Pneumococcal Vaccine in Pediatric

Availability:

• Pneumococcal Vaccine  Polyvalent (Pneumox 23)
• Pneumococcal Vaccine, Conjugate, 13 Valent (Prevenar 13)

Recommendation:

Missed / Catch-up Doses:
Unvaccinated high risk children 2-5 years

• give 2 doses of PCV 13 (6-8weeks apart)
• Administer 1 dose of PPSV23 to children age 2 years and older at least 8 weeks after the child has received the final dose of PCV13 (if possible). 
• Children with an immunocompromising condition, or functional or anatomic asplenia should receive a second dose of PPSV23 5 years after the first PPSV23
• PPSV23 can be given for children above 2 years

Unvaccinated healthy children 2-5 years

• single dose of PCV 13 

Reference:

1. www.immunize.org/catg.d/p3086
2. Malaysian Paediatric Protocols, 3rd edition.

Ototoxicity : ARB

Based on Valsartan Drug Leaflet

• No side effect of tinnitus / ototoxicity
• Uncommon (0.1% to 1%): Vertigo

Based on Valsartan + Hydrochlorothiazide Drug Leaflet

• Rare (less than 0.1%): Vertigo, tinnitus

Based on limited evidence:

• The common side effect with ARB are vertigo, while combination with diuretics were seen to also cause tinnitus

Mechanism

• There is evidence about inner ear tissues being immunologically, biochemically and functionally related to kidney tissues.
• It seems that medications affecting sodium and potassium transport alter ionic homeostasis of the inner ear causing functional problems like hearing loss, tinnitus and vertigo  
• Renal pharmacological adverse reactions have been studied in the effort of finding predictive signs of possible ADRs related to the inner ear or to the labyrinth and about medication class’s influence upon ionic transportation.
• Resulting data showed that renal ADRs couldn’t be considered markers of pharmacologically induced disturbances to the inner ear or labyrinth.
• Nevertheless, the ability of these drugs to influence the ion transport system and the ion channels and so influencing the ear and kidney ionic homeostasis could be a predicting factor for a possible pharmaceutical related ototoxicity
• Some speculate speculate that tinnitus might be related to an imbalance between the systemic and cochlear circulation, which in turn might be related to underlying pathophysiologic conditions and drug treatment

References:

1. Prevalence of Tinnitus in Patients with Hypertension and the Impact of Different Antihypertensive Drugs on the Incidence of Tinnitus: A Prospective, Single-Blind, Observational Study.
2. Ototoxicity- the hidden menace. Neil G Bauman 
3. www.drugs.com
4. Pharmacological drugs inducing ototoxicity, vestibular symptoms and tinnitus a reasoned and updated guide. European Review for Medical and Pharmacological Sciences. 2011; 15: 601-636

Medications In Anaphylaxis

DRUGS/INDICATION	CHILDREN	ADULTS
acute onset epinephrine (IM)	0.01 mg/kg (as a 1:1000 solution) IM every 5-15 minutes, maximum 0.3 mg/dose;	0.3 to 0.5 mg (as a 1:1000 solution) IM every 5-15 minutes
cardiopulmonary arrest epinephrine (IV) severe hypotension epinephrine (IV)	children: 0.01 mg/kg (as a 1:10,000 solution) intravenously every 3-5 minutes, maximum 1 mg/dose;	1 mg (as a 1:10,000 solution) intravenously every 3-5 minutes
	children: 0.01 mg/kg (as a 1:10,000 solution) intravenously every 5 minutes, maximum 0.3 mg/dose;	0.1 mg (as a 1:10,000 solution) intravenously every 5 minutes
Adjunct severe hypotension glucagon	children: consult specialist for guidance on dose;	5 mg intravenously initially, may repeat in 10-15 min if no response, followed by 5-15 micrograms/min if response seen
persistent respiratory symptoms salbutamol inhaled:	children: 0.15 mg/kg nebulized every 20 minutes for 3 doses, then 0.15 to 0.3 mg/kg every 1-4 hours when required;	1.25 to 5 mg nebulized every 20 minutes for 3 doses, then every 1-4 hours when required
symptomatic hives and rhinorrhoea diphenhydramine + ranitidine:	children: 1-2 mg/kg intravenously/intramuscularly; children: 1 mg/kg intravenously given over 5 minutes;	25-50 mg intravenously/intramuscularly 50 mg intravenously given over 5 minutes
post-emergency stabilisation methylprednisolone: prednisolone:	children and adults: 1-2 mg/kg/day intravenously children and adults: 0.5 to 1 mg/kg/day orally

 references:

Best Practice/BMJ

Management of Anaphylaxis

Treatment Algorithm

References:

1. GUIDELINE FOR THE MANAGEMENT OF ACUTE ALLERGIC REACTION. Dis 2009.
2. ASCIA Guidelines: Acute Management of Anaphylaxis 2015 
3. Bestpractice/BMJ

Administration of Injection Diclofenac

Availability: 

• Diclofenac Sodium Injection 25mg

Based on HKGU Product

• to be given as deep intragluteal injection into the upper outer quadrant
• in severe cases, 2 injections,can be given, separated by an interval of few hours, one on each buttock
• should not be given for more than 2 days

Based on other products

• There are many available formulations of Diclofenac Injections
• The older brand of Voltarol, can either be given as IM or as IV Infusion (NOT IV Bolus)
• This is because the older generations contains organic solvents and sulfites, and are proven to be irritant when given as IV.

 References:

1. The Essence of Analgesia and Analgesics. edited by Raymond S. Sinatra, Jonathan S. Jahr, J. Michael Watkins-Pitchford
2. https://www.medicines.org.uk/emc/medicine/1339

Conversion: Beta Blockers

• Three beta-blockers—carvedilol, bisoprolol, and metoprolol XL—have demonstrated improved survival rates, reduced hospital admissions, and improved New York Heart Failure Association functional class (NYHA FC)
• both these beta-blockers have convincingly shown improved mortality and morbidity outcomes in HF, and are regarded by international experts and healthcare bodies as mandatory agents to prescribe to all HF patients unless absolute contraindications exist

Bisoprolol	Selective beta-1 blocker pharmacokinetic profile allows for once daily dosing and improved patient compliance Cheaper does not require special authority to prescribe
Carvedilol	mixed beta- and alpha-blocker more likely to cause hypotension and/or dizziness Carvedilol 25-50mg bid is the most costly of the three agents
Metoprolol XL	shown survival benefit in HF (controlled release preparation) is speculated that the controlled release preparations lead to a more pronounced and even beta-blockade over 24 hours in comparison to regular release preparations
Clinical Effectiveness	mortality reduction rates were regarded as acceptable for bisoprolol in NYHA FC I-IIIa patients. switching from carvedilol to bisoprolol is a practical and safe method for clinically stable patients with LV dysfunction may provide beneficial effects in regard to prognosis and/or reverse remodeling in patients who experience difficulty with continuation or up-titration of carvedilol because of adverse effects such as dizziness or hypotension no difference regarding impact on renal function between carvedilol and bisoprolol
Patient Selection	However, taking into consideration the COPERNICUS study, it was decided that while for the NYHA FC I-III patients, this interchange will be highly encouraged for Class IIIb-IV patients, the physicians may consider leaving the carvedilol unswitched
Caution	important to exercise caution in Japan (or equivalent countries) where the recommended maximum doses of β-blockers are less than half of those in Western countries

Dose Conversion:

• There are 2 conversion table available.
• One is based on 5:1, which is calculated based on the ratio of optimal dose needed for the mortality outcome.
• Based on recommended initial starting and target doses of these 2 beta-blockers in the various clinical trials CIBIS II, US Carvedilol Studies,12 and COPERNICUS, and the Clinical Pharmacy Practice Guidelines for HF patients developed by Singapore Ministry of Health, a 5:1 dose conversion (eg, carvedilol 12.5 mg BD to bisoprolol 5 mg OM).

• Another dosing conversion are commonly seen with British guides and recommendations. This still maintains 5:1 ratio at the optimal dose. But at lower doses, a ratio of 2.5:1 is used.

Dose Titration Guide:

 

Other Beta Blocker Dose Equivalence:

 References:

1.  PRESCRIBING AND DISPENSING NEWS  No 201 JULY 2009.
2. Drugs and Therapeutics Newsletter. Sept 2004, volume 11 (3)
3. http://www.ajpb.com/journals/ajpb/2012/ajpb_mayjun2012/therapeutic-interchange-of-carvedilol-to-bisoprolol-for-chronic-heart-failure-the-singapore-experience
4. http://www.sciencedirect.com/science/article/pii/S0914508713000579
5. http://www.globalrph.com/beta_blockers.htm
6. Advice for Primary Care Regarding Beta-Blockers in Heart Failure and QOF. South East Wales Cardiac Network 2010
7. Antihypertensive Algorithm for Patients without Diabetes. Updated July 25, 2006