Content:   Inhalers & Global emissions: Impact of Anticoagulation Management Clinics (AMC) at AKUH TOX TOK! A Poisonous Candy for the children: Mothballs (Phenyl ki Goli)   Warfarin – A High Alert Drughttps://ecommons.aku.edu/pharmacy_newsletter/1040/thumbnail.jp

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Content:   Inhalers & Global emissions: Impact of Anticoagulation Management Clinics (AMC) at AKUH TOX TOK! A Poisonous Candy for the children: Mothballs (Phenyl ki Goli) Warfarin – A High Alert Drughttps://ecommons.aku.edu/pharmacy_newsletter/1040/thumbnail.jp

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eCommons@AKU Pharmacy Newsletter Publications (Newsletters & Reports) 3-2022 Pharmacy Newsletter: March 2022 Drug & Poison Information Centre Pharmacy Services, Aga Khan University Follow this and additional works at: https://ecommons.aku.edu/pharmacy_newsletter  Part of the Pharmacy and Pharmaceutical Sciences Commons 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 ServicesHafsah M Ashfaq, Clinical Pharmacist Faqeeha Shakeel, 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:Inhalers & Global emissions:........Page 1Impact of Anticoagulation Management Clinics (AMC) at AKUH.......................Page 2TOX TOK! A Poisonous Candy for the children: Mothballs ( Phenyl ki Goli)..........................................................Page 3Warfarin – A High Alert Drug.............Page 4March, 2022. Vol 36, Issue 01. NEWSLETTERPHARMACYInhalers & Global emissions:Miriam Kugele, Global Senior Manager, Environment & SustainabilityAir pollution in Pakistan is a major health concern with air quality in cities consistently above healthy levels. It is now well established that health care provision contributes a significant portion to global greenhouse gas emissions. Less well known is the fact that some treatments for respiratory illnesses can also contribute to climate change.In particular, pressurised Metered Dose Inhalers (pMDI) use gases to deliver medications, which are potent greenhouse gases. Although chlorofluorocarbons (CFCs), which as ozone-depleting propellants, have largely been replaced by hydrofluoroalkanes, these propellant gases are also up to 3,350 times more potent than carbon dioxide as greenhouse gases.A single pMDI, if fully used, can release as much greenhouse gas as a small car driven for 120 km; a single patient may use more than 12 inhalers a year.Fortunately, there are alternatives. Some propellant inhalers are better than others for delivering the same type of drug, because either they use less propellant or a less damaging propellant. In most cases, dry powder-based inhalers (DPI) can be just as clinically effective as propellant inhalers and have a small fraction of the environmental impact.   A range of estimated carbon impacts of several common inhalers can be seen below:AKU is committed to reducing its carbon emissions towards achieving net zero carbon operations, and many measures will be taken which will have direct impact on improving air quality.	 l Reducing the emissions and air pollution from energy generation and use,   such as with renewable energy installations.	 l Planning to electrify parts of the vehicle fleet.	 l Improving incineration practices such as by removing incinerators from   within health facilities and particulate control.Inhaler Drug Propellant Global warming potential of propellant      relative to CO2Est. carbon footprint of propellant per deviceVentolin® EvohalerSalbutamol HFA134a 1300 24kg (estimated at  18.5g propellantSeretide ® EvohalerSalmeterol +Fluticasone PropionateHFA134a 1300 12.95kg (estimated       at 9.96g of      propellant)FosterNext® BeclomethasoneDipropionate +Formoterol FumarateNone - Dry Powder  Inhaler0 0kgPharmacy Newsletter 2	 l Reviewing how inhalers are prescribed, dispensed, used, and disposed off.In 2020, AKU started collecting data on which inhalers are dispensed from AKU pharmacies. As part of developing AKU’s environment and decarbonization plan for all emissions areas, the AKU Pharmacy together with the Office for Environment and Sustainability and Pharmacy & Therapeutics Committee proposed various measures to reduce inhaler related emissions. These include, for example:	 l An education programme to alert physicians and pharmacists to the relative impacts of different inhalers.	 l Better understanding of prescription practices with the aim to make changes to favour lower carbon or propellant   free inhaler alternatives where clinically appropriate.	 l Developing guidelines for AKU physicians via AKU’s Pharmacy and Therapeutics Committee; and guidance materials for   patients via the Patient & Family Education (PFE) Committee.	 l Engaging with manufacturers/suppliers to reduce propellants and costs for DPIs   where possible.	 l Collecting from patients and then disposing off inhalers in environmentally safe way.	 l Sharing these learning points more widely with health professionals in countries where    AKU works.	 l Engaging the regulators e.g. Drug Regulatory Authority of Pakistan ( DRAP) and   Pharmacy & Poison Board, Kenya to initiate measures to reduce inhalers related   emissions.Practice: https://www.cmaj.ca/lookup/doi/10.1503/cmaj.211747Media contact: Communications, Unity Health, communications@unityhealth.toGeneral media contact: Kim Barnhardt, CMAJ, kim.barnhardt@cmaj.caDPI (Dry Powder inhalers)pMDI ( Pressurised metered dose inhalers)Impact of Anticoagulation Management Clinics (AMC) at AKUH Ayesha Mughal, PharmacistAnticoagulants (blood thinners) are used to treat and prevent certain medical conditions related to blood disorders.These drugs can cause major adverse drug events if misused or used without proper medical advice. Due to the complex dosing, strict monitoring, and patient non-compliance, the Joint Commission outlined the National Patient Safety Goal NPSG.03.05.01 regarding the rational use of anticoagulants. The Anticoagulation Management Clinic is a specialized clinic at Aga Khan University Hospital in which the multidisciplinary team (Hematologist, Specialized Anticoagulation Pharmacist & Nurse) focuses on the monitoring and education of the patients receiving anticoagulation therapy. This clinic is held twice a week in Ibn-e-Zuhr building and accepts referrals from all services and follows patients in clinic, ER and over the phone if required. As part of an Anticoagulation Management Service (AMS), anticoagulation pharmacists provide a range of care for both inpatients as well as ambulatory patients. The clinic services includes:	 l Rapid point of care INR testing in order to cut off the waiting time.	 l Dosage adjustment as per the INR and increasing compliance of the patients towards their medication plan.	 l Providing necessary education material about the use of anticoagulant medications, including side effects and potential    drug and dietary interactions.	 l Consultation with a specially trained pharmacist.	 l Monitored anticoagulation management, including evaluation of side effects and drug/drug or drug/food interactions.Pharmacy Newsletter 3TOX TOK! A Poisonous Candy for the children: Mothballs (Phenyl ki Goli)Faqeeha Shakeel, Pharmacist   Naphthalene is a widely used industrial and household chemical available in the form of mothballs. But it has rarely been an agent of poisoning worldwide. Naphthalene balls ingestion after timely management generally results in good outcomes unless the patient is G6PD deficient.Case: A “5 years old, 18 kg child was presented in ER with tachycardia, severe vomiting, slightly dizzy and a pungent smell coming from his mouth. Upon questioning, the mother said that the child has chewed mothballs placed in the cloth cupboard. The mother also induced vomiting immediately.”Note: Pungent smell may indicate either mothball poisoning (as it has a pungent smell when exposed to air) or rodenticide poisoning (release phosphine gas).Laboratory monitoring: 	 l Baseline CBC, electrolytes, liver function tests, renal function tests, urinalysis and urine dipstick test for   hemoglobinuria were obtained.  Note: Ingestions of more than a single mothball should be followed for several days to rule out delayed hemolysis   & Jaundice.Management: 	 l There is no specific antidote and treatment is symptomatic & supportive.	 l Activated charcoal was given to the patient as she was active.    Activated charcoal may be effective for many hours after a mothball ingestion because they dissolve slowly.  l Treated for  nausea and vomiting with antiemetic (dimenhydrinate IV: 0.5 mg/kg/dose) . l After 3 hours of observation, the child was discharged from emergency after being asymptomatic.What should you know about mothballs?	 l The mothballs are used to kill moths and other fiber insects to protect clothing. Always  place mothballs inside tightly closed  containers with holes along with the clothing or materials.Total number of patients counseled in Year 2021 was 92 (Jan -Dec 2021) . Total number of interventions made by the pharmacist was 35.Collaboration of pharmacists in anticoagulation clinics is safe, effective and results in significant improvements in overall management of the therapy with improving patient compliance and significant decrease in  sub-therapeutic & supra-therapeutic cases with minimal adverse drug reactions. Types of Intervention60%50%40%30%20%10%0%54%25%8% 11%Drug-Drug/ Food InteractionDrug dose adjustment as per INRSwitching of anticoagulantsBridging of anticoagulantsPharmacy Newsletter 4	 l Wash and air out fabrics immediately after storage and before use; they should no longer have a strong mothball smell. 	 l Store the unused portion of the box in a sealed plastic bag in a locked, childproof cabinet. Take Home Message:Mothballs are pesticides and volatilize slowly when placed in open air. Mothballs usually contain one of two active ingredients: naphthalene or paradichlorobenzene. Exposure to large quantities of naphthalene or paradichlorobenzene can lead to headaches, nausea, vomiting, diarrhea, eye/nose irritation and coughing.  Moreover, if someone is exposed for an extended duration, they can have more serious effects like liver and kidney damage.Qurat-Ul-Ain Amir Butt, PharmacistWarfarin is an oral anticoagulant that acts as a vitamin K antagonist.INDICATIONS: It is used for the prevention and treatment of venous and arterial thrombosis and embolism in patients with venous thromboembolic (VTE) disease, atrial fibrillation, prosthetic heart valves, tissue heart valves, or incidence of myocardial infarction.Steps for Warfarin OrderingBaseline CBC, SGPT, SrCr & INR should be sent before ordering warfarin.Dose is selected based on indications/ INR values.Order shall be entered & processed for 24 hours only. Physician will review warfarin orders  after every 24 hours.While processing the order for warfarin, significant drug interactions must be reviewed along with other elements of order appropriateness.Warfarin tablets available at AKUTABLET STRENGTH COLOR1 mg Pink2.5 mg Green5 mg Light orangeKey Elements of Patient Education Regarding Warfarin Identification of generic/brand names. Visual recognition of drug & tablet strength.Purpose & expected duration of therapy.Dosing & administration.What to do if a dose is missed.Importance of PT & INR monitoring.Recognition of signs & symptoms of bleeding or thromboembolism & what to do if it happens.Dietary considerations & potential for drug-drug & drug-food interactions.Avoidance of pregnancy.Importance of informing other health care providers that warfarin has been prescribed.Warfarin – A High Alert DrugThe strength & quantity of warfarin must be checked carefully before dispensing.INR must be rechecked every 2-3 days for patients who have been newly started on warfarin or those with fluctuating INR.Patients being discharged or followed up in OPD should ideally be enrolled with anticoagulation clinic.Each patient should be properly educated on correct use of warfarin & lab monitoring requirements.Provide us your Valuable Feedback!Link: https://forms.gle/FCo9ZuE4CConzFp46The Aga Khan University Hospital, Karachi

Pharmacy Newsletter: March 2022

https://ecommons.aku.edu/cgi/viewcontent.cgi?article=1040&context=pharmacy_newsletter

Pharmacy Newsletter: March 2022

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