TECHNICAL REPORT SELANGOR STATE HEALTH DEPARTMENT
2011
ISSN 2229-9483
SELANGOR STATE HEALTH DEPARTMENT, MINISTRY OF HEALTH MALAYSIA
TECHNICAL REPORT
2011
SELANGOR STATE HEALTH DEPARTMENT
MINISTRY OF HEALTH MALAYSIA
Dato' Dr. Hj Azman bin Abu Bakar
Director, Selangor State Health Department
Mdm. Zawiyah binti Mat Johor Deputy State Director of Health (Pharmacy), Selangor State Health Department Datin Ainon Elony binti Othman Deputy Director (Pharmacy Practice and Development Branch), Pharmaceutical Services Division, Selangor State Health Department
Dr. Nor Hayati binti Ibrahim Senior Principal Assistant Director, Medical Division, Selangor State Health Department
Dr. Zaharah binti Zainuddin Senior Principal Assistant Director, Public Health Division, Selangor State Health Department
Dr. Mazlina binti Mat Desa Senior Principal Assistant Director, Oral Health Division, Selangor State Health Department
Mdm. Zaiton binti Shato Pharmacist In-Charge, Petaling District Health Office
Dr. Khairul Rafizah binti Hairodin Principal Assistant Director, Public Health Division, Selangor State Health Department
Mdm. Hazlinda Nazli Binti Naem Principal Assistant Director, Pharmaceutical Services Division, Selangor State Health Department
Ms. Anusuya a/p Krishnarajah Pharmacist, Hospital Tengku Ampuan Rahimah, Klang Mdm. Lee Li Fung Senior Assistant Director, Pharmaceutical Services Division, Selangor State Health Department
Mdm. Chan Lin Yee Senior Assistant Director, Pharmaceutical Services Division, Selangor State Health Department Mdm. Aida Baizura binti Abdul Rahman Assistant Director, Administration Division, Selangor State Health Department
EDITORIAL COMMITTEE
ADVISOR
CHIEF EDITOR
EDITORS
The first Technical Report was prepared by the Selangor State
Health Department in 2009. This year marks the 3rd year of
continuing effort by all the health staff in the various health
departments in the State. A milestone has been marked in our
effort to document research findings and quality studies that are
still being carried out among the various health departments in
the State. This continuum of effort has encouraged more
studies to be conducted, which in turn will improve the quality of
health care services provided to our clients.
A big thank you goes out to all the health staff who has shared
their vision, strategies, project findings, outcome and activities
for the benefit of their colleagues and peers. These studies in
turn have been tirelessly documented for the betterment of the
healthcare services.
Director, Selangor State Health Department, Ministry of Health Malaysia.
laimer:
The views expressed in this Technical Report 2011 are for the information of the staff
of Ministry of Health only, and are not necessarily reflecting those of the
management of the Ministry of Health, unless stated expressly. The Selangor State
Health Department does not warrant or assume any legal liability or responsibility for
the accuracy, completeness or usefulness of any information, apparatus, product or
process disclosed in this report.
The Technical Report 2011 is a publication of the Selangor State Health Department
of the Ministry of Health Malaysia. Enquires are to be directed to the Publisher and
the Publisher reserves copyright on all published materials and such material may
not be reproduced in any form without the written permission of the Publisher.
For internal use only and not to be reproduced or used for any commercial purposes.
DISCLAIMER
FOREWORD
Director,
Selangor State Health
Department,
Ministry of Health Malaysia
PAGE
EDITORIAL COMMITTEE
FOREWORD
1
A PROSPECTIVE STUDY ON THE ADHERENCE OF HUMAN IMMUNODEFICIENCY VIRUS (HIV) TOWARDS HIGHLY ACTIVE ANTIRETROVIRAL THERAPY (HAART) IN HOSPITAL TENGKU AMPUAN RAHIMAH (HTAR) KLANG –A PRE-STUDY Ko Kar-Maine, Mohammad Zaki Yusof, Wong Hon Shen.
1
2 AN AUDIT ON DIABETIC FOOT CARE CAMPAIGN - DOES IT HELP? Norsabrina Sabri, Felix Loong Yew Seng
12
3 AN AUDIT ON REDUCING “AGAINST THE RULE ASTIGMATISM” IN SUPERIOR INCISION PHACOEMULSIFICATION Zalifa Zakiah Asnir, Duratul Ain Hussin, Rusnah Hussain
15
4
COMPARISON OF FONDAPARINUX AND ENOXAPARIN USE FOR
ACUTE CORONARY SYNDROME IN HOSPITAL SUNGAI BULOH
Jonathan James Arulappu, Sia Hee Peng, Pang Chia Wen
19
5 DRUG UTILIZATION REVIEW OF SELECTED PROTON PUMP INHIBITORS (PPIs) IN OUTPATIENT PHARMACY HOSPITAL SUNGAI BULOH Nurhayati Abdul Wahab, Kalaivani A/P Subramaniam, Nurnadia Shazreen Abd Wahab
28
6
EFFECTIVENESS OF POST-OPERATIVE ANALGESICS AFTER SURGICAL REMOVAL OF IMPACTED THIRD MOLAR UNDER LOCAL ANAESTHESIA Dr. J. Sureinthiren A/L Jeya Raman, Dr.Lim Yee Chin, Dr. Mohd. Noor Fareezul bin Noor Shahidan, Dr. Sivakama Sunthari A/P M. Kanagaratnam
37
7
MEDICATION RECONCILIATION IN HEMODIALYSIS UNIT: IDENTIFYING THE TYPES AND FACTORS CONTRIBUTING TO MEDICATION DISCREPANCIES Heryohana Jamaludin, Lee Yoke Ching, Maryam Omar Zaki, Noor Azimah Abdullah, Nurah Zainal Abidin, Ros Aimi Osman, Norkasihan Ibrahim, Shahirah Zainudi
41
8 STATUS KESIHATAN PERIODONTIUM DI KALANGAN PESAKIT DIABETES DI KLINIK DIABETES KLINIK KESIHATAN ANIKA KLANG, SELANGOR Azirah Bt Muhammad
55
9 THE EFFICACY OF PSYCHIATRY MEDICATION ADHERENCE CLINIC (MTAC) AT HOSPITAL TENGKU AMPUAN RAHIMAH (HTAR) KLANG, SELANGOR Khaw P.H., Manimegahlai S., Anusuya K
63
10 THE PRESCRIBING PATTERN OF ANTIHYPERTENSIVES IN PATIENTS WITH CHRONIC RENAL FAILURE. Nur Arina Binti Sariffudin, Tee Xin Yi
76
11 TRAUMA PERGIGIAN KANAK-KANAK DI HOSPITAL SUNGAI BULOH Gunasundari Devi a/p Kumara Rao
89
12 YELLOW FEVER SURVEILLANCE KLIA EXPERIENCE
Azmi AR, Balachandran K., Senthilvasan J., Mohd. Shahir M., Adi Nor Y 97
TABLE OF CONTENT
TABLE OF CONTENT
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
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A Prospective Study On The Adherence Of Human Immunodeficiency Virus (HIV) Patients Towards Highly Active Antiretroviral Therapy (HAART) In Hospital Tengku Ampuan Rahimah, Klang (HTAR) [A Pre-study]
A PROSPECTIVE STUDY ON THE ADHERENCE OF HUMAN IMMUNODEFICIENCY
VIRUS (HIV) PATIENTS TOWARDS HIGHLY ACTIVE ANTIRETROVIRAL THERAPY
(HAART) IN HOSPITAL TENGKU AMPUAN RAHIMAH, KLANG (HTAR) [A PRE-STUDY]
Ko Kar-Maine, Mohammad Zaki bin Yusof, Wong Hon Shen
Department of Pharmacy, Hospital Tengku Ampuan Rahimah, Klang
ABSTRACT
Introduction : Counselling or patient education can provide benefits in terms of patient
compliance and understanding towards a certain disease and its management. In this
prospective pre-baseline study, 31 random patients were interviewed during a 3 month
period at the Retroviral Disease (RVD) clinic Hospital Tengku Ampuan Rahimah (HTAR).
Objective : As the RVD clinic did not have a pharmacist, this study was conducted to
observe the benefits of having a pharmacist in the clinic towards improving the adherence of
the patients to their HAART regime.
Methodology : The data from these patients were compiled and measured and certain
promising data went on to show that patient education was one of the important factors that
played a role towards adherence to HAART.
Results : In general, the patients who were not counselled on HAART before were more
likely to not know much about HIV thus leading to non-compliance which was clearly shown
in the results.
Conclusions : A crosstabulation was done to differentiate whether being counselled on
HAART had significantly contributed to better compliance, and the results proved to show
that counselling done by pharmacists played an important role in patients conformance
towards HAART. However there were a few limitations to the study which included small
sample size and unwillingness of patients to take part in the study.
INTRODUCTION
The HIV/AIDS pandemic has been among the most serious natural disasters in recent
centuries.1,2 Twenty years ago, the subject of HIV, which has been found to be the cause of
AIDS (acquired immunodeficiency syndrome), would not have been the topic of a major and
serious worldwide catastrophe. Over the past 27 years, nearly 25 million people have died
from AIDS1. Malaysia is home to one of the fastest growing AIDS epidemics in the East Asia
and Pacific Region. Between the first detected case in 1986 and 2008, 84,630 men, women
and children have been infected with HIV; while 11,234 have died of AIDS.3 HIV or
AIDS causes debilitating illnesses and leads to premature death in people during their prime
years of life and has devastated families and communities. Through unprecedented global
attention and interventional efforts, the rate of new HIV infections has slowed the prevalence
rates globally. Despite the progress seen in some countries and regions, the total number of
people living with HIV continues to rise. In 2008, globally, about 2 million people died of
AIDS, 33.4 million were living with HIV and 2.7 million people were newly infected with the
virus. 4
In order to address the importance of HIV therapy in HIV patients, a comprehensive measure
is needed that can be used with samples from culturally diverse populations. Therefore, this
paper will assess the patient‟s awareness on knowledge, prejudice, personal risk, and
misconceptions about HIV. This paper aims to enhance the adherence of HIV patient to
treatment by introducing the RVD MTAC. AIDS is a late stage of HIV disease. Medications
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
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A Prospective Study On The Adherence Of Human Immunodeficiency Virus (HIV) Patients Towards Highly Active Antiretroviral Therapy (HAART) In Hospital Tengku Ampuan Rahimah, Klang (HTAR) [A Pre-study]
can help people living with HIV or AIDS live longer, healthier lives.8 To date, HIV patients are
widely treated under HAART, which is a combination of a few antiretroviral drugs.5,8 Some
people have lived for more than 20 years and have taken medicines for more than 10 years.
Specifically, greater adherence is associated with better viral suppression.8,11 Despite good
public healthcare infrastructure and greater availability of antiretroviral drugs in Malaysia
since 2005, the number of HIV-infected patients who have continuously been receiving
treatment remain disproportionately small due to the lack of adherence to the treatment
itself.1,2 This may be due to the lack of awareness on the importance of the treatment.
Recognizing variables associated with adherence is essential in identifying patients at high
risk of being non-adherent in order to develop strategies for improving compliance.
The usual treatment of HIV includes a combination of one Non-nucleoside Reverse
Transcriptase Inhibitor (NNRTI) such as Efavirenz with two Nucleoside Reverse
Transcriptase Inhibitors (NRTI) such as Zidovudine and Lamivudine. This is also known as
the first regimen. Efavirenz plus Indinavir, and Indinavir plus Zidovudine and Lamivudine was
considered as the second regimen if the patient failed or is resistant to the first regimen.
Suppression of plasma HIV-1 RNA to undetectable levels was achieved in patients given
Efavirenz plus Indinavir plus two NRTIs which are 70 percent and 48 percent (P<0.001)
respectively. The efficacy of the regimen of Efavirenz plus Indinavir was similar (53
percent) to that of the regimen of Indinavir, Zidovudine, and Lamivudine. CD4 cell counts
increased significantly with all combinations of antiretroviral (range of increases, 180 to 201
cells per cubic millimeter). 7
Antiretroviral therapy reduces mortality rates in compliant patients infected with HIV by 56
percent in a randomized clinical trial of 642 patients.12 In a 2001 study of 673 mostly poor
patients with HIV in Sao Paolo (Brazil), overall adherence to ARV among participants was
69%.13 Reviews of numerous studies revealed that 95% or greater adherence is necessary in
order to achieve and maintain undetectable viral loads among most patients treated with
highly active antiretroviral therapy (HAART). 11 In the real world of AIDS treatment, only 50%
of patients were positively affected by the HAART treatment. The explanation for this
alarming disparity of results was that "the main reason for these 'failures' was poor
adherence to HAART regimen.6
OBJECTIVES
i) To obtain the baseline knowledge or understanding of the patients regarding HIV and
its treatment (pre counselling study)
ii) To reduce non-compliancy in patients undergoing HAART.
iii) To provide a better understanding of HIV and HIV medications to new patients
starting on HAART.
METHODOLOGY
The study aims to discover the level of understanding and compliance of RVD patients
towards their antiretroviral medications. Previously, there were no pharmacists at the RVD
MTAC in HTAR and this has lead to the possibility of assessing whether the need of a RVD
MTAC pharmacist provides beneficial effects. The ultimate goal of this pre-study is to see
the difference between the patient‟s compliance and the patient‟s level of understanding of
HIV when a pharmacist is involved in the RVD clinic.
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
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A Prospective Study On The Adherence Of Human Immunodeficiency Virus (HIV) Patients Towards Highly Active Antiretroviral Therapy (HAART) In Hospital Tengku Ampuan Rahimah, Klang (HTAR) [A Pre-study]
A questionnaire was constructed by collecting a few sample questions that were used in
other hospitals that had RVD clinics. The questionnaire consists of a few basic questions
regarding HIV and HAART. The questionnaire would consist of 13 questions ranging from
“What is HIV?” to “Reasons for missing/delaying taking off medications?”
Patients were interviewed during the RVD MTAC which was held on every Wednesdays and
Thursdays in HTAR from 2 pm to 5 pm. Patients were asked on their willingness to partake in
the study and their answers were noted in the questionnaire. The duration of the study was
held for 3 months starting from March to June 2010.
The results of the questionnaire were shown by the percentage of the level of understanding
using the SPSS 15.0 for Windows. The demographic data was also correlated with the
results of the questionnaire which would directly or indirectly relate to the understanding and
compliance of the patients towards HAART.
The sample size for this study was 35 patients for both newly diagnosed patients and those
previously on HAART.
Inclusion criteria comprised of:-
i) Patients of different race
a. Malay
b. Chinese
c. Indian
ii) Patients with ages ranging from 20-80 years old
iii) Two different sexes – male and female
iv) Patients confirmed diagnosed with HIV and on HAART
Exclusion criteria
i) Patients who are deaf
ii) Patients who are blind
iii) Patients who were unwilling to participate in this study
The questionnaire would be distributed to the patients to answer by themselves or if patients
are unable to read, the questionnaire would be read to the patients.
RESULTS
The aim of the study was to interview all the patients involved in the HIV clinic but this was
difficult to achieve due to time constraint and unwillingness of patients to cooperate. This
reduced the sample size to 31 patients who were successfully interviewed. There were 19
males and 12 females on HAART and coming from various demographic backgrounds.
Charts 1 to 13 show the frequency of answers from each patient for each question in the
questionnaire.
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
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A Prospective Study On The Adherence Of Human Immunodeficiency Virus (HIV) Patients Towards Highly Active Antiretroviral Therapy (HAART) In Hospital Tengku Ampuan Rahimah, Klang (HTAR) [A Pre-study]
Chart 1: Pie chart showing frequency of patient’s answer to “What is HIV?”
Chart 2: Pie chart showing frequency of answers to question “What is HAART?”
Chart 3: Frequency of answers to question “How long do you need to be on HAART?”
Missing
Virus infection
Infection
AIDS
Weak
antibodies
Disease that
has not
progressed
into AIDS
No immunity
Strong virus in
the body
None curable
illness
Do not know
What is HIV?
Missing
Place for
HIV patients
Do not know
Others
Amtiviral
What is HAART?
Missing
Do not know
Until feeling
well
Life long
How long to take HAART?
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
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A Prospective Study On The Adherence Of Human Immunodeficiency Virus (HIV) Patients Towards Highly Active Antiretroviral Therapy (HAART) In Hospital Tengku Ampuan Rahimah, Klang (HTAR) [A Pre-study]
Chart 4: Frequency of answers to question “How long to take HAART?”
Chart 5: Frequency of answers to question “How long have you been on HAART?”
Chart 6: Frequency of answers to question “Have you been counselled on HAART
before?”
Missing
Do not know
Until feeling
well
Life long
How long to take HAART?
Missing
More than a
year
Less than a
year
How long have you been on HAART?
Missing
No
yes
Counselled on HAART before?
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
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A Prospective Study On The Adherence Of Human Immunodeficiency Virus (HIV) Patients Towards Highly Active Antiretroviral Therapy (HAART) In Hospital Tengku Ampuan Rahimah, Klang (HTAR) [A Pre-study]
Chart 7: Frequency of answers to question “Have you ever missed/delayed taking a
dose?”
Chart 8: Frequency of answers to question “How many times in a month have you
missed/delayed taking a dose?”
Chart 9: Frequency of answers to question “When did you last missed/delayed your
dose?”
Missing
No
Yes
Missed/delayed taking a dose before?
Missing
3-5
1-2
How many times in a month miss/delayed a dose?
Missing
A few
months ago
Last month
Last week
Last 3 days
Yesterday
When did you last miss/delayed a dose?
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
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A Prospective Study On The Adherence Of Human Immunodeficiency Virus (HIV) Patients Towards Highly Active Antiretroviral Therapy (HAART) In Hospital Tengku Ampuan Rahimah, Klang (HTAR) [A Pre-study]
Chart 10: Frequency of answers to question “What are the reasons for
missing/delaying a dose?”
Chart 11: Frequency of answers to question “Do you know about the side effects of
HAART?”
Chart 12: Frequency of answers to question “Where do you store your medication?
Missing
Stomach
ache
Unsuitable
timing
Unwell
Too busy
Forgot
Reasons for missing/delaying a dose?
Missing
Do not know
No
Yes
Do you know about the side effects of HAART?
Missing
Office/house
Cupboard
Floor cabinet
Specific
drawer for
pills
Room
cupboard
Kitchen
Bag
On table
Drawer
Where do you store your medication?
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
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A Prospective Study On The Adherence Of Human Immunodeficiency Virus (HIV) Patients Towards Highly Active Antiretroviral Therapy (HAART) In Hospital Tengku Ampuan Rahimah, Klang (HTAR) [A Pre-study]
Chart 13: Frequency of answers to question “How do you remind yourself to take
medication?”
DISCUSSION
From the results of this study, it was generally seen that the patients who have attended the
RVD clinics were mostly not counselled on HAART before. This led to poorer understanding
of an overview of HIV and HAART as seen from charts 1, 2, 6 and 11. It was shown that the
adherence of patients improved significantly with counselling and adapting HAART regimen
into the lifestyle of the patients.17
Non-adherence to any medical therapy is common and is almost impossible to achieve one
hundred percent compliance in one patient. It is unstable and usually underestimated by
health physicians.14 Many factors come into play towards achieving adherence to therapy.
This is undeniably true in HIV patients taking HAART as non-compliance towards HAART is
common.14,15 Studies have shown that on average 50 – 70% of patients on HAART
regiments are non-adherent to medications.16
Patient education about HAART in the context of an office visit with the physician assistant
and other healthcare providers has become an important component in the design of the
HAART regimen.15
Based on the data analyzed, it was shown that 20% of the respondent knew what HAART
was while 67% of them did not know or had never heard of the word HAART, p = 0.001 from
Pearson Chi-Square (p< 0.0.5 providing significant values). This clearly reflects the lack of
knowledge on the general idea of HIV and its effects. Lack of counselling on the patient‟s
disease and its treatment may be a contributing factor towards non-adherence towards the
patient‟s medications. Patient should be informed and educated on the importance of
understanding their treatment regime as this will increase their adherence and
compliance.5,12 It can be concluded that the importance of counselling RVD MTAC for HIV
patients would hopefully increase patient‟s knowledge and understanding about their own
treatment thus increasing their compliance and reducing the number of missing doses.13
A correlation analysis was also done on patients who have been counselled on HAART
before and their understanding of HAART. The data went on to show that most of the
patients who have been counselled on the RVD treatment knew about the side effects of
their medications. From the survey, 71% of patients who were counselled about HAART
understood its side effects as compared to the 50% who have not had any counselling on
Missing
News
Remember
naturally
Handphone
reminder
Family
members
Alarm clock
How do you remind yourself to take medication?
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
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A Prospective Study On The Adherence Of Human Immunodeficiency Virus (HIV) Patients Towards Highly Active Antiretroviral Therapy (HAART) In Hospital Tengku Ampuan Rahimah, Klang (HTAR) [A Pre-study]
HAART before, p=0.568. This correlates with certain studies showing that by having the
patient educated by healthcare personnels, the overall understanding as such in this case,
the understanding and management of HAART side effects can be thorougly understood by
patient and properly managed.13
Questions 6 and 7 were also extracted for analysis to show the correlation between patients
who were counselled on HAAR on missing/delaying their medications at least once in a
month. The results proved that 19 out of 20 patients who missed their doses are those who
have never been counselled before on HAART. Patients who were counselled on HAART
were found to adhere to their medications. Almost 80% of patient who were not counselled
on HAART often missed their dose, p=0.002. This may be due to the lack of knowledge and
understanding on the importance of taking their medications. According to one study, in the
United States, 50% to 70% of patients do not properly take prescribed medication.5,13 Thus, it
is important to implement proper counselling techniques as this will also help build a trusting
relationship between the patient and healthcare provider. A qualitative study using focus
groups of HIV-positive men and women showed improved adherence when a patient has an
established and trusting relationship with a single healthworker.12 The study also continued to
state that minor increment in adherence of patients led to marked improvement in outcomes.
People from all groups of treated individuals commonly have difficulty maintaining such a
high level of medication adherence. To help patients benefit fully from their treatment,
healthcare providers need to take time to ask about and support medication adherence.12
Our data also went on to show that there were no significant difference correlating and
comparing compliance of older and newer patients against their respective duration of
medication therapy, p=0.135. This could suggest that counselling plays an important role in
differentiating between compliant and non-compliant patients. By providing counselling, the
patient can be educated on the basic knowledge of their illness and treatment. These will
also provide them a general idea on what to expect from their treatment, which consequently
will improved their adherence to the treatment.13 For most patients, near-perfect (>95%)
adherence is necessary to achieve lasting viral suppression.5, 12, 13
This study also analyzed correlation between sex, race, working status, and marital status
against patients missing their HAART doses. All these demographic factors were found to
not have a significant impact on their missing doses with a p-value of 0.179, 0.066, 0.717,
0.676 in the same order.
There were 3 types of education level in the sample size whereby 4 patients reached primary
level, 21 secondary and 6 tertiary levels. Out of these, some patients missed a few doses
and some claimed to have never missed a single dose of their HAART medication. The
result between education level and whether patients missed their doses was calculated and
was shown to not have a significant effect (p = 0.507) This is comparable to a study showing
that having a high school or higher education level is not associated with the decision to start
HAART regimen but depended on the belief of the patient on their health status and ability to
master that regimen as well as clinical status.18 Another study also showed that education
level proved to be not statistically significant when associated with adherence to
antiretrovirals.19
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
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A Prospective Study On The Adherence Of Human Immunodeficiency Virus (HIV) Patients Towards Highly Active Antiretroviral Therapy (HAART) In Hospital Tengku Ampuan Rahimah, Klang (HTAR) [A Pre-study]
Limitations Of The Study
The small sample size could only provide limited statistical data. This limitation could be due
to patients‟ unwillingness to take part in this study and the limited time to collect the data
during HIV clinics as they are held every Wednesday and Thursday afternoon.
CONCLUSION
This sudy has shown,that providing patients with proper education in the form of counselling
would increase the patients adherence and understanding which ultimately leads to a better
treatment outcome.
Therefore, it can be safely presumed that the role of a HIV MTAC pharmacist plays an
important role in increasing the adherence and the basic understanding of what is HIV and
it‟s management in the RVD clinic at HTAR.
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mortality-rates-in-patients-co-infected-with-HIV-and-TB.aspx
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
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status, and initiation of HAART (highly active antiretroviral therapy) in adolescents.
Journal of Adolescent Health 2001 Voulme 29 (Issue 3) Supplement 1: 115-122
19. Ogundahunsi O.A, Daniel OJ, Oladapo OT. Adherence to antiretroviral drugs among
AIDS patients in Sagamu, Nigeria. International Journal of Biomedical and Health
Sciences, 2008 Volume 4 (Issue 2): 41-45
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
12 An Audit On Diabetic Foot Care Campaign – Does It Help?
AN AUDIT ON DIABETIC FOOT CARE CAMPAIGN - DOES IT HELP?
Norsabrina Sabri MD (UPM), Felix Loong Yew Seng MBBS (Malaya),
MS Orthopaedic (UKM)
Department of Orthopaedics, Hospital Ampang, Selangor
ABSTRACT
Introduction : The prevalence of diabetes mellitus in our country is on the rise along with its
complications. Orthopaedic department in Ampang Hospital encounters more and more
diabetic foot cases and some are newly diagnosed case of diabetes. Some patients are
indicated for ray amputation; however some delay their decisions and prolonged hospital
stay. A course regarding management of amputee was organized and wish to improve health
care providers‟ mindset. This is in turn hoped to help in counseling patients they attended
and help patients to make rational decision.
Objective : To determine whether diabetic foot care awareness campaign will help us in
managing diabetic foot ulcer and thereby reducing the cost of management in this group of
patients.
Methodology : Data was gathered from patients presented to us 5 months prior and 5
months after the campaign. The patients whom will respond to ray amputation and IV
antibiotics were selected. The comparison of how many patients agreed for the proposed op
on 1st advice pre and post campaign was made. The cost involved on prolonged hospital stay
has also looked into.
Results : There are 19 patients prior to campaign and 13 patients after the campaign. Pre-
campaign, 10.5% of patients agreed for Ray on 1st advice and 21.1% took almost a day to
decide. Post campaign, 76.9% of patients agreed for op on 1st advice. Average hospital stay
pre-campaign is 10 days while post-campaign is 3.6 days.
Conclusion : Better understanding among health care providers help them to counsel
patients regarding their condition and help patients to make decisions. Earlier surgery leads
to earlier discharge and obviously cutting the cost hospital has to bear.
INTRODUCTION
Diabetes mellitus prevalence rate in Malaysia has risen much faster than expected, almost
doubling the magnitude over the last decade which obviously causing the rise in diabetic
complications [1]. One of the debilitating complication is diabetic foot infection. Foot
infections in persons with diabetes are a common, complex, and costly problem [2-5].
Orthopaedic department in Ampang Hospital particularly, encounters more and more diabetic
foot cases and some are newly diagnosed diabetes mellitus. Some patients require ray
amputation of the toes. Early surgery purportedly leads to early discharge, better wound
outcome and eventually reduces the cost that hospital has to bear. One of the common
problems faced is that some patients delay their decisions which lead to delayed
intervention, more complicated management thus prolonging hospital stay. We have
organized a workshop regarding management of amputee and wish to improve health care
providers‟ mindset in terms of perception towards amputees. We hope that this will in turn
help them to counsel patients they attended and encourage patients to make rational
decision.
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
13 An Audit On Diabetic Foot Care Campaign – Does It Help?
METHODOLOGY
Data were gathered from patients presented to us 5 months prior and 5 months after the
campaign. Patients with ulcer Wagner class 3 (deep ulcer with abscess or osteomyelitis)
whom expected to respond to ray amputation and IV antibiotics were chosen. Number of
patients agreed for the proposed op on 1st advice pre and post campaign was compared.
The cost involved on prolonged hospital stay has also looked into.
Inclusion criteria:
• Diabetic patients
• Ulcer: Wagner class 3
• Infection is indicated for Ray amputation
• Stable
• No other illnesses requiring hospitalization
• Fit to give consent, sound mind
Exclusion criteria:
• Unstable, septic patients
• Needs more aggressive surgical procedure than Ray amputation
• Expected for repeated debridements
• Concurrent illness requiring hospitalization
Categories Cost
Simple dressing RM 24.60
IV Unasyn RM 27.00
Food RM22.50(4 meals/day)
Estimated minimum cost per day : RM 74.10 per patient
RESULTS
There are 19 patients prior to campaign and 13 patients after the campaign. Pre-campaign,
an estimated total of RM 4823.70 spent (simple dressing, IV Unasyn and meals) with
average of RM 253.88 per patient. Average length of stay was 10 days. Out of 19 patients,
10.5% of patients agreed for ray amputation on 1st advice (2 patients) and 21.1% took almost
a day to decide whereas the rest (13 patients) delayed their decision for 1-2 days. Post-
campaign, 76.9% of patients (10 patients) agreed for op on 1st advice with average length of
stay is 3.6 days.
Timing of decision making
0
5
10
15
A B C
24
1310
2 1
Precampaign Postcampaign
A: Agree on 1st advise
B: Delay decision by 24 hours C: Delay decision 1-2 days
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
14 An Audit On Diabetic Foot Care Campaign – Does It Help?
Average length of stay
DISCUSSION
In this short small-sampled clinical audit, whether organizing awareness campaign will help
in managing diabetic foot ulcer was looked into. The campaign was targeted to the
paramedics whom are the first-liners managing simple wounds in the peripheral settings.
This is in turn hoped to help them in counseling patients who are indicated for early simple
surgery and patient already have better understanding of the surgery itself when they come
to be assessed by the orthopaedic team. The responds were quite good though numbers are
small. Brochures and posters used were found to be helpful in improving patients‟
perspective towards early surgical intervention.
CONCLUSION
Better understanding among health care providers help them to counsel patients regarding
their condition and help patients to make decisions. Earlier surgery leads to earlier discharge
and obviously cutting the cost hospital has to bear. We hope to implement this kind of
workshop as a biannual program and aim to a larger group of healthcare providers as well as
diabetic population themselves.
REFERENCES
1. Zanariah H, Chandran LR , Wan Mohamad WB, Wan Nazaimoon WM, Letchuman GR,
Jamaiyah H, Fatanah I, Nurain MN, Helen Tee GH, Mohd Rodi. NHMS III Diabetes
Study Group, Ministry of Health, Malaysia. Universiti Sains Malaysia, 2006.
2. Lipsky BA. A report from the international consensus on diagnosing and treating the
infected diabetic foot. Diabetes Metab Res Rev 2004; 20(l1):68-77
3. Jeffcoate WJ, Harding KG. Diabetic foot ulcers. Lancet 2003; 361:1545-51
4. Tennvall GR, Apelqvist J, Eneroth M. Costs of deep foot infections in patients with
diabetes mellitus. Pharmacoeconomics 2000; 18:225-38
5. Ramsey SD, Newton K, Blough D, et al. Incidence, outcomes, and cost of foot ulcers in
patients with diabetes. Diabetes Care 1999; 22:382-7
0
2
4
6
8
10
Precampaign Postcampaign
No of days
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
15 An Audit On Reducing “Against The Rule Astigmatism” In Superior Incision Phacoemulsification
AN AUDIT ON REDUCING “AGAINST THE RULE ASTIGMATISM” IN SUPERIOR
INCISION PHACOEMULSIFICATION
Zalifa Zakiah Asnir MD (UKM),MS Ophthalmology (UKM), Duratul Ain Hussin B. Optom
(UKM), MHsc. Optom (UKM), Rusnah Hussain MD (UKM),MS Ophthalmology (UKM)
Department of Ophthalmology, Hospital Ampang, Selangor
ABSTRACT
Introduction : Significant attention is focused on attaining a good post-operative refractive
outcomes in superior incision phacoemulsification, especially in reducing Against the Rule
(ATR) astigmatism.
Objective : The purpose of this audit is to compare the amount of ATR astigmatism (Diopter
Cylinder) between sutured versus unsutured superior corneal incision phacoemulsification.
Methodology : This audit was conducted between January to December 2009, in Hospital
Ampang, Selangor, based on the patients data of phacoemulsification surgery performed by
one surgeon. Data collections were done in 2 phase. Group one were patients with ATR
astigmatism who underwent sutureless superior corneal incision in the first half of the year
while group two were patients with ATR astigmatism who underwent phacoemulsification
with sutured superior corneal incision during second half of the year. Pre–operative and post-
operative data on amount of astigmatism (DC) were obtained for analysis.
Results : Preoperatively, the mean astigmatism was 1.05 ± 0.51 DC in group one and 1.08
± 0.71 DC in group two. At twelve weeks postoperatively, mean astigmatism for group one
had increased to 2.15 ± 1.32 DC (P= 0.007) but the amount was reduced in group two, 1.00
± 0.58 DC (p= 0.804).
Conclusion : Applying a suture on superior corneal incision wound is a helpful technique to
correct pre-existing ATR astigmatism in superior incision phacoemulsification.
INTRODUCTION
Astigmatism may cause blurred vision, glare sensation, monocular diplopia, asthenopia and
visual aberrations. Regular astigmatism can be divided into With-the-rule (WTR)
astigmatism, Against-the-rule (ATR) astigmatism and the less common Oblique astigmatism
(Benjamin WJ 2006). There are numerous techniques to correct astigmatism at the time of
cataract surgery; the simplest being to place the main corneal incision along the steep
corneal meridian (Gusowski M. et al 2002). Corneal incisions cause flattening of the incised
meridian. In With-the-rule astigmatism, the vertical meridian is steepest (an American
football lying on its side), therefore a superior clear cornea incision is adequate enough to
reduce the astigmatism. Whereas in Against-the-rule astigmatism (an American football
standing on its end), temporal clear cornea incision is necessary.
However, in a clinical setting where temporal incision is not perform due to rectangular
operating theater (OT) table, small OT space, and surgeon preference, superior incision will
still be performed. This will result in further increase in the pre-existing ATR astigmatism
(Morlet M. et al 2001). A clinical audit of our surgical visual outcome in mid 2009 showed
significant amount of ATR astigmatism among our post superior incision phacoemulsification
patients. The effect of this would mean unsatisfactory vision, resulting in potential unsatisfied
patients in Eye Clinic, Hospital Ampang.
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
16 An Audit On Reducing “Against The Rule Astigmatism” In Superior Incision Phacoemulsification
Gimbel HV et al (1993) and Bazzazi N. et al (2008) have commented in their study that in
those patients with ATR astigmatism that underwent superior incision phacoemulsification,
suturing the wound significantly reduced the astigmatism. Therefore for the second half of
year 2009, we had sutured all the superior incision wound of patients that have ATR
astigmatism. At the end of the year, our department have done a clinical audit to compare
the astigmatism outcome post superior incision phacoemulsification in patients with ATR
astigmatism who underwent sutureless wound in the 1st half of 2009 compare to those
sutured wound in the 2nd half of 2009.
Currently, those patients with post op significant ATR astigmatism may require spectacles to
obtain better vision. Thus with this audit we hope to reduced the post-operative astigmatism,
therefore improving the unaided visual acuity and reduce the need for corrective glasses post
cataract surgery.
OBJECTIVE
The audit was to compare the amount of ATR astigmatism (Diopter Cylinder) between
sutured versus unsutured group of patients who underwent superior corneal incision
phacoemulsification.
METHODOLOGY
The study comprised of 2 parts :
1. Restrospective clinical audit of astigmatism outcome on all patients with ATR
astigmatism who underwent sutureless superior incision phacoemulsification from
January till June 2009 by a single surgeon.
2. Prospective clinical audit were performed on all patients with ATR astigmatism who
were planned for superior incision phacoemulsification from July till Dec 2009. These
patients were identified preopeperatively. A single suture was put on the superior
phacoemulsification wound upon completion of surgery. Refraction was performed at
3 month post surgery. Results were documented. Analysis made.
Exclusion Criteria
1. History of ocular comorbidity
2. Other Intra-operative complications
3. Post-operative infections
4. Incomplete / missing 12 weeks clinical notes
RESULTS
All data were calculated for descriptive purposes and dependant t-test was performed using
SPSS software version 17.
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
17 An Audit On Reducing “Against The Rule Astigmatism” In Superior Incision Phacoemulsification
Demographic No of patients Percentage (%)
Group Sutureless 9 41.0
Suture 13 59.0
Gender Female 15 68.2
Male 7 31.8
Race
Chinese 15 68.2
Malay 4 18.2
Indian 3 13.6
Age (years old)
50-59 2 9.0
60-69 2 9.0
70-79 18 82.0
Pre-operative Astigmatism
Technique N Mean S.D Std. Error Mean
Pre-operative
Astigmatism
Sutureless 9 1.05 0.51 0.17
Suture 13 1.07 0.71 0.19
The mean amount of astigmatism preoperatively for the sutureless group was 1.05 ± 0.51
DC, while for the suture group was 1.08 ± 0.71 DC.
dependent t–test : t = 0.936, p >0.05.
Post-operative astigmatism
Technique N Mean SD Std. Error Mean
Post Operative
Astigmatism
No Suture 9 2.15 1.32 0.44
Suture 13 1.00 0.58 0.16
The mean amount of astigmatism postoperatively for was higher in the sutureless group,
2.15 ± 1.32 DC as compared to the suture group, 1.00 ± 0.58 DC.
dependent t–test : t = 0.011, p < 0.05.
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
18 An Audit On Reducing “Against The Rule Astigmatism” In Superior Incision Phacoemulsification
DISCUSSION
In our study, we noted that there is preponderance for female to have ATR astigmatism. The
ratio is 2:1. However, this finding is not similar to a study by Goto T et al (2001) who reported
that male have a higher potential to develop ATR astigmatism.
More than 50% of the study populations were Chinese. Malays and Indians were similar in
percentage. This reflects the local population in the community that Hospital Ampang serves.
We observed that the higher age group has more tendencies to have ATR astigmatism.
Etiology of astigmatism is unknown but it is suggested that eyelid tension steepen the vertical
cornea meridian. However, ATR astigmatism is experienced by person aged over 40 years
old because there is a decrease in the lid tension as we get older (Benjamin WJ 2006).
The amount of astigmatism for both groups before surgery was similar, no significant
difference. However, our study showed that after surgery, the suture group has a significantly
lower amount of astigmatism if compared to the no suture group. This supports the findings
by Gimbel HV et al (1993) that adding a suture to the superior incision in a patient with ATR
astigmatism is beneficial. The suture helps in steepening the vertical meridian once rendered
flattened by the incision.
CONCLUSION
In conclusion our study showed that suturing the main wound in superior incision
phacoemulsification reduces the amount of post-operative ATR astigmatism. Reduced
astigmatism means better unaided vision. Thus, it can minimize financial burden for patient
to purchase glasses. This technique is another option other than temporal wound approach.
REFERENCES
1. Benjamin WJ. Borish clinical refraction. Boston : Butterworths Heinemann : 2006
2. Gusowski M, Rochtchina E, Wang JJ, Mitchell P. Refractive changes following cataract
surgery: the Blue Mountain Eye Study. Clinical Experiment Ophthalmol 2002; 30:159-
162
3. Morlet M, Minassian D, Dart John. Astigmatism and the analysis of its surgical correction.
British J Ophthalmol 2001; 85:1127-1138
4 Gimbel HV, Sun R. Postoperative Astigmatism following phacoemulsification with sutured
versus unsutured wound. Can J Ophthalmol. 1993; 28(6):259-262
5. Bazzazi N, Barazandeh B, Kashani M, Rasouli M. Opposite clear corneal incisions versus
steep meridian incision phacoemulsification for correction of pre-existing astigmatism. J
Ophthalmic Vis Res 2008; 3(2):87-90
6. Goto T, Klyce SD, Zheng X, Maeda N. Gender and age related differences in corneal
topography. Cornea 2001; 20(3):270-276
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
19 Comparison Of Fondaparinux And Enoxaparin Use For Acute Coronary Syndrome In Hospital Sungai Buloh
COMPARISON OF FONDAPARINUX AND ENOXAPARIN USE FOR
ACUTE CORONARY SYNDROME IN HOSPITAL SUNGAI BULOH
Arulappu JJ, Sia HP, Pang CW
Pharmacy Department , Sungai Buloh Hospital
ABSTRACT
Introduction : Fondaparinux and Enoxaparin are parenteral anticoagulants used for the
resolution of acute coronary syndromes (ACS). It has been demonstrated that
Fondaparinux has similar efficacy with fewer bleeding incidences and severity versus
Enoxaparin in ACS treatment. However, there was a noted increase in readmissions
amongst Fondaparinux treated patients in Hospital Sungai Buloh (HSB).
Objective : To determine whether Fondaparinux increases the risk of subsequent
readmissions, death and bleeding incidences versus Enoxaparin, the clinical
effectiveness of both agents and the correlation between treatment duration and
readmission rates.
Methodology : An eight week pilot prospective study was performed to test a suitable
study protocol to compare effectiveness and subsequent readmission rates amongst
ACS patients treated with these drugs in HSB from April to May 2011. The list of patients
was obtained via cross-referencing the dispensing records and the respective patient‟s
medical case notes through the e-HIS system. Patient‟s background, past medical
history, current medical progress, duration of treatment, Creatinine Kinase changes and
coagulation profile parameters were determined and monitored throughout the duration of
admission. At the end of the study, all the respective patient records were reviewed for
subsequent readmissions with any reasons for readmission being noted.
Results :Fondaparinux was more commonly used during the study period
(Fondaparinux= 84 patients, Enoxaparin =11 patients). The mean duration of treatment
was similar for both Fondaparinux and Enoxaparin (Fondaparinux: 3.1 days, Enoxaparin:
3.4 days). Similar short term readmission rates were observed, regardless of treatment
with Fondaparinux and Enoxaparin. (9.5 % versus 9.1%). There was a significant
reduction in cretinine kinase from baseline among patients treated with these agents
(p<0.05). Only one rebleeding episode and six fatalities were observed with
Fondaparinux. These readmissions and mortalities were not due to recurrent ACS
events. All patients treated with Enoxaparin were discharged without any complications.
Conclusion : The use of Fondaparinux has similar efficacy in resolving ACS events
versus Enoxaparin, with similar readmission rates following treatment. Thus, the current
practice of a three day Fondaparinux regiment should be continued for treating ACS in
non-renal impaired patients.
INTRODUCTION
Acute Coronary Syndrome (ACS) defines a spectrum of clinical presentations. It is
classified into ST-elevation myocardial infacrtion (STEMI) or non-ST-elevation myocardial
infarction (NSTEMI) and unstable angina (UA) based on levels of cardiac enzyme
markers (troponin and creatinine kinase) and ischemic symptoms.1,2,3,4 ACS is triggered
by impaired perfusion of myocardial tissue, mainly via thrombosis of coronary arteries.
The parental anticoagulants Fondaparinux and Enoxaparin resolve and prevent further
thrombus formation, treating ACS. Enoxaparin is a low molecular weight heparin
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
20 Comparison Of Fondaparinux And Enoxaparin Use For Acute Coronary Syndrome In Hospital Sungai Buloh
(LMWH) that increases anticoagulant effects of Antithrombin III.1,2 Fondaparinux inhibits
formation of activated Factor X, thus reduces formation of thrombin needed for
coagulation. 1,2 The Organization to Assess Strategies in Acute Ischemic Syndromes
(OASIS) 5 studies showed Fondaparinux has similar efficacy in resolving ACS (8.0
versus 8.6 % mortality and risk of recurrent MI)with significantly lower bleeding risks
(2.2% versus 4.1%)5 versus Enoxaparin. Current clinical guidelines advocate the use of
either Fondaparinux or Enoxaparin in treatment of UA, NSTEMI, and treating STEMI
events unresolved with prior thrombolytic agents such as Streptokinase, Alteplase or
Tenecteplase.1, 2, 3, 4
In Sungai Buloh Hospital (HSB), Fondaparinux is preferred due to its simpler once daily
dosing regimen (weight independent) and lower cost versus Enoxaparin
(Fondaparinux:RM 19.65/syringe vs. Enoxaparin RM 39.69/40mg syringe or RM
48.55/60mg syringe). Fondaparinux is porcine free, unlike Enoxaparin, thus making it
suitable for Muslim patients. 3, 4. However, increased readmissions were seen in patients
previously treated with Fondaparinux versus Enoxaparin in HSB for ACS events.
METHODOLOGY
This pilot project was carried out using a prospective study model. This short study was
performed to determine whether Fondaparinux truly increases risk of subsequent
readmissions, death and bleeding incidences versus Enoxaparin. The clinical
effectiveness of Fondaparinux and Enoxaparin was examined and compared via changes
in patients Creatinine Kinase levels. Finally, treatment duration of Fondaparinux or
Enoxaparin and subsequent readmissions were examined to detect any correlation
between treatment duration and readmission rates.
The data collected was for admitted patients diagnosed with acute coronary syndrome
and initiated treatment on Fondaparinux and Enoxaparin from 1 April 2011 to 27 May
2011 (8 weeks). The list of patients was obtained via cross-referencing the dispensing
records of Fondaparinux and Enoxaparin and the respective patient‟s medical case notes
through the e-HIS system. Only patients in the medical wards 4A, 4D and the Cardiac
Care Unit (CCU) were studied, as ACS patients are admitted to these wards.
Patient‟s background, past medical history, current medical progress and duration of
treatment with Fondaparinux or Enoxpaarin were determined, followed up and recorded.
The patients‟ Creatinine Kinase changes and coagulation profile parameters, namely the
patient‟s International Normalised Ratio (INR) and Haemoglobin (Hb) levels were
monitored throughout the duration of admission. At the end of the study, all the
respective patient records were traced back to see if there were any subsequent
readmissions throughout the period of the study, with any reasons for readmission being
noted and recorded to determine if readmission were due to recurrence of ACS. The lab
results (CK, Hb and INR values) at the start and end of treatment were compared with a
paired t-test.
Inclusion and Exclusion Criteria
The main inclusion criteria are that patients studied were diagnosed with Acute Coronary
Syndrome (ACS) and started on Fondaparinux or Enoxaparin. Patients treated for Deep
Vein Thrombosis and Pulmonary Embolism were excluded. Patients were excluded if
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
21 Comparison Of Fondaparinux And Enoxaparin Use For Acute Coronary Syndrome In Hospital Sungai Buloh
Fondaparinux and Enoxaparin was interchangeably used during treatment. Furthermore,
patients treated for less than two days with Fondaparinux or Enoxaparin were excluded.
Patients with severe renal impairment (Creatinine clearance (CrCl) of <30ml/min) were
excluded as Fondaparinux is contraindicated in severe renal impairment. Pregnant
patients and those currently on other anticoagulant treatments except prior streptokinase,
alteplase and tenecteplase for STEMI were excluded.
RESULTS
.
A total of 95 patients were observed during this study. 51% were diagnosed with Unstable
angina, 42% with NSTEMI and 6% with STEMI. Fondaparinux treatment was initiated in 84
patients and 11 patients were treated with Enoxaparin.
Figure 2: Comparison between number of patients on Fondaparinux and on
Enoxaparin
6.32%
42.11%51.58%
Figure 1: Percentage of Unstable Angina, NSTEMI and STEMI in patients (N=95)
STEMI NONSTEMI UNSTABLE ANGINA
84
11
0 10 20 30 40 50 60 70 80 90
Number of patients
Dru
g U
sed
Enoxaparin Fondaparinux
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
22 Comparison Of Fondaparinux And Enoxaparin Use For Acute Coronary Syndrome In Hospital Sungai Buloh
Figure 3: Percentage of patients versus duration of Fondaparinux treatment
Figure 4: Percentage of patients versus duration of Enoxaparin treatment
The duration of treatment ranged from two to five days, Majority of patients in both
groups were treated for 3 days {Fondaparinux (71.4%), Enoxaparin (54.5%)}. A
subsequent two tailed- test showed no significant difference in the mean duration of
Fondaparinux or Enoxaparin treatment. [3.1786(Fondaparinux) vs. 3.455 (Enoxaparin),
p= 0.365 (p>0.05%)
Table 1: Summary of treatment efficacy of Fondaparinux and Enoxaparin
Drug Changes in CK levels Comments
Fondaparinux -300.9 + 647.8,
(p= 0.000)
95% CI:(154.9,-447.0)
Only 78 patients with repeated CK
readings
Enoxaparin -201 + 333
p= 0.073
95% CI :(-22, 425)
Excluding outlier value:
259.5 + 286.7 ,p=0.019
95% CI :(54.4, 464.6)
0%
10%
20%
30%
40%
50%
60%
70%
80%
Days on Fondaparinux treatment
9.50%
71.40%
10.70% 8.30%
pe
rce
nta
ge o
f p
atie
nts
2 days 3 days 4 days 5 days
0%
10%
20%
30%
40%
50%
60%
Days on Enoxaparin treatment
9.10%
54.50%
18.20% 18.20%
pe
rce
nta
ge o
f p
atie
nts
2 days 3 days 4 days 5 days
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
23 Comparison Of Fondaparinux And Enoxaparin Use For Acute Coronary Syndrome In Hospital Sungai Buloh
Table 1 shows mean Creatinine Kinase values were reduced by 300 points with
Fondaparinux and 201 points with Enoxaparin treatment. These reductions are clinically and
statistically significant, (p<0.05).
Table 2: Baseline Haemoglobin and International Normalised Ratio of treated patients
Table 3: Summary of Changes in patients Haemoglobin and International Normalised
Ratio on Fondaparinux and Enoxaparin
The observed Haemoglobin and INR values in the patients were at normal levels, prior to
Fondaparinux or Enoxaparin treatment. Most patients‟ Haemoglobin and INR values were
not followed up due to short duration of admission. Statistically insignificant changes were
seen in Haemoglobin and INR values after treatment with these drugs. These results are not
reliable since Hb and INR values were only followed up in a fraction of the studied patients.
Table 4: Summary of patient’s outcomes following Fondaparinux and Enoxaparin
treatment
Table 5: Comparison of readmission rate versus treatment duration with Fondaparinux
Drug Duration of
treatment
Readmissions % Readmissions over treated
patients
Fondaparinux 3 7 11.67
4 1 11.1
Coagulation Marker Sample No Baseline Mean
Hb 66 13.876 + 1.891 , 95% CI: (13.876 + 1.891)
INR 46 1.0887 + 0.1878, 95% CI : (1.0329, 1.1445)
Monitored
parameter No Drug Baseline mean Changes
Haemoglobin 27 Fondaparinux 14.167 + 2.047 0.167 +1.532
95% CI :(-0.439, 0.773)
p=0.577
6 Enoxaparin 13.5 + 2.86
P=0.2
-0.333 + 1.258,
95% CI :(-3.459, 2.792)
p = 0.691
International
Normalised
Ratio (INR)
4 Fondaparinux 1.310 + 0.341 0.242 + 0.333
95% CI: (-0.288, 0.773)
p=0.242
1 Enoxaparin Unable to perform statistical analysis
Initial INR = 0.99
End INR: 1.02
Drug Discharged Deaths Bleeding Readmissions
Fondaparinux 80 6 1 8
Enoxaparin 11 0 0 1
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
24 Comparison Of Fondaparinux And Enoxaparin Use For Acute Coronary Syndrome In Hospital Sungai Buloh
Multiple outcomes were observed in some patients, especially successful discharges prior to
later readmissions. The bleeding episode was successfully resolved and patient was later
discharged. A 100% discharge rate was seen with Enoxaparin and 95% (80/84) discharge
rate with Fondparinux. Six fatalities were observed with Fondaparinux treatment. However, it
was attributed to non-ACS causes, namely stroke, sepsis and Hospital Acquired Pneumonia.
Only one patient was readmitted after treatment with Enoxaparin. Eight patients were
readmitted after Fondaparinux treatment. The readmission rates observed in Fondaparinux
were similar regardless of the duration of treatment. The higher readmissions in
Fondaparinux were due to sample size.
Both Fondaparinux and Enoxaparin demonstrated efficacy in resolving ACS, with
Fondaparinux linked to a greater reduction in CK values. Furthermore, the total readmission
rate was less with fondaparinux versus enoxaparin (9.5% versus 9.1%). Majority of the
patients studied presented with unstable angina and NSTEMI. Furthermore, no fatalities or
bleeding episodes were seen in Enoxaparin treated patients, unlike six fatalities and one
bleeding episode with Fondaparinux.
DISCUSSION
The findings of the study corroborates past findings that Fondaparinux and Enoxaparin are
effective treatments of Acute Coronary Syndrome (ACS) events. The majority of patients
were diagnosed with Unstable Angina (51.58%) and NSTEMI (42.1%), thus following the
recommended treatment guidelines for ACS 7. The significant reduction in patients
Creatinine Kinase values proved that ACS events were resolved. Furthermore, patients
presenting with Unstable Angina presented CK values within the normal range throughout
admission have lower mortality rates 1, 2. This corroborates with the results of a study
associating low CK levels with reduced MI recurrence and fatality. (14% risk when CK values
are 2X the normal range versus 10% when CK values are within normal range)7. The short
mean treatment duration of 3.1 days on Fondaparinux and 3.4 days on Enoxaparin
respectively did not compromise treatment efficacy. It also clinically demonstrated that the
recommended Fondaparinux and Enoxaparin treatment period for two to eight days
successfully resolves ACS events.
Four out of the six deaths observed in the Fondaparinux group were in STEMI patients. This
corroborates findings that STEMI patients have higher mortality rates,(9.7%,2.3%) 5.6.
Furthermore, the bleeding episode observed (1.1%) matches the 2.3% bleeding rate in the
OASIS 5 study 5. The observed mortality rate (7.1%) is similarwith the OASIS 5 study (5.8%)
rather than the OASIS 6 study 5, 6. This is since most patients were treated for UA and
NSTEMI, rather than STEMI. The absence of recurrent ACS event may be due to the short
duration of the study (2 months) versus the OASIS 5 study of 6 months and the small sample
size versus that used in OASIS 5 ( 84 versus 20078 patients)5,6.
The imbalanced ratio of Fondaparinux to Enoxaparin prevents direct and accurate
comparison between the drugs, unlike the OASIS 5 study. There were no fatalities, recurrent
ACS or bleeding incidences observed in patients treated on Enoxaparin, and only one case
of readmission. The results do not corroborate with the OASIS 5 results of increased
bleeding and mortality risks from Enoxaparin as compared to Fondaparinux (9.0 % versus
7.3% )5. This may be due to the small sample size studied. Furthermore, these results
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
25 Comparison Of Fondaparinux And Enoxaparin Use For Acute Coronary Syndrome In Hospital Sungai Buloh
colludes with the ACUTE and TIMI studies, which show a 1.9-2% bleeding rate in
Enoxaparin treated patients , with 5% reinfarction rate and a 9% mortality rate. 8.9.
The absence of reinfarctions and one bleeding episode may be due to the small sample
size10,11,12. This corroborates with the overall bleeding rate of 3.9 % observed in the GRACE
studies and 4.3% in the ACQUITY trial.11,12.Majority of the patients studied are diagnosed
with NSTEMI (4.7%) and UA (2.3%), that have lower rebleeding and mortality rates versus
STEMI (4.8%)11,12. Furthermore, the absence of Percutaneous Coronary Intervention (PCI)
treatment in HSB contributes to low bleeding rates. The GRACE study demonstrated that
PCI is linked to increased bleeding rates (6.0 with PCI versus 3.2% without OCI)12. The
baseline patient INR values were not elevated indicating unincreased bleeding risks. This
contributes to the low mortality rate seen, predicted by mortality results from the ACQUITY
trial (7.3% in major bleeding versus 1.2% in no major bleeding) 11. The studied patients were
at a low risk of bleeding episodes, as they lack renal impairment (6.5 versus 3.7%), and
anaemia ,associated with increased bleeding and mortality risks.10,12The six fatalities and
nine readmissions observed were due to other causes (:eg: Hospital Acquired Pneumonia
and Stroke). Thus, neither Fondaparinux nor Enoxaparin directly contributes to short term
post ACS mortality rates.
Limitations
The pilot study demonstrated that a progressive model study was not suitable to compare the
readmission rate in patients. This study was limited by the short study duration of two
months. Other studies involving Fondaparinux and Enoxaparin in ACS were for at least three
months 5.6. Thus, long term recurrence rates of myocardial infarction, readmission rates and
mortality could not be determined.
Another limitation is the small sample size (N= 95) patients. This will compensate for the
small predicted rate of recurrent ACS (less than 10%). Furthermore, the ratio of
Fondaparinux to Enoxaparin was 7.6:1, so the direct comparison between the two drugs
without prior extrapolation of the Enoxaparin results. The proceeding study should have at
least 200 patients, with an equal number of patients treated with Fondparinux or Enoxaprin
respectively. This will allow a direct comparison between the drugs and detection of the
actual ACS recurrence rates in patients.
Furthermore, patient‟s weight was estimated upon admission. Thus, their predicted renal
function may be inaccurate. Thus, patients with severe renal failure may be unintentionally
included. Thus, patient‟s weight should be taken upon admission to determine patient‟s renal
function. Patients CK, Hb and INR values were sometimes not recorded daily. Thus, the true
trend in patients ACS resolution and bleeding risks was not obtained. So, these biological
markers should be taken daily in the following study.
Finally, the patient‟s medical history was only obtained from family members and past
admissions in Hospital Sungai Buloh. Thus, it may be incomplete and failed to include prior
ACS triggered admissions in other hospitals. Furthermore, the true recurrence rate of ACS
and readmission of patients remains unknown as most patients were either transferred to or
followed up at other hospitals. The following study should include collaboration with other
hospitals to detect subsequent admissions to determine the true recurrence rate of ACS.
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
26 Comparison Of Fondaparinux And Enoxaparin Use For Acute Coronary Syndrome In Hospital Sungai Buloh
Thus, based on these limitations, the best model is a retrospective double blind study with
roughly equal numbers of patients on Fondaparinux and Enoxaparin from December 2010 to
February 2011, while recording any subsequent readmissions and recurrence of ACS from
December 2010 to May 2011.
CONCLUSION
Although this pilot study was flawed, it still demonstrated that Fondaparinux and Enoxaparin
were effective in resolving ACS events in patients in HSB. The shorter duration of treatment
did not adversely affect patient outcome, as demonstrated by the reductions in patients CK
values. Both drugs did not significantly increase bleeding risk due to insignificant changes in
Haemoglobin and INR values. The readmission rates, though more in Fondaparinux were
similar between both drugs. Fondaparinux was linked to a small risk of bleeding (1/84).
There were no treatment failures with any readmissions or fatalities due to recurrent ACS.
Conclusively, Fondaparinux does not have higher short term readmission rates and bleeding
incidences versus Enoxaparin. Thus, current three day protocol of Fondaparinux treatment of
ACS in patients with normal renal function is safe and should be maintained.
REFERENCES
1) SIGN guideline 93: Acute Coronary Syndrome (ACS), 2007, NHS Scotland
2), Jean-Pierre.B, Hamm.C, Ardisinno.C, Boersma.E, Budaj.A, Hadsai.D, et al, Guidelines for
the diagnosis and treatment of non-ST elevation Acute coronary Syndromes, The Task Force
for the Diagnosis and Treatment of Non-ST elevated Acute Coronary Syndromes of the
European Society of Cardiology . European heart journal 2007;28:1598-1660
3) Malaysian Ministry of Health Clinical Practice Guidelines on the Management of ST
Elevated Myocardial Infarction, 2007, (MOH/P/PAK/127.07
4) Malaysian Ministry of Health Clinical Practice Guidelines on the Management of Unstable
angina/ NSTEMI, 2002
5) Yusuf.M, Metha.S, Pouge.J, Chrolavicus.S, Afzal.R, Granger.C, et al. Comparison of
Fondaparinux and Enoxaparin in Acute Coronary Syndrome (OASIS 5), New england journal
of medicine 2006;354:1464-1476
6) Yusuf.M, Metha.S, Pouge.J, Chrolavicus.S, Afzal.R, Granger.C, et al . Effects of
Fondaparinux on Mortality and Reinfarction in Patients With Acute ST-Segment Elevation
Myocardial Infarction ,The OASIS-6 Randomized Trial. Journal of the american medical
association 2006;295(13):1519-1530
7) Savotinno.S, Granger.C, Ardissino.D, Gardner.L, Cavallini.C, Galvani.M, et al, The
prognostic values of Creatinine Kinase elevations extends across the whole spectrum of
acute coronary syndromes. American journal of cardiology 2002;39:22-29
8) Rubboli.A, Cappechi.A, Pasquele.G, Utilising enoxaparin in the management of STEMI.
Vascular health and risk management.,2007;3:691-700
9) Scmidt- Luke.C, Schultheiss.H, Enoxaparin injection for the treatment of high risk patients
with acute coronacy syndrome. Vascular health and risk management, 2007;3:221-227
10)Spencer.A, Moscussi.M, Granger.C, Gore.J, Goldberg.R,Goodman.S, et al, Does
comorbidity account for the excess mortality in patients with acute bleeding in acute
myocardial infarction. Circulation. 2007;116:2973-2801
11) Manoukian.S, Federick.F, Mehran.S, Voeltz.M, Ebrahinmi,R, Hamon.M, et al: Impact of
Major Bleeding on 30 day mortality and clinical outcomes in patients with acute coronary
syndrome. Journal of the american college of cardiology. 2007;49:1362-1368
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
27 Comparison Of Fondaparinux And Enoxaparin Use For Acute Coronary Syndrome In Hospital Sungai Buloh
12) Moscussi.M, Cannon.C , Klien.W, Montalescot.S, White.K, Goldberg.R, et al, Predictors
of Major Bleeding in Acute Coronary Syndromes, the Global Registry of Acute Coronary
Events (GRACE). European heart journal. 2003;24:1815-1823
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
28 Drug Utilization Review Of Selected Proton Pump Inhibitors (PPIs) In Outpatient Pharmacy Hospital Sungai Buloh
DRUG UTILIZATION REVIEW OF SELECTED PROTON PUMP INHIBITORS (PPIs) IN
OUTPATIENT PHARMACY HOSPITAL SUNGAI BULOH
Nurhayati Abdul Wahab, Kalaivani A/P Subramaniam, Nurnadia Shazreen Abd Wahab
Department of Pharmacy, Hospital Sungai Buloh
ABSTRACT
Introduction: This study is to review the drug utilization of selected proton pump inhibitors
(PPIs) in Outpatient Pharmacy Hospital Sungai Buloh.
Objective: To study the prescribing pattern and to compare the utilization of selected PPIs
which are available in Outpatient Pharmacy Hospital Sungai Buloh.
Methodology: This retrospective drug utilization review included patients from any outpatient
clinics in Hospital Sungai Buloh. Subjects must have been prescribed with Esomeprazole,
Lansoprazole or Rabeprazole from 1st January 2009 to 31st December 2009. Subjects that
were patients from ward (inpatient) as well as subjects whose medical records were unable
to be retrieved from eHIS system were excluded for this review. Data was collected through
eHIS system using PH Statistic-Dispensing Statistic by Drug. Data was collected using Data
Collection Form and analyzed using Microsoft Excel.
Results: 65% of patients were prescribed with Esomeprazole 40 mg. 42.7% of patients
within age group > 60 years old were treated with selected PPIs. More males than females
were prescribed with selected PPIs. Malay patients topped the list (64%) compared to other
races. Most patients (77.3%) were prescribed with the selected PPIs for the indication of
PUD. Once daily dosing (OD or ON) were the most common frequency (85.3%) prescribed
among patients taking the selected PPIs. These PPIs were generally most prescribed by
surgical clinics (60%). 49.3% of patients were past-treated with different type of PPI within
the same year.
Conclusion: Prescribing pattern of selected PPIs in Outpatient Pharmacy Hospital Sungai
Buloh is predominantly conquered by esomeprazole. This agrees with clinical trials which
showed that esomeprazole is superior in efficacy among all selected PPIs. The general
pattern of prescribing also agrees with current standard guidelines in practice. Selected PPIs
which are available in Outpatient Pharmacy Hospital Sungai Buloh are mostly utilized by
elderly group of patients for peptic ulcer disease prophylaxis.
INTRODUCTION
Dyspepsia is a common presenting complaint to general practitioners, and there is continuing
debate on its management1 Since the introduction of proton pump inhibitors (PPIs) in the late
1980s, these efficacious acid inhibitory agents have rapidly assumed the role for the
treatment of acid-peptic disorders1.They are now among the most widely selling drugs
worldwide due to their outstanding efficacy and safety1. They are considered the most
effective acid-suppressing medications available, and are considered first-line therapy for the
symptoms of GERD and the maintenance of esophageal healing in patients with erosive
esophagitis1. They are also highly effective for PUD, Barrett's esophagus, Zollinger-Ellison
syndrome, and as a component of combination therapy in the eradication of H. pylori1.
Nevertheless, it has been suggested that PPIs are “probably too widely prescribed for minor
symptoms, and the cost implication of this is clear”1.
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
29 Drug Utilization Review Of Selected Proton Pump Inhibitors (PPIs) In Outpatient Pharmacy Hospital Sungai Buloh
PPIs are selected for this review because of their high cost, high volume prescribed and they
are a clinically important drug1. There has been rapid increase in PPIs prescribing in recent
years, as such controlling the cost and improving the quality of prescribing is an issue of
concern. Recently in Hospital Sungai Buloh (HSB), their use has been increasing. Only 4
PPIs have been selected in this review: esomeprazole 20mg, esomeprazole 40mg,
lansoprazole 30mg and rabeprazole 20mg. The reason being they are among the most
expensive of the PPI group, the sample sizes are not too big as well as they are not too
overly prescribed for minor symptoms.
Pharmacology
The mechanism of action of PPIs are by the reduction of gastric acid secretion via the
selective and irreversible inhibition of proton-activated and potassium-activated adenosine
triphosphate (H/K-ATPase), an enzyme within the gastric parietal cells2.
The timing of administration is crucial; PPIs inactivate only active proton pumps and proton
pumps are activated primarily at mealtimes2. Thus, PPIs should be taken on an empty
stomach about 30 minutes before meals for maximum benefit2.
AIM
To review the drug utilization of selected proton pump inhibitors (PPIs) in Outpatient
Pharmacy Hospital Sungai Buloh.
OBJECTIVES
To study the prescribing pattern of selected PPIs in Outpatient Pharmacy Hospital Sungai
Buloh.
To compare the utilization of the selected PPIs which are available in Outpatient
Pharmacy Hospital Sungai Buloh.
PROBLEM STATEMENT
1. There has been a rapid increase in PPIs prescribing in recent years; as such monitoring
the pattern of prescribing is an issue of concern
2. Recently in Outpatient Department Hospital Sungai Buloh, their use have been
increasing
METHODOLOGY
A retrospective drug utilization review was conducted in this study. This meant that the drug
would be reviewed after the patient had received the medication and it might identify patterns
in prescribing, dispensing or administering drugs. In this study however, it focused mainly on
prescribing pattern of PPIs in HSB. Subjects for this study included patients from outpatient
clinics HSB prescribed with Esomeprazole, Lansoprazole or Rabeprazole. They were
identified by retrieving records using the HIS system. This review was conducted in
outpatient pharmacy HSB setting. Subjects that were included in this retrospective review
must have been prescribed with any of these three drugs irrespective of its indication from 1st
January 2009 to 31st December 2009. There was no maximum/minimum number of subjects
that could be included in this review. Subjects could either be from any specialist clinics in
Hospital Sungai Buloh (outpatient). Exclusion criteria included subjects that were patients
from ward (inpatient) as well as subjects whose medical records were not being able to
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
30 Drug Utilization Review Of Selected Proton Pump Inhibitors (PPIs) In Outpatient Pharmacy Hospital Sungai Buloh
retrieve from HIS system. Based on patients‟ identification number, patients‟ profile were
reviewed from HIS system. Data that were reviewed included:
Patient‟s demographic profile
Patient‟s drug profile
Prescriber‟s information
Indications for PPI usage
Dose prescribed
History of treatment with PPIs
Patients‟ confidentiality was maintained while data was being collected. A data collection
form was formulated to collect all these data. Data was analyzed using Microsoft Excel
software.
RESULTS
Table 1: Results tabulated based on demographic & clinical data of patients on
selected PPIs
TOTAL
LANSOPRAZOLE
30 MG
RABEPRAZOLE
20 MG
ESOMEPRAZOLE
20 MG
ESOMEPRAZOLE
40 MG
No. Of
Patients 1 10 16 48
AGE
<10
11-20 1
21-30 1 4
31-40 2 4 6
41-50 4 6
51-60 2 4 9
>60 1 6 3 22
GENDER MALE 2 9 34
FEMALE 1 8 7 14
RACE
MALAY 1 4 8 23
CHINESE 1 3 11
INDIAN 5 4 11
OTHERS 1 3
PRESCRIBER
MED 1
SURG 10 13 22
ID
ENT 1
OTHERS 1 2 25
INDICATION
HP 1
PUD 1 8 8 41
GERD 2 7 7
FREQUENCY
ON 5
BD 11
OD 1 5 16 37
HISTORY
SAME 1 1
DIFF 9 9 19
NO 1 1 6 28
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
31 Drug Utilization Review Of Selected Proton Pump Inhibitors (PPIs) In Outpatient Pharmacy Hospital Sungai Buloh
Figure 1: Total patients on selected PPIs in 2009
Figure 2: Patients on selected PPIs according to age group
Figure 3: Patients on selected PPIs according to gender
T OT AL P AT IE NT ON P P Is IN 2009
1%13%
21%
65%
L ansoprazole 30 mg
R abeprazole 20 mg
E someprazole 20 mg
E someprazole 40 mg
n = 75
P AT IE NT S ON P P Is AC C OR DING T O AG E
12 2
6
1
4 4 43
1
4
6 6
9
22
0
5
10
15
20
25
<10 11-20 21-30 31-40 41-50 51-60 >60
AG E G R OUP
L ansoprazole 30 mg R abeprazole 20 mg E someprazole 20 mg E someprazole 40 mg
1
8 714
2
9
34
0
5
10
15
20
25
30
35
L ansoprazole 30mg
R abeprazole 20mg
E someprazole20 mg
E someprazole40 mg
P AT IE NT S ON P P Is AC C OR DING T O G E NDE R
Male
F emale
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
32 Drug Utilization Review Of Selected Proton Pump Inhibitors (PPIs) In Outpatient Pharmacy Hospital Sungai Buloh
Figure 4: Patients on selected PPIs according to race
Figure 5: Indications patient being prescribed with selected PPIs
Figure 6: The frequency of taking selected PPIs as being prescribed
1
4
1
5
8
34
1
23
11 11
3
0
5
10
15
20
25
L ansoprazole 30mg
R abeprazole 20mg
E someprazole20 mg
E someprazole40 mg
P AT IE NT S ON P P Is AC C OR DING T O R AC E
Malay
C hinese
Indian
Others
INDIC AT IONS P AT IE NT B E ING P R E S C R IB E D WIT H
P P Is
1
2
8
7
8
1
7
41
0 10 20 30 40 50 60 70
G E R D
P UD
H. pylorieradication
Lans opraz ole 30 mg
R abepraz ole 20 mg
E s omepraz ole 20 mg
E s omepraz ole 40 mg
T HE F R E QUE NC Y OF T AK ING P P Is AS B E ING
P R E S C R IB E D
1
5
16
3711
5
0 5 10 15 20 25 30 35 40
L ansoprazole 30 mg
R abeprazole 20 mg
E someprazole 20 mg
E someprazole 40 mg
ON
B D
OD
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
33 Drug Utilization Review Of Selected Proton Pump Inhibitors (PPIs) In Outpatient Pharmacy Hospital Sungai Buloh
Figure 7: Prescriber of selected PPIs based on clinics
Figure 8: History of past-treatment with PPIs within a year
RESULTS AND DISCUSSION
Majority of subjects; that is 65%, were prescribed with Esomeprazole 40 mg. 42.7% of
subjects aged more than 60 years old. 60% of subjects were male compared to only 40%
female. Malay subjects topped the list (64%) compared to other races. Most subjects, 77.3%,
were prescribed with the selected PPIs for the indication of peptic ulcer diasease. 85.3% of
subjects were prescribed with once daily dosing (either OD or ON dosing). These PPIs were
mostly prescribed by surgical clinics (60%). Most subjects, 49.3%, were past-treated with
different type of PPI within the same year.
Majority of patients were prescribed with Esomeprazole 40mg; followed by Esomeprazole
20mg, Rabeprazole 20mg, and Lansoprazole 30mg. This agrees with many clinical trials
which showed that esomeprazole is superior in efficacy compared to other selected PPIs:-
Miner et al, Wilder-Smith et al, Lind et al, Röhss et al showed that esomeprazole
provided excellent gastric acid control compared with other selected PPIs18-23, 28
Healing rates of disease is higher when esomeprazole used (Castell et al & Fennerty
et al25-26, 28); maintenance of healing is also higher (Lauritsen et al)27, 28
Esomeprazole provided better day & night symptom relief (Castell et al)25, 28
Esomeprazole taken on-demand has higher therapeutic gain over placebo compared
with other selected PPIs (Bytzer et al)24, 28
Majority of patients within age group > 60 years old were treated with selected
P R E S C R IB E R OF P P Is B AS E D ON C L INIC S
1
10
1
13
2
22
1
25
0
5
10
15
20
25
30
Medical clinic S urgical clinic ID clinic E NT clinic Others
P R E S C R IB E R
L ansoprazole 30 mg R abeprazole 20 mg E someprazole 20 mg E someprazole 40 mg
HIS T OR Y OF P AS T -T R E AT ME NT WIT H P P Is WIT HIN A
YE AR
1
1
9
9
19
1
1
6
28
0 10 20 30 40 50 60
L ansoprazole 30 mg
R abeprazole 20 mg
E someprazole 20 mg
E someprazole 40 mg
S AME
D IF F E R E NT
NO
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
34 Drug Utilization Review Of Selected Proton Pump Inhibitors (PPIs) In Outpatient Pharmacy Hospital Sungai Buloh
PPIs. This was followed by age group 51-60 years old. Elderly group have a higher
incidences of getting gastro-intestinal diseases than younger people13.
Once daily dosing (OD or ON dosing) were the most common frequency prescribed for
selected PPIs. This indicates for prophylaxis. According to NICE guideline on PPI usage,
PPIs should be prescribed in a 'step down' manner; that is, the dose should be lowered to a
maintenance level after healing has been achieved, depending on the condition3.
Most PPIs were prescribed for peptic ulcer disease. According to CPG (Malaysian) guideline,
PPIs are often the drug of choice in treating PUD & for maintenance therapy after healing16.
Majority patients were past treated with PPIs within the same year. This indicates recurrence
of disease. Most patients will experience recurrence within one year following completion of
initial treatment3&17.
To investigate the cost analysis of selected PPIs, cost estimation was done based on the
following criteria:-
patients with peptic ulcer disease prescribed with selected PPIs in 2009
daily OD dosing
duration for 1 month.
Table 2: Cost analysis for selected PPIs
Drug Daily dose Price per tablet Number of patients Expected yearly
cost
Esomeprazole 20mg RM 1.80 8 RM 432.00
Esomeprazole 40mg RM 1.80 41 RM 2214.00
Lansoprazole 30mg RM 2.56 1 RM 76.80
Rabeprazole 20mg RM 1.53 8 RM 367.20
Limitation
There were some factors which limit the study:
Errors within the system – affect data collection
Doctors stopping medication in system after pharmacy have dispensed to patients;
this could not be captured because only the amount dispensed was able to be
generated through system
CONCLUSION
Prescribing pattern of selected PPIs in Outpatient Pharmacy Hospital Sungai Buloh is
predominantly conquered by esomeprazole. This agrees with clinical trials which showed that
esomeprazole is superior in efficacy among all selected PPIs. The general pattern of
prescribing also agrees with current standard guidelines in practice. Selected PPIs which are
available in Outpatient Pharmacy Hospital Sungai Buloh are mostly utilized by elderly group
of patients for peptic ulcer disease prophylaxis.
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
35 Drug Utilization Review Of Selected Proton Pump Inhibitors (PPIs) In Outpatient Pharmacy Hospital Sungai Buloh
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MD (Senior Consultant), Stefania Maggi, MD (Senior Researcher), Alberto Pilotto, MD
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8. “Helicobacter pylori Infection in Peptic Ulcer Disease: The Importance of Smoking and
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Universiti Sains Malaysia, Health Campus, Kubang Kerian, Kelantan, Malaysia; Vol. 38
No. 6; November 2007.
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11. “Prevalent Prescribing of Proton Pump Inhibitors: Prudent or Pernicious?”; Co Q. D.
Pham, BSc, BA, BScPharm, PharmD, Linda M. Sadowski-Hayes, PharmD, and
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12. Fitton A & Wiseman L. Pantoprazole: A review of its pharmacological properties and
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13. Yarnell J. Epidemiology & prevention: a system-based approach. Oxford Core Texts.
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14. Vonkeman HE, Braakman-Jansen LMA, Klok RM, Postma MJ, Brouwers JRBJ, van
der Laar MAFJ. Incremental cost effectiveness of proton pump inhibitors for the
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17. Jeong YJ, Lee DH, Choi TH, Hwang TJ, Lee BH, Nah JC, Lee SH, Park YS, Hwang JH,
Kim JW, Jeong SH, Kim W, Jung HC, Song IS. Clinical Analysis of Recurrence Rate
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TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
36 Drug Utilization Review Of Selected Proton Pump Inhibitors (PPIs) In Outpatient Pharmacy Hospital Sungai Buloh
18. Miner P Jr, Katz PO, Chen Y, et al. Gastric acid control with esomeprazole,
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Am J Gastroenterol 2003; 98: 2616-2620
19. Miner P Jr, Katz PO, Chen Y et al. Reanalysis of Intragastric pH Results based on
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omeprazole in patients with symptoms of gastro-oesophageal reflux disease. Aliment
Pharmacol Ther 2000; 14: 861-867
22. Röhss K, Hasselgren G, Hedenström H. Effect of Esomeprazole 40mg vs Omeprazole
40mg on 24-Hour Intragastric pH in Patients with Symptoms of Gastroesophageal
Reflux Disease. Dig Dis Sci 2002; 47: 954-958
23. Röhss K, Wilder-Smith C, Naucler E. Esomeprazole 20mg Provides More Effective
Intragastric Acid Control than Maintenance-Dose Rabeprazole, Lansoprazole or
Pantoprazole in Healthy Volunteers. Clin Drug Invest 2004; 24(1): 1-7
24. Bytzer P et al. Rationale and proposed algorithms for symptom-based proton pump
inhibitor therapy for gastro-oesophageal reflux disease. Aliment Pharmacol Ther 2004;
20: 389-398
25. Castell DO et al. Esomeprazole Compared With Lansoprazole in the Treatment of
Erosive Esophagitis. Am J Gastroenterol 2002; 97: 575-583
26. Fennerty MB et al. Efficacy of esomeprazole vs lansoprazole for healing moderate to
severe erosive oesophagitis. Aliment Pharmacol Ther 2005; 4: 455-463
27. Lauritsen K et al. Esomeprazole 20mg and lansoprazole 15mg in maintaning healed
reflux oesophagitis: Metropole study results. Aliment Pharmacol Ther 2003: 17: 333-
341
28. www.nexiumtouchpoints.com
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
37 Effectiveness Of Post-Operative Analgesics After Surgical Removal Of Impacted Third Molar Under Local Anaesthesia
EFFECTIVENESS OF POST-OPERATIVE ANALGESICS AFTER SURGICAL REMOVAL
OF IMPACTED THIRD MOLAR UNDER LOCAL ANAESTHESIA
Dr. J. Sureinthiren A/L Jeya Raman, BDS (Malaya), Dr.Lim Yee Chin, BDS (Malaya), Dr.
Mohd. Noor Fareezul bin Noor Shahidan, BDS (Malaya), Dr. Sivakama Sunthari A/P M.
Kanagaratnam, BDS (Malaya), FDSRCS (Eng)
Department of Oral Surgery Department, Hospital Ampang
ABSTRACT
Introduction : A Clinical Audit was carried out involving patients who underwent surgical
removal of impacted mandibular third molar under Local Anaesthesia at Oral Surgery
Department, Ampang Hospital.
Objective: To assess levels of post-operative analgesia achieved with prescription of routine
oral analgesics.
Methodology : A prospective study was conducted and involved 2 phases. Results of Phase
I was reviewed and practice modification was carried out prior to commencement of Phase II.
Data was collected using a Proforma and data analysis was done using SPSS software. Fifty
two patients (81.3%) completed the study in Phase I whereas 83 patients (95.4%) completed
the Phase II.
Results : Overall mean Pain Score for the first 3 days (PS 3) and 7 days (PS 7) post-
operatively for the study population in Phase I were 4.76 (SD ± 2.31) and 3.69 (SD ± 1.66),
respectively and in Phase II were 4.76 (SD ± 2.39) and 3.69 (SD ± 2.06), respectively. PS 3
and PS 7 were lowest in T. Diclofenac sodium 50mg and C. Tramadol 50mg group with the
scores being 3.92 (SD ± 2.57) and 3.07 (SD ± 2.13), respectively.
Conclusion : Overall, post-operative analgesia levels that were achieved within the centre
with the use of routine oral analgesics were acceptable.
INTRODUCTION
Impacted tooth is inability of a tooth to completely erupt into a normal functional position due
to lack of space (in the dental arch), obstruction by another tooth or development in an
abnormal position1. Main reason for removal of impacted tooth is caries on the impacted
tooth itself or its adjacent tooth and presence of recurrent infection of soft tissue around the
impacted tooth.
The pain post-extraction of third molar is the most widely used model in acute analgesia
clinical trials. This pain model‟s reproducibility has been well established2. Besides that, the
pain model is standardized and sensitive and provides a reliable method for comparing
analgesics in the treatment of acute pain3, 4.
OBJECTIVE
The objective of the study in general was to assess the level of post-operative analgesia
achieved and effectiveness of routine oral analgesics prescribed by our department. The
specific objectives were:
To assess average pain score:
First 3 days post-surgical removal of impacted third molar under LA
First 7 days post-surgical removal of impacted third molar under LA
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
38 Effectiveness Of Post-Operative Analgesics After Surgical Removal Of Impacted Third Molar Under Local Anaesthesia
The standard for the study was:
Average pain score for the first 3 days post-operatively to be below 6 for more than
70% of patients
Average pain score for the first 7 days post-operatively to be below 4 for more than
70% of patients
METHODOLOGY
The study was prospective in nature and was conducted in two phases (Phase I and Phase
II). Phase II of the study was conducted after results of Phase I was reviewed and practice
modifications were carried out. Target population for both phases were patients who undergo
surgical removal of impacted mandibular third molar under Local Anaesthesia at Oral
Surgery Department, Hospital Ampang. Data for both phases of study was collected using a
standard Proforma and included demographic details, types of analgesics prescribed post-
operatively and pain score levels for 7 days post-operatively.
All patients were prescribed with 2 types of analgesics post-surgery and average pain score
for the first 3 days and first 7 days post-operatively was recorded using Numeric Rating
Scale (NRS). The analgesic combinations used for the study were as follows:
Tablet Diclofenac Sodium 50mg with Tablet Paracetamol 1000mg (Phase I & II)
Capsule Tramadol 50mg with Tablet Paracetamol 1000mg (Phase I & II. In Phase I,
this group was only given to patients who are contraindicated for the prescription of
Tablet Diclofenac Sodium)
Tablet Diclofenac Sodium 50mg with Capsule Tramadol 50mg (Phase II only)
Data collection for Phase I was carried out from July 2009 until November 2009 and data for
Phase II of the study was collected from January 2010 until July 2010. Patients requiring
surgical removal of impacted mandibular third molar under General Anaesthesia were
excluded. Data was analyzed using SPSS software and Descriptive Statistics were
employed.
RESULTS
Sixty four patients were recruited for Phase I but only 52 patients (81.3%) completed the
study. Phase II recruited 87 patients and 83 patients (95.4%) completed the study. The
results of each phase are as shown below.
Table 1: Average Pain Score in Phase I of study
n = 52 Mean (Pain Score) Std. Dev
First 3 days 4.76 2.31
First 7 days 3.69 1.66
Table 2: Average Pain Score in Phase II of study
n = 83 Mean (Pain Score) Std. Dev
First 3 days 4.76 2.39
First 7 days 3.67 2.07
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
39 Effectiveness Of Post-Operative Analgesics After Surgical Removal Of Impacted Third Molar Under Local Anaesthesia
Table 3: Percentage of patients fulfilling the standard in the study
Phase I Phase II
Percentage of patients with average pain score below 6
for the first 3 days post-operatively 69.23% 74.69%
Percentage of patients with average pain score below 4
for the first 7 days post-operatively 57.69% 61.45%
The following comparisons were only carried out in Phase II of the study.
Table 4: Average Pain Score achieved with use of T. Diclofenac sodium 50mg and T.
Paracetamol 1000mg in Phase II of study
DICLO + PCM
(n = 28 )
Mean (Pain Score) Std. Dev
First 3 days 5.18 2.37
First 7 days 3.77 1.88
Table 5: Average Pain Score achieved with use of C.Tramadol 50mg and T.
Paracetamol 1000mg in Phase II of study
TRAMADOL + PCM
(n = 30 ) Mean (Pain Score) Std. Dev
First 3 days 5.08 2.14
First 7 days 4.08 2.12
Table 6: Average Pain Score achieved with use of T. Diclofenac sodium 50mg and
C.Tramadol 50mg in Phase II of study
DICLO + TRAMADOL
(n= 25 )
Mean (Pain Score)
Std. Dev
First 3 days 3.92 2.57
First 7 days 3.07 2.13
Table 7: Fulfillment of standard in Phase II of study according to analgesic groups
ANALGESIC GROUP
Percentage of patients
with Pain Score below 6
in the first 3 days
Percentage of patients
with
Pain Score below 4 in the
first 7 days
DICLO + PCM
(n = 28 ) 64.29% 50.00%
TRAMADOL + PCM
(n = 30 ) 80.00% 56.67%
DICLO + TRAMADOL
(n= 25 ) 80.00% 80.00%
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
40 Effectiveness Of Post-Operative Analgesics After Surgical Removal Of Impacted Third Molar Under Local Anaesthesia
CONCLUSION
Post-operative analgesia levels achieved within the centre with the use of routine oral
analgesics were acceptable. Combination of Tablet Diclofenac sodium 50mg and Capsule
Tramadol 50mg were able to achieve the lowest mean pain score levels among the study
population. Therefore, the addition of this combination of drugs to analgesic regime in Phase
II of the study was beneficial. Among the limitation of the study was its small sample size,
especially in Phase I of the study. In addition to that, certain factors which could have had an
influence on the pain score, for example, the presence of infection post-operatively were not
taken into consideration. Usage of more potent analgesics such as selective cyclo-
oxygenase 2 (COX-2) inhibitors and usage of adjunct medications, for example, oral
corticosteroids might be worthwhile in future studies for comparison with the current study.
REFERENCES
1. Working Party Faculty of Dental Surgery Royal College of Surgeons of England. Current
clinical practice and parameters of care: The management of patients with third molar
teeth. Faculty of Dental Surgery, Royal College of Surgeons of England. 1997
2. Mordechai A, Meyer K. Severity of baseline pain and degree of analgesia in the third
molar post-extraction dental pain model. Anesth Analg 2003; 97:163–167
3. Chang DJ, Desjardins PJ, King TR, Erb T, Geba GP. The analgesic efficacy of Etoricoxib
compared with Oxycodone/Acetaminophen in an acute postoperative pain model: A
randomized, double-blind clinical trial. Anesth Analg 2004; 99:807–815
4. Kleinert R, Lange C, Steup A, Black P, Goldberg J, Desjardins P. Single dose analgesic
efficacy of Tapentadol in postsurgical dental pain: The results of a randomized, double-
blind, placebo-controlled study. Anesth Analg 2008; 107:2048 –2055
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
41 Medication Reconciliation In Hemodialysis Unit: Identifying The Types And Factors Contributing To Medication Discrepancies
MEDICATION RECONCILIATION IN HEMODIALYSIS UNIT: IDENTIFYING THE TYPES
AND FACTORS CONTRIBUTING TO MEDICATION DISCREPANCIES
Heryohana Jamaludin, Lee Yoke Ching, Maryam Omar Zaki, Noor Azimah Abdullah,
Nurah Zainal Abidin, Ros Aimi Osman, Norkasihan Ibrahim, Shahirah Zainudi
Department of Pharmacy, Hospital Selayang
ABSTRACT
Introduction : Medication reconciliation is the process of comparing a patient‟s medication
orders to all of the medications that the patient has been taking in terms of name, dosage,
frequency, and route of administration at the time of hospital admission, discharge or during
transfer between institutions. While medication discrepancies are defined as a lack of
agreement between prescribed drug therapy indicated on the hospital discharge record and
the therapy actually received by the patient. Medication reconciliation is done to identify
medication discrepancies.
Objective : To conduct medication reconciliation in patients who undergo hemodialysis and
to find out about the types of medication discrepancies and the prevalence of medication
discrepancies if medication reconciliation is not done.
Methodology : An observational study on medication discrepencies amongst patients that
are undergoing hemodialysis at Hemodialysis Unit of Selayang Hospital.
Results : The percentage of medication discrepancies obtained in this study of 61 samples
are 15.83%, and the types of medication discrepancies commonly occurring in the
Hemodialysis Unit of Selayang Hospital are (1) change in the frequency; (2) change in the
dose; (3) omission of the drug; (4) addition of a new drug; (5) change of the drug; all in order
of the most common to the least common.
Conclusion : This study identified the factors that lead to medication discrepancies that
commonly occur in the Hemodialysis Unit of Selayang Hospital either the Patient factor or the
System factor, whereby the Patient factor comprises majority of the factors. From this study
also, the medications that are commonly associated with medication discrepancies are
obtained, namely the antihypertensives, electrolyte therapy, hematinics, cardiovascular, and
antidiabetics (in order or most common to the least common).
INTRODUCTION
Medication reconciliation is the process of comparing a patient‟s medication orders to all of
the medications that the patient has been taking in terms of name, dosage, frequency, and
route of administration at the time of hospital admission, discharge or during transfer
between institutions. This reconciliation is done to avoid medication errors such as
omissions, duplications, dosing errors, or drug interactions. It should be done at every
transition of care in which new medications are ordered or existing orders are re-written.
Transitions in care include changes in setting, service, practitioner, or level of care. This
process comprises five steps: (1) develop a list of current medications; (2) develop a list of
medications to be prescribed; (3) compare the medications on the two lists; (4) make clinical
decisions based on the comparison; and (5) communicate the new list to appropriate
caregivers and to the patient.
Any inconsistency identified during the reconciliation process is referred to as medication
discrepancies, and it could be either intentional or unintentional. An unintentional
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
42 Medication Reconciliation In Hemodialysis Unit: Identifying The Types And Factors Contributing To Medication Discrepancies
discrepancy is one in which the prescriber unintentionally changed, added or omitted a
medication the patient was taking prior to admission within the same therapeutic class, and
different dosage, frequency or route of administration. All unintended medication
discrepancies are classified into different classes as according to the severity of the potential
consequences that they might bring. Class 1 discrepancies are those unlikely to cause
significant deterioration in patient, Class 2 discrepancies have the potential to cause
moderate discomfort or clinical deterioration, and Class 3 have the potential to cause severe
complications.
Generally, the pharmacist‟s services today include more patient-oriented administrative and
public health functions. There are many functions of public health that can benefit from
pharmacist‟s unique expertise that may include pharmacotherapy, access to care, and
prevention services such as drug related problem. Major role of pharmacist includes
performing or obtaining necessary assessment of patient‟s health status; formulating a
medication treatment plan; selecting, initiating, modifying or administering medication
therapy; monitoring and evaluating the patient‟s response to therapy, including safety and
effectiveness; performing a comprehensive medication review to identify, resolve and
prevent medication-related problems, including adverse drug events; documenting the care
delivered and communicating essential information to the patient‟s or primary caregivers;
providing verbal education and training designed to enhance patient understanding and
appropriate use of his or her medications; providing information, support services, and
resources designed to enhance patient adherence with his or her therapy; and coordinating
and integrating medication therapy management services within the broader healthcare-
management services being provided to the patient.
Problem Statement
Medication reconciliation is done to identify medication discrepancies. It is usually done to
compare a patient‟s medication orders to the existing medications that the patients are
already taking. In our study, the population sample consists of the patients who come for
their routine hemodialysis. These patients are usually on a long list of medications on a long-
term basis. They come and go without their medications thoroughly reviewed by health care
providers which may lead to medication discrepancies. Thus it is our interest to know if the
patients are taking their medications as prescribed by their doctors.
OBJECTIVE
The objective of the study is to conduct the medication reconciliation in patients who undergo
hemodialysis to find out about their medication discrepancies.
The specific objectives were :
To identify the percentage of medication discrepancies.
To identify the types of medication discrepancies.
To identify the medications that are commonly involved in the medication discrepancies.
To investigate the factors that lead to medication discrepancies.
METHODOLOGY
Study design
An observational study on medication discrepancy amongst patients that are undergoing
hemodialysis at the Hemodialysis Unit of Selayang Hospital. This medication reconciliation
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
43 Medication Reconciliation In Hemodialysis Unit: Identifying The Types And Factors Contributing To Medication Discrepancies
project is conducted from the beginning of March to the end of May 2010. The goal of this
project is to interview 61 hemodialysis patients, depending on the inclusion/ exclusion
criteria. Patients are reconciled over 3 months period.
Sampling
All haemodialysis patients registered at the Selayang Hospital Haemodialysis Unit taking into
account the inclusion and exclusion criteria.
Sampling procedure is as shown below:
Obtain the name list of patient that undergoing hemodialysis at Hemodialysis Unit of Hospital Selayang.
Obtain the most recent medication list prescribed from Electronic Medical Record (EMR) – list A.
Obtain patient’s agreement to participate the interview.
Interview patient to obtain a list of medications taken by patient at home – list B.
Identify discrepancies between list A and list B.
Identify types of discrepancies (patient factor vs system factor).
Perform intervention
•Counseling
•Allergy card
•Modify drug order
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
44 Medication Reconciliation In Hemodialysis Unit: Identifying The Types And Factors Contributing To Medication Discrepancies
The list of medications prescribed during the last hospital visit will be obtained from
Medication Order Form in the Selayang Hospital Electronic Medical Record (EMR). The list
of medications that patient‟s has been taking at home will be obtained from the following
resources : patient‟s medication profile, clinical referral notes and by interviewing the patients
and their care giver.
Study Tools
A medication chart contains majority of the kind of medicine that patients in the hemodialysis
unit is taking.
All data will be recorded in the Medication Reconciliation data collection form (MRF1).
RESULTS AND DISCUSSION
Patients Demography Data
Table 1 : Patients Demography
Mean
Gender
Male 34
Female 27
Age
>65 years 20
<65 years 41
Years on Hemodialysis
<5 years 23
5 - 10 years 24
>10 years 14
Co-morbidity
Diabetes mellitus 16
Hypertension 31
Cardiovascular Disease 14
Have been counselled on medication previously
Yes 38
No 23
Allergy history
Yes 8
No 53
In this study, the subjects consist of 34 males and 27 females. 41 of them are less than
65 years old and the remaining 20 are more than 65 years old. 14 patients have been on
hemodialysis for more than ten years while 23 patients less than five years and 24
patients between five to ten years. The number of patients with diabetes, hypertension
and cardiovascular diseases are 16, 31 and 14 respectively. After the interview it was
found out that 38 patients have been counseled on their medications previously while rest
claimed to have not been counseled. Only 8 patients out of 61 claimed to have
medication allergies.
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
45 Medication Reconciliation In Hemodialysis Unit: Identifying The Types And Factors Contributing To Medication Discrepancies
Reconciliation Error Per 100 Hemodialysis Patients
Table 2 :Reconciliation error per 100 hemodialysis patients
Patients
Total number of
medication per
PS
No. of
Discrepancies
Patients
Total number of
medication per
PS
No. of
Discrepancies
1 10 0
31 14 0
2 9 3
32 10 2
3 10 1
33 9 0
4 8 2
34 9 0
5 5 1
35 8 1
6 11 3
36 13 3
7 12 1
37 7 12
8 8 1
38 8 2
9 13 1
39 8 2
10 9 0
40 8 2
11 12 0
41 8 2
12 11 6
42 6 1
13 5 0
43 8 0
14 8 0
44 6 0
15 8 1
45 10 0
16 11 2
46 12 3
17 9 1
47 11 1
18 8 3
48 8 1
19 10 1
49 9 2
20 4 0
50 8 1
21 12 1
51 4 0
22 7 0
52 9 1
23 5 0
53 14 0
24 7 0
54 11 4
25 4 1
55 6 2
26 9 1
56 7 2
27 10 3
57 4 1
28 7 2
58 8 0
29 5 0
59 7 1
30 9 0
60 5 0
61 7 1
The percentage of medication discrepancies is derived from the total number of
discrepancies over the total number of medications that the patients are on. There were 82
medication discrepancies out of 518 medications, giving the percentage of the discrepancies
as 15.83%.
From these data we can calculate the prevalence of medication discrepancies if medication
reconciliation is not done. The formula used is:
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
46 Medication Reconciliation In Hemodialysis Unit: Identifying The Types And Factors Contributing To Medication Discrepancies
Prevalence of medication discrepancies in Hemodialysis Unit
= Number of prescription with medication discrepancies / Total number of prescriptions
The result is that if medication reconciliation is not implemented, there would be 75
medication errors in every 100 hemodialysis patients. Thus suggesting the need of a full time
pharmacist at the hemodialysis unit.
Types of Discrepancy
Figure 1: Bar graph shows types of discrepancy during medication reconciliation
Alteration in the frequency of medication prescribed lead to highest number of discrepancy
with a total of 34 discrepancies. Discrepancies lead by changes in the frequency might be
due to need of adjustment of dose and frequency of medications in patient with kidney
problems. 23 discrepancies were due to the adjustment of the dose. Frequent changes in
dosage in hemodialysis patients might lead to the high number of discrepancies. Omission of
medications results in 14 discrepancies. Deterioration in patients‟ condition might be the
rationale behind the number of discrepancies. 3 discrepancies were due to addition of new
medication. In order for a better management of patients‟ health status new drugs might be
required. There were no discrepancies from alteration of route of administration. Changes of
medications only caused 2 discrepancies.
Figure 2: Percentage of Patient Factors and System Factors that contributed to
Medication Discrepancies
2 3
14
22
33
00
5
10
15
20
25
30
35
Change the
drug
Added new
drug
Omitted the
drug
Change the
dose
Change the
frequency
Change the
route
No
. o
f D
iscr
epa
ncy
Types of Discrepancy
Types of discrepancy
System factor
Patient factor
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
47 Medication Reconciliation In Hemodialysis Unit: Identifying The Types And Factors Contributing To Medication Discrepancies
From the bar graph, it illustrates that patient‟s factor is the main contributing factor for
medication discrepancies in hemodialysis patients with a total of 54 patients. While System‟s
factor only appeared in 14 patients. Coleman et. al explained that patient‟s factor might be
due to non-adherence, deficit in performance, unable to tolerate side effects and adverse
drug reactions. While system‟s factor was either due to prescriber unable to recognize
cognitive impairment in their patients, incomplete instructions given to patients and patients
receiving conflicting information from different sources as described by Coleman. Coleman
also stated that both system and patient associated factor contribute equally to the identified
medication discrepancies. Coleman stated in order to reduce the medication discrepancies
attention need to be given for both types of factors in general.
Types of Patient Factor
Figure 3: Bar graphs showing types of patient factor
In this study involving 61 patients, non-adherence has the highest percentage of 58 thus
making it the most common type of patient factor in causing discrepancies. It is then followed
by deficit in performance of 26%. 7% of patient complained of the inability to tolerate the side
effects of the medication. This is followed by adverse drug reaction which results in 6% of
patients. 2% of patients assured that their prescriptions are either not filled or the repeat
prescription was not collected and the feel that the medication is unnecessary. None of the
patients complained of financial barrier since the medications collected by patients at
Selayang Hospital as well as other government hospitals and clinics are subsidized by the
government and thus are free of charge.
58.1
25.5
7.3 5.51.8 1.8 0
0
10
20
30
40
50
60
70
Per
cen
tag
e o
f
Pa
tien
t fa
cto
r
Types of Patient factor
Patient Factor
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
48 Medication Reconciliation In Hemodialysis Unit: Identifying The Types And Factors Contributing To Medication Discrepancies
Types of System Factor
Figure 4: Bar chart showing types of system factor
The highest percentage of system factor in this study is where the prescriber is unable to
recognize cognitive impairment in their patients causing drugs not to be taken as intended
which is 42.9%. This is followed by incomplete or illegible and incorrect instruction given to
the patient with percentage of 28.6. 21.4% of patients admitted that they receive conflicting
information from different sources namely physician, pharmacist and nurses. Next is followed
by incorrect dosage, label and quantity with 7.1% occurrence. None of the patients are being
prescribed drugs with known allergies to the drugs. There are neither issues of confusion
between generic and brand name by the prescribers nor duplication of prescriptions.
42.9
28.6
21.4
7.1
0 0 005
101520253035404550
Prescriber is
unable to
recognize
cognitive
impairment
in their
patients
causing drugs
not to be
taken as
intended
Incomplete/
illegible and
incorrect
instruction
given to the
patient
Patient
received
conflicting
information
from
different
sources
Incorrect
dosage, label
and quantity
Patient being
prescribed
with known
allergies to
the drugs
Confusion
between
generic and
brand name
by
prescribers
Duplication
of
prescription
Per
cen
tag
e o
f
Sy
stem
fa
cto
r
Types of System Factor
System Factor
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
49 Medication Reconciliation In Hemodialysis Unit: Identifying The Types And Factors Contributing To Medication Discrepancies
Common Factors Causing Discrepancies
Figure 5: Bar graphs showing the common factors causing medication discrepancies.
The common types of identified medication discrepancies are provided in graph above. More
than 1 explanatory factor (i.e. patient associated or system associated) may have been used
to categorize each medication discrepancy. At the patient level, non-adherence accounted for
the greatest percentage of identified contributing factors, followed by deficit in performance
and unable to tolerate side effects. At the system level, prescriber is unable to recognize
cognitive impairment in their patient was the most common of the identified contributing
factors, followed by incomplete, inaccurate, or illegible instructions (as a result of either
handwriting or use of Latin abbreviations). Patient-associated factors were found to
contribute more to the identified medication discrepancies than system-associated factors.
There may be many factors that are affecting the patient or caregiver‟s ability to take their
medications, which need assessed and addressed. The term non-adherence is applied to
patients when they are not following the prescribed treatment. Lower educational level, less
affluent economic status, cognitive or physical impairment and some diseases such as
chronic renal failure are commonly reported poorly modifiable correlates of non-adherence.
Non-adherence rates are high in the haemodialysis population with pill burden, complex and
dynamic of medication regimens and patient motivation all being pertinent factors5. Non-
adherence to the prescribed regimen is a common problem in hemodialysis and is associated
with increased morbidity and mortality6.
Physical well-being is a fundamental component of health and quality of life, underpinning
the ability to engage in activities of daily living and participate in social, recreational and
33
14
64 4
0
5
10
15
20
25
30
35
Non-adherence Deficit in
performance
Prescriber is unable
to recognize
cognitive
impairment in their
patients causing
drugs not to be
taken as intended
Unable to tolerate
side effects
Incomplete/
illegible and
incorrect
instruction given to
the patient
PATIENT FACTOR SYSTEM
FACTOR
PATIENT
FACTOR
SYSTEM
FACTOR
Nu
mb
er o
f p
ati
ents
Factors
Common Factors Causing Discrepancies
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
50 Medication Reconciliation In Hemodialysis Unit: Identifying The Types And Factors Contributing To Medication Discrepancies
vocational roles. It has long been recognized that physical function is compromised in
patients with end-stage renal disease (ESRD). This can be attributed primarily to the effects
of uraemia and the comorbidity associated with chronic renal failure, but inactivity also
contributes to physical deconditioning and debilitation7. Dialysis patients suffer physical
limitations which interfere with self-reported health status and quality of life8.
Typically clinicians look at the primary physical or cognitive impairments, but a more detailed
assessment is needed, related to the complex process of medication management.
Physicians are unaware of cognitive impairment in more than 40% of their cognitively
impaired patients9. Clinicians intend to use their "clinical eye" to detect and monitor
cognitive deficits. Many express confidence in their ability to "see" cognitive problems in
patients, despite evidence that unstructured clinical assessments of cognition do not reliably
match neuropsychological test scores10. Clinician education may need to emphasize that
prescribing decisions should be based on valid and reliable assessments rather than clinical
presentations. Clinician education could also address the role for caregivers' and family
members' reports of patients' cognitive functioning11.
Another factor found to contribute to the potential for medication discrepancies among
patients, is the instructions incomplete or inaccurate or illegible either the patient cannot
make out the hand-writing or the information is not written in lay terms. Unclear
communication between physicians and patients often leads to uncertainty in patient care
decisions and may compromise patient safety.
Classes Of Drug Commonly Associated With Medication Discrepancies
Figure 6: Bar graphs showing Classes of drugs commonly associated with medication
discrepancies.
The following 5 medication classes accounted for mostly identified medication discrepancies:
antihypertensive 37.3% (25 cases), electrolyte 23.9% (16 cases), hematinics 20.9% (14
cases), cardiovascular 11.9% (8 cases) and antidiabetics 6.0% (4 cases).
37.3
23.920.9
11.9
6.0
0
5
10
15
20
25
30
35
40
Per
cen
tag
e o
f
dis
crep
an
cies
Classes of drugs
Class of drugs commonly associated with discrepancies
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
51 Medication Reconciliation In Hemodialysis Unit: Identifying The Types And Factors Contributing To Medication Discrepancies
Hypertension is a chronic condition that may result in stroke and heart failure.
Noncompliance is a major factor in the increasing number of deaths related to cardiovascular
disease12. Clearly, noncompliance with regard to hypertension is a major medical problem.
Reason is that patients often do not feel any adverse physical effects. Because of this,
patients do not experience any physical improvements due to the strict compliance to the
medical regimen. The most commonly cited reasons for noncompliance include, not being
convinced of the need for treatment, fear of adverse effects, difficulty in managing more than
1 dose a day, or multiple drug regimens13.
Clinical experience suggests that phosphate binders are probably the single largest
contributor to the daily pill burden14. The high pill burden from phosphate binders may affect
patients‟ adherence to therapy and their ability to maintain optimal serum phosphorus
levels15.
Cardiovascular disease (CVD) is the leading cause of mortality in ESRD patients, accounting
for approximately 50% of deaths16. There is much opportunity to increase use of medications
with known cardio-protective benefit such as aspirin, clopidogrel and ticlopidine.
Interventions Performed
Figure 7: Pie chart showing the types of intervention performed.
Throughout this study, only two types of intervention were made namely „Modify drug orders‟
and „Counseling‟. 98.5% of the intervention involves patient counseling while the rest 1.5%
involves modifying the drug orders in the Electronic Medical Record (EMR) by
communicating with the physician in charge of the patients in the Hemodialysis Unit of
Hospital Selayang.
Limitation
This study has several limitations, mainly its small sample size. Only 61 patients undergoing
hemodialysis in Hospital Selayang are involved in this study. It is a single centre study and
there may be a bias in detecting medication errors.
The medication lists by the prescribers obtained from Selayang Hospital Electronic Medical
Record (EMR) are thought to be up to date when this study was conducted. When
inaccurate lists or not-updated lists are used, errors are more likely to occur, possibly
resulting in harm to the patient.
Performed Intervention
Counselling
Allergy card
Modify drug orders (EMR)98.5%
1.5%
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
52 Medication Reconciliation In Hemodialysis Unit: Identifying The Types And Factors Contributing To Medication Discrepancies
The patient‟s own medication lists obtained from the patients themselves but in some
patients, their medications are not taken care by themselves but their caregivers. While
interviews were done, the caregivers were not around so the accuracy of the medications
cannot be justified.
CONCLUSION
The percentage of medication discrepancies obtained in this study of 61 samples are 15.83%
and the types of medication discrepancies commonly occurring in the Hemodialysis Unit of
Selayang Hospital are (1) change in the frequency; (2) change in the dose; (3) omission of
the drug; (4) addition of a new drug; (5) change of the drug; all in order of the most common
to the least common. This study identified the factors that lead to medication discrepancies
that commonly occurring in the Hemodialysis Unit of Selayang Hospital that are the Patient
factor as well as the System factor, and the patient factor comprises of the major factors.
From this study also, the medications that are commonly associated with medication
discrepancy are obtained, namely the antihypertensives, electrolyte therapy, hematinics,
cardiovascular, and antidiabetics (in order or most common to the least common).
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12. Larosa JH, Larosa JC. Enhancing drug compliance in lipid-lowering treatment. From the
Departments of Preventative Medicine and Community Health, State University of New
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
53 Medication Reconciliation In Hemodialysis Unit: Identifying The Types And Factors Contributing To Medication Discrepancies
York Health Science Center. Brooklyn, New York. Published by the American Medical
Association, 2000.
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15. Karamanidou C, Clatworthy J, Weinman J, Horne R: A systematic review of the
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December 3 – 7, 2006. Retrieved on January 1, 2010 from
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18. Medication Use Across Transition Points From the Emergency Department: Identifying
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http://www.medscape.com/viewarticle/712270
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20. Coraline Claeys, P.M. Tulkens, J. Neve, A. Spinewine – Content validation of a modified
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2009.pdfAd
21. Kathleen B. Orrico – Sources and Types of Discrepancies between Electronic Medical
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(JMCP), September 2008, Vol. 14, No.7. Retrieved on January 4, 2010 from
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22. Retrieved on January 2, 2010 from
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23. Electronic Medication Reconciliation FAQs. Retrieved on January 3, 2010 from
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TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
54 Medication Reconciliation In Hemodialysis Unit: Identifying The Types And Factors Contributing To Medication Discrepancies
APPENDICES
1.0 Data collection timetable
HD
Sessions
1 2 3 4 5 6
Session 1
Session 2
Session 3
Session 4
Researcher A B C D E F
* to fill in the number of patients and the name of patient for the appropriate session that the
researcher wishes to interview.
2.0 Medication Reconciliation data collection form (MRF1)
Medication Chart
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
55 Status Kesihatan Periodontium Di Kalangan Pesakit Diabetes Di Klinik Diabetes Klinik Kesihatan Anika Klang, Selangor
STATUS KESIHATAN PERIODONTIUM DI KALANGAN PESAKIT DIABETES
DI KLINIK DIABETES KLINIK KESIHATAN ANIKA KLANG, SELANGOR
Azirah Bt Muhammad
Dip ( Kejururawatan Pergigian ), Pos Basik ( Periodontik )
Klinik Pergigian Kelana Jaya,
Bahagian Kesihatan Pergigian, Jabatan Kesihatan Negeri Selangor
ABSTRAK
Pengenalan: Ramai pesakit Diabetes mellitus (DM) dikatakan cenderung untuk menghidapi
penyakit periodontal. Setakat ini tiada kajian pernah dilakukan untuk melihat prevalens
penyakit periodontal di kalangan pesakit ini di Klinik Diabetes, Klinik Kesihatan Anika Klang.
Sekiranya benar, maka semua pesakit Diabetes harus mendapat bimbingan dan rawatan
dari Klinik Pergigian untuk mencegah penyakit periodontal ini.
Objektif: Objektif utama kajian ini adalah untuk menentusah kejadian penyakit periodontal di
kalangan pesakit DM dan mengenalpasti kaitan faktor lain seperti umur, jantina dan paras
gula dalam darah pesakit.
Methodologi : Kajian ini adalah kajian cross-sectional yang melibatkan sampel mudah
seramai 30 peserta pesakit DM yang hadir di Klink Diabetes. Hanya mereka yang memberi
persetujuan sahaja yang terlibat. Pengumpulan data dilakukan dari bulan September hingga
Oktober 2009 iaitu selama dua bulan. Pengukuran skor penyakit periodontal dilakukan
mengunakan Skor BPE kod 0 hingga kod 4. Paras gula dalam darah pesakit adalah
berdasarkan keputusan ujian kimia yang dibuat oleh makmal di Klinik Kesihatan Anika Klang.
Keputusan: Di dapati semua pesakit DM mempunyai penyakit periodontal.Tahap skor yang
diperolehi adalah peringkat BPE kod 3 (33.7%) dan BPE kod 4 (66.3%). Pada tahap paras
gula yang sama, kaum lelaki di dapati mempunyai risiko yang lebih tinggi dibanding kaum
perempuan. Peringkat umur juga ada kaitan dengan keparahan penyakit periodontal di mana
mereka yang lebih tua adalah lebih cenderung untuk mendapat skor yang tertinggi. Pesakit
yang mempunyai paras gula 13mmol/l kebawah mendapati skor BPE kod 3 sementara
semua pesakit yang mempunyai paras gula lebih dari 13mmol/l mendapat skor penyakit
periodontal yang teruk (BPE kod 4).
Kesimpulan: Prevalens kejadian penyakit periodontal adalah 100% bagi pesakit Diabetes
Mellitus. Kejadian ini berkaitan dengan jantina, paras gula dalam darah dan peringkat umur
pesakit. Semua pesakit DM perlu menjaga kebersihan mulut dan mendapat rawatan gusi
seawal mungkin. Paras gula dalam darah harus dijaga ketahap yang baik.
PENGENALAN
Penyakit Diabetes Mellitus (DM) di takrifkan sebagai pesakit yang mempunyai paras glukos
melebihi 10mmol/l didalam darah. Banyak kajian telah menunjukkan bahawa penyakit
Diabetes Mellitus (DM) mempunyai hubungkait dengan penyakit periodontium. Setakat ini
,tiada kajian pernah dijalankan di Klinik Anika Klang untuk menentukan hubungkait antara
status kesihatan periodontium dengan paras gula didalam darah pesakit DM. Kajian ini boleh
membantu menambah informasi mengenai kaitan penyakit periodontium didalam pesakit
yang sedang menghadapi penyakit DM dan dengan itu boleh mengambil langkah pemulihan
dan pencegahan yang sewajarnya.
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
56 Status Kesihatan Periodontium Di Kalangan Pesakit Diabetes Di Klinik Diabetes Klinik Kesihatan Anika Klang, Selangor
KAJIAN LITERATURE
Periodontium adalah tisu–tisu yang mengelilingi dan menyokong struktur gigi. Struktur
penyokong gigi terdiri dari gingiva, ligamen periodontium, simentum dan tulang alveolus.
Fungsi utama periodontium adalah untuk pelekatan gigi pada tulang dan pengekalan integriti
mukosa kunyahan. Kesihatan periodontium sering di ancam oleh kehadiran lapisan plak iaitu
satu lapisan nipis yang lembut, melekit dan mudah melekat erat keatas permukaan gigi.
Permukaan plak ini jika di biarkan akan menjadi keras hasil terkalsifikasi menjadikan
permukaannya kasar dan memudahkan bakteria terkumpul. Bakteria akan berkongsi
makanan apa yang kita makan dan seterusnya akan mengeluarkan bahan buangan yang
terdiri daripada asid dan toksin. Pendedahan yang berpanjangan dari asid ini boleh
menyebabkan karies gigi .Hasil pengeluaran toksin berterusan meningkatkan kemungkinan
masuknya bakteria dan bahan toksik ini kedalam gusi untuk menyebabkan gingivitis. Dalam
keadaan ini gusi akan menjadi merah, bengkak dan mudah berdarah.
Jika gingivitis tidak di rawat, penyakit gusi akan melarat ke kawasan tisu ligamen
periodontium. Keadaan ini di panggil penyakit periodontium atau periodontitis. Penyebab
utama penyakit gusi adalah pembersihan plak yang tidak di kawal sehingga kemusnahan
struktur periodontium. Periodontitis boleh di kesan dengan adanya tanda-tanda gingivitis
bersama-sama dengan terbentuknya poket periodontal. Melalui pemeriksaan x-ray
Opthopanthogram (OPG) pula, penyakit periodontium dapat di kesan dengan kehilangan
tulang alveolus keseluruhannya. Penyakit periodontium boleh mengurangkan kualiti
kehidupan seseorang individu (Quality of Life) dari segi;
1) Paras rupa kurang sempurna.
2) Masalah pemakanan dan nutrisi kerana kefungsian gigi yang tidak sempurna.
3) Masalah sosial kerana mulut berbau dan gusi berdarah.
Tanda dan simptom periodontitis adalah
• Tanda seperti gingivitis seperti merah, keradangan dan mudah berdarah.
• Sebahagian gingiva boleh menjadi bengkak dan bernanah.
• Halitosis atau nafas berbau.
• Poket atau ruang di pinggir gingiva yang melebihi 3mm bila diukur dengan prob
periodontium.
• Pada peringkat lewat gigi akan menjadi longgar atau goyang.
Terdapat juga golongan yang lebih ramai mengidap periodontitis seperti pesakit diabetes
mellitus, perokok dan beberapa penyakit keturunan atau kongenital seperti Ehlers-Danlos.
Malaysia telah di kelaskan sebagai negara keempat tertinggi di Asia yang menghidap
diabetes. Menurut Kajian Kesihatan dan Mobiditi Kebangsaan 2006 menunjukkan 1.6 juta
rakyat atau setiap seorang daripada 8 penduduk negara ini yang berusia 30 tahun keatas
menghidap kencing manis. Ini adalah peningkatan sebanyak 80 peratus dalam tempoh 10
tahun iaitu daripada 8.3 peratus pada 1996 kepada 14.9 peratus pada 2006 dan di
anggarkan bertambah kepada 25 peratus pada 2020. Kesatuan Diabetes Antarabangsa
menjangkakan jumlah pesakit akan melonjak kepada lebih 435 juta menjelang 2020. Oleh itu
kajian tentang penyakit periodontal di kalangan pengidap diabetes perlu di lakukan. Kajian ini
boleh menyumbang untuk mengenali keperluan beban kerja dibidang periodontal serta cara
mengatasinya.
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
57 Status Kesihatan Periodontium Di Kalangan Pesakit Diabetes Di Klinik Diabetes Klinik Kesihatan Anika Klang, Selangor
OBJEKTIF KAJIAN
Objektif umum kajian ini adalah untuk menentukan apakah benar penyakit periodontium
berlaku dikalangan pesakit DM.
Objektif khusus adalah untuk menentukan kekerapan berlakunya penyakit periodontal
dikalangan pesakit DM dan kaitan paras gula pesakit DM dengan skor penyakit
periodontium yang dialami. Tahap kebersihan mulut turut diukur untuk memberi gambaran
mengenai status kebersihan mulut pesakit DM yang di kaji.
METHODOLOGI
Jenis kajian : Kajian ini dilakukan secara cross-sectional selama dua bulan dari
September 2009 hingga Oktober 2009. Pensampelan diambil dari kalangan pesakit diabetes
Mellitus yang hadir di Klinik Kesihatan Anika Klang. Hanya mereka yang memberi
persetujuan secara verbal diambil sebagai peserta kajian ini. Sampel diperolehi dengan
memilih pesakit diabetes yang mempunyai tahap gula dalam darah melebihi 10mmol/l .
Pemilihan Sampel dan Saiz : Seramai 30 orang pesakit (16 perempuan dan 14 lelaki)
melibatkan diri dalam kajian ini.
Kaedah ukuran : Status penyakit periodontal di ukur mengunakan Kod BPE 0 hingga kod
BPE 4 dimana kod 4 adalah paling teruk dan 0 adalah paling baik. Disclosing tablet telah
digunakan untuk menambah penglihatan semasa mengukur status kesihatan periodontium.
Ujian gula didalam darah pesakit DM diambil untuk menentukan paras gula semasa kajian
dijalankan. Dibawah adalah panduan untuk pengukuran status periodontal :
Kod Kreteria Rawatan
0 Sihat, tiada pendarahan/poket,
Jalur hitam kelihatan sepenuhnya. Tiada Rawatan yang diperlukan
1
Pendarahan semasa diprob tanpa
kehadiran poket yang melebihi
3.5mm/kalkulus. Jalur hitam
kelihatan sepenuhnya.
Tunjuk Ajar Higin Mulut
2
Terdapat faktor pengumpulan plak
tetapi tiada poket yang melebihi
305mm, Jalur hitam kelihatan
sepenuhnya.
Tunjuk Ajar Higin Mulut, Penskaleran,
Buang Faktor Pengumpulan Plak
3 Poket di antara 3.5mm-5.5mm,
Jalur hitam kelihatan separuh.
Tunjuk Ajar Higin Mulut, Penskaleran
Supra dan Subgingiva
4 Poket melebihi ≥6mm, Jalur hitam
tidak kelihatan.
Rawatan Terperinci diperlukan,
Penskaleran Subgingiva, Pembedahan
* Jika melibatkan furkasi, resesi
gingiva, mobolity / kegoyahan gigi.
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
58 Status Kesihatan Periodontium Di Kalangan Pesakit Diabetes Di Klinik Diabetes Klinik Kesihatan Anika Klang, Selangor
Kaedah Pengumpulan Data
Kebenaran rawatan dan pemeriksaan di perolehi selepas penerangan secara verbal
diterangkan kepada pesakit tentang kajian ini. Maklumat pesakit seperti umur, jantina dan
paras gula dikumpul. Pemeriksaan saringan periodontium dilakukan dan dicatit.
Penganalisaan Data
Kiraan mudah digunakan untuk mencerakinkan data yang telah dikumpul seperti
mengunakan kekerapan dan peratusan. Hasil analisa juga diproses mengikut jantina,
peringkat umur dan paras gula dalam darah pesakit. Graf dihasilkan daripada keputusan
analisa ini untuk mengambarkan hasil kajian dengan lebih jelas.
HASIL KAJIAN
Sosiodemografik Sampel
7.1 Peratus sampel mengikut jantina dan umur.
Jadual 1: Peratus Sampel Mengikut Jantina dan Umur
Demografik Ciri-ciri sampel Bilangan dlm sampel (n) Peratus
Jantina
Lelaki
Perempuan
Jumlah
14
16
30
46.6%
53.4%
100.0%
Umur
30-39
40-49
50-59
60-69
Semua
4
12
7
7
30
13.3%
40.0%
23.0%
23.0%
100.0%
Bilangan pesakit diabetes yang terlibat dalam kajian ini adalah seramai 30 orang seperti di
Jadual 1 iaitu 14 orang adalah lelaki manakala 16 orang adalah perempuan. Dari segi umur
pula, pesakit yang berumur 30-39 adalah seramai 4 orang, 40-49 adalah seramai 12 orang
dan pesakit yang berumur 50-59 dan 60-69 adalah masing-masing seramai 7 orang.
7.2 Prevalens keseluruhan
Rajah 1: Prevalen Kejadian Penyakit Periodontal
0
5
10
15
20
BPE 0 BPE1 BPE2 BPE3 BPE4
0 0 0
11
19
Bila
nga
n
Tahap skor penyakit periodontal
63.3%
%
36.7%
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
59 Status Kesihatan Periodontium Di Kalangan Pesakit Diabetes Di Klinik Diabetes Klinik Kesihatan Anika Klang, Selangor
Prevalen kejadian penyakit periodontal adalah 100% dimana skor BPE kod 3 adalah 36.7%
dan BPE kod 4 adalah 63.3%.
7.3 Prevalens Mengikut Jantina
Rajah 2: Prevalen Kejadian Penyakit Periodontal Mengikut Jantina
Rajah 2 menunjukkan bahawa 100% pesakit DM mempunyai penyakit periodontium tanpa
mengira jantina. Tahap skor penyakit periodontium yang dialami adalah di peringkat yang
teruk iaitu BPE 3 ( 37.0%) dan BPE 4 (63.0%). Sekiranya dibanding mengikut jantina: lebih
ramai kaum lelaki mendapat Skor BPE kod 4 iaitu 85.7%, (n=12) dibanding Skor BPE kod 3
iaitu 14.3% (n=2). Bagi kaum perempuan Skor BPE kod 3 terdiri dari 56.3% (n=9)
sementara skor BPE kod 4 adalah lebih rendah iaitu 43,7% (n=7).
7.4 Prevalen Mengikut Peringkat Umur
Rajah 3: Prevalen Kejadian Penyakit Periodontal Mengikut Umur
0
1
2
3
4
5
6
7
8
30-39thn 40-49thn 50-59thn 60-69thn
0 0 0 00 0 0 00 0 0 0
1
4
1
33
8
6
4BPE 0
BPE1
BPE2
BPE3
BPE4
85.7%
43.7%
) 14.3%
%
56.3%
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
60 Status Kesihatan Periodontium Di Kalangan Pesakit Diabetes Di Klinik Diabetes Klinik Kesihatan Anika Klang, Selangor
Rajah 3 menunjukkan peratus bilangan pesakit diabetes yang diperiksa mengikut umur.
Pada keseluruhannya, skor BPE4 adalah lebih prevalen dari BPE3 di semua lapisan umur
terbabit.
7.5 Prevalen Mengikut Paras Gula Dalam Darah Pesakit Dalam Mmol/l
Rajah 4: Prevalen Kejadian Penyakit Periodontal Mengikut Paras Gula Dalam Darah
Rajah 4 menunjukkan perbandingan skor BPE mengikut paras gula dalam darah.
Skor BPE3 dikaitkan dengan mereka yang mempunyai paras gula dalam darah yang kurang
daripada 13mmol/l dan Skor BPE4 dikaitkan dengan paras gula melebihi 13mmol/l. Ini
menunjukan, pesakit DM yang mempunyai paras gula melebihi 13mmol/l menunjukkan
keadaan penyakit periodontal yang lebih teruk iaitu skor BPE kod 4.
7.6 Status Kebersihan Mulut Pesakit DM yang dikaji
Rajah 5: Status Kebersihan Mulut Pesakit DM yang dikaji.
BPE0
BPE2
BPE4
0
2
4
6
8
10
1211
0 0 0 0
0
87
2 2
BPE0
BPE1
BPE2
BPE3
BPE4
0%
10%
20%
30%
40%
50%
60%
70%
Tidak memuaskan
sederhana baik sangat baik
kebersihan mulut 67% 16.70% 9.90% 6.60%
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
61 Status Kesihatan Periodontium Di Kalangan Pesakit Diabetes Di Klinik Diabetes Klinik Kesihatan Anika Klang, Selangor
Rajah 5 diatas menunjukkan kebersihan mulut pesakit diabetes. Sebilangan besar dari
pesakit DM mempunyai kebersihan mulut yang tidak memuaskan iaitu 67.0%. Selebihnya
hanya 6.6 % mempunyai kebersihan mulut yang sangat baik; diikuti dengan 9.9% baik.
Pesakit yang mempunyai kebersihan sederhana seramai 16.7% masih perlu meningkatkan
kebersihan mulut supaya tidak menjadi teruk. Gambaran ini menunjukkan agak ramai
pesakit DM menghidapi kebersihan yang kurang sempurna. Ini menunjukkan perlunya
pendidikan kesihatan pergigian bagi meningkatkan kesedaran dan amalan pesakit.
PERBINCANGAN
Ada beberapa faktor yang mungkin memberi limitasi kepada kajian ini. Pertamanya sampel
saiz agak kecil dan pemilihan peserta bergantung kepada kesudian pesakit mengambil
bahagian didalam kajian ini. Ini tidak dapat dielakkan kerana kesuntukan masa. Pengambilan
sampel berdasarkan bilangan pesakit yang hadir di Kinik Diabetes Klinik Kesihatan Anika
Klang. Disamping itu, pesakit yang berumur lingkungan 40-49 tahun mempunyai peratus
paling tinggi iaitu sebanyak (40.0%), diikuti pesakit yang berumur diantara 50-59 (23.0%)
dan 60-69 tahun sebanyak (23.0 %) berbanding dengan peringkat umur 30-39 tahun
sebanyak 13.3 % ( jadual 1 ). Ini mungkin menunujukan bahawa penyakit DM adalah lebih
kerap berlaku diperingkat umur 40-49 tahun.
Jika dibanding mengikut jantina, lebih ramai kaum lelaki mengalami skor BPE kod 4 (85.7%)
berbanding dengan kaum perempuan (43.7%). Ini menunjukan, pada paras gula yang sama,
risiko penyakit periodontal bagi kaum lelaki (rajah 1) adalah lebih tinggi.
Hasil kajian ini menunjukkan jantina, umur dan paras gula dalam darah pesakit mempunyai
kaitan dengan risiko penyakit periodontal. Hasil kajian yang dijalankan oleh Kementerian
Kesihatan Malaysia (NOHSA, 2000), menunjukkan lebih tinggi peringkat umur, lebih tinggi
risiko penyakit periodontal.
Skor BPE kod 3 dan 4 dalam kajian ini memberi implikasi bahawa kesemua pesakit DM
memerlukan rawatan periodonti dan pergigian yang lebih kompleks dari keadaan biasa. Oleh
itu pesakit diabetes, perlu mengawal penyakit mereka dengan mengawal pemakanan dan
ubat-ubatan yang betul supaya boleh mengekalkan paras gula yang optimum. Nasihat
daripada doktor dan pakar pemakanan adalah mustahak untuk membantu pesakit mengawal
keadaan yang tidak diingini. Glukos yang tinggi dalam darah boleh menjadi medium yang
sesuai untuk pembiakan bakteria oral. Ia juga akan menyebabkan aktiviti sel-sel pertahanan
dalam darah menurun. Kehadiran keadaan ini bersama dengan penjagaan higin mulut
kurang memuaskan, boleh memburukkan lagi masalah periodontium, memusnahkan tisu-tisu
sokongan gigi dan menyebabkan kelonggaran gigi.
Bagi pesakit diabetes yang mempunyai tahap gula dalam darah yang lebih rendah iaitu 10-
12mmol/l, skor BPE yang tertinggi adalah 3 manakala pesakit yang mempunyai tahap gula
13mmol/l dan ke atas mendapat skor BPE 4 (rajah 4). Maka mengawal tahap gula dalam
darah amat perlu dipantau untuk mengurangkan penyakit periodontium daripada menjadi
lebih teruk.
Yang amat merisaukan dalam kajian ini adalah 66.8% daripada pesakit DM mempunyai
kebersihan mulut yang tidak optimum; kerana tahap kebersihan mulut yang tidak sempurna
boleh memberi impak negatif kepada status kesihatan mulut ( rajah 4 ).
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
62 Status Kesihatan Periodontium Di Kalangan Pesakit Diabetes Di Klinik Diabetes Klinik Kesihatan Anika Klang, Selangor
Menurut kajian yang dilakukan oleh Snbberg et.al ( 2001 ) 85.0% pesakit DM didapati tidak
pernah menerima sebarang maklumat yang spesifik tentang kaitan penyakit diabetes dan
kebersihan mulut dan 83.0% tidak mengetahui kaitan diri pesakit dengan risiko kesihatan
mulut dan lalai tentang kesan-kesan sampingan penyakit tersebut mahupun kesan dari
pengambilan ubat-ubatan tertentu terhadap penyakit gusi. Bagi pesakit DM di Klinik Anika
Klang, sesuatu harus dipertingkatkan untuk memastikan pesakit DM mendapat bimbingan
kesihatan pergigian yang diperlukan.
KESIMPULAN
Prevalens penyakit periodontal bagi pesakit DM adalah 100%. Ini bermaksud penyakit
periodontium mempunyai kaitan yang rapat dengan kejadian penyakit DM. Paras gula dalam
darah pesakit DM ada satu faktor penyumbang terhadap keparahan penyakit periodontal
yang dialami. Lebih tinggi paras gula lebih teruk penyakit periodontal dialami. Didalam kajian
ini paras gula >13mmol/l merupakan suatu penanda aras yang boleh menentukan kejadian
status penyakit periodontal yang paling teruk (skor BPE4). Kebersihan mulut yang sihat
boleh mengurangkan penyakit periodontal tetapi didalam kajian ini, 66.8% pesakit adalah
pada tahap kebersihan mulut yang tidak baik.
Ini bermaksud , setiap pesakit DM perlu di beri dedahan tentang cara menjaga kebersihan
mulut dengan betul dan perlu ambil berat mengenai paras gula dalam darah mereka.
Implikasi klinikal: Pesakit DM cenderung untuk mengalami penyakit gusi. Oleh itu,
disamping mengawal paras glukos ketahap kurang dari 10mmol/l, pesakit perlu menjaga
kesihatan mulut dengan baik untuk mencegah penyakit periodontal supaya boleh mengecapi
kualiti hidup yang sempurna berpanjangan.
RUJUKAN
1. Cairo F, Rotundo R, Frazinggaro G, Muzzi L, Pini Prato GP. Minerva Stomatol, 2001
Sep-Oct : 50(9-10) 321-320.
2. Nota-nota syarahan.
3. National Oral Health Survey on Adults,2000.Kementarian kesihatan Malaysia, 2001.
4. Ronderos, M & Ryder, M.I Risk Assessment in Clinical Practice Periodontology .200-
2004:34:120-135.
5. Sanbberg, DM and Oral Care, Dental Update .May 2004 : 195.
6. Surat akhbar Metro Ahad, 15 november 2009 : E2
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
63 The Efficacy Of Psychiatry Medication Adherence Clinic (MTAC) At Hospital Tengku Ampuan Rahimah (HTAR) Klang, Selangor
THE EFFICACY OF PSYCHIATRY MEDICATION ADHERENCE CLINIC (MTAC) AT
HOSPITAL TENGKU AMPUAN RAHIMAH (HTAR) KLANG, SELANGOR
Khaw P.H., Manimegahlai S., Anusuya K.
Department of Pharmacy, Hospital Tengku Ampuan Rahimah (HTAR) Klang, Selangor
ABSTRACT
Introduction: Some of the common mental illnesses include major depressive disorder,
anxiety disorder, sleep disorder, cognitive disorder, schizophrenia, bipolar affective disorder,
substance abuse disorder, psychiatric syndrome, personality disorder and attention deficit
hyperactive disorder.
Objective: To improve patients‟ medication adherence and to improve patients‟ knowledge
on their disease and medication prescribed.
Methodology: Data was collected from the forms used in the Medication Therapy
Adherence Clinic (MTAC) which are; the Modified Morisky Scale; Pharmacist‟s intervention
form and from the DFIT (medications Dosage, Frequency, Indication and Time) score.
Results : The number of non-compliant patients decreased from 34 patients (68%) to 11
patients (22%) and the number of compliant patients increased from 16 patients (32%) to 39
patients (78%) between the first and second visits showing significant increase in compliance
towards medications (P-value < 0.001). In addition to that, there was significant reduction in
drug related problems (P-value < 0.01) from 48 drug related problems during patient‟s first
visit, and a reduction to 27 drug related problems during the second visit. There was also
significant reduction in non-compliance due to effective counselling sessions by pharmacist
during MTAC sessions (P-value < 0.05). Knowledge on how to take their medications
correctly increased from 74.5% to 92.7% showing significant improvement in DFIT (P-value <
0.001). From the 50 patients who were interviewed, 31 interventions (62%) were identified.
Difference in the mean of total drug related problems (0.42) was compared to the number of
interventions identified, showing intervention by pharmacists significantly reduced drug
related problems (P-value < 0.05).
Conclusion: The MTAC psychiatry program conducted in Hospital Tengku Ampuan
Rahimah (HTAR), Klang played a vital role in improving patient‟s adherence towards
medication and improving patients‟ knowledge on their disease and medication prescribed,
hence improving the treatment outcome and improving the overall management of the
disease.
INTRODUCTION
Mental health is defined as a state of balance in physical, mental and social well-being where
the individual is aware of his or her abilities; is able to cope with normal stresses of life; is
able to work productively; and is able to make contribution to his or her community. In a
rapidly developing country such as Malaysia; people often strive hard to survive with the
stress and tension, which may eventually contribute to mental health problems.1 Mental
illness is commonly termed to describe any significant interference to the cognitive,
emotional or social abilities; which is diagnosed base on the standardized criteria for
diagnosis listed in the International Classification of Diseases (ICD-10) or the Diagnostic and
Statistical Manual of Mental Disorders (DSM-IV).1,2
Some of the common mental illnesses include major depressive disorder, anxiety disorder,
sleep disorder, cognitive disorder, schizophrenia, bipolar affective disorder, substance abuse
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
64 The Efficacy Of Psychiatry Medication Adherence Clinic (MTAC) At Hospital Tengku Ampuan Rahimah (HTAR) Klang, Selangor
disorder, psychiatric syndrome, personality disorder and attention deficit hyperactive
disorder.3
The concept of pharmaceutical care had been introduced where the health care team which
comprises of physicians, pharmacists and other related health care professional; plays an
important role in the development of treatment therapy which will improve the patients‟
quality of life.6
However, treatment of mental illness requires good adherence in the treatment therapy.
Thus, a more comprehensive measure is required to increase the knowledge of this illness,
importance of treatment and to clarify misconception about mental illness. Introduction of the
psychiatry Medication Therapy Adherence Clinic (MTAC) is an effort to improve the
treatment therapy by cultivating adherence, monitoring of clinical progression and detection
of adverse effect.
Shoka et al. (2007) had estimated the rate of non-compliance in psychotic disorder maybe as
high as 80%; which may be confused with non-responsive to treatment and result in
switching of alternative antipsychotic.7 A separate study by Llorca et al. (2007) had discussed
partial compliance where patients do not follow the treatment therapy as instructed and thus,
unable to receive the benefits from their treatment.8 Among the ways to cultivate adherence
to treatment therapy includes illness and medication knowledge; effective and well-tolerated
treatment; frequent follow-up; social support; and family motivation.8,9 These can be done
through the operation of MTAC; where patients are monitored, counselled; and dispensed
with medications at monthly interval by the pharmacists.
Amongst the adverse effects and drug related problems which could be monitored through
MTAC includes the extrapyramidal symptoms (EPS), prolactin level and weight gain. EPS
which is very common with the usage of typical antipsychotic should be treated accordingly
to improve patients‟ quality of life. Increment in prolactin hormone which causes lactation,
occur more with the usage of typical antipsychotic.10 In females, hyperprolactinaemia may
also disrupt the ovarian function causing heavy menstruation.10 The excessive weight gain
which is more common in patients‟ using atypical antipsychotic should be cautioned as it
would eventually lead to type-2 diabetes mellitus, hyperlipidaemia and cardiovascular
disorders.11
The Pharmacy Department of Hospital Tengku Ampuan Rahimah (HTAR), Klang, had
established the Psychiatry MTAC in April 2009 which aims to assist the psychiatrists and
medical officers in the psychiatry department. The service provided by the pharmacists
includes providing adequate and relevant information to patients; cultivating adherence; and
monitoring and addressing drug related problems to improve patient‟s quality of life. The
pharmacist would act as a point of coordination and communication between the patient, the
primary health-care team, the community mental-health team and hospital-based health
professionals.
The service of MTAC is not limited to psychiatric outpatients only; but to patients whom are
warded where they will be monitored in the ward by a ward pharmacist and they in turn will
be referred to the MTAC clinic upon discharge if adherence to medication is found to be
poor. The role of the pharmacists extends to the community psychiatry team. The community
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
65 The Efficacy Of Psychiatry Medication Adherence Clinic (MTAC) At Hospital Tengku Ampuan Rahimah (HTAR) Klang, Selangor
psychiatry team is a multi disciplinary team where the pharmacist plays a role in addressing
any drug related problems and enforcing compliance towards the medications. This study
aims to identify the efficacy and benefits of the Psychiatry MTAC.
Research Objective
The objectives of the project are:
To improve patients‟ medication adherence
To improve patients‟ knowledge on their disease and medication prescribed
METHODOLOGY
Data Collection Form
Data was collected from the forms used in the MTAC which are: the Modified Morisky scale;
Pharmacist‟s intervention form and from the medications Dosage, Frequency, Indication and
Time (DFIT).
The Modified Morisky form has an eight items questionnaire which covered topics about
patient‟s knowledge on treatment regimens and treatment concerns; such as side effects,
risks and benefits. Patients‟ adherence was obtained from the values given; where Morisky
score of ≤ 3 is compliant, while Morisky score of 4 – 11 is non-compliant.
The drug related problems comprises of seventeen items which are common problems
encountered by patients. An additional column is allocated for other problems apart from the
stated. Relevant laboratory results are recorded to identify side effects of medication.
Appropriate interventions are carried out whenever necessary to resolve the drug related
problems.
The medication knowledge aims to assess patients‟ medication knowledge on the dosage,
frequency, indication and time (DFIT). A DFIT score is then generated by:
Research Design
The Psychiatry MTAC is located in the Ambulatory Care Centre (ACC) of HTAR. It operates
every Tuesdays and Thursdays from 9.00am to 1.00pm. Patients are referred to the MTAC
by the specialists and medical officers. Subsequent follow-up with the pharmacists were
recruited to this study based on the inclusion and exclusion criteria. The duration of the study
was scheduled to be six months starting from August 2010 to January 2011.
During the initial visit, referred patients will be interviewed and introduced to the MTAC and
the pharmacist will then proceed with the education of the disease and prescribed
medications; followed by adherence enforcement. The pharmacist will monitor the patient for
any drug-drug interactions, side effects and drug related problems. After the initial interview,
the pharmacist will schedule a follow-up appointment at monthly interval to evaluate the
patients‟ compliance issues, change in medications, drug-related problem, side effects of
DFIT SCORE = Patient‟s score x 100%
Number of medications x 4
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
66 The Efficacy Of Psychiatry Medication Adherence Clinic (MTAC) At Hospital Tengku Ampuan Rahimah (HTAR) Klang, Selangor
medications and monitoring of medications with narrow therapeutic index. Monitoring will be
conducted at every visit follow by necessary intervention.
For this study, data was collected on the first visit and the subsequent visit.
Sampling
The sample size collected was 50 patients who included newly diagnosed patients, referred
patients and follow-up patients. For this study, patients were recruited according to the
inclusion and exclusion criteria.
Inclusion Criteria
Patients of different races.
Patients ranging from the age of 20 to 65 years old.
Patients from both the sexes.
Patients who had been referred to MTAC by the prescriber.
Patients who were on antipsychotic medication therapy in HTAR for indications such
as schizophrenia, bipolar disorder, major depressive disorder, general anxiety
disorder, obsessive compulsive disorder ,panic disorder and drug induced disorders,
mental retardation and dementia
Exclusion Criteria
Patients who are either dumb or deaf.
Patient who were transferred to other health facilities.
Patients who have passed away.
Statistical Analysis
The answer for each data collection item was scored accordingly and all data were analyzed
using Statistical Package for Social Science© (SPSS©), version 16.0. The variables
analyzed were adherence to dosage regimen, drug related problem and medication
knowledge.
Test of normality (Shapiro-Wilk test) was conducted and it was found to be not significant.
Hence, non-parametric statistical test was used to analyze the results. For Morisky score,
drug related problems and DFIT; Wilcoxon signed-ranks test was used to analyze the results.
A P-value < 0.05 would indicate a significant difference in the result between the first month
and second month visit. For the interventions; Kruskal-Wallis test was conducted. A P-value
< 0.05 would indicate there is a significant difference in the findings.
RESULTS
Patient demographics
Based on Figure 1, majority of patients were from the age group of 21-30 years old. This is
followed by age group of 31-40 years old. The least number of patients were from the age
group of less than 21 years old. The mean age of the patients was 40 years old (range
between 41-50 years old).
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
67 The Efficacy Of Psychiatry Medication Adherence Clinic (MTAC) At Hospital Tengku Ampuan Rahimah (HTAR) Klang, Selangor
Figure 1: Distribution of patients according to age (n = 50)
In this study, a total of 50 psychiatric patients were recruited. The number of male patients
(52%) was slightly higher than the female patients (48%).
Figure 2: Distribution of patients according to gender (n = 50)
Based on Figure 3, highest percentage of patients were of Indians (42%), followed by
Chinese (32%) and Malays (24%).
Figure 3: Distribution of patients according to race (n = 50)
6%
28%
26%
10%
30%<21
21-30
31-40
41-50
>50
52%
48%
Female
Male
32%42%
24% 2%
Chinese
Indian
Malay
Others
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
68 The Efficacy Of Psychiatry Medication Adherence Clinic (MTAC) At Hospital Tengku Ampuan Rahimah (HTAR) Klang, Selangor
According to Figure 4, majority of patients (46%) were suffering from schizophrenia. This is
followed by major depression disorder (30%), psychosis and bipolar mania disorder both
having 6% of total population.
Figure 4: Distribution of patients according to diagnosis (n = 50)
Morisky Score
Based on Figure 5, 16 patients (32%) were classified as compliant to medication based on
the Morisky score on the first visit. The remaining 34 patients (68%) who were non-compliant
were recruited into the MTAC. Morisky score of 0-3 was categorized as compliant to
medication and 4-11 was categorized as non-compliant to medication. On the second visit,
the number of patients who were compliant increased to 39 patients (78%) and the number
of patients who were non-compliant decreased to 11 patients (22%). After comparing the
Morisky score between the first and subsequent visit using statistical analysis (Wilcoxon
signed-ranks test), there is a significant increase in the number of patients who are compliant
to medication between the first and second visit (P < 0.001).
Figure 5: Comparison of Morisky Score between first and second visit (n = 50)
6% 2%4%
2%
30%
2%2%
6%
46%
Bipolar Mania Disorder
Dementia
Drug Induce Psychosis
General Anxiety Disorder
Major Depression DisorderMental Retardation
Obsessive Compulsive DisorderPsychosis
Schizophrenia
16
39
34
11
0
5
10
15
20
25
30
35
40
45
Nu
mb
er o
f p
atie
nts
Compliant
Non-compliant
Second VisitFirst Visit
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
69 The Efficacy Of Psychiatry Medication Adherence Clinic (MTAC) At Hospital Tengku Ampuan Rahimah (HTAR) Klang, Selangor
Drug Related Problems
Figure 6 shows the example of drug related problems identified during the first and
subsequent visit in MTAC. A total of 48 drug related problems were identified on the first visit.
Upon the subsequent visit to MTAC, the number of drug related problems reduced to 27
whereby there was a reduction of 43.8%.
Figure 6: Drug related problems identified during the first and subsequent visit
Figure 7 shows the comparison of total mean of drug related problems between first and
second visit. The mean of drug related problems were 0.96 on the first visit. After being
referred to MTAC psychiatry, the mean of drug related problems reduced to 0.54 whereby
there is reduction by 43.8%. The P-value was < 0.005 showing significant reduction in drug
related problem between first and second visit.
Figure 7: Comparison of total mean of drug related problems between first and second
visit
0 2 4 6 8 10 12 14
Extrapyrimidal symptoms
Tardive dyskinesia
Oculogyric crisis
Hypersalivation
Blurring of vision
Palpitation
Rash
Alopecia
Amenorrhoea
First Visit Second Visit
0.96
0.54
0
0.2
0.4
0.6
0.8
1
1.2
Dru
g R
ela
ted
Pro
ble
ms
First Visit Second Visit
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
70 The Efficacy Of Psychiatry Medication Adherence Clinic (MTAC) At Hospital Tengku Ampuan Rahimah (HTAR) Klang, Selangor
Figure 8 shows comparison of number of patients who were non-compliant to their
medications between the first and the second visit. On the first visit, 31 patients (62%) were
non-compliant to their medication. After being seen by the pharmacist at MTAC, there was a
reduction in the number of patients who were non-compliant towards their medication to 20
patients (40%). There was a significant reduction in the number of patients who were non-
compliant. The P-value was < 0.05.
Figure 8: Comparison of number of patients who were non-compliant to their
medications between the first and the second visit
DFIT
According to Figure 9, patients‟ mean DFIT score was only 74.50% on the first visit. Upon the
subsequent visit, the mean DFIT score increased to 92.71% (P < 0.001), showing a
significant increase in patients knowledge on medications dosage, frequency, indication and
time.
Figure 9: Comparison of DFIT score between first and subsequent visit
31
20
0
5
10
15
20
25
30
35
Nu
mb
er o
f p
atie
nts
First Visit Second Visit
74.50%
92.71%
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
90.00
100.00
Pe
rce
nta
ge
First Visit Second Visit
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
71 The Efficacy Of Psychiatry Medication Adherence Clinic (MTAC) At Hospital Tengku Ampuan Rahimah (HTAR) Klang, Selangor
Interventions
Figure 10 shows the list of interventions identified during the first and second visit in MTAC.
From the 50 patients who were interviewed, a total of 31 interventions (62%) were identified.
The interventions were then classified into 6 categories as shown in Figure 3.10. The highest
percentage of intervention was regarding side effects (29%). This was followed by
inappropriate dosing, 23% of total interventions.
Figure 10: List of interventions identified during first and second visit
Figure 11 shows total mean of drug related problems between the first and the second visit
and the difference of mean drug related problem. The P-value was found to be < 0.05
showing intervention by the MTAC pharmacists significantly reduced the difference of total
mean drug related problems.
Figure 11: List of interventions identified during first and second visit
29%
10%
13%
23%
6%
19% Side effects
Drug interaction
Cross tappering of medication
Inappropriate dose
Compliant issues
Medication querry
0.96
0.54
0.42
0
0.2
0.4
0.6
0.8
1
1.2
Dru
g R
ela
ted
Pro
ble
ms
First Visit
Second Visit
Difference of Mean
DRP
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
72 The Efficacy Of Psychiatry Medication Adherence Clinic (MTAC) At Hospital Tengku Ampuan Rahimah (HTAR) Klang, Selangor
RESULT AND DISCUSSION
From the demographic data, the average age of patients recruited in the study was 40.2
years. Out of the total number of patients 52% of patients were male and 48% were female.
Out of the 50 patients, 42% were Indians, 32% were Chinese and 24% were Malay. The
remaining 2% were of other races. This composition of patients shows that the major races in
Malaysia were taken into consideration. The highest number of patient (46%) was suffering
from schizophrenia reflecting a major concern in this disorder.
Normality test was run to determine if the data was normally distributed or otherwise. Since
the data was not normally distributed, non-parametric test, Wilcoxon signed-ranks test were
carried out to analyze the data12. The sum of the positive and negative signed-ranks is used
to generate a P-value for each questionnaire item to determine if the result of the test and
retest are significantly different12. For example, to evaluate if there is a significant
improvement in patients, Morisky scoring between the first and the subsequent visits, the
sums of the signed ranks were evaluated. If the mean ranks were far from zero with a small
P-value, it shows significant difference in Morisky score between the first and subsequent
visits12.
According to Vitolins et al. (2000), the most common way to measure compliance to
pharmacological interventions is the use of self-report measures which includes patient
interviews and questionnaires.13 The strengths of these measures are that they are fast,
flexible, inexpensive, easy, and have face validity.13, 14 They have a high degree of specificity
for non-compliance and potentially can be a rich source of data on adherence patterns and
reasons for missed doses.13, 14
In this study, compliance was assessed using the modified Morisky score. Morisky scoring of
3 or less was classified as compliant to medication and a score of 4 to 11 were classified as
non-compliant to medication. There was a decrease in the number of non-compliant patients
from 34 patients (68%) to 11 patients (22%) and increase in the number of compliant patients
from 16 patients (32%) to 39 patients (78%) between the first and second visits. Significant
improvement in the modified Morisky score between the first and the subsequent visit (P-
value < 0.001) explains patients increased compliance towards anti-psychotic medications. A
study by Novick et al. (2008) on treatment adherence in outpatients, had reported that
medication compliance was associated with a lower risk of relapse.15, 16 This shows that
compliance towards medication will lead to improvement in treatment outcome.15, 16
A total of 48 drug related problems were identified during patient‟s first visit to MTAC. Upon
the second visit, the number of drug related problems reduced to 27. The percentage of
reduction was 43.8%. When the total mean of drug related problems in the first visit were
compared to that of from the second visit, there was a significant reduction (P-value < 0.01).
Adverse medication events and often compliance issues arising due to it can also be
reduced. This was supported by Remington et al. (2003), which reported significant
improvement in compliancy and better outcome could be achieve through identification and
addressing of adverse drug reaction.17 A systematic review of the role of pharmacists in
mental health care by Finley et al. (2003), concluded that pharmacists can bring about
improvements in the safe and efficacious use of psychotropic medications.18
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
73 The Efficacy Of Psychiatry Medication Adherence Clinic (MTAC) At Hospital Tengku Ampuan Rahimah (HTAR) Klang, Selangor
In addition to that, there was also a significant reduction in the number of patients whom
were non-compliant (P-value < 0.05). Counselling sessions by pharmacist during MTAC
sessions are proven to be effective by this significant result. In a systemic review by Bell et
al. (2005) which evaluates optimal use of medication in mental illness describes pharmacists‟
medication counselling and treatment monitoring can improve adherence to antidepressant
medications.19 The authors emphasize on the importance of providing comprehensive
medication information to patients to cultivate adherence.19 In a separate study by Al-Saffar
et al. (2008) reported that 90% of patients favour the idea of receiving information about
therapy; and counselling was found to be significantly associated with much higher recall of
medication name, management of missed dose and correct use of medications.20 In
addition, Razali et al. (1995) reported that patients with poor adherence who were allocated
to receive pharmacist medication counselling had significantly fewer relapses that required
hospitalisation.21 Report by Bell et al. (2005) showed that medication counselling conducted
by pharmacists can improve medication adherence among people commencing
antidepressant therapy.22
Another significant result that shows the role of pharmacist towards better management of
psychiatric patients is medication knowledge after joining the MTAC program as seen by
significant increase in DFIT score (P-value < 0.001) between the first and subsequent visits.
Knowledge on how to take their medications correctly has increased from 74.5% to 92.7%
hence improving patients‟ adherence towards medication. Konarzewska et al. (1997) found
that adherence to medical and behavioural regimens is important as inadequate adherence
can adversely impact the effectiveness of an intervention.23 The author also reported that
complexity of the medication regimen and number of medications prescribed will affect the
chances of patients adherence. Hence, good understanding of medication regimen will
encourages good adherence.23
Another area that was analyzed in this study was interventions. From the 50 patients who
were interviewed, 31 interventions (62%) were identified. The interventions were then
categorized into six categories namely side effects, drug interaction, cross tapering of
medication, inappropriate dose, compliance issues and medication queries. Among the side
effects identified were inability to sleep, drowsiness and increase in blood pressure.
Appropriate action was taken by the pharmacist to rectify the interventions identified by
discussing with the prescriber. A systemic review by Kaboli et al. (2006) had concluded that
interacting with the health care team, interviewing patient and counselling on medications
resulted in reduction in adverse drug events, medication errors, and improvement in
medication adherence and knowledge.24 A separate study by Stoner et al. (2002); reported
82% of pharmacists‟ interventions were accepted which lead to a 90% successful outcome
achieved.25 In additional, patients are generally very receptive and cooperative in the
treatment plan as there is a positive outcome.25
An extension of the Wilcoxon test, Kruskal-Wallis test was used to analyze numerical value
versus categorical value. Total mean of drug related problem during the first visit was 0.96
which then reduced to 0.54 during the second visit. The difference of mean of drug related
problem between the first and second visit was 0.42. When the difference in the mean of
total drug related problem were compared to the number of intervention identified, the P-
value was found to be < 0.05 showing intervention by the MTAC pharmacists significantly
reduced the difference of total mean drug related problems. With reference to Novik et al.
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
74 The Efficacy Of Psychiatry Medication Adherence Clinic (MTAC) At Hospital Tengku Ampuan Rahimah (HTAR) Klang, Selangor
(2009), non-adherence was significantly associated with an increased risk of relapse; and
reversal of risk factors may improve adherence.26 Strategies such as MTAC Psychiatry that
addresses drug related problems associated with non-adherence may lead to improved
adherence and also improved patient outcomes.26
Limitation
As with other studies, this study comes with some limitations. The small number of patients
(n = 50), may affect the significance of some results analyzed. Another limitation would be
time constraint which only allowed comparison between the first and the second visit. Hence,
long term effectiveness could not be evaluated.
CONCLUSION
This study proves that the MTAC psychiatry program conducted in HTAR, Klang plays a vital
role in improving patient‟s adherence towards medication and improving patients‟ knowledge
on their disease and medication prescribed, hence improving the treatment outcome and
improving the overall management of the disease.
RECOMMENDATION
A quality of life (QOL) study can be done as a continuation of this study. In addition to that, a
pharmacoeconomic study such as a cost benefit analysis and cost saving analysis may also
be carried out in the future.
REFERENCES
1. Yeap R, Low WY. Mental health knowledge, attitude and help seeking tendency: A
Malaysian context. Singapore Med J 2009; 50:1169-76.
2. Peters H. Mental Health: Special needs and education. Asean Journal of Psychiatry
2010; 11:1-7.
3. Australian Pharmacy Council and Committee of Heads of Pharmacy Schools of Australia
and New Zealand. Statement of mental health care capabilities for pharmacists 2009.
4. Tandor R, Nasrallah HA, Keshavan MS. Schizophrenia, "Just the Facts". Schizophr Res
2010.
5. Falkai P. Limitation of current therapies: Why do patients switches therapies? European
neuropsychopharmacology 2008; 18:135-9.
6. Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am J
Hosp Pharm. 1990; 47:533.
7. Shoka A. The wheel of compliance in schizophrenia. European Psychiatry 2007; 22:50.
8. Llorca PM. Partial compliance in schizophrenia and impact on patient outcomes.
Psychiatry Research 2008; 161:235-47.
9. Vlasnik JJ, Aliotta SL, DeLor B. Medication adherence: Factor influencing compliance
with prescribed medication plans. TCM 2005:47-51.
10. Canoso MC, Goldstein JM, Wojcik J, Dawson R, Brandmand D, Klibanski A, Schildkraut
JJ, Green AI. Antipsychotic medication, prolactin elevation and ovarian function in women
with schizophrenia and schizoaffective disorder. Psychiatry research 2002; 111:11-20.
11. Bobes J. Schizophrenia and overweight/obesity:Pathophysiology and medical
consequences. 2007; 22:89-95.
12. Sheridan JC, Lyendall S. SPSS version 14.0 for Windows. Anaysis without Anguish.
2007.
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
75 The Efficacy Of Psychiatry Medication Adherence Clinic (MTAC) At Hospital Tengku Ampuan Rahimah (HTAR) Klang, Selangor
13. Mara Z. Vitolins, Cynthia S.Rand, Stephen R. Rapp. Measuring Adherence to Behavioral
and Medical Interventions. Department of Public Health Sciences. 2000; 21:188S-194S.
14. Palmer LA, Russo P, Vasey J. Schizophrenia care and assessment program (SCAP):
The impact of clinical and functional characteristic and antipsychotic medication
treatment on outpatient and inpatient psychiatric utilization. International Congress on
Schizophrenia Research 2003.
15. Novick D, Suarez D, Haro JM. The impact Of Medication Compliance on Relapse in the
Outpatient Setting: Schizophrenia Outpatients Health Outcomes (SOHO) Study 2008; 1-
279.
16. Gianfrancesco FD, Rajagopalan K, Sajatovic M, Wang RH. Treatment adherence among
patients with schizophrenia treated with atypical and typical antipsychotic. Psychiatry
Research 2006; 144:177-189.
17. Remington G, Light M, Lasser R, Bossie C, Zhu Y, Gharabawi G. Can stable patients
with schizophrenia improve? The impact of partial compliance versus constant therapy.
International Congress on Schizophrenia Research 2003:300.
18. Finley PR, Crismon ML, Rush AJ. Evaluating the impact of pharmacists in mental health:
a systematic review of Clinical Pharmacy. Department Pharmacotherapy 2003 Dec;
23(12):1634-44.
19. Bell S, McLachan AJ, Aslani P, Whitehead P, Chen TF. Community pharmacy service to
optimise the use of medication for mental illness: A systemic review. Australia and New
Zealand Health Policy 2005.
20. Al-Saffar N, Abdulkareem A, Abdulhakeem A, Salah AQ, Heba M. Depressed patients‟
preference for education about medication by pharmacist in Kuwait. Patient Educ Couns
2008; 72(1): 94-101.
21. Razali MS, Yahya H. Compliance with treatment in schizophrenia: a drug intervention
program in a developing country. Source Department of Psychiatry, School of Medical
Sciences, Universiti Sains Malaysia, Kelantan 1995 May; 91(5):331-5.
22. Simon Bell, Andrew J McLachlan, Parisa Aslani. Community pharmacy services to
optimise the use of medications for mental illness: a systematic 2005
23. Kouarzewska B, Ruduik I, Juchnowicz D, Poplawska R. Male sexual dysfunction,
adherence to antipsychotic therapy and the quality of life in schizophrenia. Comparison of
olanzapine and risperidone. Department of Psychiatry 1997.
24. Kaboli PJ, Hoth AB, McClimon BJ. Clinical Pharmacist and Inpatient Medical Care: A
Systematic Review. Arch Intern Med. 2006:955-964.
25. Stoner SC, Worrel JA, Jones MT. Pharmacist-Designed and -Implemented
Pharmaceutical Care Plan for Antipsychotic-Induced Movement Disorders.
Pharmacotherapy 2000; 20(5).
26. Novick D, Haro JM, Suarez D. Predictors and clinical consequences of non-adherence
with antipsychotic medication in the outpatient treatment of schizophrenia. Department of
Psychiatry 2009.
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
76 The Prescribing Pattern Of Antihypertensives In Patients With Chronic Renal Failure
THE PRESCRIBING PATTERN OF ANTIHYPERTENSIVES IN PATIENTS WITH CHRONIC
RENAL FAILURE.
Nur Arina Binti Sariffudin, Tee Xin Yi
Pharmacy Department, Hospital Sungai Buloh
ABSTRACT
Introduction: To observe the prescribing pattern of antihypertensives in patients with
chronic renal failure in medical wards (Ward 4A and 4D) of Hospital Sungai Buloh (HSB).
Objectives: i) To characterise the pattern of prescribing of antihypertensives in patients with
chronic renal failure. ii) To investigate the level of conformity to the recommended guideline
by the medical wards in HSB. iii) To observe the most commonly prescribed class of
antihypertensives for patients with chronic renal failure in medical wards of HSB. iv)To
analyse the data in relation to the selected population characteristics.
Methodology: Sample was taken from medical wards (4A and 4D) of Hospital Sungai Buloh.
All patients that were admitted and discharged within 1st Jan to 31st March were included in
this study. Data was then analysed through SPSS statistical software and the
antihypertensive prescribing pattern were compared with national guideline of Hypertension
in Chronic Kidney Disease by the Malaysian Society of Nephrology.
Result: Calcium channel blocker (CCB) is the most prescribed antihypertensive either as
single or multiple antihypertensive therapies. This finding corresponds with the national
guidelines for hypertension with chronic kidney disease, which does not specify any agent as
initial therapy.
Conclusion: Findings from other studies showed that CCB has renoprotective function.
However, CCB is still not the most preferred antihypertensive that can provide excellent
renoprotective function. Other studies also concluded that maintaining adequate blood
pressure is not the key to prevent kidney function from deteriorating. In fact, choosing the
correct class of antihypertensive is more important than controlling blood pressure. We can
conclude that this study shows that CCB is the most preferred antihypertensive agent in
patients with chronic renal failure.
INTRODUCTION
High blood pressure or hypertension is a common condition in which the force of the blood
against your artery walls is high enough that it may eventually cause health problems, such
as heart disease. More specifically, hypertension is defined as persistent elevation of systolic
BP of 140 mmHg or greater and/or diastolic BP of 90 mmHg or greater. Blood pressure is
determined by the amount of blood your heart pumps and the amount of resistance to blood
flow in your arteries1. The more blood your heart pumps and the narrower your arteries, the
higher your blood pressure. Hypertension can be going on for years without any symptoms.
Uncontrolled high blood pressure increases risk of serious health problems, including heart
attack and stroke. It typically develops over many years, and it affects nearly everyone
eventually. Fortunately, high blood pressure can be easily detected2.
Two forms of high blood pressure have been described: essential hypertension and
secondary hypertension. Essential hypertension is a far more common condition and
accounts for 95% of hypertension1. The cause of essential hypertension is multifactorial, that
is, there are several factors whose combined effects produce hypertension. In secondary
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
77 The Prescribing Pattern Of Antihypertensives In Patients With Chronic Renal Failure
hypertension, which accounts for 5% of hypertension, the high blood pressure is secondary
to a specific abnormality in one of the organs or systems of the body.
Essential hypertension affects approximately 72 million Americans, yet its basic causes or
underlying defects are not always known. Nevertheless, certain associations have been
recognized in people with essential hypertension3. For example, essential hypertension
develops only in groups or societies that have a fairly high intake of salt, exceeding 5.8
grams daily. Salt intake may be a particularly important factor in relation to essential
hypertension in several situations, and excess salt may be involved in the hypertension that
is associated with advancing age, African American background, obesity, hereditary
susceptibility, and kidney failure (renal insufficiency). The Institute of Medicine of the National
Academies recommends healthy 19 to 50-year-old adults consume only 3.8 grams of salt to
replace the average amount lost daily through perspiration and to achieve a diet that
provides sufficient amounts of other essential nutrients4.
Genetic factors are thought to play a prominent role in the development of essential
hypertension. However, the genes for hypertension have not yet been identified. The current
research in this area is focused on the genetic factors that affect the renin-angiotensin-
aldosterone system. This system helps to regulate blood pressure by controlling salt balance
and the tone (state of elasticity) of the arteries2,3.
Approximately 30% of cases of essential hypertension are attributable to genetic factors. For
example, in the United States, the incidence of high blood pressure is greater among African
Americans than among Caucasians or Asians. Also, in individuals who have one or two
parents with hypertension, high blood pressure is twice as common as in the general
population5. Rarely, certain unusual genetic disorders affecting the hormones of the adrenal
glands may lead to hypertension. (These identified genetic disorders are considered
secondary hypertension.)
The vast majority of patients with essential hypertension have in common a particular
abnormality of the arteries: an increased resistance (stiffness or lack of elasticity) in the tiny
arteries that are most distant from the heart (peripheral arteries or arterioles). The arterioles
supply oxygen-containing blood and nutrients to all of the tissues of the body. The arterioles
are connected by capillaries in the tissues to the veins (the venous system), which returns
the blood to the heart and lungs. Just what makes the peripheral arteries become stiff is not
known6. Yet, this increased peripheral arteriolar stiffness is present in those individuals
whose essential hypertension is associated with genetic factors, obesity, lack of exercise,
overuse of salt, and aging. Inflammation also may play a role in hypertension since a
predictor of the development of hypertension is the presence of an elevated C reactive
protein level (a blood test marker of inflammation) in some individuals5,6. As mentioned
previously, 5% of people with hypertension have what is called secondary hypertension. This
means that the hypertension in these individuals is secondary to a specific disorder of a
particular organ or blood vessel, such as the kidney, adrenal gland, or aortic artery4.
Diseases of the kidneys can cause secondary hypertension. This type of secondary
hypertension is called renal hypertension because it is caused by a problem in the kidneys.
One important cause of renal hypertension is narrowing (stenosis) of the artery that supplies
blood to the kidneys (renal artery). In younger individuals, usually women, the narrowing is
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
78 The Prescribing Pattern Of Antihypertensives In Patients With Chronic Renal Failure
caused by a thickening of the muscular wall of the arteries going to the kidney (fibro
muscular hyperplasia). In older individuals, the narrowing generally is due to hard, fat-
containing (atherosclerotic) plaques that are blocking the renal artery7.
How does narrowing of the renal artery cause hypertension? First, the narrowed renal artery
impairs the circulation of blood to the affected kidney. This deprivation of blood then
stimulates the kidney to produce the hormones, renin and angiotensin3,6. These hormones,
along with aldosterone from the adrenal gland, cause a constriction and increased stiffness
(resistance) in the peripheral arteries throughout the body, which results in high blood
pressure8.
Renal hypertension is usually first suspected when high blood pressure is found in a young
individual or a new onset of high blood pressure is discovered in an older person. Screening
for renal artery narrowing then may include renal isotope (radioactive) imaging,
ultrasonography (sound wave) imaging, or magnetic resonance imaging (MRI) of the renal
arteries. The purpose of these tests is to determine whether there is a restricted blood flow to
the kidney and whether angioplasty (removal of the restriction in the renal arteries) is likely to
be beneficial. However, if the ultrasonic assessment indicates a high resistive index within
the kidney (high resistance to blood flow), angioplasty may not improve the blood pressure
because chronic damage in the kidney from long-standing hypertension already exists. If any
of these tests are abnormal or the doctor's suspicion of renal artery narrowing is high
enough, renal angiography (an X-ray study in which dye is injected into the renal artery) is
done. Angiography is the ultimate test to actually visualize the narrowed renal artery9.
A narrowing of the renal artery may be treated by balloon angioplasty. In this procedure, the
physician threads a long narrow tube (catheter) into the renal artery. Once the catheter is
there, the renal artery is widened by inflating a balloon at the end of the catheter and placing
a permanent stent (a device that stretches the narrowing) in the artery at the site of the
narrowing7,8,9. This procedure usually results in an improved blood flow to the kidneys and
lower blood pressure. Moreover, the procedure also preserves the function of the kidney that
was partially deprived of its normal blood supply. Only rarely is surgery needed these days to
open up the narrowing of the renal artery9.
Any of the other types of chronic kidney disease that reduces the function of the kidneys can
also cause hypertension due to hormonal disturbances and/or retention of salt. It is important
to remember that not only can kidney disease cause hypertension, but hypertension can also
cause kidney disease. Therefore, all patients with high blood pressure should be evaluated
for the presence of kidney disease so they can be treated appropriately10.
Uncomplicated high blood pressure usually occurs without any symptoms (silently) and so
hypertension has been labelled "the silent killer." It is called this because the disease can
progress to finally develop any one or more of the several potentially fatal complications of
hypertension such as heart attacks or strokes10. Uncomplicated hypertension may be present
and remain unnoticed for many years, or even decades. This happens when there are no
symptoms, and those affected fail to undergo periodic blood pressure screening.
Some people with uncomplicated hypertension, however, may experience symptoms such
as headache dizziness, shortness of breath, and blurred vision. The presence of symptoms
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
79 The Prescribing Pattern Of Antihypertensives In Patients With Chronic Renal Failure
can be a good thing in that they can prompt people to consult a doctor for treatment and
make them more compliant in taking their medications11. Often, however, a person's first
contact with a physician may be after significant damage to the end-organs has occurred. In
many cases, a person visits or is brought to the doctor or an emergency room with a heart
attack, stroke, kidney failure, or impaired vision (due to damage to the back part of the
retina). Greater public awareness and frequent blood pressure screening may help to identify
patients with undiagnosed high blood pressure before significant complications have
developed10,11.
About one out of every 100 (1%) people with hypertension is diagnosed with severe high
blood pressure (accelerated or malignant hypertension) at their first visit to the doctor. In
these patients, the diastolic blood pressure exceeds 140 mmHg. Affected persons often
experience severe headache, nausea, visual symptoms, dizziness, and sometimes kidney
failure9,11. Malignant hypertension is a medical emergency and requires urgent treatment to
prevent a stroke.
Damage of organs fed by the circulatory system due to uncontrolled hypertension is called
end-organ damage. As already mentioned, chronic high blood pressure can lead to an
enlarged heart, kidney failure, brain or neurological damage, and changes in the retina at the
back of the eyes12. Examination of the eyes in patients with severe hypertension may reveal
damage; narrowing of the small arteries, small haemorrhages (leaking of blood) in the retina,
and swelling of the eye nerve. From the amount of damage, the doctor can gauge the
severity of the hypertension.
People with high blood pressure have an increased stiffness, or resistance, in the peripheral
arteries throughout the tissues of the body. This increased resistance causes the heart
muscle to work harder to pump the blood through these blood vessels. The increased
workload can put a strain on the heart, which can lead to heart abnormalities that are usually
first seen as enlarged heart muscle12,13. Enlargement of the heart can be evaluated by chest
X-Ray, electrocardiogram and most accurately by echocardiography (ECG) ECG is
especially useful in determining the thickness (enlargement) of the left side (the main
pumping side) of the heart. Heart enlargement may be a forerunner heart failure, coronary
(heart) artery disease, and abnormal heart rate or murmurs (cardiac arrhythmias). Proper
treatment of the high blood pressure and its complications can reverse some of these heart
abnormalities.
Blood and urine tests may be helpful in detecting kidney abnormalities in people with high
blood pressure. (Remember that kidney damage can be the cause or the result of
hypertension.) Measuring the serum creatinine in a blood test can assess how well the
kidneys are functioning. An elevated level of serum creatinine indicates damage to the
kidney. In addition, the presence of protein in the urine (proteinuria) may reflect chronic
kidney damage from hypertension, even if the kidney function (as represented by the blood
creatinine level) is normal14. Protein in the urine alone signals the risk of deterioration in
kidney function if the blood pressure is not controlled. Even small amounts of
microalbuminuria may be a signal of impending kidney failure and other vascular
complications from uncontrolled hypertension. African American patients with poorly
controlled hypertension are at a higher risk than Caucasians for most end-organ damage and
particularly kidney damage15.
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
80 The Prescribing Pattern Of Antihypertensives In Patients With Chronic Renal Failure
Uncontrolled hypertension can cause strokes, which can lead to brain or neurological
damage. The strokes are usually due to a haemorrhage (leaking blood) or a blood clot
(thrombosis) of the blood vessels that supply blood to the brain14. The patient's symptoms
and signs (findings on physical examination) are evaluated to assess the neurological
damage. A stroke can cause weakness, tingling, or paralysis of the arms or legs and
difficulties with speech or vision. Multiple small strokes can lead to dementia (impaired
intellectual capacity). The best prevention for this complication of hypertension or, for that
matter, for any of the complications, is control of the blood pressure. Recent studies have
also suggested the angiotensin receptor blocking drugs may offer an additional protective
effect against strokes above and beyond control of blood pressure14,15.
In patients co-morbid with non-diabetic renal disease, the combination of Angiotensin
Converting Enzyme Inhibitor (ACEIs) and Angiotensin Receptor Blockers (ARBs) are proven
to reduce the rate of doubling of serum creatinine and End-stage renal disease (ESRD) more
than monotherapy with either agent in non-diabetic proteinuric renal disease. Hypertension
may be a cause or consequence of renal failure. Renal disease is the most important cause
of secondary hypertension. Hypertension in renal disease is often associated with an
elevated serum creatinine, proteinuria and/or haematuria. Approximately 50-75% of
individuals with GFR<60 ml/min/1.72m2 [Chronic kidney disease (CKD) stages 3-5] have
hypertension. Hypertension accelerates the progression of renal disease and may lead to
end stage renal disease (ESRD). Tight control of BP is therefore important16,17. The target
BP should be < 130/80 mmHg for those with proteinuria of < 1g/24 hours and < 125/75
mmHg for those with proteinuria of > 1g/24 hours. (Level I) All antihypertensive drug classes
can be used to achieve this goal. In the management of hypertension in renal disease,
control of BP and proteinuria are the most important factors in terms of retarding the
progression of renal disease. Antihypertensive agents that reduce proteinuria thus have an
advantage17. Meta-analyses of 49 randomized trials obtained from MEDLINE and Cochrane
Library Central Register of Controlled Trials from January 1990 to September 2006
concluded that ACEI conferred an anti-proteinuric effect greater than other anti-hypertensive
drugs18. Overall 30% reduction in incidence of ESRD with ACEI can be expected. The anti-
proteinuric effect and reduction in ESRD was beyond that attributable to the BP lowering
effect. This anti-proteinuric effect of ACEI was most prominent in patients on a low sodium
diet or those treated with diuretics. Patients with proteinuria >3g/24 hours benefited the
most18.
The advantage of ACEI is most readily apparent in patients with rapid progression of renal
disease associated with proteinuria. ARBs are similar to ACEI in lowering BP and reducing
proteinuria. The combination of ACEIs and ARBs has also been proven to reduce the rate of
doubling of serum creatinine and ESRD more than monotherapy with either agent in non-
diabetic proteinuric renal diseases17.
Renal insufficiency should not be a contraindication to starting ACEI or ARB therapy, nor
should it be a reason for discontinuing therapy. Serum creatinine level should be checked
within the first two weeks of initiation of therapy. If there is a persistent rise of serum
creatinine of ≥30% from baseline within two months, ACEIs should be stopped. Similar
caution should be exercised with the use of ARBs16,17. In patients with renal disease and
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
81 The Prescribing Pattern Of Antihypertensives In Patients With Chronic Renal Failure
hypertension with an elevated serum creatinine of >200 mmol/L, thiazide diuretics may not
be effective antihypertensive agents and therefore loop diuretics are preferred.
Concurrent diuretic therapy will often be necessary in patients with renal insufficiency since
salt and water retention is an important determinant of hypertension in this setting. CCBs
may be used in renal disease. In those with proteinuria, the non-dihydropyridine group of
CCBs namely diltiazem or verapamil are preferred, as they have an additional antiproteinuric
effect. The combination of an ACEI and a non-dihydropyridine CCB is more anti-proteinuric
than either drug alone. More recently, aldosterone antagonists have been shown to have
additive antiproteinuric effects when administered with ACEI and/or ARB in patients with
CKD. However, larger randomised prospective trials are needed to confirm the efficacy and
safety of aldosterone antagonists on proteinuria and CKD progression18.
Several recommendations for a good control of BP would be target BP should be <130/80
mmHg for those with proteinuria of <1g/24 hours and <125/75 mmHg for those with
proteinuria of >1g/24 hours; ACEIs are recommended as initial anti-hypertensive therapy;
ARBs should be used in patients intolerant to ACEIs; dietary salt and protein restriction is
important; concurrent diuretic therapy is useful in patients with fluid overload; and non-
dihydropyridine CCBs can be added on if the BP goal is still not achieved19.
Research Objective
The aim of the research is to observe the prescribing pattern of antihypertensives in patients
with chronic renal failure in medical wards (Ward 4A and 4D) of Hospital Sungai Buloh
(HSB).
Objective of the study
i. To characterise the pattern of prescribing of antihypertensives in patients with chronic
renal failure.
ii. To investigate the level of conformity to the recommended guideline by the medical
wards in HSB.
iii. To observe the most commonly prescribed class of antihypertensives for patients with
chronic renal failure in medical wards of HSB.
iv. To analyse the data in relation to the selected population characteristics.
METHODOLOGY
This research project is a retrospective cross sectional study. Patients were selected from 1st
January till 31st March from the medical wards (ward 4A and 4D) of Hospital Sungai Buloh.
All the patients admitted and discharged during that period will have their case notes studied
through the eHIS program in the hospital‟s computer system. eHIS is a database that collects
patient‟s medical records into an online system. Only patients who fit the inclusion criteria
were selected as the sample population for this study. Inclusion criteria were: patients that
have been diagnosed with chronic kidney disease (persisting serum creatinine values higher
than the reference level of >150 umol/L for men and >125umol/L for women) either in the
ward or before admission and patients that had been diagnosed with hypertension prior to
admission (BP >130/90mmHg). The exclusion criteria were: patients that had chronic heart
failure, patient with diabetes, patients diagnosed with end-stage renal failure (creatinine
clearance<15ml/min), patients that were receiving renal replacement therapy or renal
transplant or dialysis. The prescribed antihypertensive during the admission period and
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
82 The Prescribing Pattern Of Antihypertensives In Patients With Chronic Renal Failure
discharged medication was compiled and compared against the national guideline of
Hypertension in Chronic Kidney Disease by the Malaysian Society of Nephrology.
Data that had been collected were then being analysed to select the sample population that
fits the inclusion criteria whilst excluding those that fits the exclusion criteria. The data was
compiled and analysed using statistical software known as the SPSS Statistical Editor.
Quantitative analysis was being used to analyse the data. Data such as gender are known as
nominal data as they have no ranking order while data such as age groups were classified as
ordinal data as these data had a ranking order. Besides analysing the frequency of a certain
prescribed antihypertensive and also the general prescribing pattern, there were two main
tests that had been carried out to determine the significance difference or correlations
between the data which are Mann-Whitney test and Spearman correlation ranking test. A
Mann-Whitney test is a non-parametric test used to analyze the whether there was a
statistical significant data difference between an ordinal and a nominal data. Spearman
correlation test is used to analyze whether there‟s a statistical significant correlation between
two ordinal data. A data is said to be significant when the p value is lesser than 0.05. A
Spearman correlation coefficient of lesser than 0.3 is said to have a weak correlation, a
moderate level of correlation when the value is between 0.3 to 0.6 and a strong correlation
for a value of more than 0.6. The correlation value can be positive or negative.
The proposal of the title was done in April 2011 and gotten an approval within the same
month. Data compilation was carried out right after the title had been approved. The final
presentation of the research was carried out in May 2011 and a final report write up was
submitted on 15th July 2011.
RESULTS
Out of all the patients admitted during the period of 1st Jan 2011 to 31st March 2011 to Ward
4A and Ward 4D in Hospital Sungai Buloh, only 38 patients fulfilled the aforementioned
inclusion criteria. Therefore, the sample size for this research is 38 patients. Among these 38
patients, the male patients had a slight majority of 58% (n=22) while female patients made up
the remaining 42% (n=16) of the sample population, as shown in Table 1. The age of sample
population ranges from 30 years old to 89 years old, with majority of the patients are from the
age group of 60 to 69 years old (44%, n=17), followed by those in the age group of 70 to 79
years old (32%, n=12). Table 2 shows the age distribution of the sample population. There
was no statistical significant gender difference in age. (Mann-Whitney U=160.5, p=0.625,
mean rank for male=18.8, female=20.47) and in this sample population, female tend to be
older than male. There was no statistically significant correlation between age and the
number of antihypertensive prescribed (Spearman correlation coefficient=-0.292, p=0.075).
Table 1: The gender distribution of the sample population
Frequency Percent
Male 22 58
Female 16 42
Total 38 100.0
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
83 The Prescribing Pattern Of Antihypertensives In Patients With Chronic Renal Failure
Table 2: The age distribution of the sample population
Age Group Frequency Percent
30-39 1 2.6
40-49 2 5.3
50-59 5 13.2
60-69 17 44.7
70-79 12 31.6
80-89 1 2.6
Total 38 100.0
The six types of antihypertensives that have been prescribed to the sample population are:
angiotensin-converting enzyme inhibitors (ACE inhibitors), angiotensin receptor blockers
(ARB), beta-adrenergic antagonist (β-blocker), calcium channel blocker (CCB), diuretics and
α-adrenergic-antagonist (α blocker).
As shown in Table 3, majority of the sample population are on combinations of two
antihypertensive (39.5%, n=15), while those with a single antihypertensive made up of 36.8%
of the sample population (n=14); 13.2% of them are on combinations of 4 antihypertensive
(n=5), while the smallest percentage of the sample population are on combinations of three
antihypertensive (10.5%, n=4).
Table 3: The frequency of patients in terms of number of antihypertensive prescribed
Number of antihypertensives Frequency Percent
1 14 36.8
2 15 39.5
3 4 10.5
4 5 13.2
Total 38 100.0
Out of the 6 types of antihypertensive, the most commonly prescribed antihypertensive is
calcium channel blockers (38%, n=29), followed by β-blocker (28%, n=21), diuretics (20%,
n=15), ACE inhibitor (12%, n=9), ARB (1%, n=1) and lastly, α blocker (1%, n=1).
Table 4: The frequency of all types of antihypertensive prescribed
Antihypertensive Frequency Percentage (%)
ACE inhibitor 9 12
ARB 1 1
β-blocker 21 28
Calcium Channel Blocker 29 38
Diuretics 15 20
α blocker 1 1
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
84 The Prescribing Pattern Of Antihypertensives In Patients With Chronic Renal Failure
Based on Table 3, there are 14 patients that are on single antihypertensive therapy. Among
them, 64% are on calcium channel blocker (n=9), 21% of them are on diuretics (n=3), and
14% of the patients that have been prescribed only one antihypertensive are on beta
adrenergic receptor blockers (n=2). A breakdown of the percentage is shown in Table 5.
Table 5: The breakdown of types of antihypertensive prescribed for patients on mono-
antihypertensive therapy
Frequency Percentage (%)
Beta Blockers 2 14.3
CCB 9 64.3
Diuretics 3 21.4
Total 14 100.0
Out of the 15 patients that are on double antihypertensive combinations, majority of the
patients (60%, n=9) are on a combination of CCB and β blockers, while the rest are either on
a combination of ACE inhibitor with diuretic (13.3%, n=2); CCB with diuretic (13.3%, n=2);
ACE inhibitor with CCB (6.7%, n=1) or ACE inhibitor with β blocker (6.7%, n=1), as shown in
Table 6.
Table 6: A breakdown of the types of antihypertensive prescribed for patients with
combinations of 2 antihypertensive
Frequency Percentage (%)
ACEi and B 1 6.7
ACEi and CCB 1 6.7
ACEi and D 2 13.3
B and CCB 9 60.0
CCB and D 2 13.3
Total 15 100.0
As shown in Table 7, half of the patients with combinations of 3 antihypertensive had been
prescribed a combination which consists of beta blockers, CCB and diuretics (50%, n=2),
while a quarter of them had been prescribed a combination that consists of ACE inhibitor,
beta-blocker, and a diuretic (25%, n=1) while another quarter of them had been prescribed a
combination that consists of ACE inhibitor, beta-blocker, and CCB.
Table 7: Types of antihypertensives prescribed for combinations of 3 antihypertensive
Frequency Percentage
ACEi + B + D 1 25
ACEi + B + C 1 25
B + C + D 2 50
Total 4 100
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
85 The Prescribing Pattern Of Antihypertensives In Patients With Chronic Renal Failure
Out of the 5 patients that have been prescribed a combination of 4 antihypertensive, majority
of them are on a combination of ACE inhibitor, beta-blockers, CCB and diuretics (60%, n=3)
while only 1 patient each was being prescribed a combination of either: beta-blocker, CCB,
diuretic, alpha-blocker (20%, n=1), or ARB, beta blocker, CCB and diuretic (20%, n=1). Table
8 summarizes a breakdown of the above findings.
Table 8: Types of antihypertensives prescribed for combinations of 4 antihypertensive
Frequency Percentage
ACEi + B + C + D 3 60
B + C + D + alpha blocker 1 20
ARB + B + C + D 1 20
Total 5 100
DISCUSSION
There is no doubt that having a strict and good control over blood pressure in patients with
renal impairment is really beneficial. In a study which consists of two randomized, multicentre
trials had shown a not significant but a definite reduction of glomerular filtration rate (GFR)
over 3 years with good control of protein intake and blood pressure20. However in another
study done in the United States, there seems to be no significant benefit of having a tight
control of blood pressure even in patients with hypertensive kidney disease. All but
angiotensin-converting enzyme inhibitors have a significant benefit in slowing down the rate
of GFR declining compared to other antihypertensive such as calcium channel blockers and
beta blockers21.
From the results above, we observed a prescribing pattern favouring calcium channel
blockers, including patients on single antihypertensive and also multiple antihypertensive
combinations. An investigation done by medical centre in USA showed that calcium channel
blocker had significantly helped to reduce the decline of reciprocal creatinine and also helped
to reduce the rate of decline in renal function compared to other antihypertensives22. The
Journal of The American Society of Nephrology published a paper based on several large
multicentre trials back in 2005 which supports the benefit of using calcium channel blockers
especially in cases of patients with CKD. In this report, it summarizes that CCB is as equally
as renoprotective as other antihypertensive agent such as diuretics. Also, the concurrent use
of CCB with either ARB or ACE inhibitor does not affect the renoprotective function of CCB.
An ARB or ACE inhibitor can be added to CCB in cases of patients with proteinuria22,23.
Therefore, CCB is an excellent antihypertensive agent as a single agent or with combination
therapy, even in patients without the presence of renal impairment24.
The other two other major trial, which are the Controlled ONset Verapamil INvestigation of
Cardiovascular Endpoints (CONVINCE) and African-American Study of Kidney Disease and
Hypertension (AASK) trial, concluded that maintaining good blood pressure is not enough to
ensure kidney function from deteriorating. The class of drug prescribed is more important. In
the CONVICE trial, CCB is equivalent to other standard antihypertensive such as beta
blockers as the initial antihypertensive therapy. However, there were more hospitalizations
due to haemorrhagic events. The AASK trial concluded that ACE inhibitor has the best
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
86 The Prescribing Pattern Of Antihypertensives In Patients With Chronic Renal Failure
renoprotective function compared to CCB and beta blockers in hypertension cases
complicated by mild to moderate renal impairment, and beta blockers are more effective in
renal protection than CCB25.
As shown in Table 4, there were more than one type of antihypertensive that had been
prescribed to certain patients; therefore the total number of times the antihypertensive had
been prescribed was amount to more than the total number of sample population. This
shows that in cases of patients with uncontrolled hypertension, more than one type of
antihypertensives are needed to maintain adequate control and also to protect renal function
from worsening. However, the choice of antihypertensive must achieve maximal renal
protection but at the same time maintaining the minimal side effect profile possible. However,
based on the national guideline of Hypertension in Chronic Kidney Disease by the Malaysian
Society of Nephrology, there wasn‟t any preferred first line agent for patients with non-
diabetic kidney diseases26. The K/DOQI Clinical Practice Guidelines on Hypertension and
Antihypertensive Agents in Chronic Kidney Disease, patients that have >20mmHg of their
targeted blood pressure should be prescribed can be initiated with 2 antihypertensive
instead of one as one antihypertensive at maximum dose still couldn‟t maintain adequate
control of good blood pressure27.
CONCLUSION
From this study, we can conclude that CCB is the mainstay of treatment option for
hypertension as we observed an overwhelming use of CCB and it is the most frequently
prescribed antihypertensive whether as a single antihypertensive agent or combination with
other antihypertensive. There is no doubt the CCB is one of the recommended initial
antihypertensive therapy, but it still lacks the efficacy in renoprotective function that ACE
inhibitor or ARB has. Furthermore, this study also showed that the prescribing pattern in
medical wards of HSB conforms to the recommended guideline as there are no specific
antihypertensive agent that are preferred over the others in cases of hypertension with
chronic renal failure.
The limitation of this study would be the lack of sample data to make any significant findings
to support the data. This can be overcome through a longer period of study and also to
extend the sample population to other medical wards in HSB.
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TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
89 Trauma Pergigian Kanak-kanak Di Hospital Sungai Buloh
TRAUMA PERGIGIAN KANAK-KANAK DI HOSPITAL SUNGAI BULOH
Gunasundari Devi a/p Kumara Rao,
Dip. (Kejururawatan Pergigian), Pos Basik (Pergigian Pediatrik)
Klinik Pergigian Kelana Jaya,
Bahagian Kesihatan Pergigian, Jabatan Kesihatan Negeri Selangor
ABSTRAK
Pengenalan: Tujuan kajian ini dijalankan adalah untuk mengetahui pola kes klinikal trauma
pergigian dengan mengenalpasti kekerapan kes trauma pergigian mengikut bangsa, jantina,
umur, punca trauma, jenis trauma, jenis gigi yang terlibat dan rawatan.
Objektif: Menjalankan kajiselidik ke atas kejadian dan jenis trauma pergigian di kalangan
kanak-kanak yang di rujuk ke Hospital Sungai Buloh, dari Disember 2008 hingga Jun 2010.
Metodologi: Kajian dijalankan secara retrospektif. Sampel terdiri daripada seramai 108
pesakit kanak-kanak yang berumur di antara 0 hingga 16 tahun. Borang Pengumpulan Data
telah dibentuk mengikut kehendak objektif.
Hasil: Hasil kajian menunjukkan bahawa kanak-kanak berbangsa Melayu mengalami kadar
trauma pergigian yang paling tinggi (94.0%). Kanak-kanak lelaki lebih ramai mengalami
trauma pergigian (77.0%) berbanding dengan kanak-kanak perempuan (23.0%). Kanak-
kanak yang berumur di antara 0 hingga 6 tahun yang paling kerap mengalami trauma
pergigian (40.0%). Punca utama kejadian trauma pergigian adalah akibat terjatuh (54.0%).
Jenis gigi yang kerap mengalami trauma adalah gigi insisor sentral rahang maksila sama
ada kegigian primer (61.0%) ataupun kegigian sekunder (66.0%). Jenis trauma yang sering
terjadi pada kegigian primer adalah subluksatan (41.0%) manakala trauma avulsi (41.0%)
paling kerap berlaku pada kegigian sekunder. Sebanyak 94.0% kegigian primer dirawat
sebagai rawatan konservatif. Manakala bagi kegigian sekunder pula, sebanyak 26.0%
dirawat sebagai rawatan konservatif dan 18.0% rawatan tampalan.
Kesimpulan: Secara keseluruhannya didapati, trauma pergigian semakin meningkat di
kalangan kanak-kanak. Oleh itu, langkah-langkah pencegahan haruslah ditekankan lagi.
PENGENALAN
Kekerapan kecederaan gigi di kalangan kanak-kanak sekolah di serata dunia adalah di
antara 2.6% (Macko et al.1979) sehingga 43.8% (Marcenes dan Murray, 2001).
Kebanyakkan daripada trauma pergigian melibatkan gigi insisor sentral maksila, di mana
ianya akan memberi impak dalam psikologikal yang akan menjejaskan kualiti kehidupan
seorang kanak-kanak dan juga ibubapanya. Kanak-kanak yang baru bertatih iaitu dalam
lingkungan berumur 1 hingga 3 tahun lebih terdedah kepada kecederaan ke atas gigi primer
mereka. Kanak-kanak lelaki mengalami trauma pergigian dua kali ganda lebih dari kanak-
kanak perempuan. Perbezaan ini disebabkan oleh tingkahlaku dan aktiviti harian di antara
kedua-dua jantina.
Punca trauma pergigian akan berbeza mengikut umur kanak-kanak, di mana kanak-kanak
kecil lebih mengalami trauma di sebabkan terjatuh manakala kanak-kanak yang lebih
dewasa akan cenderung ke atas kemalangan jalanraya. Kecederaan yang lazim berlaku
adalah trauma terhadap tisu lembut, tisu keras dan tisu periodontium. Tujuan kajian ini
dijalankan adalah untuk memahami tentang prevalen kes-kes trauma pergigian di kalangan
kanak-kanak, mengenali jenis-jenis trauma pergigian serta rawatannya dan dapat
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
90 Trauma Pergigian Kanak-kanak Di Hospital Sungai Buloh
mengesyorkan beberapa langkah pencegahan yang bersesuaian untuk mengekalkan
kesihatan gigi seumur hidup.
OBJEKTIF
Objektif Umum
Menjalankan kajiselidik ke atas kejadian dan jenis trauma pergigian di kalangan kanak-kanak
yang dirujuk ke Hospital Sungai Buloh, Selangor dari Disember 2008 hingga Jun 2010.
Objektif Spesifik
i. Mengenali kes-kes trauma pergigian mengikut umur, jantina dan bangsa.
ii. Mengenalpasti punca kejadian trauma di kalangan kanak-kanak.
iii. Mengenalpasti jenis-jenis trauma pergigian di kalangan kanak- kanak.
iv. Kaedah rawatan tisu keras, tisu lembut dan gigi yang terlibat.
METODOLOGI
Jenis Kajian
Jenis kajian yang dijalankan adalah secara retrospektif.
Pemilihan Sampel
Sampel seramai 108 pesakit kanak-kanak yang berumur 0-16 tahun diambilkira. Tempoh
data yang dikumpul ialah selama 1 tahun 7 bulan iaitu dari bulan Disember 2008 hingga Jun
2010. Sampel dikelaskan kepada bangsa, jantina, umur, punca trauma, tempat kejadian, dan
juga jenis gigi yang terlibat. Jenis trauma terhadap tisu keras, tisu periodontum dan tisu
lembut turut diambilkira.
Kaedah Pengumpulan Data
Borang Pengumpulan Data telah disediakan mengikut kehendak objektif.
Pemprosesan dan Penganalisisan Data
Data diproses dengan menggunakan perisian Microsoft Excel Versi 2007. Kaedah
pengolahan data adalah secara statistik deskriptif dengan penggunaan kekerapan dan
peratusan.
HASIL KAJIAN
Prevalen
Hasil kajian ini dikategorikan mengikut prevalen seperti berikut:
a) Bangsa
Rajah 1 menunjukan peratusan kes trauma pergigian di kalangan kanak-kanak mengikut
bangsa. didapati kanak-kanak berbangsa Melayu paling ramai terlibat dalam kejadian trauma
pergigian (94.0%).
.
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
91 Trauma Pergigian Kanak-kanak Di Hospital Sungai Buloh
Rajah 1: Kes Trauma Pergigian Mengikut Bangsa
b) Jantina
Rajah 2 menunjukan peratusan kes trauma pergigian di kalangan kanak-kanak mengikut
jantina. Daripada rajah di bawah, didapati kanak-kanak lelaki mengalami trauma pergigian
lebih daripada kanak-kanak perempuan.
Rajah 2: Kes trauma pergigian mengikut jantina
c) Umur
Rajah 3 menunjukan peratusan kes trauma pergigian di kalangan kanak-kanak mengikut
umur. Daripada rajah di bawah, didapati kanak-kanak berusia dari umur 0 hingga 6 tahun
mengalami trauma pergigian yang paling tinggi (40.0%).
Rajah 3: Kes Trauma Pergigian Mengikut Umur
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92 Trauma Pergigian Kanak-kanak Di Hospital Sungai Buloh
Etiologi
Rajah 4 menunjukan peratusan kes trauma pergigian di kalangan kanak-kanak mengikut
punca. Berpandukan rajah di bawah, didapati punca terjatuh adalah yang paling tinggi
(54.0%) diikuti dengan kemalangan (32.0%).
Rajah 4: Kes trauma pergigian mengikut punca
Jenis- Jenis Trauma
a) Gigi yang Lazim Mengalami Trauma
Jadual 1: Kekerapan dan Peratusan Jenis Gigi Yang Mengalami Trauma Pada Kegigian
Primer dan Sekunder.
Jenis Gigi yang
Mengalami Trauma
Gigi Primer
(Kegigian Susu)
Gigi Sekunder
(Kegigian Kekal)
Kekerapan (n) % Kekerapan (n) %
Insisor Sentral Maksila 32 61.0 91 66.0
Insisor Lateral Maksila 11 21.0 25 18.0
Kanin Maksila 2 4.0 3 2.0
Insisor Sentral Mandibel 3 6.0 12 9.0
Insisor Lateral Mandibel 2 4.0 5 4.0
Kanin Mandibel 2 4.0 2 1.0
Jumlah 52 100.0 138 100.0
Jadual 1 di atas menunjukkan, gigi Insisor Sentral Maksila Kegigian Primer (61.0%) dan
Kegigian Sekunder (66.0%) paling kerap mengalami trauma.
Jadual 2: Kekerapan dan Peratusan Jenis Trauma Pada Tisu Keras yang Sering
Berlaku Pada Kegigian Primer dan Sekunder.
Jenis trauma
(Tisu keras)
Gigi Primer Gigi Sekunder
Kekerapan (n) % Kekerapan (n) %
Korona 2 25.0 24 45.0
Korona & pulpa 5 62.5 22 42.0
Korona & apeks 1 12.5 6 11.0
Apeks 0 0.0 1 2.0
Jumlah 8 100.0 53 100.0
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
93 Trauma Pergigian Kanak-kanak Di Hospital Sungai Buloh
Jadual 2 menunjukkan, trauma korona dan pulpa Gigi Primer (62.5%) dan trauma yang
melibatkan korona Gigi Sekunder (45.0%) paling kerap berlaku.
b) Jenis Trauma Pada Tisu Periodontium
Jadual 3: Kekerapan dan Peratusan Jenis Trauma Pada Tisu Periodontium Kegigian
Primer Dan Sekunder.
Jenis trauma
(Tisu
periodontium)
Gigi Primer Gigi Sekunder
Kekerapan (n) % Kekerapan (n) %
Konkusi 0 0.0 4 5.0
Subluksatan 18 41.0 22 26.0
Intrusi 3 7.0 8 9.0
Ekstrusi 1 2.0 6 7.0
Peluksatan 7 16.0 10 12.0
Avulsi 15 34.0 35 41.0
Jumlah 44 100.0 85 100.0
Berpandukan Jadual 3, subluksatan adalah kerap berlaku di kalangan Gigi Primer (41.0%).
manakala pada Gigi Sekunder, avulsi adalah tertinggi (41.0%).
c) Jenis Trauma Pada Tisu Lembut
Jadual 4: Kekerapan dan Peratusan Trauma yang Melibatkan Tisu Lembut.
Tisu lembut Kekerapan (n) %
Laserasi 82 74.0
Abrasi 29 26.0
Jumlah 101 100.0
Daripada Jadual 4, didapati laserasi pada tisu lembut (74.0%) yang paling kerap berlaku
berbanding dengan abrasi (26.0%).
d) Jenis trauma yang melibatkan rahang
Jadual 5: Kekerapan dan Peratusan Trauma yang Melibatkan Tulang Rahang.
Rahang Kekerapan (n) %
Maksila 2 50.0
Mandibel 2 50.0
Jumlah 4 100.0
Jadual 5 menunjukkan kekerapan trauma yang melibatkan tulang rahang adalah sama ke
atas rahang maksila dan rahang mandibel.
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
94 Trauma Pergigian Kanak-kanak Di Hospital Sungai Buloh
Rawatan
Rawatan yang diberikan kepada trauma tisu lembut iaitu laserasi dan abrasi adalah
pembersihan dan sutur. Ini diikuti dengan pemberian ubat antibiotik jika perlu. Kajian
menunjukkan kebanyakan kes trauma bagi kegigian primer telah dirawat secara konservatif
(94.0%) dan cabutan (6.0%). Manakala bagi gigi sekunder pula, terdapat beberapa jenis
rawatan yang dapat diberikan bagi mengekalkan gigi tersebut di dalam mulut. Jenis-jenis
rawatan yang diberikan adalah seperti rajah di bawah di mana rawatan konservatif (26.0%),
rawatan tampalan (18.0%) dan sebagainya.
Rajah 5: Jenis Rawatan Trauma Pergigian Gigi Sekunder.
PERBINCANGAN
Dari segi taburan bangsa, bangsa Melayu (94.0%) didapati paling ramai mengalami trauma
pergigian berbanding dengan bangsa India dan Cina. Ini adalah berkait rapat dengan
demografi penduduk di kawasan Sungai Buloh. Kajian ini juga turut disokong oleh kajian
yang di lakukan oleh Leong dan rakan-rakan pada tahun 2002 ( Leong et al. 2002). Dari hasil
kajian ini, didapati kanak-kanak yang berumur di bawah 6 tahun (40.0%) adalah yang paling
ramai terlibat dalam trauma pergigian.
Dari segi hasil kajian yang telah diperolehi, kanak-kanak lelaki (77.0%) adalah yang paling
ramai mengalami trauma pergigian. Kajian ini bertepatan dengan kajian yang telah
dijalankan oleh Nik Hussein et al. (2001) dan Adekoya et al. (2005). Ini kerana kanak-kanak
lelaki lebih gemar melakukan aktiviti yang mencabar dan aktiviti luar yang lasak serta agresif.
Punca utama trauma pergigian adalah terjatuh (54.0%) dan diikuti dengan kemalangan
jalanraya (32.0%). Ianya telah disokong oleh beberapa kajian, (Altay et al. 2001; Soriano et
al. 2004; Saroglu et al. 2002).
Secara keseluruhannya, gigi anterior merupakan gigi yang paling kerap mengalami trauma
berbanding dengan gigi posterior. Ini disokong oleh Andreasen et al. (1972) dan Fried et al.
(1995). Ini bertepatan dengan hasil kajian yang telah dilakukan, di mana gigi insisor sentral
maksila lebih kerap mengalami trauma. Jenis kecederaan luksatan adalah yang paling
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
95 Trauma Pergigian Kanak-kanak Di Hospital Sungai Buloh
banyak dialami oleh kanak-kanak. Fraktur enamel adalah jenis trauma yang paling kerap
berlaku dalam kajian ini.
Setiap kes trauma pergigian memerlukan perhatian dan rawatan serta-merta. Jenis rawatan
adalah bergantung kepada jenis trauma dan jenis gigi yang terlibat. Pelbagai jenis rawatan
telah diadakan bagi merawat kegigian sekunder dalam mengekalkan gigi seumur hidup.
Manakala bagi kegigian primer, rawatan konservatif sudah mencukupi. Bagi fraktur rahang
maksila dan mandibel, rawatan jenis reduksi terbuka dan reduksi tertutup akan dilakukan.
KESIMPULAN
Daripada kajian ini dapat disimpulkan bahawa bangsa Melayu lebih ramai terlibat dalam kes
trauma pergigian. Ini di sebabkan oleh demografi penduduk di kawasan Sungai Buloh. Kadar
kejadian (prevalen) trauma pergigian di kalangan kanak-kanak lelaki adalah lebih tinggi.
Tambahan pula, trauma pergigian lebih kerap berlaku pada kanak-kanak dalam lingkungan
umur di antara 0 - 6 tahun.
Terjatuh dan kemalangan jalanraya merupakan punca utama terjadinya trauma pergigian.
Hasil kajian menunjukkan trauma jenis luksatan adalah paling banyak terjadi, diikuti dengan
kecederaan korona yang tidak rumit. Manakala gigi insisor sentral rahang maksila adalah
gigi yang paling kerap mengalami trauma. Ini mungkin disebabkan kedudukan gigi yang lebih
terdedah kepada persekitaran.
Secara amnya didapati, trauma pergigian semakin meningkat di kalangan kanak-kanak. Oleh
sebab itu, langkah-langkah pencegahan terhadap trauma pergigian haruslah ditekankan
melalui risalah-risalah serta media massa kepada ibubapa dan kanak-kanak yang terlibat.
RUJUKAN
1. Adekoya C – Sofowora, R.Bruimah & E.Ogunbodede : Traumatic Dental Injuries
Experience in Suburban Nigerian Adolescents. The internet journal of Dental Science.
2005 Volume 3 Number 1.
2. Altay N dan Gungor HC. Retrospective study of dento – alveolar injuries of children in
Ankara, Turkey. Dental Traumatology. 2001: 17: 201-204. Journal of the American
Academy of Family Ph.
3. Andreasen JO, Bakland LK, Matas RC dan Andreasen FM . Traumaatic intrusion of
permanent teeth in a Danish population sample. International Journal of Oral Surgery.
1972: 1: 235-239.
4. Dewhurst SN, Mason C dan Roberts GJ. Emergency treatment of orodental injuries: a
review British Journal of oral and maxillofacial surgery. 1998: 36: 165-175.
5. Flores MT,Andreasen JO dan BaklandLK. Guidelines for the evaluation and management
of traumatic dental injuries. Dental Traumatology. 2001: 17: 193-196.
6. Fried I dan Erikson P. Anterior tooth trauma in the primary dentition; Incidence,
classification, treatment methods and sequelae: A review of the literature, Journal of
Dentistry for Children. 1995: 256-261.
7. Leong PL, Ahmad F dan Ahmad A. An exploratory study on dental and maxillo-facial
injuries treated by dental officers in Kulim District. A compendium of Abstracts. Oral
Health Division. Ministry of Health Malaysia. 2002:13.
8. Macko DJ, Grasso JE, Powell EA, Dohrty NJ. A study of fractured teeth ia a school
population. J Dent Child 1979: 46: 130-133.
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
96 Trauma Pergigian Kanak-kanak Di Hospital Sungai Buloh
9. Marcenes W, Murray S.Social deprivation and traumatic dental injuries among 14 year old
schoolchildren in Newham, London. Dent Traumatol 2001: 17(1): 17-21.
10. Nick – Hussein P. Traumatic injuries to anterior teeth among schoolchildren in Malaysia,
Dental Traumatology 2001: 17: 149-152.
11. Soriano EP, Caldas Jr AF, Goes PSA. Risk factors related to traumatic dental injuries in
Brazilian schoolchildren. Dent Traumatol 2004: 246-250.
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
97 Yellow Fever Surveillance KLIA Experience
YELLOW FEVER SURVEILLANCE KLIA EXPERIENCE
Azmi AR, Balachandran K., Senthilvasan J., Mohd. Shahir M., Adi Nor Y,
KLIA Health Office
ABSTRACT
Introduction: Yellow fever is an acute viral haemorrhagic disease cause by an arbovirus
transmitted by infected Aedes and other mosquitoes in the forests of Africa and South America.
Case fatality rate 15 – 50%.
Objective: The purpose of this report is to highlight various issues pertaining to Yellow Fever,
it‟s epidemiology, case definition, diagnosis, treatment and control globally and the control
programmes of this disease in our countries.
Methodology: Data for the Yellow Fever Surveillance collected from the return collected in
monthly basis and presented in tables and graphs.
Results: Several issues have been identified related to Yellow Fever surveillance: poor
compliance of vaccination requirement among the travellers from Yellow Fever Risk Countries,
insufficient monitoring among arriving Malaysian, lack of referral from Immigration, ineffective
control of mosquitoes breeding by premise owners, failure of Pest control operators (PCOs) to
play an important role in preventing breeding of Aedes.
Recommendation: Awareness activities need to be enhanced further by distributing brochures
and through website, regular briefings and training on Yellow Fever requirement to Immigration
Officers, enforcement of Destruction of Disease-Bearing Insects Act 1975 amended in 2000 will
be enhanced, activities by the PCOs should monitored closely and regulation related to
disinsectisation requirement which is being drafted at Ministry of Health should be expedited.
Keywords: Yellow Fever, Yellow Fever Risk Countries, Aedes aegypti, disinsectisation.
INTRODUCTION
Yellow fever is an acute viral haemorrhagic disease transmitted by infected mosquitoes. The
"yellow" in the name refers to the jaundice that affects some patients 1.
It is caused by the the yellow fever virus, an arbovirus of the Flavivirus genus and is transmitted
by the bite of an infective Aedes aegypti mosquitoes and by other mosquitoes in the forests of
Africa and South America2.
Up to 50% of severely affected persons without treatment will die from yellow fever. There are
an estimated 200 000 cases of yellow fever, causing 30 000 deaths, worldwide each year1.
The virus is endemic in tropical areas of Africa and Latin America. The number of yellow fever
cases has increased over the past two decades due to declining population immunity to
infection, deforestation, urbanization, population movements and climate change1.There is no
cure for yellow fever. Treatment is symptomatic, aimed at reducing the symptoms for the
comfort of the patient1. Vaccination is the most important preventive measure against yellow
fever.
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
98 Yellow Fever Surveillance KLIA Experience
The purpose of this report is to highlight various issues pertaining to Yellow Fever, it‟s
epidemiology, case definition, diagnosis, treatment and control globally and the control
programmes of this disease in our country.
Forty-five risk countries in Africa and Latin America are at risk. There are an estimated 200 000
cases of yellow fever (causing 30 000 deaths) worldwide each year. Although the disease has
never been reported in Asia, the region is at risk because the conditions required for
transmission are present there3.
The latest list of countries at risk of Yellow Fever is show in the following Table13.
Table 1. Countries with risk of yellow fever virus (YFV) transmission1
AFRICA CENTRAL AND SOUTH AMERICA
Angola
Benin
Burkina Faso
Burundi
Cameroon
Central African Republic
Chad2
Congo, Republic of the
Côte d‟Ivoire
Democratic Republic of the
Congo2
Equatorial Guinea
Ethiopia2
Gabon
Gambia, The
Ghana
Guinea
Guinea-Bissau
Kenya2
Liberia
Mali2
Mauritania2
Niger2
Nigeria
Rwanda
Senegal
Sierra Leone
Sudan2
Togo
Uganda
Argentina2
Bolivia2
Brazil2
Colombia2
Ecuador2
French Guiana
Guyana
Panama2
Paraguay
Peru2
Suriname
Trinidad and Tobago2
Venezuela2 1Countries/areas where “a risk of yellow fever transmission is present,” as defined by the World
Health Organization, are countries or areas where “yellow fever has been reported currently or
in the past, plus vectors and animal reservoirs currently exist” (see the current country list within
the International Travel and Health publication (Annex 1) at www.who.int/ith/en/index.html ). 2These countries are not holoendemic (only a portion of the country has risk of yellow fever
transmission). See Maps 3-18 and 3-19 and yellow fever vaccine recommendations (Yellow
Fever and Malaria Information, by Country) for details.
A traveler‟s risk for acquiring yellow fever is determined by various factors, including
immunization status, location of travel, season, duration of exposure, occupational and
recreational activities while traveling, and local rate of virus transmission at the time of travel1,3,.
Yellow Fever Virus (YFV) transmission in rural West Africa is seasonal, with an elevated risk
during the end of the rainy season and the beginning of the dry season (usually July–October)3.
Whereas the risk for infection in South America is highest during the rainy season (January–
May, with a peak incidence in February and March). Given the high level of viremia that may
occur in infected humans and the widespread distribution of Ae.aegypti in many towns and
cities, South America is at risk for a large-scale urban epidemic1,3,.
The risk of acquiring yellow fever is difficult to predict because of variations in ecologic
determinants of virus transmission. For a 2-week stay, the risks for illness and death due to
yellow fever for an unvaccinated traveler traveling to an endemic area in:
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
99 Yellow Fever Surveillance KLIA Experience
West Africa are 50 per 100,000 and 10 per 100,000, respectively
South America are 5 per 100,000 and 1 per 100,000, respectively3
CLINICAL PRESENTATION OF YELLOW FEVER
Once contracted, the virus incubates in the body for 3 to 6 days, followed by infection that can
occur in one or two phases. The first, "acute", phase usually causes fever, muscle pain with
prominent backache, headache, shivers, loss of appetite, and nausea or vomiting. Most patients
improve and their symptoms disappear after 3 to 4 days 1,4,5. However, 15% of patients enter a
second, more toxic phase within 24 hours of the initial remission1,4,5. The patient rapidly
develops jaundice and complains of abdominal pain with vomiting. Bleeding can occur from the
mouth, nose, eyes or stomach. Kidney function deteriorates. Half of the patients who enter the
toxic phase die within 10 to 14 days, the rest recover without significant organ damage1,4,5.
MALAYSIAN’S POLICY ON YELLOW FEVER SURVEILLANCE AND ACTIVITIES AT KLIA
HEALTH DEPARTMENT
World Health Organization (WHO) in 1998 in a Yellow Fever Technical Consensus Meeting,
Geneva, 2-3 March 1998 has already recognized the need for surveillance of Yellow Fever 6.
Malaysia is free from Yellow Fever but it has the yellow fever vector Aedes aegypti. Therefore
Malaysia continues to monitor the incidence of Yellow Fever. This disease has been included in
the list of 29 diseases that must be notified under the Infectious Disease Control and Prevention
1988 (Act 342)7.
Prevention and control at the main entry points are:
1. Surveillance of Yellow Fever
2. Vector Control activities as required by IHR 2005.
3. Monitoring of disinsectisation of international aircraft
YELLOW FEVER SURVEILLANCE
Surveillance of Yellow Fever at KLIA Health Office began in 2004 and is carried out by the
Health Quarantine Unit and the Communicable Disease Control Unit. This surveillance involves
travelers arriving from various international destinations to KLIA Main Terminal Building and the
Low Cost Carrier Terminal.
The objective of this activity is to ensure that Malaysia is kept free from Yellow Fever and this is
done by conducting surveillance on arriving travelers to ensure that they do not bring the
disease in to Malaysia. The activities are :
1. Screening for Yellow Fever involving travelers including distinguished delegates who
arrive from/through Yellow Fever risk countries. The travellers arriving in Malaysia
within 6 days from the last date of embarkation from a Yellow Fever risk country without
a valid vaccination certificate shall be quarantined at the Health Quarantine Centre upon
arrival for a period not exceeding 6 days i.e. the incubation period of Yellow Fever.8
The travellers arriving in Malaysia after 6 days from the last date of embarkation from a
Yellow Fever risk country will be allowed entry into Malaysia even without a valid
vaccination certificate as the period has exceeded the incubation period of Yellow Fever.
The international yellow fever vaccination certificate becomes valid 10 days after
vaccination and remains valid for a period of 10 years.10,14
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
100 Yellow Fever Surveillance KLIA Experience
2. Carrying out quarantine procedures and surveillance upon travelers not fulfilling the
conditions of a valid Yellow Fever vaccination certificate in accordance with the
requirements under the Communicable Diseases Act, 1988.
3. Conducting talks and training to Immigration Officers at KLIA who are actively involved in
assisting KLIA Health Office in screening arriving international travelers from Yellow
Fever risk countries to be referred to Health Quarantine Centre.
From 2006 till 2010, 1.2 million travellers have visited YF risk countries. Out of this 1,682
(1.44%) didn‟t posses a valid YF vaccination certificate. From this 1,682, 1407 (84%) were
placed under quarantine and the remaining 275 (16%) were placed under surveillance (Table
2). 9
Table 2 : Number of travelers with valid and non valid certificate, quarantined and under
health surveillance from 2006 till 2010
Year No. of
travellers
visited YF
risk
countries
Travellers
with valid
certificate
( 0 – 6
days)
Travellers
without
valid
certificate
( 0– 6 days
)
Travellers
depart
from risk
YF > 6
days
Travellers
with valid
certificate
and depart
> 6 days
YF risk
countries
Traveller been
quarantined
Travellers under
health surveillance
Non
VIP
VIP Total Non
VIP
VIP Total
2006 11205 8805 378 2022 10827 281 0 281 88(*A ) 9 97
2007 19420 15962 498 2960 18922 426 0 426 71(*B ) 1 72
2008 26620 23424 440 2756 26180 395 0 395 43 2 45
2009 28884 26800 217 1867 28710 181 0 182 33 2 35
2010 30658 29250 149 1259 30482 123 0 123 26 0 26
Total 116787 104241 1682 10864 115121 1406 0 1407 102 14 275
VECTOR CONTROL ACTIVITIES
In ensuring the airport is free of Aedes aegypti, KLIA Health Office has implemented two
methods of monitoring which are Aedes inspection and Ovitrap study.
Ovitrap study is carried out to detect the presence of Aedes mosquito and it‟s species in the
vicinity. It is done within the perimeter of airport up to 400 meter from the perimeter. Ovitrap
study is carried out using Mosquito Larvae Trapping Devices or MLTD. Installation of traps and
reexamination is done every seven days. (the mosquito aedes aegypti life cycle).
In accordance with IHR 2005 all entry points should be free from Aedes aeypti (Ovitrap Aedes
aegypti should be 0 )10 and Overall Aedes Index should be less than 10% (< 10%). Studies
carried out by KLIA Health Office from 2006 until 2010 shows that, KLIA has been free from
Aedes aegypti until 2009 (Figure 1). One breeding was found in the year 2010.
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
101 Yellow Fever Surveillance KLIA Experience
Figure 1 : Trend of Ovitrap Breeding at KLIA from 2006 till 2010
Premises inspection within the perimeter was carried out weekly to trace the source of Aedes
breeding and to identify a potential breeding. Any premises found with breeding of Aedes will be
issued a compound of maximum value of RM 500.00 under Section 13 (1) of Destruction of
Disease-Bearing Insects Act 1975 amended in 2000.
Trend of Aedes breeding from 2006 till 2010 has increased as shown in the Figure 2
Figure 2: Trend of Aedes Breeding at KLIA from 2006 till 2010
A total of 12 compounds, and two Notices under Section 13 (1) and Section 8 of the Destruction
of Disease-Bearing Insects 1975 amendment 2000 were issued to owners of premises.
MONITORING OF DISINSECTISATION OF INTERNATIONAL AIRCRAFT
Inspection and disinsectisation of international aircraft was implemented at KLIA from 2003 with
the objective to ensure no disease-bearing insects are introduced into Malaysia and to monitor
the cleanliness of international aircraft. There are two options / methods of disinsectisation i.e.
Residual and spraying (Pre-Embarkation, Top of Descent, On Arrival). WHO recommends the
use of the active ingredient d-phenothrin (2%) for space spraying, and permethrin (2%) for
residual disinsection11.
This procedures requires the flight operator to ensure that the disinsectisation is done before
landing at any international airport in Malaysia. Documents relating to disinsectisation and
General Declaration of Health must be submitted to the Health Quarantine Center. Information
on disinsectisation of the aircraft will be recorded monthly. The report will be sent to the Ministry
of Health Malaysia.
0
10
20
30
2006 2007 2008 2009 2010
27
17 15
710
0 0 0 0 1
Aedes albopictus Aedes aegypti
0
2
4
6
8
10
2006 2007 2008 2009 2010
4 4
8 89
0 0 0 0
5
Aedes albopictus Aedes aegypti
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
102 Yellow Fever Surveillance KLIA Experience
ISSUES AND DISCUSSION
Compliance of vaccination requirement among travellers from Yellow Fever Risk Countries has
improved. However there are still travellers who fail to produce vaccination certificate on
arrival. Among the reasons quoted is that they are unaware of this requirement.
The existing monitoring mechanism for Malaysians arriving from Yellow Fever Risk Countries
whereby random check are carry out at the Immigration autogate is insufficient to ensure
compliances among Malaysian.
There were travellers from Yellow Fever Risk Countries were not referred by the Immigration
officer to Health Quarantine Centre at entry point. This could be due to lack of knowledge as a
result of high turnover of Immigration Officers at entry point.
Owners of premises within the airport had been found ineffective in their effort to identify and
control the breeding and potential breeding areas.
Pest control operators (PCOs) appointed by the airport authorities have not played an important
role in preventing breeding of Aedes.
Personnel involved in monitoring of Aedes breeding have been burdened with other public
health activities at KLIA.
Disinsectisation of inbound international flight was unsatisfactorily carried out as required under
IHR 2005. Disinsectisation is important to prevent the disease bearing vector transmission into
Malaysia. At this moment this is not a legal require
RECOMMENDATIONS
To improve the compliance among arriving travelers. Awareness activities need to be enhanced
further.
To improve the awareness among Malaysians who travel to Yellow Fever Risk Countries. The
travel agencies and Embassy (Malaysia and Foreign) should play an important role to ensure
this vaccination requirement is full filled prior travelling to Malaysia. This can be done by
distributing brochures and through their website.
Regular briefings and training on Yellow Fever requirement to Immigration Officers can
increase referrals of travellers from Yellow Fever Risk Countries to Health Quarantine Centre.
Regular education activities on prevention on mosquito breeding and the enforcement of
Destruction of Disease Bearing Insects Act 1975 amended in 2000 will be enhanced to curb
Aedes breeding.
Activities by the PCOs should monitored closely in ensuring the activities carry out are effective
in preventing Aedes breeding.
TECHNICAL REPORT 2011 SELANGOR STATE HEALTH DEPARTMENT
103 Yellow Fever Surveillance KLIA Experience
Regulation related to disinsectisation requirement which is being drafted at Ministry of Health
should be expedited
REFERENCES
1. WHO 2011 – fact sheets of YF from http://www.who.int/mediacentre/factsheets/fs100/en/
2. WHO 2010 International travel and health
3. Yellow Book 2012: Chapter 3: Infectious Diseases Related To Travel
4. WHO 1998 (2) - District guidelines for yellow fever
5. Mosquito-Borne Illnesses in Travelers: A Review of Risk and Prevention: Yellow Fever
from http://www.medscape.com/viewarticle/730561_7 18 August 2011
6. WHO 1998, Yellow Fever Technical Consensus Meeting, Geneva 2-3
7. Laws of Malaysia Act 342 Prevention and Control of Infectious Disease Act
8. Case Definitions for infectious Diseases in Malaysia, 2nd Edition 2006, Ministry of Health
Malaysia
9. Laporan Teknikal dan Pengurusan Pejabat Kesihatan KLIA 2010. (Unpublished)
10. International Health Regulation 2005, WHO 2005
11. Schedule of Aircraft Disinsection Procedures, Australian Quarantine and Inspection
Services V2.0, Page 5