Monday, July 31, 2017

Daflon:Chronic Venous Insufficiency

Availability in Hospital Keningau:
  • Diosmin 450mg & Hesperidin 50mg Tablet

Product Information:
  • There is no data on the duration of Daflon as per Product Information for Chronic Venous Insufficiency(CVI).


Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS):
  • No duration indicated.
  • According to guidelines, Relief study which included 5052 patients that received Micronised Purified Flavonoid Fraction (MPFF) over 6 months. MPFF significantly reduced symptoms and signs, and reduced ankle oedema.


Studies:
  • There is a study in which patients were given Daflon 500mg twice daily for 6 months and patients showed progressive improvement from baseline in the symptoms of CVI.
  • In another study, patients were given twice daily 500mg Daflon for 1 year, there were baseline values in physician-assessed clinical symptoms (functional discomfort, cramps and evening edema), ankle and calf circumference, and patient overall assessment of symptom severity was demonstrated at each 2-months evaluation.


References:
  • Antignani, P. L., & Caliumi, C. (2007). Medical Treatment of Chronic Venous Insufficiency. Vascular Disease Prevention, 4(2), 117-124.
  • Management of Chronic Venous Disease:Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS)
  • Daflon Product Information

Wednesday, July 26, 2017

Pertussis: Re-Vaccination for Healthcare Workers



Vaccination

  • DTaP is a vaccine that helps children younger than age 7 develop immunity to three deadly diseases caused by bacteria: diphtheria, tetanus, and whooping cough (pertussis)
  • Tdap is a booster immunization that offers continued protection from those diseases for adolescents and adults.
  • If there is an increased risk of pertussis in a healthcare setting evidenced by documented or suspected healthcare-associated transmission of pertussis, revaccination of healthcare personnel with Tdap vaccine may be considered.

Factors For Revaccination

  • Vaccinating healthcare personnel with Tdap is not a substitute for infection prevention and control measures, including post-exposure antimicrobial prophylaxis.
  • There is no supportive evidence that additional Tdap doses would prevent pertussis disease and transmission in a healthcare setting.
  • Because infants are at greatest risk for severe or fatal pertussis, healthcare personnel who work with infants or pregnant women should be prioritized for revaccination, if implemented.

Duration of protection

  • Vaccine effectiveness studies suggest the duration of protection against pertussis afforded by Tdap vaccination in adolescents is less than 4 years but is not well defined in adults; therefore the optimal interval between Tdap doses is not known.
  • a booster dose of pertussis containing vaccine is recommended for pregnant women (> 32 weeks gestation) and healthcare worker contacts who have not received a dose of pertussis containing vaccine in the preceding 5 years and no Td-IPV in the preceding month.
  • Although licensed for a single dose, it is anticipated that for continued protection from pertussis, additional doses will be required periodically, possibly up to every 10 years.

Effectiveness

  • Tdap vaccination of health care workers does not obviate the need for postexposure antibiotic prophylaxis.

Against Re-vaccination

  • Currently, NHS UK does not recommend proactive vaccination of health due to the limited supplies of the vaccine

 References:

  1. National Antibiotic Guideline 2014
  2. CASE INVESTIGATION AND OUTBREAK MANAGEMENT FOR HEALTHCARE PERSONNEL: PERTUSSIS 2010
  3. https://www.cdc.gov/vaccines/vpd/pertussis/tdap-revac-hcp.html
  4. http://www.webmd.com/children/vaccines/dtap-and-tdap-vaccines#1
  5. Pertussis Vaccination of Health Care Workers. ACOEM Medical Center Occupational Health Section Task Force on Pertussis Vaccination of Health Care Worker, 2011

Pertussis : Chemoprophylaxis


Availability in Hospital Keningau
  • Azithromycin 250mg
  • Clarithromycin 250mg
  • Erithromycin 400mg
  • Bactrim 
High Risk Groups:
  • The need for prophylaxis in the following high risk groups is particularly important infants
  •  non-immunized children
  • immuno-compromised individuals
  • pregnant women
  • individuals with chronic respiratory illness, including asthmatics
 Treat /give prophylaxis to close contacts of case with the following as a guide:
  • If symptomatic people are already beyond their infectious period, which ends 21 day after cough onset, treatment is not of use. However they should be referred for medical evaluation.
  • For asymptomatic individual, if their last exposure occurred beyond 21 days, prophylaxis is not needed.
Table 1: Antimicrobial Agents for Treatment and Prophylaxis of Pertussis
Drug
Infant<6months
INFANT ≥6
MONTHS AND
CHILDREN
Adults
Erythromycin (stearate)
< 30 days of age:
not preferred as it is
associated with infantile
hypertrophic pyloric
stenosis, Use if azithromycin is
unavailable. Dosage
is 40 – 50 mg/kg per
day in 4 divided
doses for 14 days.
1 – 5 months of
age: 40-50 mg/kg/day divided into 4 doses, for 14 days.
40-50 mg/kg/day in
4 divided doses, for
14 days (maximum
2 g/day)
2 g/day in 4 divided
doses, for 14 days.
Erythromycin Ethyl Succinate

80-100 mg/kg/day divided into q8hr or q6hr dosing for 14 days
400 mg four times a day for 14 days for 14 days*
Clarithromycin
For those unable to
tolerate
erythromycin.
Not recommended
during pregnancy.
Not recommended
for use in infants <1
month of age; for
infants >1 month of
age use child dose.
15 mg/kg/day
divided into 2
doses, for 7 days
(maximum 1 g/day).
1 g per day in 2
divided doses for a
minimum of 7 days.
Azithromycin
5-day course.
For those unable to
tolerate
erythromycin.
Preferred antimicrobial
for use in
children <1 month
of age; 10 mg/kg
per day in a single
dose for 5 days.
for infants >1
months of ag; 10
mg/kg/day in a
single dose for 5
days
10 mg/kg/day on the
first day, then 5
mg/kg once daily for
next 5 days
(maximum 500 mg).
500 mg on the first
day, then 250 mg
once daily for next 5
days.
Trimethoprim-
Sulfamethoxazole
(Bactrim®, Septra®)
Should not be used
for children <2
month of age (risk
of kernicterus);
for infants >2
TMP 8 mg/ kg per
day, SMZ 40 mg/
kg/day in 2 divided
doses, for 14 days.
TMP 320 mg per
day, SMZ 1600 mg
per day in 2 divided
doses, for 14 days.
*based on pharmakinetic and product recomendation, an alternative dosing to EES 400mg QID is 800mg BD

Caution
  • Macrolides taken by pregnant or breastfeeding mothers have been reported with
  • an increased risk of infantile pyloric stenosis. The risk is presumed to be lower for azithromycin than for erythromycin;
  • however there have been reports in the literature of pyloric stenosis in infants of women treated in pregnancy with azithromycin. 
  • Inform patients to contact their doctor if vomiting or irritability with feeding occurs.
Therapy Rationale
  • In a 2007 Cochrane systematic review of antibiotics for pertussis, the authors concluded that although antibiotic therapy for cases was effective in eliminating B. pertussis, it did not alter thesubsequent clinical course of the illness.
  • Short term use (azithromycin for 3–5 days; clarithromycin or erythromycin for seven days) was as effective as erythromycin for 10–14 days in eradicating B. pertussis from the nasopharynx and had fewer side effects
References:
  1. CASE INVESTIGATION AND OUTBREAK MANAGEMENT FOR HEALTHCARE PERSONNEL: PERTUSSIS 2010
  2. https://www.cdc.gov/vaccines/vpd/pertussis/tdap-revac-hcp.html
  3. http://www.webmd.com/children/vaccines/dtap-and-tdap-vaccines#1
  4. Guidelines for the Public Health Management of Pertussis Public Health Medicine Communicable Disease Group HSE. October 2013
  5. Pertussis Antibiotic Recommendations for Treatment and Prophylaxis. Milwaukee Health Dept (2004)
  6. Health Professionals Advice: Azithromycin now fully funded. 3 December 2012 
  7. National Antibiotic Guideline, 2014

Metformin VS Metformin XR

Drug availability in Hospital Keningau:
  • Metformin HCl 500mg Tab
  • Metformin 500mg Extended Release (ER) Tablet

Pharmacokinetics:
  • Pharmacokinetic studies demonstrate that maximum metformin concentrations are reached within about 7 hours after administration with ER formulations.
  • Immediate-release (IR) maximum concentrations are seen within about 2-3 hours.
  • The slower absorption with ER formulations allows for convenient once-daily dosing, which can improve adherence, particularly in patients taking multiple medications.

Efficacy:
  • No significant changes in terms of efficacy between both formulation
  • A randomized, double-blind, parallel trial comparing metformin IR 500 mg twice daily vs ER 1000 mg or ER 1500 mg once daily, A1c changes were similar among all three groups at 24 weeks.

GI Side Effects:
  • Adherence and tolerability are often limited by the gastrointestinal (GI) side effects of metformin, such as diarrhea, nausea, and bloating.
  • There was  a more than two-fold difference in the frequency of any GI adverse event during the first year of treatment (19.8 vs. 9.23% for immediate-release metformin vs. metformin-XR, respectively; p = 0.0414).
  • The predominant GI adverse event in these cohorts was diarrhea, which was reported in 13.50 and 3.08% of the immediate-release metformin and metformin-XR cohorts, respectively (p = 0.0169).
  • Likewise, a multisite retrospective analysis study found that GI side effects were reduced in patients transitioned from IR to ER metformin (26.34% vs 11.71%, P = .0006)

Recommendation:
  • In view of efficacy, there is no significant differences in terms of efficacy between both agents.
  • However in view of GI side effects and compliant issues, may consider to change to Metformin XR

References
  • http://www.medscape.com/viewarticle/845753
  • http://www.medscape.com/viewarticle/475277_4
  • Ali, S., & Fonseca, V. (2012). Overview of metformin: special focus on metformin extended release. Expert opinion on pharmacotherapy, 13(12), 1797-1805.


Methylcobalamin vs Neurobion

Availability in Hospital Keningau:
  • Neurobion (Vitamin B1, B6, B12)
  • Mecobalamin 500 mcg Tab
Indication:
  • According to FUKKM Neurobion is indicated for Vitamin B1, B6, B12 deficiencies.
  • According to FUKKM Mecobalamin is indicated for peripheral neuropathies.
Peripheral Neuropathy:
  • While Neurobion is not indicated for neuropathy, there was a study in which patients were prescribed Tab Neurobion for neuropathy.
  • Efficacy was judged by documenting improvement in pain of at least 2 points from the baseline as assessed by numeric pain rating scale. Neurobion was found to be efficacious in 87.4% patient.
  • In another study 108 patients with diabetic neuropathies were randomly assigned to the mecobalamin or the vitamin B 12 group
  • After 12 weeks of treatment, in addition to the significant changes of symptoms in the mecobalamin group, nerve reflection and conduction velocity were also improved to a certain extent
  • In a randomised, placebo-controlled, double-blind study in 50 patients with diabetic neuropathy. In this study, somatic and autonomic symptoms were significantly improved in the treatment group, although no statistical change was found in the neurophysiological studies.
Vitamin
NEUROBION
Individual Tab
RDA / for PN
B1 / Thiamine
100mg
10mg
·  5-30mg daily
·  Up to 300mg in deficiency
B6 / Pyridoxine
200mg
10mg
·  50-300mg
·  Doses above 1-6g can cause severe and progressive sensory neuropathy characterized by ataxia (loss of control of bodily movements)
B12 / Cyanocobalamin
200mcg
500mcg
[mecobalamin]
·  50-6000mcg/day
·  Bioavailability 25%

References:
  • RIZVI, A., AHMAD, A., & RIZVI, Z. Efficacy of Combination of Vitamin B1, B6 and B12 in Management of Diabetic Peripheral Neuropathy. age, 20(16), 5-1.
  • https://www.ncbi.nlm.nih.gov/labs/articles/18491996/
  • http://askdis.blogspot.my/2015/11/vitamin-b-for-peripheral-neuropathy.html

Thursday, July 20, 2017

Rabies: Vaccine and Rabies Immunoglobulin

Availablity in Hospital Keningau:
  • Verorab (PVRV - purified inactivated rabies vaccine, prepared on vero cell) – Sanofi Pasteur
Risk Category:
RISK CATEGORY
TYPE OF EXPOSURE
ACTION TO BE TAKEN
1
Touching/feeding animal.
Licking of intact skin.
Nil if history is reliable.
If history not reliable, treat as category 2.
2
Nibbling of uncovered skin.
Superficial scratch, no bleeding.
Licking of broken skin.
Apply wound treatment.
Administer vaccine.
Do not administer anti-rabies immunoglobulin.
Stop vaccination if animal is rabies negative in laboratory tests, or remains healthy after 10 -14 days observation (dog or cat). Continue vaccination if animal is not found/captured.
3
Bites/scratches which penetrate the skin and draw blood.
Licking mucous membrane.
Multiple bites.
Any wild animals bites
Apply wound treatment.
Administer vaccine.
Administer anti-rabies immunoglobulin.
Administer anti-tetanus and antibiotic treatment.
Stop vaccination if animal is rabies negative in laboratory tests, or remains healthy after 10 - 14 days observation (dog or cat). Continue vaccination if animal is not found/captured.



  • Effective treatment soon (within a few days, but as soon as possible) after exposure to rabies can prevent the onset of symptoms and death.
  • Post-exposure prevention consists of local treatment of the wound, administration of rabies immunoglobulin (if indicated), and immediate vaccination



Post Exposure Vaccine (PEP)
  • Indicated for Risk Category 2 and 3
  • Vaccination after exposure (post-exposure) is recommended for all individuals who have had contact with an animal (e.g., bites or abrasions) that they believe may be, or which is proven to be, rabid.
  • Area for injection for vaccine;
  • i. Adult - IM at deltoid area
  • ii. Children – IM at anterolateral aspect of thigh.
  • Pregnancy and Infancy are never contraindications to PEP.


Status
Dosing
Previously unvaccinated people
  • 4 doses at day 0, 3, 7, and 14.
  • In addition to rabies vaccine, these people should also receive a dose of RIG at the same time as the first dose of the vaccine to provide rapid protection that persists until the vaccine works

Previously vaccinated people
  • 2 doses at day 0 & 3 and RIG is unnecessary and should not be given.

Immunocompromised patient
(corticosteroids, other immunosuppressive agents, chloroquine, and immunosuppressive illnesses e.g. congenital immunodeficiency, HIV, leukaemia, lymphoma, generalized malignancy)
  • 5 doses at day 0, 3, 7, 14 and 28.
  • In addition to rabies vaccine, these people should also receive a dose of RIG at the same time as the first dose of the vaccine to provide rapid protection that persists until the vaccine works.



Rabies Immunoglobulin:
  • Rabies Immunoglobulin is indicated for Risk Category 3 only
  • Human anti-rabies immunoglobulin(HRIG)-20iu/kg body weight
  • Heterologous (equine) immunoglobulin(RIG) -40iu/kg body weight
  • Route of administration: IM at an anatomical site distant from vaccine administration.
  • If immunoglobulin is not available, it can be delayed up to 7 days post 1st vaccine given.
  • Beyond the seventh day, RIG is not recommended since an antibody response to the vaccine is presumed to have occurred.

References:
  • Interim Guideline for Human Rabies Prevention and Control in Malaysia.
  • http://www.who.int/rabies/human/postexp/en/
  • WHO Guide for Rabies Pre and Post Exposure Prophylaxis In Humans