I spared a mother further sleepless nights

One mother came in to see specialist. Her child also took medicine from a GP. Came to my bench and I went thru her child's current meds and asked if the child is taking any other meds.

She was wise enough to draw a list. I went through with her the drugs and which not to take together. Saw triprolidine plus pseudoephedrine (Actifed). Pointed to her that when child takes this, child may not go to sleep easily.

She looked at me, then look at the child then gave a face and said ,"Doctor never told me."

Then told her to give it to child 3-4 hours before bed time.

Propofol coma vs ES

Wah heng ah. Got read this abstract before exam.

A. Borgeat1 , O. H. G. Wilder-Smith1, P. Jallon2 and P. M. Suter1

(1) Department of Anaesthesiology, Geneva University Hospital, 24 Rue Micheli-du-Crest, CH-1211 Geneva 14, Switzerland
(2) Department of Neurology, Geneva University Hospital, 24 Rue Micheli-du-Crest, CH-1211 Geneva 14, Switzerland

Abstract Status epilepticus is one of the most frequent neurological emergencies in the intensive care unit. Standard treatment includes intravenous barbiturates, benzodiazepines and phenytoin. However, drug coma is sometimes necessary to control refractory status epilepticus. We report such a case, successfully treated by intravenous propofol coma to EEG burst suppression

Intensive Care Medicine Volume 20, Number 2 / February, 1994 0342-4642 (Print) 1432-1238 (Online)

Blog response: Wenky's eye drop misadventure

http://wenkyland.blogspot.com/2007/04/amidst-swelling.html#comments

How to apply eye drops - the better way.

A lot of people apply eye drops using the following method:
1. Open eye
2. Drip the amount stipulated
3. Close eye
4. Shake head

- This will cause poor adsorption/absorption and some of it will run down into your mouth.

Proper methods should be used to instill eye drops especially those on anti - HTN and have glaucoma as well. I.e. Patients using timolol eye drops may experience drug-induced heart failure or orthostatic hypertension as the drug starts working systemically instead of just within the occular region.

The correct way:

1. Place thumb and index finger at the top of your nose.
2. Press down on lower eye lid and pull gently down
3. You may be able to see a tiny hole in the edge of the eye lid (in the mirror), that is a duct which you should press on if not the drug will flow into your mouth instead of staying on your eye.
4. Practice a few times holding down your lower eye lid to form a cup for holding your eye drop while maintaining a good amount of pressure on the duct.
5. When applying eye drops, always apply only 1 drop every 5 mins - this is the max amount your eye can take at one go.
6. Carefully drip one drop into the cup you form from the lower eye lid and slowly close your eye. If you close too fast, you may extert too much pressure, causing the eye drop to spill out.
7. Move your eyes through 6 cardinal points while closing your eye to distribute the eye drop evenly.

You may wish to do this one eye at a time and remember - only 1 drop per eye per 5 minutes while pressing on the duct.

With the eye drop flowing down the throat, the taste would be usually horrendous as the formula for eye drops do not allow flavourings or masking agents. =.=.

Anger management

Have you ever seen 2 women fight before? I can tell you that it's not a pretty sight. Usually starts with a fierce loud exchange of words and during that shout/scream fest, their voices get louder and louder and louder. Their lungs eventually cannot take in enough oxygen compared to the amount of gas being expelled and these people would start turning purple in the face.

It's a vicious cycle

Shout/shout/scream/scream -> decreased level of oxygen in the head -> cannot think properly -> start to generate more nonsensical responses -> then shout/shout/scream/scream-> decreased level of oxygen in the head ->....

One should look at oneself when one gets mad and furious. The sight of oneself will turn oneself off.

People with flare ups should get some time out from the source of instigation to prevent provocation and another spark.

When people get angry, they can execute the most unthinkable actions - may be dangerious and potentially fatal.

An intermediary may be needed to split the 2 parties and calm them down.

Migraine @@

Have you ever taken so much paracetamol/acetaminophen that you can just march down Geylang, swear at the uncles there and get a beating so bad yet not feel anything.

PS my so much = 6 x 500mg. Max allowed = 8 tabs (500 mg each).

My body feels numb but my inaugural headache continues pulsing.

Photophobia developed after my first lecture of the day - felt like a vampire in the sun.

Never knew there was a foundation for migraine suffers and they are selling aura art?!

Chewren dosing for paracetamol
= 10-15mg/kg/dose q4-6hrs
Max 600mg/kg/day
Max max 4,000mg/day (adult dose)

One of my friends have a interesting comment, "Kids grow so fast that I have to reweight them every time I dose paracetamol!" =.=

I may be the only one with odd CNS s/e from paracetamol - can get a bit manic next morning (not my regular class room mania but more of the dun care, just run across the express way kind)

Reminder to self - CVS patients

Most patients with CVS disorders (HF, HTN, Arrhythmias, PVD, etc) usually have a multitude of drugs (aka medication hamper) and most of the time drugs are used in combination and patients may have multiple co-morbidities.

Today's counselling session was fun, way too funny as the instructors were pulling all kinds of tricks as difficult patients - last day anyway so play play. Some simple questions with DIFFICULT PATIENTS =.= love Challenging cases, so next time go out and work - like a bed of roses ^^. After today's challenge, I think it is time to resurrect a project which I started while I was in Guardian Pharmacy - a emergency list of language translation. This one was my farewell gift - we had a Japanese clinic in the medical centre. After exams then settle. Planning to come out with a list of commonly used terms and phrases and translate them with phonetics or if possible the spelling - so the patient can read if dun understand what the heck talking me. The instructor hit me at a weak spot - my failure in the use of mandarin (still remembered during my Secondary Skool days, the Mandarin teacher ran up to me after I merely passed the exam:"...不要充考了hor.及格就夠了!")

Patients come from all walks of life and we should be able to communicate with the patient in whatever language he/she is comfortable with. Cannot speak the language, seek help from a relative or a patient or staff nearby.

Cimetidine is a drug to look out for in prescriptions as it inhibits a plethora of enzymes common with most hepatically metabolised drug-substrates.
- Need to increase the dose of drugs that need prior activation by the liver, e.g. Acyclovir
- Need to decrease dose of drugs that are active moieties
- Interacts with warfarin (increase bleeding time)
- Can be substituted with other H2-antagonists such as famotidine

Amiodarone (Affectionately known as Amy要打人) is a drug that is used to treat arrhythmias
- Interact with cimetidine (may cause heartblock)
- Outpatient use should be that of a tapering dose as patients who are on long term amiodarone has chances of heart block
- May cause drug induced problems in patients with thyroid disorders because it contains 2 iodine atoms (attached to phenyl ring)

RALES found that the combo of Spironolactone + ACEi + Loop Diuretic decreases mortality in HF patients

Pharmacist main roles with patients prescribed medication hampers are to
-Intervene on potentially lethal D/Is
-Monitor and counsel patients on drug combos that may require monitoring and not necessary to stop

Japanese

1. Take one tablet 2 times daily
Ichinichi nikai ichijo zutsu nonde kudasai
一日二回１錠ずつ服用して下さい。

2. Take two tablets 2 times daily
Ichinichi nikai nijo zutsu nonde kudasai
一日二回２錠

3. Take three tablets 3 times daily
Ichinichi sankai sanjo zutsu nonde kudasai
一日三回3錠

4. Do not take this with vitamins containing iron
Tetsubun no haitte iru bitaminzai wa isshoni nomemasen
鉄分の入っているビタミン剤の場合一緒に服用で・shy;ません。

5. Shake well before use.
Nomu maeni yoku futte kudasai
使用前によく振ってください。

6. Do you have any form of allergies
Arerugih wa arimasuka
何かのアレルギーはありますか。

7. Did the doctor give you any special instructions
Isha kara nanika shiji wa arimashita ka
医者から特に何か指示を受けていますか。

8. Have you taken this before
Kore o nonda koto arimasuka
これを服用した事はありますか。

9. Take 2 spoonsful 2 times daily
Ichinichi nikai supuhn nihai nonde kudasai
一日二回スプーン2杯服用してください。

10. Take this in the morning
kore o asa nonde kudasai
これを朝服用してください。

11. Take this after food
Shokugo ni nonde kudasai
食後に服用してください。


12. Take this before food
Shokuzen ni nonde kudasai
食前に服用してください。

13. This is for cough
Kore wa seki no kusuri desu
これは咳・shy;の薬です。

14. This is for runny nose
Kore wa hanamizu no kusuri desu
これは鼻水の薬です。

15. This is for fever
Kore wa netsu no kururi desu
これは熱の薬です。

16. Take this when you require it
Hitsuyoh na toki nonde kudasai
必要なとに服用して下さい。

17. Take this when you feel pain
Itami o kanjitara nonde kudasai
痛みを感じたら時服用して下さい。

- Translations courtesy of my fellow NOG guide and 1998 or 1989 Miss World Japanese Interpretator ^^

Reminder to self - smoking cessation and anticoag.

Pharmacists are essential in terms of patient counselling supported by their heavy pharmaceutical product knowledge (second to none hor)

Smoking cessation (you may want to refer to this godly paper or the MOH guidelines):

Smokers smoke because of
- Nicotine addiction
- Habit
- Emotion

Give patients a brief overrall view of the products available to allow them to chose which they think will suit them better (no one knows better about the patient than the patient themselves) so as to increase patient compliance

You can play around with the different dosage forms to reach the nicotine replacement level if the patient is indeed addicted to nicotine.
- Try to make up the patient's total nicotine intake then step down

Agaration of the amount of nicotine
- Lite - 0.5mg /stick
- Normal - 1mg /stick
- Malaysian Normal - 1.5mg /stick
All as written on ciggie box

The 16hours patch (15mg, 10mg, 5mg) gives lesser side effects than the 24 hours patch (21mg, 14mg, 7mg)

The 10 mg inhaler has a very low BV (approx 30-40%)

The 2mg gum has only a BV of 50%


Warfarin (you may want to refer to the Pharmacy Guidelines or the British Guidelines)

All restructured hospitals only stock 1 brand - Marevan and the colour is pretty important to differentiate them and to test for patient compliance:
5mg - Pink
3mg - Blue
1 mg - Brown

Vitamin K comes in a while for for reconstitution as infusion. When giving patient oral Vitamin K treatment, remember to draw out required amounts to dilute - if you give a few ml, the chances of patients getting a complete dose as possible may be non-existent.

Vit K works pretty fast to lower INR, so you may want to do an INR check the very next day.

Didn't update blog for some time

Because was very busy REading ReaDing rEadIng...

AHA/ACCF warfarin therapy guidelines

MOH Clinical Pharmacy practice Guidelines for Anticoagulation-Warfarin. (yesssss. Pharmacists also got clinical guidelines. Come work with me ^^)

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Today went for the CASE's talk on medicine

The talk was interesting - it kept going on generic drugs and patent drugs, but I feel that it really missed out on services pertaining to issuance of medication. I can give you all the best drugs in the world, but if lousy advice was dispensed, what is the use? It may even kill you.

Generics - drugs that have expired patents - so they can be copied and sold e.g. Dhamol (paracetamol / acetominophen)
Patent drugs - aka original innovator, innovator, proprietary, brand drugs e.g. Panadol (paracetamol / acetominophen)

So far I hope the general public have learnt the following about generic and patent drugs:
- Generic drugs and patent drugs are very similar : I quote Miss Fatimah, "... both will take you to your destination..." Patent drugs may be likened to Mercedes Benz and generics likened to Hyundai - Mercedes may look nicer
- Patent drugs go through a lot of human testing and the cost of bringing it from day one to the market is a lot higher.
- Generics just required to show bioequivalence: meaning that it works physiologically the same as the patent drug, active ingredients are the same, etc.
- Generics are usually a lot cheaper
- Patent drugs are usually more costly but there's no choice when generics are not available
- If generic substitution was done properly, the cost savings can be tremendous.
- Expiry dates between generics and branded drugs are similar. The pharmacist will not be that unethical to sell close to expiry drugs.

Others
- Pharmacists can help check for potential drug interactions
- HSA's responsible for mainly registered drugs
- MOH is in charge of spot checking doctors (practice issue)
- Singapore-treated patients pay only about 10% of the healthcare cost in terms of drugs - compared with 11 - 14 % in USA and UK and as high as 30% in the Philippines and Vietnam
- Please bring ALL YOUR MEDICATIONS that you are taking when youre admitted or going for your regular appointment: this aids in Drug Recon(solidation), the pharmacist will calculate what you need and in any case if changes in drug therapy, pack your drugs to be stopped or continued and add on drugs that your current amount may not fulfill.
- SMA provides a Medik Awas card service for those with known drug allergies.
- The expiry date of drugs is usually a date when the drug degrade to 90% potency (e.g. 10mg -> 9mg)

However, these were not mentioned (to simplify things):
- Studies on humans are done large scale on patent drugs only
- Some pharmacists and doctors prefer to use patent drugs for certain more critical diseases.
- Some hospitals may use innovator drugs to treat patients at low cost: if they make it to formulary or if the tender given is a very good deal.
- The % cost of healthcare in the form of drugs is so low because diagnostics cost a lot more - perhaps a subsidy for diagnostics now?
- Carry along your entire prescription listing on admission: it helps in immediate ER treatment.

I poised a question to Dr Tan, spokesperson for SMA about sharing responsibilities in patient care between doctors and pharmacists in a community setting:

"So far, we have heard about generic drugs and brand drugs - products mainly. I would like to seek the opinion or perhaps the stand of SMA on the concept of sharing the responsibilities of patient care in a community setting?

For example, certain drugs with an increased potential for abuse and special instructions and storage requirements to pass through a second checkpoint -i.e. asking a patient to bring a doctor's precription to a pharmacy instead of being packed and given by a clinic assistant.

Let me elaborate in 2 scenarios
- in the recent hoo-ha about Dormicum and Subutex, perhaps the issues evolved could be better managed if 2 checkpoints were implemented: 1st is the doctor's assessment, 2nd is through the pharmacist. In such a way, only patients with a real need for such medication will go through the appropriate steps to get their medication.

- Drugs with special storage conditions such as Angised sublingual (check price in CASE here). During my pharmacy training, I was quite appalled when patients come in with Angised in plastic containers dispensed by clinics, saying that the medication is no longer effective for their chest pains and they had to take more potent drugs which may cost higher and more side effects (I had to coax some patients to tell me about their previous medications - some were prescribed Herbesser, chew before swallowing).

I think it would be best to make full use of a pharmacist knowledge to benefit consumers even though it may use some initial opportunity cost.

So would it be better if for the consumer if certain drugs can only be given through a pharmacist with a doctor's prescription if we want to give the patient the best care possible?"

His answer basically covered with the following points [ if there's any discepancies, pls post comments hor - didn't copy answer, only stand there jittery and red as I saw some one with a passive annoyed look liaoz]
- Singapore, Malaysia and other parts of the region, doctors are allowed to dispense compared with UK and USA.
- So far the system works, patients have immediate access to their medication
- As for such issues, complaints can be lodge with the SMA (or SMC - can't really decipher)
- SMA feels that the clinics that are dispensing medications are good and do not have any issues
- There's no need for 2 checkpoints
- and here comes the standard answer - "Here is not the forum to discuss such issues" (3rd time I heard this liaoz =.=)

Perhaps I was too jittery about what I was going to say (some people reach an age where they become so concious about what they are about to say that they did not dare to say it anymore - skin thinning liaoz), or my timing was off again, or doctors were trained to counter such discussion or I was too chong hey. But I hope to drive home the point about our place in the healthcare sector.

I'm not interested in what market share but more interested in patient care.

Frontline community pharmacies can do a lot given the chance, but we will have to take first baby steps by convincing the public about our usefulness.

Take on the responsibilities before you can be given the rights. (Something I always say to people who discuss with me dispensing issues - even to doctors and medical students) - It's like gardening- why want a plant when you can't even nurture it?

I hope I didn't miss out any pointers or write anything wrong in this post - correct me via a comment plox

Knuckling - a "new" method for applying nasal spray

Today had a rogue customer-cum-boh chap about father scenario in a community setting. Not easy when the patient is absent and you end up counselling the third party to reply message to the patient @@.

Made a few blunders here and there,
- Realised I was leaning against the table
- Was looking down at the patient - he sat, I stood
- Didn't realised I mentioned "expectorant" when I wanted to pass him a normal cough linctus
- Should have intro the range of Duro-tuss products available
- Forgot to give frequency of use and ended with the word "often"
- Never explained in depth about certain instructions and their importance.
- No need to shake Afrin spray but I still ask to shake (because of consistency)
- My big handwriting and gaps left behind in the earlier questions rendered me insufficient space to write - only 1 sheet given *sianz 0.5* discrimination against people with big handwriting bleah
- and most idiotic of all - DUNNO HOW TO SIMULATE PHARMACIST AND DOCTOR COMMUNICATION ... should have asked doctor direct about patient when son boh hiu right? *tock on th head*

With regards to nasal sprays, there are several techniques of use out there.
Most common method is the use of a finger to press down on nostril and inhale through the other. But then hor, if you suffered from rhinitis, I confirm you will super jiak lat if you do that.

During congestion of your nose, your nasal conchae would have become swollen and tender. Adding pressure to that area may because pain and may trigger a bout of sneezing = more pain!

Some may use the pointed cap of the spray to jam up the nostril but I find that a bit yucky - especially if you forgot to clean the cap later. Ast least skin will secrete their own anti-microbial substances

My tester heard my technique for the first time. When I was counselling he was thinking "Oh realllllyyyyy"-because I never explained the background behind the technique (tell son for what, his father suffering but he boh chap) - whether he eventually accepted it or not is another issue.

1. Wash hands
2. Stand by nasal spray
3. Shake nasal spray
4. Using your non-spraying hand, fold your index finger towards palm and insert the knuckle into the other nostril that is not being sprayed into.
5. The knuckle should fit snuggly into the nostril and the skin folds help to form a tighter seal as compared to you pressing on your tender nasal conchae or using a rigid spray cap.
6. Start inhaling through your nose and spray a dose.
7. Breathing in deeply through nose as possible.
8. Repeat with the other nostril if needed.
9. Some people would pinch the nose after spraying to suck in another time (to try to get some stuff into the sinual cavity)
10. If using a steroidal spray, you may want to gargle mouth after use.

Should we conduct a multicentre RCT on techniques of spraying stuff into stuffed noses?

Reminder to self

A lot of hypertensive patients walik into a community pharmacy not to be treated for their hypertension but to get treatment for other ailments. A pharmacist must have good knowledge on the patient's current situation, the disease and the appropriate drug therapy for the ailment the OTC is meant for.
- there is a need for us to have a thorough knowledge on OTCs
- there is a need for us to understand the seriousness of the chronic ailment

Do not just stay there and yak away at the patient. Take note of non-verbal cues nd get the patient more involved and get them interested in the pharmacotherapy.

The more difficult cases usually involve a third party helping the patient get the meds when the patient is MIA...
- try to get the third party to repeat whatever advice given so that they can relay it better
- where possible, use PILs
- try to convince the third party about the methods of administration and therapy so they can convey it better

Show empathy
- allow the patient to connect with you
- make the patient more involved in the drug therapy
- show/demonstrate techniques of use before being asked (take initiative)

Be specific
- some patients do not know how to decide
- in terms of frequency of use, make sure one specify the time and frequency, do not use words like "often", "regularly". Try to give something more specific, e.g. TDS, every 2 hrs etc. If not some patients will be CONSTANTLY using the drug.

Try to convince the patient and be true to your principles of "Doing no harm, then do something good"
- If patient insists that they wanted a drug even though you have already told them the implications, just give it to them with a warning, or if it is really serious, REFUSE TO DISPENSE. Depending on individual opinion, I think it would be better to lose a customer (in retail) than to lose a life.

Nasal Sprays for Rhinitis

Nasal sprays: Get relief but get hooked too?
Tessa Wong
14 March 2007
Straits Times

"Available without a prescription, they clear blocked noses instantly, but can cause addiction
NASAL sprays gave Ms Shu Lee blessed relief from a chronically stuffed nose, but being able to breathe freely came at a shocking price. She became addicted to these sprays.

A polyclinic doctor had recommended them to alleviate her lifelong nasal problem. Available without a prescription and costing only $10 a bottle, they seemed an obvious option. The effect was dramatic.

'This wonder drug helped me breathe properly for the first time in my life,' said Ms Lee, a 27-year-old advertising executive.

The spray relieves blocked noses instantly - but only temporarily - using a highly addictive chemical compound called oxymetazoline, the main ingredient in popular brands Afrin and Iliadin. When its effect wanes, it causes rebound congestion so users must inhale more to get relief, hence developing a dependency.

Ms Lee was soon inhaling four times a day - twice the maximum recommended dose.
And although the label said the spray must not be used more than three days in a row, she progressed to buying a bottle every month.

'I took it everywhere I went,' she said, adding that in the three years she was addicted to it, she spent more than $350 on her habit.

Experts estimate that at least half the 800,000 Singaporeans who suffer from chronic nasal congestion have been dependent on these sprays at some point. Extreme dependencies may even require surgery to cut away or shrink swollen nasal tissue. Severe addiction, which may cause side effects such as paranoid psychosis, is estimated to affect 1 per cent of patients getting ear, nose and throat (ENT) treatments. But doctors say the real numbers could be far higher, as many people are unaware that they are addicted.

ENT specialist Adrian Saurajen, who is based at Mount Elizabeth Medical Centre, said: 'When nasal sprays are used continuously for more than a week, they can cause dependency.'

Reported cases are rare here, but there is concern because Singapore has the highest incidence of allergies in the world, said ENT specialist Gerard Chee, of the G H Chee Ear Nose Throat and Dizziness Centre.

Ms Lee went cold turkey when she realised the extent of her addiction, going through 'two months of sheer agony and three months of discomfort' before she got over it.

'I had sleepless nights from the congestion. Sometimes I couldn't breathe through my nose even in the daytime,' she said.

That was more than four years ago.

Since then, her sense of smell and taste has largely returned, and - oddly enough - she does not suffer from nasal congestion any more.

'I'm just glad I kicked the habit,' she said.
twong@sph.com.sg

Double-edged

THE spray relieves blocked noses instantly - but only temporarily - using a highly addictive chemical compound called oxymetazoline, the main ingredient in popular brands Afrin and Iliadin.

When its effect wanes, it causes rebound congestion, so users must inhale more to get relief, hence developing a dependency. "

I personally feel that the report could be worded better with some sensitivity - not because I support any drug industry, but rather use of words such as "addicted" can really hurt a person's life.

Let's say if the person's family members are not very well-informed and they jump at catchwords thrown to them by the media such as the word "addicted" especially when they are connected with the word "drugs" - imagine the chaos that can result. This may sound extreme but then a person's life may just fall apart when they are ostracised on par with heroin due to people who jump at certain catch words instead of seeing the whole picture.

These are the products containing oxymetazoline in Singapore:

AFRIN NASAL SPRAY 0.05%
ILIADIN SOLUTION 0.025%
ILIADIN SOLUTION 0.05%
ILIADIN SOLUTION FOR NOSE 0.01%
ILIADIN SPRAY 0.05%
KOTRIN NASAL SPRAY 0.05%
NAZOLIN NASAL SPRAY 0.05%
OXAZOLINE NASAL DROPS 0.05% w/v
OXY-NASE NASAL DROPS 0.025%
OXY-NASE NASAL DROPS 0.05%

A lot of these products can be sold anywhere and bought anywhere, take for example Afrin Nasal Spray - note that it is GSL (General Sales List) - even your Chinese Medicine Hall can stock it for sale.

Oxymetazoline and ephedrine sprays are examples of decongestants and these are not meant for long - term usage. They should be used max for 3 days with a break of few days in between (drug holiday). If this spray (under normal dosing), it's time to see doctor as it could be something more serious and need long-term treatment or alternative forms of treatment.

Miss Shu Lee's case is a case of treatment failure. She should have followed up with a doctor or pharmacist instead of going on her own accord to overdose herself with oxymetazoline. It is not advisable to use the decongestant sprays for so long. The relief from such sprays is only temporary - in some practices, these sprays are used to unblock the nose before applying other sprays for long-term use such as corticosteroids, beclomethasone, mometasone and fluticasone.

If she returns to her doctor, she may be directed to use a corticosteroidal spray that may cost more but with a better safety profile. These sprays are also used prophylatically so you won't have much of sudden onset of nasal blockage.

The doctor may order some lab tests to check whether she has certain allergies - in this way she will know what triggers to avoid. X-rays and CT scans may also be warranted if the blockage is very often - to check for anatomical problems where surgies may be carried out.

Non-pharmacologic methods to help includes using inhalation and maintaining a clean sleeping or working or home environment. Some people get nasal blockage at certain places - work, home or school but as soon as they leave, the blockage stops. This may be due to the aircondition of the place and may mean that the aircon need cleaning. The same thing applies if the person wakes up with a blocked nose - he/she may want to change and/or clean the bedsheets and mattress as well as pillows - these may be due to dust mite allergies. Mites from different regions give different allergy profiles - when you travel overseas (even to dusty places), you may realise that you may not get the stiffles despite the dust.

Reminder to self

"We are not out there just to tell patients ji zgi sa bai, sa liap ji bai, as pharmacists we supposed to do more" - wise words of the only local male BCPP (Board Certified Pyschiatric Pharmacist) in Singapore.

Today was counselling session - pharmacist do not just blapper the name and instructions for meds to patients - if like that, our training can just pour down the drain. Given the opportunity we should do more. Opportunity begets opportunities - more you value-add to the patients' drug therapy, more would they want to seek help and advice from you. Got to let the doctor rest hor =p.

Other reminders - Anti-coag can take with Anti-platelet (according to guidelines) since there are 2 different mechanisms of action. But then antiplatelet's order (safety considerations and patient's profile withstanding) should be aspirin, clopidogrel then ticlopidine.
The following format is advisable for medical hamper scripts:

1. Explain every drug in detail
2. Ask if there are any questions
3. Summarise and simplify dosage and regime

Classic signs and symptoms of metabolic syndrome:
1. Obese
2. high LDL and TG
3. Low HDL
4. Poor glucose control
5. HTN

H2 blockers also given to prevent GI bleeding during anticoag therapy

Q1W dosing of alendronate 70mg produces less GI effects than QD dosing alendronate 10mg
It is advisable to bring the patient down to the shop floor to explain supplements (e.g. calcium supplements) in detail so that the patient understands better when needed.
Vit D supplement needed for those people who are housebound, do not see much of the sun - since cannot auto synthesis.
Alendronate to be taken 2 hours after last intake of med or food. Best method is as follows:
Take alendronate first thing when you wake up with a full glass of water (nothing else- the rest will interfere with alendronate absorption). Stay upright for 30min before you take anything else - in the mean time can go walk walk, etc.


Remember to write in full as possible e.g. supp = supplement or suppository - calcium suppository anyone?

Digoxin increases ejection fraction not ejeculation fraction.

Chemotherapy induced nausea and vomitting (CINV) comes in 3 types - anticipatory, acute and delayed.
Acute use a sedative, e.g. lorazepam. Loarazepam can also cause amnesia which may help forget the previous noxious effects leading to vomitting.
Acute CINV is usually given prophylaxis or just before the chemo itself.
Delayed CINV is treated for 5-7 days post chemotherapy
Aprepitant is only approved for cisplatin -containing regimes. (120mg, 80mg, 80 mg)