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July 2013
Endocrinologists reiterate call for better
glucose control
News
Feature
Tocotrienols protect the
brain
Acne be gone!
3
News | Pharmacy Today | July 2013 Endocrinologists reiterate call for better
glucose control
By Pank Jit Sin
E
ven as Malaysia heads toward industrial nation status, the health of its people
seem to be going south, with heart disease and diabetes reaching worrying levels.
Zanariah Hussein, of Hospital Putrajaya,
and Chan Siew Pheng, both senior consultant
endocrinologists, said many individuals with
type 2 diabetes remain unidentified, untreated and at risk for complications. Although
control programs exist, the disease continues to drive the bulk of kidney disease and
blindness cases, both of which morbidities are
closely associated with type 2 diabetes.
Dr. Zanariah said: “Many people are unaware that they have diabetes until a complication develops. Diabetes complications are
numerous, varied and sometimes extremely
frightening, but more importantly, can be lifethreatening.” Hence, it is important to provide
diabetes prevention education as early detection of symptoms can significantly reduce the
risk of developing complications later on.
Although the figures have been thrown
about many times, Dr. Zanariah said it was
important to look at the increase and to take
affirmative action to curtail the wave of diabetes sweeping the country. The National
Health and Morbidity Survey 2011 (NHMS
2011) picked up a 40 percent increase in diabetes in those aged 30 years and above compared to the 2006 survey (from 14.9 percent to
20.8 percent).
Dr. Zanariah said among the problems preventing patients from achieving their glycemic goals are the failure of some clinicians to
adopt a ‘treat-to-target’ approach, [which requires individualized therapies]; suboptimal
dosing of available therapies; concern of the
patient over hypoglycemia and weight gain;
and underuse of medications due to cost or
complexity of therapy. In Malaysia, only
22 percent of patients achieve the desired
HbA1c level of less than 7.0%. (Med J Malaysia
2011;66(2):175-81)
The failure of patients to achieve glycemic
control isn’t unique to Malaysia, as even countries like Australia and Singapore only have
30 and 33 percent, respectively, of patients
achieving desired glycemic control. (MJA
2006;185:305-9, Singapore Med J 2001;42:501-7)
Treatments causing less weight gain and
less hypoglycemia are desirable
Dr. Chan said the major cause of hypoglycemia is the treatment regimen of type 2 diabetes itself, namely the older secretagogues
and insulin. Overdosing and an erratic eating pattern will also cause blood sugar levels to fluctuate. While most hypoglycemic
episodes tend to be mild, the RECAP-DM
(Real-life Effectiveness and Care Patterns of
Diabetes Management) Asia Pacific study
4
News | Pharmacy Today | July 2013 showed that more than one-third of type 2
diabetic patients reported hypoglycemia of
varying severity during the 6-month period
prior to study enrolment. (Diab Res Clin Pract
2010;doi:10.1016/j.diabres.2010.05.008)
While mild hypoglycemia will not cause
problems, apart from headache, sweating,
palpitations and tremors, if untreated it may
progress to severe hypoglycemia. Severe hypoglycemia is serious and can lead to loss of
consciousness, convulsions and seizures.
One side effect often overlooked is the risk
of dementia in those suffering from hypoglycemia. A 2009 retrospective study revealed
that the lifetime relative risk of developing
dementia increases with the number of severe hypoglycemic episodes a person encounters. Those suffering from three or more
severe episodes of hypoglycemia are almost
twice as likely as those who have never experienced hypoglycemia to develop dementia in
their lifetime.
Newer therapies such as dipeptidyl-peptidase-4 (DPP-4) inhibitors and glucagonlike peptide-1 (GLP-1) agonists tend to be
weight neutral or even cause weight loss.
These agents reduce the risk of hypoglycemia
because they behave in a glucose-dependent
manner. Hence, they cannot cause hypoglycemia and are very safe. While the newer
therapies only bring down HbA1c by about
0.5 to 1.0%, combination therapy will usually
provide sufficient glucose lowering.
Both Dr. Chan and Dr. Zanariah were
speaking at a media workshop on diabetes
management held in Petaling Jaya recently.
‘Man flu’ could be real, expert says
T
here may be some truth behind the ‘man flu’ concept, according to research led by
Durham University, UK, neuroscientist Amanda Ellison.
Men have more temperature receptors in the brain, which causes them to experience flu symptoms more acutely, according to research printed in Ms Ellison’s book, Getting
Your Head Around the Brain.
Male and female children start out responding to colds in the same way because the preoptic nucleus, the area of the brain which balances a variety of the body’s functions such as
temperature is the same size. However, when boys hit puberty, testosterone starts to act on
the area, located in the brain’s hypothalamus and attached to a hormone gland, making it
larger.
People’s temperature increases when they get a cold to help fight off the bugs. The bugs
can’t survive at a higher temperature.
“So, men run a higher temperature and feel rougher – and if they complain they feel
rough then maybe they’re right,” Ms Ellison says in a Telegraph article (24 January). Her
findings were drawn from studies of the brain postmortem as well as from images obtained
from brain scans, but she admitted there are limitations to this line of research.
“My role is to put two and two together. There is no hard evidence that the feelings are
worse in males and females. This is a possible cause – but the argument will rage on.”
5
News | Pharmacy Today | July 2013 Tocotrienols protect the brain
By Leonard Yap
A
specific type of vitamin E called tocotrienol has been found to protect
the brain and prevent it from further
degradation due to aging and stroke, says a
researcher.
Vitamin E has been known for a long time
to be a potent antioxidant, but tocotrienols
have now been shown to have neuro-protective effects in the human brain, particularly
the white matter region, said Yuen Kah Hay,
a professor of pharmaceutical technology at
Universiti Sains Malaysia, Penang.
Prof Yuen said tocotrienols, via their neuro-protective properties, may help minimize
tissue injury in the brain during a stroke. Subsequently, tocotrienols may lower the risk of
physical and cognitive effects associated with
stroke, like vision loss and paralysis.
The benefits of taking tocotrienols include
the fact that it is not a drug and has an extremely low risk of side effects. People who
consume tocotrienols do not have worry
about taking it for long periods of time as a
brain-protecting supplement, Prof Yuen said.
There is an ongoing study on the effects of
tocotrienol supplementation to retard peripheral neuropathy and cognitive dysfunction in
type 1 and type 2 diabetic patients. It is currently being done with the Clinical Research
Centre of Seberang Jaya Hospital in Penang,
and is led by Prof Yuen and Dr Irene Looi, a
consultant neurologist.
Prof Yuen said there is also a trial investigating the effects of tocotrienols on transient
ischemic attacks (TIA) and stroke at the Ohio
State University, US. The study is being fund-
ed by the Performance Management and Delivery Unit (PEMANDU) Malaysia.
Vitamin E in the form of tocopherols was
first discovered in 1922. Tocotrienols were
discovered about 25 years later. Work in the
1930s revealed the chemical structure and
biological function of alpha-tocopherol. In
the 1940s, studies found that vitamin E protects unsaturated fatty acids in human tissue
against oxidation. (Am J Clin Nutr 1987;46(1
Suppl):183-6)
Prof Yuen said tocotrienols are more rare,
but are present in considerable amounts in
palm oil. Malaysia was the first country to
commercialize tocotrienols from palm oil.
Current scientific knowledge has found that
tocotrienols have unique biological activities
not found in tocopherols.
An example of this is the ability of alphatocotrienols at extremely low concentrations
to protect neurons from degenerating when
exposed to massive amounts of glutamate, a
nerve excitatory signal.
Prof Yuen was speaking at the Malaysian Pharmaceutical Society’s Annual
General Meeting held in Kuala Lumpur,
recently.
6
News | Pharmacy Today | July 2013 CPD points achievable even with a hectic
schedule
By Pank Jit Sin
T
he continuing professional development (CPD) rollout will be mandatory
by 2014 and, understandably, many
pharmacists are anxious, mainly because of
a lack of understanding and uncertainty on
how to achieve the points total.
Associate Professor Chua Siew Siang, of
the department of pharmacy, Universiti Malaya, said many pharmacists are worried about
meeting the specified mandatory 30-point annual total. Currently, many pharmacists look
at the CPD program as a points-collection
mechanism and a product-education exercise.
Dr Chua went through the various methods of achieving the 30-point annual quota,
which is divided into a number of categories and some subcategories. Chief among
the methods of acquiring CPD points is attendance at conferences, either local or international, from which a pharmacist would
earn 20 CPD points. Such conferences should
be three or more days in length and involve
speakers of international standing.
Alternatively, a pharmacist could attend
scientific meetings of chapters of academies,
universities, colleges, associations, institutions, the Ministry of Health (MOH) or others. The number of points awarded varies according to the duration of the event, and the
maximum amount of points that can be accumulated in this manner is 20.
Those looking for a more interactive route
towards CPD accumulation can attend workshops, courses or attachments. The amount of
points to be gained in this manner depends
on the amount of time spent and is capped at
30 points.
Dr Chua pointed out that in the case of
professional attachments, credit points are
awarded only to participants from outside the
place of work.
A pharmacist can also choose to complete
CME sessions, topic seminars, lectures and
journal clubs. One can also attend formal lecture
rounds, hospital clinical meetings or engage in
reflective notes. Each activity should not exceed
seven points per session per day, and each session should not be less than one hour.
Many other methods of achieving CPD
points are available to suit various personality types and time restrictions, said Dr Chua.
The entire list of areas where CPD points can
be obtained can be accessed at: www.mps.
org.my/newsmaster.cfm?&menuid=37&actio
n=view&retrieveid=3638
CPD is a continual process of life-long
learning. It falls to pharmacists to develop
systematic maintenance, development and
broadening of their knowledge. Coupled with
the proper skills and attitude, this will ensure
their continuing competence and professionalism throughout their careers.
Dr Chan noted that CPD involves any relevant learning activity, be it formal and structured or informal and self-directed.
7
News | Pharmacy Today | July 2013 Gonorrhea now a challenge due to
antibiotic resistance
By Leonard Yap
G
onorrhea used to be relatively easy to
treat and required just a single-class
antibiotic. Unfortunately, this is no
longer true as the antibiotic arsenal against
gonorrhea is rapidly dwindling, says an expert.
Not long ago, a single dose of ciprofloxacin was all that was required to win the battle against gonorrhea, said David Livermore
(Ph.D), a professor of medical microbiology
at the University of East Anglia, and lead researcher on antibiotic resistance for the Health
Protection Agency, UK.
A decade ago, there were reports of resistance against ciprofloxacin among sex workers in the Philippines. In addition, the cephalosporins were beginning to lose ground
against the bacteria. By 2010, ceftriaxone resistance was detected in patients in Japan,
France and Spain, Prof Livermore said. [J Antimicrob Chemother 2010;65:2141-8]
The byword for antibiotics in the current
situation of resistance is ‘antibiotic stewardship.’ This stewardship refers to the judicious
use of antibiotics. Antibiotics have been a life
saver for millions of people worldwide ever
since penicillin was discovered by Alexander
Fleming in 1928. Unfortunately, antibiotics
have been used relatively indiscriminately for
conditions that do not require an antibiotic,
like the common flu.
The treatment of gonorrhea has been exemplary because only patients who require
antibiotics receive them and the treatment regime is extremely simple – one dose of oral
ciprofloxacin. Genitourinary medicine physicians have exercised extreme restraint in pre-
scribing antibiotics and have followed guidelines to the letter. Yet, resistance has become a
serious issue, he said.
Prof Livermore suggested that treatment
regimens could have been approached differently i.e., cycling the antibiotic options to
enhance the fight against gonorrhea, by utilizing cefixime, ciprofloxacin and spectinomycin, all of which were available and active against gonorrhea. This strategy, instead
of using a single antibiotic agent, may have
stemmed the tide of resistance. In addition,
using a multi-dose regimen may have also
slowed the progression to resistance.
Prof Livermore said the lack of new antibiotic agents is exacerbating the problem of antimicrobial resistance. This can be attributed
to the fact that antibiotic discovery is difficult,
particularly those targeting gram-negative
bacteria like gonorrhea. New classes of agents
that target different sites of the body are difficult to come by, and this is further hampered
by the fact that antibiotics are not very prof-
8
News | Pharmacy Today | July 2013 itable for big pharmaceuticals, which restrict
the amount of funds channeled into research
for these drugs.
In 1943, penicillin was 100 percent effective
against Neisseria gonorrhea at a dose of 72
mg, but by 1969 it took 3 g of penicillin plus
probenicid to be fully effective. In 1984, ciprofloxacin at a single dose of 250 mg became the
standard prescription. [J Antimicrob Chemother
2010;65:2141-8]
An estimated 448 million new infections
of curable, sexually transmitted infections
(STIs) like syphilis, gonorrhea, chlamydia and
trichomoniasis occur yearly worldwide. Some
STIs exist without symptoms. It is estimated
that up to 70 percent of women and a significant proportion of men with gonococcal and/
or chlamydial infections experience no symptoms at all.
Both symptomatic and asymptomatic
infections can lead to the development of
serious complications. [Sexually transmitted
infections www.who.int/mediacentre/factsheets/fs110/en/ Accessed on 27 May]
Prof Livermore was speaking at the 9th
International Symposium on Antimicrobial
Agents and Resistance (ISAAR) 2013 held in
Kuala Lumpur.
READ JPOG ANYTIME, ANYWHERE.
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10
News | Pharmacy Today | July 2013 A natural alternative for joint disorders
By Saras Ramiya
J
oint disorders are commonly due to
arthritis or years of use that cause joints to
wear away leading to pain, stiffness and
swelling.
Arthritis is a complex family of musculoskeletal disorders, which consist of more than
100 different diseases or conditions that can
affect people of all ages, races and genders.
Three of the common diseases that make up
arthritis are osteoarthritis (OA), rheumatoid
arthritis and juvenile arthritis.
Arthritis usually involves the breakdown
of cartilage, pain, inflammation and stiffness.
It is one of the most prevalent chronic health
Research has showed that
the mussels contain a combination
of bioactive enzymatic nutrients,
naturally-occurring components
such as omega-3 fatty acids,
glycosaminoglycans (important
constituents of joint cartilage and
synovial fluid) and nourishing
marine minerals
problems and a common cause of disability.
OA is the most common form of arthritis.
Age is the most powerful predictor of OA.
The incidence rises steeply with advancing
age and affects all joints.
The Community Oriented Program for the
Control of Rheumatic Diseases (COPCORD)
survey in Malaysia showed that 14.4% of
those with a rheumatic complaint had pain
in the joints, while more than half of those
Walking is a preferred activity to maintain joint health
with knee pain had clinical evidence of OA. (J
Rheumatol 2007;34(1):207-13)
The risk factors for arthritis include age,
genetics, gender (60% of all arthritis patients
are women), obesity, joint injuries and repetitive movement. Arthritis can affect any joint
in the body and every aspect of a patient’s
life. Knee OA, especially, can shorten many
healthy years of life, affecting more women
than men aged above 50.
There is no cure for joint disorders – only
prevention and management of symptoms.
The primary prevention is to maintain a
healthy weight and to avoid trauma to joints
e.g., repetitive knee bending. Treatment includes modification of activities, analge-
11
News | Pharmacy Today | July 2013 sics, non-steroidal anti-inflammatory drugs
(NSAIDs) and other drugs acting on the musculoskeletal system eg, glucosamine.
Natural products have been used to relieve
pain and inflammation. One such product is
the New Zealand green-lipped mussel extract, which is patented as Biolane®. Biolane is
a safe and effective joint health solution that
has played a pivotal role for over 30 years in
allowing patients to enjoy a better quality of
life and keeping them on the go. (Practitioner
1980;224(1347):955-60)
John Croft, the noted marine scientist and
author, is regarded as one of the world’s leading experts on the life cycle, farming methods and therapeutic uses of the New Zealand
green-lipped mussel (Perna canaliculus).
Research has showed that the mussels contain a combination of bioactive enzymatic nutrients, naturally-occurring components such
as omega-3 fatty acids, glycosaminoglycans
(important constituents of joint cartilage and
synovial fluid) and nourishing marine minerals. A unique cold extraction method is used
to produce Biolane from freshly harvested,
live, healthy mussels.
Known internationally as ‘The Mussel
Man,’ Mr Croft was responsible for the development and research programs associated
with Biolane and other marine-based theraInternational Events
International Pharmaceutical Federation (FIP)
World Congress 2013
31/8 to 5/9; Dublin
www.fip.org/dublin2013/
peutic products since the late 1960s.
“Biolane is an anti-inflammatory and has
four anti-inflammatory mechanisms, but its
main function is inhibiting the enzymes in
our body that denature our joint tissues. As a
bonus, it happens to protect the stomach lining,” said Mr Croft.
Enzymes called matrix metalloproteases
(MMP) denature every cell in the body in a
process which starts at birth and occurs at a
faster rate in arthritis patients as well as the
elderly. Biolane moderates the activities of
MMP to maintain a balance, he said.
Studies have shown that Biolane improves
osteoarthritis and rheumatoid arthritis in 70%
of patients who take it. (Townsend Letter for
Doctors and Patients 2000;204:98-111, Practitioner 1980; 224(1347):955-60)
Biolane is contained in NuvaFlex B™, formerly known as NT-Flam™, and is now classified as a registered health supplement available from Nuvanta Sdn. Bhd.
Croft was in Malaysia recently to celebrate
not only the launch of NuvaFlex B, but also
his 81st birthday. Also present at the launch
were New Zealand High Commissioner to
Malaysia His Excellency Mr. David Pine, the
CEO of Zuellig Investments Pte Ltd Dr. Daniel
Zuellig, and the Business Unit Manager of
NuvaFlex B, Datin Swanee Teh.
13
News | Pharmacy Today | July 2013 Hallowed be thy liver
By Leonard Yap
J
ust as we suffer from the effects of stress,
our livers also take quite a beating. Poor
lifestyle habits and questionable diets put
the liver through great strain, yet we expect
it to perform day-in, day-out without a hitch.
Over time, our liver function may wane from
all that abuse – but there are ways of giving
your liver time to recuperate and regenerate.
The first thing a person with fatty liver
should do is to diet, exercise and adopt lifestyle changes, said Lucio Cavicchioli, international medical director of Rottapharm
Madaus, Italy.
It is the ‘golden rule’ for the liver – to give
it a break and time to recover and grow, Dr
Cavicchioli said. If we regularly consume
foods high in fat and protein, the liver goes
into overdrive as it has to constantly detoxify
the food by producing oxidative chemicals
like hydrogen peroxide to oxidize fat and
proteins for disposal. This causes the accumulation of free radicals, which have to be
removed from the liver as soon as possible to
avoid damage to the organ. If free radicals are
not removed quickly, the liver is considered
to be in oxidative stress, Dr Cavicchioli said.
The liver prefers a diet low in cholesterol
and high in carbohydrates, which means that
a plant-based diet is best for overall health.
Using antioxidant supplements, in addition
to eating plenty of fruits and vegetables, is the
key to a healthy liver. Avoiding alcohol is also
an important step because the liver has the
all-important role of detoxifying alcohol from
the blood stream.
Fatty liver, also known as steatosis, is re-
versible and amenable to diet and lifestyle
improvements, but once it progresses to nonalcoholic steatohepatitis or worse, cirrhosis,
the chances of saving your liver become extremely difficult.
Silymarin, a compound derived from milk
thistle, has been used since ancient times for
its liver-protecting and antioxidant properties.
Unfortunately, the efficacy of silymarin
can be something of an issue. Silymarin is a
mixture of four constituents: silibinin, isosilibinin, silicristin and silidianin. Silibinin is
the active ingredient of the mixture, and the
ratio of how much silibinin is present ensures
that the right amount of it reaches the liver,
Dr Cavicchioli said.
Several clinical trials have
shown the successful treatment of
elevated liver enzyme levels
This is why Rottapharm’s Legalon formulation is special. The mixture contains 55%
silibinin, which is quite ideal as too high or
low proportions of silibinin affect its efficacy,
he said. Pure silibinin is water-soluble and,
therefore, will not reach the liver for it to be
effective.
Several clinical trials have shown the successful treatment of elevated liver enzyme
levels (associated with a fatty liver) within
six months of administration. There has been
some evidence to show that Legalon can be
used to protect the liver, even when it has
reached the stage of cirrhosis. It will not reverse cirrhosis, but will provide some protection and buy time for the liver to heal. Patients
14
News | Pharmacy Today | July 2013 should be prescribed the maximum dose of
Legalon for the best effects, or else its results
will be no better than a placebo, Dr Cavicchioli said.
Dr Cavicchioli was speaking at a Rottapharm Madaus symposium in Kuala Lumpur.
Rottapharm Madaus Ireland received nominations for the European Strategic Manufacturing Award, which celebrates excellence in
all aspects of manufacturing.
The nominations were for:
• Outstanding Achievement in Continuous
Improvement Award
• Green and Sustainable Manufacturing
Award
• Factory of the Future Award
Rottapharm was the only company to receive more than one nomination, as well as
the Outstanding Achievement in Continuous
Improvement Award. It was also judged The
Winner of the Winner through the SMA e-F@
ctory Hall of Fame Award.
The first award was presented in recognition of the company’s efforts to reduce costs,
motivate employees and lower wastage.
The second award was recognition of the
company’s strong business case of World Class
Manufacturing by deploying numerous IT
solutions, delivering the business a competitive advantage and ongoing continuous improvement programs.
MTMAY1-12/001
16
Feature | Pharmacy Today | July 2013 Skin Health
Feature
Acne be gone!
By Leonard Yap
A
cne is a ‘pain,’ as many will attest. It
may not be life-threatening, but its impact on quality of life can be great. For
the many people who have had to put up with
it for a long time, there is frustration and embarrassment, and even anger and depression.
Nevertheless, there is hope.
“Acne is one of the most common skin
conditions, affecting more than 460 million
people in the region. It is one of the most
common adolescent problems, and despite
the myth that acne affects mainly teenagers,
many people continue to have acne well into
their adulthood,” said Hew Yin Keat, a GP
with a sub-specialty in esthetic medicine and
dermatology.
Many of us have spent an arm-and-a-leg on
the overwhelming number of treatments out
there, but do they actually work? If you were
to ask your mother, she may tell you to stop
eating chocolate and oily items. If you check
out online forums, they may tell you what
works for one person, but not for the next. On
the pharmacy shelves, you’ll find a huge array of products, each claiming it can do the
job. So who do we believe?
An online survey conducted in 2012 by
Menarini Asia Pacific on 1,020 Asians aged
between 18 and 35 years in four countries –
India, Malaysia, Singapore and the Philippines – found that about 30% of respondents
spent more than an hour a week looking for
17
Feature | Pharmacy Today | July 2013 Skin Health
acne-related information and solutions. As
they were unsure of the right treatment, the
survey respondents were willing to try multiple products. The survey revealed that 10%
had tried more than 10 products.
less severe. According to some studies, girls
with acne are more likely to suffer from anxiety and depression. These girls will also socially withdraw and this can affect their ability to have long-lasting relationships.
Self-esteem affected by acne
The survey also found that two-in-three
Asians felt embarrassed and self-conscious
when they had acne, with one-in-three thinking about their acne two to five times a day.
The respondents also refrained from social
activities and only felt comfortable meeting
close friends.
In Malaysia, the survey found that respondents were socially inhibited by acne and that
it kept them from attending events. Acne was
also something they preferred not to discuss,
even with close friends. The aversion to the
topic could also be the reason why seeing a
dermatologist was also not common practice.
Nonetheless, acne was always on their minds
and they had noticeable expectations about
the product they used.
Acne may be a physical manifestation and,
perhaps, a ‘rite of passage’ into adulthood,
but it also accompanies a significant development of particular parts of the brain, said
Elaine Yong, a lecturer and developmental
psychologist.
“What we have noticed [in teenagers] is
that the front part of the brain, the prefrontal cortex, is not fully matured and, therefore,
teenagers are not really logical. Instead, a part
of the brain named the amygdala, which is
responsible for emotions, is fully matured.”
This leads to teenagers having ‘teenagers
syndrome,’ making them more susceptible
to emotional and rash judgments. This reaction to emotions is observed more in girls, Ms
Yong said.
Girls are generally more sensitive in nature and, therefore, more likely to feel embarrassed and self-conscious, even if their acne is
Clearing the confusion on acne management
In the hope of guiding consumers through the
clutter of acne information, Menarini created
the Clear the Confusion Campaign.
“While researching treatments for acne, we
realized there is a lot of information out there,
but we weren’t sure it was right,” said Cheah
Chor Eng, general manager of Menarini Malaysia.
“In order to help clear the confusion, we
wanted to help more young adults find the
truth about acne and how it affects them, regardless of age. We hope that once they gain
this understanding, they will realize that Papulex™ effectively addresses the root causes of
acne,” Mr Cheah said.
“The Papulex range of products targets the
root causes of acne with its unique combination of three clinically proven ingredients.
Patients experiencing any type or severity
of acne can use Papulex. It can also be used
alone or with existing prescription treatment,
making it ideal for the maintenance of acneprone skin,” Dr Hew said.
Papulex has a unique triple-action formula
that addresses the three root causes of acne:
1.
EU-Patented ABA Technology: Unique to
Papulex, EU-patented ABA technology
helps block the proliferation of Propionibacterium acnes in the outer layer of the
skin.
2.
Helps reduce inflammation: Papulex contains 4% nicotinamide, a natural molecule
derived from vitamin B3 that has potent
anti-inflammatory properties. Studies
have shown that nicotinamide is as effective as clindamycin gel in reducing acne
severity and lesion counts without induc-
18
Feature | Pharmacy Today | July 2013 ing bacterial resistance.
3.
Helps reduce sebum production: Papulex
contains zinc PCA to help regulate sebum
production, which causes oily skin and
acne. A clinical study demonstrated that
1% zinc PCA led to a significant decrease
Skin Health
of the sebum rate 28 days after its twicedaily application, while no significant variations were observed in the placebo group.
The Papulex™ range is available at selected
clinics in Malaysia.
Prescription acne treatments carry risks
Acne is a tough condition to treat and it’s important to give the right advice on treatments,
as Pharmacy Today New Zealand finds out.
A
cne is particularly prevalent during
adolescence, and some teenagers will
face an on-going battle with this common skin condition.
There is a wide range of treatment options
available in pharmacies, both OTC and on
prescription, but health professionals should
be aware of both the risks and the benefits of
using them.
Acne develops when skin gets greasy and
pores block up to form whiteheads, blackheads and pimples.
According to everybody.co.nz, acne can
improve with topical treatments, but they can
take several weeks or months to be effective.
Pharmacists can also
offer some general advice
to manage acne
However, getting in early with treatment
can help prevent future scarring.
People may prefer to try a product on a
small area of the face to start with to test how
the skin reacts, but most products are designed to be used on the entire affected area
and not individual spots.
Acne face washes and cleansers can reduce
the greasiness of the skin. Products may include an antiseptic or antibacterial agent, or
mild salicylic acid.
Benzoyl peroxide, found in some acne
creams, lotions and gels, can eliminate some
bacteria on the skin. It peels off the skin’s top
layer, which unblocks the pores.
However, if the person has a lot of blackheads, it can aggravate the skin. If this occurs,
the pharmacist should advise the customer to
discontinue use.
Retinoid gels or creams such as tretinoin
are mainly used for blackheads, to dry out the
skin and make it peel.
As retinoid solutions can irritate the skin,
people should only apply a small amount,
spread very thinly, and use it no more than
once a day.
These products may initially make the acne
worse, but this should improve after a few
weeks. People using retinoid products should
be extra vigilant with sun protection as they
are more susceptible to sunburn. The products are also not suitable for pregnant women.
Azelaic acid creams are a twice-daily acne
treatment. If the cream irritates the skin, people can reduce application to once a day, or
19
Feature | Pharmacy Today | July 2013 apply a smaller amount.
Pharmacists can also offer some general
advice to manage acne – cleanse regularly but
avoid over-scrubbing, do not pick or squeeze
pimples and opt for non-oily moisturizers.
Pharmacists should refer patients to a GP
if the acne does not respond to topical treatments or if the person’s acne is severe.
Be aware of side effects
A GP or dermatologist may prescribe isotretinoin, an oral retinoid, as an acne treatment,
but there is a range of possible side effects,
everybody.co.nz says.
Women who are pregnant, or who become
pregnant while taking isotretinoin, or less
than one month after treatment, have a high
risk of causing damage to the baby and must
not use it.
There are also links between the use of
isotretinoin and depression, and the New
Zealand Medicines and Medical Devices
Skin Health
Safety Authority (Medsafe) advises health
professionals to monitor patients for the
development of depression during treatment.
People may also take oral antibiotics as an
acne treatment. They must take them for three
months or more, depending on the severity of
the acne.
Females on the oral contraceptive pill
should be aware that antibiotics can reduce
the effectiveness of the pill, so they may need
to use additional forms of contraception.
Diet still a controversial area
While there is debate in the medical field
around links between diet and acne, studies
have shown a low glycemic index diet can
help prevent acne.
This includes plenty of fresh fruit and
vegetables, whole grain, lean meats and seafood, and reducing the intake of processed
foods.
Atopic eczema is a dynamic skin disorder
By Saras Ramiya
A
topic eczema is a dynamic and
progressive condition as it can develop from an acute to subacute to
chronic phase.
Characteristics of eczema
In the acute phase, there is superficial erosion
and the skin surface is wet and leaky. In the
subacute phase, the skin surface is scaly, erythematous and itchy, and this occurs repeatedly. The end-result is chronic lichenified,
thickened skin, with pigmentory changes and
increase in skin marking, says pediatric dermatologist Leong Kin Fon, of Kuala Lumpur
Hospital.
“Atopic eczema is potentially reversible if
you manage the disease early with appropriate treatment. If managed in the acute and
subacute stages, patients can recover because
the inflammation is at the level of epidermis
and dermis, and the regenerative potential of
the skin is still preserved.
“If the disease is managed early, the skin
will become hypo- or hyperpigmented, and
20
Feature | Pharmacy Today | July 2013 after a year or so, the skin will be back to normal. If you allow the disease to progress, it
will become chronic and after another year or
so, the skin will become nodular or leucodermal and it becomes less reversible,” said Dr
Leong.
Besides being dynamic, progressive and
reversible, atopic eczema also varies even in
the same patient e.g. acute phase on the face,
subacute on the forehead and chronic on the
back.
Patients with atopic eczema have dry skin
because eczematous skin has a skin-barrier
dysfunction. Because of this, there is evaporation of water and exposure of the dermis to
pathogens, irritants and allergens, resulting
in inflammation and itchiness. The disorder
will initiate the vicious cycle of dryness, itch,
scratch, inflammation and infection.
Treating atopic eczema
The main focus in treating atopic eczema is
the stratum corneum, which is the outermost
layer of the skin. The stratum corneum performs at least 11 functions, and those that are
closely related to atopic eczema are barrier
function, hydration, anti-infection, and initiation and coordination of inflammation.
The stratum corneum, together with the
epidermis, is the first-line barrier against infection and is the innate immune system. In
atopic eczema, all three components of the
lipid bilayer are reduced, especially ceramide.
As a result, there are microscopic gaps in the
lipid bilayer that facilitate the evaporation of
water to the surroundings and penetration of
allergens and pathogens. Physiological lipids
or non-physiological lipids e.g. mineral oils,
petrolatum products and dimethicone, can be
used to fill the gaps.
The second component that is compromised in eczema is the water-holding capacity, also known as humectant. Filaggrin is the
main contributor to the natural humectant
Skin Health
in our skin. Some of the natural humectants
in our skin include sodium PCA, free amino acids, glycerine and urea. Hence, different brands use different humectants. A good
moisturizer should have both humectant and
occlusion effects.
The third aspect that is compromised in eczema is pH. The pH of the epidermis is maintained at 7.35, while the pH of the stratum
corneum is 4.5 to 6, which is the normal physiological acid mantle. This layer is important
for the normal peeling process of the skin and
it attracts good bacteria while repelling bad
bacteria i.e. Staphylococcus aureus.
In eczema, a near neutral or alkaline pH of
the stratum corneum activates the protease
enzyme and inactivates the protease inhibitor. This promotes desquamation and skin
peeling, reduces the production of lipids and
attracts S. aureus to colonize the eczematous
skin, which makes the skin more prone to infections. It is important to use an emollient
that will not disrupt this acid mantle.
The final aspect of eczema is innate immune
dysfunction due to the lack of antimicrobial
peptides (natural antibodies and antibiotics
in our skin) and dysfunction of the toll-like
receptor, resulting in recurrent infections and
bacteria colonization by S. aureus, which not
only causes secondary bacterial infection, but
also stimulates the immune system via its super-antigen effect.
“It is very important when you talk about
skin maintenance in atopic eczema to balance
these interlinked aspects. You have to make
sure all [aspects] are in a balanced state if you
want to get good results. So, it’s important to
have an appropriate combination of emollient
and cleanser,” said Dr Leong.
The European guidelines for atopic eczema
state that emollients should be prescribed in
adequate amounts, and they should be used
liberally and frequently e.g. for emollient
cream or ointment a minimum of 250 g per
21
Feature | Pharmacy Today | July 2013 week. Emollient bath oils and soap substitutes
should also be used. Regular use of an emollient has a short- and long-term steroid-sparing effect in mild-to-moderate atopic eczema.
The treatment aim in the first two weeks
is to induce remission using an antibiotic and
anti-inflammatory agent. For localized areas,
antibiotics that can be considered include mupirocin, retapamulin, fusidic acid and gentamicin. For extensive areas, systemic agents
like cloxacillin and first- and second-generation cephalosporin like erythromycin can be
used.
“For young children, we prefer using steroids e.g. 1% hydrocortisone cream, clobetasone butyrate and desonide ointment for the
first week, and after remission is induced, a
proactive management of the stubborn areas,” said Dr Leong. Steroids should be tapered slowly to class 1 once daily every alternate day for two to four weeks, he added.
According to the UK system, there are four
classes of steroids. (Figure 1) A class 4 steroid
is 300 times stronger than a class 1 steroid.
“You also need to know the formula that you
want to use e.g. clobetasone ointment is stronger than cream, and cream is stronger than lotion.
“The next thing you need to know are the
target sites. Skin thickness varies with a patient’s age, site of application and stage of
disease. Skin absorption of topical steroids
varies with site of application due to different
Skin Health
skin thickness e.g. 30% of steroids is absorbed
when applied on the eyelids and genitalia; 7%
on face, 4% on flexures’ 1% on forearm; 0.1%
on palm; and 0.05% on sole,” said Dr Leong.
Steroids should be followed up with steroid-sparing measures i.e. moisturizers with
anti-inflammatory properties, calcineurin inhibitors and phototherapy in a combination
approach. Caution is needed when treating
the area around the eyes, occluded sites and
in younger children. Different preparations
can be used e.g. cream for wet and dry eczema, and ointment for dry eczema.
“Lastly, when you have induced remission,
grab the opportunity to educate the patient
or patient’s parents on moisturizing, cleansing and anti-itching measures to maintain
remission,” said Dr Leong. He was speaking at a dermatology workshop for pharmacists, organized by Stiefel, a GlaxoSmithKline
company.
STEROID
TARGET SITES
STAGE
CHRONIC
Class 4
Clobetasol propionate
Class 3
Mometasone furoate
Fluticasone propionate
Betamethasone valerate
Class 2
Clobetasone butyrate
Desonide
Class 1
Hydrocortisone
acetate/base
Intralesional
Occlusion
Ointment
Cream
Lotion
Palm/Soles
Lichenified
Adults
Elderly
Limbs
Children
Flexures
Infant
Face
STAGE
ACUTE
Figure 1: Steroids, preparations, age, stages and sites
Periorbital
22
Feature | Pharmacy Today | July 2013 Skin Health
It is challenging to treat patients with psoriasis
Manage expectations of sensitive-skin
remedies
It can be a challenge trying to find safe and
effective treatment options for people with
sensitive skin, as Pharmacy Today New
Zealand finds out
S
ensitive skin is a generic term used to
describe skin with a reduced tolerance
to cosmetics and personal care products,
and it most commonly occurs on the face. It
can result in stinging, itching and burning
sensations.
People may find that products which do
not cause a reaction on other parts of the
body do react when used on the face.
According to the Dermnet website, approximately 50% of women and 40% of men
report having sensitive skin.
New Zealand dermatologist Louise
Reiche said sensitive skin is both an inherited skin condition and an ailment that can
23
Feature | Pharmacy Today | July 2013 develop later in life.
A key way for pharmacists to distinguish
between sensitive skin and an allergic reaction to skin products is whether or not the
person is experiencing physical symptoms,
Ms Reiche said.
“Sensitive skin is self-perceived – [skin]
feels irritable, tight, tingly, but [there is]
nothing the outsider can see. An allergic
reaction shows as redness, swelling or eczema at sites of application [of skincare or
cosmetics].”
It can be triggered through overuse of
face washes and scrubs. Sun damage and
excessive use of make-up can also contribute to sensitive skin.
Pharmacists should also ask patients
whether the skin reacted immediately after
using a product on the skin, how long they
have had the skin condition, such as a rash,
and whether they have a history of developing rashes, Ms Reiche said.
This can help pharmacists determine
whether there is a link between certain
products and the skin condition.
People with sensitive skin should opt for
fragrance-free and hypoallergenic skincare
products, Ms Reiche said.
If symptoms do not clear up after using
these products, the pharmacist should refer
the customer to a dermatologist for a more
comprehensive assessment.
Dietary changes can ease rosacea
Rosacea is another common facial skin condition which can trigger skin sensitivity.
Rosacea sufferers may experience persistent redness, rashes, bumps, pimples and
localized facial swelling.
When it comes to treating rosacea, the
most important piece of advice is to ensure
sufferers have adequate sun protection, Ms
Reiche said.
Pharmacists can also advise people to
Skin Health
minimize their caffeine, alcohol and spicy
food intake as these can all aggravate the
skin of people with rosacea.
Topical azelaic acid cream, metronidazole cream or tetracycline antibiotics and
non-irritating cleansers can all treat rosacea.
Dermatitis and psoriasis can be a challenge
Petra Eyserth, a pharmacist at Unichem Lee
and Hart in Warkworth, said it is common
for people to come into the pharmacy with
contact dermatitis, and for children to present with eczema. Less frequently, people
come to the pharmacy with psoriasis, a
chronic, scaly rash.
Contact dermatitis most often affects
people who work a lot with water and detergents, such as mums with young children, and hairdressers, and appears as redness, blisters, swelling and cracks, often on
the hands.
Mechanics can also develop contact dermatitis from working with grease and petroleum.
Not everyone in these careers will get
contact dermatitis, but some will develop
it over time. If the problem persists over
a long period of time, some people might
even need to consider changing their career, Ms Reiche said.
However, this is not always a practical
solution, as mothers, for example, “can’t
just run away” from their job.
Mothers with babies are constantly
washing their hands, as they are changing
nappies and preparing food, and this can
irritate the skin, Ms Eyserth said.
As a preventative measure, people can
try barrier creams and gloves.
Pharmacists can also recommend treatment options. “They [people with contact
dermatitis] have to make sure they use a really good hand cream at night to give the
hands a break during the night and to nour-
24
Feature | Pharmacy Today | July 2013 ish them again and make sure they’re moisturized,” Ms Eyserth said.
Wearing cotton gloves overnight can also
help to ensure the skin retains moisturizer.
Based in rural Dannevirke, Ward’s Pharmacy treats a lot of people with contact dermatitis, pharmacist manager Alex Graham
said.
Dermatitis is rife in Dannevirke’s farming community, where people often deal
with sprays, solvents, fertilizers and detergents. At least one person a day comes into
Ward’s Pharmacy suffering from the complaint, Mr Graham said.
Often, it is just a case of giving the customers advice, such as reminding them to
wear gloves or switch from normal soap
to an aqueous cream or tar-based, pine-oil
product.
Ensure the customer knows that aqueous
creams should only be used as soap, not a
moisturizer, as it may aggravate atopic eczema, he said.
Sometimes, they may need a hydrocortisone cream or to be referred to the doctor.
Because there is a big advice component to treating dermatitis, Mr Graham
has pamphlets and self-care cards in the
pharmacy. He sees some children, but they
have often already been to a doctor or
Skin Health
dermatitis clinic.
Experimentation may be needed to find right
product
Pharmacists can recommend hypoallergenic
products for people with sensitive skin, but
it is also important to manage people’s expectations about the products as there is no
guarantee that what works on one person will
work on the next person.
“Unfortunately, people often have to
invest a bit of money and time to find the
right combination of ingredients and the
right skincare routine. There might be just
one ingredient in the whole product that
the person can’t tolerate,” Ms Eyserth said.
Taking a comprehensive history of the
skin condition gives the pharmacist the
best shot at finding a suitable solution.
If the person is young and healthy, with
no underlying health conditions, quite often the pharmacist can recommend some
skincare products available in the pharmacy first, Ms Eyserth said.
However, if the person is older and
has an underlying health condition such
as diabetes, or shows symptoms such as
swelling, blistering and discharge, the
pharmacist should refer the person to a GP
for further assessment.
Advice for managing skin conditions
Sensitive skin is not visible, but the sufferer can experience uncomfortable and sometimes painful symptoms, such as tight
and tingly skin.
An allergic reaction to skin products will show as redness, swelling or eczema on the body where the skincare product or
cosmetic has been applied.
As everyone reacts differently to various chemicals, someone with a skin condition may have to try a few products to work
out what is best for her.
Make sure to manage people’s expectations about solutions for skincare products and explain there is no guarantee it will
work for them.
If the person has an underlying health condition and the skin is swelling, blistering and has discharge, the pharmacist should
refer her to a GP for further assessment.
25
Spotlight | Pharmacy Today | July 2013 Spotlight
Ironing out blood health problems
Good blood health is important for cognitive development in children, improved fitness and work
capacity in adults and the overall wellbeing of pregnant women. Read on to find out the important
role pharmacists can play in advising consumers on improving and maintaining blood health with
iron supplementation.
I
ron, a vital component of blood, is important for the function and formation of
hemoglobin, the molecule that transports
oxygen to all tissues of the body.
Iron deficiency, the most common form of
malnutrition in the world, refers to a negative
iron balance when daily intake of iron does
not meet dietary needs.
Iron deficiency anemia is an advanced
stage of iron deficiency. It occurs when levels of hemoglobin fall significantly below the
normal range. A reduced amount of hemoglo-
26
Spotlight | Pharmacy Today | July 2013 bin simply means blood is not able to carry
enough oxygen to the rest of the body.
Medical literature has shown that a deficiency in iron levels may lead to a decrease
in a person’s work capacity and productivity. Iron deficiency has also been associated
with premature newborns, low birth weight,
increased prenatal and maternal mortality,
child mortality, and impaired cognitive development, and behavioral and physical growth
of infants and children.
The cause of iron deficiency anemia is multifactorial. It ranges from heavy, long or frequent menstrual bleeding; bleeding caused by
chronic diseases such as cancer; peptic ulcer
disease and gastrointestinal bleeding due to
regular use of OTC pain relievers; the body’s
inability to absorb enough iron due to celiac’s
disease or Crohn’s disease; undernutrition
due to a lack of iron in the diet; and a higher
requirement of iron such as when pregnant or
breastfeeding.
Symptoms of iron deficiency anemia include fatigue, lethargy, dizziness, fainting, breathlessness, irritability, depression,
pounding in the ears, palpitations, poor appetite, pallor, cold extremities, tachycardia,
mouth ulcers and systolic murmurs.
Iron deficiency anemia is strongly associated with people from the lower socioeconomic
group, women of child-bearing age, women
who have had multiple pregnancies, women
who have had closed spaced pregnancies,
vegetarians who do not consume an ironrich diet, adolescents with poor eating habits, smokers and people with irritable bowel
problems.
As a person goes through different life cycles from infancy to adolescence to adulthood,
iron requirements of the body also change.
During adolescence, teenage boys and girls
go through a period of intense growth. This
growth spurt may leave them susceptible to
iron deficiency anemia if they are not getting
proper nutrition and eating regular meals.
Teenage girls have a higher risk of iron
deficiency anemia as they have started menstruating and often do not get enough iron to
keep up with menstrual losses.
Pregnant women are predisposed to anemia as they require up to 50 percent more
iron during pregnancy. This is because during pregnancy, plasma volume, red blood cell
volume and hemoglobin mass increases disproportionately, leading to a marked increase
in the demand for iron.
Pregnant women need additional iron to
support the nutritional needs of themselves
and the growing baby. However, many women do not have sufficient stores of iron at the
start of their pregnancy to meet the growing
demand of their body, putting them in the risk
group for iron deficiency anemia.
Women who were anemic during the third
trimester of pregnancy, lost a large amount of
blood during childbirth, or had twins or other
multiple births have a high risk of postpartum anemia.
Lactating women also have a higher iron
requirement as they need to restore the iron
they lost during pregnancy and delivery.
They also need to meet the iron requirement
of the newborn through breast milk.
In older adults, iron deficiency anemia
may be a symptom of an underlying gastrointestinal condition. Common causes include
NSAID use, colonic cancer or polyp, gastric
cancer and inflammatory bowel disease.
Iron deficiency anemia can be prevented or
managed by maintaining a balanced diet that
contains all the nutrients needed in the right
proportions. This is the simplest way of ensuring a person has all the necessary vitamins
and minerals needed to make healthy red
blood cells and to reduce the chance of iron
deficiency.
However, some people might not get all
the nutrients they need from diet alone. Here,
27
Spotlight | Pharmacy Today | July 2013 iron supplements can play a key role in filling
the nutritional gap. It is common for doctors
to prescribe iron supplements to prevent and
treat anemia.
It is important to select the right supplementation that is suited to a person’s daily
needs at different cycles of life. Common side
effects of iron supplements include abdominal distress, nausea, vomiting, diarrhea, darkcolored stool and constipation. This is why
choosing an iron supplement the body can
tolerate is important for optimizing iron absorption.
Constipation, a prominent side effect of
iron supplements, can cause discomfort. This
can be alleviated by drinking more water, incorporating fiber-rich foods such as high-fiber
cereals, cooked beans, whole wheat bread and
oats into the diet, and eating five servings of
fruits and vegetables daily. Exercises like running, swimming and aerobics can also help
by improving blood circulation to the colon
to get it going.
Adverse effects of oral iron can be minimized by starting oral supplements with half
the recommended dose and gradually in-
creasing to the full dose. The effects can also
be managed by dividing the dose of these
supplements and taking them with food.
To allow better iron absorption, it is recommended that the prescribed iron supplement
be taken in two or four equally spaced doses. Some people may consider taking enteric
coated or delayed-response iron preparations
as they may have fewer side effects. However,
these are not well absorbed and are not recommended.
It is also important to note that taking vitamin C supplements with food helps the absorption of iron. Calcium supplements should
be taken separately from iron as the former
can inhibit iron absorption. Tea and coffee can
also have a negative influence on iron uptake
and should not be taken one to two hours before taking iron supplements.
Iron deficiency cannot be cured overnight.
Treating iron deficiency anemia should focus
on increasing iron stores in the body. A combination of an iron-rich, nutritious diet and iron
supplementation can help cater to the differing iron requirements of different genders
and ages at varied points in their life.
28
Spotlight | Pharmacy Today | July 2013 Olive leaf helps stave off diabetes
R
ecent research has shown that olive
leaf extract can substantially reduce
the risk factors for people with predia-
betes.
The research, published online in the science
journal PLOS ONE on 14 March, reviewed
the outcome of a randomized, double-blind,
placebo-controlled, cross-over trial. Fortysix overweight middle-aged men, at risk of
developing type 2 diabetes and cardiovascular
disease, took either a capsule containing olive
leaf extract or placebo over a 12-week period.
It would appear that olive
leaf extract is indeed a helpful
supplement for people with
prediabetes, with the size of
the effect being similar to some
prescription drugs
The University of Auckland Liggins Institute led the study, which was co-funded by
the New Zealand Government and health and
beauty company Comvita. Comvita prepared
and supplied the olive leaf extract.
Wayne Cutfield, the lead researcher and
Liggins Institute director, said in a media release that supplementation with olive leaf
improved how insulin was secreted and functioned in overweight men involved in the trial.
Insulin controls the body’s metabolism by
stimulating the transport of glucose and fat
into cells.
“We saw significant improvements in standard measures of insulin action and secretion
compared with placebo. The changes were
of similar magnitude to those achieved with
the commonly prescribed diabetes medication metformin, suggesting that these results
could also have clinical relevance for patients
with type 2 diabetes,” Professor Cutfield said.
Medical researcher Shaun Holt said the
study was “very well undertaken” and
showed positive results despite its “modest
size.”
“It would appear that olive leaf extract is
indeed a helpful supplement for people with
prediabetes, with the size of the effect being
similar to some prescription drugs. It will be
interesting to see the results of larger studies in different patient populations,” Dr Holt
said.
29
Spotlight | Pharmacy Today | July 2013 Soft brush best for sensitive
O
ne in four people suffers from sensitive teeth, and pharmacists should
be prepared to help with treatment
advice.
Sensitive teeth can result in a vicious cycle
for the sufferer – the pain of sensitivity can
lead to poor oral health because it is too painful to brush the teeth. This, in turn, worsens
the sensitivity problem.
According to the New Zealand Dental Association website, tooth sensitivity is most common in the 25 to 45 age group, women, people
who brush too vigorously and those who consume large amounts of wine or citrus drinks.
People who have had treatment for gum
disease or who have had the eating disorder
bulimia can also experience sensitive teeth.
People with sensitive teeth most often experience sudden, sharp and stabbing pain
when they eat or drink cold food or drinks,
and when brushing their teeth.
Pharmacists can recommend using a desensitizing toothpaste and a soft toothbrush.
They should also remind people to use a nonscrubbing approach.
Pharmacists should refer people to a dentist if the sensitivity continues to check for
gum disease or other more serious oral health
issues.
30
Spotlight | Pharmacy Today | July 2013 Age spots no more
By Malvinderjit Kaur Dhillon
A
ge spots, also known as liver spots, on
the face will understandably dent a
person’s efforts to maintain youthfullooking skin. Along with its evil friends, uneven skin tone and dull skin, age spots can sap
the confidence of anyone.
Kinohimitsu recently launched J’pan ProWhite Regimen, a range of skincare products developed specifically to target problem areas affected by age spots and pigmentation.
Uneven skin tone, dull skin and age spots
are often the result of an uneven accumulation
of excess melanin and poor liver health. Skin
that is repeatedly exposed to harsh UV rays
may see an increase in melanin production
as melanin helps protect skin from UV light.
However, excess melanin can result in unsightly brown spots.
The J’Pan ProWhite Regimen combines
Kinohimitsu J’pan UV Bright Drink and Kinohimitsu J’Pan ProWhite to prevent age spots.
The UV Bright Drink is made of grape seed extract and other skin-brightening polyphenols
which protect against harmful UV rays by providing up to 9 hours of UV protection.
ProWhite contains glutathione, a naturally
occurring antioxidant in the liver. It protects
cells from oxidative stress and free-radical
damage. A deficiency in glutathione may slow
the process of cell renewal.
Apart from glutathione, the product also
boasts camu camu and maqui berry, both rich
in antioxidants.
Both products in this regimen work in combination to repair and eliminate spots, as well
as to promote a healthy liver. They protect the
skin from UV rays, while working to make
skin appear healthy and luminous.
The Kinohimitsu J’Pan ProWhite Regimen is available at leading pharmacies for
RM199.00.
31
Pharmacy Practice | Pharmacy Today | July 2013 Pharmacy Practice
The Common Cold
By Dr. Adyani Md Redzuan
Coordinator for Master of
Clinical Pharmacy Programme
Faculty of Pharmacy
Universiti Kebangsaan Malaysia
T
Introduction
he common cold is an acute, self-limiting viral infection affecting the mucus
membranes of the upper respiratory
tract. It is one of the most common acute ill-
Recognised by
Academy of Pharmacy
Every
mont
earn 1 h
CPD p
oint
nesses affecting the population of all ages,
prompting frequent use of over-the-counter
and prescription medications, and alternative
remedies.
Colds account for much of the absenteeism
32
Clinical Pharmacy | Pharmacy Today | July 2013 from school and the workplace (in about 50%
of cases, at least a day away from usual activities), and are one of the major reasons for visits
to the family physician.
The common cold is associated with an
enormous economic burden as assessed by
lost productivity and expenditures for treatment. Data extrapolated from a US telephone
survey conducted between 2000 and 2001 suggest that about 500 million non-influenza viral
respiratory infections occur yearly, resulting in
estimated direct costs of US$17 billion and indirect costs of US$22.5 billion annually.
Epidemiology
Colds occur at a rate of about one to three episodes per person per year according to surveys
from the US and UK, with infants averaging
about six to eight episodes per year. Women
appear to have more colds than men, possibly
because of their greater exposure to children,
and the elderly also have a higher incidence of
respiratory infections.
Colds can occur throughout the year, but in
temperate countries there is peak incidence in
autumn, especially September (possibly due to
the reopening of schools), midwinter and early
spring. In tropical areas, most colds arise during the rainy season.
Etiology
Up to 90% of all acute respiratory infections
are caused by viruses, and over 100 virus types
have been positively identified as causative
agents. Rhinoviruses and coronaviruses cause
about 40% and 10 to 20% of colds in adults,
respectively. Other viruses such as parainfluenza, respiratory syncytial, adenosackie, echosackie and coxsackie viruses have also been
implicated.
The transmission of these viruses can occur by
any of the three major mechanisms:
1.Hand contact with secretions that contain
the virus, either directly from an infected
person or indirectly from environmental
surfaces.
2.Small-particle aerosols lingering in the air
for an extended time.
3. Direct hit by large-particle aerosols from an
infected person.
Although all these mechanisms are likely to be
involved in the spread of any respiratory virus, the primary routes of transmission differ
between viruses.
For instance, influenza viruses are thought
to be spread mainly via small-particle aerosols, whereas hand contact followed by selfinoculation with the virus into the nose or eye
has been reported as the most efficient way of
transmission for rhinoviruses. However, aerosol transmission of rhinoviruses has also been
clearly documented.
Studies of married couples indicate that
saliva is poorly associated with transmission (e.g. via kissing). Dramatic temperature
changes, cold weather, wet feet, chilling of the
body as well as fatigue, poor nutritional status
or general state of health may contribute to the
severity of a cold, but exposure to the causative
virus must occur first.
Pathophysiology
Following exposure to the virus, the mucus
layer covering the nasal epithelium must be
penetrated before the viral particles bind to
specific cell receptor sites and penetrate the
host cell. Once inside the cell, viral nucleic acid
is released from the protective envelope. Replication, transcription and translation of the viral genome occurs with the production of new
viruses, which are released following the rup-
33
Clinical Pharmacy | Pharmacy Today | July 2013 ture of the host cell.
The local multiplication leading to the death
of host cells causes desquamation of the respiratory epithelium and the typical cold symptoms. As the virus disseminates, the body’s
defense mechanisms respond with an inflammatory reaction in the affected areas involving
the release of immunomodulators and inflammatory mediators, the release of kinins which
are potent autocoids, the generation of immunoglobulins, specifically IgA, and increased
tissue perfusion, permitting lymphocytes to
concentrate at the site of the infection.
Histamine release, however, is not a significant factor in upper respiratory infections. The
incubation period for rhinoviruses and coronaviruses is one to two and three days, respectively. Acute viral infections usually terminate
when the host develops a sufficient immune
response. Unfortunately, immunity to specific
cold viruses begins to fade about 18 months after exposure.
Symptoms
The most common symptoms of the common
cold are nasal discharge and congestion (80 to
100%), sneezing (50 to 70%), sore throat (50%)
and cough (40%). In most cases, symptoms
persist for about seven days, with peak effects occurring on day two and three, while
in about 25% of cases symptoms may last two
weeks. The extent and sequence of appearance of these symptoms generally follows a
pattern.
The initial symptom is usually a sore throat,
often described as dryness, scratchiness or
soreness rather than pain. This is usually followed by varying degrees of nasal congestion
and rhinorrhea. The initial nasal discharge is
clear, then becomes thicker and opaque as the
infection progresses due to the large number
of epithelial and white blood cells being shed,
and may become purulent if secondary bacterial infection occurs.
The congestion may lead to sinusitis, headache and nasal irritation resulting in sneezing.
Otic symptoms such as pain or a plugged sensation may also occur, predominantly in children. Postnasal drip can cause coughing or laryngitis, and conjunctivitis and watering eyes
are initially present.
The cough accompanying a cold usually
starts as dry and non-productive, but becomes
productive as the increased bronchial secretions and cellular debris from phagocytic activity accumulate. The cough is most frequently
caused by the common cold, and is the symptom of an underlying condition accounting for
a large percentage of visits to the physician.
In association with the cold, coughs last for
no longer than one to two weeks. Coughs can
also be induced by sinusitis, postnasal discharge that irritates receptors in the pharynx,
by stimulation of receptors in the sinus, or
even just the result of mouth breathing, which
allows poorly conditioned air to dry the upper
airways.
Dry, non-productive coughs that persist
for some weeks after the other symptoms of a
cold have disappeared may indicate any of the
following:
l An exaggerated response to virus-induced
respiratory damage or bronchitis
l Asthma in a child, especially if the cough is
worse at night
l Gastroesophageal reflux if associated with
heartburn and sour taste in the mouth
l Chronic obstructive lung disease
l Lung cancer
l Symptoms of left ventricular heart failure
Environmental irritants such as cigarette
34
Clinical Pharmacy | Pharmacy Today | July 2013 smoke or volatile chemicals can also cause
cough by irritating receptors in the larynx,
trachea and bronchi. Dry, non-productive
coughs can also be present as an adverse effect of certain medications such as angiotensin converting enzyme (ACE) inhibitors.
Fever of any significant degree is seldom
present, although chill sensations are quite
common in adults. Conversely, children are
more prone to develop fever (38 to 39°C) during a cold episode. These symptoms, although
discomforting, seldom cause serious complications or residual pathologic damage to the respiratory tract.
As symptoms peak in severity by day two
or three, nasal discharge worsens and may
become thicker and discolored. This mucopurulent discharge is common with a viral acute
respiratory tract infection and does not necessarily indicate the presence of bacteria.
Differential diagnosis
Since individual symptoms of the common
cold are similar to those of other conditions
such as pharyngitis, influenza, sinusitis, bronchitis and allergic rhinitis, it is important to
differentiate between them, assess for selftreatment or if deemed necessary, refer the
patient to a physician.
Treatment
When a patient presents with symptoms of
the common cold, the pharmacist should assess the symptoms to determine whether it is
indeed a cold and whether over-the-counter
therapy is appropriate. Medical history and a
complete list of current medication use is also
important because many OTCs used to treat
the common cold are not advised for patients
with certain medical conditions.
Treatment options for the common cold are
mostly OTCs and should be aimed at treating
the symptoms which are most bothersome.
Many patients are eligible for self-treatment,
but those with ischemic heart disease, hypertension, hyperthyroidism, increased intraocular pressure, prostatic hypertrophy and diabetes should obtain medical advice before taking
any OTC product.
If patients also complain of fever, shortness
of breath or a worsening of symptoms after
self-treatment, they should be referred to a
physician. There is no known cure for the common cold, therefore symptom relief is the primary goal of treatment.
Non-pharmacological treatment
There are several non-pharmacological measures to treat the common cold. Patients
should be advised to increase fluid intake,
especially if the cough is productive. Other
measures include plenty of rest, adequate nutrition, humidifiers, steam showers and nasal
irrigation if the stuffiness is intolerable.
Classic traditional remedies such as chicken
noodle soup and hot tea with honey have not
been proven to help with symptoms, but will
increase fluid intake and can be recommended. If the patient complains of an irritated nasal
mucosa, saline nasal sprays may help to soothe
the area and warm salt water gargles can help
to soothe a sore throat.
Many patients request information on herbal products to treat the symptoms of a cold.
Some of the most common herbal products
used for this purpose include echinacea, zinc
and vitamins C and E.
Echinacea angustifolia has been used to
treat the common cold since the late 1800s, but
with limited evidence of efficacy. Echinacea is
an immunostimulant that helps the body fight
an infection from common rhinoviruses. Ac-
35
Clinical Pharmacy | Pharmacy Today | July 2013 cording to recent studies, the effects of echinacea are still unproven, with no significant effect
on the infection or illness caused by rhinoviruses. Due to the many formulations, product
standards and variability in dosing, future
research is needed to determine true efficacy.
If patients want to try echinacea, there is no
consensus on the dose, and instructions on the
package should be followed. Common adverse
reactions linked to echinacea include skin rash,
gastrointestinal disturbances and sore throat.
Zinc, usually in lozenges form, has also been
used for the treatment of the common cold. It
works by blocking the adherence of the rhinovirus to the nasal epithelium. In vitro, zinc may
also inhibit the replication of viruses known to
cause the common cold.
Some studies have found zinc to be effec-
tive in symptom improvement, but other studies have also shown no benefit over placebo in
treating the common cold. For zinc to be most
beneficial, it should be started at the first sign
of symptoms, used in doses of at least 13.3-mg
elemental zinc, and continued for the duration
of the cold. The most common side effect of
zinc lozenges is metallic taste.
Vitamin C has been traditionally associated
with preventing the common cold, with 67% of
the population believing that taking vitamin C
will decrease symptoms. Doses of more than 1
g per day may decrease the duration of illness
by one day or less and decrease the severity of
symptoms by 20%. This is true only if vitamin
C supplementation is started at the onset of
symptoms. Patients should be reminded that
doses of 1 g or more daily can cause gastroin-
Disorder
Signs and symptoms
Allergic rhinitis
Watery eyes; itchy nose, eyes or throat; repetitive sneezing; nasal congestion; watery rhinorrhea;
red, irritated eyes with conjunctival injection (i.e. prominent conjunctival blood vessels)
Asthma
Cough, dyspnea, wheezing
Bacterial throat infection
Sore throat (moderate-to-severe pain), fever, exudate, tender anterior cervical adenopathy
Common cold
Sore throat (mild-to-moderate pain), nasal congestion, rhinorrhea and sneezing common; lowgrade fever, chills, headache, malaise, myalgia and cough possible
Croup
Fever, rhinitis and pharyngitis initially, progressing to cough (may be ‘barking’ cough), stridor and
dyspnea
Influenza
Myalgia, arthralgia, fever >37.8°C to 38.9°C, sore throat, non-productive cough, moderate-to-severe
fatigue
Otitis media
Ear popping, ear fullness, otalgia, otorrhea, hearing loss, dizziness
Pneumonia or bronchitis
Chest tightness, wheezing, dyspnea, productive cough, changes in sputum color, persistent fever
Sinusitis
Tenderness over the sinuses, facial pain aggravated by Valsalva’s maneuver or postural changes,
fever>38.6°C, tooth pain, halitosis, upper respiratory tract symptoms for >7 days with poor
response to decongestants
West Nile virus infection
Fever, headache, fatigue, rash, swollen lymph glands and eye pain initially, possibly progressing to
gastrointestinal distress, central nervous system changes, seizures or paralysis
Whooping cough
Initial catarrhal phase (rhinorrhea, sneezing, mild cough) of one to two weeks, followed by one to
six weeks of paroxysmal coughing
Source: OTC Advisor, Self-care for fever, cough cold and allergy, American Pharmacist Association 2010.
36
Clinical Pharmacy | Pharmacy Today | July 2013 testinal disturbances such as diarrhea.
Vitamin E has also been studied for its effects on the common cold. Nutritional status is
important for the body to fight infection, and
vitamin E has been suggested to improve immune response, especially in the elderly population. Studies have shown no benefit from 200
IU per day on the number of days of infection,
but they did show that fewer patients had the
cold when taking vitamin E for an extended
period of time. Based on this information, vitamin E can be recommended at that dose for
patients who do not get adequate nutrition.
Pharmacological treatment
Decongestant
The best option for the treatment of nasal
stuffiness is decongestants. Many products
containing oral decongestants are combination products, and combinations should only
be used when the patient has all of the symptoms that the drug will treat.
Pseudoephedrine and phenylephrine are
the most common OTC agents used to treat
cold symptoms. The onset of action is 30 to 60
minutes after the dose is taken orally. Decongestants work by causing blood vessel constriction by stimulating the alpha-adrenergic
receptors. This action will cause a decrease
in the amount of fluid in the nasal passage.
The usual adult dose for phenylephrine is 10
mg every four hours, and for pseudoephedrine, 60 mg every four to six hours. Child dosing is also recommended at half the dose for
children between six and 12 years old, and a
quarter of the dose for children between two
and six years.
Oral decongestants have long been linked
to increased blood pressure and heart rate.
The incidence of increased blood pressure
and heart rate are more common with oral
formulations than topical because of the higher doses needed to produce symptom relief.
Phenylpropanolamine was removed from
the market in 2000 due to concerns of an increased risk of hemorrhagic stroke. There is
also a risk of stroke with pseudoephedrine,
but that is more prevalent if the agent is taken
at higher-than-recommended doses.
Studies have shown that pseudoephedrine
can cause an increase of 1 mmHg in systolic
blood pressure, no significant effect on diastolic pressure, and an increase of three beats
per minute in heart rate. If a patient has controlled hypertension, oral decongestants can
be recommended with little concern.
For patients with uncontrolled hypertension, closer monitoring is prudent. As senior
citizens make up a large percentage of those
purchasing OTC medications, counseling
them on these products is crucial to decrease
potential adverse effects.
Topical decongestants are another option for nasal stuffiness. Phenylephrine, oxymetazoline, naphazoline and xylometazoline
are examples of drugs found in OTC topical
decongestants. These products may be advantageous because of a quick onset of action
and cost. Dosing of topical decongestants is
typically two or three sprays every four to six
hours, but newer formulations provide prolonged duration of effect for eight to 12 hours.
It is important that they not be used more frequently than every four to six hours and never more than three days due to rhinitis medicamentosa, which can worsen the symptoms.
Antihistamines
Clear nasal discharge or rhinorrhea is another symptom of the common cold and is best
treated with antihistamines. Sedating antihis-
37
Clinical Pharmacy | Pharmacy Today | July 2013 tamines have anticholinergic activity and will
have a drying effect in the nasal passageway
and may also decrease sneezing episodes.
This suggests that antihistamines act through
nonspecific sedating or anticholinergic mechanisms rather than through any histaminereleasing action of the virus.
It is important for the
pharmacist to understand how to
assess the patient’s symptoms, make
the appropriate recommendations,
and understand when it is time to
refer the patient to a physician
Nonsedating OTC antihistamines (eg, cetirizine) do not have anticholinergic properties
and may not be effective in treating rhinorrhea associated with the common cold. Examples of sedating antihistamines include chlorpheniramine and diphenhydramine. They
are typically dosed every six or eight hours,
depending on the product. Other side effects,
besides drowsiness, related to anticholinergic
properties are dry mouth, difficult urination
and constipation.
Antihistamine use is contraindicated in
patients with hypersensitivity to the specific
drug and in lactating mothers. They should
be used with caution in patients who have
glaucoma, prostatic hypertrophy, breathing
problems or chronic bronchitis. Due to the anticholinergic effects of some antihistamines,
the severity of dementia and the risk of falls
and fractures can increase in elderly users of
these medications.
Practitioners prescribing antihistamines
for geriatric patients should start with the
lowest minimum dose and increase gradually. In addition, they should be aware of
the paradoxical excitation that may occur
with antihistamine use in some children and
in the elderly. Antihistamine drug-drug interactions can occur with central nervous
system depressants, MAOIs, phenytoin, ketoconazole, erythromycin and cimetidine.
Adverse effects of antihistamines include
drowsiness, dry mouth, nervousness and
dizziness.
Other agents
Sore throats are commonly caused by viruses,
including those responsible for producing
the common cold. Usually in patients with
cold, sore throat is also scratchy and may be
caused by drainage from the sinuses. If the
sore throat is bothersome, patients may take
OTC pain relievers such as acetaminophen,
ibuprofen or naproxen.
Lozenges may also offer relief as many
contain local anesthetics to numb the area (eg,
benzocaine and dyclonine). Lozenges should
be used every three to four hours as needed.
Alternatively, gargling with warm salt water
may also ease symptoms.
Antitussive/expectorant
When a patient complains of a cough associated with the common cold, it is usually dry
and nonproductive. This can be treated when
it interferes with the patient’s lifestyle.
Antitussives are indicated for cough suppression associated with acute upper respiratory tract infection, but the data to support the
efficacy of codeine and dextromethorphan in
suppressing the cough of the common cold
are equivocal.
If required, dextromethorphan is the antitussive agent of choice. It is equipotent with
codeine on a mg-for-mg basis, and it has less
abuse potential. It also has limited drug interactions and adverse effects, and is avail-
38
Clinical Pharmacy | Pharmacy Today | July 2013 able in pediatric formulations. Cautious use
of dextromethorphan is recommended in
patients with a high fever, rash, or persistent
headache, nausea or vomiting. Drowsiness
and gastrointestinal disturbances occur rarely
with dextromethorphan use.
An expectorant can be used to help break
up mucus in patients with a productive cough
associated with a cold, yet a well-hydrated
body, achieved by drinking more than eight
8-ounce glasses of water daily will produce
the same benefit.
The efficacy of expectorants in clearing
secretions and providing a clinical benefit remains to be proven. Guaifenesin and bromhexine are examples of expectorants available
on the market.
Antiviral/antibiotics
Specific antiviral therapy is generally not
useful for the treatment of common cold illnesses. The neuraminidase inhibitors oseltamivir and zanamivir have a modest effect on
influenza virus infections, but the difficulty of
distinguishing influenza from other common
cold pathogens and the need to start treatment early in the illness for maximum benefit are practical limitations to the use of these
agents for mild upper respiratory infections.
Antibacterial therapy is of no benefit in the
treatment of the common cold.
Special population
There are very few well-designed, prospective studies published in the literature evaluating the efficacy and safety of the pharmacological agents used in the treatment of colds
in pregnancy, during lactation, or in children
or the elderly.
The first generation H1-antagonist have
been used in pregnancy, but when the medica-
tions were ingested close to term, withdrawal
symptoms have been observed in neonates
shortly after birth.
The second generation H1-antagonists are
classified for use in pregnancy where the benefits would outweigh the risks. In well-designed studies, loratadine and the active metabolite of terfenadine have been measured
in breast milk from mothers ingesting these
compounds during lactation. No terfenadine
was detected. The potential doses received
by nursing infants have been calculated to be
of the order of 0.5% of that ingested by the
mother, and are not considered to put the infants at risk.
There are a few pharmacokinetic and
pharmacodynamic studies in children of the
first-generation H1-antagonist, chlorpheniramine, diphenhydramine and hydroxyzine,
and of the second generation H1-blockers,
terfenadine, astemizole, loratadine and cetirizine. In most cases, the elimination of these
compounds is much more rapid than found
in young adults. However, apart from the
recommended, empirically-defined doses,
which are smaller than those recommended
for adults, no modification of the frequency of
dosing has been established.
OTC cold products should not be used
in children younger than two years of age
because there are no data to determine appropriate dosing or to support their safety
in this population. Parents, instead, must be
educated regarding the risk of serious adverse effects that may occur in children below the age of two years who are given nonprescription cold products. If a young child’s
cold symptoms warrant pharmacological
treatment, they should be prescribed only
those medications approved by the Drug
Control Authority for use in children below
39
Clinical Pharmacy | Pharmacy Today | July 2013 two years.
Some individuals should refrain from taking nonprescription cold medications without
consultation with a healthcare professional.
Exclusions from self-treatment include patients with fever (oral temperature >38.6°C),
chest pain or shortness of breath; patients
whose symptoms worsen; patients who develop additional symptoms; patients with concurrent underlying chronic cardiopulmonary
disease (eg, asthma), AIDS or chronic immunosuppressant therapy; and patients who are
frail or elderly. In addition, pharmacists should
carefully review the product labeling before
recommending nonprescription cold medications for young children, the elderly, pregnant
women and those with comorbid conditions.
Conclusion
The role of the pharmacist is very important when making recommendations for
treating common cold. It is important for
the pharmacist to understand how to assess the patient’s symptoms, make the appropriate recommendations, and understand when it is time to refer the patient to
a physician.
Pharmacists can also stress the importance
of non-pharmacological measures when
treating common cold, especially among the
pediatric population. Patients should be encouraged to seek medical attention from their
primary healthcare provider if symptoms
appear to worsen or linger, or if they experience high fever or signs of infection.
Most colds occur during the rainy season
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