NEWSLETTER OF THE SOCIETY OF HOSPITAL PHARMACISTS OF HONG KONG

香港醫院藥劑師學會通訊

Editoral Board Eric CHEUNG Kenneth CHEUNG Sau Chu CHIANG Derek CHOW Kenneth CHUNG Wai Him HUNG Fanny KWOK Ellen LAI Eva LAI Daisy LAM Michael LING Ivan MAK Cindy NG Man Keung NG Ting Fung NG Wing Yan POON Errol WONG Johnny WONG

Editorial It is not long to go before Christmas! During this ‘Advent’ period, the festival of Christmas, all of us are busy in ticking the ‘to-do-list’, making sure we share the joy with our loved ones in the perfect way. Apart from preparing for Christmas, ‘Advent’ is also a good period of time for us to reflect what we have done in the past year and plan for the coming year. A solid planning can take us far. Young pharmacists, what is your career plan for the coming year? Reading this issue’s interview with Mr. Kenneth LAW will definitely give you some insight in local pharmacy profession and help with you planning.

Disclaimer

The SHPHK Connection welcomes articles submitted by readers. The articles are accepted for publication subject to editorial abridgment or modification. Views expressed in named articles are those of the individual authors. Neither the SHPHK Connection nor SHPHK assumes any responsibility for these articles. Letters to the editor should bear the name of the writer. While anonymous letters will not be accepted, pseudonym may be used for publication, except when the writer comments on previous letters or articles which the authors have used the real name for publication.

Talking about planning, ever think about practice overseas? Australia would be a good choice if you enjoy hot weather and all sort of outdoor activities. In this issue, our connection has extended to the “Down Under”..... and probably more global. Mr. Vincent WONG, a pharmacist practising in Australia will share with us his review on advances in oral anticoagulation therapy and how results in the ROCKET-AF trial could be interpreted. Ms. Dorothy LAM, a former Australian pharmacist, will share with us role of pharmacist in the speicalty of haematology/oncology through her encounter with a patient suffering from a condition known as MDS. Mr. Kemo LAM also shares with us his UK experience in oncology pharmacy and one of his interventions in Clinical Pearls. Medication Reconciliation, a term I’m sure all of us had heard of. It is a process to ensure accurate and complete medication information of patient transfer at interfaces of care. But do you know how you could introduce this service, just by its name, in our mother tongue? If not, our clinical pharmacist Richie will tell us more

13/F, Kingsfield Centre, 18 Shell Street, Hong Kong

December 2011

about medication reconciliation in this issue’s ‘Do you know’. Richie will also share her thought with us in the young pharmacist sharing. Updated clinical knowledge is essential for pharmacist; attending clinical pharmacy forum is a good way keeps us on track. But if you missed last Pharmacy Practice Forum, no worry, Cindy has prepared a detailed recap for the Forum. Many of us might have been puzzled by last issue’s Clinical Twister. Mr. Raymind MAK has come up with an answer to share with us. There are more interesting content in this issue, don’t miss the new story from Storyman and pharmacy news by Ellen to keep you updated. Last but not least, our prestigious President Mr. SO Yiu Wah will update us on advertisement issue regarding milk forumla. On behalf of the SHPHK Connection Editorial team, wish all of you Merry Christmas and Happy New Year !

Ivan MAK is a resident pharmacist working at United Christian Hospital.

Also in this Issue... P.1 .................................................... Editorial P.2 ........................................... Clinical Pearls P.3 ............... Clinical Pharmacy: Rivaroxaban P.5 ..... Recaps from Clinical Pharmacy Forum P.6 ......................................... Clinical Twister P.7 ........................................... 與 Law 化對談 P.9 .......................................... Inspiring Story P.10 .......................................... Society News P.11 ............................... Drug News and Alert P.12 ........... Career as Specialist Pharmacists

http://www.shphk.org.hk

Oncology Pharmacists in UK Aseptic Preparative Services Similar from the practices all over the world, the roles of oncology pharmacists in UK are developed from the Aseptic Preparative Service (APS). APS can only be exempted from the licensing requirements of the Medicines Act UK provided that: 1. the preparation is under supervision of a responsible pharmacist; 2. the preparation uses closed systems; 3. licensed sterile medicinal products are used as ingredients; 4. products are allocated a shelf life of no more than 1 week and the shelf life should be supported by stability data; and 5. all activities are in accordance with defined NHS guidelines . A comprehensive and correctly implemented APS system of Quality Assurance incorporating the principles of Good Manufacturing Practice (GMP) had been set up in accordance with the NHS guidelines in my previous practice. For example:  Documentation - standard operating procedures, worksheets, records and reports, labels  Personnel, training and competency assessment  Aseptic Processing Validation  Microbiology and Physical Monitoring  Aseptic Cleaning  Quality control of manufactured products We provided day-to-day cytotoxic reconstitution services to wards and the day case unit. I needed to oversee that all work within the aseptic unit complies with the requirements of GMP. This involved the implementation and regular review of the APS system (mentioned above), Policies and local Guidelines through Standard Operating Procedures.

The Role of a Specialist Oncology Pharmacist The role was then extended to specialist oncology pharmacist including but not limited to the following aspects:  provide professional verification of prescriptions;  run pharmacy nurse led nadir clinic monitoring WBC, ANC, platelet and other laboratory results;  provide specialist clinical expertise on the prescribing, preparation and administration of chemotherapy therapies; 

provide counselling service to patients on the use of medications and chemotherapy;

 provide clinical pharmacy services on wards;  ensure prescribing practices in line with the Drugs and Therapeutics Committee and Cancer Network

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drug therapy decisions; and  perform audit of adverse drug reactions and report to MHRA.

An Intervention Case to Share During my practice as a specialist clinical oncology pharmacist in UK, I have come across some cases in relation to the intervention of chemotherapy treatment. Below is a case that I found valuable to share with: “A patient was on ECF every 21 days (three pre-surgery and three post-surgery cycles) for oesophageal cancer: 1. Epirubicin 50mg/m2 IV Day 1 2. Cisplatin 60mg/m2 IV Infusion Day1 3. Fluorouracil (5-FU) 1400mg/m2 IV Continuous Infusion (via infusor pump) for 7 days on day1, day8 and day15 On cycle 1, day 15 5-FU infusor pump had been omitted due to neutropenia (neutrophil count was 0.56). On cycle 2 the day before chemotherapy, neutropil count was increased to 1.14. Patient had been deferred for 7 days by the nadir clinic. Besides, renal function was impaired after one cycle of chemotherapy: creatinine clearance was dropped from 56ml/min to 42ml/min.” I had picked up above information at the stage of prescription verification for the deferred cycle 2 chemotherapy. Without specialist oncology pharmacist’s intervention, the patient would have a large probability developing neutropenic sepsis which is a major life threatening side effect of chemotherapy. I recommended the prescriber adjust 20% dose reduction for Epirubicin in order to prevent neutropenic sepsis. Besides, Cisplatin dose was recommended adjust to 50mg/m2 instead of 60mg/m2 due to the impaired renal function. The consultant prescriber agreed with the pharmaceutical care plan and made the final decision in line with my recommendation. As a result, the patient completed the whole chemotherapy treatment plan safely and achieved the intentional treatment goal.

Way Forward of Oncology Pharmacists in UK Currently, the roles of oncology pharmacists in UK had been further extended to Cancer Network Pharmacist, Clinical Trial Oncology Pharmacist, Palliative Care Oncology Pharmacist and Independent Prescribing Consultant Oncology Pharmacist. The report of the “Chemotherapy services in England: ensuring quality and safety” published on 21 August 2009 revealed that the government in UK would like to develop “A&E Oncology Pharmacist” in the future.

Kemo LAM is a pharmacist working at the Queen Mary Hospital

ROCKET AF:

Rivaroxaban? What does it mean to pharmacist? In November, 2010, a new oral anticoagulant drug, rivaroxaban, was “landed on earth” with a high profile presentation at the American Heart Association (AHA) 2011 at Chicago, which is the study based on the Rivaroxaban Once daily Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF). [1] Confirmed with the preliminary results presented at the conference, the ROCKET-AF study was recently published in the New Journal of Medicine (10 August 2011). [2] Meanwhile, the United Kingdom Clinical Pharmacy Association has issued guidance on the appropriate use of new oral anticoagulant medicines for the prevention of stroke for patients with atrial fibrillation and expected to be licensed for this indication in 2011/2012.So, what is the pharmacology of rivaroxaban? what is the ROCKET-AF study about? And what are the actual potential advantages of this new anticoagulant to the clinical pharmacy practice? Does it mean warfarin can be put “to an end”? Since the 1960s, warfarin has been the only anticoagulant drug in regular use for treating patients with thromboembolic disease. It is until 2008, rivaroxaban, (one of the new anticoagulant, the other one is dabigatran) was registered in Australia for the prevention of venous thrombosis after elective knee or hip replacement therapy. [3] [4] And since then, rivaroxaban is believed to be effective anticoagulants which offer potential advantages over heparin and warfarin. Pharmacologically, rivaroxaban is a competitive reversible antagonist of activated factor X (Xa). Factor Xa is the active component of the prothrombine complex that catatlyses the conversion of prothrombin (factor II) to thrombin (factor IIa).[5] The purpose of the Rocket-AF study was to compare once-daily rivaroxaban with dose-adjusted warfarin for the prevention of stroke and systemic embolism in patients with non-valvular trial fibrillation who were at moderate-to-high risk for stroke. The primary hypothesis was that rivaroxaban would be non-inferior to warfarin for the prevention of stroke or systemic embolism. Warfarin requires frequent coagulation monitoring and subsequent dose adjustments, whereas rivaroxaban may provide more consistent and predictable anti-coagulation, and is therefore more “patient” friendly. In this

double-blinded trial, researches randomised 14264 patients with non-valvular AF and a moderate-to-high risk of stroke (i.e. CHADS2 score of 2 or more) to receive rivaroxaban 15mg daily, rivaroxaban 20mg daily or dose-adjusted wafarin (target international normalised ration 2-3). The primary efficacy end-point was stroke or systemic embolism and it occurred in 188 patients taking rivaroxaban and 241 patients receiving warfarin (p<0.001 for non-inferiority). The secondary efficacy end-point included primary end-point or death from cardiovascular cause. For this secondary efficacy outcomes, mycocardial infarction occurred in 101 patients (0.9% per year) in the rivaroxaban group and in 126 patients (1.1% per year) in the warfarin group. There were 208 deaths (1.9% per year) in the rivaroxaban group and 250 deaths (2.2% per year) in the warfarin group. Furthermore, the study also investigate the primary safety outcome, a composite of major and non-major clinically relevant bleeding events. This occurred in 475 patients in the rivaroxaban group and 1449 patients in the warfarin group (p=0.04). Though the study didn't show that rivaroxaban was inferior to warfarin in the prevention of subsequent stroke or systemic embolism, the study revolutionise treatment of patients with AF compared with warfarin. In fact there are many potential and advantages of this direct factor Xa inhibitor:[6] 1. Fast onset and offset of action 2. Few drug an food interactions 3. Fixed dosage and no regular monitoring for dose adjustments 4. Potentially have a lower risk of major bleeding 5. Increase prescribing anticoagulant 6. Increased used in elderly Having said that, however, many critical issues have been found out for the drug as well: [6] 1. Potential for lack of emphasis on education and bleeding risk with new anticoagulants 2. Lack of routine monitoring will lead to less warning regarding bleeding events (e.g. in people with worsening renal function or commencing interacting medications

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3. More frequent adherence

dosing

leads

to

reduced

4. Lack of monitoring may significantly reduce persistence; cessation of new anticoagulants may not be clear to prescriptions, as patients often don't tell their doctors when they become non-persistent 5. No antidote has been developed so far to reverse the condition of over-anticoagulated Therefore, as a conclusion, direct factor Xa inhibitor represents a new and potentially exciting development in anti-thrombosis therapy. They have the potential to be as effective, safer and easier to use than conventional drugs, which is warfarin. However, clinical evidence has not yet shown superiority to older anti-coagulants in all aspects and problems like management of bleeding and adherence are the most concern of this new medication. Therefore, it’s still early to say “warfarin can be put to end” as we still need more evidence-based data for the safety and compliance issues of the drug.

Vincent WONG is a practising hospital pharmacist working in Western Australia

References 1. Off orbit? ROCKET AF: Rivaroxaban noninferior to warfarin, but superiority analyses at odds accessed at http://www.theheart.org/article/1148785.do at 2nd July, 2011

2. Manesh et al. (2011) Rivaroxaban versus Warfarin in Nonvalvular Atrial Fibrillation. NEJM (published on August 10, 2011) 3. Eriksson BI, Borris LC, Friedman RJ, Haas S, Huisman MV, Kakkar AK, et al; RECORD1 Study Group. Rivaroxaban versus enoxaparin for thromboprophylaxis after hip arthroplasty. N Engl J Med 2008;358:2765-75. 4. Kakkar AK, Brenner B, Dahl OE, Eriksson BI, Mouret P, Muntz J, et al; RECORD2 Investigators. Extended duration rivaroxaban versus short-term enoxaparin for the prevention of venous thromboembolism after total hip arthroplasty: a double-blind, randomised controlled trial. Lancet 2008;372:31-9. 5. Verma AK, Brighton TA. The direct factor Xa inhibitor rivaroxaban. Med J Aust 2009;190:379-83. 6. Luke R.E. Bereznicki & Gregory M. Peterson. New Antithrombotics for Atrial Fibrillation Cardiovascular therapetucis: Cardiovascular Therapeutics 2010: 1-9, Blackwell Publishing Ltd

....what is the Chinese name of Medication reconciliation?

Medication reconciliation is (? or was) a hot topic in Hong Kong and it is also a medication safety goal of a lot of countries. In English-speaking world, we, of course, have no problem at all though the term is still a little too long. Folks in the states like to call it “med rec”, where we like to call it MR in Hong Kong (though we also call “mental retardation” as MR, hahaha) Well, Hong Kong is definitely a metropolitan. We cannot survive here if we can just speak one language. Chinese and English are equally important in our daily life. Therefore, we NEED a Chinese term for medication reconciliation. It is convenient for us to communicate among ourselves so as to communicate with our counterparts in China. It was then discussed seriously in the Medication Reconciliation Interest Group under the clinical pharmacy subcommittee of the Hospital Authority (HA).

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Quite a lot of suggestions were brought up in the meeting including the followings. 協調 which was used in the previous presentation in China, 修和 which is used by Catholics when talking about relationship with god, 執正 which carries the meaning of bringing chaotic things into order 理順 which implies that we are just matching the drug list but also to solve drug-related problems, 用藥總歸戶 which is quoted from a Taiwanese website 用藥持續性照顧 from a Taiwanese website as well 藥物整合 from Mainland and Taiwanese website 調解、調停、修正、執正、整理、整頓 are all other possible choices.

To be continued on P.5

Safety concern about bisphosphonate Osteoporosis is defined as a systemic skeletal disorder of compromised bone strength, predisposing an individual to an increased risk of fracture. The foundation of osteoporosis prevention and treatment is a bone healthy lifestyle beginning at birth and continuing throughout life. Insuring adequate intakes of calcium and vitamin D along with other bone-healthy lifestyle practices are the first steps in prevention and treatment. Combined with adequate calcium and vitamin D intakes, bisphosphonates are the prescription medication of choice, with teriparatide, denosumab, raloxifene, and calcitonin considered alternative agents. Mr Kenneth CHUNG, pharmacist working at Queen Elizabeth Hospital shared with us some updates on bisphosphonate in the Pharmacy Practice Forum held on 4 November at Kwong Wah Hospital. The safety of long term bisphosphonate is a topic of much debate as adverse events continue to be reported. Safety concerns with potentially severe clinical outcomes that have been reported with long-term use of bisphosphonates include atypical subtrochanteric and femoral fractures, osteonecrosis of the jaw, and esophageal cancer. He pointed out that the data are suggestive of an increased prevalence of osteonecrosis of the jaw (ONJ) and ONJ-like findings with increased duration of exposure to oral bisphosphonates, with the highest prevalence occurring at four or more years of use. However, these results should be interpreted with caution as this study is a prevalence study and was not designed to determine whether the outcome occurred before or after initiation of therapy. With regard to the atypical subtrochanteric and femoral fractures, there is no agreement on the extent to which cumulative use of bisphosphonates increases the

risk of atypical fractures. Furthermore, the available evidence regarding the possible association between oral bisphosphonates and esophageal cancer is inconclusive. Consequently, no conclusion can be reached as to whether long-term use of bisphosphonates is associated with esophageal cancer. The safety of long-term bisphosphonate therapy continues to be unclear as study results are conflicting as to whether or not ONJ, atypical femoral fractures or esophageal cancer are associated with use of bisphosphonates for the prevention and treatment of osteoporosis. More studies or evidence are required to support the association between the use of bisphosphonates and the abovementioned side effects.

Cindy Ng

is a pharmacist working at the Queen Elizabeth Hospital

Ritchie KWOK

is a clinical pharmacist working at the Queen Mary Hospital

In the meeting we discussed the appropriateness of these terms in terms of its meaning, ability to describe the current practice, the length of the term and how wildly it is used in Asia Pacific area. We have then shortlisted four options in the meeting which included “藥物修和”, “藥物協調”, “藥物理順” and “藥物整合”. After that, we voted with the score of 1-4 (4 being the best) for these four terms and concluded to use藥物整合 as our official Chinese translation. This conclusion was then proposed in the meeting of clinical pharmacy subcommittee and to be further confirmed by Pharmacy Service Operation Management (PSOM) of HA.

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l T

a s e

Answer for October 2011 Issue

This care plan is presented by Mr. Raymond MAK of Queen Mary Hospital. And congratulations to Mr. MAK as he will be awarded gift voucher for medical books for his successful solution of this clinical twister! Care to win your prize as well? Keep an eye on our next Clinical Twister and help solving it!

Ms.Chan is a case with active problem of CHF and concurrent newly onset AF, besides her listed PMH. A number of aspects of her clinical conditions is worth commenting on, as follows: 1. AF Stroke risk associated with AF  given her AF background, her CHADS2 score amounts to 3 (1 for CHF, 1 for HT, 1 for Age ≥ 75), giving an annual risk of stroke of 5.9%. According to ESC guidelines, patients with a CHADS2 score of ≥2 should be given oral anticoagulant such as warfarin/dabigatran. Considering her advanced age, however, the benefit of anticoagulation to prevent stroke must be balanced against the risk of haemorrhage, since relatively higher risk of intracranial haemorrhage is associated with patients aged ≥75. There is insufficient data to fully gauge her bleeding risk, only her age and her hypertension currently count against her. Based on available information, the balance would still seem in favour of anticoagulation. Dabigatran at a lower dose of 110mg twice daily may be considered. Plavix may be stopped if dabigatran is chosen as the anticoagulation therapy. Rate control for AF  there is no appropriate drug in her current regimen for AF control. She is currently on nifedipine, a dihydropyridine calcium antagonist which is not indicated in AF. Non-dihydropyridine calcium antagonists such as diltiazem/verapamil are generally recommended. However, considering that CHF is now superimposed on her AF, choice or use of calcium antagonist is limited since in CHF only felodipine and amlodipine are considered non-detrimental to heart failure. These agents are both dihydropyridine which are unsuitable for AF control. An option could be to switch nifedipine to a β-blocker (e.g. bisoprolol / carvedilol / metoprolol). A once daily agent such as bisoprolol (initiate at 1.25mg/d titrating to target 10mg/d if tolerated) is preferred unless BP control is an issue in which case carvedilol may be chosen which has additional BP-lowering effect. If β-blocker does not control her AF or that it is not tolerated, amiodarone is an alternative.

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2. CHF  Continue with regular low dose or prn frusemide as appropriate for fluid and symptoms control.  Consideration should be given if haemodynamically stable, to add an ACEI to her β-blocker since both provide significant mortality and morbidity benefits, and should be offered to all HF patients if tolerated and not contraindicated. This should also help to counter K+-loss from frusemide.

3. Hypertension  There is no information about her current status of BP control. With the institution of the proposed agents above that also lowers BP, hopefully adequate BP control is achieved. There is indeed room for up-titration of the proposed agents (β-blocker/ACEI) after initiation to target doses both for CHF and BP control.

4. OA knee  Avoid use of NSAIDs since they blunt the effect of diuretics, exacerbate fluid retention and may be harmful in HF. 5. Haemoglobin status and iron supplementation  It is appropriate to discontinue iron supplementation based on patient's haematological presentation, as while she is on oral iron, her serum iron level is adequate and her TRF saturation high, her Hgb has remained static. It appears her marrow is hypo-responsive to iron therapy. Continued iron supplementation is unlikely to benefit her further and might produce adverse drug reactions.

與Law化對談

「呢件事，我同大家share返」 從DI到DM

Law化小檔案 羅國明 Law Kwok Ming Kenneth 九龍中醫院聯網藥劑部部門經理 / 伊利沙伯醫院藥 劑部部門經理 曾為香港醫院藥劑師學會擔任財政等工作

印象中的Law化是個很「clinical」的人，而他在擔 任 部 門 經 理 之 前 就 正 正 主 要 負 責 d r u g inf ormation ( DI) 一職。「別人覺得 困 難 的 問 題 我 卻有興趣做；做得多，自然經驗多，亦會有更多人 找我，也就與外界有更多的聯繫」從多年的經驗中 ，Law化分享做DI最重要的是莫給自己 壓 力 ; 放 下 自 己是「drug e xpe rt」的心理包袱， 遇 上 不 確 定 答 案的難題莫急於作出回應，亦不妨與同事交流意見 。Law化亦分享了一個一直警惕着他的經歷：「剛 入 行 時 有 一 次 醫 生 致 電 來 查 詢 指 病 人 對 ciprof loxacin敏感，問可否使用nali d i xi c a c i d 。 當時雖然不太確定，但卻因放不下心中的自尊而答 了可以使用。隨後查書發現兩者為同類藥物，便立 刻致電更正，但醫生已憤怒不已。」

日 積 月 累的 經 驗 、 知識除了令La w化成為一個成功的 DI p h ar ma c is t 外，原來也有助他擔任部門經理一 職。「在一次有關治療轉移性乳癌的會議上，一位 醫生分享了一個個案。患者是一位年僅廿多歲的女 子，雖然測試結果顯示她屬HER2(human ep i d e r ma l gr o w t h fa ct or 2) 陰性，按治療指引理 應不獲處方trastuzumab，但臨床觀察下該病人在 接受trastuzumab治療後稍見療效。在臨床實況與 經費運用等考慮下，究竟該病人應否繼續接受 trastuzumab治療？管理層往往不能單純遵從指引 ，而是在兩難間作出決定。臨床的知識可有助了解 前線的想法，再配合管理的角度，為病人提供最合 適的幫助。」然而，藥劑師的培訓並不以擔任管理 層 為 目 標， 對 於 部 門管理，La w化有以下看法：「其 實我們可反思管理層是否一定要由同業擔當？像前 醫 管 局 行政 總 裁 蘇 利民（Sh a n e Solom on），他本 身 是 文 學士 ( 社 工 ) ， 並非醫護出身。」 Wo rk - L i f e B a l an ce 據說Law化經常留在藥房工作至8、9時才離開，在 繁忙的工作以外又有什麼嗜好？「我的好處就是…沒 有什麼嗜好!」話雖如此，Law化透露他有早上跑步 的習慣。那麼家庭生活又有沒有被繁重的工作影響

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呢？「還好，星期六、日一有時間便會陪伴家 人， 唯 一遺 憾 是 無 法看顧小朋友的功課。」 不論公營或私營的藥劑部，都先後延長服務時 間甚或提拱24小時服務，對不少藥劑師來說， 在生理上、家庭、興趣的時間都需要適應和調 整，亦因此成為一些同事離開醫院的其中一個 原因，Law化又有何意見？「這是很自然的想 法，同事決定去哪裡工作一定有自己的原因， 例如工種、穩定性、時間、待遇、地點位置凡 等因 素 」L aw 化 並 謂不擔心人才流失。 Law化從容不迫的回應令我想起了《誰搬走了 我的 乳 酪? 》 ( W h o M oved M y C h ee se?) 一書 。乳酪山不見了，便去找另一個乳酪山吧。面 對未來行業內的變化，我們接受改變之時也去 想應 變 的方 法 ， 擔 憂、壓力自然消失。 那些 年 ，一 個 人 的 環遊世界之旅 談到這裡，是時侯說一些輕鬆的事情吧。聞說 Law化在回香港工作前曾經「環遊世界」，當 初為何有這個想法呢？「在英國讀書受同學影 響，夢想見識世界。在當地工作了一段時間後 遇上一個機會，便決定辭去工作、把屋出租， 自己一人揹著背囊環遊世界。」那麼可否分享 當 中 一 些 難 忘 經 歷 ？ 「 截 順 風 車 (hi tc hhi k in g ) 的時候，停下來載我的男 女老

幼都有，主動幫助素未謀面的人，心想是不可 能的事，所以很想了解他們，知道當中原因。 」「很幸運一路上遇上的都是友善的人，一次 在紐西蘭截順風車時遇上一位女士，言談間知 道我是藥劑師，便我帶到她工作的醫院，甚至 介紹那裡的藥劑師給我認識。」接下來談到陌 生人大雨中倒車載他回家休息、為他煮飯、零 下廿二度去位處室外的洗手間的體驗……旅程上 除了難忘的經歷，Law化亦感受到各種對人、 生命及世界的看法。「我們中國人會期望子女 出人頭地，但外國人第一句說的卻是希望他們 的子女擁有愉快的人生。」 後記 「呢件事，我同大家share返」大概是我在整個訪 問個程中聽到最多的句子。在接近兩個半小時的訪 問中，Law化除了回答我們的問題外，也教了我們 很多行內知識和歷史 ( 例如駐院藥劑師 的 由 來 、 流 感針疫苗計劃等，實在不能盡錄)。訪問以外，普通 科門診會議上亦經常聽到Law化說「我同大家 share返」，分享醫院的經驗給一班在普通科門診 工作的同事。其實整個行業的進步、發展是很依靠 大家無私的分享，Law化樂於分享的態度，亦正正 是我們一班編輯、撰稿人的信念。 郭綠雯 九龍醫院駐院藥劑師

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黃亦夫 明愛醫院駐院藥劑師

The Wallet and the Purse It was a dark night in the park. A man was standing under a lamp post, appeared to be looking for something. He repeatedly searched his pockets, and ploughed around the ground. He seemed to be in a hurry, too. “Can I help you mister?” A lady passing by asked kindly. “Eh, yes, ma‛am. I am looking for my wallet. And I can‛t go home without my damned wallet.” So the lady started looking around. An old woman saw it and also began the search. But she had no idea what they were looking for. Several other people joined them later. Through word of mouth, some thought they were searching for a bag, a file and even a box. Then a little boy came by and asked the man, “Can I help you, sir?” “Yes, I dropped my wallet. It‛s red and about the size of my palm. Please help me find it, boy.” “May I ask where you dropped it, sir?” asked the boy reflexively. “Over there among the bush,” said the man without a thought. ”Damn it … where‛s is it … ? ” The man murmured to himself frustratingly, and got on with his business. The boy stood, scratched his scalp, and asked, “So why don‛t you search over there, where you dropped it?” The man was a bit angry now, “How can I find my wallet where it is so dark in the bush. At least there is a street lamp here?” ***************

Of course this is an absurd story. It probably would not happen in real life. But … wouldn’t it really? Often times when we encounter a problem, the first thing we want is “a solution”. If we face a big problem, and we are under pressure to deal with it immediately, a solution, or any way to make the problem disappear, would be welcomed. Look around ourselves, and you will notice there are many occasions when we just grab a solution and tell people things are settled, the problem is fixed. And we have many names for this kind of situation : “knee jerk solution”, “quick fix”, “band-aid method”, “treat the head for a headache”, “homework”, “scapegoat”, “barking up the wrong tree” … How proliferating this “looking-for the-wallet-under-the-street-lamp” phenomenon is nowadays! In the end the problem still exists, and will happen again. If the culprit or the root cause is not found and corrected, the problem will even get worse. Offering an unrelated solution can provide a false sense of security. Sometimes, no solution (yet) is better than a “wrong tree” solution. So when we have a problem, don’t look for the solution immediately. Look for the cause of the problem, analyze it, and THEN look for solutions. And the story continues …… *************** “Sir, I think we really need to look over there in the bush,” insisted the boy. “I can fetch you a torch…” “Hey, mister, I found a purse,” yelled the lady, “Is that your wallet?” “Oh, not really. But I‛ll just take that. Thanks a lot everyone.”

Storyman 9

會長的話

香港母乳代用品銷售守則 較 早 前 政 府 擬 訂立《香 港 母 乳代 用 品 銷 售 守 則》，有意參 考 世 衞《國 際 母 乳代用品銷售 守 則》 ht tp://w w w.who.int /nutrition/publicati ons/ infant fe e ding/92415 41601/en/，以 草擬本地相關守則，藉此監管母乳代用品的生 產商及分銷商，禁止其以不正當手法宣傳或銷 售母乳代用品及相關物品。 為應對政府籌劃規管母乳代用品的生產商及分 銷商，禁止其以不正當手法宣傳或銷售母乳代 用品及相關物品，本地奶粉商急忙於今年五月 成立「香港嬰幼兒營養聯會」，藉着自我約束的 方法，以圖緩和政 府的監 管。奶粉商 有此一 着 亦甚高明，籍着「聯會」所邀請的專家，包括醫 生和營養師，以抗衡由政 府成立的專家小組。 讓公眾覺得聯會所做的活動，以及聲明都因為 有醫護人員的支持而變得中立和有份量，擺脫 所有宣傳的商業性 質，此 等高明 的包 裝 手法， 對一般市民而言，確實有效。可是奶粉商在十月 十八日，籍「聯會」名義的新聞發報，訂出業界 自律《嬰兒配方奶粉市場推廣守則》後，政府、

消委會以及香港母乳育嬰協會都不認同六大奶 粉商的做法。政府今次能夠「企硬」，不像之前 「放 生」製 藥公司直接 銷售 補血 針，表現得甚 有骨氣。 衞生署能夠着眼廣告對市民的影响，的確是值 得嘉許的。記得在20 0 4年，衞生署建議把九類 保健 聲稱，以附表 形式納入《不良醫藥廣告 條 例》內。可見署方的而且確 能夠關心市民的健 康。只可適當時的立 法會，因為某 些 緣故而放 寬 規管，不包括排 毒、改善免疫 力及 減肥等三 項聲稱。 提 起 廣 告，現 時 有 不少 製 藥 商 籍 着 發 例 的 漏 洞，向市民直接 宣傳產品，並 以 超市禮卷 作為 推廣，把藥物當作一 般商品來推 銷。甚至有會 導致畸胎的暗瘡藥在報章上作宣傳，這些宣傳 容 易吸引市民誤 用藥 物，後 果非常危險，期望 署方能多加監管。 蘇曜華 香港醫院藥劑師學會會長

備註：原本建議禁止九類保健聲稱，並以附表形式納入《不良醫藥廣 告條例》包括： 調節體內糖分或葡萄糖，包括改變胰臟機能 調節血壓 調節血脂或膽固醇 預防、消除或治療乳房腫塊 調節泌尿生殖系統的機能，包括改善泌尿生殖問題的徵狀 調節內分泌系統，包括保持或改變激素分泌 有關纖體或減肥的聲稱，包括燒脂、除脂、控制食欲、吸脂及去水 腫  調節身體的免疫系統，以預防包括癌症、慢性疾病及感染等疾病； 或改變化療、放射治療治療的作用  促進排毒、清毒或降毒       

條例後來刪去最後三類

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SHPHK joins “Care for your Heart” (「關心您的心」) to alert drug-food interaction of warfarin SHPHK jointly conducted a survey on patient receiving warfarin from April to June 2001 with Care for your Heart, a cardiac patients mutual support association. 300 patients on warfarin for an average of 3 years or more were interviewed. The results showed that: - 53% of patients did not know about drug- and/or food-interactions of warfarin - 73% of patients had taken food that should not be taken during warfarin therapy; - 26% of patients had taken food in amounts more than recommended during warfarin therapy;

- 9% of patients had been admitted to hospital due to side effects of warfarin. So Yiu Wah, President of SHPHK and Dr. David Siu, cardiologist, both addressed that patient counseling is very important in the anticoagulation treatment with warfarin. Attention should be paid on patient education to avoid warfarin-interacting drugs and food substances, including health supplements, over-the-counter medicines and traditional Chinese medicine, without prior consultation with a doctors or a pharmacists.available.0mg film-coated tablets. Summary of Product Characteristics. Revised May 2009.

FDA alerts possible QT prologation with high dose citalopram and potential interaction between citalopram and CYP2C19 inhibitors FDA has received post-marketing reports of QT interval prolongation and Torsade de Pointes associated with Celexa (Citalopram) and its generic equivalents. In addition, FDA has evaluated the results of a thorough QT study assessing the effects of 20-mg and 60-mg doses of citalopram on the QT interval in adults. In this randomized, multi-center, double-blind, placebo-controlled, crossover study, 119 subjects received citalopram 20 mg per day (Day 9), citalopram 60 mg per day (Day 22), and placebo. The overall summary of findings is as follows:

Citalopram Dose

Increase in QT Interval (ms) (90% Confidence Interval (ms))

20 mg/day

8.5 (6.2, 10.8)

60 mg/day

18.5 (16.0, 21.0)

40 mg/day

12.6* (10.9, 14.3)*

*

Estimate based on the relationship between citalopram blood concentration and QT interval.

Compared to placebo, maximum mean prolongations in the individually corrected QT intervals were 8.5 and 18.5 milliseconds (ms) for 20 mg and 60 mg citalopram, respectively. For 40 mg citalopram, prolongation of the corrected QT interval was estimated to be 12.6 ms. As a result, FDA recommended that: - Citalopram causes dose-dependent QT interval prolongation. Citalopram should no longer be

prescribed at doses greater than 40 mg/day. - Citalopram should not be used in patients with congenital long QT syndrome. - Patients with congestive heart failure, bradyarrhythmias, or predisposition to hypokalemia or hypomagnesemia because of concomitant illness or drugs, are at higher risk of developing Torsade de Pointes. - Hypokalemia and hypomagnesemia should be corrected before administering citalopram. Electrolytes should be monitored as clinically indicated. - Consider more frequent electrocardiogram (ECG) monitoring in patients with congestive heart failure, bradyarrhythmias, or patients on concomitant medications that prolong the QT interval. - The maximum recommended dose of citalopram is 20 mg/day for patients with hepatic impairment, who are greater than 60 years of age, who are CYP 2C19 poor metabolizers, or who are taking concomitant cimetidine, however, no dose adjustment is necessary for patients with mild or moderate renal impairment. - Patients should be advised to contact a healthcare professional immediately if they experience signs and symptoms of an abnormal heart rate or rhythm while taking citalopram.

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FDA approves Soliris for rare pediatric blood disorder On Sept. 23, 2011, The U.S. Food and Drug Administration approved eculizumab (Soliris) to treat patients with atypical Hemolytic Uremic Syndrome (aHUS), a rare and chronic blood disease that can lead to renal failure and is also associated with increased risk of death and stroke. Eculizumab is a monoclonal antibody that binds with high affinity to compliment protein C5, which inhibits its cleavage to C5a and C5b and prevents the genearation of termination compliment complex C5b-9. In patients with paroxysmal nocturnal hemoglobinuria (PNH), eculizumab inhibits terminal complement mediated intravascular hemolysis. The FDA first approved eculizumab in March 2007 to treat paroxysmal nocturnal hemoglobinuria (PNH), a rare type of blood disorder that can lead to disability and premature death. Eculizumab is classified as an orphan drug, i.e. those that demonstrate promise for the diagnosis and/or treatment of rare diseases or conditions. It is indicated for the treatment of adult patients with paroxysmal nocturnal hemoglobinuria (PNH) to reduce hemolysis, and for the treatment of adult and pediatric patients with atypical hemolytic uremic syndrome (aHUS) to inhibit complement-mediated thrombotic microangiopathy. It is not indicated for the treatment of patients with Shiga toxin E. coli related hemolytic uremic syndrome (STEC-HUS).

The most frequently reported adverse reactions of eculizumab in the PNH randomized trial (≥10% overall and greater than placebo) are: headache, nasopharyngitis, back pain, and nausea. The most frequently reported adverse reactions in aHUS single arm prospective trials (≥15% combined per patient incidence) are: hypertension, upper respiratory tract infection, diarrhea, headache, anemia, vomiting, nausea, urinary tract infection, and leukopenia. Terminal complement inhibition with eculizumab increases the susceptibility to serious meningococcal infections. Eculizumab is thus contraindicated in patients with unresolved serious Neisseria meningitidis infection and patients who are not currently vaccinated against Neisseria meningitidis, unless the risks of delaying eculizumab treatment outweigh the risks of developing meningococcal infection. There are no other FDA-approved treatments for aHUS, and the safety and effectiveness of current standard treatment, plasma therapy (plasma exchange or fresh frozen plasma infusion), have not been studied in well controlled trials. Eculizumab will continue to be available only through a restricted program, and prescribers must enroll in a registration program and provide a medication guide to patients who receive the drug.

Recent increase in ceftibuten-resistant gonococci Table 1 - Percentage of Neisseria gonorrhoeae strains with reduced susceptibility to ceftibuten isolated from patients of the SHS in 2011. Month in 2011 January

Isolates with reduced susceptibility to ceftibuten 2 / 77 (2.6%)

February

0 / 94 (0%)

March

1 / 100 (1.0%)

April

8 / 95 (8.4%)

May

9 / 112 (8.0%)

June

2 / 76 (2.6%)

July

13 / 94 (13.8%)

August

26 / 130 (20%)

September

10 / 83 (12.0%)

The Centre for Health Protection is switching the standard first line treatment of gonococcal infection in SHS from ceftibuten to ceftriaxone due to reduced susceptibility to ceftibuten.

Neisseria gonorrhoeae is a Gram-negative cocci that causes genital tract infection, gonorrhea, in human. Urethritis in men and cervicitis in women are the most common clinical disease manifestation of Neisseria gonorrhoeae infection. Untreated infection may result in ascending infection such as pelvic inflammatory disease or even disseminated infection. Ceftibuten 400 mg in a single oral dose has been adopted by Social Hygiene Services (SHS) as the first line antibiotic of choice for uncomplicated gonococcal infections since 1997. It has remained

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effective against most strains of gonococci with non-susceptible rates largely less than 5% till mid 2011. Starting from July 2011, the Public Health Laboratory Centre (PHLC) of CHP detected a rise in gonococcal strains with reduced susceptibility to ceftibuten from patients of the SHS at rates of above 5% for three months consecutively. This had also been observed in some other countries such as the UK and Japan. Such reduction susceptibility is mainly conferred by the presence of a mosaic penA gene in these strains. At present, ceftriaxone is still highly active against these strains. Based on these observations, CHP is switching the standard first line treatment of GC in SHS from ceftibuten to ceftriaxone. CHP also recommended ceftriaxone to be the antibiotic of choice for empirical treatment of gonococcal infection by community based doctors.

Ellen LAI

is a pharmacist working at the Queen Mary Hospital

What can pharmacists contribute in helping patient to fight cancer? It was a busy afternoon in the Cancer Day Clinic. The waiting room was packed with patients coming for chemotherapy. Mr. E. was sitting in a corner with his wife and was waiting patiently. “Thank you for waiting Mr. E, how are you today? I am sorry to tell you it may take a little longer this afternoon before the treatment is ready, there is training underway in the aseptic suite”. I greeted him good afternoon and supplied him some pre-medications before the chemotherapy.

What is MDS? Myelodysplastic syndromes represent a heterogeneous group of clonal haematopoietic stem cell disorders characterized by ineffective haemopoiesis, cytopenias and dysplasia in one or more myeloid lineages. The major clinical problems in these disorders are morbidities caused by peripheral blood cytopenias and the potential for MDS to transform into acute myeloid leukaemia (AML).

At that moment, I noted he was holding a novel with a handmade bookmark, and I asked

The challenge of managing MDS is majority of patients are of advanced age (median age of presentation is 65 to 70 years old). In view of the complications from aggressive chemotherapy and allogeneic transplants, many patients are unable to tolerate intensive treatment.

“This is a very unique bookmark, very thoughtful of you! May I ask who the little one on the picture is?”

[Adopted from National Network (NCCN)]

“No worry love, I don’t mind waiting.” Mr. E. replied serenely - he was always calm and contented.

Comprehensive

Cancer

“This is my grandson-he is three years old now.” Mr. E. replied in delight. A proud grandfather indeed, you could feel the joy rolling on his face. “Actually I could not say enough thank you the personalised care the cancer team has provided in the past few years. I still remember the time when I learned from the doctor that I got a condition called MDS in 2008. My haematologist told me I may only live for another six months. And the only treatment available during that time was transfusions and supportive care. I am too old for bone marrow transplant. I could not help but feeling despaired - not because I was afraid of dying, but it was a shock for my family. I was holding my grandson, who was only three months old. Then I asked myself how much time may be left with my beloved family? Would there be days I could see my grandson to start walking and talking? If I passed away in a few months’ time, he may not remember me when he grown up………” Just about the same time, a turning point came along. Australian Leukaemia and Lymphoma Group (ALLG) was recruiting patients with newly diagnosed Myelodysplastic Syndrome (MDS) for a new clinical trial. The treatment involved daily oral Thalidomide and a 7-day course of daily subcutaneous injection of 5-Azacitidine 75mg/m2, with treatment cycle repeated every 28 days. It is a phase I/II trial looking at the safety and efficacy of combining the two novel agents in patients with de novo or secondary MDS. “I decided to participate in that new trial - at least this is a hope for me and my family“, said Mr. E. “Three years later and here I am! Every day when I wake up in the morning, it is a blessing! This extra time is precious, though sometimes I do feel a bit tired…which is probably the side effect from my chemotherapy. I manage to fit in a lot and spend more special moments with my family. I enjoy having a stroll with my wife in the park every day. Now my grandson can run really fast like happy feet, jumping and yelling granddad, granddad…... he truly brings lots of fun to us. What a miracle!” Pharmaceutical Care for Patients with Cancer Diagnosis of a life threatening disease can be devastating. Majority of patients experience a significant emotional distress and feeling of uncertainty about treatment, side effects and likely impact on family and the future. At the point of diagnosis, patients always have to deal with an enormous amount of complex information. Sometimes, a life changing decision has to be made at this juncture as well.

Most patients cope better when they accept the truth and learn more about their conditions. Pharmacists can play an invaluable role on patient education, counselling, providing supportive treatment or just being a good listener helping them through difficult times. With an increased understanding about anti-cancer therapy involved, some patients may feel empowered as they could take in control of what to expect from the treatment.

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Apart from surgery and radiation therapy, treatment of cancer may involve a course of complex chemotherapy regimens. Many patients are prescribed with supportive medications concomitantly to address the high toxicity profile in most cancer chemotherapy. These may include anti-emetics, anti-infective medications, analgesics, vitamin supplements, G-CSF etc. Owing to the complexity and length of the treatment, patients often have regular visits to the hospital. It enables pharmacists to develop an ongoing relationship with individuals and their carers over the course of therapy. The role of oncology/haematology pharmacists are not only confined in cytotoxic admixing and protocol screening. Pharmacists are in ideal position to promote quality use of medicines and evidence based prescribing. In collaboration with other health professionals pharmacists should assume professional responsibility in pursuing optimal pharmaceutical care plan for individual patients. The pharmaceutical care plan usually includes: • Therapeutic goals of chemotherapy – Adjuvant, neo-adjuvant, curative or palliative. • A monitoring plan for relevant laboratory measurements e.g. a baseline CBC, electrolytes, RFTs, LFTs, for certain chemotherapy gated heart pool scan (GHPS), Diffusion Lung Capacity

for Carbon Monoxide (DLCO), and nadir count. • Rationale of supportive care measures to prevent potential and expected side effects from specific chemotherapeutic regimens. • Assessment of patient’s medications compliance • Identify and make recommendations on specific medication related problems, e.g. polypharmacy, drug-drug interactions, drug-disease interactions. Pharmacist’s contributions in clinical trials Anti-cancer drug development is a fast growing area. In liaison with the principle investigators, clinical trial nurses and data mangers, pharmacists are responsible in assuring the smooth running of all clinical trials and strict adherence to trial protocol, legislative requirement and good clinical practice. Pharmacists overseeing conduction of clinical trials should be familiar with the code of practice for clinical trials e.g. standards set forth in Good Clinical Practice (GCP) and ensure confidentiality in any aspect of the studies. Our role is not confined to clerical duties such as maintenance and profiling inventory record of all trial medications. Occasionally, pharmacists could also involve in assessment and review of patient’s progress, and alerting the principal investigator of any adverse events and document any information for future assessment.

Epigenetics & Azacitadine Epigenetics refers to the heritable changes in gene expression without DNA sequence alteration. Epigenetic modfications primarily involves DNA methylations and histone modifications, both of which are potentially reversible. DNA methylation is mediated by an enzyme DNA methyltransferase (DNMT). It has been postulated that cancer was a result of aberrant methylation leading to activation of promoter gene and inactivation of tumor supressor gene. In MDS, silencing of CDKN28, a tumor suppressor gene, occurs due to its high frequency of methylation. Azacitadine is a DNMT inhibitor, which at low dose induces cell differentiation and demthylation. 75-100mg/m2 IV or SQ for 7 days repeated every 4 weeks. Treatment is recommended for at least 4 cycles and may be continued as long as patients continue to benefit. Mr. E. is doing well and in complete remission after 24-mths of study period; his CBC is within normal range where he does not require further blood transfusion and growth factor support. One of the most rewarding experiences working in the cancer care area is to see patients could survive in a life threatening illness. Seeing Mr. E is enjoying good health and quality time with his family, the cure or clinical improvement may have come from the therapeutic intervention, but the Dorothy LAM is a clinical pharmacist working at comfort and strength come from a team support, Queen Mary Hospital genuine understanding, respect for them as a person.

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