEPIRIDE + GATIFLOXACIN: Gatifloxacin can
affect blood glucose levels. Both hyper &
Hypoglycemia have been reported. Severe cases of
hypoglycemia during treatment with gatifloxacin has
resulted in coma & even death
GLIMEPIRIDE DRUG-DRUG INTERACTION
MODERATE INTERACTION
Glimepiride + hydrocortisone/methyl
prednisolone/ dexamethasone/ ethinyl
estradiol/ hydrochlorthiazide/
amitryptyllin/phenobarbital/ theophylline /INH/
levothyroxine: may interfere with blood glucose
level control & reduce effectiveness of glimepiride Glimepiride + aspirin/ ibuprofen/ amoxicillin/
clarithromycin: increase effects of glimepiride & cause blood sugar levels to get too low
GLIMEPIRIDE (CONTD)
Glimepiride + aluminium hydroxide/magnesium carbonate: increase the effects of glimepiride. Should be administered at least two hrs. before or after magnesium carbonate
Glimepiride + ethanol: avoid alcohol. Both hyper & hypoglycemia may occur
Glimepiride + ampicillin/atenolol/diclofenac/ranitidine/escitalopram/ fluconazole/metoprolol: increase effects of glimepiride & may cause hypoglycemia
DISEASE INTERACTION
RENAL/LIVER DISEASE
GLIMEPIRIDE
VISION WITHOUT ACTION IS A
DREAM. ACTION WITHOUT
VISION IS SIMPLY PASSING
THE TIME. ACTION WITH
VISION IS MAKING A
POSITIVE DIFFERENCE.