Mrs ABC is a heart failure patient who had undergone a mitral valve replacement

four years earlier. She was taking warfarin, aspirin, enalapril, frusemide &

digoxin as well as regular paracetamol for joint pain.

One morning, Mrs ABC collapsed, and seemed briefly to lose consciousness.

So, an ambulance was called. On arrival at the local emergency department, Mrs

ABC was pale, sweaty and tachycardic, with low blood pressure. Blood tests

taken at the emergency department showed that Mrs ABC had a raised INR of

8.9, and it was thought there might have been a problem with her warfarin dose.

The result of investigation showed that Mrs ABC was overwarfarinized. About 1

week ago, doctor increased her warfarin dose althought her INR was 4.9.

According to Protocol Medication Therapy Adherence Clinic (MTAC) Warfarin,

the doctor should withhold the dose for 0-2 day, decrease the dose by 10% from

the original dose & INR should be monitored within 3-8 days.

Warfarin is a narrow therapeutic drug. Therefore, there is a need for close

monitoring in warfarin treatment.

Pharmacy Bulletin

Warfarin is a commonly prescribed medicine in Hospital Alor Gajah, and it

appears in the list of high-alert medications because overanticoagulation or

underanticoagulation has important consequences. In addition, medication errors

that lead to adverse drug events may be more common with warfarin because it

has a large number of drug-drug and drug-food interactions.

Warfarin tablets that available in Hospital Alor Gajah:

Warfarin sodium tablets, USP are indicated for:

Prophylaxis and treatment of venous thrombosis and its extension, pulmonary

embolism (PE).

Prophylaxis and treatment of thromboembolic complications associated with

atrial fibrillation (AF) and/or cardiac valve replacement.

Reduction in the risk of death, recurrent myocardial infarction (MI), and

thromboembolic events such as stroke or systemic embolization after myocardial

infarction.

Volume 1/2014

Hospital Alor Gajah

Advisor:

Dr Suraidah bt

Karim

Chief Editor:

Pn Siti Mariam Bt

Md. Ali

Editor:

Lai Siew Shyuan

Contributors:

Cho Yet Tyng

Lai Siew Shyuan

Lim Wei Ching

Nur Athira bt

Hashim

In this issue:

WARFARIN

Warfarin

Insuman®

Know your

Medicine

Kursus Anjuran

Unit Farmasi

Pindaan

Formulary KKM

Pharmacy

department

news

Senario:

Narrow Therapeutic Drug — Warfarin

Dosage Forms and Strengths

Indications and Usage for Warfarin

Warfarin Initiation

Goal INRs per Indication:

Indication INR Target

1. Atrial Fibrillation

2. DVT / PE treatment & prophylaxis

3. Mechanical valve in aortic position

2-3

1. Mechanical valve in mitral position

2. “High risk” patient with mechanical valve in aortic position

3. “ High risk” patient with bioprostetic valve in the mitral position

2.5-3.5

The appropriate initial dosing of Warfarin sodium varies widely for different patients. The initial dose is

influenced by:

Clinical factors including age, race, body weight, sex, concomitant medications, and comorbidities Genetic factors (CYP2C9 and VKORC1 genotypes)

Dosing Initiation:

In patients beginning warfarin therapy, the initiation dose may start with doses between 5 to 10mg for the

first 1 or 2 days for most individuals and subsequent dosing based on the INR response.

In elderly patients or in patients who are debilitated, malnourished, have CHF, have liver disease, have had

recent major surgery, or are taking medications known to increase the sensitivity to warfarin (e.g. amioda-

rone), the starting dose should be of < 5mg with subsequent dosing based on the INR response.

Suggested algorithm for initiating warfarin (Goal INR 2-3*)

*Deviation from this algorithm may be necessary for goal INR 2.5 – 3.5.

Monitoring

Baseline PT/INR/PTTT, full blood count (FBC) with platelets and liver function test (LFT) should be

obtained prior to warfarin initiation. If baseline level not available, it should be obtained within 24 hours.

In hospitalized patients, PT monitoring is usually performed daily, starting after the second or third dose

until the target therapeutic range has been achieved and maintained for at least 2 consecutive days; then two

or three times weekly for 1 to 2 weeks; then less often, depending on the stability of INR results.

In out patients starting warfarin therapy, initial monitoring may be reduced to every few days until a stable

dose response has been achieved. When the INR response is stable, the frequency of testing can be reduced

to intervals as long as every 4-8 weeks.

Target INR 3.0 (Range 2.5 – 3.5)

* If INR 2.2 – 2.4, consider no change with repeat INR in 7-14 days.

Target INR 2.5 (Range 2.0 – 3.0)

* If INR 1.8 – 1.9, consider no change with repeat INR in 7-14 days.

** If INR 3.1 – 3.2, consider no change with repeat INR in 7-14 days.

Warfarin Dose Adjustment Guidelines

Limitations of Use:

Warfarin sodium has no direct effect on an established thrombus, nor does it reverse

ischemic tissue damage. Once a thrombus has occurred, however, the goals of anticoagulant treatment

are to prevent further extension of the formed clot and to prevent secondary thromboembolic complica-

tions that may result in serious and possibly fatal sequelae.

Prepared by: Lai Siew Shyuan References:

1)Protocol Medication Therapy Adherence Clinic Therapy: Warfarin, Bahagian

Perkhidmatan Farmasi, Kementerian Kesihatan Malaysia, 2010.

2)Warfarin. Refer at: http://www.drugs.com/pro/warfarin.html (Revised 1/2014)

Insuman® range is comprised of different formu-

lations to cover all diabetes treatment regimens

Intermediate-acting insulin (isophane insulin):

Insuman® Basal

Fast-acting insulin (regular insulin): Insuman®

Rapid

Combination of fast and intermediate-acting

insulin (biphasic isophane insulin): Insuman®

Comb 30

What is Insuman® ?

Insuman® is recombinant human insulin

(Insulin HPR) produced by r-DNA technology.

The structure and activity are identical as

compared to the semi-synthetic human insulin

products currently marketed in several

countries, but the manufacturing process of the

active ingredient differs.

Insuman® is already

in KKM contract

since 2 Jun 2014.

Jom, kenali Ubat ini...

Different types of Insuman®

Diabetese treatment regime

The most commonly reported side effects

include hypoglycemia, injection site

reactions (e.g changes in fat tissue at the

injection site) and allergic reactions

(e.g. itching and rash), and oedema

Insuman is to be injected using AllStar Pen. Different insulin is to be injected using different AllStar Pen in

order to help the patient to differentiate their insulin. (Purple colour AllStar Pen for Insuman Basal or

Comb 30 and Teal colour AllStar for Insuman Rapid (SAI))

Insuman® types & information

How to inject Insuman®

3ml cartridge

100 IU insulin human per ml

Pharmacodynamic effects:

- Onset of action: within 60 minutes

- Maximum action: between 3-4 hours

- Duration of action: 11-20 hours

Before insertion into the pen, Insuman Basal must be resuspended by gently tilting the cartridge

back and forth (at least 10 times)

Each cartridge contains 3 small metal(stainless steel) bullets for quick and thorough mixing

Once the cartridge has been inserted into the pen, the insulin must be resuspended again prior to

each injection, by gently tilting the pen back and forth at least 10 times

The fluid must have a uniformly milky appearance

3ml cartridge

100 IU insulin human per ml

Clear, colourless solution with no solid particles visible

PD effects:

- Onset of action: 30 minutes

- Maximum action: between 1-4 hours

- Duration of action: 7-9 hours

Biphasic isophane insulin suspension

- 30% dissolved insulin

- 70% crystalline protamine insulin

Appearance

- Milky-white suspension after resuspension (gently tilt back and forth at least 10 times)

Indication

- Diabetes mellitus where treatment with insulin is required

PD effects:

- Onset of action: 30-60 minutes

- Maximum action:2-4 hours

- Duration of action: 12-19 hours

Prepared by: Cho Yet Tyng

Instruction of use

Instruction of use

Besides exhibition in hospital area, we also carried

out “know your medicine” exhibition in rural area.

On 22 Jun 2014, we organized this exhibition at

Taman Kuala Permai, Kuala Sungai Baru, Melaka.

On 7 May 2014, “Know Your Medicine”

exhibition was carried out by pharmacy

department at the main lobby of Hospital Alor

Gajah. The objectives of this exhibition were:

1)To equip consumers with skills to know &

understand their medicines, &

2)To use medicines rationally.

‘Know Your medicine’ programe was organised by

ministry of Health (MOH) and Consumer Association of

Malaysia (FOMCA) to increase consumer awareness of

the rational use of medicine. It was launched by former

Health Minister YB Dato 'Chua Soi Lek at Dataran

Pahlawan Melaka Megamall, Melaka on June 2007. This

campaign is now extended to all pharmacy facilities at the

hospital, health clinic and State Enforcement Branch to

ensure the message reached the target groups.

Hospital Alor Gajah

Know Your Medicine

exhibition held at main

lobby Hospital Alor

Gajah on 7 July 2014.

Exhibition held at

Taman Kuala

Permai, Kuala

Sungai Baru, Melaka

on 22 Jun 2014.

Prepared by: Nur Athira Bt Hashim

Seramai 35 peserta telah menghadiri kursus ini. Peserta-peserta adalah terdiri daripada

Pegawai Farmasi, Penolong Pegawai Farmasi, Penolong Pegawai Perubatan, Ketua

Jururawat, Jururawat Terlatih dan Jururawat Masyarakat dari Hospital Alor Gajah dan

PKD Alor Gajah.

Objektif kursus ini adalah untuk memperkenalkan perkhidmatan Medication Therapy

Adherence Clinic (MTAC) yang terdapat di Hospital Alor Gajah (Diabetes / Asthma /

COPD / RVD /Hemodialysis) dalam memberi penekanan kepada penggunaan ubat yang

betul serta meningkatkan kepatuhan pesakit terhadap ubat-ubatan mereka.

Seminar MTAC Hospital

Alor Gajah telah dianjurkan

oleh Unit Farmasi pada

10 April 2014

Pn Suhadah bt Ahad

Prepared by: Lim Wei Ching

Have a break...

Pindaan Formulari KKM Bil 1/2014

Pindaan kategori Preskriber

Ubat yang dikeluarkan daripada FUKKM

No. Generic name Old

Category

New

Category

Reason/s for approval

1 Irbesartan 300mg / HCTZ

12.5mg Tablet

A* A/KK Enable up-titration for patients

who are already on the combi-

nation therapy.

2 Montelukast sodium 10mg

Tablet

A* A/KK It is found that there are many

poorly controlled asthma pa-

tients and these patients are be-

ing managed by FMS, hence it

would be good if this poorly

controlled asthma patients be

given Montelukast 10mg as

part of their treatment.

3 Celecoxib 200mg Capsule A* A Treatment option for manage-

ment of acute pain.

4 Simvastatin 10mg, 20mg

& 40mg

A/KK B Based on total utility scores

calculated using the designed

Medicines Scoring System,

simvastatin is considered to be

the first-line treatment of hy-

percholesterolaemia.

No. Nama Generik Sebab Alternatif

1. Lovastatin 20mg Tablet Hasil kajian Medicines Scoring System

yang dijalankan mendapati Lovastatin

mendapat total utility score (TUS) yang ren-

dah di bawah kumpulan HMG-coenzyme a

reductase inhibitor (statin). Oleh yang

demikian, ahli panel telah memutuskan un-

tuk mengeluarkan Lovastatin dari FUKKM

dan menurunkan kategori presrkiber

Simvastatin daripada A/KK ke B bagi

menggantikan Lovastatin.

Simvastatin

10mg, 20mg

& 40mg

Tablet

Pharmacy Department

Lai Siew Shyuan PF U44

Premvanan A/L Karunanithy PF U41

Frank Ong PPF U36

Marzimah bt Ramli PPF U36

Mohd Mizan Bin Mustapar Pembantu Awam H11

Mahawa Bt Meon

PPF U32

News