Wednesday, November 25, 2009

Glutamin for TPN

As respond to Lai Peng's post on TPN :
  • Glutamine : as a cellular protective effect by converting to glutathione in cell (once uptaken). Glutathione will then exhibit antioxidant effect and prevent cellular and end-organ damage.

  • Glutamine improve cellular hydration, improve anabolic effect
  • Glutamine also improve immunological function by :

  • ↑ T-cell DNA Synthesis
  • ↑ Lymphocyte Counts
  • ↑ Macrophages Phargocytosi
  • ↑ Rate to restore IgA to Normal
  • ↑ Glutathione

  • ↓ Infections rate ; ↑ Survival Rate

SUMMARY OF RESEARCH FINDINGS (click the table to view it clearer)

Fan YP, Yu JC, Kang WM et al. Effects of glutamine supplementation on patients undergoing abdominal surgery. Chin Med Sci J. 2009; 24: 55-9.

-Jiang ZM, Jang H, Furst P. The impact of glutamine dipeptides on outcome of surgical patients: systematic review of randomized controlled trials from Europe and Asia. Clinc Nutrition Supp 2004; 1:17-23

-Zheng YM, Li F, Zhang MM, et al. Glutamine dipeptide for parenteral nutrition in abdominal surgery: A meta-analysis of randomized controlled trials. World J Gastroenterol 2006; 12: 7537-41

-Song JX, Tu XH, Li CJ. Glutamine dipeptide-supplemental parenteral nutrition in patients with colorectal cancer. Clin Nutr Supp 2004; 1: 49-53.

-Mertes N, Schulzki C, Goeters C, et al. Cost containment through L-alanyl-L-glutamine supplemented total parenteral nutrition after major abdominal surgery: a prospective randomized double-blind controlled study. Clinc Nutr 2000; 19: 395-401.

-Bozzetti F, Biganzoli L, Gavazzi C, et al. Glutamine Supplementation in Cancer Patients Receiving Chemotherapy: A Double-blind Randomized Study. Nutrition 1997; 13: 748-51.

Monday, November 23, 2009

The Second Wave

Note to all Malaysians. While the first wave of swine flu origin Influenza A (H1N1) appears to be tapering off, it is too early to relax.

Time to put that face mask on.

It has been made official that the second wave of the swine flu pandemic has hit Montreal and public health authorities are responding by opening the floodgates of vaccination centres to all 5- to 19-year-olds, a group hit particularly hard by the potentially fatal H1N1 virus1. The number of cases in the nothern hemisphere, especially in the US and Britain is also increasing.

"If the second wave occurs, the virus could spread fast like the Spanish flu in 1918. That was also a H1N1 virus and killed millions in the second wave. But the current one is not a pure H1N1 as in 1918 but a mixed one that is mild and we need to study it further," Health Minister Datuk Seri Liow Tiong Lai said2.

"The US has declared a national emergency over the H1N1. It shows the second wave is hitting the northern region, so we have to be prepared to face this second wave.” In Malaysia, 77 people have died since the H1N1 outbreak in May this year.

Judging by the speedy spread of the first wave, Malaysian experts suggest that the second wave will hit hard coming December. Some anticipate that the waves might arrive sometime mid next year or in two to three years time. Irregardless of when the unpredictable second wave strikes, the government remains optimistic they will have the situation under control. Currently, the government has increased surveillance on the number of cold and cough cases as well as H1N1 at the Kuala Lumpur International Airport. On another matter, Liow said the 1Malaysia community clinics will be launched early next year, run by hospital attendants and nurses to provide direct outpatient treatment.

Having attended one of the briefings organized by Hospital Tengku Ampuan Rahimah, Klang, it dawned upon me on the level of danger that we are exposed to once the second wave of H1N1 englufs our nation. We have underestimated the potential malignancy of the pandemic and should strap up all efforts to minimize transmission and reduce mortality that is expected to rise three folds.

The wards may end up looking like this if the spread of H1N1 is not under control. Hospital admissions rise.

Vaccines to protect against the 2009 H1N1 flu virus is now available. Both the flu shot (in the arm) and the nasal spray form of 2009 H1N1 vaccines have been produced and licensed by the Food and Drug Administration. Administration of the 2009 H1N1 flu shot began in the early weeks of October in the United States.

Since the initial stockpile in Malaysia is low, the Advisory Committee on Immunization Practices (ACIP) has recommended that the following groups receive the vaccine before others: pregnant women, people who live with or care for children younger than 6 months of age, health care and emergency medical services personnel with direct patient contact, children 6 months through 4 years of age, and children, especially those younger than 5 years of age and those who have high risk medical conditions are at increased risk of influenza-related complications. Current studies indicate the risk for infection among persons age 65 or older is less than the risk for younger age groups. Therefore, as vaccine supply and demand for vaccine among younger age groups is being met, programs and providers should offer vaccination to people over the age of 65.

HTAR (and i’m sure many government hospitals across the nation) place much importance of having their healthcare and emergency medical services personnels vaccinated because front-line healthcare workers (i.e. doctors, pharmacists and nurses) are prone to being infected due to the nature of their profession and this can be a potential source of infection for vulnerable patients. Also, increased absenteeism in this population could reduce healthcare system capacity. Vaccination is free.

Yeap, vaccination is free. Great. So are the other shots that i am supposed to take as well such the seasonal influenza vaccine and Hepatitis B vaccine. My questions are

  1. Does the seasonal flu vaccine also protect against the 2009 H1N1 flu
  2. Can i take the seasonal vaccne and Pandemrix® at the same time
  3. How many doses of Pandemrix® are required
  4. Are there any reported side effects from GSK’s Pandemrix because there’s the recent scare of what is being called dystonia following the seasonal flu vaccine.

So, let’s address these questions separately with reference to CDC’s H1N1 recommendations dated 13 November 2009. If you wish to read more or have unanswered questions swirling in that head of yours, you can visit their official website. Good stuff.

Does the seasonal flu vaccine also protect against the 2009 H1N1 flu?

Straight to the point, the seasonal flu vaccine will not protect you against 2009 H1N1 flu.

Can the seasonal vaccine and the 2009 H1N1 vaccine be given at the same time?

Inactivated 2009 H1N1 vaccine (i.e. Pandemrix®) can be administered at the same visit as any other vaccine, including pneumococcal polysaccharide vaccine (this means i can take it with the seasonal flu vaccine and the Hepatitis B vaccine offered by the hospital). Live 2009 H1N1 vaccine can be administered at the same visit as any other live or inactivated vaccine EXCEPT seasonal live attenuated influenza vaccine.

How many doses of vaccine are required?

The vaccine is supplied in separate vials, one containing the adjuvant, and the other the inactivated virus, which require mixing before intramuscular injection. Originally it was thought that two doses given 21 days apart would be required for full effiency. Subsequent testing has allowed the UK programme to consist of just a single dose for most people, with a two-dose schedule for children under the age of 10 years and immunocompromised adults. So i guess i’ll just be taking a single dose. Thank god! I hate those prickly needles.

Are there any reported side effects from the 2009 H1N1 vaccine?

Since Pandemrix® is new in the market, its side effects has not made its way in an official report. However, GlaxoSmithKline stated in their patient information leaflet that the common side effects are headache, tiredness, pain, redness, swelling, fever and aching muscles and joint pain3. These side effects doesn’t sound so menacing right? My friend who works in the bureau said that it has been reported that one doctor collapsed right after taking the injection. This happened in two different hospitals in West Malaysia.

I mean this is all quite a scare following the story of Desiree Jennings4, a 28 year old cheerleader who was apparently healthy until August when she received the seasonal flu vaccine. She developed an apparent neurological reaction in which she has difficulty speaking and walking, with involuntary muscle contractions and contortions. Her symptoms (including speech) are relieved, however, by walking backwards or by running. She also seems to have attacks of muscle contortions. This lady who is a victim of a rare vaccine reaction is now the latest poster child in the war against vaccines.

I am not hinting to you that you shouldn’t take the vaccine. It is a matter of choice. Pandemrix has been authorized under ‘Exceptional Circumstances’ which mean that it has not been possible to obtain full information about the pandemic vaccine but one should be noted that the benefits of Pandemrix are greater than its risks for the prophylaxis of influenza in the officially declared H1N1 pandemic situation. Since no post marketing surveillance data is available, the company that makes Pandemrix® promises to collect information on the safety of the vaccine while it is being used. Plus, the European Medicine Agency will review any new information that may become available and update the public on a regular basis.

Just a word of caution to those planning to receive Pandemrix®. People who are allergic to eggs might be at risk for allergic reactions. So, be careful!

To all healthcare personnels out there, do take everyday actions to stay healthy.

  1. Wear a mask most of the time. The WHO and CDC recommend the use of NIOSH N95 respirators as a measure of protection against the H1N1 swine flu virus
  2. Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue properly in the trash after you use it.
  3. Wash your hands often with soap and water before and after contact with patients. If soap and water are not available, use an alcohol-based hand rub.
  4. Avoid touching your eyes, nose or mouth.
  5. Get an MC if you’re sick! CDC recommends that you stay home from work limit contact with others to keep from infecting them.

These measures will continue to be important even after the vaccine is available for everyone because they can prevent the spread of other viruses that cause respiratory infections.5

All countries should immediately now activate their pandemic preparedness plans. Countries should remain on high alert for unusual outbreaks of influenza-like illness and severe pneumonia. After all it really is all of humanity that is under threat during a pandemic.

Dr. Margaret Chan

  1. Montreal Gazette. Canada: Second wave of H1N1 hitting Montreal. November 14, 2009.
  2. Rajoo, D. A. for Malaysian worries with second wave of H1N1. May 8, 2009.
  3. European Public Assessment Report. Pandemrix. Dated October 2009.
  4. Novella, S. Neurologica blog. The dystonia flu-shot case. October 30, 2009
  5. Centers for Disease Control and Prevention: 2009 H1N1 Recommendations. November 13, 2009.

Sunday, November 22, 2009

Gems of CDR & TPN

[This post is contributed by Lai Peng]

1. If patient is on FOLFOX regimen (
IV Oxaliplatin 85mg/m2, IV Folinic acid 200 mg/m2, IV bolus 5FU 400 mg/m2, IVI 5FU 600 mg/m2 )
• Then we have to dilute Folinic acid into Dextrose 5% instead of NS 0.9%. This is because Oxaliplatin is diluted with D 5%, so Folinic acid & Oxaliplatin can run concurrently (according to Malaysia oncology guidelines)
• IV infusion of 5FU is a 22-hour infusion

2. 5 FU is a low emetic agent, so can give IV Metoclopramide TDS, no need to give IV Granisetron

Cisplatin never give in bolus form, it is always given as infusion
• Premedication must be given with cisplatin :
Granisetron, MgSO4, Dexamethasone
• MgSO4 is given because pt might get hypoMg2+
• If pt is on intermediate or high dose of cisplatin, then need to supply 2 MgSO4
Hydration protocol always give to pt undergo cisplatin tx i.e. give NS0.9% before & after cisplatin infusion
• Low dose: 20-39 mg/m2
• Intermediate dose: 40-80 mg/m2
• High dose : 80-120 mg/m2

1. For paed case, lipid cannot be added into the TPN bag because the TPN bag for paeds is very small as the volume should be small & lipid is unstable.

2. Infusion time of lipid in paeds pt is
16 or 20 hours with a break of 4-8hours.
• the break time is for liver to clear things up as it will metabolise the lipid & liver in neonates is not fully developed
• lipid & bilirubin can compete for the binding with albumin. Thus, break is needed during infusion, if not neonates will get jaundice(high % in neonates)

3. When compounding TPN bags,
lipid is the last to be added.
• It is white colour, thus cannot see if there is any particle inside the bags
• Lipid has negative charge, thus it may interact with electrolytes & dextrose and thus unstable
• Light & Dextrose 50% can cause creaming so unstable

4. Amino acids that are available in TPN are
Vamin, Glamin, Aminoplasmal & Vaminolact
• Vamin & glamin are used for pt > 11 yrs old
• Aminoplasmal for pt > 2 yrs old
• Vaminolact for neonates
• Glamin contains Glutamine (non-essential AA in body), it helps in immune system & protects gut lining. It will become conditionally essential for patient who is in severe stress, e.g. trauma, pt with muscle wasting & pt in ICU.

More information on...
Vamin at

Glamin at

Aminoplasmal at

Vaminolact at

Aspirin in Diabetes (in Doubt?)

Extracted from :No benefits of aspirin for primary prevention in diabetics, meta-analysis suggests November 10, 2009 | Shelley Wood (

Another meta-analysis—this one focused on diabetics—is questioning the role of aspirin for the primary prevention of cardiovascular events [1]. Writing in a paper published online November 6, 2009 in BMJ, Dr Giogria De Berardis (Consorzio Mario Negri Sud, Maria Imbaro, Italy) and colleagues conclude that "a clear benefit of aspirin in the primary prevention of major cardiovascular events in people with diabetes remains unproved."

Effect of aspirin compared with placebo or no aspirin on relative risk of clinical events in patients with diabetes

End point
Relative risk
95% CI
Major cardiovascular events
Cardiovascular death
All-cause mortality
Any bleeding

"In the most recent guidelines from the Canadian Diabetes Association, for the first time they fully acknowledged the lack of definite data on the efficacy of aspirin, and they leave to the physician the decision of whether or not to use aspirin based on the characteristics of the individual patients. And the other [guideline groups] are starting to move from certainty to uncertainty as well."

There's strong basic research evidence suggesting that diabetes can represent a particular situation associated with poor response of platelets to aspirin, and there are many reasons for that," Nicolucci noted. "Diabetes is associated with hyperglycemia, hyperinsulinemia, insulin resistance, oxidative stress, and advanced glycation end products, and all these factors can be responsible for activation of platelets [via] different pathways that are not blocked by aspirin."

Related papers:
  1. De Berardis G, Sacco M, Strippoli GFM, et al. Aspirin for primary prevention of cardiovascular events in people with diabetes: Meta-analysis of randomised controlled trials. BMJ 2009; DOI:10.1136/bmj.b4531. Available at:
  2. Antithrombotic Trialists' (ATT) Collaboration. Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials. Lancet 2009; 373:1849-1860.
  3. Antithrombotic Trialists' Collaboration. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ 2002; 324:71-86.
  4. Haynes R, Bowman L, Armitage J. Aspirin for primary prevention of vascular disease in people with diabetes. BMJ 2009; DOI:10.1136/bmj.b4596. Available at:
(also in

Wednesday, November 18, 2009

Pharmacist Critical Allowance Cut-UNTRUE!

[Credits to members of Pharmacists for Pharmacy group]

Dear fellow pharmacists,

Over the past few weeks, there has been much commotion regarding the possibility of the critical allowance currently being enjoyed by pharmacists working in the civil service being withdrawn.

As such you may be very interested in the following emails.
This was the correspondence received by some of our group members:

From: MalaysianPharmaceuticalSociety To: "" Sent: Wed, November 18, 2009 12:04:28 AM

Subject: Critical Allowance

Dear Council Members,

Datuk Nancy Ho had checked with Pn Eisah and it is confirmed that "news" on the discontinuation of existing critical allowance of pharmacists in government service for those who qualified is not true.

But thanks to all who responded to this issue.

Regards KKLam =

Then, En.Abas replied:

From: Abas Hussin [] Sent: Wednesday, November 18, 2009 11:52 AMTo: MalaysianPharmaceuticalSociety; Pn Eisah Bah Farmasi; Selvaraja

Subject: Re: Critical Allowance

There is a big lesson we must learn from this big hoo ha about the discontinuation of the pharmacist critical allowance - before we open up our mouth and write in to the newspaper, please make sure that we have got our info and facts right. I hope that you could remind all MPS members and non MPS member pharmacists about this. that's all.thank u.

This is clearly a good lesson on how fast a rumour can spread (really wonder who spread it in first place) and how we should act responsibly and rationally in handling the issue. Hopefully our fellow pharmacists will show the same level of eagerness (if not more) in discussing/writing to the papers when it comes to other issues like better pharmaceutical care for patients, dispensing separation etc.

Sunday, November 15, 2009

Necrotising Fasciitis

LKL, a 54-year-old male was a referred case from a primary hospital for further management. He has been diagnosed with necrotising fascilitis and is currently on:
-IV metronidazole 500 mg tds
-IV cefepime 1g bd
-Mepilex dressing (every 3 days)

Issues of interest:
-What are the rationale of using IV metronidazole and IV cefepime?
-What is Mepilex dressing?

Necrotising fasciitis ('decaying infection of the fascia'), is a soft tissue infection commonly known as flesh-eating disease. It consists of 4 types:
Type 1: Streptococci, Group A, C, G
Type 2: Clostridia sp.
Type 3: Polymicrobic: aerobic+anearobic
Type 4: Community-acquired methicillin-resistant Staphylococcus aureus (MRSA)

These bacteria proliferate in an environment of local tissue hypoxia in patient with trauma, recent surgery or medical compromise (e.g. diabetes mellitus).

All types of necrotising fasciitis require prompt surgical debridement and antibiotics. Gram stain/culture is used to determine the etiology.

If streptococci/clostridia sp. are the identified major pathogens, the drug of choice is penicillin G (alternative: clindamycin).

To ensure adequate treatment, there must be coverage for aerobic and anaerobic bacteria. The anaerobic coverage can be provided by metronidazole or third-generation cephalosporins.

If the etiology is polymicrobial, the drug of choice is imipenem or meropenem. Vancomycin is added if MRSA is suspected.

In LKL, IV metronidazole and IV cefepime have been started. IV metronidazole is for anaerobic coverage while IV cefepime, a 3rd-generation cephalosporin, provides coverage for Streptococci. [Note: It is not known if the previous hospital has carried out Gram stain]

Mepilex is an absorbent, atraumatic dressing made from polyurethane foam which absorbs exudate and maintains a moist wound-healing environment whilst minimising the risk of maceration.

1. Mayner M. Necrotising fasciitis [Online].2009 March 25 [cited 2009 November 15]; Available from: URL:
2. The Sanford Guide to Antimicrobial Therapy 2006. 36th ed. p. 41.
3. Wikipedia. Necrotising fasciitis [Online]. 2009 November 10 [cited 2009 November 15]; Available from: URL:
4. SMTL Dressings Datacard. Available from: URL:

Friday, November 6, 2009

Ceramah by JKN Selangor

The following notes are taken from the lecture on Poisons Act 1952, Poisons Regulations 1952, and Poisons (Psychotropic Substances) Regulations 1989 by Mr. Tan from Bahagian Perkhidmatan Farmasi, JKNS.

1. In answering some questions, we need to classify a particular poison first.
Try to find these poisons in the poisons list (1st schedule)--it is not that straightward!
[Scroll down for answers]

Sodium cyanide
Cresol, methyl phenol, hydroxy toluene, thymol
BCG vaccine

2. Some 'guidelines' to help us recognise/remember the psychotropic substances:

  • Minor tranqulisers, e.g. 1,4-benzodiazepines, clobazam, zolpidem, zopiclone
  • Sedatives, e.g. barbiturates
  • Appetite suppresants, e.g. phentermine
  • Strong analgesics, e.g. buprenorphine, pentazocine
  • 3. In the 3rd Schedule of PA52: Psychotropic Substances,
    substances structurally derivated from 1,4-benzodiazepines include midazolam, alprazolam...

    4. Draft a format for........
    The Prescription Register for Psychotropic Substances
    In accordance with r19 & r22 of P(PS)R89:

    Name and Strength of Psychotropic Substance:______________________

    Date Supplied/Administered/Received Serial No. Name & Address of Patient/Supplier Quantity Supplied/Administered/Received Balance Stock
    [Chronological order]

    4. 'Tips' from Mr. Tan ( 'if you don't know this, sure lose mark'; 'take my word, sure come out')
    s5- Sale of poisons by wholesale
    s19- Supply of poisons for the purpose of treatment by professional men
    s21(2)- Form of prescription for Group B Poisons
    s24(1)- The prescriptioin book
    s30- Control of import, export, manufature, sale etc of psychotropic substances

    r12(a)- Labelling of dispensed medicine
    r21 & r22- Prescription register for psychotropic substances
    r23- Supply to outpatients in government hospitals
    r26 & 27- Labelling of psychotropic substance for sale (for purpose other than medical, dental, or animal treatment)

    5. In answering questions, don't use short form for acts (i.e. don't write PA52, but write 'Poisons Act 1952'; but can write 's11' (for section 11) and 'r3' (for regulation3).

    [Read as 'For salbutamol, look under Adrenaline and other substances structurally derived from phenethylamine']

    Salbutamol-Adrenaline and other substances structurally derived from phenethylamine
    Ephedra, alkaloids of
    Anticoagulant substances
    Cortisone, hydrocortisone
    Sodium cyanide-
    Hydrogen cyanide
    Local anaesthetics
    Cresol, methyl phenol, hydroxy toluene, thymol-
    Sex hormone
    BCG vaccine-
    Vaccines, sera, toxoids...
    Vaccines, sera, toxoids...

    Thursday, November 5, 2009

    Acarbose - prevents MI and CV diseases

    Currently, the important of monitoring of postprandial (aftermeal) sugar has been highlighted because more clinical studies have proven that postprandial hyperglycemia is harmful to any patient due to the metabolic disequilibrium.
    (Monnier L,Lapinski H, Colette C. Contributions of fasting and postprandial plasma glucose increatments to overall diurnal hyperglycemia of type 2 diabetic patients: variations with increasing levels of HbA(1c). Diabetes Care 2003; 26: 881-5)

    In a meta-analysis of seven randomized, double-blinded, placebo-controlled acarbose studies with a minimum of 52weeks treatment duration, it founds that, acarbose showed favorable trends towards risk reduction of all cardiovascular events (p=0.0061). A significant risk reduction for MI (p=0.021)

    (Hanefeld M, Cagatay M, Petrowitsch T et al. Acarbose reduces the risk of myocardial infarction in type 2 diabetic patients: meta-analysis of seven long term studies. European Heart Journal 2004; 25: 10-6)

    (This page is authored by Mai and is reproduced at