Content:   TOX TOK! Liquid Nicotine Used in E-Cigarettes can Harm Children Monkey Pox FAQs Clinical Understanding of Different Formulations of Tenofovir: TDF Versus TAF Fluids And Electrolytes Maintenance Calculation In Pediatric Patients A NEW Warning : FDA recommends thyroid monitoring in babies and young children who receive injections of iodine-containing contrast media(ICM) for medical imaging. CHOLERA The 2 Million Dollar Injection Retinoic Acid Preparations & their Differhttps://ecommons.aku.edu/pharmacy_newsletter/1041/thumbnail.jp

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eCommons@AKU Pharmacy Newsletter Publications (Newsletters & Reports) Summer 7-1-2022 Pharmacy Newsletter : July 2022 Pharmacy Department Aga Khan University Follow this and additional works at: https://ecommons.aku.edu/pharmacy_newsletter  Part of the Pharmacy and Pharmaceutical Sciences Commons Recommended Citation Pharmacy Department, "Pharmacy Newsletter : July 2022" (2022). Pharmacy Newsletter. Book 42. https://ecommons.aku.edu/pharmacy_newsletter/42 Newsletter advisory committee/members of Pharmacy & Therapeutic CommitteeEditor-in-ChiefDr. Munira Moosajee,Chairperson P & TCEditor Syed Shamim RazaDirector, Pharmacy ServicesEditorial StaffUmer Ali Khan, Business Manager, Pharmacy ServicesKashif Hussain, Manager, Pharmacy servicesHafsah M Ashfaq, Clinical Pharmacist Faqeeha Shakeel, Clinical PharmacistQuratulain Amir Butt, PharmacistPublished byDrug & Poison Information CentrePharmacy Services Aga Khan University Hospital Stadium Road, P.O. box 3500, Karachi 74800, Pakistan Pharmacy Newsletter provides information regarding the decisions of P & TC, current concepts in drug therapy, warnings and cautions issued by various regulatory agencies, drug interactions, ADRs and matters related to drug usage.Opinions expressed are of authors and does not necessarily represent AKUH’s view/recommendations.Publication of this newsletter has been through an endowment grant from Pharmacist group of Ontario, CanadaDrug & Poison Information Centre, Tel: +92 21 34861504, 1506, 1477, 1479Email: drug.information@aku.edu hospital.aku.edu/Karachi/pharmacyInside this Issue:TOX TOK! Liquid Nicotine Used in E-Cigarettes can Harm Children:........ Page 1Monkey Pox FAQs:................................ Page 2Clinical Understanding of Different Formulations of Tenofovir: TDF Versus TAF.............................................. Page 3Fluids And Electrolytes Maintenance  Calculation In Pediatric Patients ......... Page 4CHOLERA:............................................. Page 6The 2 Million Dollar Injection..............Page 7Retinoic Acid Preparations & their Differences.............................................. Page 8July, 2022. Vol 36, Issue 02. NEWSLETTERPHARMACYTOX TOK! Liquid Nicotine Used in E-Cigarettes can Harm ChildrenHafsah Ashfaq - Clinical Pharmacist.Toddlers are the most vulnerable group to swallow or have contact with a poisonous substance.The American Academy of Pediatrics (AAP) usually offers tips to prevent and to treat exposures to poison. One of the most important exposures nowadays includes E-cigarettes.  The refills for E-cigs, are being sold in hundreds of different flavors, including flavors and colors that would be absolutely appealing to kids. There are many cases reported globally. Few of the prominent cases are quoted below:Case 1: A 1-year-old child died from liquid nicotine poisoning in December 2014— the first such death in the United States. Poison control centers now receive thousands of calls each year about young children who have been exposed to vaping-related products.Case 2: A young child was inadvertently exposed to liquid nicotine [approximately 703mg (35mg/kg)] and collapsed almost immediately. She required aggressive care including intubation and mechanical ventilation, but recovered within 24 hours with no permanent sequelae.Poison InformationToxicity level ToxicAlso known as Nicotine, vape, electronic cigarette, e-cigarette, vape penDescription Vaping products are used for their nicotine component. These products are not meant to be swallowed and not meant for children to usePossible symptoms of overdose/poisoningIngesting or chewing tobacco can cause vomiting, sweating, drowsiness / tiredness, shaking, confusion, seizures, and even death.Symptoms typically develop within 30 minutes to 2 hours after an oral exposure. Symptoms may be immediate after inhalational exposure.Toxic dose A teaspoon of concentrated liquid nicotine can be fatal for the average 26-pound toddler.Antidote There is no specific antidote.Pharmacy Newsletter 2Monkey Pox FAQs:Hafsah Ashfaq – Clinical PharmacistMonkeypox virus belongs to the Orthopoxvirus genus in the family Poxviridae. Monkeypox is a rare disease with symptoms that are similar to but milder than the symptoms of smallpox.Q: What are the symptoms for Monkey Pox?A: Fever, malaise, headache, weakness, and pustules on face or vesicles on legs. Fever before rash and lymphadenopathy are common . These lesions are often described as painful until the healing phase when they become itchy (crusts).Q: How is Monkeypox transmitted?A: Monkeypox is transmitted by symptomatic individuals through close contact with lesions, bodily fluids, or respiratory secretions and objects that have had contact with lesion crusts or bodily fluids (e.g., contaminated linens, bandages, dishes).Q: What to do for patients with Monkey pox?A: For patients with monkeypox, isolation precautions should be followed until coverings have fallen off, and a fresh layer of intact skin has formed. This could take up to 2-4 weeks from the beginning of prodrome.Q: Is there any Vaccine available in Pakistan for Monkey pox?A: In Pakistan, currently no vaccine is available for Monkey Pox. Smallpox/monkeypox vaccine (JYNNEOS™) is approved in US that can help protect against smallpox, monkeypox, and other diseases caused by orthopoxviruses, including vaccinia virus. JYNNEOS™ is usually administered as a series of 2 injections, 4 weeks apart. People who have received smallpox vaccine in the past might only need 1 doseReference: www.cdc.govTreatment: Treatment is primarily supportive and symptomatic. Intravenous fluids can be administered. Persistent vital sign abnormalities, altered mental status, muscle weakness, and seizures indicate a more severe poisoning. Urine acidification (while theoretically helpful in enhancing elimination) is not recommended. Also avoid using H2 blocker or proton pump inhibitor initially because nicotine will be absorbed more easily in an alkaline environment.Monitoring of patient: No testing is required in patients with mild or no symptoms. Creatine kinase, lactate, urinalysis should be performed in patients with severe poisonings. The CDC has recently reported pulmonary illnesses associated with the use of vaping devices (i.e., e-cigarettes) when they are used to aerosolize substances for inhalation(i.e., nicotine or illicit products). Patients present with respiratory symptoms, including cough, shortness of breath and fatigue. Monitor pulse oximetry, obtain chest radiograph, CT scan of the chest and pulmonary function tests as indicated.Take home message: Elders who use e-cigarettes are advised to store the products and any refill materials in child-resistant packaging and out of the reach of children.References: • www.illinoispoisoncenter.org • www.my.clevelandclinic.orgPharmacy Newsletter 3Clinical Understanding of Different Formulations of Tenofovir: TDF Versus TAFQuratulain Amir Butt - Pharmacist.Tenofovir is commercially available as prodrugs, tenofovir disoproxil fumarate (TDF) & tenofovir alafenamide (TAF).Tenofovir Disoproxil Fumarate (TDF) Tenofovir Alafenamide (TAF)Indication Treatment of chronic hepatitis B and HIV-1 infection.Brand name Vireof 300mg Wymly 25mgDose 300mg once daily 25mg once dailyPharmacokinetic differenceTDF has a shorter plasma half-life & rapidly gets converted to tenofovir while in the plasma, substantially exposing vital organs to tenofovir.TAF has a longer plasma half-life & remains stable in plasma. It only gets converted to tenofovir intracellularly.A low dose of TAF (25mg) is bioequivalent to 300mg TDF in terms ofplasma levels of tenofovir.Pharmacodynamic differenceTAF shows similar clinical efficacy as TDF but with better patienttolerability & compliance.Pharmacological differenceSignificant renal & bone toxicity(Up to 28% or more)Decreased incidence of renal &bone toxicity (Up to 5% or less)Use in pregnancy US FDA pregnancy category:Category BUS FDA pregnancy category:Not assigned yet.Although TAF use was associated with more weight gain compared toTDF, both regimens appear safe and effective during pregnancy.Renal dose adjustment •	 CrCl ≥50 mL/minute: No dosage adjustment necessary•	 CrCl 30 to <50 mL/minute: 300 mg every 48 hours or 150 mg once daily•	 CrCl 10 to <30 mL/minute: 300 mg twice weekly (every 72 to 96 hours)•	 CrCl <10 mL/minute: Avoid use. If no alternative therapy is available, then may consider 300 mg every 7 days; use with caution and close monitoring•	 CrCl ≥15 mL/minute: No dosage adjustment necessary.•	 CrCl <15 mL/minute: Use is not recommended.Hepatic dose adjustment No dose adjustment is required. •	 Mild impairment (Child- Pugh class A): No dosage adjustment necessary.•	 Decompensated cirrhosis (Child-Pugh class B or C):Use is not recommended.References:https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)60616-X/fulltext#seccestitle160https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5892670/Pharmacy Newsletter 4Fluids And Electrolytes Maintenance Calculation In Pediatric PatientsMehreen Sohail - Pharmacist.Maintenance fluid and electrolytes are important due to normal losses from body basal metabolism. Normally, body metabolism results in two types of by-products: heat and solutes. Heat is involved in basal energy expenditure and is considered as “insensible water losses” whereas, solutes are usually excreted in the urine which is also known as “urinary water losses”.It has been observed that the metabolic rate of a body decreases with increasing age. In other words, neonates generate more heat and solute from basal metabolism as compared to children and adolescents. Therefore, they require more fluids and electrolytes per units of body weight and vice versa.In general, infants become dehydrated faster as compared to older patients. It is because an adolescent can tolerate 12-18 hours without any oral intake. However, an infant needs IV maintenance fluid within 4-6 hours of last feeding.Several estimates of maintenance fluid needs exist, including surface area method (may underestimate needs/be inaccurate when weight is less than 10 kg), basal caloric method (most accurate, but less practical), and estimations using weight. Estimations of maintenance needs using body weight are the most clinically practical, but they may overestimate the needs.Estimation of Maintenance Fluid Requirements Using Body Weight for Neonates:	  < 1500 g = 130–150 mL/kg/day	  1500–2000 g = 110–130 mL/kg/day	  Term neonate = 80–150 mL/kg/dayNote: Once the neonate weighs more than around 2–3 kg, the Holliday-Segar method is preferred.Estimation of Maintenance Fluid Requirements Using Body Weight for Older Infants and ChildrenHOLLIDAY-SEGAR METHODWEIGHT 24-HOUR FLUID HOURLY RATE3 to 10 kg 100ml/kg/day 4ml/kg/hr11 to 20 kg 1000 + 50ml/kg/day for each kg >10 40 + 2 ml/kg/hr for each kg > 10More than 20 kg 1500 + 20ml/kg/day for each kg > 20 60 + 1 ml/kg/hr for each kg > 20References:•	 Sandra Benavides, Pharm.D, Milap C. Nahata, Pharm.D., FCCP, Pediatric Pharmacotherapy, 2013, United States of America.•	 Derek S. Wheeler, Pediatric Critical Care Medicine, Second Edition, 2014 Springer London Heidelberg New York Dordrecht.Pharmacy Newsletter 5A NEW Warning : FDA recommends thyroid monitoring in babies and young children who receive injections of iodine-containing contrast media(ICM) for medical imaging.FDA approved a new warning for the entire class of iodinated contrast media (ICM) injections for children 3 years or younger. The warning describes the risk of underactive thyroid or a temporary decrease in thyroid hormone levels. These risks and recommendations pertain to ICM given as an injection through an artery or vein.What to do?Babies and young children may need to be monitored by their health care professionals after receiving ICM. If thyroid dysfunction is detected, treat as clinically needed to avoid future cognitive and other developmental disabilities. Most reported cases were transient subclinical hypothyroidism and did not require treatment.Who is at Risk?Few pediatric patients are at an increased risk, including prematurity, low birthweight or the presence of cardiac or other conditions. Patients with cardiac conditions may be at greatest risk since they often require high doses of contrast during invasive cardiac procedures.Also known as “contrast dye” or “X-ray dye,”Procedures that use ICM include X-rays of blood vessels, joints, and organs, and some computed tomography (CT) scans.ICM are given as injections into arteries, veins, or other body cavities; however, the information in this Drug Safety Communication pertains to ICM given as an injection through an artery or veinCommon side effects associated with ICM include flushing in the face, nausea or vomiting, mild itchiness, and skin rash.  BEAT THE HEATSome tips to protect yourself against the heat waveWear loose, light-weight clothes.Remember to maintain an adequate level of hydration. Eat cold and hydrating foods.When outdoors, seek shade & cover your head. Use umbrellas & hats. Limit strenuous outdoor activities specially during day times.Take regular cool showers.Make sure to get enough rest.Pharmacy Newsletter 6CHOLERA:Sehej Hussain – Resident Pharmacist Cholera is an acute diarrheal illness caused by infection of the intestine with Vibrio cholera bacteria. Pakistani health authorities have reported more than 2,000 cholera cases between 1st January-17th May nationwide amidst the contaminated water crisis as the country grapples with a water crisis exacerbated by a brutal heat wave in South Asia. Emergency relief has been initiated in at-risk areas including setting up of mobile water tanks to ensure the population has safe, clean drinking water and setting up medical tents to treat individuals suffering from cholera symptoms.TreatmentOral rehydration salts can treat up to 80% of cases.Intravenous fluids needed for severe cases.Medications can diminish duration of diarrhea, reduce volume of rehydration fluids needed, and shorten duration of the disease.Supplements: Research suggests that prescribed supplements may lessen and shorten the duration of diarrhoea in children affected by cholera.SymptomsHow to Update Allergy in Patient Profile:PreventionDehydrationDiarrheaVaccinationMaintain HygieneWash Vegetables & FruitsWash HandsBoil waterNausea & VomitingsStep 1: Step 2: Step 3:Select Patient==Update patient Enter MR #Tick Generic / ClassAllergies == Select Class Id& Generic IDPharmacy Newsletter 7The 2 Million Dollar InjectionMariyum Usmani - Resident PharmacistOnasemnogene abeparvovec is a gene therapy medication used to treat spinal muscular atrophy (SMA), a serious condition of the nerves that causes muscle wasting and weakness. It is indicated for the treatment of pediatric patients less than 2 years of age. It works by replacing the function of the missing or nonworking SMN1 gene with a new, working copy of an SMN gene.Onasemnogene abeparvovec is the first and only gene therapy approved by the FDA for the treatment of SMA, including those who are pre-symptomatic at diagnosis.With a whopping cost of 2.1 million USD (42 Crore PKR) for a one-dose treatment, onasemnogene abeparvovec is currently the most expensive therapeutic agent in the United States.On the 12th of May 2022, The Aga Khan University Hospital received Onasemnogene abeparvovec free of cost. On 13th of May 2022, the medication was successfully administered to a 4-month-old baby girl diagnosed with Spinal Muscular Atrophy. The child was discharged with a promising prognosis and hope for recovery.The question arises, is this medication worth its price? The simple answer, yes.In the initial clinical trial that was conducted with onasemnogene abeparvovec, all children were alive at the conclusion of the study and many were able to sit, roll, crawl, play and some could even walk! A main study showed that it reduces the need for artificial ventilation in babies with spinal muscular atrophy. In a study conducted, 20 out of the 22 babies given onasemnogene abeparvovec were alive and breathing without a permanent ventilator after 14 months, when normally only a quarter of untreated patients would survive without needing a ventilator. The study also showed that onasemnogene abeparvovec can help babies sit unaided for at least 30 seconds, a milestone that is never achieved in untreated babies with severe forms of SMA.This level of effectiveness, delivered as a single, one-time therapy, is revolutionary and provides exceptional hope for families battling SMA.References • https://www.zolgensma.com • https://www.zolgensma.com/clinical-studies • https://www.fda.gov/vaccines-blood-biologics/zolgensmaPharmacy Newsletter 8The Aga Khan University Hospital, KarachiRetinoic Acid Preparations & their DifferencesFaqeeha Shakeel- Clinical PharmacistGeneric name: Cis-Retinoic Acid, Isotretinoin (Synthetic Retinoic Acid)Generic name: All-Trans Retinoic Acid (Natural Retinoic acid)Strength: 20mg, 10mg Strength: Capsule = 10 mg,Indication: Isotretinoin is used primarily in the treatment of acne. The drug has also been used in several other conditions including Squamous cell carcinoma, Neuroblastoma.Indication: Tretinoin is indicated for the induction of remission in patients with acute promyelocytic leukemia. Tretinoin (orally or topically) has been studied in the treatment of psoriasis, dermatoses, and various cancers.Dose: Adult: *Acne: The initial oral dose should be 0.5 to 2 mg/kg/day in 2 divided dosesPeads: *Acne: Initial: Oral: 0.5 mg/kg/day in 2 divided doses for 4 weeks, then increase dose to 1 mg/kg/day in 2 divided doses *Neuroblastoma: 80 mg/m2/dose every 12 hours for the last 2 weeks (14 consecutive days) of a 4-week cycle for 6 cycles.Dose: Adult: Remission induction of acute promyelocytic leukemia: 45 mg/m2/day PO (divided twice daily). Peads: Remission induction of acute promyelocytic leukemia: 25 mg/m2/day in 2 divided dosesProvide us your Valuable Feedback!Just drop us an email with subject Newsletter Feedback. Email us at : drug.information@aku.edu Or fill your feedback through Link: https://forms.gle/FCo9ZuE4CConzFp46For Formulary assistance visit http://portal.aku.edu/pharmacy/olf.asp or Call 34861504/1506ADR reporting Link:https://vaems.aku.edu/aems_prod/Default.asp

Pharmacy Newsletter : July 2022

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Pharmacy Newsletter : July 2022

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