Creating Value for Doctors, Pharmacists and Patients Vol:4
ue s Is s i Th n I
Issue: 19 Jan 15 - 31
2008 Price Rs 20/-
Doctors Section 1- 2 & 11-12 Pharmacist Pages 3 - 4 & 9 -10 Patient Education 5 - 6 & 7- 8
Editor Desk WISHING ALL READERS HEALTHY - 2008. Community pharmacists are the first point of contact for millions of Indians every day .Nearly 75% of pharmacies are run by non-pharmacists, like in any other developing country. Despite not having any formal education in pharmacy or medicine they are trusted, easily accessible and provide curative drugs to community. A mere 10% increase in their capacity and functional competency will save thousands of crores to society. It can be safely assumed the current knowledge level of retail chemist is no more than that of a lay person on health matters. By deploying less than ten crores in next two years we can create two lakh additional basic health workers. The recent conference organized by SEARPHAR forum in collaboration with WHO-INDIA office on Challenges and opportunities for pharmacists in healthcare in India made several recommendations. We request the government to implement conclusions and recommendations immediately. In spite of investing thousands of crores in public health infrastructure nearly 80% of citizens prefer to use private sector health service providers. There is urgent need to get back the trust and credibility lost and brings back people to utilize the public health infrastructure. We need to put Government money where people are there. Corporate Social Responsibility seems to be Greek and Latin for major Pharma companies .Except Dr.Reddys laboratories and Ranbaxy Pharma most of the companies CSR programmes do not have much Impact. If wrong data is input the output is also wrong. Many times this happens across India an all healthcare settings. While the Doctor is stressed for time, the patient has huge anxiety about disease state and fear in communicating correctly. The father of Patient Education in India Dr.Aniruddha Malpani is doing great work in improving patientPhysician relationship.
(V. Bhava Narayana)
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Editor & Publisher
V. Bhava Narayana Associate Editors
EDITORIAL BOARD Prof.B.Suresh, President Pharmacy council of India
Dr. Aniruddha Malpani, M.D Dr. Mahesh Sharma,
Dr. Jawahar Bapna, Rtd Director, IIHMR
Prof. G.P.Mohanta
S.W. Deshpande, DG, AIDCOC
M.D (Ayurveda)
Dr. P.Hanumantha Rao, ASCI, Hyd
This Publication is Only for the use of Medical & Pharmacy Professionals Printed, Published and Owned by V. Bhavanarayana, and printed at Kala Jyothi Process Pvt. Ltd., 1-1-60/5, R.T.C. 'X' Roads, Musheerabad Hyderabad - 20. Published at 3-3-62/A New Gokhale Nagar, Ramanthapur, Hyderabad - 500 013, R.R. Dist. Editor : V. Bhavanarayana * RNI No.: APBIL/2004/12036 Postal LIC NO : HSE 806/2004-06. C Pharmed Trade News, 2004 * Person responsible under PRB act for selection of news
COLD & R.U.M I am not aware of the recent statistics of use of antimicrobials in Indian population. But in U.S.A 50 % antibiotics prescribed are not used properly. ”Common cold’’ usually involves the sinuses 1) “Common Colds” are associated with computed tomographic (CT) changes of sinuses in more than 85 % of cases and these abnormalities resolve without antibiotics. 2) Mucopurulent rhinitis (thick, opaque or discolored nasal discharge) frequently developed 1 to 3 days after the onset of the common cold because nasal secretions contain desquamated epithelial cells, polymorphonucler cells and nonpathogenic bacteria that normally colonize the upper respiratory tract.
I have come to know about certain Fluroquinolones like Ciprofloxacin suspension, Dispersible 100 mg DT, (Suspension Ciprofloxacin 125 mg+ Tinidazole 150 mg), Gatifloxacin suspension, Ofloxacin suspension 50 mg/5 ml. (It can produce cartilage erosions in young animals, some company advocates it is only for use for older who can not take solid dosage form. But dose is in sub therapeutic level to use in an adult patient. In special circumstances Fluroquinolones may be justified in children younger than 18 years when alternative safe therapy is not available. For children who weigh 45 kg or more, adult regimens are advised, if Fluroquinolones are used.
Amit Pachal Pharmacist, Central Hospital, South Eastern Railway Garden reach, Kolkata-700043, West Bengal Pharma691@gmail.com Pharma691@rediffmail.com
This is not an indication for bacterial infection and there is not an indication for antimicrobial use. Children and adults with viral respiratory tract infections and with bronchitis with no underlying lung disorders receive unnecessary antibiotics.
Differentiating features of pharayngitis caused by group A Streptococci and viruses Classic Streptococcal Pharyngitis
Viral Pharyngitis
Season
Late winter or early spring
All season
Age
Peak; 5-11 Years
All ages
Symptoms
Sudden onset Sore throat, may be severe headache, abdominal pain, nausea, vomiting
Onset varies. Sore throat, often mild fever varies, myalgia, arthalgia, abdominal pain may occur with influenza.
Signs
Pharyngeal erythema and exudates, Tender enlarged anterior cervical nodes Tonsilar hypertrophy, scarlet fever rash, absence of cough, rhinitis, hoarseness, conjunctivitis and diarrhea
Characteristic exanthemes Often have cough rhinitis, hoarseness, conjunctivitis or diarrhea
Ref: Principles and practice of pediatric infectious diseases, Long SS, Pickering LK, Prober CG, 1997:202 Problems in using excessive antibiotics: 1) Increase bacterial resistance 2) Unwanted adverse effects, Clostridium difficile colitis, drug rash, drug fever and excessive expense. Once allergic may lead to alternative broad-spectrum antibiotics.
SMS Survey Population stabilization
Why Physician over prescribe antibiotics: a) Insufficient time b) Lack of understanding of Natural History of Disease c) Clinician experience and patient experience and expectation d) Economic pressure; Concern about patients/parents, satisfaction and retention.
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a) Provide data on pathogenesis of diseases b) Use of NSAIDs and 1 st generation antihistaminic in every cold and symptoms c) Media and medical community reach to common public. *****Precautions & Attention:**** PhaRMeD TRADE NEWS
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RECOMMENDATIONS AND CONCLUSIONS National Health Care Programmes 1 Pharmacists must get fully integrated in the health care team as part of the national health and drug policies. This should be facilitated by recognizing the pharmacists as human resource for health in the national policies. 2 Policy makers should view pharmacies as part of the health care sector and pharmacists as health care professionals providing health care services and focus on them as they do with other health care professionals. 3 The National Rural Health Mission (NRHM) is a new initiative by the government to provide health services in rural areas wherein pharmacists should get connectivity with the rural health systems and become a part of community of carers. 4 Pharmacists should be utilized for improving access to essential medicines and their rational use in proper selection of medicines, ensuring their quality, improving logistics of their procurement, storage and distribution and providing information on medicines to the patients, physicians and nurses. 5 The services of community pharmacists should be utilized in referring, counseling and participation in DOTS strategy of the Revised National Tuberculosis Control Programme (RNTCP). 6 The Malaria Fact Card project found successful in Zimbabwe, Tanzania and Ghana should be adopted in India through national pharmaceutical associations for better consumer understanding of the use of malaria medications, increased awareness, prevention strategies and early treatment. 7 Pharmacists should be encouraged to educate the public in the thrust areas in Reproductive Child Health (RCH II) by scaling up contraceptive acceptance and playing an meaningful role in family planning by displaying contraceptives at a prominent place in pharmacies with appropriate signages for helping the patient in choice of contraceptives; distributing family planning literature freely; being counsellors next door; and spreading the message of small family norm and its advantages. 8 Pharmacists should be integrated in NACO’s programmes developed for the prevention and control of HIV/AIDS in India and should be involved in procurement, storage, distribution and proper use of qualityARV medicines. Pharmacists need to be actively involved in the
practices. Greater participation by pharmacists in all practice settings would be an important tool to increase the reporting of ADRs and other drug-related problems in pharmacovigilance.
Community Pharmacy Practice 10 The distribution and sale of medicines and cosmetics are governed by various drug laws like the D & C Act and Rules, NDPS Act, etc. The provisions of the existing Schedule N of the D & C Rules with regard to staff, equipment, space, storage conditions, GPP, etc. are inadequate to meet new challenges in community pharmacy practice. These need amendment, considering the changing practice of pharmacy. 11 There is a need to accord legal status to Good Pharmacy Practice (GPP) concept and to create an accreditation authority for retail pharmacies to ensure high standards of pharmaceutical care. 12 There is a need to evolve minimum educational requirements for persons engaged in pharmacies as ‘PharmacyAssistants’.
Hospital Pharmacy Practice 13 The National Human Rights Commission (NHRC) issued exhaustive directives relating to the manufacture, storage and distribution of large volume parenterals (LVP) wherein the role of the pharmacist in drug management in Hospitals and Medical Stores Depots got highlighted. However, no practical steps have been taken by the Government to make necessary changes in policies connected with proper deployment of pharmacists. All the Recommendations of the NHRC should be implemented without any further delay. 14 The provisions of the existing Schedule K of the D & C Rules should be reviewed with a view to laying down standards in respect of staff, equipment, space, GPP, etc. 15 The Department of Pharmacy in every hospital, including corporate hospitals, should have administrative structure similar to that of other Departments like Medicine, Surgery, Gynecology, etc. The structure and status to be accorded to the Department of Pharmacy as well as to pharmacists and other staff working therein should be at par with other departments. 16 Pharmacists should be fully utilized in rendering professional services in hospitals and nursing homes. There should be adequate number of pharmacists in the above settings. 17 The Medical Council of India should lay down the minimum standards of hospital pharmacy in terms of staff, space and equipments as they have prescribed for other departments in hospitals attached to medical colleges.
9 surveillance of drug safety issues within the context of their
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18 A Pharmacy and Therapeutics Committee (P&TC) must be created in every hospital so that utilization of medicines is done judiciously and Hospital Formulary is compiled. The Head of the Pharmacy Department should be the Member-Secretary of the Committee. 19 In order to provide up-to-date information on medicines to patients, physicians and other health personnel, it is essential to create a Drug/Medicine Information Center in every hospital pharmacy.
Government Pharmacy Practice Settings 20 A uniform cadre and administrative structure may be prescribed for all the pharmacists working in various central and state government settings. 21 The pharmacists should be trained and utilized for the benefit of the rural society under the NRHM 2005.
Pharmacy Education and Continuing Education 22 The minimum qualification for registration as pharmacist continues to be diploma in pharmacy obtained after the 10 + 2 stage of education. It is essential to upgrade minimum qualification for registration as pharmacist to a level capable of providing superior pharmaceutical care. For those who wish to go for pharmacy practice, the curriculum should be patient oriented. 23 The curriculum and training for the minimum registrable qualification of degree in pharmacy course has to be modified giving main focus on subjects like pharmacy practice, rational use of drugs, pharmaceutical care and clinical pharmacy and should be more oriented towards community, hospital and clinical pharmacy practices to generate a sound foundation of professional and trained pharmacists. 24 For in-service and working pharmacists continuing professional development via continuing education programmes, aimed at keeping pharmacists abreast with new developments, are to be organized and made mandatory. 25 Pharmacy educators should ensure that the curriculum is so
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amended that the importance of pharmacists in pharmacovigilance gets properly highlighted.
Role of Stakeholders 26 The strategies to build the image of pharmacists shall require improving competency of pharmacists at all levels. The area of pharmacy practice is the primary challenge. 27 Associations, professional bodies, regional forums and government bodies should advocate and educate policy makers and generate general consciousness of the society for the pharmaceutical services for better health care. 28 For greater recognition and appreciation, it is necessary for associations to document evidence that demonstrates the impact of pharmacists on society. In this connection, a national data base should be generated and archived.
Implementation 29 The pharmaceutical education, research and profession are presently controlled by more than one department and ministry making the whole process complicated. Government should consider creation of a separate “Department in MoH” or “Ministry of Pharmaceuticals”. 30 To create a focus on pharmacy education and pharmaceutical services in community, hospital and government pharmacy settings, a “Planning and Coordination Body” should be established. 31 The successful implementation of these strategies shall require cooperation among all stakeholders and sectors, both government and private.
From: A REPORT ON Challenges& Opportunities for Pharmacists in Health Care in India
Share with your Patients pages 5-6 & 7-8 Create Value for your Customers JAN, 15-31, 2008
Page 4
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PATIENT EDUCATION As a parent, the things you say and do have a tremendous influence on the decisions your child makes - especially when it comes to using drugs or alcohol. Research shows that kids who learn a lot about the risks of drugs from their parents are up to 50% less likely to use. By talking to your kids about drugs and alcohol, you can help them make better choices and live safer, healthier lives. Starting the conversation with your kids and keeping communication open is never easy -- but it's also not as difficult as you may think. Whether you're having trouble finding the time or finding the right words, Time to Talk is here to provide the support and resources you need when it's time to talk to your kids about drugs and alcohol.
3. Get the results of any test or procedure. Ask when and how you will get the results of tests or procedures. Don't assume the results are fine if you do not get them when expected, be it in person, by phone, or by mail. Call your doctor and ask for your results. Ask what the results mean for your care. 4. Talk to your doctor about which hospital is best for your health needs. Ask your doctor about which hospital has the best care and results for your condition if you have more than one hospital to choose from. Be sure you understand the instructions you get about followup care when you leave the hospital. 5. Make sure you understand what will happen if you need surgery. Make sure you, your doctor, and your surgeon all agree on exactly what will be done during the operation. Ask your doctor, "Who will manage my care when I am in the hospital?" Ask your surgeon: Exactly what will you be doing?
Visit www.timetotalk.org today
DIABETES A weight loss of 10 kg can reduce mortality by 20 per cent and improve control of diabetes by 50 per cent. This was suggested at the Continuing Medical Education session at the ongoing 63rd annual conference of the Association of Physicians of India
About how long will it take? What will happen after the surgery? How can I expect to feel during recovery? Tell the surgeon, anesthesiologist, and nurses about any allergies, bad reaction to anesthesia, and any medications you are taking
A NEW INITIATIVE
Dr. S.N. Shah highlighted that Metabolic Syndrome (ie. high insulin
The Ministry of Health and Family Welfare, Government of India, has
levels in the fasting state and abnormal blood sugar in the fasting
launched the pilot phase of the National Programme for Prevention and
state) with other associated conditions such as obesity is a serious
Control of Diabetes, Cardiovascular Diseases and Stroke (NPDCS) on the
threat to the health of young people.
4th of January 2008.
He said that various studies show that 4 to 5 per cent of the adoles-
High burden pf premature mortality and morbidity, increasing economic
cents in India are suffering from this problem. World wide more than
burden and limitations in the existing health system has led to the formulation
300 million people are suffering from obesity and this could double
of this national programme. The Honourable Union Minister for Health and
in the next 25 years. Hence a healthy lifestyle with proper diet and
Family Welfare highlighted the need for integrated prevention of NCDs
exercise is the only way to prevent this menace.
through healthy lifestyles. Shri. Montek Singh Ahluwalia, chief guest of the launch, offered the support of the Planning Commission and emphasized
AT DOCTOR CHAMBER
the need for prevention programmes in existing health care schemes such
1. Ask questions if you have doubts or concerns. Ask questions and
as Central Government Health Services and Employment State Insurance
make sure you understand the answers. Choose a doctor you feel
scheme.
comfortable talking to. Take a relative or friend with you to help you
The objectives of the pilot phase are :
ask questions and understand the answers. 2. Keep and bring a list of ALL the medicines you take. Give your doctor and pharmacist a list of all the medicines that you take,
1) to assess the prevalence of risk factors for Non- Communicable Diseases.
including non-prescription medicines. Tell them about any drug
2) risk reduction for prevention of NCDs (Diabetes , CVD and Stroke).
allergies you have. Ask about side effects and what to avoid while
3) early diagnosis and appropriate management of Diabetes,
taking the medicine. Read the label when you get your medicine, including all warnings. Make sure your medicine is what the doctor ordered and know how to use it. Ask the pharmacist about your
Cardiovascular Diseases and Stroke. The pilot phase is undertaken in 6 districts in 6 states with a financial outlay of 50 million rupees.
medicine if it looks different than you expected.
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How to Talk to your Doctor A doctor who cannot take a good history and a patient who cannot give one are in danger of giving and receiving bad treatment. . .
- Paul Dudley White The simple fact that in over 80 per cent of cases the diagnosis of the illness can be made purely on the basis of what the patient tells the doctor (what is called a medical history) should emphasize the importance of one’s ability to talk intelligently to one’s doctor! While the capability of absorbing the relevant details of an individual’s medical history is one of the key skills of a competent physician, being able to provide a lucid history is a key skill on the part of a good patient. You need to be able to describe your problem as accurately as possible. For example, if your problem is a headache, you should be able to provide all the details! For instance: Where does it hurt? Has the pain spread elsewhere ? How severe is the pain? What does the pain feel like? Is it a sharp, dull, or throbbing pain? When does it occur? What makes it better? What makes it worse? Have you noticed any other symptoms or signs recently, such as fever, shortness of breath or blood in the urine? When did the problem start? Has it changed since then? Have you felt like this before? If so, when? What made the pain better then? Is it affecting your daily activities such as sleeping or eating ? In this context, a useful aide memoir includes the following details: ◆ ◆ ◆ ◆ ◆ ◆ ◆
Site: Location (e.g., pain is in the chest and then spreads to the left arm). Quantity: Bringing up a cupful of sputum when coughing. Quality: It feels like an elephant is sitting on my chest! Setting: I usually develop such aches after fighting with my wife. Aggravating factors: Stomachache becomes worse after eating. Alleviating factors: Breathlessness becomes better after resting. Associated Symptoms: Other related complaints.
If you remember to categorize all your problems systematically, not only can you make better use of your time with your doctor but you can also help him arrive at a correct diagnosis more quickly! You could rehearse the details you are going to provide to your doctor with a friend or a relative. You could also summarize them on a single sheet of paper, just to make sure you don’t forget any vital aspect. It is a medical truism that if the doctor listens to the patient intelligently, he will be able to make the diagnosis correctly. However, just like learning to take in a good history is a skill the doctor needs to master, providing an intelligent history is a skill the patient needs to learn. Patients are often slipshod while recounting their medical history so that the doctor needs to methodically extract the facts from them: and this exercise can be a painful for both! The common gaffes patients make include: ◆ ◆ ◆ ◆
Getting bogged down in irrelevant details. Not providing all the facts. Not furnishing the information in a chronological sequence. Jumbling up the details, so that they jump from one problem to another completely unrelated one.
Remember to tell your doctor what you think the reason for your problem is! This ‘revelation’ can often provide the doctor with a useful clue. Ultimately, do not forget that you are the expert on yourself ! You should also be able to provide relevant information about your health status, both past and present. The following aspects need to be highlighted: ◆ ◆ ◆ ◆ ◆ ◆ ◆
Your medical history (including instances of surgery and hospitalization). Your family’s medical history. Allergies you are prone to. Medications you have taken (and are still taking). Your daily routine. Your work schedule. Pressures you have been subject to (and are still subject to).
To sum up, the following suggestions will help you communicate effectively with your doctor: 1. Plan well ahead of time what you intend discussing with your doctor about your problem. Your own observations about your health problem can prove invaluable in helping the doctor make an accurate diagnosis. Carry written lists to make sure you don’t forget any crucial aspects! 2. If you are confused by complex medical terms, ask for simple definitions. There is no need to be embarrassed; after all, your doctor does want you to understand what is happening to you! Remember that your doctor’s objectives and yours are the same to help you to get better as soon as possible!
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3. Repeat in your own words what you think the doctor meant and also ask: ‘Is my version correct?’ Such a clarification will ensure that you understand clearly what the doctor is saying and will also allow him to present the information to you again, if required, in a manner which you can comprehend. 4. Share your point of view with your doctor since he needs to know what’s working and what’s not. He or she obviously can’t read your mind, so it is important for you to put across your thoughts and observations. If you feel rushed, worried, or uncomfortable, do convey your apprehensions to the doctor. Try to voice your feelings in a positive and courteous manner. For example: “I know you have many patients to see, but I’m really worried about my condition. I’d feel much better if we could talk about it a little more.’ If necessary, you can offer to return for a second visit to discuss your concerns. 5. Take notes on what the doctor’s analysis of your problem is and what you need to do to rectify the situation. 6. Discuss frankly with your doctor if any part of the visit has been annoying or dissatisfactory, such as a lengthy waiting time or discourteous staff. Your approach ought to be tactful, but honest. 7. Don’t hesitate to voice your apprehensions about what you may have heard from well-meaning but ill-informed friends or relatives regarding your condition. The doctor may be able to dispel any misconceptions. 8. Discuss any self-medication practices you’ve used which have relieved symptoms. 9. Don’t waste your doctor’s time by asking irrelevant questions (for example, about your brother-in-law’s medical problem ). Such a digression is likely to upset the doctor! Also, try to do as much homework as possible, so that you can ask your doctor questions specific to your particular problem. After all, if you can find the answers to your questions from another source, say, a book or by asking the nurse or receptionist, you can save your doctor’s precious time, something which he will deeply appreciate. You can, nevertheless, ask your doctor to confirm that the knowledge you have acquired is accurate! Even though most patients realize the need to ask their doctor certain important questions, many of them get tongue-tied when they actually come face to face with their doctor. Not only can they not think straight, but they also often forget what questions to ask! But remember that you will only get answers if you ask the right questions! Rudyard Kipling’s five best friends - What? When? Why? Where? How? - should help guide you as to what to ask! A simple example would be asking: ‘What is wrong with me? When did the disorder originate? Why? What can you do about it?’ A clear understanding of what precisely your doctor has told you is crucial if you’re going to work together as a team. At the end of your visit, you should be able to: 1. 2. 3. 4.
Describe your condition fairly accurately. Know what additional tests are needed and why. Explain your treatment, including the use of medications. State if and when you need to return.
If you can’t fulfil the preceding objectives, you’re not communicating properly with your doctor! Remember that communication between a doctor and a patient is a two-way process. Both the doctor and the patient must work together on activities such as listening as well as speaking to one another. Honesty and openness with each other are also important factors. The more honest you are, the better your doctor can help you. Much of the communication between the doctor and the patient is personal, as well as confidential. In order to obtain optimum results, you may need to be open about sensitive subjects such as sex, sexually transmitted diseases and death even if you feel embarrassed or uncomfortable. Doctors are accustomed to talking about personal matters and will try to ease your discomfort to the maximum extent possible. It would definitely be advantageous to take a family member or a friend with you while visiting the doctor’s clinic. You will feel more confident if someone accompanies you. Also, a friend or relative can help you remember what you planned to tell or ask the doctor. He or she can also help you remember the doctor’s advice. But don’t let your companion play too prominent a role; after all, the communication is between you and your doctor. Also, you may want to spend some time alone with the doctor to discuss personal matters. Therefore, let your companion know in advance the extent to which he or she can be helpful. If a relative or a friend has been taking care of you at home, taking that person along when you visit the doctor could prove beneficial. In addition to the questions you have in mind, your caregiver may have certain concerns he or she could like to discuss with the doctor. Even if a family member or a friend can’t accompany you to the clinic, he or she can still help. For example, such a person can serve as your sounding board, helping you to practice what you want to say to the doctor before the visit. And, after the visit, talking with that person about what the doctor said can remind you about certain important points and help you come up with fresh questions to ask the next time. Most capable doctors will agree that they learn from their patients all the time, just as a good teacher learns from his students ! A skillful doctor treats the patient as the captain of the ship and himself as the navigator, and a balance of respect between the doctor and the patient can foster a partnership in which both learn all the time! However, remember that playing an active role in your own health care places the responsibility for reliable communication with your doctor squarely on you!
Dr. Anuraddha Malpani, M.D Director, Health Education Library for People
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ROLE OF CHEMIST IN EDUCATING CARE GIVERS ON DIARRHEA MANAGEMENT The World Health Organization (WHO) estimates that 500,000 children under the age of 5 years die every year in India due to diarrhea. The major cause of these deaths is lack of knowledge amongst the caregivers regarding diarrhea. These deaths can be prevented if caregivers are informed about the correct practices for Diarrhea management. ORS has been an important part of diarrhea management for over 25 years, keeping millions of children from unnecessary dehydration and possible death as a result of diarrhea. Reduced Osmolarity Oral Rehydration Salts (ORS) has come out as one of the most important medical solution for diarrhea management. This is the simplest form of treatment and prevention of dehydration associated with diarrhea. To add to this an important development has been the discovery that dehydration from acute diarrhea of any etiology and at any age, except when it is severe, can be safely and effectively treated in over 90% of cases by the simple method of oral rehydration using ORS. WHO and UNICEF have recommended this single formulation of ORS to prevent or treat dehydration from diarrhea irrespective of the cause or age group affected. The Low Osmorality ORS, which is the new formulation, was approved by the Drug Controller of India in 2004 and is available in the market. This formulation is approved by the WHO and UNICEF as well as is endorsed by the IAP National task force. This product has been developed after intensive research and is as safe and effective as standard ORS for preventing and treating dehydration from diarrhea. -New Low Osmolarity WHO recommended ORS is more effective because research has shown that: ◆ It reduces stool output or stool volume by about 19% when as compared to the original ◆ It reduces vomiting by 29% ◆ It reduces the need for unscheduled IV therapy by 39% This successful formula was based on reducing the osmolarity of ORS solution. This was done by marginally reducing the solution’s glucose and salt concentrations. Studies had shown that the efficacy of ORS for treatment of children with acute diarrhea is improved by reducing its sodium concentration to 75 mEq/l, its glucose concentration to 75 mmol/l, and its total osmolarity to 245 mOsm/l. This compared to the original solution which contained 90 mEq/l of sodium with a total osmolarity of 311 mOsm/l. There has been a concern that the original solution, which is slightly “hyperosmolar” when compared with plasma, may risk hypernatraemia (high plasma sodium concentration) or an increase in stool output, especially in infants and young children. The highlight of this improved formulation is that it reduces stool output, incidence of vomiting and intravenous fluid requirement. As chemists, you play an important role in dissemination of correct information. It is imperative for caregivers to know about the curative and preventive measures of diarrhea management. The correct mixing and use of low osmolarity ORS is imperative for caregivers to ensure the safety and good health of their children. Laboratory experiments showed that reduced osmolarity solutions promote water and sodium absorption more efficiently than standard WHO ORS -Composition of new low osmolarity WHO ORS -Sodium : 75 mmol/L -Glucose : 75 mmol/L -Potassium -Chloride : 20 mmol/L 65 mmol/L -Osmolarity : 245 mmol/L Most of the brands now follow the uniform formulation of reduced osmorality ORS Price Points: Pack Size Quantity of water required Price Range Small (4.2/4-3/4.4 gms) 200 ml Rs.3.00-Rs. 4.00 Large (20.7/21- 5/21.8 gms) 1000ml (1 litre) Rs.7.50-Rs. 14.50 Usage Guidelines: ❃ Take 200 ml (one glass) water for a smaller sachet (for 200 ml) and 1 litre (one jug) water for a bigger sachet (for 1 litre) of WHO ORS ❃ For making ORS solution use boiled water that has been cooled at room temperature ❃ Use clean utensils for making ORS and wash your hands before preparing the solution ❃ Pour the entire content of ORS packet to make the solution. ❃ Mix it well ❃ Use the entire solution within 24 hours ❃ Give the child ORS after each loose stool Administration: Show caregivers how much ORS to give after each stool and give her enough packets to last for 2 days
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Age
Amount of ORS to Amount of ORS to provide give after each stool for use at home Less than 24 months 50-100 ml (1/4-1/2 cup) 500 ml/day 2-10 years 100-200 ml (1/2-1 big cup) 1000 ml/day 10 years or more As much as the child can take 2000 ml/ day It is important to inform caregivers to stock ORS at home as diarrhea can strike anyone anytime. Caregivers should be advised on the necessity of regular intake of fluids during Diarrhea. Fluid replenishment at home can be ensured by providing WHO ORS solution or appropriate home available fluids such as sugar salt solution, salted fluids such as salted rice water or a salted yogurt drink, vegetable or chicken soup with salt and even green coconut water. It is equally important to avoid the intake of certain fluids such as energy drinks, sweetened drinks, sweetened tea / coffee, canned fruit juices which can cause osmotic diarrhea and hypernatraemia, further deteriorating the patient’s health. Unnecessary use of antibiotics and antidiarrheals should be avoided and medicines should be given only when prescribed by a qualified doctor. One should avoid any self medications especially in case of small children. Diarrhea is, in reality, as much a nutritional disease as one of fluid and electrolyte loss. Children who die from diarrhea, despite good management of dehydration, are usually malnourished. During diarrhea, decreased food intake, decreased nutrient absorption, and increased nutrient requirements often combine to cause weight loss and failure to grow: the child’s nutritional status declines and any pre-existing malnutrition is made worse. In turn, malnutrition contributes to diarrhea which is more severe, prolonged, and possibly more frequent in malnourished children. This vicious circle can be broken by: ◆ Continuing to give nutrient rich foods during diarrhea; ◆ Giving a nutritious diet, appropriate for the child’s age, when the child recovers. Additional energy dense food must be provided to children above six months of age and also for at least 2 weeks, to compensate for the loss of body nutrients. Small and frequent feedings helps as the child may not be able to take large quantity of foods. It is also essential that additional energy dense food is given to a child above six months during diarrheal episodes since there is a significant loss of nutrients during diarrhea. If these steps are followed, malnutrition can be prevented and the risk of death from a future episode of diarrhea is much reduced. WHO and UNICEF recommend mothers to give the child only breast milk up to 6 months. Mother’s milk is the best food for the child up to six months as it has all the nutrients required for the child. In addition to this it has numerous substances which can help protect the child against many infectious diseases. Furthermore, the electrolyte composition of human milk makes additional water unnecessary for the child even under dry and hot climatic conditions, reducing the risk of giving contaminated water. The many anti-infectious factors reduce the severity of symptoms of illness particularly diarrheal diseases. Epidemiological studies in both developed and developing countries reveal a lower incidence of diarrheal diseases, otitis and acute respiratory infections in breastfed compared with bottle-fed infants. During diarrheal episodes it is important that mothers continue to breast-feed their infants more often and for longer duration during each feed. Caregivers need to be educated on how to detect the symptoms of Diarrhea in a child which require medical attention. The critical signs of Diarrhea include: child becomes sicker, is not able to drink or breastfeed or is drinking poorly, develops fever and /or passes blood in the stool. In case of such signs caregivers should immediately rush their child to the nearest doctor for treatment to prevent further complications due to diarrhea. Improper post-diarrheal care can result in permanent retardation of the child’s growth in future, and sometimes even death. Diarrhea can be prevented by following a few general precautions at home. Babies’ caretakers should ensure cleanliness around themselves and the baby at all times. An effective way of maintaining this is to wash their and the baby’s hands with good quality soap after defecation, after washing babies bottom, before eating / feeding and before preparing / handling or eating food . In a study done by London School of Hygiene and Tropical Medicine it was observed that washing hands occasion can reduce the incidence of diarrhea by 42-47%. So it’s important that hands should always be washed with a good soap. Thus following these treatment and preventive steps during diarrhea can reduce the morbidity and mortality due to diarrhea. As Chemists you could make a difference by informing and educating caregivers around you on the preventive and curative measures of diarrhea management so that no child gets left behind. In this way you can fulfill your duty as an Indian citizen and ensure our children live a safe and healthy life.
JAN, 15-31, 2008
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WHO IS A DISPENSER? This article will discuss dispensing as if it were only performed by trained pharmacists, pharmacy auxiliaries, or other qualified health workers. In many, if not most, countries, dispensing is performed by a wide variety of personnel, not all of whom have had formal training. In the real world, a prescriber is anyone with a recommendation for treatment; a dispenser is anyone who gives out the treatment. Formally, we think of a dispenser as a person trained in the art of preparing and giving out medicines. In a global sense, however, a dispenser can literally be any person who prepares and gives out remedies, regardless of training. Thus, dispensers include not only qualified health workers (pharmacists, physicians, nurses, basic health workers, even veterinarians), but also self-appointed health workers who have access to any substance that they believe can cure. These dispensers would include friends, relatives, store keepers, taxi drivers, and others. Consider the scenario in most countries. The qualified pharmacist’s role is often suggested by the advertisement: “Drugs - Retail and Wholesale.” In their retail role, druggists, or their employees, will provide medicines and advice on any number of health conditions. On the wholesale side, they provide drugs to the entire private, and often to the public, health care system. Many drugs are sold to small local village shops, where they might be sold to anyone who can buy them. The buyer, in turn, might resell the drugs to someone else, who might possibly resell them again, and so on. The informal private drug distribution and trade network remains a mystery. But one thing is certain: where there is a demand for drugs, there will be a supply—and “dispensers” will
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dispense them, it is hoped, in accordance with good dispensing practices that will enhance rational drug use. In many health care institutions, especially in the developed countries, the role of the pharmacist in patient care, especially in dispensing drugs to patients, becomes more and more important. Pharmacists contribute to the safe and effective use of pharmaceuticals at times when drugs are dispensed. They also play a significant role in promoting rational use of drugs though such means as providing drug information to patients and carrying out drug utilization studies. A safe dispenser needs knowledge about different drugs, the specific product being dispensed, and communication/consultation skills. This person needs to be aware of promotional and marketing techniques that may be used. To be an effective dispenser, he/ she needs an adequate drug supply, dispensing equipment, a relationship with the prescriber, and status in the community. (From –Dispensers role in rational drug usage)
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PHARMED NEWS ‘Painless Painkiller’ injection Ahmedabad based Troikaa Pharmaceuticals limited unveiled a new version of it painless painkiller injection, DYNAPAR AQ 1ml, which causes no pain while injected .Unlike diclofenac injections available in the market, which have to be administered in the buttock, DYNAPAR AQ 1ml, can be administered in the arm muscle, thereby avoiding the thick fat layers of the buttock and enhancing its efficacy. Mr. Ketan Patel, Managing Director, Troikaa Pharmaceuticals said “At Troikaa, our focus has been to address unmet medical needs through innovative drug delivery. The introduction of Dynapar AQ in 1 ml dose is in line with our promise to provide technology that augments existing health care treatments.” Dr. Vijaya Jaiswal, Vice President, Medical Services, Troikaa Pharmaceuticals said, “Currently available diclofenac injections deliver 75 mg diclofenac in 3 ml. This relatively larger volume (3 ml) of injection causes muscle damage, locally at site of injection. Therefore, ironically, diclofenac injections which are administered to alleviate pain, cause pain at site of injection. DYNAPAR AQ is a novel high concentration diclofenac injection which delivers the full dose of 75 mg diclofenac in just 1 ml, and hence causes minimum muscle damage, and hence minimum pain at injection site. Besides, the muscles in the arm
More than 90% inhibition of the DPP-IV enzyme was observed within 1 hour at all doses tested. In preclinical studies, the compound appears to be effective and well tolerated when given at pharmacological doses.
ADA RECOMMEDATIONS The American Diabetes Assn. published revised Clinical Practice Recommendations in the Jan. 1 Diabetes Care. Among the guidelines: ❖ Testing should be considered for all adults who are overweight or obese and have additional diabetes risk factors. ❖ For type 2 diabetes prevention, consider metformin, in addition to lifestyle changes, for those at very high risk: obese, younger than 60, with combined impaired fasting glucose and impaired glucose tolerance, plus other risk factors. ❖ The general A1c goal for non-pregnant adults is less than 7%. For selected individual patients, the A1c goal is as close to normal as possible, or less than 6%. ❖ A low-carbohydrate diet as well as a low-fat diet can be recommended for weight loss. Closely monitor lipid profiles and kidney function in patients on a low-carbohydrate diet. ❖ A statin is recommended for children older than 10 with type 1 diabetes if diet and other lifestyle changes have not succeeded in lowering LDL cholesterol levels to less than 160 mg/dL.
region cannot easily accommodate 3 ml volume of injection. Therefore currently available diclofenac injections need to be administered in the buttock. DYNAPAR AQ with just 1 ml volume can be conveniently
Quinolone antibiotics - Tendon disorders
inflammation. Diclofenac injections are used for managing acute pain due
New Zealand. Medsafe, New Zealand’s Medicines and medical devices safety authority, is reminding prescribers of the risk of tendon disorders, such as tendonitis, tendon rupture and tendinopathy, associated with the use of Quinolone antibiotics. The Agency notes that the onset of these adverse effects can occur as early as the first few hours after the initial dose and as late as six months after treatment. Patients should be advised to inform their prescriber immediately of symptoms suggestive of tendon disorders, such as oedema, erythema, and sharp pain, particularly with walking and palpitation. According to the Agency of the 104 cases of tendon disorders reported so far to New Zealand’s Centre for Adverse Reactions Monitoring (CARM), 69% involved quinolones, mainly ciprofloxacin, norfloxacin and enoxacin. Prescribers are cautioned to be vigilant when prescribing quinolones to patients already receiving steroid therapy, those with renal insufficiency or who are elderly as these risk factors are known to increase the likelihood of
to surgery, trauma, injury, colic etc. With the launch of the new version,
Quinolone-associated tendon disorders.
administered in the arm muscles. Apart from saving patient from embarrassment, it becomes especially advantageous in overweight patients who have thick layers of fat in the buttock region, because this fat hampers the absorption of the injected dose, resulting in inadequate efficacy of the presently available diclofenac injections. Now, with the availability of DYNAPAR AQ 1 ml, in case of overweight patients, doctors can administer the dose in the arm muscles and provide optimum pain relief.” DYANAPR AQ (Aqueous diclofenac injection) manufactured by Troikaa Pharma’s patented Aquatech process, is the world’s first and only diclofenac injection, which delivers the full dose of diclofenac in 1 ml. Diclofenac is a non steroidal anti-inflammatory drug (NSAID), widely prescribed for reducing pain and
Troikaa Pharma has extended its global patent application on DYNAPAR AQ, to over 110 countries.
Glenmark Pharmaceuticals Glenmark Pharmaceuticals announced that its lead candidate for Type II Diabetes GRC 8200 has received the International Non-proprietary Name (INN) “Melogliptin”, from the World Health Organization (WHO). This name was selected during the recently held 45th consultation on non-proprietary names and was made by the International Panel for Pharmacopoeia and Pharmaceutical Preparations. GRC 82O0, Glenmark’s lead DPPIV inhibitor, is an oral DPPIV inhibitor in development for type 2 diabetes. It is currently in Phase II clinical trials. Phase I studies showed that the compound was very well tolerated by the subjects at all dosage levels and there were no significant adverse events reported.
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