BULETIN PENAWAR Inside this issue

BULETIN PENAWAR
VOLUME 3/2016
OGOS 2016
Inside this issue:
Overactive Bladder
2
By Cik Chan Li Peng
Editorial Board
Calcium Lactate Versus Calcium Carbonate
ADVISOR:
 DR SITI NORLINA BINTI MD
SAID
By En John Wong
EDITORS:
 PN SITI ROSNAH BT SURADI
Scars
 EN MOHD SHAFIE B ZABIDI
By Cik Lui Mei Yi
4
6
 PN PATRICIA LIM MING HUA
 PN LI SHIN GIE
Alopecia
By Cik Siti Hajar Abdul Aziz
HOSPITAL SULTANAH
AMINAH JOHOR BAHRU
Kementerian Kesihatan Malaysia
Jalan Persiaran Abu Bakar Sultan,
80100 Johor Bahru.
Tel: 07-2257000
Fax: 07-2242694
E-mail:
publichsajb@moh.gov.my
Majlis Sambutan Tahun Baru Cina Dan
Hari Jadi Jan-Mac Jawatankuasa Kebajikan Dan Social Jabatan Farmasi
By Pn Monishah Mohanan Pilai
8
J A B A T A N
F A R M A S I ,
H O S P I T A L
S U L T A N A H
A M I N A H
J O H O R
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2
Overactive Bladder Syndrome
BY CIK CHAN LI PENG
Introduction
Overactive bladder syndrome (OAB) is characterized by urinary urgency, associated with or without urinary
incontinence. The International Continence Society defines OAB as a symptom syndrome suggestive of lower
urinary tract dysfunction. OAB is often associated with urinary frequency and nocturia in the absence of
pathologic or metabolic conditions that may cause or mimic OAB such as urinary tract infections, polyuria, transitional cell carcinoma of the bladder, and underlying neurologic abnormalities.
Pathophysiology
In a normal healthy person, the detrusors of the bladder wall
remain quiescent as urine slowly accumulates to about 150200 milliliters. At this stage, a healthy person is able to postpone the desire to pass urine although the detrusors sense
the presence of urine. However, when the volume exceeds
450-500 milliliters, the bladder contracts initiating an intense desire to micturate. In patients with overactive bladder, these irritative symptoms usually occur before the
thresholds are reached. The aetiology of this problem is multifactorial and complex.
Signs & Symptoms
Urgency
Sudden compelling desire to pass urine, difficult
to defer
Frequency
Voiding too often during the day
Nocturia
Waking up to void (> 1 time/night)
Urge Incontinence
Involuntary leakage that is associated with
urgency
Risk Factors







Insulin-dependent diabetes
Age >75 years old
Arthritis
Increased BMI (>30)
Stroke
Spinal cord injury
Oral hormone replacement therapy
Diagnosis
Based on patient’s history;
Onset, nature, duration, severity
 Medical and surgical history
 Bladder Diary
 Medications that can affect bladder function:
Anticholinergics or antimuscarinics, antidepressants,
antipsychotics, sedatives or hypnotics, diuretics,
caffeine, alcohol, narcotics, alpha-adrenergic blockers, alpha-adrenergic agonists, beta-adrenergic agonists, calcium channel blockers.

J A B A T A N
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H O S P I T A L
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Diagnosis
Physical examination

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
Abdominal examination
Genitourinary examination
Gynecologic examination
Assess rectal tone & prostate (men)
Pelvic muscle strength, assess for prolapse of pelvic organ,
urethral mobility
Rectal examination
Management
1. Behavioral Therapy
 Dietary and lifestyle modification
 Pelvic floor muscle therapy (PFMT)
 Self-monitoring with bladder diary
2. Medications
Focused neurologic examination
 Pelvic reflexes, innervation of the feet, and the patient's
mental status
 Urinalysis
 To exclude microhematuria, pyuria, urinary tract infection, and glucosuria

Potential Medications
Antimuscarinics
 Tolterodine, Oxybutynin, Darifenacin, Solifenacin.
 Reduce amplitude of contraction to improve bladder capacity and
voluntary contractions.
 Side effects: dry mouth, blurred vision, constipation and drowsiness.
 Monitoring: Review 4 weeks after starting treatment. If improvement is
optimal, continue treatment. If there is intolerable side effects or
suboptimal improvement, change the dose or try an alternative agent.
Review treatment 4 weeks later.
3. Surgery
Desmopressin
 Synthetic analogue of vasopressin which reduces urine volume.
 Used in women who cannot tolerate nocturia.
· Avoid in women > 65yo with cardiovascular disease or hypertension.
Intravesical
botulinum toxin
injection
 A neurotoxin that inhibits the contraction of detrusor muscles, thereby
reducing the symptoms of OAB.
 Use is limited by possible risk of urinary retention, pain over injection
sites, rashes, myalgia and lethargy.
 Use in: patients who are refractory to conventional drugs and the
symptoms persist for over 6 months.
Tolterodine 4mg Tab
References
1. Gormley E, Lightner D, Burgio K, Chai T, Clemens J, Culkin D et al. Diagnosis and Treatment of Overactive Bladder (Non-Neurogenic) in Adults: AUA/SUFU Guideline.
The Journal of Urology. 2012;188(6):2455-2463.
2. Newman DK, Dmochowski R. Overactive bladder: Diagnosis and treatment in primary care (Slides with transcript) [Internet]. Medscape pharmacists. 2008 [cited
28 April 2016]. Available from: http://www.medscape.org/viewarticle/571913
3.Lum M. Treating an overactive bladder - Health | The Star Online [Internet]. Thestar.com.my. 2010 [cited 14 April 2016]. Available from: http://
www.thestar.com.my/lifestyle/health/2010/10/27/treating-an-overactive-bladder/
J A B A T A N
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4
Calcium Lactate
Versus
Calcium Carbonate
By En John Wong
Introduction

Calcium lactate and calcium carbonate are commonly used as a calcium supplement for patients with calcium deficiency or high risk of osteoporosis.

Calcium is also used as phosphate binders in patients with hyperphosphatemia due to chronic kidney disease. However, calcium lactate is less commonly used for this indication. They bind to phosphate through ionic binding in the
gastrointestinal tract. This results in the formation of an insoluble complex, calcium phosphate, and thus preventing
phosphate from getting absorbed in the intestine and allowing more phosphate to be excreted in faeces.

Unlike calcium lactate, calcium carbonate can be used as an antacid in treating patients with conditions such as heart
burn and gastric acid hypersecretion. It works by neutralizing hydrochloride acid produced by parietal cells in stomach
to produce neutral salt, calcium chloride and carbon dioxide gas. Hence, calcium carbonate may cause bloating sensation due to this mechanism.
“Calcium carbonate
contains higher elemental
calcium and is more
cost effective.”
Calcium Source
Carbonate
Lactate
Elemental
Calcium
Cost-Effectiveness
Shelf Life

Calcium carbonate has elemental
calcium of 40%, which is much
higher than that in calcium lactate, 11%.


Both calcium carbonate and calcium lactate have a similar
bioavailability of 20-33%.
Calcium carbonate tablets can be
stored for a longer period of time
as compared to calcium lactate
(Shelf life: 4 years and 2 years
from the date of manufacture
respectively).

Therefore, calcium carbonate
has an added advantage over
calcium lactate in the perspective
of inventory management.

As a result of longer shelf life,
calcium carbonate requires less
frequent monitoring of expiry
date.

40%
11%

“Calcium carbonate has a
shelf life of 4 years versus
calcium lactate of 2 years.”
As a result of higher elemental
calcium in calcium carbonate and
similar bioavailability, calcium
carbonate seems to provide a
better source of calcium if used
as a calcium supplementation.
Besides, calcium carbonate is
less expensive when compared
to calcium lactate (Unit cost:
RM0.04 and RM0.16 respectively).
References:
1. Sakhaee K, Bhuket T, Adams-Huet B, Rao D. Meta-analysis of Calcium Bioavailability. American Journal of Therapeutics. 1999;6(6):313-322.
2. Understanding Different Types of Calcium: Part 2 [Internet]. DrNibber.com. 2016 [cited 18 February 2016]. Available from: https://
drnibber.com/understanding-different-types-of-calcium-part-2/
3. Kressel G. Bioavailability and Solubility of Different Calcium-Salts as a Basis for Calcium Enrichment of Beverages. FNS. 2010;01(02):53-58.
4. Cervelli M, Shaman A, Meade A, Carrol R, McDonald S. Effect of gastric acid suppression with pantoprazole on the efficacy of calcium carbonate as a phosphate binder in haemodialysis patients. Nephrology. 2012;17(5):458-465.
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Comparison between calcium carbonate and calcium lactate:
Safety and efficacy as phosphate binder
1.
Calcium carbonate requires an acidic environment for dissolution and does not appear as effective in
patients with neutral gastric pH due to achlorhydria or administration of H2-antagonist. Calcium lactate
maybe a better option of phosphate binder in this situation.
2.
All commercially available phosphate binders seem to be safe for short-term use but insufficient
evidence exists to recommend one binder over another as a first-line therapy.
3.
As calcium carbonate has high elemental calcium, concern is building about the long-term effects of
calcium overload and its association with vascular calcification.
Safety and efficacy as calcium supplement
1.
Calcium carbonate is the most widely used, but its administration results in hypercalcemia in up to 50%
of patients, especially when co-administered with vitamin D analogues.
2.
Other problems with using large amounts of calcium carbonate is that it can lead to constipation and
abdominal distention. Calcium lactate which has less elemental calcium can serve as an alternative
when this happens.
3.
Nevertheless, all types of calcium supplements are usually safe when prescribed in doses ranging from
1000-2500mg daily.
4.
Development of kidney stone is not a major concern, because urine calcium rises by only about 60mg
for every 1000mg ingested. It should be noted that even a history of kidney stones does not constitute a
contraindication to calcium supplementation. The only exception is an individual with absorptive hypercalciuria.
“In conclusion, despite the reduced
effectiveness of calcium carbonate as
phosphate binder in some conditions, calcium
carbonate is still preferred over calcium lactate
as a source of calcium as it brings more
benefits than disadvantages to most patients and
it helps to reduce the medical expenditure of
hospitals.”
5.
6.
7.
8.
Calcium Carbonate 500mg Tablet
Hutchison A, Smith C, Brenchley P. Pharmacology, efficacy and safety of oral phosphate binders. Nat Rev Nephrol. 2011;7(10):578-589.
Takahashi N, Shoji T, Matsubara K, Hitomi H, Hashimoto M, Kiyomoto H et al. Effect of Histamine H2-Receptor Antagonist on the Phosphorus-Binding Abilities of Calcium Carbonate and Calcium Lactate in Hemodialysis Patients. J Am Soc Nephrol. 1999;10(5):1090-4.
Schaefer K, Umlauf E & von Herrath D. Reduced risk of hypercalcemia for hemodialysis patients by administering calcitriol at night. Am.
J. Kidney Dis. 1992;19(5):460-464.
Heaney RP. Calcium supplements: practical considerations. Osteoporosis Int. 1991;1(2):65-71.
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Scars: Treatment & Prevention
B A H R U
P A G E 6
By Cik Lui Mei Yi
A scar is a mark left on the skin after a wound or an injury to the surface of the skin has healed. The more the skin
is damaged, the longer it takes to heal and the greater the likelihood of a noticeable scar. After a wound is
healed, the scar continue to alter as new collagen is formed and blood vessels formation return to normal. Most
scars will fade and improve in appearance over 2 years following an injury. Ultimately, several factors affect scar
formation, including the depth and size of the wound, patient’s age, gender, ethnicity and heredity.
STAGES OF HEALING
TYPES OF SCARS
A flat, pale scar is the most common
type of scar. Initially it appear as a red/
dark mark and slightly raised, but will
become paler and flatter over time.
Inflammation begins immediately after a wound is
formed. A localised release of inflammatory mediators is
A hypertrophic scar is a red, raised scar
triggered and vasodilation occurs. This results in an influx
along a wound that remains this way for
of phagocytic leucocytes which digests and autolyse
a number of years. A keloid scar is also
devitalised tissue. This stage results in the classical signs
red and raised, but excess scar tissue
of inflammation: redness, heat, pain and swelling.
results in the scar growing beyond the
boundaries of the original wound.
Granulation tissue comprised of collagen and extracel-
A pitted scar have a sunken appearance
and is usually caused by acne or chickenpox. This type of scar formation is due
to loss of an underlying fat layer.
and
tightening,
resulting
in
movement restrictions. This type of scar
are common in burn victims.
lular matrix fills the wound defect and angiogenesis occurs. As the wound defect fills, the wound gradually
contracts and epithelial tissue begins to form at the
wound edges. Eventually, complete epithelisation occurs with epithelial cells fully resurfacing the wound.
A scar contracture is caused by skin
shrinking
Proliferation is when the wound starts to rebuild itself.
Remodelling occurs once the wound is closed. Tensile
strength is regained as collagen fibres remodel and reorganise itself. The wound devascularises and returns to
its original state of blood supply. The first 3 months after
wound injury is when remodelling is at its peak.
POST-OPERATIVE WOUND CARE
Practice wound hydration with
Clean wound with saline. Avoid
Remove any non-absorbable sutures
foam dressings changed daily or
alcohol or iodide as these chemi-
and apply skin tape to reduce ten-
every other day.
cals are cytotoxic to healing cells.
sion during remodelling.
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MINIMIZATION OF SCARS
Silicon Gel Sheet is a self-adhesive silicon gel sheet, effective for both hypertrophic and keloid scars. It
should only be used on healed skin and not open wounds. Silicone applied over the scar provide occlusion and hydration of the stratum corneum, down-regulating keratinocyte stimulation and prevent
further signalling to produce more collagen. As a result, collagen is normalized and hypertrophic/keloid
scarring is prevented. Application: Cut the gel sheet slightly larger than the scar and apply every 2
hours with 30 minutes rest intervals between. Each sheet can be washed twice daily and reused for up
to 3 to 4 weeks. Treatment should last for 2 to 4 months on average to see an effect.
Intralesional Steroid Injections can be used off-label to minimise the formation of hypertrophic/keloid scars. Corticosteroid inhibits the expression of genes that reduce collagen production and increase degradation. Dose: The common corticosteroid used is Triamcinolone Acetonide Injection. In HSAJB, only the 40mg/ml injection is available. The
initial dose per site varies depending on lesion. Generally, a dose of 0.1 to 0.2 ml/cm 2 of involved skin is used, with a
maximum of 2 ml each time. For a thick lesion scar, the full-strength 40mg/ml injection is preferred and for moderate
hypertrophic scar, 10mg/ml is preferred. Repeat injections every months for 4 to 5 months or until the scar is flattened.
Pressure Garments are usually used for large burn scars. Local hypoxia by physical pressure induces regeneration of fibroblasts, suppresses collagen production and activates collagenase, thereby accelerating collagen degradation. Application: Worn over the scar for 23 hours a day, for 6 to 12 months. Pressure
garments yield better results if worn as early as 2 weeks after wound closure.
Surgery can improve the appearance of scars as it can change the positioning, width or shape of the scar and can
release a tight scar close to a joint to improve movement. However, surgery on an existing scar will leave a new scar
that can take up to 2 years to improve in appearance. Surgery is risky and it can worsen existing hypertrophic scar
OTC PRODUCTS
while keloid scars post-surgery may grow back larger.
Hiruscar®
contains:
(reduce
visibility),
allium
cepa
aloe
vera
(moisturizer for smoother feel), allan-
Mederma® contains: allium
toin (remove old skin layers for new
cepa,
panthenol
Bio-Oil® contains: PurCellin Oil (light-
skin to grow), vitamin B3 (improves
(moisturiser), hyaluronic acid
consistency, non-greasy oil and aids
elasticity and control oil production)
(moisturiser)
lecithin
absorption), vitamin A (improve ap-
and vitamin E (reduce redness). Ap-
(barrier
minimise water
pearance of scar), vitamin E and
ply 2 to 3 times a day, for 4 to 8
loss). Apply once a day for at
chamomile oil, rosemary oil and lav-
weeks (new scars) or 6 to 8 months
least 8 weeks (new scars) or 3
ender oil (emollient). Apply twice a
(old scars).
to 6 months (old scars).
day for a minimum of 3 months.
allatoin,
to
and
References:
1. Son D, Harijan A. Overview of surgical scar prevention and management. J Korean Med Sci. 2014;29(6):751-7.
2. Yao K, Bae L, Yew WP. Post-operative wound management. Australian Family Physician,. 2013;42(12):867-70.
3. Fulton JE. Silicon gel sheeting for the prevention and management of evolving hypertrophic and keloid scars. Dermatol Surg. 1995;21:947-51.
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ALOPECIA
Cik Siti Hajar Abdul Aziz
Introduction
Alopecia is the medical term for hair loss.
Types of Alopecia
Causes
Prevalence
Alopecia Areata
Male-pattern hair loss
Female-pattern hair loss
Genetics
Age
Stress
Illnesses
Alopecia areata: 1-2% lifetime risk
Symptoms
Male pattern baldness: 1 in 4 men by
the age of 30
Female pattern baldness: 12% in
females aged 20-30
Patchy hair loss
Nail pitting
Exclamation mark hairs
Receding hair line
Alopecia areata is usually associated with other autoimmune diseases
Diagnosis
Videodermascopy: viewing scalp and hair at 15-20x magnitude.
Hair pull test: Grip small amount of hair between thumb and
forefinger, and hair is gently pulled. Positive test if more than 6
hairs shed.
Pathophysiology
Male and female pattern baldness: Dihydrotestosterone binds to androgen receptors on hair follicles,
causing growth of thinner, shorter hair due to decreased expression of growth maintaining factors.
Alopecia areata: Triggers (eg environmental, stress, physical) cause the body’s immune system to
attack hair follicles.
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Treatments for female and male-pattern baldness
5-alpha reductase inhibitors
Minoxidil 5% (Rogaine)
Spironolactone
Inhibits 5-alpha reductase, which
converts testosterone to dihydrotestosterone.
Stimulates production of VEGF in Used for female-pattern hair
dermal papillae cells.
loss.
Dose: 1mg daily.
Increases flow of blood, nutrients and Dose: 100-200mg daily.
oxygen to hair follicle, prolongs
growth phase.
Side effects include postural
hypotension, electrolyte disCan cause dryness, itchiness, rapid turbances, menstrual irreguhearbeat, blood pressure changes, larities, fatigue and hemadizziness/light-headedness.
tologic disturbances.
Approved by FDA for treatment of
androgentic alopecia in males.
Can take several months to be effec- Off-label use for alopecia.
tive.
Side effects include allergic reactions, impotence, decreased libido,
depression.
Hair loss returns after medications
are ceased.
Dose: 1ml twice daily.
Treatments for alopecia areata
Intralesional corticosteroids
Anthralin
Depot corticosteroids injected intralesionally results in hair regrowth.
Anthralin or dithranol, exerts immunosuppressive and anti-inflammatory
properties.
Most suitable for areas with limited extent
of hair loss and cosmetically sensitive sites.
Side effects: skin atrophy, increased
intraocular pressure and cataracts if used
near eyes.
Methylprednisolone
injection is listed in
FUKKM for this
dication.
Dose: 40mg every
6 weeks for 6
months.
acetate
40mg
in-
Side-effects: scaling, staining of treated
skin and fabrics, folliculitis.
Dithranol 0.01%-0.5% in Vaseline and
Dithranol 1% in Lassar’s paste are listed in
FUKKM for this indication.
Dose: Cream to be applied overnight
until low-grade erythema and continued
for 3-6 months.
4 -
References:
1.
Shapiro J. Clinical practice: Hair loss in women. N. Engl. J. Med. 2007:357(16):1620–30.
2.
Chu TW, AlJasser M, Alharbi A, Abahussein O, McElwee K, Shapiro J. Benefit of different concentrations of intralesional triamcinolone acetonide in alopecia areata: An intrasubject pilot study. J Am Acad Dermatol.
2015;73(2):338-40
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MAJLIS SAMBUTAN TAHUN BARU CINA DAN HARI JADI JAN-MAC
JAWATANKUASA KEBAJIKAN DAN SOSIAL JABATAN FARMASI
By Pn Monishah Mohanan Pilai
Pada 28 Februari 2016 yang lalu, Jawatankuasa Kebajikan dan Sosial Jabatan Farmasi telah menganjurkan Majlis Sambutan Tahun Baru Cina. Sambutan ini telah diadakan di ruang tengah Unit Farmasi Logistik, Hospital Sultanah Aminah
Johor Bahru .
Sambutan ini bertujuan untuk meraikan staf yang beragama Cina di Jabatan Farmasi dan juga sekaligus meraikan hari
lahir staf yang lahir antara bulan Januari hingga ke Mac. Dengan adanya sambutan ini, warga jabatan farmasi dapat
berkongsi bersama- sama meraikan perayaan ini bersama dengan staf jabatan lain dan secara langsung mengeratkan
silaturrahim staf HSAJB. Tepat jam 12.45 tengah hari majlis dimulakan dengan ketibaan Pn Siti Rosnah Suradi selaku
wakil penaung Jawatankuasa Kebajikan Dan Sosial Jabatan Farmasi, Dr Siti Norlina yang tidak dapat hadir kerana ada
urusan rasmi di Hospital Muar.
Seterusnya, majlis diiringi dengan bacaan doa dan disusuli dengan ucapan daripada Pn Siti Rosnah Suradi. Selepas itu,
majlis ini dimeriahkan lagi dengan acara potong kek bagi staf yang lahir pada bulan Januari, Februari dan Mac. Mereka
yang terlibat telah menerima cenderahati sumbangan ikhlas daripada pihak jawatankuasa. Majlis kali ini jugadimeriahkan dengan satu cabutan bertuah bagi setiap staf yang menyambut hari lahir antara bulan Januari dan Mac.
Tidak lupa juga penyampaian hadiah kepada staf yang ditukarkan ke tempat baru, staf yang telah melahirkan cahaya
mata dan staf yang telah mendirikan rumahtangga. Hadiah persaraan kali ini diberikan pada perhimpunan pagi bulan
Mac, iaitu pada 8 Mac 2016.
Majlis di akhiri dengan jamuan makan tengahari yang disertai oleh Ketua-ketua Unit daripada Jabatan Farmasi. Pelbagai juadah enak disediakan untuk para tetamu menjamu selera. Secara keseluruhannya, sambutan Tahun Baru Cina Jabatan Farmasi berjalan dengan lancar dan meriah.