management system Help older patents understand joint pain Feature Expanded role for pharmacists will beneft patents Forum Aslan raises US$22m to advance drug development Business Community program can improve heart health News News | Pharmacy Today | November - December 2013 2 Award for Changi hospitals medication management system By Rajesh Kumar C hangi General Hospitals closed loop medication management system in- corporating QR codes has won the prestigious digital healthcare award. The system aims to enhance patient safety, im- prove staf productivity and reduce human error in medication administration. Unlike the conventional barcode, the QR Code technology has greater information storage capacity and is capable of being read in 360 degrees, from any direction. This elimi- nates any interference and negative efects from backgrounds, said Dr. Goh Min Liong, acting chief medical informatics ofcer at the Eastern Health Alliance (EHA) that includes CGH and other health providers. Medication administration in hospitalized patients is a complex series of inter-related processes that involve ordering of medica- tions, reviewing the order, supplying and then administering of the medications. This requires close coordination and com- munication among all the healthcare provid- ers to provide drug therapy accurately. There are several points for human errors that could results in delayed, omited or incorrect medi- cation therapy. Ward nurses manually retrieve medica- tions from a limited range of ward stocks. Correct serving of medication depends on nurses manually checking that the right dose of the right drug is given to the right patient. The nurse can pick up the wrong medicine, pour the wrong amount or may give it to the wrong patient. Certain institutions have tried to address that by having double checks, i.e. having two people check every single dose of every single medication before its administration to pa- tient. But that is not cost efective, said Dr. Goh. Two people can easily make two difer- ent human mistakes. By replacing the second person with a machine, the error rate can be drastically cut. We think it is more of a fool proof system than others. The closed loop medication management system with QR code medication verifcation at point-of-care eliminates the risk of admin- istrating a medicine that does not match the doctors prescription. Once doctor generates the prescription electronically, the order goes to a central phar- macy. A robotic dispenser in pharmacy auto- matically picks up the medicines and packs them in a bag, with a barcode stuck on it. The patient also wears a barcode bracelet. The barcode on the medication bag has to match with the barcode on the prescription and the patient. When the nurse scans the patients barcode, The system ensures that the barcode on the medication pack matches with the one on the prescription and on the patients bracelet before a drug can be safely administered. News | Pharmacy Today | November - December 2013 3 it pulls up all the medications and their exact dosages that the patient is supposed to have at that particular time. If the medication, dos- age and its time doesnt match, the barcode reader will show up an error. The system improves healthcare stafs ef- fciency, giving them more time for quality patient care. Data from the system also pro- vides clinical analytics to improve patient outcomes. What is diferent about the CGH system is that we pack the medication in unit dosage. That really improves the accuracy. Some hos- pitals pack the entire supply of medications in a single sachet, said Ms. Phyllis Yap, chief information ofcer of the Integrated Health Information Systems (IHiS) that developed the system for CGH. This ensures that the right medication in right dosage goes to the right patient at the right time, said Yap. Although nursing homes are also part of the EHA, the closed loop medication manage- ment system will not be rolled out for them due to what Goh and Yap termed as unfavor- able economies of scale. We must have volumes to justify the huge investment that the (close loop system) war- rants, concluded Yap. The award was presented during the inau- gural Digital Healthcare Week recently held in Singapore. News | Pharmacy Today | November - December 2013 4 Feeling angry? Have a chat By Rajesh Kumar W hen you are angry, simply talking to someone about it may well pro- tect you from the negative impact of stress and anger. The very act of describing your feeling can have a signifcant impact on the bodys physiological response to the situation such as heart rate and cardiac output, US research suggested. [PLoS ONE 2013; doi:10.1371/jour- nal.pone.0064959] To test the hypothesis, the researchers asked 102 men and women to complete a difcult math task in the presence of evalua- tors trained to ofer negative feedback as they worked through the assignment. Negative feedback was designed to elicit anger in some participants and shame in oth- ers. At the end of the task, participants were given a questionnaire that appraised their feelings (eg. How angry are you right now?), or a set of neutral questions that did not as- sess their emotional state. In the anger condition, participants who completed the questionnaire about emotional state had diferent physiologi- cal responses, measured by heart rate changes, compared to those who answered neutral questions. Among these, reporting on ones emotional state was associated with a smaller increase in heart rate compared to others. Measurement efects exist throughout the sciences - the act of measuring ofen changes the properties of the observed. Our results suggest that emotion research is no excep- tion, wrote authors Drs. Karim Kassam from Carnegie Mellon University in Pitsburgh, Pennsylvania, UK and Wendy Mendes from the University Of California San Francisco, California, US. What impressed us was that a subtle ma- nipulation had a big impact on peoples phys- iological response. Essentially, were asking people how theyre feeling and fnding that doing so has a sizeable impact on their cardio- vascular response, said Kassam. Describing your feeling can have a signifcant impact on the body's physiological response
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Download the digital edition today at www.jpog.com Essential Clinical Practice Tool On-The-Go The FREE MIMS app delivers critical prescribing information, medical news and CME articles as well as clinical calculators essential to physicians daily practice needs. With MIMS available across multiple platforms and devices, you can now easily and conveniently fnd the most up-to-date and relevant drug information you need anytime, anywhere. MIMS mobile/tablet app facebook.com/mimscom www.mims.com Join over a million MIMS members who have incorporated MIMS into their daily workow. Connect with MIMS today. Forum | Pharmacy Today | November - December 2013 6 T he expanded role of pharmacists to help manage the health of patients can beneft both patients and physicians. Pharmacists in Canada have recently been given broader responsibilities including, in some provinces, prescribing privileges, abil- ity to order and interpret laboratory tests, and ability to vaccinate and inject medications. The Canadian example has the potential to be replicated in other countries, including in Singapore. In the United Kingdom, United States, New Zealand, Australia, and gradu- ally in Singapore, pharmacists are being in- volved in collaborative care arrangements. There is strong evidence that pharmacists care can beneft patients, especially in provid- ing vaccines and managing high blood pres- sure, diabetes, heart failure, asthma and other conditions. As pharmacists more actively participate in medication management, physicians should be aware that in inter-professional models of Expanded role for pharmacists will benefit patients Based on a paper jointly writen by a physician and a pharmacist in Canada, summarizing the opportunities for collaborative care. Forum | Pharmacy Today | November - December 2013 7 care, every member of the team is accountable for the care he or she provides and is not to be held directly liable for the acts of others. Pharmacists, who have specialized ex- pertise in drug dosing, drug interactions, pharmacology and related areas, can help physicians manage safe prescribing in com- plex (ofen elderly) patients taking 5 or more drugs. They can also help in tapering patients of medications. Evidence from randomized trials showed that pharmacist involvement in patient care can provide beneft, and resulted in favor- able disease-specifc outcomes for the man- agement of hypertension, dyslipidemia, heart failure, anticoagulation therapy, asthma and diabetes. Sound evidence A systematic review of 19 randomized trials of pharmacist care for hypertension showed a reduction in systolic blood pressure of 8.1/3.8 mm Hg compared with usual care. Pharma- cist care for dyslipidemia reduced low densi- ty lipoprotein cholesterol by 0.28 mmol/L and helped achieve target lipid values. Another systematic review of pharmacist care in patients with heart failure showed a reduction in hospital admission for heart failure of 31 percent, compared with usual physician and nurse care. Collaborative care by non-specialist pharmacists working with GPs to manage the treatment of patients with heart failure also improved prescribing of dis- ease-modifying medications, but showed no diference in death or hospital admission for worsening heart failure. Improved control of international normal- ized ratios (INR) and patient satisfaction have been consistently reported in pharmacist-led anticoagulation clinics. Asthma and diabetes care by pharmacists can result in improve- ments in pulmonary function tests and gly- cated hemoglobin. Opportunities to improve care Once established, collaborative care with pharmacists will likely yield tremendous benefts to both patients and physicians. The expanding scope of pharmacists practice of- fers many opportunities to improve patient care. However, it is also an ongoing process that must be evaluated as regulated activities change, new pharmacists enter practice and scopes of activities continue to expand In the interests of patient care and the joint responsibilities arising from an expanded scope of pharmacists practice, physicians should refect on the best way to improve adequate and timely communication with pharmacists in their practice. Physicians may wish to communicate with pharmacists by telephone, because pharmacists can be easily reached during working hours. Reciprocal communication arrangements could be made that allow physicians to be notifed by pharmacists in a timely fashion about prescription renewals, modifcations or initiation of new therapy for their patients. The use of computer-based prescribing and electronic health records could facilitate this task; if these are unavailable, faxes or emails could be sent directly to the physician. Communication is a means of not only relay- ing messages about prescription changes, but also clarifying who will be responsible for or- dering tests and acting on the results. Inter-professional education is the key The key to establishing an efective collab- oration between physicians and pharmacists could be the provision of inter-professional Forum | Pharmacy Today | November - December 2013 8 education. Many universities are already making special eforts to bring together un- dergraduate and graduate students in the felds of pharmacy and medicine for training in interdisciplinary care. At the Universit de Montral and Uni- versity of Alberta, in Canada, students from the nursing, medical and pharmacy faculties are already being jointly exposed to complex patient cases to prepare for interdisciplinary functioning in the real-world seting. Region- al continuing medical education courses on the expanded scope of pharmacists practice could provide working knowledge to physi- cians on how to optimize collaborative care. Paper authored by Dr. Cara Tannenbaum, Faculties of Medicine and Pharmacy at the Universit de Montral and Dr. Ross Tsuyuki, Faculty of Medicine and Dentistry, both at the University of Alberta in Alberta, Canada. [CMAJ 2013; doi:10.1503/cmaj.121990] Smart Rx. Every Time. www.MIMS.com News | Pharmacy Today | November - December 2013 9 Community program can improve heart health By Radha Chitale A n afordable community program improved key vitals including cho- lesterol, body fat and stamina among over 200 participants at risk for cardiovascu- lar events, according to data from researchers at the National University of Singapore (NUS) department of pharmacy and the Singapore Heart Foundation. The Heart Wellness Programme at the Singapore Heart Foundations Heart Well- ness Centre in Bishan was designed to assist patients who were recovering from heart at- tack or stroke or who were at high risk for having these to making the lifestyle changes necessary to improve health and delay dis- ease progression. The researchers, led by Assistant Professor Joanne Yeh Chang, Mr. Ong Kheng Yong and Mr. Kwan Yu Heng of the NUS Department of Pharmacy, surveyed 207 patients who par- ticipated in the program for 12 months be- tween 2010 to 2011. Of these, 137 were cardiovascular rehabil- itation patients. The rest were primary pre- vention patients who had, for example, hy- pertension, diabetes, or other cardiovascular risk factors. The program, to which participants were referred by their physicians afer being deemed stable for community-based exer- cise, ofered individualized exercise plans, advice on diet and smoking cessation, and psychosocial counseling for $3 per session as well as fexible scheduling. The most signifcant improvement was for low-density lipoproteins (LDL), which improved about 12 percent from baseline. Participants also improved their total choles- terol and their 6-minute walking test. These measures improved more cardiac rehabilitation patients than among the pri- mary prevention patients, although Chang noted this was probably because these pa- tients were relatively healthy at baseline. Notably, while primary prevention patients showed no change in their high-density li- poprotein levels, the cardiac rehabilitation group improved about 8 percent from base- line. Though smaller, the health gains among primary prevention patients would prob- ably translate into signifcant cardiovascular improvement in the long term, Chang said, efectively preventing future cardiovascular events. Patients in both groups failed to im- The program aims to assist patients rehabilitating from heart atack or stroke or at high risk for both events. News | Pharmacy Today | November - December 2013 10 prove certain measures including visceral fat density and abdominal circumference, though this may have been a function of their advancing age and the short duration of the trial period. Ong said they might see greater improvement as they gather more data. This positive pilot study to confrm the ef- fectiveness of the Heart Wellness Programme should be followed up with future studies to assess patients long-term heart health and quality of life and the impact on healthcare costs. Importantly, Chang said further anal- yses should include paterns and efects of medication use among patients at cardiovas- cular risk, which was not included in the cur- rent data. Cardiovascular disease is one of the top causes of death in Singapore, Ong said. Future expansion to the program has po- tential in improving the cardiovascular well- ness and longevity of Singaporeans. By Elvira Manzano T here is no beneft to using ibuprofen over paracetamol in most patients with upper respiratory tract infections (UR- TIs). Steam inhalation therapy also does not ofer any advantage, research has shown. Clinicians should probably not advise patients to use steam inhalation in daily practice as it does not provide symptomatic beneft for acute respiratory infections. Simi- larly, routinely advising ibuprofen, rather than as required, is not likely to be efec- tive, said lead study author Professor Paul Litle from the University of Southampton in Southampton, UK. For most patients, clini- cians should not ofer ibuprofen rather than paracetamol as there is litle beneft. The study of 889 patients across 25 GP practices in the UK showed that treatment with ibuprofen or steam inhalation rath- er than paracetamol did not help improve URTI symptoms (cold, sore throat, cough, si- nusitis and otitis media). Four of 207 patients receiving steam inhalation experienced mild Ibuprofen may be no better than paracetamol for URTI symptoms Ibuprofen, however, may be considered in patients with chest infections and in children <16 years of age. News | Pharmacy Today | November - December 2013 11 scalding. [BMJ 2013;347:f6041] There was also no diference in symptom control between patients taking ibuprofen/ paracetamol combination and those receiv- ing only paracetamol. Patients treated with ibuprofen were also more likely to return to their GPs within a month of starting thera- py for new or worsening symptoms. There were 17 complications overall two in the paracetamol group, 11 in the ibuprofen group and four in the ibuprofen/paracetamol combination group, although most were not serious and mainly self-limiting. Litle said it is possible that ibuprofen is interfering with an important part of the im- mune response, resulting in the progression of symptoms in some individuals. We must be a bit cautious as the fndings are surpris- ing. For the moment, I would personally not advise most patients to use ibuprofen for control of cough and colds and sore throat, he said. However, ibuprofen may be con- sidered in patients with chest infections and in children <16 years of age for short-term control of symptoms. Paracetamol is a mild analgesic and anti- pyretic commonly used for headache, other minor aches and pain. It is also a major in- gredient in many cold and fu remedies. The medicine is generally safe when taken at therapeutic doses (up to 4,000 mg per day for adults), but small overdoses can cause liver damage. Ibuprofen is a non-steroidal infamma- tory drug (NSAID) indicated for arthritis, fever, dysmenorrhea and pain. It has both analgesic and antiplatelet efects. While its painkilling efect begins as soon as a dose is taken, its anti-infammatory efect takes longer to begin (up to 3 weeks to get the desired results). Ibuprofen is contraindi- cated in people with ulcer due to increased bleeding risk, those taking steroids or other NSAIDs. By Rajesh Kumar S ingapores Health Sciences Authority (HSA) is alerting the public to an unreg- istered medicinal product called Oxy- ELITE Pro which has been linked to numer- ous cases of serious liver injuries in the US and one case in Hong Kong. Although not approved for sale in Singa- pore, OxyELITE Pro is being sold illegally through the internet and some members of the public may have purchased the product from overseas, an HSA spokesperson said. Labeled to contain herbal extracts, the product is marketed as a dietary supplement and fat burner to achieve rapid weight loss. Preliminary laboratory tests conducted by HSA on the capsules bought online found the product to contain 1,3-dimethylamyla- mine (DMAA) and yohimbine which are po- HSA warns of serious liver injuries with OxyELITE Pro News | Pharmacy Today | November - December 2013 12 tent western medicinal ingredients that are not allowed to be present in supplements sold locally. Health products containing such ingredi- ents require registration as medicinal prod- ucts and can cause serious adverse efects when consumed without medical supervi- sion. Investigations are ongoing to detect other potentially undeclared ingredients which may have caused the liver injuries. The US Food and Drug Administration (FDA) recently reported 29 cases of acute non-viral hepatitis in the state of Hawaii. Al- though the actual cause of the liver injuries has not been identifed, investigations have found that 24 of these cases were associated with the use of this medicinal product. Eleven of the 29 cases have been hospi- talized with acute liver injury: two of these cases have resulted in liver transplants and one person has died as a result of the com- plication of serious liver injuries. The most commonly reported symptoms of liver inju- ries experienced by the patients include loss of appetite, jaundice, dark urine and light- colored stools. The US Centers for Disease Control and Prevention (CDC) is currently investigat- ing other cases of liver injury in other US states that may be related to these events in Hawaii. The US FDA is also investigating the contents of the product OxyELITE Pro and its manufacturing premises, as well as whether counterfeit products or any other ingredients could be related to these cases of acute liver injuries. To date, HSA has not received any adverse reaction reports associated with the use of the product, although it could be possible that consumers who have sufered side ef- fects may not have told their doctors or phar- macists about the use of this product. HSA is warning that anyone selling Oxy- ELITE Pro will face a fne of up to $10,000 and/or imprisonment for up to 2 years under the Poisons Act. Over 20 cases of acute non-viral hepatitis in the US and one in Hong Kong have been linked to OxyELITE Pro. An authoritative tool featuring a comprehensive list of health topics in easy-to-read format and patient-friendly tone, to aid patient counselling sessions at retail pharmacies. 6 Shenton Way, #15-08 OUE Downtown 2, Singapore 068809 Tel: (65) 6290 7400 Fax: (65) 6290 7401 The newest drug information support from MIMS Counselling Guide For Pharmacists Singapore Edition of MIMS Pharmacy 2014 Interested in getting your personal copy of MIMS Pharmacy? Contact us at enquiry.sg@mims.com today. PRINT ONLINE MOBILE INTEGRATED Access to Updated and hew Health Topics for continuous Pharmac] Education Useful reference for Pharmac] practice latest Drug lnformation with Product Packshot 2 n d E d i t i o n 2 0 1 3 / 2 0 1 4 SI NGAPORE w w w . m i m s . c o m S I N G A P O R E 2 0 1 3 / 2 0 1 4 ISSN 2335-6731 Schwabe Flash Ad_Tebonin.ai 1 7/18/2013 2:35:53 PM MPG2013-SG_010813.pdf 1 8/1/13 12:19 PM MPG-SG170x244_1013hr.pdf 1 10/9/13 2:31 PM Feature | Pharmacy Today | November - December 2013 14 Aged Care P harmacists play a vital role in manag- ing elderly osteoarthritis suferers pain by helping them to understand their treatment options and the condition itself. Of the 140 types of arthritis, osteoarthritis a weakness in the joints is the most com- mon. Almost half of people over the age of 60 sufer from osteoarthritis and the majority of people over the age of 80 have it. People should see a health professional if they are experiencing the following symp- toms for more than two weeks to check for osteoarthritis: stif joints afer geting out of bed or siting for a long time, pain in or near the joints, swelling in or near the joint, mus- cle weakness or creaking sensation with bone movement, according to the Arthritis New Zealand website (www.arthritis.org.nz). Arthritis New Zealand educator Mr. Lulia- no Tinielu says, pharmacists play a vital role in explaining to patients why they need to take their osteoarthritis medication and the correct way to take it. GPs only have 15 minutes with their pa- tients and thats it. Thats where the pharma- cist comes in; by helping them understand the logic behind taking their medications properly. Osteoarthritis suferers most ofen experi- ence joint pain in the knees, hips, spine and hands. The main treatment for this condition is pain relief, such as paracetemol. As the condition is classifed as a non-infammatory form of arthritis, nonsteroidal anti-infamma- tory drugs are generally going to be inefec- tive. In cases of extreme pain, health profes- sionals may recommend a medication which Help older patients understand joint pain Osteoarthritis is common and progresses with age, so pharmacies are well placed to assist people who need pain relief, reports Pharmacy Today New Zealand GPs only have 15 minutes with their patients, and that's where pharmacists come in. Feature | Pharmacy Today | November - December 2013 15 Aged Care combines paracetamol and codeine. Howev- er, as the condition progresses, some people do experience infammation in the joints. In these instances, the pharmacist can recom- mend ibuprofen or a cream or gel to rub into the skin to reduce the pain and swelling. Feedback Arthritis New Zealand receives from osteoarthritis suferers is that, when pharmacists explain the importance of tak- ing their medication, and provide cues, such as taking medication at meal times, this helps them to stick to a medication regimen, Tinielu says. If patients understand the logic then they are more likely to take their medications properly, Mr. Tinielu says. He believes pharmacists are underutilised in arthritis management and says having pharmacists based at family doctors practic- es who could spend time discussing the con- dition with the patient, would be benefcial. Supplements not widely efective Alternatives to medication, such as natu- ral health products, including glucosamine, chondroitin and fsh oil, are sometimes rec- ommended for treating arthritis, but there is no frm evidence to support their use, Tinielu says. The supplements are thought to reduce stifness and pain in the joints. A 2009 Co- chrane summary on the use of glucosamine for improving pain in osteoarthritis sufer- ers showed afer 6 months pain improved at about the same level in people taking fake pills as it did in the people taking glucos- amine supplements. However, one brand of supplements, Rot- ta, did appear to show slightly greater pain relief in the people taking them, compared with those not taking them. A BPAC resource, Symptomatic Management of Osteoarthri- tis, states a capsaicin cream, which contains a chilli pepper extract, could help to relieve joint pain. BPAC advises people to assess the efec- tiveness of capsaicin cream or glucosamine and discontinue use if it is not efective afer three months. It also states there is no clini- cal evidence for the efectiveness of multi- vitamin and mineral supplements, copper bracelets and acupuncture on treating osteo- arthritis symptoms. On the other hand, some suferers report these supplements are efec- tive, but pharmacists should be aware this is an expensive treatment for people to main- tain. Exercise, diet help to improve joint pain While age is a major trigger for osteo- arthritis, excessive weight can also trigger this condition because it puts strain on the joints. Pharmacists should encourage people with osteoarthritis to exercise regularly and maintain a healthy diet to help control their weight. Exercises which involve stretching, strengthening and aerobics are essential to maintain and restore joint movement, reduce pain and stifness, improve muscle strength, manage weight and increase energy and wellbeing. Feature | Pharmacy Today | November - December 2013 16 Aged Care Elderly at risk of food-drug interactions T he more drugs people are on, the more chances there are of interactions with food, which may inhibit their vitamin and mineral uptake, a professor of pharma- ceutical nutrition says. As the elderly tend to be on more medica- tions, they tend to fall into the high-risk catego- ry for drug and nutrition interactions, said Pro- fessor Gil Hardy of the University of Auckland School of Pharmacy, Auckland, New Zealand. Around 50 percent of the elderly population are on omeprazole and other protein-pump in- hibitors, which can impair their absorption of vitamins C, B12 and iron, Professor Hardy says. Patients on these drugs can beneft from supplements, including a B12 intramuscular injection. Proactive community pharmacists ought to at least point out the possibility of interactions to patients when they pick up their prescrip- tions, although, as this is such a new area of research, neither they nor GPs tend to be too well versed in the subject, Hardy says. Professor Hardy thinks pharmacists are probably already suggesting supplements to counteract interactions of some drugs with food. According to the New Zealand Nutrition Foundation about 5 percent of older people at home, 25 percent in acute and rehabilita- tion hospitals and over 50 percent in nursing homes are undernourished. One of the ways to combat this is by ofer- ing extra-fortifed drinks during the day, such as Complan, Sustagen and Ensure, the founda- tion says in a 14 June bulletin. Old-age psychiatrist Dr Chris Perkins says reasons elderly people may not be eating well include living on their own, sufering from dementia and forgeting to eat or how to cook, not being able to get to the shops, not having good teeth and being served uninspiring food in some residential care. Community pharmacists can help remind their customers living in their own homes to eat regularly by initiating a conversation about food, Perkins says. Evidence on the value of supplements for elderly residential care patients is inconclu- sive but, if supplements are used, it is impor- tant, for adherence and absorption, to give them at meal times. Research into the impact of vitamins C, E, B6, B12 and folate on reducing dementia has produced some positive results, but the evi- dence is inconsistent. The more drugs people are on, the more chances there are of interactions with food, which may inhibit their vitamin and mineral uptake
Feature | Pharmacy Today | November - December 2013 17 Aged Care
U se it or lose it. That moto can be ascribed to many things not least the health of the aging human body and mind. Keeping ft and active is recognised as the best way to stay well as people age and the idea has been incorporated into government health policy. The Singapore Ministry of Health has pub- lished detailed guide lines recommending at least 30 minutes of aerobic physical activity fve days a week as well as fexibility, balance and resistance activities. Exercise can include any thing from walk- ing to the shops and doing the vacuum ing to bowls, tai chi and ball room dancing. Its never too late to start becoming phys- ically active, Age Concern New Zealand chief executive Ms. Ann Martin says. Whatever your age, regu lar activity will improve your health, make you feel beter and make it easier to do every day tasks. Staying active can help older people by: increasing their strength to lif and carry gro- ceries, improving fexibil ity to tie shoe laces, wash hair or hang up washing, aiding bal- ance to climb stairs or get on and of a bus or simply giv ing them the energy to play with grandchildren. Other health benefts include: reducing the risk of developing high blood pres sure, car- diovascular disease, cancer, osteoporosis and dia betes; easing the pain of arthri tis and oth- er physical disabili ties, and improving sleep. Exercise also benefts mental health Exercise can also improve mood and self esteem, while lowering stress levels and reducing the risk of depression, Mar- tin says. There are immediate and long- term ben- efts physically, mentally and socially. There is also the beneft of helping to maintain in- dependence in eve ryday living and broaden- ing social networks, leading to new friends and a sense of purpose. Even people who are cur rently the least active are like ly to receive a boost from an in- crease in activity. It is wise to start gently and build up gradually. Finding something enjoyable at a level that is comfortable is a good place to start, Martin says. People with chronic health conditions or injuries should discuss physical activity options with their doctor frst, and anyone who feels unwell or has pain during exercise should stop immediately and seek medical Active aging brings health benefits Staying active while aging makes everyday tasks easier and improves health overall. It is wise to start gently and build up gradually
Feature | Pharmacy Today | November - December 2013 18 Aged Care
advice, she advises. Some doctors or practice nurses may pre- scribe a Green Prescription, which includes advice on staying active. Martin says Age Concern welcomes any ini tiatives to encourage people to engage in healthy physical activity as they age. Its never too late to make a diference geriatrician Dr. John Scot is a geriatrician with Wait- emata DHB, divid ing his time between North Shore and Waitakere hospitals and outpatient clinics in New Zealand. Scot works with older people who are frail and strug gling with the demands of daily life, either because of their age or due to illnesses, such as stroke or emphysema.Some exercise programmes are tailored for the therapeu tic needs of individual patients and then there are programmes to encourage people to be more active generally. The health benefts of exercise are enor- mous, Scot says. Its not just about being stronger and being able to walk further with- out fall ing over. There are also bene fts for mental health, mood, digestion, cardiac func- tion and lung function. A huge part is geting people to maximize their function. There is no upper age limit. I see people well into their nineties and even the odd cen- tenarian. There is no point at which you stop being able to derive a beneft. Scot believes societys view on what it means to be old is changing. Someone in their seventies doesnt really seem that old these days. Scot also encourages younger people to become more active to insure their health in older age. The trick is making it a habit and fnding something you enjoy, he says. Feature | Pharmacy Today | November - December 2013 19 Aged Care By Rajesh Kumar M en and women with hypertension were 1.3 times to 2.4 times less likely to take their prescription medications afer retirement, according to a study. Men, but not women, with diabetes had the same rate of medication non-adherence. Poor adherence to prescription medication is common and can afect the ability to man- age hypertension and diabetes, two illnesses linked with heart disease and death. Although substantial research has been conducted on factors that infuence medication adherence such as patient demographics, physician and pharmacist characteristics and other factors, litle is known about the efects of life changes on medication adherence. Researchers from Finland, the United King- dom and Sweden looked at the efect of retire- ment on medication adherence in a cohort of 21,052 retired government employees in Fin- land. They linked data on flled prescriptions from national registers to each patient, follow- ing them 3 years before retirement to 4 years afer retirement. Of the 21,052 retirees, 3,468 people had hypertension and 412 had type 2 diabetes in the period before retirement. Me- dian age at retirement was 61 years, and 75 percent women of the total 3,880 people were women. For men and women with hypertension and men with type 2 diabetes, retirement was linked to 1.3- to 2.4-fold increases in poor medication adherence, said Professor Mika Kivimki of the Department of Epi- Retired people less likely to take medications for hypertension, diabetes Loss of routine or believing poor health will improve can lend retirees to stop medications. demiology and Public Health at University College London (UCL), London, UK. We saw no signifcant diference in this adherence patern between age groups, socio- economic strata or patients with and without depression or co-morbid cardiovascular dis- ease. These paterns suggest that our fnd- ings were robust and not limited to a specifc group. The researchers suggested several reasons for the drop in taking medications. The per- ception that poor health will get beter with re- tirement, loss of a familiar daily routine or the transition from workplace to non-workplace health care in Finland could all be factors. These fndings suggest that retirement may increase medication non-adherence, a timely issue given that the proportion of peo- ple aged 65 years or older is growing rapidly. Further research is needed to determine the generalizability of our fndings across mul- tiple setings and in other populations, the authors concluded. Business | Pharmacy Today | November - December 2013 20 Aslan raises US$22m to advance drug development By Rajesh Kumar S ingapore frm Aslan Pharmaceuticals has raised US$22 million in the second round of funding to advance its drug development activities. Aslan licenses preclinical and early clini- cal compounds from global pharmaceutical companies, focusing on oncology and in- fammation diseases, and uses development resources available across Asia to progress the drugs through clinical development. The company currently has three drugs in the pipeline, including the lead compound ASLAN001 a small-molecule pan-HER (hu- man epidermal growth factor receptor) in- hibitor licensed from Array BioPharma, US, which is being developed for gastric cancer. The drug candidate showed positive data in a phase II study completed earlier this year. ASLAN002 is a cMET inhibitor, licensed from Bristol Myers Squibb, which is in phase I trials for solid tumours. It is likely to enter phase II clinical trials in 2014. ASLAN003, licensed from Almirall, is a novel potent and selective inhibitor of the DHODH enzyme that could potentially be a safer and more efective therapy than cur- rent treatments for rheumatoid arthritis. It is scheduled to enter a multiple ascending dose phase I study in Singapore to assess its safety profle, tolerability and pharmacokinetics. The new money will not only fund the ongoing clinical development of the above drugs, but will also support the licensing of additional compounds in 2013 and 2014, said a company spokesperson. The fnancing was led by Cenova Ventures and included new investors, Morningside Group of Hong Kong and XinChen Ventures from Taiwan, in addition to existing inves- tors BioVeda Capital of Singapore and Saga- more Bioventures of the US. We are proud to have assembled such a strong group of investors from China, Tai- wan and the US that can support the devel- opment of our portfolio through efcient and high quality clinical centers in the region, said company chief executive Dr. Carl Firth. This round will allow us to complete at least fve further studies and deliver robust proof of concept data on several of our programs. The company was established in April 2010 by a group of industry experts Dr. Firth, Dr. Alan Barge, Dr. Mark McHale and Mr. Jef Tomlinson. The following year, it raised US$12m in a funding round led by Bioveda and Sagamore, along with a number of pri- vate investors. Its frst drug is likely to reach the market in 2017. Oncology and infammation diseases are the focus of the company's current activities. Business | Pharmacy Today | November - December 2013 21 Servier, SIgN team up to develop targeted therapies By Rajesh Kumar F rances largest pharmaceutical com- pany Servier has entered into a re- search collaboration with A*STARs Singapore Immunology Network (SIgN) to discover and develop targeted immunother- apeutic drugs to tackle cancer and autoim- mune disorders. SIgNs strong expertise in translational human immunology and Serviers in-depth knowledge in drug discovery and develop- ment will push the frontiers of immunother- apy for complex and difcult-to-treat dis- eases, said SIgN acting executive director Associate Professor Laurent Rnia. The two parties earlier collaborated under similar public-private partnership in 2011 to develop anti-cancer drugs that can suppress tumor-initiating cells (TICs), also known as cancer stem cells. Several human monoclonal antibodies directed at restricting the growth of TICs have since been generated for further development into therapeutic antibodies. The success of that frst collaborative proj- ect prompted Servier to expand its partner- ship with SIgN with three more research col- laboration agreements. Neither Servier nor SIgN have disclosed the fnancial details of ei- ther the previous or the three new agreements citing commercial sensitivities. By expanding this partnership, the compa- ny is expressing its goal to collaborate closely with leading scientists worldwide, to discov- er and develop innovative medicines, particu- larly in the feld of cancer, said Servier Chief Executive Dr. Jean-Philippe Seta. We believe that high quality of the re- search done at the SIgN is a unique opportu- nity to achieve this goal, said Seta. Incidentally, Servier recently entered into a similar agreement with Shanghai Institute of Materia Medica in Shanghai, China, to col- laborate on the development of lucitanib, a targeted antitumor drug candidate with anti- angiogenic efects. Neither Servier nor SIgN have disclosed the fnancial details of the agreements citing commercial sensitivities
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a n ytim e, a n yw h ere JPOG(P-O-D)206x276_0113.indd 1 1/17/13 11:53 AM Clinical Pharmacy | Pharmacy Today | November - December 2013 23 Introduction In the South East Asian region in 2011, there were 71.4 million people with diabetes, representing 9.4 percent of the population. Projections estimate that by 2030, this will rise to 120.9 million an increase of 69 per- cent. [International Diabetes Federation. IDF Diabetes Atlas. Fifh edition, 2012] The defning feature of type 2 diabetes is insulin resistance, where muscle and liver cells become progressively less responsive to the hormones efect. Initially the pancreas responds by producing more insulin, but eventually beta-cells become exhausted and insulin production ceases. Normally insulin stimulates the uptake of glucose into cells, but in diabetes plasma glucose levels rise. The consequence of elevated glucose levels long term is damage to blood vessels. This leads to complications, both microvascular (eg, retinopathy, neuropathy) and macrovas- cular (eg, myocardial infarction). Complica- tions due to diabetes are a major cause of dis- ability, reduced quality of life, and death. Lifestyle modifcation a healthy diet and regular exercise is the foundation of diabe- tes management. As the disease progresses, oral medication and eventually insulin injec- tions become necessary to maintain plasma glucose levels in a normal range. Several classes of oral antidiabetic medications are available. Metformin is the preferred frst- line therapy, as it has a long-standing evi- dence base for efcacy and safety, is inexpen- Saxagliptin/metformin: Novel once-daily oral antidiabetic drug combination for type 2 diabetes Drug Profile Type 2 diabetes is a major cause of morbidity and mortality worldwide. It usually occurs in adults but is increasingly seen in younger people. Lifestyle modifcation is the foundation of diabetes management, but as the disease progresses patients eventually require treatment with oral medications and eventually insulin injections. Several classes of oral antidiabetic medications are now available, diferent combinations of which may be tried if frst-line metformin monotherapy fails to control blood glucose. This report describes the burden of diabetes and profles a novel once-daily oral antidiabetic drug combination saxagliptin/ metformin. Clinical Pharmacy | Pharmacy Today | November - December 2013 24 sive and may reduce risk of cardiovascular events. [Diabetes Care 2013;36(Suppl 1):S11- S66] When metformin fails to maintain con- trol of plasma glucose levels, another agent is added. Options include oral therapies sulfonylureas, thiazolidinediones, DPP-4 inhibitors and injected GLP-1 receptor ago- nists and insulin (available in a variety of for- mulations). If a combination of two glucose- lowering drugs is inefective, a third may be added or the oral medications replaced by a regimen of multiple daily doses of insulin. [Diabetes Care 2012;35:1364-1379] Saxagliptin/metformin Pharmacology Saxagliptin is a competitive dipeptidyl peptidase-4 (DPP-4) inhibitor, a recently in- troduced class of oral drugs for type 2 dia- betes. It prevents the deactivation by DDP-4 of glucagon-like peptide-1 (GLP-1) and glu- cose-dependent insulinotropic polypeptide. These incretin hormones are secreted from the gut in response to food intake and de- crease postprandial glucose levels by stimu- lating insulin secretion, inhibiting glucagon secretion and delaying gastric emptying. [J Pharmacol Pharmacother 2011;2:230-235] Metformin is an insulin sensitizer. It is thought to act by activating AMP-kinase to decrease hepatic glucose production. [Diabe- tes Care 2012;35:1364-1379] Pharmacokinetics Upon oral ingestion saxagliptin is rapidly absorbed, with a bioavailability of around 67 percent. It is principally hydrolyzed by cyto- chrome (CYP) 3A4/5. The major metabolite (5-hydroxy saxagliptin) is also active, with half the potency of saxagliptin. Peak plasma concentrations of saxagliptin are reached within 2 hours, and within 4 hours for the major metabolite. Elimination is via both re- nal and hepatic pathways, with 75 percent excreted in the urine and 22 percent in the fe- ces. None of the pharmacokinetic parameters are afected by gender, body weight, age, or race; however a dose reduction is required in moderate to severe renal impairment. [Kom- biglyze-XR Prescribing Information] When metformin is taken in extended- release formulation peak plasma concen- trations are achieved in 4-8 hours (median 7). Absorption increases when taken with food (ie, AUC); however there is no efect upon peak plasma concentration or its tim- ing. Metformin is excreted unchanged in the urine. [Kombiglyze-XR Prescribing Informa- tion] Clinical efcacy In clinical trials of up to 24 weeks duration, saxagliptin monotherapy lowered HbA1c by 0.4 to 0.9 percent. When used together with metformin, HbA1c is reduced by up to 2.53 percent. The saxagliptin/metformin combi- nation has been shown to be efective in both treatment-nave patients as well as in those inadequately controlled by metformin alone. [J Pharmacol Pharmacother 2011;2:230-235] A long-term study over 52 weeks showed that saxagliptin/metformin was non-inferior to a glipizide/metformin combination while less likely to cause weight gain or hypoglycemia. [Int J Clin Pract 2010;64:1619-1631] Adverse efects While the long-term safety profle of sax- agliptin remains to be determined, typical adverse events include infections (respira- tory and urinary tract) and headache. Ad- verse events atributable to metformin are Clinical Pharmacy | Pharmacy Today | November - December 2013 25 predominantly gastrointestinal, including diarrhea, nausea and vomiting. [Kombig- lyze-XR Prescribing Information] Important- ly, there is no change in body weight with the combination of saxagliptin plus metfor- min. [NPS Radar February 2013. Sitagliptin, vildagliptin and saxagliptin dipeptidyl peptidase-4 inhibitors (gliptins) for add-on therapy in type 2 diabetes mellitus. Website: www.nps.org.au] This is signifcant given that overweight/obesity has deleterious efects on plasma glucose control in type 2 diabe- tes. There is also a low risk of hypoglycemia with saxagliptin either as monotherapy or in combination with metformin. The US regulatory authorities require that the cardiovascular (CV) risk associated with new antidiabetic drugs must be estimated. To satisfy this requirement, a meta-analysis of phase II and phase III trials of saxagliptin was undertaken. No evidence of an in- creased CV risk was found. On the contrary, saxagliptin was associated with benefcial changes to CV risk factors (blood pressure, lipid profle, body weight), suggesting that saxagliptin may in fact reduce the risk of ma- jor adverse CV events. [Cardiovascular Diabe- tol 2012:11:6] Dosing In patients with type 2 diabetes, the rec- ommended dose of saxagliptin is either 2.5 or 5 mg/day. The commercially available for- mulation combining saxagliptin with met- formin extended-release (Kombiglyze-XR) is available in strengths of 5 mg saxagliptin / 500 mg metformin, 5 mg saxagliptin / 1,000 mg metformin, and 2.5 mg saxagliptin / 1,000 mg metformin. One combination pill should be taken daily with the evening meal. The starting dose should be individualized based on the patients current regimen, with the dosage then adjusted according to efective- ness and tolerability. In patients also taking a strong inhibitor of CYP3A4/5 (eg, ketoconazole, atazanavir, clarithromycin, indinavir, itraconazole, ne- fazodone, nelfnavir, ritonavir, saquinavir or telithromycin) the dosage should be limited to 2.5 mg saxagliptin / 1,000 mg metformin once daily. Place within guidelines The recent Position Statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) recommends that glucose targets and medications should be individ- ualized to the particular patient. Lifestyle interventions, including diet, exercise and education, are the foundation of any man- agement strategy for type 2 diabetes. The optimal choice for frst-line therapy is met- formin (unless contraindications are pres- ent). [Diabetes Care 2012;35:1364-1379] Type 2 diabetes is a progressive chronic disease and frequently additional medications are required to maintain control of plasma glu- cose levels. [Diabetes Care 2012;35:1364-1379] There are few data to guide the choices of second- and third-line therapies; however it is important to minimize side efects where possible. [Diabetes Care 2012;35:1364-1379] Patients frequently prefer oral to injectable therapies, and given the favorable profle of DPP-4 inhibitors with respect to weight gain and risk of hypoglycemia, novel combi- nations such as saxagliptin/metformin may be an optimal choice for a wide range of pa- tients. Clinical Pharmacy | Pharmacy Today | November - December 2013 26 Teriparatide, denosumab combo better at improving BMD By Rajesh Kumar A combination of teriparatide and de- nosumab might be more efective than either agent alone at increasing bone mineral density (BMD) in postmeno- pausal women at high risk of fractures, ac- cording to a randomized controlled trial. Some therapies licensed to treat osteoporo- sis work by inhibiting bone turnover (anticat- abolic agents) and others by stimulating bone formation (anabolic agents) to increase BMD. These therapies lower but dont complete- ly eliminate fracture risk. The researchers found that combining the anticatabolic drug denosumab and anabolic drug teriparatide increased BMD more than either agent on its own, and more than what has been reported with other approved therapies. [Lancet 2013; doi:10.1016/S0140-6736(13)60856-9] They enrolled 100 postmenopausal women with osteoporosis between September, 2009 and January, 2011and assigned them in a 1:1:1 ratio to receive 20 g teriparatide daily, 60 mg denosumab every 6 months, or both. BMD was measured at baseline and 3, 6, and 12 months. Of them, 94 women who completed at least one study visit afer baseline were as- sessed in a modifed intention-to-treat analy- sis. At 12 months, posterior-anterior lumbar spine BMD increased more in the combina- tion group (9.1%, [SD 3.9]) than in the teripa- ratide (6.2% [4.6], p=0.0139) or denosumab (5.5% [3.3], p=0.0005) groups. Femoral-neck BMD also increased more in the combination group (4.2% [3.0]) than in the teriparatide (08% [4.1], p=0.0007) and denosumab (2.1% [3.8], p=0.0238) groups, as did total-hip BMD (combination, 4.9% [2.9]; teriparatide, 0.7% [2.7], p<0.0001; denosumab 2.5% [2.6], p=00011). Our fndings are in contrast to those of previous trials that assessed the efect of bisphosphonates combined with teripara- tide or parathyroid hormone (PTH). In ran- domised controlled trials of postmenopausal women who received alendronic acid and teriparatide or PTH for various durations, ef- fcacy did not difer between the combination- therapy and individual-therapy groups, said the researchers Dr. Joy Tsai and Dr. Alexander Uihlein of the endocrine unit at Massachusets General Hospital, Boston, Massachusets, US, and colleagues. Similarly, combined teriparatide and zole- dronic acid given for 12 months was not as- sociated with beter results than each drug individually. In a study in which alendronic acid was added to previously started teripara- tide therapy, however, the results were more promising. Combined teriparatide and denosumab reduced the risk of esteoporosis- related fractures beter than either drug alone. Clinical Pharmacy | Pharmacy Today | November - December 2013 27 Although more studies are needed to as- sess reductions in fracture risk and to explore the efects of diferent doses and durations of treatment, the researchers said their results suggested that this specifc combination of drugs could be a useful option in the treat- ment of patients with osteoporosis at espe- cially high risk of fracture. In an accompanying commentary, Drs Richard Eastell and Jennifer Walsh of the aca- demic unit of bone metabolism at the North- ern General Hospital in Shefeld, UK, said the fndings provide proof of concept for the additive efect of the combined therapy, but its safety needs to be confrmed and the re- duction in fracture risk needs to be quantifed so that cost-efectiveness can be assessed. Also, what will happen when teriparatide is stopped since the current license only sup- ports its use for a maximum of 24 months, the commentators asked. [Lancet 2013; doi:10.1016/S0140-6736(13)60984-8] Pharmacologic interventions for ankylosing spondylitis By Elvira Manzano A nkylosing spondylitis (AS), a form of arthritis that starts in young adults, is a chronic progressive condition for which there is currently no cure. In Singapore, about 5,000-10,000 people sufer from AS, which af- fects both spinal and peripheral joints. Chronic back pain may not be the frst manifestation of the disease, said Dr. Lui Nai Lee, consultant rheumatologist at the Singa- pore General Hospital (SGH). Occasionally, peripheral joint pain or extra-articular mani- festations such as anterior uveitis, psoriasis, infammatory bowel disease and dactylitis may be the presenting symptoms. In the advanced stages, patients develop butock atrophy, loss of lumbar lordosis, and thoracic kyphosis, with a stooped forward neck or a question mark posture. The condi- tion afects men two to three times more com- monly than women. NSAIDs frst line-treatment for AS Regular physiotherapy (ie, supervised ex- ercises) and education are the cornerstone of non-pharmacological treatments for AS. Non- steroidal anti-infammatory drugs (NSAIDs), including coxibs, are the recommended frst- line drugs. About 75 percent of patients respond to NSAIDs, 20 to 50 percent nevertheless remain on active disease while on treatment. Those with persistently active, symptomatic dis- ease may require continuous treatment with AS treatment is the key in high-risk, rapidly declining patient. Clinical Pharmacy | Pharmacy Today | November - December 2013 28 NSAIDs to control their symptoms (pain and stifness). Long-term use of NSAIDs however can cause serious side efects, Lui warned. Cardiovascular and gastrointestinal risks should be taken into account when prescrib- ing NSAIDs. This is because NSAIDs, in time, can cause heart burn, gastritis, ulcers and bleeding. He added patients, particularly those who self-medicate, use non-prescrip- tion NSAIDs beyond the recommended dos- age, or those at high-risk for NSAID-toxicity should be made aware of this. Physicians and pharmacists have a role to play, he added. Other pharmacologic options Corticosteroid injections to the local site of musculoskeletal infammation may be con- sidered, said rheumatology professor Robert Landew from the Academic Medical Center, University of Amsterdam, the Netherlands, who was in Singapore for a short visit. For axial disease, the use of systemic corticosteroids and disease modifying anti- rheumatic drugs (DMARDs), including sul- fasalazine and methotrexate, is not supported by evidence. Possible side efects with the drugs include nausea, diarrhea, increased risk of infections, liver damage, lung damage, and bleeding. Sulfasalazine, however, may be considered in patients with peripheral ar- thritis. For patients with persistently high-disease activity despite conventional treatments, bio- logics such as anti- tumour necrosis factor therapy (ie, adalimumab, etanercept, infix- imab and golimumab) should be given, he said. Biologics are given as a subcutaneous injection or as an intravenous injection over a period of time. Response should be assessed at least 12 weeks of treatment, Landew add- ed. Adalimumab has been shown to be efec- tive in reducing signs and symptoms of AS and infammation (as shown by MRI), im- proving work productivity and quality of life, with positive efects on bone mineral density and concomitant diseases. [Ann Rheum Dis 2008;67:1218-1221] As for patients with axial disease, there is no evidence to the obligatory use of DMARDs prior to or concomitant with anti-TNF thera- py, said Landew. Considerations for taking TNF-blockers Luis message to physicians: TNF-block- ers can potentially cause a fare-up of tuber- culosis (TB). Hence, patients are routinely screened for past history of TB prior to start- ing therapy. Patients on this medication also have an increased risk for serious infections. Those with infammatory back pain, but not mechanical low back pain, should be treated with long term NSAIDs because of NSAIDs good efcacy record for acute symptoms and potential to retard long-term damage. Pa- tients with active disease despite treatment with NSAIDs may be put on TNF-blocking agents, he added. At the Autoimmunity and Rheumatology Centre, Singapore General Hospital (SGH), where Lui is consultant rheumatologist, ma- jority of patients diagnosed with AS, are on long-term NSAIDs, 10 percent need biologic therapy, while six patients do not require any pharmacological treatment. Eighty-percent of those with AS are ethnic Chinese, 6 per- cent and 4 percent are Indians and Malays, respectively. People respond to diferent medications with varying levels of efectiveness. At the end of the day, efective early treatment should focus on patients with high disease activity and those who are likely to have radiologi- cal progression and rapid functional decline during the natural course of AS, both experts said. Clinical Pharmacy | Pharmacy Today | November - December 2013 29 Microencapsulation key to uniform drug release M icrocapsules containing brain tu- mor drug may simplify treatment and provide more tightly con- trolled therapy for the disease, according to research. [Adv. Mater. 2013;25: 4529] Brain tumors are one of the worlds deadli- est diseases, said researcher Mr. Mohammad Reza Abidian, assistant professor of bioengi- neering, chemical engineering and materials science and engineering at Penn State Univer- sity in Pennsylvania, US. Typically doctors resect the tumors, do radiation therapy and then chemotherapy. The majority of chemotherapy is done in- travenously. But the drugs are very toxic and are not targeted, resulting in a lot of side ef- fects. Another problem with intravenous drugs is that they go everywhere in the blood- stream and do not easily cross the blood brain barrier so litle gets to the target tumors. To counteract this, high doses are necessary. We are trying to develop a new method of drug delivery, said Abidian. Not intrave- nous delivery, but localized directly into the tumor site. Current treatment already includes leav- ing wafers infused with the anti-tumor agent BCNU in the brain afer surgery, but when the drugs in these wafers run out, repeating invasive placement is not generally recom- mended. BCNU has a half-life in the body of 15 minutes, said Abidian. The drug needs pro- tection because of the short half-life. Encap- sulation inside biodegradable polymers can solve that problem. Encapsulation of BCNU in microspheres has been tried before, but the resulting prod- uct did not have uniform size and drug distri- bution or high drug-encapsulation efciency. With uniform spheres, manufacturers can design the microcapsules to precisely control the time of drug release by altering polymer composition. The tiny spheres are also inject- able through the skull, obviating the need for more surgery. The researchers looked at using an electro- jeting technique to encapsulate BCNU in poly (lactic-co-glycolic) acid, an approved biode- gradable polymer. In electrojeting, a solution containing the polymer, drug and a solvent are rapidly ejected through a tiny nozzle with the system under a voltage as high as 20 kilovolts but with only microamperage. The solvent in A scanning electron micrograph of BCNU loaded microspheres (black and white background) with 3D rendered images of brain cancers cells (yellow) and released BCNU (purple). P h o t o
c r e d i t :
M o h a m m a d
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A b i d i a n .
We are trying to develop a new method of drug delivery
Clinical Pharmacy | Pharmacy Today | November - December 2013 30
the liquid quickly evaporates leaving behind anything from a perfect sphere to a fber. Electrojeting is a low cost, versatile ap- proach, said Abidian. We can produce drug-loaded micro/nano-spheres and fbers with same size, high drug-loading capacity and high drug-encapsulation efciency. The researchers tested solutions of poly- mer from 1 percent by weight to 10 percent by weight and found that at 1 to 2 percent they obtained fatened microspheres, at 3 to 4 per- cent they had microspheres, at 4 to 6 percent they had microspheres and microfbers, at 7 to 8 percent they had beaded microfbers and above 8 percent they obtained only fbers. Depending on the desired applications, all the shapes are useful except for the beaded fbers, said Abidian. While fbers are not good for drug delivery, they are good for tis- sue engineering applications. Pharmacy Today provides the latest information for community, hospital and industrial pharmacists, pharmacy staff, pharmacy students, government agencies and the pharmaceutical industry. THE ONLY NE WSPAPE R I N SI NGAPORE TARGETI NG PHARMACY PROFESSI ONALS For more information on sponsorship opportunities, please contact: enquiry.pharmacytoday@mims.com For pharmacy news, views and editorial matters, contact: pharmacytoday.sg@mims.com The leading pharmacy publication in New Zealand, Malaysia and the Philippines is now in SINGAPORE! PT-SG-Filler209x282FINAL_0813.indd 1 8/6/13 4:16 PM After Hours | Pharmacy Today | November - December 2013 32 TIMOR LESTE: A PATH LESS TRODDEN P h o t o s
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T i n g By Rajesh Kumar T he small beach facing the deep blue Banda sea in Baucau, north eastern part of Timor Leste, is arguably one of the most unspoilt beaches in Asia. Its vernacular name, Imia-Mata Bundura, literally means powdery white sand beach and it delivers on what it promises. Then some. Crystal clear waters, thriving coral beds kissing the shoreline, awe inspiring views and star-saturated night skies. Above all, no throng of tourists. For now, at least. For intrepid travelers always on the look- out for a path less trodden, Timor Leste may well be the next big fx. As the country re- turns to peace afer decades of violence and destruction and slowly builds its economy, the government is hoping its unspoilt beach- es like Imia-Mata Bundura, natural beauty, abundant marine life and great diving and hiking spots would atract enough visitors to kick start its tourism sector. Located between Indonesia and Australia, Timor Leste is part of the Coral Triangle (in- cluding tropical marine waters of Indonesia, Malaysia, Papua New Guinea, Philippines and Solomon Islands) that contains hundreds of species of reef building corals. The sheer diversity of marine life in the region has earned it the nickname Amazon of the seas. For this very reason, Atauro and Jaco islands are fast becoming popular with die hard divers looking for exotic locales. Just four days ago, we had three adult blue whales coming through the lagoon. Nowhere else in the world can you see them this close to the shore, said Mr. Kevin Austin, chief ex- ecutive of Sustainable Marine Industry Devel- opment Facility that runs Baucau Beaches, a tourism project to help the impoverished lo- cal community with high unemployment. Most of the time, we spot green turtles, sharks, reef sharks, and occasionally manta rays, Austin told me and other visiting media persons. That aside, the World War II era Japanese bomb shelters in Venilale, Lekirika Mana sta- lactites/stalagmites cave system high in the eastern tropical forests and remnants of the After Hours | Pharmacy Today | November - December 2013 33 centuries of Portugese colonial rule add just a dash of history to what, for us, was quite an adventurous voyage into the unspoilt un- knowns. We were told that Lekirika Mana cave was used as a shelter by rebel forces hiding from the Indonesian military during the laters brutal occupation of Timor Leste soon afer the Portugese lef in 1975. The occupation continued until the countrys self determina- tion in 1999, followed by UN administration until December 2012. In the capital city Dili, the Jesus Statue (Cristorae) located atop Cape Fatucama on the eastern tip, Cathedral of Immaculate Con- ception and the Presidential Palace seemed popular with domestic and international visi- tors alike. About 8 kilometers west of Dili lie Tasitolu Wetlands, a protected area comprising three salt lakes, an esplanade, and a beach. The area was designated Tasitolu Peace Park in 2002 due of its cultural and historical signifcance. Tasitolu is notorious as the site where Indo- nesian soldiers allegedly killed and dumped many young rebels during the countrys bloody independence struggle. Nearby is Pope John Paul II monument that commemorates the pontifs visit to the country in 1989, during the Indonesian oc- cupation. The catholic country of 1.2 million proud, friendly people comprises the eastern half of the island of Timor the nearby islands of Atauro and Jaco, and Oecusse, an exclave on the northwestern side of the island within Indonesian West Timor. The two halves were occupied by the Dutch and the Portuguese respectively, the Dutch half now with Indo- nesia. Timor Leste has embarked on a slow and painful path to progress, thanks to money from its oil and natural gas bounty. But it is proving to be a long and arduous journey. In its eforts to atract tourists, Timor Leste will not emulate Bali with its night clubs, neon signs and unchecked urban sprawl. Instead, the focus will be on sustainable eco-tourism with particular regard for the fragile envi- ronment, the countrys tourism minister said. One can only hope so. Along with a redesign that helps enhance ease of access to crucial clinical information, MIMS.com can now be accessed through a FREE mobile application, available on both the iTunes App Store and Google Play Store. With MIMS available across multiple platforms and devices, you can now easily and conveniently fnd the most up-to-date and relevant drug information anytime, anywhere. MIMS.com now comes with a brand new look and mobile app! Join over a million MIMS members who have incorporated MIMS into their daily workow. Connect with MIMS today. MIMS mobile/tablet app facebook.com/mimscom www.mims.com Publisher : Ben Yeo Managing Editor : Greg Town Senior Editor : Rajesh Kumar Contributing Editors : Radha Chitale, Elvira Manzano Publication Manager : Jason Bernstein Business Managers : Carrie Ong, Josephine Cheong, Melanie Nyam Designers : Lisa Low, Agnes Chieng, Sam Shum Production : Jenny Lim Circulation Executive : Christine Chok Accounting Manager : Minty Kwan Advertising Coordinator : Angeline Chua Published by : MIMS Pte Ltd 6 Shenton Way #15-08 OUE Downtown 2 Singapore 068809 Tel: (65) 6290 7400 Fax: (65) 6290 7401 Email: enquiry.pharmacytoday@ mims.com Pharmacy Today is published 6 times a year by MIMS Pte Ltd. Pharmacy Today is on controlled circulation publication to pharmacists in Singapore. It is also available on subscription to members of allied profes- sions. The price per annum is US$48 (surface mail) and US$60 (overseas airmail); back issues at US$5 per copy. 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Editorial Advisory Board Associate Professor Chui Wai Keung Head of Department of Pharmacy, Faculty of Science, National University of Singapore (NUS) Assistant Professor Lita Chew Chief Pharmacist, Ministry of Health, Singapore Registrar, Singapore Pharmacy Council Head, Pharmacy Department, National Cancer Centre Singapore Assistant Professor, Department of Pharmacy, NUS Associate Professor Alexandre Chan Department of Pharmacy, NUS Associate Consultant Clinical Pharmacist, Department of Pharmacy, National Cancer Center Singapore. Dr. Joyce Yu-Chia Lee Assistant Professor of Clinical Pharmacy, Department of Pharmacy, NUS Principal Clinical Pharmacist, National Healthcare Group Polyclinics