Monday, September 3, 2018

Deregulation of medicines update

It is heartening to see more and more medical products get successfully deregulated from Pharmacy to GSL (General Sales List), and others from Prescription-only (POM) to Pharmacy. For a complete list of the medicines and the exemption criteria, you could refer to the HSA webpage here.

Do note that the deregulation for any particular medicine applies not only to the product brand name but it is also SIN (registration number) and packaging-specific.

Some recent deregulated items to GSL which is another term for over-the-counter aka no need to register on purchase are:

- Fluimucil for phlegm
- Nizoral for dandruff control
- Kefentech Air (ingredient and strength same as the good 'o Kefentech plaster) for muscle and joint pains
- Zyrtec R for allergy, itch and runny nose
- Telfast 120mg for allergy, itch and runny nose
- Nurofen and its variants for pain, fever
- Aleve for pain, fever
- Strepsils Chesty Cough lozenge for phelgm
- Rhinathiol syrups (except the one with Promethazine) for phlegm
- Loceryl nail lacquer for nail fungus treatment
- Regaine 2%/ 5% and all other minoxidil-containing brands for hair loss treatment

* New fastum gel, Mucosolvan and Mucolix are on waiting list to be released over-the-counter

As many of the moderate-to-strong steroid creams are now conveniently available as Pharmacy-only, do take note that they are only allowed for use in patient above 18 years old (not sure why the magic number is 18, not 17, 12 or any other) according to the HSA's regulation. Main reasons against 'self-medication' for children are the increased risks versus adults for adrenal hormone suppression, Cushing's syndrome and risk of infection on applied area. So please don't kpkb when the pharmacist refused to dispense for use in children.

Most medications are meant for short-term relief of minor ailment conditions and have no sufficient data for prolonged (eg. weeks or months) usage. So even though the above list of medicines can be freely purchased 'without restrictions', do exercise caution when self-medicating. I would not go into the dreary details of their adverse effects and drug interactions as you could easily look them up via online resources like Medscape, Mayoclinic or just ask your pharmacist if in doubt.

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Sunday, September 2, 2018

Insights from CE - The Expanding Health Benefits of Prebiotics and Probiotics

  • Probiotics are defined as “live microorganisms that, when administered in adequate amounts, confer a health benefit on the host."
  • Prebiotics are food source for the good bacteria. Some examples are conjugated linoleic acid, polyunsaturated fatty acid, human milk oligosaccharides, and oligosaccharides (eg, fructooligosaccharides, galactooligosaccharides, inulin, mannan-oligosaccharide, and xylooligosaccharide).
  • Members of a genus may share the same mechanism of action, in the same way drug classes share a mechanism of action. For example, all Bifidobacterium species produce short-chain fatty acids. Some mechanisms appear specific to a species or subspecies. For example, Bifidobacterium longum subsp infantis metabolizes human milk oligosaccharides while Bifidobacterium animalis subsp lactis does not, leading to better gut colonization in premature infants by B. longum subsp infantis.
  • Probiotics pose a theoretical risk of infection for patients who are immunosuppressed, critically ill, and either very young or old.
  • Development of the infant immune system requires stimulation from the gut microflora.
  • The European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) prefer L. rhamnosus GG or S. boulardii for the prevention of Antibiotic-Associated Diarrhea in children.
  • Lactobacillus reuteri 17938 is the best-studied strain for reducing infant colic.
  • Induction or maintenance of remission in ulcerative colitis: insufficient evidence to recommend for routine use.
  • Coadministration of probiotics with antibiotics
    • Intake with oral doxycycline did not impact survival of a probiotic containing Lactobacillus acidophilus LaCH-5 and Bifidobacterium animalis subsp lactis Bb-12. Empirically, a probiotic bacterial strain is unlikely to be killed if it is not susceptible to the antibiotic the patient is taking. In vitro susceptibility studies have found that most Lactobacilli are variably sensitive to penicillins, cephalosporins, fluoroquinolones, and macrolides. Most are not susceptible to cotrimoxazole, metronidazole, or (with the exception of L. acidophilus) vancomycin. Destruction of Saccharomyces boulardii by antibacterial agents is not a concern as it is an yeast.
  • Benefit from a probiotic is not determined by the number of strains, but rather the right strains that have been shown to have benefit for a specific condition.

Previous related post:
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Insights from CE - Drug Interaction (Alert) Overload

In a nutshell, not all computerizes / automated drug interaction alerts are of clinical importance, this resulted in so-called "alert fatigue".  Currently most software systems could not function more specifically based on factors like dose, timing, age, gender, pharmacogenetics, comorbidity, or the duration of drug therapy. What are some ways to avoid this problem of "alert fatigue"?



- Reduce topical medicines that are unlikely to pose risk. With exception of example, timolol eye drops as it can worsen bradycardia when given with other drugs that slow cardiac conduction, like verapamil or digoxin, especially in patients with heart failure or who already have a slow heart rate.

- Identify formulation-specific interactions. Example, potassium pills are not to be given with anticholinergic drugs. The concern is that anticholinergic drugs reduce gastrointestinal (GI) motility, making it more likely that potassium chloride pills will adhere to the GI mucosa and cause ulceration. This interaction can confuse software systems. Potassium chloride solutions and powders may get flagged as a problem although they are not of concern. And of course inhaled anticholinergics are not of concern too.

-  In a VA study, 20% of overridden warfarin interaction alerts were for an interaction between warfarin and vitamin E. All of these alerts were triggered by prescriptions for a multivitamin containing 60 iu of vitamin E. But, vitamin E doses less than 400 iu are not expected to interact with warfarin.

- Drug interactions can occur because of effects that persist after a long-acting drug has been discontinued or because discontinuation of a drug alters hepatic metabolism of the victim drug.

"The effects of some drugs may be present after they are discontinued. For example, most monoamine oxidase (MAO) inhibitors bind to monoamine oxidase for the life of the enzyme, so it takes several weeks after discontinuing an MAO inhibitor for the enzyme to reaccumulate. This is why a 14-day washout period is recommended between discontinuing an MAO inhibitor and starting another serotonergic drug. Some drugs with extremely long half life are of concern as well.

Discontinuation of a cytochrome P450 (CYP) enzyme inhibitor or inducer can lead to loss of efficacy or toxicity of a CYP substrate. For example, dosage increases of some atypical antipsychotics (risperidone [Risperdal], quetiapine [Seroquel], etc) may be necessary during coadministration of carbamazepine (Tegretol) because it is a powerful inducer of multiple CYP enzymes and P-glycoprotein. Subsequent discontinuation of carbamazepine can increase exposure to the atypical antipsychotic and put the patient at risk for adverse effects like akathisia and Parkinsonism. Clinicians may fail to detect this interaction.19 "Uninduction" after discontinuation of carbamazepine can take one to two weeks.20 The ideal drug interaction alert for discontinuation of carbamazepine would provide options for managing the interaction."

Hard-stop alerts problems

A few as described below which I have extracted from the article.

"One institution experienced unintended consequences when they initiated a study to evaluate a new hard-stop rule for the interaction between trimethoprim/sulfamethoxazole (TMP/SMX, Bactrim, etc) and warfarin.24 This interaction was considered a good candidate for a hard-stop alert because it reliably increases the INR and leads to bleeding complications. The study found that the hard-stop was effective in reducing coadministration of warfarin and TMP/SMX. However, the study was stopped early after the hard-stop alert was linked to important delays in treatment for both warfarin and TMP/SMX."

"Even the interaction between phosphodiesterase inhibitors and nitroglycerin may have situations in which it may be appropriate for patients to have access to both drugs. In the inpatient setting, coadministration of IV nitroglycerin and sildenafil might be indicated in patients with severe pulmonary hypertension and angina in an intensive care setting with monitoring.26 In the outpatient setting, a patient who has a prescription for as-needed use of sildenafil (Viagra) for erectile dysfunction might also have a prescription for sublingual nitroglycerin for use in case angina ever occurs."

"One institution set a Level 2 alert requiring a response from the clinician after initial research indicated that proton pump inhibitors (PPIs) might reduce the efficacy of clopidogrel (Plavix). As more conflicting research results were published, the interaction became more controversial. The interaction was downgraded to a Level 3 information-only alert. At that point, analysis of alert data found that the alert had led some clinicians to discontinue clopidogrel rather than the PPI, an unintended consequence that might place the patient at risk of a cardiovascular event. Clinicians were notified so that appropriate care could be ensured for patients affected by the alert. This vignette should be a reminder of the need to continually reassess alert advice as new data becomes available."


Drug Interactions in Assessment Tool for Drug Interaction Software37
Clinically Important (True-Positive) Drug Interactions
  • Carbamazepine + Clarithromycin (Biaxin)
  • Digoxin (Lanoxin) + Amiodarone
  • Digoxin + Clarithromycin
  • Digoxin + Itraconazole (Sporanox)
  • Nitroglycerin + Sildenafil
  • Simvastatin + Amiodarone
  • Simvastatin + Gemfibrozil (Lopid)
  • Simvastatin + Itraconazole
  • Warfarin + Amiodarone
  • Warfarin + Fluconazole (Diflucan)
  • Warfarin + Gemfibrozil
  • Warfarin + Naproxen (Aleve, etc)
  • Warfarin + TMP/SMX
Clinically UN-Important (False-Positive) Drug Combinations
  • Acetaminophen/Codeine + Amoxicillin (Amoxil, etc)
  • Carbamazepine + Erythromycin ophthalmic
  • Digoxin + Sildenafil
  • Metformin (Glucophage) + Erythromycin ophthalmic
  • Warfarin + Digoxin
  • Warfarin + Pravastatin (Pravachol)

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Tuesday, December 22, 2015

Times when you could do without (or with) a prescription

You could do without a prescription when you...

Have a common cold & flu

As seasonal common cold is arising from virus (influenza type c), you could hop to your nearest pharmacist to get medications for symptomatic relief. This is because viral cold is usually self-limiting and would recover when your body's immune system wins the virus, unlike bacterial infections which are often more severe and would then require antibiotics. Frequent use of antibiotics that are not indicated can give rise to antibiotic-resistant problem (read more).

Examples of medications for symptomatic relief are - paracetamol for a mild fever and aches, expectorant or mucolytics for phlegm, cough suppressant for dry / itchy-throat cough, antihistamine for runny nose, menthol or anti-inflammatory lozenges to sooth a sore-throat.

HOWEVER, if you have any of the following:

- travel history to an endemic or malaria-prone area in the past few months
- a fever that does not subside within 3 days
- has wheezing / signs of breathlessness
- or has persistent (up to a week) purulent colored phlegm
- started a new medication (that could cause neutropenia)
Then it is time to pay your doctor a visit for an appropriate diagnosis and treatment.

Have a wart or corn?

You could go for over-the-counter treatments like Duofilm liquid or  corn plasters which both contain salicylic acid. This chemical will make the hardened skin layer peel over time, turning the area white initially.  It works for both corn and warts.

Another otc choice for wart is Wartner, which freezes off the wart. Wart is a viral-induced skin problem. A wart has a cauliflower-like appearance and may gradually grow bigger. Unlike warts, corn can't be freeze-off.

Young children, immuno-compromised or diabetic persons should seek doctor's advice before self-treatment.

Have hereditary hairloss

That is if your parent(s) have hair loss problem as they age and you find yourself in their footsteps, you could hop to the pharmacist to get some hair tonics or this topically applied medication called Minoxidil which comes in various strengths. It is now available over-the-counter. It works for both male and female baldness in most cases but if no results is seen within 6 months of use, then you might want to discontinue use and seek alternative.

If you think your hair loss problem is due to dietary deficiency, you could take some hair supplements (usually containing amino acids, collagen and some herbs). If you think you are suffering from some scalp disease, which resulted in the hair loss, then it is important to first get it diagnosed and treated.

People who are taking long-term medications or have any medical condition should first let your pharmacist know before seeking self-treatment.

Have mild to moderate eczema

Eczema is an allergy skin condition where there's itching, rashes and possibly dryness (which exacerbates the itch). It can occur at any age and be triggered by food or allergens in the environment.

For mild cases which resolve by themselves, avoidance of allergens and a good moisturizer to protect the skin would usually serve well as prevention measures. For bothersome cases in which you can't identify what things you need to avoid, you could visit a doctor for a skin-prick test. Sometimes to your dismay, it could be things that are hard to avoid eg. haze, dust-mites. Exposure to allergens often cause the eczema to persist or worsen. Nevertheless, use of a suitable moisturizer on a regular basis and a soap-free cleanser should be the first line of remedy for all cases to help maximize skin protection.

For moderate eczema cases, you may also need oral anti-itch medication and/or steroid cream to treat the symptoms.

For severe or persistent cases not improving despite self-treatment, you may require stronger prescription therapies such as steroid from the doctor. Once the inflammatory symptoms of eczema has been controlled, you could consider stepping down to self-treatment and prevention.

Take note to avoid prolonged and regular use of steroid creams as they could thin the skin or make the area under treatment more prone to skin infections (especially if there are any broken skin from scratching).

Constipation and mild diarrhea

For constipation, you could get laxatives over the counter and they can be broadly classified as for short-term fast relief or for longer term slower relief. The fast relief ones are usually senna tablet, bisacodyl tablet or suppository and enemas. These are not recommended for prolonged regular usage as they can cause dependence (lazy bowel) and abdominal cramps. The slower relief ones but safe for long term use are lactulose, fibres and probiotics. Lactulose and fibres would take about 2-3 days for onset, may be milder in effect and occasionally cause bloating, so you might want to start low and continue them for a while.
Drinking more water, healthy lifestyle and having a balance diet can't be emphasized enough for people who suffer from long term constipation.

Diarrhea may prove a bit more complex in terms of the choice of therapy because it may arise from various causes:
traveller's diarrhea or pathogenic diarrhea, irritable bowel syndrome, medications or colon diseases (cancer, inflammatory bowel disease etc).

Any diarrhea with fever, blood in stool, severe cramps or persisting beyond 2 days should warrant a doctor's visit.

The first-line of treatment for traveller / infectious diarrhea is NOT to simply stop the diarrhea but to drink re-hydration salt with enough fluid to prevent getting dehydrated. Taking charcoal pills (available over-the-counter) may help in the initial phase of food poisoning by absorbing the toxins. If you are certain that your diarrhea is mild or not infectious in nature, then you could take Lomotil (diphenoxylate) or Imodium (loperamide) which are medications to reduce your gut movement in stopping the diarrhea. They DO NOT prevent dehydration. Avoid prolonged usage as you would not want to 'mask' the diarrhea and have bacteria or toxins continuing to manifest in your intestines.

For prevention of traveller's diarrhea, you could take probiotics on a daily basis to 'strengthen' your gut. Although it's best to abide by the rules of “boil it, cook it, peel it, or forget it”. 

Any medications (eg. augmentin, metronidazole..) that are warranted for bacterial or protozoal diarrhea treatment would need to be prescribed by the doctor.

Young children, the at-risk group (elderly, diabetic) or anybody with signs of dehydration should seek medical attention immediately.

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Saturday, November 9, 2013

Cautions for thiazolidinediones use - in heart failure or with insulin

Administration of thiazolidinediones with insulin is cautioned. Rosiglitazone is not approved for use with insulin, as stated in the warning section of the package insert.[3] When rosiglitazone is taken with insulin, the frequency of edema increases.

Recommendations and Considerations

Thiazolidinediones (eg. Actos, Avandia) may cause or exacerbate congestive heart failure in some patients.
  • Initiation of these drugs in patients with established NYHA Class III or IV heart failure is contraindicated.
  • After initiation of Actos, Actoplus Met, and Duetact, and after dose increases, observe patients carefully for signs and symptoms of heart failure (including excessive, rapid weight gain, dyspnea, and/or edema). 
  • If these signs and symptoms develop and heart failure is confirmed, appropriate management of heart failure should be initiated.  Discontinuation or dose reduction of Actos, Actoplus Met, or Duetact should be considered.

Information for the Patient

Patients should be informed that Actos, alone or in combination with other antidiabetic agents, can cause fluid retention, which may exacerbate or lead to heart failure. 
  • Patients should be asked to watch for and report to their healthcare professional any signs and symptoms of heart failure, including edema from fluid retention, shortness of breath or trouble breathing, unusually fast increase in weight, and unusual tiredness.

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Thursday, October 24, 2013

Back to updates - Mefloquine, Quinolones, new anticoagulants (Box warnings)

It's time to catch up with more drug news after more than half a year of Marketing study instead of Pharmacy study. @.@

Black Box in the Nutshell...

It is an anti-malarial medicine which can be purchased directly from the pharmacy. Brand name: Larium

The FDA is advising the public about strengthened and updated warnings regarding neurologic and psychiatric side effects associated with the antimalarial drug mefloquine hydrochloride. The neurologic side effects can include dizziness, loss of balance, or ringing in the ears.  The psychiatric side effects can include feeling anxious, mistrustful, depressed, or having hallucinations.

Neurologic side effects can occur at any time during drug use, and can last for months to years after the drug is stopped or can be permanent.  Patients, caregivers, and health care professionals should watch out for these side effects. When using the drug to prevent malaria, if a patient develops neurologic or psychiatric symptoms, mefloquine should be stopped, and an alternate medicine should be used.  If a patient develops neurologic or psychiatric symptoms while on mefloquine, the patient should contact the prescribing health care professional.  Source:

Quinolone antibiotics
- most side effects are CNS effects, tendonitis, blood sugar changes, and QT prolongation
- quinolone-related nerve damage is very rare but it can persist for a long time even after stopping the antibiotic
- to let doctor know if patients develop peripheral neuropathy such as pain, burning, numbness, etc.

New anticoagulants: Dabigatran, Rivaroxaban, Apixaban
- Increased stroke risk in patients with Atrial Fibrillation if therapy is discontinued due to their shorter half-lives (so their blood thinning effect wears off faster)
- Important to emphasize patient compliance

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Tuesday, November 13, 2012

Insomnia - an overview

"Have you got anything to help with sleep?" - This is one common question that people ask at the pharmacy. A simple question it may sound but there is really more to it than meets the eye...

Here's some questions for you to think about when finding your insomnia remedy:

1) How long have you had the insomnia?

Insomnia can be broadly classified into 3 types: Source: MedicineNet
  • Transient insomnia usually is due to situational changes such as travel, extreme climate changes, and stressful events. It lasts for less than a week or until the stressful event is resolved.
  • Short-term insomnia usually is due to ongoing stressful lifestyle or events, medication side effects or medical conditions and lasts for one to three weeks.
  • Chronic insomnia (long-term insomnia) often results from depression, digestive problems, sleep disorders, or substance abuse and continues for more than three weeks.

 2) The causes...

Is it mood or stress-related?
What medications are you on? Have you just started on a new medication?
Do you have poor sleep habits?
Is there any recent lifestyle changes disrupting your sleep pattern?
Do you have any underlying medical conditions that could be causing your insomnia? eg. heartburn, back pain etc...

Sleeplessness can also be the cause of a mix of physiological and psychological factors. If it is transient sleeplessness, it would often go away with adequate rest and the help of short-term sleeping-aid.

Here are some possible causes and risk factors.

3) What have you tried?

You may have tried things like melatonin, other sleep supplements or even sleeping pills expecting to have a quick remedy. Have you also tried any lifestyle changes eg. exercises or relaxation techniques and environmental changes to aid you in falling asleep? Find out through trial and errors what worked for you and what didn't. Remember there isn't such a thing as one size fits all. Over-reliance on sleeping pills for a 'quick fix' may cause dependence and make insomnia worse in the long run without truely treating the root cause of the problem.

You can read up more here - Sleep Hygiene

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Sunday, November 11, 2012

Stress-induced stomach ulcer

Gastric problem seems to be getting very prevalent these days. Dr. Joseph F. Montague, author of the book Nervous Stomach Trouble - "You do not get stomach ulcers from what you eat. You get ulcers from what is eating you."
To treat stomach ulcer, it is not just about taking medications (of course medications can play a part in reducing your stomach acid and treat any H. pylori infection). It also involves lifestyle adjustments and behavorial treatment such as time management, pacing and relaxing yourself and having regular meals. Also avoid eating food that are very spicy or oily. I ever heard from a doctor who said "The food you most hate to give up is the one that you should avoid when you have a stomach problem."

If you have a gastric problem that persists more than 2 weeks despite a course of gastric medicines or on and off for over 3 months despite medicines and lifestyle changes, you should see a doctor to check against any possibilty of ulcer or H.pylori infection.


Drug interactions to be aware of with gastric medications:
Omeprazole is a cyp2c19 and cyp3a4 enzyme inhibitor. Caution to be exercised when administering with other medicines such as plavix (clopidogrel)

Cimetidine is a multiple cyp enzymes inhibitor which can affect the level of other medicines in the body.
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