Supplementation in Osteoarthritis

• role of diet or dietary supplements in the treatment of osteoarthritis (OA) remains unclear.
• Research into diet as an independent factor has focused on antioxidants (eg, vitamins C and E) and on vitamin D.
• use of glucosamine and chondroitin for osteoarthritis (OA) has been controversial, and these widely used remedies are of uncertain benefit; results of randomized trials have varied

Chondroitin and Glucosamine

• Glucosamine typically been studied at a dose of 500 mg three times daily, and chondroitin at a dose of 400 mg three times daily.
• Glucosamine should not be administered to patients who are allergic to shellfish.
• The balance of evidence from high-quality trials has shown little to no evidence of clinically meaningful benefit

Evidence

• A 2015 Cochrane review of 43 randomized trials including 9110 patients with mostly knee OA found that chondroitin, either alone or in combination with glucosamine, resulted in a statistically significant improvement in pain scores in studies with <six months of follow-up. 
• Although the benefit was considered clinically meaningful, the effect was small, with an 8-point greater improvement of pain (range 0 to 100) from mostly low-quality trials
• In a multicenter randomized non-inferiority trial, 606 patients with severe pain from knee OA were treated with either the combination of chondroitin sulfate and glucosamine or celecoxib. At six months follow-up, there were no significant differences between the two groups in reduction in pain, stiffness, functional limitation, and joint swelling. 
• However, important limitations of the study design include the lack of a placebo arm as well as the preparation of the chondroitin and glucosamine, which may not be generalized to other compound mixtures

Vitamin C

• analyzed data strongly suggested a relationship between vitamin C intake and progression of OA; the risk of progression was reduced threefold in patients with mean vitamin C intakes above 152 mg per day.

Vitamin E and Beta Carotene

• may also reduce the risk of progression, but the data on these nutrients were less consistent.
• In comparison, intake of these three nutrients did not affect the rate of development of OA
• In contrast to the observational data, the administration of vitamin E (500 international units per day) for six months did not provide pain relief or prevent radiographic progression

Vitamin D

• risk of OA progression increased threefold in patients with low vitamin D intake
• Other observational data have also suggested an association with pain and radiographic
• low intake and serum levels of vitamin D did not increase the risk for developing OA in the Framingham follow-up analysis
• several randomized trials of vitamin D treatment have found no benefit from this approach, although one trial reported a small degree of symptomatic improvement

Recommendations

• Not routinely recommend to use glucosamine and chondroitin for OA these medications, but there appear to be few risks associated with their use. 
• In patients who use these medications we advise their discontinuation if significant relief is not achieved after a six-month trial
• Supplementation with these agents for the treatment of OA is not suggested; randomized trials have failed to confirm that dietary supplementation with such agents can provide the potential benefits suggested by data from observational studies

References

• www.uptodate.com

Malaria: Treatment

 

 

 Reference:
CPG 2014: Management Guideline of Malaria in Malaysia

Amphotericin B: Toxicity Management

• Eventhough the guide above suggests that test dose is not required, based on the individual products, Test dose is recommended
• for guide on Test Dose and Administration, refer to http://askdis.blogspot.my/2016/02/amphotericin-b-stability-and.html 

Reference:
Guideline for the prevention, diagnosis and management of cryptococcal meningitis among HIV-infected persons: 2013 update

Crytococcal Meningitis : Treatment

 References:

1. Clinical Practice Guidelines for the Management of Cryptococcal Disease: 2010 Update by the Infectious Diseases Society of America
2. Guideline for the prevention, diagnosis and management of cryptococcal meningitis among HIV-infected persons: 2013 update

PID: Treatment

	Recomended	Alternatives
NAG 2014
IV Therapy (for moderate to severe disease):	Cefuroxime 1.5gm IV q8h OR Ceftriaxone 2gm IV q24h PLUS Doxycycline 100mg PO q12h PLUS Metronidazole 500mg IV/PO q8h Duration of treatment is 14 days	Ampicillin/Sulbactam 3gm IV q6h PLUS Doxycycline100mg PO q12h
Outpatient therapy (for mild disease)	Ceftriaxone 250mg IM in a single dose OR Cefotaxime 1gm IM in a single dose PLUS Doxycycline 100 mg PO q12h for 14 days	Ceftriaxone 250mg IM in a single dose OR Cefotaxime 1gm IM in a single dose PLUS Azithromycin (1gm once per week for 2 weeks)
CDC STD Treatment Guideline 2015
IV Therapy	Clindamycin 900 mg IV every 8 hours PLUS Gentamicin loading dose IV or IM (2 mg/kg), followed by a maintenance dose (1.5 mg/kg) every 8 hours. Single daily dosing (3–5 mg/kg) can be substituted	Ampicillin/Sulbactam 3 g IV every 6 hours PLUS Doxycycline 100 mg orally or IV every 12 hours
IM/Oral Therapy	Ceftriaxone 250 mg IM in a single dose PLUS Doxycycline 100 mg orally twice a day for 14 days WITH* or WITHOUT Metronidazole 500 mg orally twice a day for 14 days Other parenteral third-generation cephalosporin (e.g., ceftizoxime or cefotaxime) PLUS Doxycycline 100 mg orally twice a day for 14 days WITH* or WITHOUT Metronidazole 500 mg orally twice a day for 14 days	Azithromycin (500 mg IV daily for 1–2 doses, followed by 250 mg orally daily for 12–14 days (as monotherapy) OR In combination with metronidazole (12 days) Azithromycin 1 g orally once a week for 2 weeks in combination with ceftriaxone 250 mg IM single dose

Rationale for IV

• doxycycline should be administered orally when possible (due to pain). Oral and IV administration of doxycycline provide similar bioavailability.
• Although use of a single daily dose of gentamicin has not been evaluated for the treatment of PID, it is efficacious in analogous situations
• For the clindamycin/gentamicin regimen,  oral therapy with clindamycin (450 mg orally four times daily) or doxycycline (100 mg twice daily) can be used to complete the 14 days of therapy. 
• However, when tubo-ovarian abscess is present, clindamycin (450 mg orally four times daily) or metronidazole (500 mg twice daily) should be used to complete at least 14 days of therapy with doxycycline to provide more effective anaerobic coverage than doxycycline alone.
• Ampicillin/sulbactam plus doxycycline has been investigated in at least one clinical trial and has broad-spectrum coverage.  Ampicillin/sulbactam plus doxycycline is effective against C. trachomatis, N. gonorrhoeae, and anaerobes in women with tubo-ovarian abscess.
• Another trial demonstrated high short-term clinical cure rates with azithromycin, either as monotherapy for 1 week (500 mg IV daily for 1 or 2 doses followed by 250 mg orally for 5–6 days) or combined with a 12-day course of metronidazole

Rationale for IM/Oral

• these regimens are similar to those treated with intravenous therapy
• Patients who do not respond to oral therapy within 72 hours should be reevaluated to confirm the diagnosis and should be administered parenteral therapy on either an outpatient or inpatient basis
• No data have been published regarding the use of oral cephalosporins for the treatment of PID.
• addition of metronidazole should be considered to provide anaerobic coverage
• The recommended third-generation cephalsporins are limited in the coverage of anaerobes. Therefore, until it is known that extended anaerobic coverage is not important for treatment of acute PID, the addition of metronidazole to treatment regimens with third-generation cephalosporins should be considered
• Azithromycin has demonstrated short-term clinical effectiveness in one randomized trial when used as monotherapy) or in combination with metronidazole , and in another study, it was effective when used
• If allergy precludes the use of cephalosporin therapy, use of fluoroquinolones for 14 days (levofloxacin 500 mg orally once daily, ofloxacin 400 mg twice daily, or moxifloxacin 400 mg orally once daily) with metronidazole for 14 days (500 mg orally twice daily) can be considered

References:

1. http://www.cdc.gov/std/tg2015/pid.htm
2. National Antibiotic Guideline 2014
3. www.uptodate.com

Bromelain / Pineapple : Use and Effectiveness

Availability

• not available in hospital
• available in community as part of medication to assist digestion (Quest Enzyme Digest)
• product containing bromelain is available in UK and some other countries 

General

• Bromelain is a mixture of enzymes found in pineapples (Ananas comosus) that digest protein (proteolytic).
• Pineapple has been used for centuries in Central and South America to treat indigestion and reduce inflammation

Surgery, Sprains and Strains, and Tendinitis

• Although studies show mixed results, bromelain may reduce swelling, bruising, healing time, and pain after surgery and physical injuries.
• It is often used to reduce inflammation from tendinitis, sprains and strains, and other minor muscle injuries.
• Studies of people having dental, nasal, and foot surgeries found it reduced inflammation.
• In Europe, bromelain is used to treat sinus and nasal swelling following ear, nose, and throat surgery or trauma.

Wounds and Burns

• Studies in animals suggest that bromelain, when applied to the skin, may be useful in removing dead tissue from third-degree burns, a process called debridement.
• One preliminary study of a debridement agent that is derived from bromelain to treat people with second- and third-degree burns showed a benefit.
• Severe burns require a doctor's care.
• Do not apply bromelain to broken skin.

Sinusitis (Sinus Inflammation)

• Although not all studies agree, bromelain may help reduce cough and nasal mucus associated with sinusitis.
• It may also relieve the swelling and inflammation caused by hay fever.

Infection

• Evidence from test tube and animal studies suggests that bromelain can kill some viruses and bacteria.
• More research, including human studies, is needed to see whether it truly works.

Contraindications/interaction

• Bromelain is POSSIBLY SAFE for most people when taken in appropriate amounts. Bromelain may cause some side effects, such as diarrhea and stomach and intestinal discomfort
• Not enough is known about the use of bromelain during pregnancy and breast-feeding. Stay on the safe side and avoid use.
• Bromelain might increase the risk of bleeding during and after surgery. Stop using bromelain at least 2 weeks before a scheduled surgery
• Taking bromelain might increase how much antibiotic the body absorbs. Taking bromelain along with some antibiotics might increase effects and side effects of some antibiotics
• demeclocycline (Declomycin), minocycline (Minocin), and tetracycline (Achromycin), Amoxicillin

Recommendations

• May be effective in reducing inflammation from infection and injuries.
• Dietary consumption of pineapple (fruit or juice) may not achieve similar amount of bromelain used in the study
• Benefit in cough and cold in pediatric compared to cough and cold products is not substantiated as cough and cold products are reported as ‘ineffective in pediatrics’.

References

1. http://umm.edu/health/medical/altmed/supplement/bromelain
2. http://www.webmd.com/vitamins-supplements/ingredientmono-895-bromelain.aspx?activeingredientid=895&activeingredientname=bromelain

Eye Drops vs Ear Drops

• One reason for this is that eye drops must be sterile. Some ear drops are sterile (e.g., Ciprodex, Floxin Otic [U.S.], etc), but some are not (e.g., Cipro HC [U.S.], etc).
• Plus, eye tissue is much more sensitive than ear tissue.
• Ear drops are generally more acidic than eye drops, and can be irritating to the eyes
• eye drops can’t automatically be substituted for ear drops to help patients save money. Eye drops must be specifically indicated on the prescription
• There are reports of errors where ear drops have been administered into patients’ eyes. Putting these products in the eyes can cause redness and swelling of the eyes, and blurred vision.
• Flushing the eyes with water or saline, and a visit to the emergency department or ophthalmology clinic might be required

Storage

• Most eye drops and ear drops can be stored at room temperature. However, there are a few commonly used eye drops that do require refrigeration.
• Both Azasite (azithromycin, U.S. only) eye drops and Xalatan (latanoprost) eye drops should be stored in the refrigerator. Remember this when you are locating the product in the pharmacy to dispense.
• Fortunately, these products can be left at room temperature for a number of days (six weeks for Xalatan and 14 days for Azasite) after they are dispensed to patients.
• Proparacaine (Alcaine, etc) eye drops also need to be refrigerated. Plus patients need to refrigerate proparacaine eye drops once they are dispensed. Make sure to affix an auxiliary label to indicate this if you dispense proparacaine eye drops.
• Proparacaine isn’t likely to be dispensed commonly in outpatient settings.
• To prevent mix-ups between eye drops and ear drops, it’s a good idea to store these products in separate places in the pharmacy, or use shelf tags.

How to Supply

• most common conversion for drops to mL is 20 drops/mL.
• However, some insurance companies or employers might require you to use a conversion of 15 or 16 drops/mL.

Reference:

1. www.PharmacistsLetter.com
2. https://www.ismp.org/newsletters/acutecare/articles/20061019.asp