MALAYSIA AUGUST 2014 Pharmacists may be better … · MALAYSIA AUGUST 2014 Pharmacists may be better stroke case managers than nurses ... aims to be at the helm of brand marketing

MALAYSIA AUGUST 2014

Pharmacists may be better stroke case managers than nurses

spotlightManaging acute sports injuries

Feature Community pharmacies ‘first port of call’ for coughs, colds

NeWsPharmaceutical industry turns to edutainment

PT IMPACT Rottapharm Agiolax.pdf 1 3/26/13 10:38 AM

AUGUST 2014 3

Pharmacists may be better stroke case managers than nursesElvira Manzano

Patients recovering from a minor stroke are

more likely to attain optimal blood pressure

and lipid control if they are actively managed by

pharmacists, a randomized controlled trial has

shown.

Researchers compared pharmacist- vs nurse-

led care in 279 adults (mean age, 68 years) who

had minor ischemic stroke or transient ischemic

attack between 2009 and 2012 and whose blood

pressure or lipid levels were above the Canadian

guideline targets.

“Both pharmacist- and nurse-led care resulted

in significant improvements in blood pressure

and LDL cholesterol control at 6 months. Howev-

er, even greater improvements were seen in pa-

tients whose care was managed by a pharmacist

care manager who was empowered to initiate

and titrate medications,” said principal investiga-

tor Professor Finlay A. McAlister, of the University

of Alberta in Edmonton, Canada.

More patients in the pharmacist-led group met

the guideline-recommended targets for systolic

blood pressure (≤140 mmHg) and LDL choles-

terol (≤2.0 mmol/L) compared with patients in the

nurse-led group (43.4 vs 30.9 percent; p=0.03).

Clinical events occurred infrequently during the

study, with no significant differences in cardiovas-

cular events and deaths between groups. [CMAJ

2014; doi:10.1503/cmaj.140053]

At baseline, more than 75 percent of patients

were taking antiplatelet agents, antihypertensive

medications, or statins, but none met the guide-

line targets for systolic BP and LDL cholesterol.

The average systolic BP was 134 mmHg and the

average LDL cholesterol was 3.23 mmol/L. About

two-thirds had a moderate-to-high risk stroke risk

based on the ABCD score.

Patients were randomized to active prescribing

by pharmacists or nurse-led screening and feed-

back to primary care physicians (control group),

in addition to usual care. At 6 months, gains were

greater in the pharmacist-led group vs the con-

trol group (OR 2.31, 95% CI, 1.29-420, p=0.005).

The benefits of pharmacist-led care were largely

driven by the higher proportion of patients who

AUGUST 2014 4

met their LDL cholesterol targets (51.1 vs 33.8

percent for nurse-led care; p=0.003). The 12.5

percent difference in the percentage of patients

who achieved blood pressure and lipid control

exceeded the pre-specified 10 percent threshold

necessary for a meaningful endpoint.

Patients in the pharmacist-led group had more

medication changes over the study period (192

by pharmacist case managers, 71 by their attend-

ing physicians, 26 by patients) compared with

those in the nurse-led group (85 by physicians,

26 by patients).

“Case management by non-physician health-

care providers can improve risk factor manage-

ment for at-risk patients. It is more effective if the

case manager can actively modify medications,”

said McAlister. However, he cautioned that the

study does not support calls for pharmacists to

prescribe medication without the supervision of

a primary care doctor or a specialist within the

team.

“We believe both approaches hold great

promise not only for patients with stroke or tran-

sient ischemic attack but also for patients at high

risk of vascular disease,” the researchers said.

Optimization of blood pressure and lipid con-

trol reduces the risk of heart attack, secondary

stroke, and death in these patients.

AUGUST 2014 NEWS 5

Pharmaceutical industry turns to edutainmentMalvindErjit Kaur dhillon

Medicine need not be boring nor dull, as a

medical edutainment company demon-

strates.

EP Plus Group Sdn Bhd, formed in 1997,

aims to be at the helm of brand marketing for the

pharmaceutical industry by introducing fresh

and inventive ideas to promote products.

EP Plus Group’s head of marketing Jennifer

Yong said: “We want to share medical knowl-

edge in a fun and exciting manner. We try to

take different approaches, so when doctors at-

tend our medical talks or round-table discus-

sions, they are in a stimulating environment. We

prioritize starting and ending on time, as well as

making sure there are a lot of take-home mes-

sages. We are constantly pushing the boundar-

ies and innovating as we want to challenge the

status quo.”

The group’s resolve to be different was dem-

onstrated at the recent 23rd Malaysian Congress

of Obstetrics and Gynaecology, where EP Plus

launched a new concept in women’s health-

care, with an emphasis on a healthy vagina and

prevention of antimicrobial resistance.

The launch, which took place at the EP Plus

booth, showcased splashes of creativity as the

booth was designed along the concept of a

bathroom, combining the products Multi-Gyn®

and Monurol®.

Revolving around evoking the five senses, the

booth featured a rain shower on the inside and

half-covered curtains on the outside. This was

to draw curious visitors into the booth. Agent M,

a vagina-shaped mascot, also made an appear-

ance in the booth, giving away tickets to visitors

for an opportunity to be photographed with it in

the photography booth.

“The launch also aimed to create a higher

noise level to draw the attention of the crowd.

Internally, we want to tell people this is the way

we are going to move forward. This is the first

time we’ve done a conceptual booth and we will

constantly be coming up with different concepts

and ideas in line with the brand strategy,” Ms

Yong said.

The group works towards enriching lives by

introducing innovative European pharmaceu-

tical products to the Southeast Asian market.

These products are unique as some of them

are the first in their class. One such example is

the Multi-Gyn range of products, especially Ac-

tiGel®. This natural product helps prevent and

treat bacterial vaginosis via biologically active

2QR complex and the use of aloe vera extract to

restore and keep the flora of the vagina healthy.

EP Plus takes pride in being a medical

edutainment specialist, with aspirations to be

the most desired, innovative and leading medi-

cal edutainment brand by 2020. It is one step

closer towards this goal by standing out from

the crowd through its approach of sharing med-

ical knowledge in a refreshing way

AUGUST 2014 NEWS 6

Advocating personal hygiene through a multichannel campaign

L to R: Dr Chin Wai Seong, Siti Nordiana, Yamusiah, Ashlee Ng, Datuk Harjeet Singh, Chong Yen Nee, Norhayati and Christabel Wong pledging their commitment at the cam-paign launch.

dr joslyn ngu

Personal hygiene has always been an im-

portant point for Lifebuoy, prompting the

launch of the innovative Salam Sesuci Lifebuoy

– Spread Peace, Not Germs campaign recently.

The Salam Sesuci Lifebuoy campaign aims

to promote active hand washing and bath-

ing with soap. With the proper shield against

germs, Malaysians can stay protected regard-

less of place and time. “Most of us know that

personal hygiene is an important element in

staying protected. We understand that during

this fasting month the emphasis is on self-re-

flection and purification via the mind and body,

hence personal hygiene is especially important

during this time,” said Ashlee Ng, a personal

care director at Unilever Malaysia.

The campaign’s priority is to educate par-

ents, especially mothers, regarding microor-

ganisms that are too small to be viewed with the

naked eye but are present everywhere and can

be spread through personal contact. Mothers

play the main role in inculcating proper hygiene

habits amongst their children and have strong

emotional stakes in their children’s health, said

Ms Ng.

“We are pleased that the Salam Sesuci Life-

buoy campaign understands the prominence of

personal hygiene especially during Ramadan

and directs its focal point at mothers as they

are the first line of defense in ensuring the best

health for their children and family,” said Datuk

Harjeet Singh Hardev Singh, deputy secretary

general (strategic) of the Ministry of Women,

Family and Community Development. “This ini-

tiative is in sync with the ministry’s efforts in in-

tegrating women and community as part of the

mainstream national development process and

improving Malaysia’s overall social well-being.”

Besides advocating the healthy routine of

personal hygiene, the campaign also supports

the practice of giving. The campaign encour-

ages mothers and their families to pledge their

commitment to hand-washing in a dedicated

Facebook page. Once the number of pledges

reaches the 80,000 mark, RM80,000 will be do-

nated to two underprivileged homes, namely

Rumah Taqwa and Rumah Putera Harapan.

“We are taking small steps by targeting 80,000

AUGUST 2014 NEWS 7

pledges. As a brand, we have always worked

towards leaving a positive impact on society

through the solutions we offer,” explained Ms

Ng.

Other than the Facebook pledging activ-

ity, the campaign also encompasses a se-

ries of webisodes that emphasizes on es-

sential values and beneficial health and

hygiene pointers during Ramadan, explained

through stories and testimonials of fami-

lies from different backgrounds. In addition,

educational resources such as infographics

will be used to increase understanding and

awareness.

“We want people to continue embracing this

healthy practice even after Ramadan and Hari

Raya. Using just one medium is not enough,”

explained Ms Ng. “That is why we trust that

speaking to the local community, through local

identifications and in local voices is important to

get the message across effectively.”

For more information on the campaign and

to pledge, visit www.facebook.com/Lifebuoy

Malaysia

AUGUST 2014 NEWS 8

Challenging type 2 diabetics towards better disease managementPanK jit sin

A new nutrition program, the Glucerna® Chal-

lenge Me program, is part of Abbott’s ef-

forts to educate and improve the quality of life

of people with type 2 diabetes (T2D) through

proper nutrition and provision of useful tools.

Running for 12 weeks, the Challenge Me pro-

gram allows participants to create a simple plan

that incorporates a healthy meal plan, special-

ized nutrition and exercise.

Malaysia has been plagued by increasingly

high rates of diabetes in recent years, with the

National Health and Morbidity Survey 2011 esti-

mating the prevalence of diabetes to affect one-

in-five for adults aged 18 years and above by

2020.

Proper diabetes management is important

because people with the condition are two to

four times more likely to suffer a heart attack or

stroke compared to healthy individuals. They

are also at additional risk of other health compli-

cations such as kidney failure, blindness, lower-

limb amputation and death.

These factors make proper management

especially important to people with T2D. Here,

maintaining healthy blood sugar levels is the first

step to proper diabetes management. Addition-

ally, weight management and physical activity

are important factors to take into consideration

as they contribute to additional health-related

complications in people with diabetes.

Medical director of Abbott Nutrition Malaysia

Dr Shaalani Ramachandran said: “The effective

management of diabetes is becoming increas-

ingly important because of the prevalence of this

disease. Whilst everyone should be vigilant in

monitoring their nutritional intake and all-round

health, research and experience have shown

that diabetics often struggle with this. That’s

why we developed the Glucerna Challenge Me

– to provide people with diabetes with an easy-

to-use resource that helps them take charge of

managing their condition and feel confident they

can lead a healthier lifestyle.”

More information regarding the program can

be obtained at www.glucernachallengeme.com.

my or by calling 1-800-88-6233.

Patients with diabetes should be advised to follow a regular exercise plan that suits them

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AUGUST 2014 NEWS 10

Consensus on menopause hormone therapydr joslyn ngu

Hormone replacement therapy (HRT) can

be a confusing topic. In view of this,

healthcare practitioners have to be careful in

getting the right information and ensuring that

their sources can be trusted.

Examples of reliable sources are interna-

tional organizations such as the International

Menopause Society and North American Meno-

pause Society, said Dr Peter Roos, department

of gynecology, University of Cape Town, South

Africa. Local sources i.e. South African Meno-

pause Society (SAMS) and Malaysia Meno-

pause Society (MMS) are also important, as

disease management is different in every part

of the world. Dr Roos was speaking at the 23rd

Congress of the Obstetrical & Gynecological

Society of Malaysia held in Kuala Lumpur, re-

cently.

In 1997, the first consensus meeting on

menopause in the East Asian region was held

in Geneva, Switzerland. Among the consen-

sus statements formed was that every woman

should be educated on the risks and benefits of

using HRT in menopause, and given the free-

dom to choose if they wish to use HRT or not

to, Dr Roos said.

Another consensus was on the existence

of convincing data that showed HRT relieved

vasomotor symptoms, and reduced the risk of

coronary artery disease (CAD), osteoporosis

and Alzheimer’s disease (AD). Although long-

term use of HRT increases the risk of bleeding

and breast cancer, its benefits still outweigh the

risks, Dr Roos said. The 1997 consensus also

mentioned that women may continue to use

HRT indefinitely with surveillance and under-

standing of the risks. For women with meno-

pause, HRT may improve their quality of life.

In 2013, numerous organizations collabo-

rated to produce the global consensus state-

ments of menopause hormone therapy (MHT).

The statements were very similar to those writ-

ten in 1997, Dr Roos said. One of the 2013 con-

sensus statements said that for women aged

below 60 and less than 10 years after meno-

pause, MHT is the most effective treatment for

vasomotor symptoms, and also an effective

preventive method for osteoporosis in at-risk

women. The consensus also recommended

the use of systemic MHT in premature ovarian

insufficiency prior to natural menopause. (Cli-

macteric 2013;16:203-4)

The 2013 consensus also acknowledged

that the risk of ischemic stroke and venous

thromboembolism (VTE) increased with oral

MHT. However, absolute risk of ischemic stroke

and VTE with oral MHT is rare for women aged

below 60, and some studies demonstrated

the reduction of this risk through the usage of

transdermal instead of oral MHT.

In women older than 50, the association be-

tween MHT and breast cancer is a complicated

AUGUST 2014 NEWS 11

issue, Dr Roos said. It is commonly linked with

the introduction of progesterone. Nevertheless,

the resulting risk is small and decreases after

discontinuation. Even so, the 2013 consensus

does not recommend custom-compounded bi-

oidentical hormone therapy and the usage of

MHT in breast cancer survivors.

Menopause is an important event that has

a strong medical and social impact on wom-

en’s lives. There are significant associations

between menopause and aging with increased

risks of cardiovascular disease (CVD), osteo-

porosis, lower genitourinary problems, AD

and vascular dementia. As the age of onset of

menopause remains between 50 and 60 years

while the average women’s lifespan increases,

menopause will become an increasingly bigger

issue, Dr Roos said.

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AUGUST 2014 FEATURE 13

Community pharmacies ‘first port of call’ for coughs, colds

When it comes to battling coughs and

colds, some of the best advice pharma-

cists can give comes from listening to the cus-

tomer and hearing about their symptoms.

New Zealand’s Unichem Miramar Pharmacy

owner and pharmacist Ann Privett said listen-

ing to what the customer has to say helps in

finding the right product for the right symptom.

“Everyone has a symptom they would like to be

treated the most.”

People often need guidance when it comes

to cough and cold remedies, as each cold is dif-

ferent and presents a different set of symptoms,

she said.

Asking what remedies they have tried be-

fore for particular symptoms can be helpful,

because the biggest trap is recommending

something that has not worked for them in the

past, Ms Privett said. “There’s nothing worse

than blowing your credibility by recommending

something they have already tried and which

has failed.”

When it comes to coughs and colds, Ms

Privett is a firm believer in “old-fashioned” rem-

edies, such as the “mysterious power” of chest

rubs like Vicks® and some natural health prod-

ucts. “It’s treating the whole person rather than

just the cough or cold.”

Natural health remedies have been steadily

growing in popularity since Ms Privett began

work as a pharmacist in the 1970s, but she

suggests taking a cautious route when recom-

mending alternative treatments. “Some people

don’t believe in it, you have to suss it out before

you recommend it,” she said.

If a customer seems open to a recommenda-

tion, ask them if they would like to find out more

about a natural remedy for their symptoms.

Ms Privett most often recommends anything

with at least zinc and vitamin C in it, as well as

products with echinacea and olive leaf extract.

But natural health products are recommended

as an extra line of defence alongside conven-

tional treatments, she said.

“You’ve got to be caring, understanding, give

hints and tips and lots of TLC. All we’re doing

is giving symptom relief, because no one can

cure it.”

Stand out from supermarkets

With many cough and cold remedies available

in lower strength formulas from supermarkets,

it is important for pharmacies to distinguish

Pharmacists can help distinguish between serious and non-threatening symptoms

AUGUST 2014 FEATURE 14

themselves as the medicine specialists, New

Zealand’s Green Cross Health professional ser-

vices manager Alison Van Wyk said.

A strong focus on care and advice is what

helps pharmacies stand out from supermar-

kets, as pharmacists can ask a range of ques-

tions about the customer’s current medicines

and their lifestyle, and then present the best

possible solution for their ailment. Finding out

what medicines the customer might already be

taking for their cold is key to preventing any

double-ups on dosages. “You can’t get that in a

supermarket,” Mrs Van Wyk said.

Pharmacist Martin Harris at Massey Amcal

Pharmacy, New Zealand, believes pharmacy is

the “main player” when it comes to taking care

of coughs and colds. “There’s not a lot you can

do in conventional medicine apart from relieve a

few symptoms, it’s all viral and there’s not a lot

your GP can do,” Mr Harris said.

People come “far and wide” for his Get Well

Fast pack of vitamins and natural health rem-

edies, including a herbal cough and cold tonic,

which he made with the help of some medical

herbalists. As owner of the Nutrition Medicine

Clinic, Mr Harris is an advocate for taking care of

the natural health of a person, and their family,

to help reduce the severity of illnesses in winter.

In combination with the knowledge a phar-

macist offers when it comes to coughs and

colds, there are many medicines which can only

be purchased from a pharmacist, especially

high-strength products.

“It’s not just about the products, it’s about

the helpful hints,” Mrs Van Wyk said. This rep-

utation as the medicines specialist is seeing

more and more people coming into pharmacies

especially to speak to the pharmacist, and that

is a “very strong message”, she said.

Be wary of serious symptoms

Distinguishing between symptoms of a cold or

more serious symptoms of influenza or strep

throat is important. Strep throat if left untreated

can lead to rheumatic fever.

Colds generally do not present with high fe-

ver, joint pains, or body chills, and symptoms

usually take a few days to develop compared

with flu symptoms, which can develop with-

in three to four hours, according to the PTNZ

Healthcare Handbook 2013.

Mrs Van Wyk said encouraging health litera-

cy is vital and this includes engaging in conver-

sations with customers about their illness and

symptoms, especially how long they may have

had certain symptoms for.

Keeping an eye out for customers who are

complaining of a particularly sore throat is im-

portant, and pharmacists should make sure

customers are aware of the risks of strep throat

and rheumatic fever.

New Zealand Self Medication Industry execu-

tive director Tim Roper said pharmacists are gen-

erally seen as the “first port of call” for customers

on their journey to full health. “The key is that the

pharmacist uses his or her skill to treat the self-

limiting condition and look for red flags that could

require a GP referral,” Mr Roper said. –PTNZ

FA_Circarol_Pharmacy Today_Aug 2014.pdf 1 6/12/2014 10:00:37 AM

saras raMiya

Sports injuries are any form of injuries related

to any sports activity or exercise and can

be acute or chronic. Acute injuries may occur

immediately after contact or non-contact sports,

exercise or physical activity and must be man-

aged promptly, consultant sports physician Dr

Mohd Nahar Azmi Mohamed says.

Chronic injuries are injuries that develops

slowly and is persistent and long-lasting, or

constantly recurring for months or even years

when patients do not receive the appropriate

treatment or have not been treated at all. Chron-

ic injuries may start with mild symptoms and

low-grade pain, and are often ignored or simply

overlooked, Dr Nahar told Pharmacy Today.

Discussing acute injuries further, he said pa-

tients will usually have the five cardinal signs

of inflammation, which are swelling, redness,

warmth, pain and loss of function or deformity

after they sustain injuries. The signs may or

may not appear immediately but subsequently

patients will suffer from, and complain of, the

symptoms which also depends on the severity

of injuries.

“For example, a football player sprains his

ankle after being tackled or running on uneven

surface and sustains injuries. He will have imme-

diate pain and swelling. The swelling area may

feel warm and look red or bruised depending on

the degree of injuries. Because of the swelling

he cannot move and starts to limp.”

As head of the sports medicine department

in University Malaya Medical Centre (UMMC),

Dr Nahar related that about 30-35% of patients

presenting at UMMC’s sports medicine clinic

have sports injuries. However, this figure is an

estimation and does not represent the percent-

age of the incidence of sports injuries in Malay-

sia. “We need to have a database to determine

the percentage of sports-related injuries in our

country,” he said.

Furthermore, he said the level of awareness

of sports injuries among the public and even

among pharmacists and general practitioners

is still low in general. Most of the patients will

not even seek medical attention immediately af-

ter sustaining injuries. They just rest or go for

a massage and hope that they will recover. Of

course, they do not experience pain when they

rest so they mistakenly think that they have re-

covered from their injuries. Even when some

of them seek treatment or advice from a phar-

macist or general practitioner, they are usually

prescribed painkiller and heat rub ointment and

asked to rest for a few days or months and told

that they can resume playing games after that.

By the time the resting period is over and they

resume playing games, they still feel pain, are

weak or even have stiffness. Finally, they de-

cide to stop playing games. “From our experi-

AUGUST 2014 SPOTLIGHT 16

Managing acute sports injuries

Dr Mohd Nahar Azmi Mohamed


ence, some patients have complained that the

injured area is worsening and the swelling has

increased after they applied heat rub oitment or

went for a massage.”

Dr Nahar said the most appropriate advice

where acute injuries are concerned is applying

the RICE protocol i.e. rest, ice, compression and

elevation as soon as possible for 15-20 minutes.

Applying RICE will provide many benefits i.e. im-

prove constriction of the torn muscle or vessel

so it will stop the bleeding and prevent any fluid

leak from the tissue which, in turn, will stop the

swelling; reduce pain, temperature and redness

of the inflamed area; and improve the range of

motion when the swelling has reduced provided

there is no suspicious sign of fractures.

“Applying RICE for 15-20 minutes after an

injury and then repeated four to six times a

day for the next 48 to 72 hours after injuries.

If patients still have pain after three days, they

should be advised to consult a doctor. Even if

there is an obvious suspicious of fracture, im-

mediate referral is required.”

Ethyl chloride spray is frequently used in any

sports coverage or sports event although it is

not appropriate to treat injuries. “Most of the

time we may see the medical aid team spray on

the injured area and let athletes continue with

their sports activities. This is not effective and

is not helping the athletes to treat their injuries.

They may claim that the spray will help relieve

pain so that the athletes are able to continue

playing. However, this may be due to the anes-

thetic effect and it may cause further injury.

“I have also seen people spraying ethyl chlo-

ride on the athlete’s socks which is not the cor-

rect way to use it. Ethyl chloride spray is a local

anesthetic, which only provides temporary relief

and has superficial effect.”

The anesthetic effect is felt only if ethyl chlo-

ride is sprayed on the affected area until the

skin turns white. Injured athletes who are expe-

riencing pain may obtain relief by using the eth-

yl chloride spray but it is only temporary relief

and when they continue with the sports activ-

ity, their injuries may worsen. Therefore, he said

ice should be made available at sports events.

Other form of cold treatment other than ice such

as cold pack or Cryo Cuff® can also be used if

available.

In addition to cold therapy, oral NSAIDs can

be prescribed to reduce inflammation and pain.

There are a few topical medications that can re-

duce inflammation e.g. Reparil® and arnica gel,

which are also beneficial in treating acute sports

Treat acute sports injuries promptly


injuries. Doctors can also prescribe reparil tab-

let and papain to reduce inflammation. Dr Nahar

said Reparil gel with or without Reparil tablet

and NSAIDs are commonly prescribed to pa-

tients with injuries at UMMC’s sports medicine

clinic.

Topical NSAIDs such as ketoprofen gel or

diclofenac gel can be used as part of sports in-

juries management.

Physiotherapy is included as part of the treat-

ment. Initially, physiotherapy can manage the

pain and the recovery and healing process.

When the symptoms are reduced, patients have

to undergo a rehabilitation program before they

can resume sports activities.

Pharmacists should refer patients to a doctor

when initial treatment does not improve the pain

and swelling after three days. Patients should

also be referred immediately when they present

with any deformity in their limbs or any part of

their body. They should preferably be referred

to a sports physician, orthopedic surgeon or a

general practitioner who has experience treat-

ing sports injuries if patients do not improve.

In his take home message, Dr Nahar pointed

out that sports injuries are becoming more com-

mon lately because everyone is becoming more

physically active and health conscious. There-

fore, it is best for pharmacists to be aware of

and prescribe appropriate treatment and refer

patients who are not improving and those with

any deformity.

With regard to raising the level of awareness

of sports injuries among the public, Dr Nahar

said: “We would like to organize a forum to raise

the awareness of the public so they know what

to do when they sustain injuries. At the moment,

I think most of us are focusing on athletes and

students who are involved in competition sports.

We do need to give full awareness to the public

as well to educate them and make them under-

stand the steps they need to take when injured

during sports or physical activity.”

KEY POINTS■ The five cardinal signs of inflammation

in acute injuries are swelling, redness, warmth, pain and loss of function.

■ Apply ice for 15-20 minutes after an in-jury. 4-6 times per day for the next 48-72 hours.

■ In addition to ice, prescribing an oral and or topical NSAIDs to reduce pain and inflammation e.g. diclofenac sodi-um or any COX-2 inhibitor, Reparil, ar-nica or papain.

■ Avoid heat rub and massage during the acute stage of injury.

■ Refer patients when they are not im-proving with treatment or if they present with any deformity.


Menopause, a new phase in lifesaras raMiya

Hot flushes, mood swings and heavy pe-

riods are some of the symptoms that

women have to endure when they reach the

perimenopause stage. Pharmacists have an im-

portant role in helping women who are under-

going perimenopause.

For starters, pharmacists can have conversa-

tions with their customers who walk in with com-

plaints of night sweats, memory problems and

a host of other signs and symptoms, and gently

tell them that they could be going through peri-

menopause and advise them on remedies that

can help them along the way.

Consultant obstetrician and gynecologist

Dr Wong Kim Lei defines perimenopause as

the years covering pre-menopause and meno-

pause. Perimenopausal symptoms may first

appear from the age of 40 onwards, about five

to 10 years before menopause, and become

worse when women attain menopause. Meno-

pause is reached when a woman has not had

menses for 12 consecutive months. This is fol-

lowed by the post-menopausal years.

According to clinical psychologist Hariyati

Shahrima Abdul Majid (PhD), perimenopause

brings about changes not only in physical

health but also psychological health. “In our so-

ciety, when we talk about psychological health

people often fear or are ashamed to talk about it

because it is considered a taboo in our society.”

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However Ms Hariyati emphasized that it is

important to create awareness so people re-

alize that they should not be ashamed to talk

about perimenopause and the psychological

problems involved.

Signs like mood swings, memory problems

and not sleeping well can result in women feel-

ing stressed. People have to recognize that

these signs point to the development of peri-

menopause, a normal process that takes place

over time.

“When women experience symptoms of per-

imenopause, their bodies are undergoing fluc-

tuating levels of hormones. There are different

hormones that control our wellbeing,” said Dr

Wong.

For women, the most important hormone

is estrogen. During perimenopause, the num-

ber of eggs in the ovaries is close to depletion,

causing hormone levels to fluctuate. The fluctu-

ation in hormone levels is caused by the lack of

eggs to provide a constant level of hormones,

and leads to signs and symptoms like mood

swings and changes in the body, metabolic

rate, hair and skin. “These changes are scary to


women but if they prepare themselves well and

know that these things can happen then they

are more comfortable with the changes,” said

Dr Wong.

There are ways to chart the changes in hor-

mone levels i.e. by measuring the levels. Blood

tests can detect levels of estrogen, progester-

one, follicle stimulating hormone and luteiniz-

ing hormone. Generally, during puberty, some

eggs will mature while some don’t and this

causes fluctuation in hormone levels. In women

aged 20-40, hormone levels are constant, eggs

mature at the same time and menstrual cycles

are regular. From the age of 40 onwards, the

number of eggs reduce and eventually deplete

– ovulation may or may not happen – causing

fluctuation in hormone levels, said Dr Wong.

The most common complaint by women

aged 40 and above is hair loss. Apart from

perimenopause, other factors like imbalance of

growth hormone, stress and chemicals used on

the hair i.e. hair dye or other chemicals used to

style the hair, may be causing hair loss. How-

ever, the most important factor to the reced-

ing hairline is estrogen depletion. About 80%

of women lose half their hair when they reach

menopause. Another sign that indicates peri-

menopause is graying of hair, said Dr Wong.

In general, the fluctuation of hormones

causes a lot of discomfort in women. They ex-

perience sudden episodes of hot flushes, which

make them irritable. They can’t sleep at night

due to night sweat and are tired in the morn-

ing. These symptoms, in addition to aches and

pains make them feel moody, irritable and tem-

peramental, said Dr Wong.

She added that lifestyle is very important.

Women need to understand what they are going

through and obtain support from their husband

and children. Exercise and adequate nutrition,

including proper diet and nutritional supplemen-

tation e.g. Nuvafemme®, is very important. Seek

help from a gynecologist to determine whether

the problems are due to perimenopause or oth-

er pathological problems, she said.

Changes in estrogen levels affect a part of

the brain called hypothalamus, which secretes

neurotransmitters such as norepinephrine, se-

rotonin, dopamine and acetylcholine as well as

catecholamine and cortisols, said Ms Hariyati.

The direct relationship between the changes in

estrogen and these neurotransmitters actually

has an impact on mood and wellbeing. “As a re-

sult, you may actually feel a decrease in positive

emotions. It is not necessarily something that

you desire or something that you actually create

but it comes with the differences of the changes

in the neurotransmitter.”

“Reduced estrogen levels are also associ-


ated with increase in stress hormones called

catecholamines or cortisol which can also re-

sult in changes in your emotions so you’re more

likely to be stressed or angry,” said Ms Hariyati.

Changes in estrogen levels are also associated

with changes in another neurotransmitter called

acetylcholine, which processes and stores in-

formation.

Ms Hariyati advised that women should

take measures to ensure that these changes

do not impact their quality of life and wellbeing

because in their 40s, many women are at the

height of their career.

Women can use the Perimenopause Crys-

tal Quiz, which is a simple self-assessment

that is supposed to shed light on symptoms

experienced by women aged 40-56, said Datin

Swanee Teh, Nuvanta NuvaceuticalsTM business

unit manager and a pharmacist.

Regarding treatment for perimenopause

signs and symptoms, Datin Swanee said, “We

need to take the cue from Japanese women

who have a high intake of soy. They hardly have

symptoms of menopause or perimenopause.”

Researchers have discovered that the phy-

toestrogen genistein found in soy mimics the

properties of estrogen produced by a woman’s

body naturally. When estrogen levels are low,

genistein helps fill in the gap. When levels are

high, genistein will compete with estrogen in the

body thereby regulating hormonal fluctuations,

said Datin Swanee.

Genistein benefits mood, memory, bone and

heart without any adverse effects on breast or

uterine tissues. Research has also highlighted

genistein’s metabolic-regulating benefits, es-

pecially on fat cells. Genistein is a fat regulator,

which reduces belly fat and inhibits fat accu-

mulation to complement the woman’s effort in

achieving a healthy weight, she added.

Datin Swanee pointed out that a genistein

supplement should be one that is derived from

100% organic soy and is non-genetically modi-

fied. Drinking soymilk is insufficient and not ad-

visable, as it would take at least two gallons of

soymilk to derive the amount of genistein from

one tablet and 80% of soy products in the mar-

ket are genetically modified, she added.

Dr Wong, Ms Hariyati and Datin Swanee

were speaking at a workshop, which was orga-

nized by the Nuvaceuticals division of Nuvanta

Sdn Bhd recently, to raise awareness on

perimenopause.

Left to right: Dr Wong, Datin Swanee and Ms Hariyati with two women who are going through menopause

B i o O i l _ J P O G _ M a r 1 4 - 1 2 0 1 4 - 0 1 - 1 5 T 1 6 : 4 8 : 3 1 + 0 8 : 0 0

AUGUST 2014 PHARMACY PRACTICE 24

Managing COPD in primary care

By Professor Neil Barnes

london Chest hospital, london, uK

By Dr. Ong Kian Chung

President, singapore CoPd association Mt Elizabeth Medical Centre, singapore

Introduction

Chronic obstructive pulmonary disease

(COPD) is a chronic disease involving air-

ways inflammation that affects about 5 percent

of the older population.

While cigarette smoking is the biggest risk

factor, long-term exposure to indoor air pollu-

tion caused by burning of biomass fuels, oc-

cupational dust and chemicals, and underde-

veloped lungs are among other contributing

factors.

Until recently, it was thought that only 15 to

20 percent of cigarette smokers would even-

tually develop COPD at some stage in their

lives. It is now known that about half of smok-

ers will develop this debilitating disease. By

2020, COPD will be the third leading cause of

death worldwide (after ischemic heart disease

and stroke) and the sixth leading cause of dis-

ability.

In many countries, COPD exacerbations are

now either the most common or second most

common reason for hospitalization with an iden-

tifiable medical condition. The situation is likely

to get worse due to an aging population. That

puts general practice in an even more important

position to diagnose the patients before their

lung function deteriorates irreversibly.

COPD is characterized by increased CD8+

T-cells and macrophages in biopsies, and in-

creased neutrophils in sputum.

Diagnosis

Diagnosis of COPD is a two-step process. The

first is making a clinical diagnosis. A GP should

suspect COPD if a smoker or ex-smoker com-

plains of dyspnea, cough, frequent chest infec-

tions and chronic sputum production. But first,

rule out other diseases including asthma, tu-

berculosis, congestive heart failure, obliterative

bronchiolitis and diffuse panbronchiolitis using

differential diagnosis.

The second part of the diagnosis is equally

as important, but happens rather patchily. It con-

sists of the need to confirm clinical diagnosis by

performing spirometry lung function test (LFT).

It is a fairly simple procedure and doesn’t cost

much. Still, many GPs don’t use it. That’s akin to

managing someone with hypertension without

measuring their blood pressure.

In spirometry, more than 80 percent of the

values of forced expiratory volume in one sec-

ond (FEV1), as predicted on the basis of an indi-

vidual patient’s age, sex and ethnicity, will clas-

sify them as having mild COPD, whereas 30 to

50 percent of predicted FEV1 indicates severe


disease. A FEV1 of less than 30 percent of the

predicted value suggests very severe COPD.

While confirming the COPD diagnosis, the lev-

el of lung function also tells you something about

their likelihood of problems in the future. The

worse their lung function, the more likely they are

to run into other health problems in the future.

Practice guidelines

The revised Global initiative for chronic Obstruc-

tive Lung Disease (GOLD) guidelines define two

separate aims in COPD management: symptom

reduction and risk reduction.

The COPD Assessment Test (CAT) is an

eight-point unidimensional measure of health

status impairment. The score ranges from 0 to

40. A score of more than 10 indicates a ‘more

symptomatic’ patient who should be placed into

B or D groups of the assessment chart. The 0-4

point modified British Medical Research Council

(mMRC) dyspnea scale also helps understand

the level of breathlessness (see Figure).

The assessment of risk can either be done

using the FEV1/FVC (forced vital capacity) ratio

with spirometry, using 1-4 GOLD classification

of airflow limitation or it can be based on the

number of exacerbations the patient has had

during the past year. Post-bronchodilator FEV1/

FVC of <0.70 confirms persistent airflow limi-

tation. Patients with a history of two or more

exacerbations per year or very severe airflow

limitation belong to the high risk groups C or D.

Treatment

Treatment strategy for COPD is similar to isch-

emic heart disease as it uses a range of different

4

(C) (D) 2 or more

3

2

(A) (B) Less than 2

1

mMRC 0-1CAT<10

mMRC >2CAT=10

Ris

k(G

old

Cla

ssifi

catio

n of

Airfl

ow L

imita

tion)

Risk

(Exacerbation history)

Symptoms(mMRC or CAT score)

drug and non-drug therapies such as smoking

cessation, lifestyle changes, flu vaccination to

help prevent chest infections, pulmonary reha-

bilitation and drug therapy. The latter includes

short- and long-acting β2-agonists (SABA/

LABA) and muscarinic antagonists (SAMA/

LAMA), inhaled corticosteroids (ICS), phospho-

diesterase-4 (PDE-4) inhibitors and long-acting

anticholinergics such as tiotropium that are

commonly recommended in varying combina-

tions, depending on the disease severity.

Patients with COPD are at high risk of devel-

oping other comorbidities such as cardiovas-

cular disease, osteoporosis, depression and

anxiety, skeletal muscle dysfunction, metabolic

syndrome and lung cancer that can have a sig-

nificant impact on their prognosis. Depending

on their clinical condition, the GOLD guidelines

recommend that an appropriate fluid balance

with special attention to administration of diuret-

ics, anticoagulants, and treatment of comorbidi-

ties and nutritional deficiencies should be con-

sidered.

COPD exacerbations deteriorate quality of

life, reduce lung function that becomes irrevers-

ible in many patients, lead to avoidable hospital-

izations and death. Although frequent exacerba-


tions amount to two or more breathing attacks in

a year, each patient needs to be judged individu-

ally. If someone ends up in a hospital just once

with a really bad exacerbation, that should be

taken as a red flag from the risk reduction point

of view.

Emphasis on risk reduction is, in fact, the

most important change over the previous GOLD

guidelines. Just as in the management of isch-

emic heart disease you want to stop your pa-

tients having angina and chest pain, but also

want to stop them from having a myocardial in-

farct. That concept is familiar to most GPs be-

cause it is how they approach the treatment of

other chronic diseases.

Compliance

Compliance with drug or non-drug therapies

can be a challenge. A good doctor-patient re-

lationship can, however, help improve compli-

ance. If patients feel that the doctor has listened

to them and that the treatment addresses their

needs, they are more likely to stick to the drug

and non-drug treatment regimen. A simple drug

regimen also helps. If patients are required to

take multiple medications at different times of

the day, they have more chances to slip up.

One of the problems with COPD patients is

that they begin to exercise less because they

easily get short of breath. And because they ex-

ercise less, they end up developing other health

problems. That’s why it is important to recom-

mend physical activity at an early stage of COPD.

The more they keep themselves active, the better

it will be not just for their COPD symptoms, but

also for other associated chronic diseases.

The aims of COPD management

Reduce symptoms:

Relieve symptoms, improve exercise

tolerance, improve health status

Reduce risk:

Prevent disease progression, prevent and

treat exacerbations, reduce mortality

To answer the quiz for your CPD points, please go to www.mims-cpd.com.my

P u b l i s h E r

Ben Yeo

C o n t r i b u t i n g E d i t o r s

Saras Ramiya, Pank Jit Sin, Malvinderjit Kaur Dhillon, Dr Joslyn Ngu (Malaysia)

P H A R M A C Y P R A C T I C E E D I T O R

Prof Dr P.T. Thomas

g E n E r a l M a n a g E r

Kimberly Lai

d i v i s i o n M a n a g E r

Meera Jassal

b u s i n E s s M a n a g E r s

Grace Yeoh, Sumitra Pakry, Tiffany Collar

d E s i g n E r

Ken Koh

P r o d u C t i o n

Jasmine Chay

C i r C u l a t i o n E x E C u t i v E

Saratha Nadarajah

a C C o u n t i n g M a n a g E r

Christine Goh

P u b l i s h E d b y

MIMS (Hong Kong) Limited 27th Floor, OTB Building 160 Gloucester Road, Wanchai, Hong Kong Tel: (852) 2559-5888 Fax: (852) 2559-6910 Email: [email protected]

Pharmacy Today is published 11 times a year by MIMS Medica. Pharmacy Today is a controlled circulation publication to pharmacists in Malaysia. It is also available on subscription to members of allied professions. The price per annum is US$48 (surface mail) and US$60 (overseas airmail); back issues at US$5 per copy. Editorial matter published herein has been prepared by professional editorial staff. Articles ending with PTNZ have been adapted from Pharmacy Today New Zealand. Views expressed are not necessarily those of MIMS Medica. Although great effort has been made in compiling and checking the information given in this publication to ensure that it is accurate, the authors, the publisher and their servants or agents shall not be responsible or in any way liable for the continued currency of the information or for any errors, omissions or inaccuracies in this publication whether arising from negligence or otherwise howsoever, or for any consequences arising therefrom. The inclusion or exclusion of any product does not mean that the publisher advocates or rejects its use either generally or in any particular field or fields. The information contained within should not be relied upon solely for final treatment decisions.

© 2014 MIMS Medica. All rights reserved. No part of this publication may be reproduced in any language, stored in or introduced into a retrieval system, or transmitted, in any form or by any means (electronic, mechanical, photocopying, recording or otherwise), without the written consent of the copyright owner. Permission to reprint must be obtained from the publisher. Advertisements are subject to editorial acceptance and have no influence on editorial content or presentation. MIMS Medica does not guarantee, directly or indirectly, the quality or efficacy of any product or service described in the advertisements or other material which is commercial in nature. Printed in Malaysia by KHL Printing Co Sdn Bhd. Lot 10 & 12, Jalan Modal 23/2, Seksyen 23, Kawasan MIEL, Fasa 8, 40000 Shah Alam, Selangor Darul Ehsan.

PP17931/12/2013(033147) ISSN 1170-1927

Ed itor ial adv isory board

Dato’ Eisah A. Rahman Pharmaceutical Services Division, Ministry of Health

Datuk Nancy Ho President,Malaysian Pharmaceutical Society

Yip Sook Ying Secretary, Malaysian Pharmaceutical Society

Assoc Prof Dr Mohamad Haniki Nik Mohamed Malaysian Academy of Pharmacy

Prof Dr P.T. Thomas Dean, School of Pharmacy, Taylor’s University

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