As the coronavirus continues to make the news, a host of untruths has surrounded the topic. In this special article, I address some of these myth and conspiracies busted by WHO. A novel coronavirus is a new strain of coronavirus that has not been previously identified in humans. Coronaviruses (CoV) are a large family of viruses transmitting between animals and people that cause illness ranging from the common cold to more severe diseases such as the Middle East respiratory syndrome (MERS-CoV) and severe acute respiratory syndrome (SARS-CoV). To read in detail about coronavirus see the article Coronavirus Must Know information for Pharmacist Myth 01: You can catch COVID-19, no matter how sunny or hot the weather is Countries with hot weather have reported cases of COVID-19. To protect yourself, make sure you clean your hands frequently and thoroughly and avoid touching your eyes, mouth, and nose. Exposing yourself to the sun or to temperatures higher than 25 degrees DOES NOT prevent the coronavirus disease (COVID-19). Myth 02: Catching the new coronavirus DOES NOT mean you will have it for life. Most of the people who catch COVID-19 can recover and eliminate the virus from their bodies. If you catch the disease, make sure you treat your symptoms. If you have cough, fever, and difficulty breathing, seek medical care early – but call your health facility by telephone first. Most patients recover thanks to supportive care. Myth 03: Being able to hold your breath for 10 seconds or more without coughing or feeling discomfort DOES NOT mean you are free from the coronavirus disease (COVID-19) or any other lung disease. The most common symptoms of COVID-19 are dry cough, tiredness, and fever. Some people may develop more severe forms of the disease, such as pneumonia. The best way to confirm if you have the virus-producing COVID-19 disease is with a laboratory test. You cannot confirm it with this breathing exercise, which can even be dangerous. Myth 04: Drinking alcohol does not protect you against COVID-19 Frequent or excessive alcohol consumption can increase your risk of health problems. Myth 05: COVID-19 virus can not be transmitted in areas with hot and humid climates From the evidence so far, the COVID-19 virus can be transmitted in ALL AREAS, including areas with hot and humid weather. Regardless of climate, adopt protective measures if you live in, or travel to an area reporting COVID-19. The best way to protect yourself against COVID-19 is by frequently cleaning your hands. By doing this you eliminate viruses that may be on your hands and avoid infection that could occur by then touching your eyes, mouth, and nose. Myth 06: Cold weather and snow CAN kill the new coronavirus. There is no reason to believe that cold weather can kill the new coronavirus or other diseases. The normal human body temperature remains around 36.5°C to 37°C, regardless of the external temperature or weather. The most effective way to protect yourself against the new coronavirus is by frequently cleaning your hands with alcohol-based hand rub or washing them with soap and water. Myth 07: Taking a hot bath to prevent the new coronavirus disease Taking a hot bath will not prevent you from catching COVID-19. Your normal body temperature remains around 36.5°C to 37°C, regardless of the temperature of your bath or shower. Actually, taking a hot bath with extremely hot water can be harmful, as it can burn you. The best way to protect yourself against COVID-19 is by frequently cleaning your hands. By doing this you eliminate viruses that may be on your hands and avoid infection that could occur by then touching your eyes, mouth, and nose. 08: The new coronavirus CAN be transmitted through mosquito bites. To date there has been no information nor evidence to suggest that the new coronavirus could be transmitted by mosquitoes. The new coronavirus is a respiratory virus which spreads primarily through droplets generated when an infected person coughs or sneezes, or through droplets of saliva or discharge from the nose. To protect yourself, clean your hands frequently with an alcohol-based hand rub or wash them with soap and water. Also, avoid close contact with anyone who is coughing and sneezing. 09: Hand dryers effective in killing the new coronavirus No. Hand dryers are not effective in killing the 2019-nCoV. To protect yourself against the new coronavirus, you should frequently clean your hands with an alcohol-based hand rub or wash them with soap and water. Once your hands are cleaned, you should dry them thoroughly by using paper towels or a warm air dryer. 10: Ultraviolet disinfection lamp kills the new coronavirus UV lamps should not be used to sterilize hands or other areas of skin as UV radiation can cause skin irritation. 11: Thermal scanners are effective in detecting people infected with the new coronavirus Thermal scanners are effective in detecting people who have developed a fever (i.e. have a higher than normal body temperature) because of infection with the new coronavirus. However, they cannot detect people who are infected but are not yet sick with a fever. This is because it takes between 2 and 10 days before people who are infected become sick and develop a fever. 12: Spraying alcohol or chlorine all over your body kill the new coronavirus No. Spraying alcohol or chlorine all over your body will not kill viruses that have already entered your body. Spraying such substances can be harmful to clothes or mucous membranes (i.e. eyes, mouth). Be aware that both alcohol and chlorine can be useful to disinfect surfaces, but they need to be used under appropriate recommendations. 13: Vaccines against pneumonia protect you against the new coronavirus No. Vaccines against pneumonia, such as pneumococcal vaccine and Haemophilus influenza type B (Hib) vaccine, do not provide protection against the new coronavirus. The virus is so new and different that it needs its own vaccine. Researchers are trying to develop a vaccine against 2019-nCoV, and WHO is supporting their efforts. Although these vaccines are
Laboratory Testing Guide For (COVID-19)
This article provides interim guidance to laboratories and stakeholders involved in COVID-19 virus laboratory testing of patients. Laboratory Testing Guiding Principles The decision to test should be based on clinical and epidemiological factors and linked to an assessment of the likelihood of infection. PCR testing of asymptomatic or mildly symptomatic contacts can be considered in theassessment of individuals who have had contact with a COVID-19 case. Screening protocols should be adapted to the local situation. Rapid collection and testing of appropriate specimens from patients meeting the suspected case definition for COVID-19 is a priority for clinical management and outbreak control and should be guided by a laboratory expert. Suspected cases should be screened for the virus with nucleic acidamplification tests (NAAT), such as RT-PCR. If case management requires, patients should be tested for other respiratory pathogens using routine laboratory procedures, as recommended in local management guidelines for community-acquired pneumonia. Additional testing in the laboratory should not delay testing for COVID-19. As co-infections can occur, all patients that meet the suspected case definition should be tested for COVID-19 virus regardless of whether another respiratory pathogen is found. In an early study in Wuhan, the mean incubation period for COVID-19 was 5.2 days among 425 cases, though it varies widely between individuals. Virus shedding patterns are not yet well understood and further investigations are needed to better understand the timing, compartmentalization, and quantity of viral shedding to inform optimal specimen collection. Although respiratory samples have the greatestyield, the virus can be detected in other specimens, including stool and blood. Local guidelines on informed consent should be followed for specimen collection, testing, and potentially future research. Specimen Collection and Shipment Safety procedures during specimen collection Ensure that adequate standard operating procedures (SOPs) are in use and that staff is trained for appropriate specimen collection, storage, packaging, and transport. All specimens collected for laboratory investigations should be regarded as potentially infectious. Ensure that health care workers who collect specimens adhere rigorously to infection prevention and control guidelines. Specimens to be collected At a minimum, respiratory material should be collected: upper respiratory specimens: nasopharyngeal and oropharyngeal swab or wash in ambulatory patients and/or lower respiratory specimens: sputum (if produced) and/or endotracheal aspirate or bronchoalveolar lavage in patients with more severe respiratory disease. (Note high risk of aerosolization; adhere strictly to infection prevention and control procedures). Additional clinical specimens may be collected as COVID-19 virus has been detected in blood and stool, as had the coronaviruses responsible for SARS and MERS. The duration and frequency of shedding of the COVID-19 virus in stool and potentially in urine is unknown. In the case of patients who are deceased, consider autopsy material including lung tissue. In surviving patients, paired serum (acute and convalescent) can be useful to retrospectively define cases as serological assays become available. Packaging And Shipment Of Clinical Specimens Specimens for virus detection should reach the laboratory as soon as possible after collection. Correct handling of specimens during the transportation is essential. Specimens that can be delivered promptly to the laboratory can be stored and shipped at 2-8°C. When there is likely to be a delay in specimens reaching the laboratory, the use of the viral transport medium is strongly recommended. Specimens may be frozen to – 20°C or ideally -70°C and shipped on dry ice if furtherdelays are expected (see Table 2). It is important to avoid repeated freezing and thawing of specimens. Transport of specimens within national borders should comply with applicable national regulations. International transport of potentially COVID-19 virus-containing samples should follow the UN Model Regulations, and any other applicable regulations depending on the mode of transport being used. Ensure Good Communication With the Laboratory And Provide NeededIinformation. Alerting the laboratory before sending specimens (COVID-19) encourages proper and timely processing of samples and timely reporting after testing. Specimens should be correctly labeled and accompanied by a diagnostic request form. Laboratory testing for COVID-19 virus Laboratories undertaking to test for COVID-19 virus should adhere strictly to appropriate biosafety practices. Nucleic Acid Amplification Tests (NAAT) For COVID-19 Virus. Routine laboratory confirmation testing of cases of COVID-19 is based on the detection of unique sequences of virus RNA by NAAT such as real-time reverse-transcription polymerase chain reaction (rRT-PCR) with confirmation by nucleic acid sequencing when necessary. The viral genes targeted so far include the N, E, S and RdRP genes. Examples of protocols used may be found here. RNA extraction should be done in a biosafety cabinet in a BSL-2 or equivalent facility. Heat treatment of samples before RNA extraction is not recommended. Laboratory Confirmation Of Cases By NAAT In Areas With No Known COVID-19 Virus Circulation. To consider a case as laboratory-confirmed by NAAT in an area with no COVID-19 virus circulation, one of the following conditions need to be met: A positive NAAT result for at least two different targets on the COVID-19 virus genome, of which at least one target is preferably specific for COVID-1 virus using a validated assay (as at present no other SARS-like coronaviruses are circulating in the human population it can be debated whether it must be COVID-19 or SARS-like coronavirus specific);OR One positive NAAT result for the presence of beta coronavirus, and COVID-19 virus further identified by sequencing partial or whole genome ofthe virus as long as the sequence target is larger or different from the amplicon probed in the NAAT assay used. When there are discordant results, the patient should be resampled and, if appropriate, sequencing of the virus from the original specimen or of an amplicon generated from an appropriate NAAT assay, different from the NAAT assay initially used, should be obtained to provide a reliable testresult. Laboratories are urged to seek confirmation of any surprising results in an international reference laboratory. Laboratory-Confirmed Case By NAAT In Areas With Established COVID-19 Virus Circulation. In areas where COVID-19 virus is widely spread a simpler algorithm might be adopted in which, for example, screening by rRT-PCR of a single discriminatory target is considered sufficient. One or more
WHO Recommended Hand Sanitizer Formulation
This Guide to Local Production of WHO-recommended Hand Sanitizer Formulations is separated into two discrete but interrelated sections: This guide will help in preventing the spread of Coronavirus pandemic across the globe by using WHO recommended hand sanitizer Part A provides a practical guide for use at the pharmacy bench during the actual preparation of the formulation (Hand Sanitizer). Part B summarizes some essential background technical information and is taken from the WHO Guidelines on Hand Hygiene in Health Care (2009). PART A: GUIDE TO LOCAL PRODUCTION OF HAND SANITIZER Part A is intended to guide a local producer in the actual preparation of the formulation (Hand Sanitizer). Materials required (small volume production) REAGENTS FOR FORMULATION 1: REAGENTS FOR FORMULATION 2: Ethanol 96% • Hydrogen peroxide 3% • Glycerol 98% • Sterile distilled or boiled cold water • Isopropyl alcohol 99.8% • Hydrogen peroxide 3% • Glycerol 98% • Sterile distilled or boiled cold water • 1-liter glass or plastic bottles with screw-threaded stoppers, or • 10-liter plastic tanks (preferably in polypropylene or high density polyethylene, translucent so as to see the liquid level) • Stainless steel tanks with a capacity of 80–100 liters (for mixing without overflowing) • Wooden, plastic or metal paddles for mixing • Measuring cylinders and measuring jugs • Plastic or metal funnel • 100 ml plastic bottles with leak-proof tops • 500 ml glass or plastic bottles with screw tops • An alcoholometer: the temperature scale is at the bottom and the ethanol concentration (percentage v/v) at the top METHOD: 1-LITRE PREPARATIONS These can be prepared in 1-liter glass or plastic bottles with screw-threaded stoppers. Recommended amounts of products: FORMULATION 1 FORMULATION 2 • Ethanol 96%: 833.3 ml • Hydrogen peroxide 3%: 41.7 ml • Glycerol 98%: 14.5 ml • Isopropyl alcohol 99.8%: 751.5 ml • Hydrogen peroxide 3%: 41.7 ml • Glycerol 98%: 14.5 ml Step by step preparation: The alcohol for the formula to be used is poured into the large bottle or tank up to the graduated mark. Hydrogen peroxide is added using the measuring cylinder. Glycerol is added using a measuring cylinder. As glycerol is very viscous and sticks to the wall of the measuring cylinder, it should be rinsed with some sterile distilled or cold boiled water and then emptied into the bottle/tank. The bottle/tank is then topped up to the 1-liter mark with sterile distilled or cold boiled water. The lid or the screw cap is placed on the tank/bottle as soon as possible after preparation, in order to prevent evaporation. Immediately divide up the solution into its final containers (e.g. 500 or 100 ml plastic bottles), and place the bottles in quarantine for 72 hours before use. This allows time for any spores present in the alcohol or the new/re-used bottles to be destroyed. Final Products FORMULATION 1 FORMULATION 2 Final concentrations: • Ethanol 80% (v/v), • Glycerol 1.45% (v/v), • Hydrogen peroxide 0.125% (v/v) Final concentrations: • Isopropyl alcohol 75% (v/v), • Glycerol 1.45% (v/v), • Hydrogen peroxide 0.125% (v/v) Quality Control Pre-production analysis should be made every time an analysis certificate is not available to guarantee the titration of alcohol (i.e. local production). Verify the alcohol concentration with the alcoholmeter and make the necessary adjustments in volume in the preparation formulation to obtain the final recommended concentration. Post-production analysis is mandatory if either ethanol or an isopropanol solution is used. Use the alcoholmeter to control the alcohol concentration of the final use solution. The accepted limits should be fixed to ± 5% of the target concentration (75%–85% for ethanol). The alcoholmeter is for use with ethanol; if used to control an isopropanol solution, a 75% solution will show 77% (± 1%) on the scale at 25°C Efficacy It is the consensus opinion of a WHO expert group that WHO recommended hand rub formulations can be used both for hygienic hand antisepsis and for presurgical hand preparation. Hygienic Hand Rub The microbicidal activity of the two WHO-recommended formulations was tested by WHO reference laboratories according to EN standards (EN 1500). Their activity was found to be equivalent to the reference substance (isopropanol 60% v/v) for hygienic hand antisepsis.
Guide On Preventing the Spread of (COVID-19)
Coronaviruses are a large family of viruses, some causing illness in people and others that circulate among animals, including camels, cats, and bats. Rarely, animal coronaviruses can infect people exposed to infected animals, and then spread among people, as has been seen with MERS-CoV and SARS-CoV, and likely now with SARS-CoV-2, the virus that causes COVID-19. This interim guidance may help prevent this virus from spreading among people in their homes and in other residential communities. This interim guidance is intended for: People with confirmed or suspected COVID-19 People with confirmed COVID-19 Household members, intimate partners, and caregivers in a nonhealthcare setting Prevention Steps for (COVID-19) People with confirmed or suspected COVID-19 People with confirmed COVID-19 Stay home except to get medical care People who are mildly ill with COVID-19 are able to isolate at home during their illness. You should restrict activities outside your home, except for getting medical care. Do not go to work, school, or public areas. Avoid using public transportation, ride-sharing, or taxis. Separate yourself from other people and animals in your home People: As much as possible, you should stay in a specific room and away from other people in your home. Also, you should use a separate bathroom, if available. Animals: You should restrict contact with pets and other animals while you are sick with COVID-19, just like you would around other people. Although there have not been reports of pets or other animals becoming sick with COVID-19, it is still recommended that people sick with COVID-19 limit contact with animals until more information is known about the virus. When possible, have another member of your household care for your animals while you are sick. If you are sick with COVID-19, avoid contact with your pet, including petting, snuggling, being kissed or licked, and sharing food. If you must care for your pet or be around animals while you are sick, wash your hands before and after you interact with pets and wear a facemask. See also Coronavirus: Must-Know Information For Pharmacists Call ahead before visiting your doctor If you have a medical appointment, call the healthcare provider and tell them that you have or may have COVID-19. This will help the healthcare provider’s office take steps to keep other people from getting infected or exposed. Wear a facemask You should wear a facemask when you are around other people (e.g., sharing a room or vehicle) or pets and before you enter a healthcare provider’s office. If you are not able to wear a facemask (for example, because it causes trouble breathing), then people who live with you should not stay in the same room with you, or they should wear a facemask if they enter your room. Cover your coughs and sneezes Cover your mouth and nose with a tissue when you cough or sneeze. Throw used tissues in a lined trash can. Immediately wash your hands with soap and water for at least 20 seconds or, if soap and water are not available, clean your hands with an alcohol-based hand sanitizer that contains at least 60% alcohol. Clean your hands often Wash your hands often with soap and water for at least 20 seconds, especially after blowing your nose, coughing, or sneezing; going to the bathroom; and before eating or preparing food. If soap and water are not readily available, use an alcohol-based hand sanitizer with at least 60% alcohol, covering all surfaces of your hands and rubbing them together until they feel dry. Soap and water are the best options if hands are visibly dirty. Avoid touching your eyes, nose, and mouth with unwashed hands. Avoid sharing personal household items You should not share dishes, drinking glasses, cups, eating utensils, towels, or bedding with other people or pets in your home. After using these items, they should be washed thoroughly with soap and water. Clean all “high-touch” surfaces every day High touch surfaces include counters, tabletops, doorknobs, bathroom fixtures, toilets, phones, keyboards, tablets, and bedside tables. Also, clean any surfaces that may have blood, stool, or body fluids on them. Use a household cleaning spray or wipe, according to the label instructions. Labels contain instructions for safe and effective use of the cleaning product including precautions you should take when applying the product, such as wearing gloves and making sure you have good ventilation during the use of the product. Monitor your symptoms Seek prompt medical attention if your illness is worsening (e.g., difficulty breathing). Before seeking care, call your healthcare provider and tell them that you have, or are being evaluated for, COVID-19. Put on a facemask before you enter the facility. These steps will help the healthcare provider’s office to keep other people in the office or waiting room from getting infected or exposed. Ask your healthcare provider to call the local or state health department. Persons who are placed under active monitoring or facilitated self-monitoring should follow instructions provided by their local health department or occupational health professionals, as appropriate. If you have a medical emergency and need to call 911, notify the dispatch personnel that you have, or are being evaluated for COVID-19. If possible, put on a facemask before emergency medical services arrive. Discontinuing home isolation Patients with confirmed COVID-19 should remain under home isolation precautions until the risk of secondary transmission to others is thought to be low. The decision to discontinue home isolation precautions should be made on a case-by-case basis, in consultation with healthcare providers and state and local health departments. Prevention Steps for (COVID-19) Household members, intimate partners, and caregivers in a nonhealthcare setting Household members, intimate partners, and caregivers in a nonhealthcare setting may have close contact with a person with symptomatic, laboratory-confirmed COVID-19 or a person under investigation. Close contacts should monitor their health; they should call their healthcare provider right away if they develop symptoms suggestive of COVID-19 Close contacts should also follow these recommendations: Make sure that you understand and can help the patient follow their healthcare provider’s instructions for the medication(s) and
Adverse Drug Reactions (ADRs) Informative Guide
Introduction An adverse drug reaction (ADRs) is an unwanted, undesirable effect of a medication that occurs during usual clinical use. Adverse drug reactions occur almost daily in health care institutions and can adversely affect a patient’s quality of life, often causing considerable morbidity and mortality. Adverse drug reactions may cause patients to lose confidence in or have negative emotions toward their physicians and seek self-treatment options, which may consequently precipitate additional ADRs. Around 5% of all hospital admissions are the result of an ADR, and around 10%– 20% of inpatients will have at least one ADR during their hospital stay (Kongkaew 2008; Lundkvist 2004; Pirmohamed 1998). This article discusses methods of ADR detection and classification and associated treatment strategies. Defining ADRs The definition of an ADR is often confused with that of an adverse drug event (ADE). The World Health Organization (WHO) defines an ADE as “Any untoward medical occurrence that may present during treatment with a pharmaceutical product but which does not necessarily have a causal relationship with this treatment” (WHO 2005). The WHO defines an ADR as “a response to a drug which is noxious and unintended and which occurs at doses normally used in man for prophylaxis, diagnosis, or therapy of disease or for the modification of physiologic function.” Classification of ADRs Adverse drug reactions were originally classified into two subtypes. Type A ADRs are dose-dependent and predictable; they are augmentations of known pharmacologic effects of the drug, such as orthostatic hypotension with antihypertensive medications. Type B ADRs are uncommon and unpredictable, depending on the known pharmacology of the drug; they are independent of dose and affect a small population, suggesting that individual patient host factors are important (Pirohamed 2003; Edwards 2000). Hypersensitivity (allergic) reactions to drugs are examples of type B ADRs. Type A reactions were later called augmented, and type B reactions, bizarre. Two further types of reactions were eventually added: chronic reactions, which relates to both dose and time (type C), and delayed reactions (type D). Withdrawal later became the fifth category (type E), and most recently, unexpected failure of therapy became the sixth (type F) (Rohilla 2013; Edwards 2000). Type of Reaction (Mnemonic) Features Examples Management A: Dose related (Augmented) Common Related to the pharmacologic action of the drug – exaggerated pharmacologic response Predictable Low mortality Dry mouth with tricyclic antidepressants, respiratory depression with opioids, bleeding with warfarin, serotonin syndrome with SSRIs, digoxin toxicity Reduce dose or withhold drug Consider effects of concomitant therapy B: Non–dose related (Bizarre) Uncommon Not related to the pharmacologic action of the drug Unpredictable High mortality Immunologic reactions: anaphylaxis to penicillin Idiosyncratic reactions: malignant hyperthermia with general anesthetics Withhold and avoid in future C: Dose related and time related (Chronic) Uncommon Related to the cumulative dose Hypothalamic-pituitary-adrenal axis suppression by corticosteroids, osteonecrosis of the jaw with bisphosphonates Reduce dose or withhold; withdrawal may have to be prolonged D: Time related (Delayed) Uncommon Usually dose related Occurs or becomes apparent sometime after use of the drug Carcinogenesis Tardive dyskinesia Teratogenesis Leucopenia with lomustine Often intractable E: Withdrawal (End of use) Uncommon Occurs soon after withdrawal of the drug Withdrawal syndrome with opiates or benzodiazepines (e.g., insomnia, anxiety) Reintroduce drug and withdraw slowly F: Unexpected failure of therapy (Failure) Common Dose related Often caused by drug interactions Inadequate dosage of an oral contraceptive when used with an enzyme inducer Resistance to antimicrobial agents Increase dosage Consider effects of concomitant therapy Populations at Greatest Risk Due To ADRs Pediatrics Adverse drug reactions are common in the pediatric population. Developmental changes affect the pharmacodynamics and pharmacokinetics of many of the drugs used in neonates, infants, and children. For example, gastric emptying is delayed in neonates and infants, resulting in longer absorption time and potentially increasing the risk of an ADR. The volume of distribution also differs, compared with adults, as does protein-binding capacity, phase I and II metabolic pathways, and glomerular filtrate rate. Therefore, extrapolation of pediatric dosages from adult dosages should be avoided (Fabiano 2012). Geriatrics The WHO defines elderly as individuals 60 years and older. The percentage of people in this age category continues to rise and the total is expected to reach 2 billion by 2050 (Brahma 2013). As the number of drugs increases, the risk of medication nonadherence also increases, further increasing the risk of an ADR. By examining the patient’s medication record and evaluating for duplicate therapies or medications being used to potentially treat ADRs caused by other medications, pharmacists can help reduce unnecessary prescribing and optimize the patient’s drug therapy regimen. Detecting and preventing ADRs in the older adult population remains a challenging, yet important part of good clinical practice. Tools available to assist in evaluating potentially inappropriate prescribing in older adults include the Beers Criteria, IPET (Improved Prescribing in the Elderly Tool), MAI (Medication Appropriateness Index), and STOPP (Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions) (Petrovic 2012). Renal and Hepatic Impairment Most drugs are metabolized by the liver and excreted by the kidneys. Impairment or failure of either of these organs can affect drug absorption, distribution, bioavailability, CYP metabolism, and clearance. Monitoring the laboratory values and adjusting the doses of drugs using these metabolic and excretory pathways can prevent an ADR. Special consideration should be given to identifying and, if possible, avoiding drugs that undergo extensive hepatic first-pass metabolism in patients with hepatic impairment. Pharmacovigilance can be used to assist prescribers with dosing or alternative drug selection in these patients. Conclusion As medication experts, pharmacists are a vital part of the treatment team, especially when an ADR occurs. Treating an ADR consists mainly of supportive therapy with symptom management. Furthermore, additional steps should be taken to determine the cause of the patient’s symptoms and whether they can be attributed to the use of a drug. Begin by evaluating the nature of the event. Thoroughly review the medical history available in the patient’s chart. Identify and document the clinical reaction, including the patient’s subjective report of symptoms. Review the patient’s medication list, and then
Warning! 10 Drugs That May Cause Memory Loss
Dementia is an overall term for diseases and conditions characterized by a decline in memory, language, problem-solving and other thinking skills that affect a person’s ability to perform everyday activities. Memory loss is an example. Alzheimer’s is the most common cause of dementia. Causes Of Dementia Dementia is caused by damage to brain cells. This damage interferes with the ability of brain cells to communicate with each other. When brain cells cannot communicate normally, thinking, behavior and feelings can be affected. The brain has many distinct regions, each of which is responsible for different functions (for example, memory, judgment, and movement). When cells in a particular region are damaged, that region cannot carry out its functions normally. Different types of dementia are associated with particular types of brain cell damage in particular regions of the brain. For example, in Alzheimer’s disease, high levels of certain proteins inside and outside brain cells make it hard for brain cells to stay healthy and to communicate with each other. The brain region called the hippocampus is the center of learning and memory in the brain, and the brain cells in this region are often the first to be damaged. That’s why memory loss is often one of the earliest symptoms of Alzheimer’s. While most changes in the brain that cause dementia are permanent and worsen over time, thinking and memory problems caused by the following conditions may improve when the condition is treated or addressed: Depression Medication side effects Excess use of alcohol Thyroid problems Vitamin deficiencies 10 Drugs That May Cause Memory Loss 1. Antianxiety drugs2. Cholesterol drugs3. Antiseizure drugs4. Antidepressant drugs5. Narcotic painkillers6. Parkinson’s drugs7. Hypertension drugs8. Sleeping aids9. Incontinence drugs10. Antihistamines 1. Antianxiety drugs (Benzodiazepines) Why they are prescribed: Benzodiazepines are used to treat a variety of anxiety disorders, agitation, delirium and muscle spasms, and to prevent seizures. Because benzodiazepines have a sedative effect, they are sometimes used to treat insomnia and the anxiety that can accompany depression. Examples: Alprazolam (Xanax), chlordiazepoxide (Librium), clonazepam (Klonopin), diazepam (Valium), flurazepam (Dalmane), lorazepam (Ativan), midazolam (Versed), quazepam (Doral), temazepam (Restoril) and triazolam (Halcion) 2. Cholesterol-lowering drugs (Statins) Why they are prescribed: Statins are used to treat high cholesterol. Examples: Atorvastatin (Lipitor), fluvastatin (Lescol), lovastatin (Mevacor), pravastatin (Pravachol), rosuvastatin (Crestor) and simvastatin (Zocor). How they can cause memory loss: Drugs that lower blood levels of cholesterol may impair memory and other mental processes by depleting brain levels of cholesterol as well. In the brain, these lipids are vital to the formation of connections between nerve cells — the links underlying memory and learning. (The brain, in fact, contains a quarter of the body’s cholesterol.) A study published in the journal Pharmacotherapy in 2009 found that three out of four people using these drugs experienced adverse cognitive effects “probably or definitely related to” the drug. The researchers also found that 90 percent of the patients who stopped statin therapy reported improvements in cognition, sometimes within days. In February 2012, the Food and Drug Administration ordered drug companies to add a new warning label about possible memory problems to the prescribing information for statins. Alternatives: If you’re among the many older Americans without known coronary disease who are taking these drugs to treat your slightly elevated LDL (“bad”) cholesterol and low HDL (“good”) cholesterol), ask your doctor or other health care provider about instead taking a combination of sublingual (under-the-tongue) vitamin B12 (1,000 mcg daily), folic acid (800 mcg daily) and vitamin B6 (200 mg daily). 3. Antiseizure drugs Why they are prescribed: Long used to treat seizures, these medications are increasingly prescribed for nerve pain, bipolar disorder, mood disorders, and mania. Examples: Acetazolamide (Diamox), carbamazepine (Tegretol), ezogabine (Potiga), gabapentin (Neurontin), lamotrigine (Lamictal), levetiracetam (Keppra), oxcarbazepine (Trileptal), pregabalin (Lyrica), rufinamide (Banzel), topiramate (Topamax), valproic acid (Depakote) and zonisamide (Zonegran). How they can cause memory loss: Anticonvulsants are believed to limit seizures by dampening the flow of signals within the central nervous system (CNS). All drugs that depress signaling in the CNS can cause memory loss. Alternatives: Many patients with seizures do well on phenytoin (Dilantin), which has little if any impact on memory. Many patients with chronic nerve pain find that venlafaxine (Effexor) — which also spares memory — alleviates their pain. 4. Antidepressant drugs (Tricyclic antidepressants) Why they are prescribed: TCAs are prescribed for depression and, increasingly, anxiety disorders, eating disorders, obsessive-compulsive disorder, chronic pain, smoking cessation and some hormone-mediated disorders, such as severe menstrual cramps and hot flashes. Examples: Amitriptyline (Elavil), clomipramine (Anafranil), desipramine (Norpramin), doxepin (Sinequan), imipramine (Tofranil), nortriptyline (Pamelor), protriptyline (Vivactil) and trimipramine (Surmontil). How they can cause memory loss: About 35 percent of adults taking TCAs report some degree of memory impairment and about 54 percent report having difficulty concentrating. TCAs are thought to cause memory problems by blocking the action of serotonin and norepinephrine — two of the brain’s key chemical messengers. Alternatives: Talk with your health care provider about whether nondrug therapies might work just as well or better for you than a drug. 5. Narcotic painkillers Why they are prescribed: Also called opioid analgesics, these medications are used to relieve moderate to severe chronic pain, such as the pain caused by rheumatoid arthritis. Examples: Fentanyl (Duragesic), hydrocodone (Norco, Vicodin), hydromorphone (Dilaudid, Exalgo), morphine (Astramorph, Avinza) and oxycodone (OxyContin, Percocet). These drugs come in many different forms, including tablets, solutions for injection, transdermal patches, and suppositories. How they can cause memory loss: These drugs work by stemming the flow of pain signals within the central nervous system and by blunting one’s emotional reaction to pain. Both these actions are mediated by chemical messengers that are also involved in many aspects of cognition. So the use of these drugs can interfere with long- and short-term memory, especially when used for extended periods of time. Alternatives: In patients under the age of 50 years, nonsteroidal anti-inflammatory drugs (NSAIDs) are the frontline therapy for pain. Unfortunately, NSAID therapy is less appropriate for older patients, who have a much higher risk of dangerous gastrointestinal bleeding. Research shows the risk goes up with the dosage and duration of treatment. 6. Parkinson’s drugs (Dopamine agonists) Why they are
Handling of LASA (Look-Alike Sound-Alike) Drugs
Look-Alike Sound-Alike (LASA) medications include medications that are visually the same in physical appearance or packaging and names of medications that have similar spelling or similar phonetics. As more medicines and new brands are being marketed in addition to the thousands already available, many of these medication names may look or sound alike. Confusing medication names and similar product packaging may lead to potentially harmful medication errors. The increasing potential for LASA medication errors was also highlighted in the Joint Commission’s Sentinel Event Alert. Emphasis on patient safety in the naming of medicines is now undertaken by national and international regulatory and advisory boards. The World Health Organisation’s International Non-proprietary Names Expert Group works to develop international non-proprietary names for pharmaceutical medicinal substances for acceptance worldwide. Healthcare organizations need to institute risk management strategies to minimize adverse events with LASA medications and enhance patient safety. To aid in this effort, this article on Handling of Look-Alike Sound-Alike Medications is published, it is hoped that errors relating to LASA medications can be minimized, if not eliminated, through identification and implementation of safety precautions. Common Risk Factors Common risk factors associated with LASA medications include: Illegible handwriting Incomplete knowledge of drug names Newly available products Same packaging or labeling Similar strengths, dosage forms, frequency of administration Similar clinical use Strategies To Avoid Errors Procurement Storage Prescribing Dispensing/Supply Administration Patient Education 1. Procurement (a) Minimize the availability of multiple medicine’s strengths. (b) Whenever possible, avoid the purchase of medicines with similar packaging and appearance. As new products or packages are introduced, compare them with existing packaging. 2. Storage (a) Use Tall Man lettering to emphasize differences in medications with sound-alike names. Tall Man lettering (or Tallman lettering) is the practice of writing part of a medicine name in upper case letters to help distinguish soundalike, look-alike medications from one another to avoid medication errors. Tall Man lettering involves highlighting the dissimilar letters in two names to aid in distinguishing between the two. The Institute for Safe Medication Practices (ISMP), U.S Food and Drug Administration (FDA), The Joint Commission and other safety-conscious organizations have promoted the use of Tall Man lettering as one means of reducing confusion between similar medication names. Examples of Tall Man lettering are metFORMIN and metoPROLOL. (b) Use additional warning labels for look-alike medicines. Warning labels should be uniform throughout the respective facility to facilitate identification. 3. Prescribing (a) Write legibly. Write clearly whether on an inpatient order or on a prescription. (b) The prescription should clearly specify the name of the medication, dosage form, dose and complete direction for use. (c) Include the diagnosis or medication’s indication for use. This information helps to differentiate possible choices in illegible orders. (d) Whenever possible, drug names in computerized prescriber order entry (CPOE) should incorporate Tall Man lettering. (e) Communicate clearly. Take your time in pronouncing the drug name whenever an oral order has to be made. Ask that the recipient of the oral communication repeat the medication name and dose. Verbal orders should be limited to emergency situations only. 4. Dispensing (a) Identify medicines based on their name and strength and not by its appearance or location. (b) Check the appropriateness of the dose for the medicines dispensed. (c) READ medication labels carefully at all dispensing stages and perform a triangle check. Triangle check is to check actual medicines against the medicines’ labels and against the prescription. (d) Double-checking should be conducted during the dispensing and supply process. (e) Highlight changes in medication appearances to patients upon dispensing. 5. Administration Read medication labels carefully during the administration process and perform a triangle check. Triangle check is to check medicine against the medication label and against the prescription. 6. Patient Education (a) Inform patients on changes in medication appearances. (b) Educate patients and their caregivers to alert healthcare providers whenever a medication appears to vary from what is usually taken or administered. (c) Encourage patients and their caregivers to learn the names of their medications. Table 1. FDA-Approved List of Generic Drug Names with Tall Man Letters
11 Drug Interactions Every Pharmacist Should Know
Drug-Drug interactions are defined as the change in efficacy or toxicity of one drug by prior or concomitant administration of a second drug. Drug interactions always involve Pharmacokinetics Pharmacodynamics In pharmacodynamic interactions, one drug alters the sensitivity or responsiveness of tissues to another drug by having the same (agonistic) or a blocking (antagonistic) effect. These effects usually occur at the receptor level but may occur intracellularly. In pharmacokinetic interactions, a drug usually alters absorption, distribution, protein binding, metabolism, or excretion of another drug. Thus, the amount and persistence of available drugs at receptor sites change. Pharmacokinetic interactions alter magnitude and duration, not type, of effect. They are often predicted based on knowledge of individual drugs or detected by monitoring drug concentrations or clinical signs. 11 Drug Interactions Following below are the clinically important drug interactions a pharmacist should know. 1. Fluoxetine and Phenelzine Object drug Precipitant Drug Effect Mechanism Related Drugs Options Fluoxetine Phenelzine Central serotonin syndrome Inhibit serotonin metabolism, monoamine oxidase inhibitors (MAOIs) may potentiate the pharmacologic activity of selective serotonin reuptake inhibitors (SSRIs) Dextromethorphan, Meperidine, and other selective serotonin reuptake inhibitors (SSRIs) You should wait at least 14 days after stopping Phenelzine before you start treatment with Fluoxetine. 2. Digoxin and Quinidine Object drug Precipitant Drug Effect Mechanism Related Drugs Options Digoxin Quinidine Interaction range from nausea and vomiting to death A marked increase in plasma concentration levels of digoxin – Pharmacists should anticipate the need to reduce the digoxin dose by one half 3. Sildenafil and Isosorbide Mononitrate Object drug Precipitant Drug Effect Mechanism Related Drugs Options Sildenafil Isosorbide mononitrate Sildenafil may markedly increase the hypotensive effects of isosorbide mononitrate In the presence of PDE5 inhibitors, nitrates can cause intense increases in cyclic guanosine monophosphate and dramatic drops in blood pressure Nitroglycerin Pharmacists should advise patients not to take sildenafil with isosorbide mononitrate and nitroglycerin 4. Potassium Chloride and Spironolactone Object drug Precipitant Drug Effect Mechanism Related Drugs Options Potassium Chloride Spironolactone Hyperkalemia which will lead to cardiac failure and death Excretion of sodium ions while saving potassium ions Amiloride or triamterene absorbable forms of potassium bicarbonate, citrate, acetate, glauconite, and iodide salts Patients who are prescribed spironolactone must undergo an evaluation of serum potassium levels 5. Clonidine and Propranolol Object drug Precipitant Drug Effect Mechanism Related Drugs Options Clonidine Propranolol Mysterious hypertension Clonidine is a central alpha-2 adrenergic agonist that suppresses the sympathetic nervous system from the brain. This activity leads to a decrease in the norepinephrine amounts available in the synaptic cleft of the adrenergic neuron. Alpha-1 receptors then become sensitized because of less norepinephrine available in the cleft. When clonidine is suddenly withdrawn, the result is a large increase in norepinephrine in the synaptic cleft of the adrenergic neuron. The sensitized alpha-1 receptors are stimulated, leading to an exaggerated vasoconstriction. — Avoid taking these two drugs simultaneously 6. Warfarin and Diflunisal Object drug Precipitant Drug Effect Mechanism Related Drugs Options Warfarin Diflunisal G.I Bleeding ·Antiplatelet effects and GI erosion associated with NSAIDs and the anticoagulant effect of warfarin.·Some individual NSAIDs may also alter the pharmacokinetics of warfarin Keto-profen, piroxicam, sulindac, diclofenac, and ketorolac A non-NSAID alternative such as acetaminophen or opioid analgesics is preferred. To be cautious, limit the acetaminophen dose to 2 g/day for no more than 7 days. INR should be monitored closely when acetaminophen exceeds 2 g/day or chronic use >7 days occurs. 7. Theophylline and Ciprofloxacin Object drug Precipitant Drug Effect Mechanism Related Drugs Options Theophylline Ciprofloxacin Toxic increases in theophylline Hepatic metabolism of theophylline is inhibited by ciprofloxacin via the cytochrome P-450 enzyme system Clarithromycin, erythromycin, fluvoxamine, and cimetidine Levofloxacin or ofloxacin should be considered as an alternative to ciprofloxacin 8. Pimozide and Ketoconazole Object drug Precipitant Drug Effect Mechanism Related Drugs Options Pimozide Ketoconazole Prolong the QT interval, Ventricular arrhythmias Pimozide is a CYP3A4 enzyme substrate, and ketoconazole is a potent inhibitor of CYP3A4. This leads to marked increases in pimozide serum levels Itraconazole, clarithromycin, erythromycin, diltiazem, and nefazodone Terbinafine should be considered as an alternative to Ketoconazole 9. Methotrexate and Probenecid Object drug Precipitant Drug Effect Mechanism Related Drugs Options Methotrexate Probenecid Increase in methotrexate levels Probenecid acts as an active tubular secretion inhibitor and prevents methotrexate from being excreted, thus potentially causing toxicity. Penicillin’s and Salicylates Use Acetaminophen alternative to Salicylates or NSAID’s 10. Bromocriptine and Pseudoephedrine Object drug Precipitant Drug Effect Mechanism Related Drugs Options Bromocriptine Pseudoephedrine Severe peripheral vasoconstriction, ventricular tachycardia, seizures, and possibly death The mechanism may be due to the synergistic effects of both drugs on the dopaminergic system. — If these two drugs must be taken concurrently, the patient’s cardiovascular and mental status should be closely monitored. 11. Simvastatin and Amiodarone Object drug Precipitant Drug Effect Mechanism Related Drugs Options Simvastatin Amiodarone Increased simvastatin/ lovastatin concentrations and risk of myopathy/ rhabdomyolysis Inhibition of the metabolism of simvastatin/ lovastatin by CYP3A4 — Preferable statin alternatives include fluvastatin, rosuvastatin, or pravastatin. Predisposing risk factors for rhabdomyolysis include advanced age (>65 years), uncontrolled hypothyroidism, and renal impairment.
Coronavirus: Must-Know Information For Pharmacists
A novel coronavirus is a new strain of coronavirus that has not been previously identified in humans. Coronaviruses (CoV) are a large family of viruses transmitting between animals and people that cause illness ranging from the common cold to more severe diseases such as the Middle East respiratory syndrome (MERS-CoV) and severe acute respiratory syndrome (SARS-CoV). Symptoms Common human coronaviruses, including types 229E, NL63, OC43, and HKU1, usually cause mild to moderate upper-respiratory tract illnesses, like the common cold. Most people get infected with these viruses at some point in their lives. These illnesses usually only last for a short amount of time. Symptoms may include runny nose headache cough sore throat fever a general feeling of being unwell Human coronaviruses can sometimes cause lower-respiratory tract illnesses, such as pneumonia or bronchitis. This is more common in people with cardiopulmonary disease, people with weakened immune systems, infants, and older adults. Diagnosis A community pharmacist or health care provider may order laboratory tests on respiratory specimens and serum (part of your blood) to detect human coronaviruses. Laboratory testing is more likely to be used if someone suffering from severe disease or is suspected of having MERS. If your patient experiencing symptoms, you should ask him about any recent travel or contact with animals. Most MERS-CoV infections have been reported from countries in the Arabian Peninsula. Therefore reporting a travel history or contact with camels or camel products is very important when trying to diagnose MERS. Transmission Human coronaviruses most commonly spread from an infected person to others through the air by coughing and sneezing close personal contact, such as touching or shaking hands touching an object or surface with the virus on it, then touching your mouth, nose, or eyes before washing your hands rarely, fecal contamination In the United States, people usually get infected with common human coronaviruses in the fall and winter. However, you can get infected at any time of the year. Most people will get infected with one or more of the common human coronaviruses in their lifetime. Young children are most likely to get infected. However, people can have multiple infections in their lifetime. Prevention How to Protect Yourself? There are currently no vaccines available to protect you against human coronavirus infection. You may be able to reduce your risk of infection by doing the following wash your hands often with soap and water for at least 20 seconds avoid touching your eyes, nose, or mouth with unwashed hands avoid close contact with people who are sick How to Protect Others? If you have cold-like symptoms, you can help protect others by doing the following stay home while you are sick avoid close contact with others cover your mouth and nose with a tissue when you cough or sneeze, then throw the tissue in the trash and wash your hands clean and disinfect objects and surfaces Treatment There are no specific treatments for illnesses cause by human coronaviruses. Most people with common human coronavirus illness will recover on their own. However, you can do some things to relieve your symptoms take pain and fever medications (Caution: do not give Aspirin to children) use a room humidifier or take a hot shower to help ease a sore throat and cough If you are mildly sick, you should drink plenty of liquids stay home and rest