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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 Summer is a time for holiday with sunshine and outdoor activities! While sharing the exciting moments with our friends and family, it is also a wonderful moment to share interesting cases and gather idea during Pharmacy Practice Forum in July. In the Forum, some of our colleagues shared their experience in dealing with paediatric caring. Don’t worry if you missed the forum. The forum recap will definitely help you in recalling the memory. Though we are working hard to improve the quality of pharmaceutical service, strengthening the fundamental elements of our service is also very important. Different systems have been implemented to improve the accuracy of the dispensing process in our daily practice; however, the fundamental principle of these systems may be missed. One of our colleagues shares her experience in dealing with a near-miss case and shows us the importance of staff education.

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.

October 2011

Nutritional support is one of the pharmaceutical services that we provide. Among various ready-to-use formulations on the market, it may not be easy to decide which one is the most suitable for individual patients. The Clinical Pearls focused on how pharmacists can help in suggesting appropriate parenteral nutritional product for patients. If you have encountered any interesting cases in your work, do not hesitate to share with us through the email address: [email protected].

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

Cases with atrial fibrillation (AF) are commonly seen during our daily practice though it may not be easy for us to handle. In this issue, a colleague presents us a challenge regarding AF management in the new column clinical twister, showing different considerations during providing evidence-based therapy to patients. As in previous issues, you will not miss the inspiring story as well as the young pharmacist sharing! Without contributions from a number of people, the newsletter can never be published successfully; and of course, your contribution is most welcomed! While enjoying the October issue of the SHPHK Connection, you are welcome to use this newsletter as a tool to share with other colleagues about daily operation or clinical cases during your daily work! We are looking forward to your comments and opinions!

Eva LAI is a resident pharmacist working in the United Christian Hospital.

Also in this Issue... P.1 .................................................. Editorial P.2 ........................................ Clinical Pearls P.4 ................................... Medication Safety P.5 .. Recaps from Clinical Pharmacy Forum P.5 ....................................... Clinical Twister P.8 ........................................ Inspiring Story P.10 ............................ Drug News and Alert P.12 ............... Young Pharmacists’ Sharings

http://www.shphk.org.hk

Let not be starved to death An 86 years old lady was admitted for above-knee-amputation of the left leg due to chronic wet gangrene. The right leg has also been amputated for the Are you same reason. Past medical history included hypertension, diabetes, hungry, love? Parkinsonism, previous stroke, vascular dementia with depressive features and oesophagitis due to hiatus hernia. After the surgery, the patient was transferred to a convalescent hospital for rehabilitation. However, the patient had very poor oral intake and has a drop in serum albumin from 25g/dL to 20g/dL. She also had difficulty in swallowing. Nasogastric tube had been inserted to facilitate enteral feeding but patient struggled to pull out the feeding tube. Enteral feeding was not possible unless patient was restrained. She also developed intolerance to enteral feeding and had complaints of diarrhoea. Thus, on Day 8 after surgery this patient was transferred back to an acute geriatric unit for suspected refusal of feeding due to severe dementia or post-operative catabolic state. Megestrol and cyproheptadine had been initiated as appetite stimulants; thiamine and oral phosphate were also started to prevent refeeding syndrome. When seen, this patient weighed 40kg. Since oral and enteral nutrition were failed in this patient, her doctor was considering starting short-term peripheral parenteral nutrition and asked for pharmacist's advice. How are you going to resolve this clinical problem?

This is the second article in the series of Nutrition Support in Care of Older People. You may wonder if this is an appropriate indication for parenteral nutrition. If the patient has dysphagia, enteral feeding via nasogastric (NG) tube is always a viable option. However, it becomes a challenge in patients with dementia to keep the NG tube in place. The drop in albumin may or may not be due to poor feeding: usual half life of albumin is 21 days and serum albumin may not respond as rapidly as markers e.g. prealbumin to a short term change in nutritional status.

syndrome can be described as potential fatal shifts in fluid and electrolytes that may occur in malnourished patients receiving artificial refeeding (2). Cardinal feature of refeeding syndrome is hypophosphataemia. This may be accompanied by abnormal sodium and fluid balance, changes in glucose, protein and fat metabolism, thiamine deficiency, hypokalaemia and hypomagnesaemia. For details, Mehanna et al. produced a succinct review on refeeding syndrome.

Based on NICE guideline 32 on Nutrition Support in Adults, this patient was at risk of malnutrition as she had been eaten little for more than 5 days and this poor feeding was likely to persist for some time (1). Since this patient also had dysphagia and it was not feasible to insert an NG tube, initiating parenteral nutrition is justified. There was no central catheter inserted and treatment was supposed to be short-term. Peripheral parenteral nutrition was considered.

To prevent refeeding syndrome, nutrition support should only be initiated in patients at risk at no more than 50% of requirement or at maximum 10kcal/kg/day for the first 2 days. Energy level should be increased slowly to meet or exceed full needs by Day 4-7(1,2,3). Fluid status of the patient should be closely monitored and circulatory volume should be restored if appropriate. Thiamine, phosphate and magnesium are important in glucose metabolism; whilst increased blood glucose on refeeding stimulates insulin release and leads to an intracellular shift of potassium. Thiamine should be given at 200-300mg daily PO immediately before and during the first 10 days

Before working out the energy requirement and choosing an appropriate ready-to-use parenteral nutrition product, one should be mindful of problems on referring. Refeeding

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of refeeding (2). The nutrition support regimen should provide supplementation of potassium (usual requirement 2-4mmol/kg/day), phosphate (likely requirement 0.3-0.6mmol/kg/day) and magnesium (likely requirement 0.4mmol/kg/day IV, or half dose PO) unless prefeeding levels are high (2). Vitamin B compounds, multivitamins and trace elements supplementation could also be considered. There are many different ways to work out total energy requirement when considering starting parenteral nutrition. One commonly adopted approach is to work out a regimen that

provides 25-35kcal/kg/day of total energy (2,3). Be reminded that this is the full energy need for the patient but not the target to start off with refeeding. In our case, the target daily total energy requirement is approximately 1000-1400kcal (Patient weighed 40kg). Total fluid requirement can be calculated with the formula 1500ml + (20ml/kg for every kg body weight above 20kg) and thus is 1900ml for our patient. Therefore a ready-to-use parenteral nutrition product can be chosen based on these parameters.

Kenneth CHEUNG is a pharmacist working at the United Christian Hospital

On further evaluation, the patient was found to have started refeeding with Vamin G 500ml alternating with Dextrose 5% + Sodium Chloride 0.45% (D5+1/2 NS) 500ml for the previous 24 hours. The interesting combination was made up as an alternative to Vitrimix, which has been withdrawn from market. Prefeeding levels of electrolytes were normal. Based on the estimated daily requirement 1000kcal of energy and 1900ml of fluid for this patient, two ready-to-use parenteral nutrition products in our formulary were identified as likely nutrition support to provide. Eventually, Kabiven peripheral 1440ml 1000kcal was recommended as a step-up treatment to the current combination of Vamin and D5+1/2NS. The fluid requirement was then made up with increased oral intake of water and IV fluid replacement may be considered to prevent dehydration. It was found that the in-house oral phosphate formula provided subtherapeutic dose of phosphate compared to the amount of phosphate in the chosen product. This oral phosphate supplementation for this patient was discontinued. The patient was discharged with 3-day treatment of this Kabiven product and transferred back for rehabilitation. Soon after transfer, the patient became less agitated and was put on enteral nutrition via NG tube with optimal intake. Serum albumin had slowly increased but two months later it remained low at 32g/dL. This case illustration may involve oversimplification of formulating nutrition support for a patient. It is always advisable to consult pharmacists with expertise in nutrition support service for a more comprehensive work-up. Reference:

1. National Institute for Health and Clinical Excellence. Nutrition Support in Adults. Clinical Guideline CG32. February 2006. 2. Mehanna HM, Moledina J, Travis J. Refeeding syndrome: what is it, and how o prevent and treat it. BMJ. 2008;336:1495-8. 3. Sexton J, Campbell H, Rahman M, Truner P. Parenteral nutrition in adults: the basics. Pharm J 2009;283:275-8

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Medication Incident Safety Sharing Program (MISS P) All hospital Pharmacists are encouraged to submit Medication Incident Cases and Medication Safety Solutions to the SHPHK for sharing. This is not simply an MI reporting program like those being successfully run by the public hospital network or individual private hospitals. We are not focusing on the number or frequency of the MIs. Our aim is to collect educational cases and/or solutions so that members of the SHPHK could benefit by learning from other colleagues’ unfortunate mistakes and/or innovative ideas. All submitted materials will be handled in strict confidence. The identity of the institution or the personnel involved will not be revealed. Please support us by sending your cases to Mr Michael Ling, Medication Safety Co-ordinator of SHPHK, at [email protected].

Back to the Fundamental While a senior dispenser was checking refill drugs, he found a bag of Pregabalin 150mg wrongly picked as Carbamazepine CR 200mg. The SD called for the staff concerned who was a dispenser student having her summer attachment in my hospital. “I picked it according to the location code.” The student did pick the drug from location E5C2, but the drug was not Pregabalin 150mg. This answer was alarming! The SD immediately checked the drug shelves and questioned the staff who was responsible for drug refill and drug return. He traced all recent transactions of both items to ensure no incorrect drug was dispensed. The student was then left unattended. That’s all?

added to supplement our basic standards of good dispensing practice? Have we forgotten or abandoned the most fundamental principle?

READ THE LABEL – N – Read the drug Name D – Read the Dosage form S – Read the Strength Read NDS from the picking labels, from the drug shelves, from the original bottles / packages and from the prescriptions is the ultimate solution to prevent human error in the dispensing process. Emphasize READ THE LABEL to our juniors

READ THE LABEL to Prevent Picking Error

Summer is regarded as a high risk period because we have new comers in our workforce. They are either locally-trained or Pharmacy students from overseas, or they can be Pharmacy interns and even dispenser students. Besides, from time to time, there are new colleagues joining our Pharmacy.

To minimize risk of picking error, we invented Location Code System to separate SALADs as far away as possible. Drugs are picked, guided not by the drug name and strength, but by their location code. However, have we forgotten that the procedural guidelines and systems developed were meant to be

Emphasize and re-emphasize the correct dispensing practice, i.e. READ THE LABEL, so that this basic concept is rooted in the minds of our juniors. We could help them to develop this into a habit and they will then help to influence other colleagues in keeping this as the basic requirement.

“No!” I talked to the student, “you did very well to read to location code, but did you read the drug label? Did you check what you had picked before you put it into the plastic bag?”

Demonstrate How to READ THE LABEL “I am sorry I did not read the drug name.” The student said. “Shall we do it together again?” 1. 2.

Always find the drug shelf by reading the location code, not by memorizing the location.

We went to location E5C2, according to the label.

READ THE LABEL - NDS Read out aloud or read in your heart

We read from the label: N: Pre- Ga-Ba-Lin D: Capsule S: 150mg

Read NDS from the drug package.

We took the drug box and checked if it is Pre-Ga-Ba-Lin 150mg.

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what is printed on the label

3. 4.

Check the Appearance of the drug you pick.

We took out the strip-packed drug. “Pre-Ga-Ba-Lin 150mg” was printed on the back of the strip pack. For loose-packed drugs, check if you are familiar with the size, colour and marking on the tablets / capsules.

5.

Pick required quantity.

We cut the required capsules and placed them into the labeled bag. For loose-packed drugs, count the required quantity. Check NDS from the original bottle before returning excess tablets / capsules.

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Read NDS again from the drug shelf label before We checked the drug shelf E5C2 printed with “Pre-Ga-Ba-Lin 150mg” before returning the drug. returning unused drug onto the shelf.

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Sharing on overseas attachment experience at University of Illinois at Chicago & Potential adverse reactions by “inactive ingredients” in drugs A satellite pharmacy service model was established at UIC Medical Center to cater medication needs of paediatric patients.

In the evening of 12 July, the Pharmacy Practice Forum dedicated a 90-minute discussion on paediatric clinical pharmacy. The forum was kicked off by Ms. Amanda Li, clinical pharmacist working at Queen Mary Hospital (QMH). She shared with us her 3-month overseas training in paediatric clinical pharmacy at the University of Illinois at Chicago (UIC) Medical Center. Amanda highlighted her training activities in different practice settings, including discharge counselling in general paediatrics, formulating TPN orders in neonatal ICU, multidisciplinary ward round in paediatric ICU, and medication reconciliation in a paediatric nephrology clinic. Paediatric clinical pharmacists at UIC Medical Center seems to have assumed a pivotal role in the paediatric multidisciplinary team: not only as a drug information provider but also a facilitator of transition when doctors rotate in and out of the team.

However, it was surprising to the participants of the forum that our US counterparts still employ a paper-based/manual system rather than an electronic platform to work out TPN orders. Amanda also shared a case to illustrate how US clinical pharmacists minimise leukopenia and thrombocytopenia due to mycophenolate mofetil by manipulating its dosing: changing from its usually BD dosing to QID at smaller doses based on their understanding on the drug’s pharmacokinetic.

Finally, Amanda wrapped up by sharing her works at QMH and her vision on potential paediatric clinical pharmacy services that could be incorporated into her current service model including TPN prescribing, Drug Information and Pharmacokinetic services.

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The discussion was then relayed to Ms. Cindy NG, clinical pharmacist working at Queen Elizabeth Hospital. Cindy shared her insight on potential harm of pharmaceutical excipients to paediatric patients based on what she learnt from the 44th ASHP mid-year clinical meeting. The whole discussion stemmed from a cluster of 16 neonatal deaths in the US due to benzyl alcohol toxicity. The culprit was found to be using water for injection preserved with benzyl alcohol for flushing after administration of parenteral drugs. This had resulted in metabolic acidosis, encephalopathy, intracranial haemorrhage, respiratory depression and thus deaths due to copious amount of benzyl alcohol administered. Cindy provided us with a comprehensive overview of toxicity of various commonly used preservatives: benzyl alcohol, propylene glycol, sulfites, benzoates, benzalkonium chloride, aspartame and saccharin. She also highlighted products currently used in public hospital that contains such preservatives. Subsequent to Cindy’s presentation, there has been a heated discussion on using benzyl alcohol containing preparations in paediatric population: In practice, is there any cut-off with respect to age or amount of benzyl alcohol administered that could guide “safe use” of such preparations? There appeared to be no consensus over this matter, nor does literature provide us with a sound guidance on making such recommendation. Given the

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amount to administer would be far less than flushing, a conservative approach may be to avoid using benzyl alcohol as much as possible unless the benefit outweighs the risk of using these products. For fellow pharmacists working in public hospitals, guidance could be sought from The Hospital Authority Healthcare Technology Assessment Report: Health Hazards of Benzyl Alcohol Preserved Parenteral Solutions and Medications published in 2005. And also thanks to Mr. Michael LING for sharing two relevant articles from American Academy of Pediatrics (AAP). • "Inactive" Ingredients in Pharmaceutical Products http://aappolicy.aappublications.org/cgi/re print/pediatrics;76/4/635 • "Inactive" Ingredients in Pharmaceutical Products: Update (Subject Review) http://aappolicy.aappublications.org/cgi/re print/pediatrics;99/2/268 Please note that APP has issued a statement of retirement for the second article in 2004. Its content may not be up-to-date and should be treated with caution. If you would like further details on this forum, please go to http://www.shphk.org.hk for the complete presentation files.

Kenneth CHEUNG is a pharmacist working at the United Christian Hospital

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Glad to share with you an interesting case. Let’s see what you would do if you were the pharmacist seeing this patient.

CY Chan, a 90 years old lady with the past medical history as below, 1. Hx of gastrectomy 20+ years ago 2. Hx of cholecystecomy 3. Hx of adhesive IO with enterotomy done in 2002 and 2003 4. Hx of chronic gastritis with intestinal metaplasia on OGD in 1/2011 5. HT 6. OA knee This time, she was admitted to the hospital p/w bilateral LL swelling for a couple of days.

P/E Alert with good BP control Bilateral pitting ankle edema up to knee (Left >right) Calves bit firm on left; non-tender Chest - No wheeze CVS – HS I+II; no murmur Abdomen -soft and non-tender Neuro- non focal CXR showed cardiomegaly with only minmal pulmonary congestion ECG showed AF; Q III, no ST/T changes

Labs K: 2.7 mmol/L (3.3 mmol/K after 2 doses of 1g syrup K)

Imp: CHF, newly onset AF

SCr: 73 mcmol/L; Urea 7.6 mmol/L; Albumin 21 g/L

Current Medication List 1. FeSO4 300mg BD 2. MV 2tab daily 3. Adalat R 20mg BD 4. Pariet EC 20mg daily

Total Bilirubin 9 mcmol/L; AST: 21 U/L; ALT 18 U/L; ALP: 149 U/L Iron: 11; TIBC:12; TRF saturation: 97; Hgb 8.8 g/dL (static); RBC 4.13 1012/L; MCV 67.4 fL; MCH 21.3 pg; MCHC 31.4 g/dL; Plt 355 109/L

Mx - Oral lasix with good response - Off FeSO4 - Add SFI Plavix for AF

So fellow pharmacists, do you have any recommendation(s) on the above treatment? Send us your patient assessment(s) to [email protected] to win a prize! Gift Coupon for Medical Reference Books will be awarded to the participants who give BEST THREE ASSESSMENTS and their recommendations will be published in the next issue. ********************************************************************* Are you puzzled by a clinical situation that would make a good topic for this column? Or do you relish an opportunity to test your skill in resolving a clinical challenge? Please send us a clinical scenario or indicate your interest in providing us with a patient assessment by e-mailing us at [email protected].

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The Fourth Message In a time before civilization, a settlement of a few thousand people was established along the Great River Valley. The river provided a fertile piece of land where the people could grow crops and rear livestock. The population multiplied and flourished. The people respected the river and worshiped it as the Great River God. Thanksgiving rituals were performed every Spring and the people would wish for a good year to come. Once every few years, there would be heavy rain storm and overflowing of the river. The whole region would be flooded, crops would be destroyed and livestock and human would be flushed away. The people attributed this to the wrath of the Great River God because of their wrong doings. In order to appease the super being, they would sacrifice a teenage child every Autumn and threw him into the river to drown. Although the sacrificial rite did not always work, it was still performed year after year. The child would be selected by the Chief of the tribe, and every family dreaded the day when the selection was due. Then one year, as the Chief was getting old and frail, some of the villagers came forward and disputed the way a child was chosen. It was criticized to be unfair, because the Chief always chose a child from a poor family and never someone among his own relatives. They accused the Chief of conspiracy with the more prestigious clans by taking gifts in return for a favor for not choosing someone‛s child. They demanded a fair way of selection. They requested that each adult person would place a pebble in front of the door of a household. The household with the most pebble would donate a child for the sacrificial offering. This new way of picking the child was said to be fair and reasonable. It was practiced for several years, until some people gathered together and plotted against the richer households, for the latter was a minority in number within the population. And in return some rich folks would pay the others to drop the pebbles elsewhere. A supposedly fair system lost its original virtue. Soon, the villagers were divided in their support for the autocratic and democratic ways of sacrifice selection. Violence broke out among fractions of the population, while sadly floods continued to devastate the land. Then one day, a man in ragged clothes, bearded face and unkempt hair came to the village. He told the villagers he has a better way to prevent the flood. They took him to the Chief for questioning. “I was one of the children whom you threw to the river many years ago. I was saved by the Great River God, who now sends me back to you to give you four important messages,” said the man calmly and with confidence. “What are these messages?” asked the Chief suspiciously in front of the crowd. “The Great River God wants you to move your people up the slope of the valley; build houses there instead of near the river. Plant fruit trees on high lands and keep paddy fields on low lands,” announced the bearded man loudly, “This is his first message.” The Chief thought the suggestion reasonable and ordered the whole village to start building homes and farms up the hill. After a month, the man instructed the Chief again, “ask the stronger men of your village to come with me. We will carry boulders to the two sides of the river and build dykes along its length.” The boulders, mixed with mud and sand, formed an elevated embankment that could contain the water within the river despite raised water levels. “This is the second messages from the Great River God!” The man explained. At the same time, the man made the Chief mobilize the female and younger folks to dig many wide trenches along the contour of the land, each one leading back to some points along the downstream of the river. Dams with gates would lead excess water away from the river, and these canals would in turn irrigate the farm lands as well as lower the water level of the river. They even built reservoirs to keep the water for drier seasons. “This is the third message.”

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Reflections on Medication Reconciliation

After the construction work was completed, the heavy rain did come. Miraculously this year, the water from the river did not flood the land. Water was diverted away from the river, keeping the water levels below the height of the embankment. Both crops and lives were preserved. Excess water was stored in the reservoir, and the rest flowed along the canals, keeping the paddy fields irrigated. The people were amazed by the wisdom of the man. The Chief wanted to make the man his successor. And this time, instead of opposing the decision of the Chief, every villager placed a pebble at the front door of the man‛s hut, signifying support to elect him as his Chief and leader. People asked him about the last message from the Great River God. The man smiled, and said, “The last message is that the Great River God respects lives and loves children. He never wanted you to sacrifice any human beings for him.” His voice was filled with regret for the children that had lost their lives due to the ignorance of the people. “And difficulties must be faced head on and never relegated to simple decisions like offering sacrifice,” he continued. “Decisions should not be made by one person, nor by vote casting without having thoroughly understanding the nature of the problem, or appreciating the different interests vested among the people. There are more than two ways to deal with problems. The only solution that will work is one based on knowledge and support by the people,” he took a long breath, “and this is the ultimate message.” ***************

Having grown up under colonial rule, and subsequently reverted back to an autocratic motherland, the people of Hong Kong are understandably yearning to break away from the yoke, and enjoy the freedom of deciding on their own fate. The struggle for political democracy is justified and should be well respected. However, while democracy is by far a better system than dictatorship, it should perhaps not be relied upon as the ultimate solution for every trouble society faces today. Democracy has its own pitfalls. Such minority-obeys-majority system, if based solely on vested interest of individuals, may lead to win-lose outcomes. In countries with a more mature stage of democratic development, issues are thoroughly discussed and debated, the interest of the minority is protected, and the overall progression of the country is recognized. There are many examples of democratic states resorting to violence when the fractions are divided. Back in our workplace, no one would expect our department to be run democratically, our boss be elected by the workers, or every decisions be put to a vote. We often complain that we have to do what we are told, like “a crab trapped under a rock”. Should democracy be introduced into the workplace? On the other hand, some departments may let certain decisions be made by voting or drawing lots, e.g. leave quota allotment, shift regimens, unforeseen relief duties, overtime stay behind. Often times, voting is made without due consideration processes. While dictatorship may seem more efficient and democracy may seem more fair, it may be worthwhile to explore on a third alternative : consultative autocracy. Opinions from the majority should be harvested, discussion with reasoning should be encouraged, and the final decision should then be made by a small group of people responsible for the overall management of the department. Knowledge, reasoning and the interest of the minority should be the basis of such decision.

Storyman

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FDA modifies dosing recommendations for Erythropoiesis-Stimulating Agents On June 24, 2011, the U.S. FDA recommended more conservative dosing guidelines for erythropoiesisstimulating agents (ESAs) when used to treat anaemia in patients with chronic kidney disease (CKD) because of the increased risks of cardiovascular events such as stroke, thrombosis, and death. Product labels for ESAs have recommended dosing to achieve and maintain hemoglobin levels within the range of 10 to 12 grams/deciliter (g/dL) in patients with CKD. The modified package insert removes this previous concept of a “target hemoglobin range.” The modified recommendations for dosing ESAs in patients with CKD are based on data from clinical trials including TREAT (Trial to Reduce Cardiovascular Events with Aranesp Therapy), which showed that using ESAs to target a hemoglobin level of greater than 11 g/dL increased the risk of serious adverse cardiovascular events, such as heart attack and stroke, and provided no

additional benefit to patients. As a result, the package insert for ESA products now recommends individualising dosing and using the lowest dose of ESA sufficient to reduce the need for transfusion for each patient. For patients with the anaemia of CKD NOT on dialysis: - Consider starting ESA treatment only when the hemoglobin level is less than 10 g/dL and when certain other considerations apply. - If the hemoglobin level exceeds 10 g/dL, reduce or interrupt the dose of ESA. For patients with the anaemia of CKD on dialysis: - Initiate ESA treatment when the hemoglobin level is less than 10 g/dL. - If the hemoglobin level approaches or exceeds 11 g/dL, reduce or interrupt the dose of ESA.

FDA approves rivaroxaban to reduce risk of DVT after hip, knee replacements On July 1, the U.S. FDA approved rivaroxaban (Xarelto, Bayer) for the prevention of venous thromboembolism (VTE) in adult patients undergoing elective hip or knee replacement surgery. Rivaroxaban is a highly selective direct factor Xa inhibitor with oral bioavailability. Inhibition of Factor Xa interrupts the intrinsic and extrinsic pathway of the blood coagulation cascade, inhibiting both thrombin formation and development of thrombi. Rivaroxaban does not inhibit thrombin (activated Factor II) and no effects on platelets have been demonstrated. The recommended dose is 10 mg rivaroxaban taken orally once daily. The initial dose should be taken 6 to 10 hours after surgery, provided that haemostasis has been established. The duration of treatment depends on the individual risk of the patient for venous thromboembolism which is determined by the type of orthopaedic surgery. The recommended treatment duration is 5 weeks for major hip surgery and 2 weeks for major knee

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surgery. More than 6,000 patients undergoing hip or knee replacement surgery received rivaroxaban in clinical studies. Among patients undergoing knee replacement surgery, 9.7% of those treated with rivaroxaban had VTE compared with 18.8% of patients who received enoxaparin. In a study involving hip replacement surgery, 1.1% of patients who received rivaroxaban had VTE compared with 3.9% of those who received enoxaparin. In another study of hip replacement patients, 2.0% of those treated with rivaroxaban had VTE compared with 8.4% of those who received enoxaparin. Commonly reported side effects include nausea, bleeding, anaemia, increased transaminases and increased GGT.

FDA approves indacaterol for COPD On July 1, 2011, FDA approved indacaterol inhalation powder (Arcapta Neohaler, Novartis) for the long term, once-daily maintenance bronchodilator treatment of airflow obstruction in patients with chronic obstructive pulmonary disease (COPD), including chronic bronchitis and/or emphysema. Indacaterol is a long-acting beta2-adrenergic agonist. The recommended dosage is one 75-microgram capsule inhaled once daily. Apart

from its licensed indication, indacaterol is not indicated to treat acute deteriorations of COPD or asthma. The safety and efficacy of indacaterol was demonstrated in six confirmatory clinical trials that included 5,474 patients ages 40 and older with a clinical diagnosis of COPD. Those treated had a smoking history of at least one pack a day for 10 years and exhibited moderate-to-severe decreases in lung function. Most common adverse reactions (>2% and more common than placebo) are cough, oropharyngeal pain, nasopharyngitis, headache and nausea.

Belatacept for Kidney Transplant Patients The US Food and Drug Administration (FDA) approved belatacept (Nulojix, Bristol-Myers Squibb Company) for the prophylaxis of organ rejection in adult patients receiving a kidney transplant, in combination with basiliximab induction, mycophenolate mofetil (MMF), and corticosteroids. Belatacept, a selective T-cell (lymphocyte) costimulation blocker, binds to CD80 and CD86 on antigen-presenting cells thereby blocking CD28 mediated costimulation of T lymphocytes. Belatacept was evaluated in two open-label, randomized, multicenter, controlled Phase 3 studies enrolling more than 1,200 patients and compared two dose regimens of belatacept with another immunosuppressant, cyclosporine. They demonstrated that the recommended belatacept regimen is safe and effective for the prevention of acute organ rejection. The recommended dosage of belatacept is as follows:Initial phase: 10mg/kg IV on Day 1 (day of transplantation, prior to implantation), Day 5 (approximately 96 hours after Day 1 dose), end of Week 2, Week 4, Week 8 and Week 12 after transplantation; Maintenance phase: 5mg/kg IV at the end of Week 16 after transplantation and every 4 weeks (plus or minus 3 days) thereafter. Most common adverse reactions (≥20% on belatacept treatment) are anaemia, diarrhoea,

urinary tract infection, peripheral edema, c o n s t ip at io n, hypertension, pyrexia, graft dysfunction, cough, nausea, vomiting, headache, hy p o k a l e m i a, hyperkalemia, and leukopenia. Belatacept is associated with increased risk for post-transplant lymphoproliferative disorder (PTLD), predominantly in the central nervous system. It is used only in patients who are EBV seropositive, and is contraindicated in patients who are EBV seronegative or with unknown serostatus because the risk of PTLD is particularly increased in patients who are EBV seronegative. Use of belatacept has not been established for the prophylaxis of organ rejection in transplanted organs other than kidney. Use in liver transplant patients is not recommended due to an increased risk of graft loss and death in a clinical trial with more frequent administration of belatacept than studied in kidney transplant, along with MMF and corticosteroids.

Ellen LAI

is a pharmacist working at the Queen Mary Hospital

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「 多功 能 」 產 物

現 今 社 會 越 來 越 追 求 多功 能 的產 品，多功 能 智 能 手 提電 話 便 是 其 中 一 個 表 表 者，現 在 幾 乎人 人都 機 不 離 手… … 這 些 產 品 都 與 我 們 的日常 生 活息 息相 關，進佔生 活 的 一定 地位。無 疑，它們 為 我們帶 來便利。但 是，在 帶 來 方便 的同時，大 家有否 想 過，它們也 為我們帶 來危 機 呢？假 如， 不 幸 地，現在你 的智 能 手 提電 話 遺 失了，你會否 感到徬徨無 助？想找朋友求助嗎？但 是，所有聯 絡 資 訊 都 遺 失了。想 看 看 今 天 的 約 會 時 間 地 點 嗎？可是，「行事曆」都沒有了。作出反 思，在日 常生活中，我們又 是否太 過倚賴某一人和事呢？ 萬 一 稍 有 差 池，我 們 又 有 何 應 急 之 策？我 們 有 「備份」嗎？ 在我們 的工作 環 境，也不 難 察覺 有些「全能」的 同事 在我們 的身邊 默 默耕耘。例如，有些「電 腦 專才」一手包辦藥房整個電腦系統，從藥房網頁 到 藥 物 包 裝自建 的電 腦 系統 去改善 藥 物安全管 理，用甚麼 A pache, Php, My SQL , XO OPS 去 建構伺服器、資料庫和網頁程式，對 很多人來 說 這 些 都 是 看不 明 聽 不懂 的 外 星 文 字，更 不用 說要去駕馭它們。又例如，有些藥劑師有豐富的 臨 床 專 科 知 識 和 經 驗，在一 些專 科 病 房 出 謀 獻 策。他們，都 在我們 的身邊 充當顧問 的 角色，解 決各種奇難雜症，為藥房建立形象，為藥劑專業 出一分力。

然 而，今 年 晉 升 機 會 多，同 事 升 職 或 另謀 高 就 去別處 工作，應該替他們高興。但是，所謂居安 思危，假 若這 些「專家」離 我們而去，我們 又會 否 頓 時 感 到 徬 徨 失 措 呢？未 雨 綢 繆，防患 於 未 然，我 們 必 需 要 做 好 準 備。薪 火 相 傳 是 辦 法。 「一 代傳一 代」，讓專家訓練出新一 代的專家， 這一份才能和智慧才得以好好承傳。星星之火， 可以 燎 原，要 藥 劑 專 業 繼 續 發 熱發 亮，我 們 必 須要團結，分享大家的成果，使其發揚光大。 同時，我們每一位也一定要好好裝備自己，為迎 接 每 一項 新挑 戰做 好準備。將 來 藥 劑專 業 的 漫 漫 長 路 並不 易 走，現 在 只可以 說 是 一 個 開 始。 從改善日常藥 房 運作到 專 科知 識，在 將 來香 港 藥 劑 業 發 展 上 都 缺 一不可。或 許，我 們 需 要 更 多全能之士，去承擔和付出。你，準備好了嗎？ 今 時 今日，我 們 都 緊 貼 著 潮 流。多功 能 智 能 產 品 的 普及程 度可謂空 前絕 後；藥 劑 專 業 的 發 展 也一 樣，多方面的 發 展 正引導 著 我們 邁向 一 個 新紀元。

輕苗淡寫 張樂朋 聖母醫院駐院藥劑師 Michael LING

is a pharmacist working at the Kwong Wah Hospital

In Hong Kong drugs with abuse potential are listed under the Dangerous Drugs Ordinance, Chapter 134, Laws of Hong Kong. So why not DD or DDO? Where does the “A” come from? No one can affirm why we refer DD as DDA in Hong Kong, or when it first started. But my personal suspicion is that narcotics and drugs of abuse were once controlled under the Dangerous Drugs Act of the UK. In Britain, nurses and pharmacists did refer them as DDA, but that was ages ago. This term might have been imported by our predecessors who came or came back from the U.K. And once it arrived, it stays. So do our British counterparts still call these drugs DDA? No! History has it that in the 1910’s, the UK became aware of the need to control narcotics. The Dangerous Drugs Act was established in 1920. (“Act” is the UK’s equivalent term for chapters of law to “Ordinance” in Hong Kong). The DD Act served the country for over 50 years, and was replaced by the Misused of Drugs Act in 1971. Under the MDA, the list of drugs of abuse has expanded, and narcotics, stimulants, cannabis, etc are referred to as “Controlled Drugs”. Nurses and Pharmacists now call them CD. So even the British do not use the term DDA any more. Well, knowing the history, would you not think it is a sign of ignorance and complacency to use the term DDA? Being the specialist in drugs, should pharmacists not take the lead to use the correct term? Of course, it is not a matter of life and death, just a bit ridiculous. So let’s drop the “A” and just say “DD” to our nursing colleagues. Oh, one more thing ….. there are still places where narcotics are controlled by a Dangerous Drugs Act. Examples include, the Philippines, Malaysia, the Bahamas, Jamaica, Mauritius, and even Soloman Islands. If we work there, let’s speak of “DDA”, but not in Hong Kong.

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