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Make the pharmacist occupation respectable again
News Bringing CMPA to light
Feature Understanding common feeding issues in infants
Spotlight Pharmacists should brush up on oral health advice
Pharmacy Practice Benefits and Risks of hormone replacement therapy in menopause
News | Pharmacy Today | June 2013
Make the pharmacist occupation respectable again
By Pank Jit Sin
he business of running a pharmacy and running a sundry shop is not much different today, with up to 80 percent of floor space in a community pharmacy taken up by daily-use items such as cosmetics, haircare products and groceries. “The pharmacy section is often just a small corner at the back of the shop,” said Rainee Joy, a pharmacist and CEO of Lovy Pharmacy. “What is our focus? We are supposed to provide professional healthcare services, but because of cash-flow constraints, we have to resort to these measures.” Another red-zone practice, said Ms Rainee, is ‘throwing price’ or being known as a ‘discounter’. This practice is so rampant that consumers often discuss which pharmacy has the cheapest prescription medicines and supplements. Beyond discounts, Ms Rainee pointed to the practice of selling medicines without prescription. Apart from being unethical, it is also illegal and could lead to serious repercussions. Ms Rainee also touched upon the issue of pharmacists conducting unlicensed practices. “We have intruded upon the roles of other healthcare professionals such as doctors and pathologists.” Some pharmacists today provide blood pressure measurement in their pharmacy, proceed to diagnose hypertension and subsequently prescribe an antihypertensive agent. Needless to say, such a practice should be stopped, she said.
Instead of resorting to such ‘red-zone’ practices, Ms Rainee suggested pharmacists sell quality professional pharmacy services, and brand themselves as ethical professionals. By upholding the profession, Ms Rainee said wider roles will open up for pharmacists as they will be seen as more than mere ‘licensed drug pushers’ and as legitimate sources of knowledge on drugs and medicines. She also encouraged pharmacists to retail their products within a more standardized price range. By upholding the profession to the highest ethical standards, pharmacists can further justify the delegation of dispensing rights to them. This would, in turn, translate into better profits and sales. On the Lovy Pharmacy business model, Ms Rainee said the pharmacy does not have to resort to selling sundry goods as it works synergistically with BP Diagnostic Centres. Health-conscious individuals who come for screening are directed to the right place ie, either to doctors or pharmacists – all of whom are housed under the same roof. “We work side by side with our diagnostic center, which consists of a diversified team of healthcare professionals including doctors, pharmacists, nurses and nutritionists. Here, the services are provided by the right professionals who have been entrusted with the right roles, without intrusion from other professions.”
Medications containing aspirin should be avoided. even if the patient does not feel ill. However. lentils. followed by severe pain and joint inflammation that can last five to 10 days. . people with gout either produce too much uric acid or their kidneys are unable to dispose of it sufficiently. shell fish. beans. and is also made by the body. Drugs such as allopurinol or probenecid will help control uric acid levels and should be taken over a long period of time. Drugs such as colchicine or corticosteroids administered as tablets or an injection into the joint can be used for a short period. knee. Marmite and Vegemite • avoid large amounts of red meat • drink alcohol in moderation • drink plenty of non-alcoholic fluids as dehydration can trigger an attack. anchovies. Excess uric acid is transferred by the kidneys to urine and removed by the body. sardines. The big toe where it joins the ball of the foot. Uric acid accumulation results in tiny needle-shaped crystals in the joints. tip of the elbow and fingers can all be affected. Uric acid is a by-product of the metabolism of foods rich in purines. kneecap. it is important to adjust your diet if you suffer from gout. Gout mainly affects middle-aged men.4 News | Pharmacy Today | June 2013 Dietary changes to treat gout W hile eating or avoiding certain foods may not help all arthritis sufferers. the instep. A gout attack can occur overnight. Dietary changes recommended are: • avoid or restrict foods high in purines such as offal. peas. ankle. but the dose should be adequate and the drug should be taken at the first sign of the attack. fish roe. wrist. and is closely linked with the level of uric acid in the body. Medical advice should be sought early as an NSAID can be effective as a pain reliever. causing inflammation and pain.
The amount of cow’s milk involved. In severe cases. means a person may be able to tolerate two glasses of milk without a problem. GI tract symptoms include itching of the mouth and lips. The guidelines aim to help healthcare professionals better understand the symptoms and signs of CMPA in . lactose cannot be broken up into its components – glucose and galactose. coughing. An allergy. on the other hand. CMPA can also manifest as anaphylaxis. is often referred to as lactose intolerance. Respiratory symptoms include sneezing. Intolerance. and a consultant pediatrician and consultant clinical immunologist/allergist. Lactose intolerance takes longer to present. the mechanisms involved are very different: this is the major difference. Exposure in CMPA is not limited to consumption of cow’s milk. In infants with CMPA. flushing and swelling. “Usually. said Dr Amir. a life-threatening reaction. Symptoms involving the skin include itching. gastrointestinal (GI) tract and respiratory tract.” said Dr Amir. the most common form of food allergy among infants in Malaysia. Dr Amir Hamzah and Dr Chai Pei Fan advocating the guidelines for the management of CMPA in children cheek after consuming cow’s milk causes the baby’s lips to swell. Due to this. a mother kissing her baby’s C From L-R: Prof Lee. However. vomiting and diarrhea. as well as the time between exposure and reaction. CMPA presents within two hours of exposure to CMP.5 News | Pharmacy Today | June 2013 Bringing CMPA to light By Malvinderjit Kaur Dhillon CMPA and lactose intolerance ow’s milk protein allergy (CMPA). Lactose intolerance involves a non-immunological mechanism which occurs due to lactase deficiency.” said Dr Amir. tightness in the throat and dyspnea. it is defined as an intolerance. but also includes smelling or coming into physical contact with it eg. wheezing. hives or welts. both two very different conditions. abdominal pain. a professor of pediatrics and a senior consultant pediatrician. The terms ‘intolerance’ and ‘allergy’ have been used too loosely and interchangeably. one may easily be mistaken for the other. but then start to show symptoms after consuming a third glass. highlighted the management guidelines on CMPA in children released last year. can be used to differentiate between CMPA and intolerance. “Based on the similar signs and symptoms of CMPA and lactose intolerance. said Amir Hamzah Abdul Latif. Children with CMPA develop symptoms in several organ systems such as the skin. says an expert. as defined and endorsed by the World Allergy Association since 1999. president of the Malaysian Society of Allergy and Immunology (MSAI). When a hypersensitivity reaction occurs without an immunological mechanism. In fact. is when there is immune system involvement. a small amount of protein is enough to elicit symptoms. Managing CMPA Lee Way Seah.
The experts were speaking at the launch of the CMPA Awareness Campaign organized by MSAI and the Malaysian Paediatric Association (MPA) to help educate parents about CMPA among children. But once a child has developed CMPA symptoms. Some parents also opt for hypoallergenic (HA) formulas and it seems to be a logical choice for them to make. in a situation where the mother is unable to breastfeed. However.6 News | Pharmacy Today | June 2013 young children and infants. Another popular choice is soy formula. The panel of experts speaking at the CMPA Awareness Campaign Right diagnosis for CMPA Chai Pei Fan. The launch was in conjunction with the recent World Allergy Week 2013. The guidelines for the management of CMPA in children 2012 can be accessed online at www.pdf .” said Prof Lee. HA formula is an option. The overall principle is to promote breastfeeding.” he said. The panel of experts stressed that prevention is better than cure. as well as provide comprehensive advice on how to approach CMPA. we provide guidelines on products available. They encouraged mothers to breastfeed if they are able to as this is the best way to prevent CMPA.org/file_ dir/6296706325048109343baa. “The guidelines are especially helpful as they are based on products available in Malaysia.allergymsai. In discussing some of the misconceptions parents have about CMPA. Sometimes. stressed it is essential for parents to seek the opinion of a GP or specialist to get the right diagnosis and proper advice on what milk substitute to use. this is not an appropriate formula choice. He also urged parents to use the allergy risk checklist and to seek medical advice if they notice symptoms of CMPA. he said. they need to know that HA formulas are used for prevention. However. The common practice is to change from one brand of cow’s milk to another. a consultant pediatrician and consultant pediatric gastroenterologist and hepatologist. If a parent is unable to exclusively breastfeed and the child has a high risk of developing CMPA. parents also go for lactose-free formulas as they are not aware that CMPA and lactose intolerance are entirely different problems. as we believe it can help prevent or lower the incidence of CMPA. “… parents often form their own assumptions and will carry out their own interventions. The checklist provides healthcare professionals with the medical history of the child and parents. It is provided in a CMPA information leaflet available at healthcare centers.
Once or twice a day is sufficient if the probiotic is being taken as a preventative measure. having them with breakfast and dinner. Probiotics – it’s all in the details Pharmacists should also advise patients to be consistent when taking probiotics.7 News | Pharmacy Today | June 2013 Probiotics can improve gut health stressful and busy lifestyle can take its toll on the digestive system. Ms Johns said. Nicola Johns Pharmacy owner Nicola Johns said. probiotics are more widely accepted and people are more open to trying them. This will help patients keep on track of their routine and to finish the required course. However. While probiotics are recommended for a wide group of people. Healthy Food Guide nutritionist Claire Turnbull said. it is a good idea to look at the research and the studies on different strains. the nutritionist said. . Ms Turnbull added. However. pollution and drinking too much caffeine and alcohol can all deplete beneficial bacteria from the body. it was a major exercise in education. for example. she said. if the person is vomiting or is starting to get a cough and cold. A Selling probiotics is no longer an uphill battle Selling probiotics has also become easier over the last couple of years as there is increased public awareness. While probiotics are beneficial for most people. when it comes to deciding which probiotics are the best to recommend. Lifestyle and environmental factors such as stress. Ms Johns said. for example. she said. They work by correcting the shortage of good bacteria in the system. Probiotics can also aid digestion because the level of processing in food today can leave it lacking in vitamins and nutrients which aid gut health. probiotics can help many people get gut health back on track. However. The course needs to be completed for it to be effective. Previously. It is also important to check the label on the probiotics to see how they are meant to be stored because they have to be kept at the right temperature for them to work. such as blood in the stool. it is beneficial to increase the frequency to every few hours – increase the frequency rather than the dose. Ms Turnbull said. As a result. which makes it easier to talk to the patients about them. diarrhea and abdominal cramps. How many probiotics a person takes and how often also depends on the symptoms the patient has. she added. It is a good idea to develop a routine around taking them. Ms Johns would not recommend a probiotic which had shown resistance to antibiotics. constipation. it is important to seek medical advice if there are significant changes to bowel health. Probiotics can help with a range of digestive health problems including indigestion. she said. patients with autoimmune disorders should check with their specialist on whether it is safe for them.
The smoking cessation campaign is into its third year and is supported by the Ministry of Health.” said Soumitra Sen. “The Pledge to Quit Right campaign by GSK has seen success in other markets and we are excited to introduce it in Malaysia. and learn how to stay away from cigarettes for good. Our research shows that many smokers may have the will to quit. with the provision of helpful advice. The Pledge to Quit Right campaign – a holistic. .” said Lokman Hakim Sulaiman. reading materials and a community support system with other smokers on the same M By Saras Ramiya The Pledge to Quit Right campaign is the first of its kind drive targeted at Malaysians who want a smoke-free environment journey to increase their chances of success.9 News | Pharmacy Today | June 2013 Continuous mission to help Malaysians stop smoking alaysians can now pledge to support the drive towards a cigarettefree country with the new Pledge to Quit Right campaign. The BSP also allows users to conveniently share updates of their progress on Facebook and through other channels to enhance support from family and friends in their endeavor. “The Ministry is pleased to see GSK’s continuous efforts to help smokers quit smoking and raise awareness on the techniques of smoking cessation. this first-of-its-kind pledge drive is also targeted at Malaysians wishing for a smoke-free environment. aided by daily motivation and advice. nicotine replacement therapy and GSK’s Behavioural Support Programme (BSP). Designed not just for smokers who are committed to quit. All they need to do to show their support for a cigarette-free Malaysia is to post their pledges on the Pledge to Quit Right board at the Pledge to Quit Right roadshow or on the mobile Pledge to Quit Right board transported by Era FM and My FM radio cruisers. GSK. I commend GSK for once again participating in the National World No Tobacco Day 2013 celebration event. the BSP is a free webbased program that empowers smokers to plan and monitor their own quit-smoking journey. Asia Area Marketing Director (Wellness).” said Datuk Dr Lokman. Deputy Director General of Health (Public Health). as well as healthcare professionals who are to be recruited to educate patients and customers on the use of smoking cessation aids through GlaxoSmithKline Consumer Healthcare Sdn Bhd’s comprehensive Quit Right platform. The campaign also endeavors to help smokers plan how to quit smoking. quitter-at-heart smoking cessation campaign – continues GSK’s ongoing effort to raise awareness amongst smokers as well as non-smokers on the right way to quit smoking. “We are also pleased to be collaborating with [GSK] on some of our own initiatives. through the Pledge to Quit Right campaign this year. Launched in 2012. but have not taken any concrete steps due to lack of knowledge on smoking cessation methods or fear of failure.
MOH’s pharmaceuticals services senior director. the pledges we’re collecting will spur them on.250.” “With the Pledge to Quit Right campaign. Cosway Pharmacy has been selected as a recognized establishment for the training of PRP. our stop-smoking aid that uses nicotine replacement therapy. This liberalization will allow pharmacy graduates to undergo PRP training at private pharmacy facilities such as private hospitals. and we want to encourage more of them to journey towards not just trying to quit. This will enable them to receive recognition through accreditation of commu- nity pharmacy program under the Malaysian Pharmacy Board.” said Mr Sen. With the Pledge to Quit Right campaign. garnering support from family and friends.10 News | Pharmacy Today | June 2013 “Many smokers have thought of quitting. Eisah said the decision was made to provide a platform for pharmacists to become involved in the private pharmaceutical sector. training was limited to government hospitals and facilities.pharmacy. and community pharmacies. The MOH’s liberalization of the training scope of pharmacists comes after the shortening of compulsory training for pharmacists from three years to one year effective 2011. The MOH also hopes to increase the number of registered pharmacists in Malaysia. *The Community Pharmacy Benchmarking Guidelines can be found at www. Previously. in research and development. Pharmacies wishing to participate in the program will need to ensure their premises meet the rules and regulations set in the Community Pharmacy Benchmarking Guidelines*. but to quit for good using the right methods. we are incorporating important elements that improve the rates of success. and using tested systems such as the three-step. knowing that the nation is supporting their desire to be cigarette-free. such as consulting Certified Smoking Cessation Service Providers (CSCSP) at pharmacies.my/v2/sites/default/files/document-upload/ community-pharmacy-benchmarking-guideline-2011. Eisah was speaking at the launch of the 100th Cosway Pharmacy in Kuala Lumpur.gov. Community pharmacies interested in being listed as training facilities for graduates are encouraged to submit their applications to the MOH. They can then go on to be awarded a free store under the Free Store program. Cosway Pharmacy is also giving the opportunity for pharmacists who fulfill the attachment requirement to be trained on managing a pharmacy store. said Dato’ Eisah Abdul Rahman. which at January 31 stands at 10. 12-week quit smoking plan with NiQuitin.pdf . MOH liberalizes pharmacists training scope By Malvinderjit Kaur Dhillon T he Ministry of Health (MOH) has relaxed the training scope of provisionally trained pharmacists (PRP) with the aim of increasing the pharmacist-to-people ratio by 2016.
PHARMACY TODAY PTMAY-13/001 .
and these include: • Losing weight.12 News | Pharmacy Today | June 2013 De-liver us from NAFLD on-alcoholic fatty liver disease (NAFLD) is a condition where fat accumulates in the liver of people who drink little or no alcohol. NAFLD is a rather common condition. such as those found in fish. olive oil and nuts. Take your medications as directed and closely monitor your blood sugar • Lower your cholesterol • Protect your liver. high levels of blood triglycerides. rapid weight loss. obesity. it can progress to liver failure. Imaging procedures can be used to diagnose NAFLD. computerized tomography (CT) and magnetic resonance imaging (MRI). Avoid alcohol and follow the instructions on all medications and over-the-counter drugs . which measure the liver enzyme markers alanine aminotransferase (ALT). such as whole-wheat breads and brown rice • Exercise and be more active. toxins and chemicals. If you are overweight or obese. high cholesterol. metabolic syndrome. N By Leonard Yap There are currently not many therapeutic options for NAFLD. Eat a healthy diet that’s rich in fruits and vegetables. Elevated levels of these enzyme markers usually denote a problem with the liver and may help the doctor make a diagnosis. The tissue sample is examined in a laboratory to look for signs of inflammation and scarring. Avoid things that will put extra stress on your liver. malnutrition. the accumulated fat may cause inflammation and scarring of the liver. and for most people. This more serious form of NAFLD is sometimes called non-alcoholic steatohepatitis. Include whole grains in the diet. These include certain types of medications. Follow your doctor’s instructions to stay in control of your diabetes. gastric bypass surgery. and Wilson’s disease. At its most severe. causes no signs or symptoms. Unfortunately. Reduce the amount of saturated fat in your diet and instead select healthy unsaturated fats. such as pesticides. These include ultrasound. The best ways to detect NAFLD are liver function blood tests. Incorporate more activity in your day • Control your diabetes. Aim for at least 30 minutes of exercise most days of the week. in some people with NAFLD. type 2 diabetes. aspartate aminotransferase (AST) and gamma glutamyl transferase (GGT). A wide range of diseases. If there is a suspicion of a more serious form of NAFLD. Lifestyle adjustments are usually prescribed. A biopsy is typically done using a long needle inserted into the liver to remove liver cells. conditions and factors can increase the risk of developing NAFLD. the doctor may advocate a liver biopsy. reduce the number of calories you eat each day and increase your physical activity in order to lose weight • Choose a healthy diet.
. in Hong Kong. specifically phosphatidylcholine from soy. phospholipids appear to have antioxidant properties and have been found to reduce inflammation and scarring of the liver. The bimonthly journal is proud to announce its CME-accreditation in the following Asian countries: HONG KONG. which are also known as essential phospholipids (Essentiale®. For further details. Malaysia and Singapore For over 35 years. JPOG has been the only regional. From the research bench to your patient’s bedside – JPOG raises the quality of life of women and children in Asia. In addition. Studies have shown that these essential phospholipids. are incorporated JPOG is NOW CME-Accredited.. MALAYSIA and SINGAPORE. Nutritional supplements have shown some benefit in protecting the liver and aiding recovery from oxidative damage. sanofi) are vital nutrients which can support the liver. Supplements containing polyunsaturated fatty acids. Pick up a copy today and start earning CME points. peer-reviewed journal of paediatrics.com today..jpog. Indonesia.13 News | Pharmacy Today | June 2013 into the cell membrane of both normal and damaged liver cells to increase membrane fluidity and active transport cross the membrane. Low-density lipoprotein cholesterol (LDL-C) and total cholesterol levels appear to decrease with the consumption of phospholipids. obstetrics and gynaecology in Asia. INDONESIA. visit www.
but not the immune system. In the majority of people. skin (urticaria. distinct differences between the two. An example of this is lactose in- . Without a basic understanding and strict use of the various terminologies used to describe these hypersensitivity reactions. Food intolerance involves the body’s metabolism. An allergen is a type protein found in offending food or food component that sets of a chain of immune reactions including the release of histamine in the hypersensitive individual. food allergy is a specific form of intolerance to food or a food component that activates the immune system. The release of histamine causes a variety of symptoms that are seen in the following: gastrointestinal system (vomiting.15 Feature | Pharmacy Today | June 2013 Pediatric & Digestive Health Feature Understanding common feeding issues in infants H ypersensitivity reaction to food is becoming more common. Essentially. however. On the other hand.1 Food hypersensitivity can be further classified into immune-mediated food hypersensitivity (food allergy) or non-immune mediated food hypersensitivity (food intolerance). atopic dermatitis) and respiratory system (asthma attack. the offending allergen will not elicit such adverse reactions. There are. healthcare professionals face an uphill task to optimizing patient care in those who are susceptible. Food intolerance occurs when the body is unable to digest food or a food component completely. The World Allergy Organization recognizes food hypersensitivity as an umbrella term to describe objectively reproducible symptoms as a result of exposure to susceptible food that are otherwise tolerated by normal persons. Differentiating between food allergy and food intolerance It is very common for the general public and healthcare professionals alike to use ‘food allergy’ and ‘food intolerance’ interchangeably. rhinitis).2 An example of the commonest form of food allergy seen in the early years is cow’s milk protein allergy. food intolerance describes feeding problems commonly encountered in infants. diarrhea).
passing through the esophagus. Infants may swallow excess air during feeding especially if they drink too rapidly. It is very common for infants to spit up simply because infants cannot sit up during feeding. Excessive crying is unexplained prolonged crying of healthy infants whose basic needs are met. There are many things that can cause abdominal gas and worsen crying in infants: • Swallowing of air during sucking. and keeping infants in an upright position for at least 15 minutes after feeding. Spitting up can also happen because infants’ stomachs are quite small and can get quite easily distended by feeding. for example the change from breastfeeding to infant formula. It is for this reason that accurate diagnosis to differentiate between the two can only be made by means of a combination of clinical history and dietary investigations followed by food challenge or food reintroduction. The lower esophageal sphincter is a valve located between the esophagus and the stomach that opens to let milk flow into the stomach and tightens to prevent milk (and stomach contents) from moving back into the esophagus. Mild constipation occurs when infants experience difficulty and discomfort in passing hard and dense stools for two or more weeks. are in no discomfort. Spitting up should not be a cause of concern if infants seem content. Colic is a pattern of weeks-long excessive crying and occurs in intervals. the lower esophageal sphincter may be immature and unable to keep all of the stomach’s contents in place. As infants swallow milk. are lying down during feeding or the bottle nipple has holes that are too big. Constipation Although a normal bowel pattern is desirable and thought to be an indicator of good health. Spitting up can be reduced by burping infants after every 1-2 ounces feed to prevent build up of air in the stomach. which is the inability of the body to breakdown lactose due to a lack in the enzyme lactase. Fussiness. A change of type of formula may be recommended if the source of colic is due to food hypersensitivity. Exactly what causes fussiness. slower feeding to allow stomach contents more time to empty into the intestines. . Infants who have been crying intensely for a period of time can swallow in extra air. • Swallowing of air when crying.2 Symptoms of common feeding issues Spitting up Spitting up is an effortless return of swallowed formula or breast milk through the mouth or nose after feeding. excessive crying and colic is unknown. Constipated infants may have tolerance.16 Feature | Pharmacy Today | June 2013 Pediatric & Digestive Health thriving and are not experiencing any breathing problems during spit ups. it glides pass the back of the throat into the stomach. although it is thought that abdominal gas could be a cause. the frequency of infants’ bowel movements vary so much that it is difficult to define constipation in infants. The symptoms of food intolerance are not dissimilar from food allergy. • l Improper feeding. excessive crying and colic Fussiness is the inability of infants to settle down or be soothed. Constipation tends to happen when infants are going through dietary transition. Also. and usually manifest as gastrointestinal intolerance. avoid overfeeding at any one time or stop feeding once the infant seems full. Certain milk formulas may lead infants to have excessive gas due to intolerance to lactose or milk protein.
Diarrhea is a symptom that is more commonly associated with acute viral gastroenteritis . and can be due to intolerance to lactose or milk protein present in cow’s milk. In contrast. The byproducts of lactose degradation in the large intestine cause the symptoms of gas. while glucose enters the bloodstream causing a spike in blood glucose concentration. In the lactose-intolerant individual. and loss of elasticity in skin. In formula-fed infants. Lactose intolerance Lactose intolerance simply means the body cannot digest lactose. Dehydrated infants require medical help immediately.characterized by sudden onset and lessens in one to several days. galactose is absorbed into the liver to be converted into glycogen as storage. low pH value. Signs of dehydration in infants include urinating less often than usual. This spike in blood glucose concentration is not seen in lactose-intolerant individuals and a rise in blood glucose of less 1. The hydrolysis of lactose produces galactose and glucose. producing various gases including hydrogen. Hence. This is a noninvasive test that measures the amount of hydrogen in an individual’s breath as an indication of lactose nonabsorption. Under normal circumstances. chronic diarrhea that last for weeks and months in infants is more likely to be due to gastrointestinal intolerance to milk or its components.3 • Plasma glucose test. The symptoms of lactose intolerance can be easily mistaken for irritable bowel syndrome. where lactase is produced in the brush borders of the small intestine. Prolonged diarrheal episodes can lead to dehydration in infants. fatty acid and glucose. unusual drowsiness or lethargy. all of which are byproducts of lactose fermentation in the colon. The primary site for lactose digestion and absorption happens in the small intestine. dry mouth. Causes of common feeding issues in infants Symptoms of common feeding issues in infants are usually gastrointestinal in nature. This test can be used in infants and children as it measures the acidity of stool due to lactic acid. irritability.3 • Stool acidity test. bloatedness and abdominal discomfort seen in infants with lactose intolerance.4 Milk protein intolerance Infants with symptoms of milk protein intol- stomach ache and/or a swollen belly and start to drink less.5 mmol/L is indicative of lactose intolerance. Undigested lactose creates an osmotic load . very little hydrogen is detectable in the breath. Once hydrolyzed. which results in loose and watery stools. Diarrhea Diarrhea is frequent and watery bowel movement. the undigested lactose is fermented in the colon. a natural sugar that is found in milk and dairy products. It is a disaccharide that is hydrolyzed by lactase to yield glucose and galactose. The hydrogen gas will be partially excreted in the mouth that is detected by the test. a careful past medical history and dietary review is important to make the accurate diagnosis.17 Feature | Pharmacy Today | June 2013 Pediatric & Digestive Health in the large intestine. A change in the type of infant formula may be useful in diarrhea that is caused by milk intolerance. Several tests exist to confirm lactose intolerance and they are as follows: • Hydrogen breath test. Presence of lactose intolerance is indicated by a high acidity level ie. Ensuring adequate water intake in formula-fed infants may also help to relieve constipation. drawing more water into the colon. changing the type of formula may be useful to ease constipation.
frequent spit ups or refusal to feed. sometimes hours to days after intake of milk. Some infants may have chronic redness of cheeks and earlobes.5 Although switching infant formula is the first step towards happy and healthy infants. colic. The reactions due to milk protein intolerance are often delayed. and the switches were often made in response to a perceived health problem such as regurgitation. Onset of milk protein intolerance is almost always during infancy and this disorder can sometimes go undiagnosed. blood tests may be required to check if the infant is anemic. A study by Nevo et al which looked at infant feeding patterns in the first six months of life found that nearly 50% of parents switched infant formula without consulting a healthcare professional. According to a survey.5 This clearly reflects that parents are unsure Preventing tummy discomfort in infants Symptoms of tummy discomfort are very common in infants.18 Feature | Pharmacy Today | June 2013 Pediatric & Digestive Health of that. Questions on whether cow’s milk has been recently introduced to the diet and infant’s bowel habits are useful information in making a diagnosis. Infants with milk protein intolerance typically present with symptoms such as rashes. stomach upset. Parents are likely to suspect that infant formulas may be the culprit when their infants have prolonged diarrhea. Infants with milk protein intolerance tend to be fussy after feedings as well. excessive crying. On top . Diagnosing milk protein intolerance can be difficult because there are no specific test to confirm the diagnosis. These symptoms can be sources of frustration for mothers. erance means that their bodies are not tolerating cow’s milk proteins. specifically whey and casein. up to 84% of Malaysian mothers admit to having feeding difficulties with their infants. this survey noted that symptoms of vomiting. milk protein intolerance is confirmed after absolute dietary elimination of cow’s milk protein for 3-4 weeks. gas and diarrhea are the top four concerns encountered in infant feeding. therefore. More often than not. constipation. diarrhea. vomiting and fussiness. Parents lacked knowledge on the content of infant formula It is a natural tendency for parents to consider a switch in infant formula to improve symptoms of tummy discomfort. An allergy test may be performed to rule out milk allergy as infants with milk protein intolerance will test negative in such tests. many parents lack knowledge on what type of infant formula is most suitable. most of them chose another cow’s milk-based formula. depends on detailed medical history and physical examination. Although these over-the-counter products may offer some relief. the soothing effects are only temporary and do not address the root cause of the problem. gastroesophageal reflux and fussiness. There were also 12% of parents noted in this study who made more than two switches of infant formula over a span of six months. This was revealed in the same study by Nevo that when parents made the switch. Sometimes. A clinical improvement of symptoms should be noted during this time. inconsolable crying. causing endless worrying and sleepless nights because their child is not feeling well. Knowing whether infants have milk protein intolerance. The rashes are usually transient and can appear as tiny bumps on the cheeks and upper arms. It is very common for Malaysian mothers to use traditional methods like gripe water or Chinese medicated oil to relieve symptoms of tummy discomfort in infants.
suggesting that these formulas could have different therapeutic uses. especially if they have strong family history. more importantly. Helping parents make the right choices A wide variety of infant formulas is available out there in the market and they are described in various terminologies.19 Feature | Pharmacy Today | June 2013 Pediatric & Digestive Health sitivity response when given to infants.6 However.70 kD (particularly 10 . at minimum. For a formula to be labelled as hypoallergenic. it can be confusing and overwhelming to discern what is the suitable choice for infants with tummy discomfort. which is the relative or absolute absence of lactase that develops in childhood in different racial groups. found in regular cow’s milk-based infant formula are allergenic.8-10 Lactose-free formulas Infants with tummy discomfort are likely to be introduced to a trial of lactose-free formula during the diagnosis process to see if symptoms improve. placebocontrolled studies. Depending on the sizes of predigested protein formed. These tests include efforts to determine the molecular weight of residual peptide. the amount of immunologically recognizable material present and the ability of the formula to elicit an immune response in preclinical studies. Primary lactase deficiency is the commonest cause of lactose malabsorption and lactose intolerance.40 kD). any hypoallergenic formula may be of therapeutic use in infants with tummy discomfort. in the first 4-6 months of life. emerging evidence has shed light on the possible differences between partially and extensively hydrolyzed formulas.7 Majority of the world’s leading health organizations on child nutrition seem to agree on the suitability of hypoallergenic formula for infants who could be at risk of milk hypersensitivity. This perception needs to be changed because specific infant formulas are available for infants with tummy discomfort and parents need to be educated on what are the appropriate choices. It is common for parents to think that changing the brands of infant formula will improve tummy discomfort.6 Hypoallergenic formulas have to undergo rigorous preclinical formulation and testing to ensure that they do not elicit any hypersen- . help to distinguish the minority of infants who may benefit from specialized formulas. it has to. hypoallergenic formulas are formulas which contain predigested protein that are formed using enzymatic processes to break down large protein peptides into smaller fragments. these formulas can be further classified as partially hydrolyzed (containing larger peptide fragments) or extensively hydrolyzed formulas which has smaller peptide fragments. For lessinformed parents. Lactose-free formulas are usually indicated in infants with primary lactase deficiency. which explains the frequent switches and poor choices for their infants. ensure 95% confidence that 90% infants with documented milk hypersensitivity will not react with defined symptoms to the formula under double-blind. Hypoallergenic formulas It is thought that protein peptides in the range of 10 . Hence.11 It is recognized that lactose-intolerant individuals have varying degrees of lactase defi- of the contents of infant formulas. Pharmacists play an important role in advising parents on choices of infant formulas based on available evidence and. Essentially. while specialized formulas such as extensively hydrolyzed formulas should be used in infants with documented cow’s milk protein allergy.
J Pediatr Gastroenterol Nutr 2007. Bhatia J.346-349. diarrhea. 12. However. fussiness. 2. 10. Kissous-Hunt M. 8. J Allergy Clin Immun 2004.118:1279-1286. et al. Am Fam Physician 2009. constipation and sometimes. Pediatrics 1982.92:902–908.9(1):31-41. when they should be educated on the type of infant formula that is suited to resolve the symptoms. Garrison MM. Accessed on: 25 Apr 3. The AAP also noted that isolated soy protein-based formulas has no proven value in the management of infantile tummy discomfort. Nevo N. Most parents think that switching the brand of infant formula may help. Arch Dis Child 2007. Expert Rev Clin Immunol 2013. Tummy discomfort can cause symptoms such as excessive crying. 6(Suppl 1):S12-S23.113:832-836. 5. especially if the infant has prolonged tummy discomfort and at risk of malnutrition. Vandenplas Y. 4. especially if they are first-time parents.org/article/en/expid/ basics-food-allergy-intolerance/. 13.20 Feature | Pharmacy Today | June 2013 Pediatric & Digestive Health Tummy discomfort in infants ciency and correspondingly. et al. 9.106.16(1):47-49. Paediatri Child Health 2011. 11. Pediatrics 2006. 6. O'Connor NR.45:234–239. et al.Committee on Nutrition.79(7):565-570. These infants went on to be symptom-free when they were given predigested protein formulas.184-190. Heyman MB. IeJSME 2012.13 Soybased formulas may be of value in infants with documented cow’s milk protein allergy who cannot tolerate the palatability of extensively hydrolyzed and/or amino acids formulas.70:7-10. Johansson SG. Food allergy and food intolerance.121:1062-1068. et al. European Food Information Council. tummy discomfort in infants are likely to be due to intolerance to certain components of cow's milk such as lactose and milk proteins.12 The American Academy of Pediatrics (AAP) has specified the use of soy-based formulas in the following conditions: (a) for infants with galactosemia and hereditary lactase deficiency (rare) and (b) in situations in which a strict vegetarian diet is preferred. American Academy of Pediatrics. Pediatrics 2008. Barreling PM. et al. it may be sensible to consider lactose-free formulas in infants with tummy discomfort. are able to tolerate varying amounts of dietary lactose.11 Soy-based formulas Soy formulas are often marketed as alternative formulas suitable for infants with tummy discomfort.14 Caring for infants with tummy discomfort can be stressful and overwhelming for mothers. Most of the time. 7. However. 14. it may not be so for most infants. et al. Pharmacists can help parents in making the right choices to bring comfort to their infants References: 1. gas. . colic.3(12):16-18. et al. Critch J. Lowe AJ. Lothe L.eufic. Advance for NPS & PAS 2012. Pediatrics 2000. Available at: www. Pediatrics 2000. Hypoallergenic infant formulas that contain predigested proteins and lactose-free may resolve symptoms of tummy discomfort.106. A study by Lothe et al found that symptoms of tummy discomfort did not improve or deteriorated in more than half of infants who had tummy discomfort and given a soy-based formula.
“Pharmacists are within communities. Further advice on the NZDA website includes flossing daily. The Australian Dental Association advocates that pharmacists work with dentists to ensure they give compatible information and are up to date on the latest oral health promotions. For example. Dr Crum said. The basics for a healthy mouth are a good. Pharmacy Today New Zealand reports W hile pharmacists should send patients with toothache directly to a dentist.21 Spotlight | Pharmacy Today | June 2013 Spotlight Pharmacists should brush up on oral health advice With around a third of adult New Zealanders not brushing their teeth twice daily with fluoride toothpaste. pharmacists have an important role to play in spreading the oral health message. they can also help reinforce good oral hygiene. twice-daily cleaning with fluoride toothpaste and regular visits to a dentist. the Australian Dental Association’s Peter Alldritt told the AJP. as this washes the fluoride away. New Zealand Dental Association (NZDA) chief executive David Crum said in an email to Pharmacy Today. customers buying baby bottles present a good opportunity for pharmacists to remind them to protect their babies’ . according to the Australian Journal of Pharmacy (AJP). are trusted by communities and should be encouraging the public to seek regular dental care. Anxiety over visiting a dentist. The advice a pharmacist gives can make or break a customer’s future oral health outcomes. They should also support public health measures to reduce dental disease such as water fluoridation and. mean pharmacists are often the first port of call for people experiencing oral health issues. combined with pharmacy’s longer opening hours. most importantly. quitting smoking and not rinsing after brushing. encourage customers to adopt simple oral health measures at home.” Dr Crum said. low-sugar diet. either due to the cost or fear of pain.
when customers come in with oral health issues. but being located across the road from a dental surgery has increased mouthwash sales. Ms Rama said. If a customer comes in complaining of bad breath. Providing advice does not create direct sales. it is a good opportunity for complementary selling and relationship building. remineralizes the mouth and helps clear food from around teeth.govt. Preventative oral health recommendations for children include reinforcing the ‘Breast is best’ message for babies and switching from a bottle to a cup as soon as possible (Healthcare Handbook. or applying turmeric or baking soda. People generally buy toothpaste at the supermarket rather than from her pharmacy.nz has a downloadable publication in various languages informing families of the free oral health services for children and covering oral hygiene basics. . Bleeding gums are often a symptom of low vitamin C. to alleviate different tooth problems. Patients with continual bad breath or gingivitis should be sent to a dentist as soon as possible to prevent their teeth eventually falling out. owner Julie Knudsen said. Ms Knudsen said. sales of fluoride tablets are low despite NZ’s West Coast having an unfluoridated water supply. p141). from discoloration to bleeding gums. Her customers do not seem to mind that these toothpastes usually do not contain fluoride. Chewing sugar-free gum for adults stimulates saliva production. Some of her advice for treating problems like mouth ulcers and bad breath involves simple home remedies like rinsing with salt and warm water. or a sign of stress. Bad breath often linked to digestion issues. Dr Alldritt said. health. for which she may suggest a vitamin B supplement. generally not available in supermarkets. Ms Rama also stocks a wide range of herbal toothpaste.22 Spotlight | Pharmacy Today | June 2013 Often. Ms Rama said. However. Mouth ulcers can also be due to a vitamin or mineral deficiency. so she may recommend a herbal toothpaste or a pill with Indian gooseberry due to its high vitamin C content. teeth by not putting infants into bed with a bottle of milk or juice. she will sell a product to treat acute symptoms and a remedy for the root causes. and Ms Rama will give advice on diet. The Healthcare Handbook 2012 (p105) recommends mouthwash containing chlorhexidine for bad breath and gingivitis. the problem is usually related to digestion. the New Zealand Dental Association website said. The NZ Ministry of Health’s website www. For ayurvedic-trained central Auckland pharmacist Hansa Rama. at the Buller Pharmacy. which buffers against food-acid. Sufferers of persistent halitosis may also have a non-dental health issue and should see a doctor. Fluoride in toothpaste essential for healthy teeth Fluoride’s power to reduce tooth decay by 2030% outweighs the potential risk that it may leave white spots on children’s teeth. but she builds up customer trust and they come back to her with other health issues. the Healthcare Handbook says. but cautions prolonged use may stain teeth.
Besides having to consume the traditional three bowls of oats. provides the three-bowl equivalent with just two spoonfuls.1% in 2011. Dedicated and health-conscious individuals may not find it a pain to religiously consume three bowls of oats every day. and when you compare the Malaysian staples of nasi lemak or roti canai. The options for breakfast in Malaysia abound. . In 2011. With Active Oat 35 powder. consumers can now more easily reap the full benefits of oats and its cholesterol-lowering properties. let alone keeping up with the three-bowl-aday regimen. (Am J Clin Nutr 2010. This translates to a staggering 10 million people. but it is a challenge for most other people. a bowl of oats just cannot compete. which contains PromOat™. you need to consume three bowls a day for 60 consecutive days. Those on hectic schedules have little time for breakfast. But what many people do not know is that to get the desired cholesterol-lowering effects from oats. which make eating oats even more of a chore. most people cannot tolerate its bland taste or lumpy texture. it reduces bile acid reabsorption by binding to bile acid in the intestinal tract and to produce more bile acid quickly. But things have gotten a lot easier with a new form of oats in the market! Kordel’s Active Oat 35™. Second. multicenter clinical trial of nearly 400 patients which tested the ability of oat beta-glucan to reduce serum LDL-C.23 Spotlight | Pharmacy Today | June 2013 PromOat health without the bloat By Leonard Yap onsuming oats has long been used as a way to reduce blood cholesterol. the National Health and Morbidity Survey 2011 (NHMS 2011) found that the percentage of Malaysians suffering from high cholesterol had increased from 20. It also reduced total cholesterol levels by 5%. consuming that amount of oats may cause bloating or gas in some people. parallel-design. it lowers the absorption of dietary fat and cholesterol by expanding and increasing the viscosity of food in the small intestine to form a physical barrier and reduce excessive cholesterol absorption. In addition.92(4):723-32) So why should we care about LDL-C and total cholesterol levels? High cholesterol levels have become an increasing concern for Malaysians. an oat beta-glucan. So how do oats work? It is believed that oat beta-glucans have a dual-action mechanism C on the digestive tract. There have been various studies to access oat beta-glucan’s effects on reducing cholesterol. or nearly one-in-three.7% in 2006 to 35. (Nutr Rev 2011. First. One study showed that people who took oat beta-glucan had a 10% reduction in low-density lipoprotein cholesterol (LDL-C) after 4 weeks compared to those who did not take it.69(6):299-309) This appeared to confirm findings from a doubleblind.
Fungal infections can usually be treated with topical creams and/or powders. . according to the New Zealand Healthcare Handbook 2012. tinea pedis (or athlete’s foot) is the most common. is tinea cruris or jock itch. oozing. The condition is more common in hot. neck or shoulders. Antidandruff shampoos with selenium sulphide can treat it. while towels and socks should be washed in hot water and slippers worn in communal changing areas. The infection will often have a well-defined border and can spread to the buttocks. but severe in the sick or those with low immunity. Tea-tree oil and garlic are possible natural treatments. Cracks on the foot and toes may also appear. Pharmacy staff should advise customers to bleach their bath areas to prevent spreading the infection.24 Spotlight | Pharmacy Today | June 2013 Topical treatments first-line for fungi infections minor irritation in healthy people. Often going hand in hand with athlete’s foot due to transfer via towels. usually making itself known between the toes and giving a “white and soggy” look. tinea cruris can cause the groin and inner thigh to turn a reddish brown and to itch intensely. which usually affects the trunk and limbs. Ringworm is often caught from kittens. some clear skin in the middle and can look similar to other skin conditions like dermatitis. Signifiers are inflamed nail beds and failure of previous antifungal treatments. Customers should keep the infected area dry and avoid sharing towels. Often indistinguishable from tinea infections. fungal infections are part of the stock and trade of pharmacy. while fingernail infections are common in gardeners and people who spend a lot of time with their hands in water. Less common. should be referred to a pharmacist. in the nails. coppery brown or pale patches. Pharmacy staff should advise customers to wear gloves while gardening. humid climates or when people sweat a lot. which can be used as both a preventative and curative. which will also prevent mould infections. Toenail fungal infections can occur on their own or in conjunction with athlete’s foot. but it needs to be different from the one used under the arms to avoid cross-contamination. usually on the trunk. This advice also applies to ringworm (tinea corporis). scalp or beard. or topical antifungal products applied overnight for at least a fortnight. repeated. Malassezia infections can affect the scalp and may cause dandruff or create pink. Of those affecting the skin. An antiperspirant for sweaty feet will also help prevent tinea developing. Infections which are large. Topical nail antifungals usually treat the condition. ranging from general sale to pharmacist-only. crumble or fall off. Both make the nail look thick and discolored and it may become brittle. and looks like a circular itchy red patch on the skin. but probably more annoying. mould infections picked up through soil are much harder to treat and need a pharmacist’s attention. but occasionally prescription oral medicine is needed. A It often has a raised edge. or in any way severe.
Women who have had gestational diabetes may go on to develop T2DM later in life. There are three main types of DM: • Type 1 DM results from the body’s failure to produce insulin. It is compact. Other known risk factors that damage blood vessels. increased thirst and hunger. should also be kept under control. • Type 2 DM (T2DM) results from insulin resistance. The HGM-112 also has an error indication when expired. You use a disposable lancet contained within the button-activated device to obtain a small drop of blood from your fingertip or palm. This may be due to the pancreas not producing sufficient insulin or beta cells not responding to the insulin produced.5 g. T2DM was previously referred to as non insulindependent diabetes mellitus or adult-onset diabetes. The classical symptoms of diabetes include frequent urination. like hypertension. Tobacco cessation should also be part of the management strategy.25 Spotlight | Pharmacy Today | June 2013 Blood glucose monitoring improves diabetes control By Leonard Yap iabetes mellitus (DM) is a degenerative disease affecting beta cells of the pancreas. sometimes combined with an absolute insulin deficiency. Treatment should target lowering blood glu- D cose and attempting to sensitize ‘ailing’ beta cells to the effects of insulin. damaged or reused strips are used to ensure reading accuracy. about 347 million people worldwide have DM. Preventing these symptoms from progressing will enhance its management. and was previously referred to as insulin-dependent diabetes mellitus or juvenile diabetes. There are many brands available and one such product is the Omron HGM-112 blood glucose monitoring system. a condition in which cells fail to use insulin properly. Most people check their blood glucose levels using a personal blood glucose meter. The drop of blood on the disposable test strip is then inserted into the meter. Early diagnosis of DM can be accomplished through relatively inexpensive blood testing. weighing a mere 25. easy-to-use and pocket-sized system. which provides a reading after just five seconds. It is important to recognize these symptoms and understand that DM is a disease that affects most organs in the body. According to the WHO. • Gestational diabetes occurs when pregnant women without a previous diagnosis of diabetes develop high blood glucose levels. .
Patients should also be advised to: • avoid foods known to cause indigestion or heartburn • eat small meals slowly • avoid tight waistbands. however. neck. Antacids and alginates are commonly used as a first-line treatment. some symptoms can be similar to those of a heart attack. H 2 antagonists are pharmacy-only medicines used to block the action of histamine on gastric acid cells to reduce acid release. Heartburn is common in pregnancy because the stomach is pushed upwards by the baby. For other non-urgent instances. . lose weight. stop smoking and raise the bed head • see a doctor if symptoms persist for longer than two weeks. shoulders or arm. Medications such as iron tablets and antiinflammatories can also aggravate the condition. and gets worse with exercise. treatments can be offered. while proton pump inhibitors reduce gastric acid secretion by a direct action on stomach gastric acid-releasing cells. Urgent medical help is required for anyone describing pain which radiates through the jaw.26 Spotlight | Pharmacy Today | June 2013 Eating small meals slowly reduces heartburn Pharmacy staff are well placed to offer advice and treatment for heartburn. bending over or lying down soon after a meal • reduce alcohol intake.
a physiological phase in a woman’s life. To help to alleviate the menopausal symptoms. the term HRT is still very commonly used. hormone replacement therapy (HRT) is used in menopause to supplement the body with either estrogen or a combination of estrogen and progesterone. therefore. These symptoms include hot flushes. some women may experience a variety of debilitating vasomotor symptoms and vulvovaginal changes termed as the climacteric or menopausal syndrome. mood swings and vaginal dryness which may differ in severity between individuals and can affect the quality of life and health of women2. and to be consistent in this article we will retain the term HRT. sleep disturbances. there is a decline in the production of estrogen and progesterone which are hormones produced by a the ovaries20. . Women are considered as postmenopausal if their menstruation has ceased consecutively for at least a year. A few years before and after reaching menopause. University of Malaya Recognised by Academy of Pharmacy Every mont earn 1 h CPD p oint ost women reach menopause (the last menstrual period) around the age of 5020. which are mainly a consequence of reduction in estrogen production20. There are some quarters who feel that the term ‘HRT’ is misleading and. There are two types of HRT: • estrogen-only HRT • combined HRT (estrogen plus progestogen). is a disease due to hormone deficiency13.27 Pharmacy Practice | Pharmacy Today | June 2013 Pharmacy Practice Benefits and Risks of hormone replacement therapy in menopause By Dr Chua Siew Siang B. should be substituted with ‘postmenopausal hormone therapy’ to M avoid the perception that the natural process of menopause. As a woman approaches menopause. Pharm (Hons). night sweats. PhD Department of Pharmacy Faculty of Medicine. reduction in bone mass. However.
thrombosis and increase in blood pressure22. levonorgestrel. Ethinyl estradiol is commonly used in oral contraceptives. gastrointestinal disturbances such as nausea. but is now rarely used in HRT for menopausal women because it has distinct effects on hepatic metabolism4. tablet. but not all are available in Malaysia19. mood swings. abdominal cramps and bloating. pruritus and dyspareunia10. HRT is used for the control of menopausal symptoms and to improve the quality of life of affected women. nestorone and promegestone • l estranges (first-generation progestogens) such as norethisterone. with the addition of another tablet which contains a progestogen for days 17 to 28 of the cycle. Subsequent courses are repeated without any interval22. gestodene. transdermal patch. dydrogesterone. Estrogens used in HRT include: • conjugated equine estrogen • ethinyl estradiol • 17β-estradiol • estradiol valerate • estradiol hemihydrate • estrone sulphate • esterified estrogens. breast tenderness or enlargement. norgestimate and dienogest • drospirenone. Stefanick describes in detail the history and trends in estrogen and progestin use dating back as early as 1889 when French physiologist Charles Edouard BrownSequard self-injected an extract of testicles of dogs and guinea pigs to reverse aging19. vomiting. vaginal candidiasis. Globally. while the progestogen component is usually cyproterone acetate. consist of estrogen given on the first day of menstruation (or any time if Benefits of HRT Basically. intrauterine device. altered lipid profile (which may lead to pancreatitis). cholestatic jaundice. implant or injection. the Merck Manual featured several treatments for climacteric symptoms. i. unscheduled vaginal bleeding or spotting.28 Pharmacy Practice | Pharmacy Today | June 2013 menstruation has ceased or is infrequent) for 28 days. Side effects of HRT include headache. there are various pharmaceutical dosage forms of HRT. dydrogesterone and progesterone derivatives such as medrogestrone • pregnanes such as medroxyprogesterone acetate. norgestrel. Trends in the use of HRT in menopausal women have fluctuated like a rollercoaster for the past few decades. norethisterone or medroxyprogesterone. cream or gel and vaginal ring.e. In 1899. megestrol acetate and cyproterone acetate • norpregnanes such as trimegestrone. endometrial proliferation.8. Most of combined HRTs for the alleviation of menopausal symptoms or the prevention of osteoporosis in women with a uterus. Most HRTs contain conjugate estrogen or estradiol hemihydrate/valerate.21. Progestogens used include4: • micronized progesterone. Systematic reviews have shown that HRT is effective for alleviating vasomotor symptoms such as hot flushes and night sweats as well as symptoms associated with vaginal atrophy such as vaginal dryness. norethisterone acetate and lynestrol • gonane progestogens: • second-generation progestogens such as norgestrel and levonorgestrel • third-generation progestogens such as desogestrel. including a product Ovarin® which was de- . drospirenone. weight gain. glucose intolerance. changes in libido. dizziness. edema.
there was a drastic worldwide decline in the use of HRT.25 mg conjugated equine estrogen) was approved in 194219.62-0. stated that there was no significant increase in risks of any clinical outcome in women aged between 50 and 59 years due to the use of HRT3. the negative impact of HRT created by the initial WHI announcement in 2002 has instilled sufficient fear and anxiety among healthcare providers as well as affected women that the negative reputation of HRT could not be erased completely although more positive effects of HRT were reported in rived from cow ovaries. By 2001. In addition. there were reports which suggested that estrogen therapy could prevent bone loss. p=0. Conflicting reports on the effects of estrogen on coronary heart disease occurred around 1985. However. This breast cancer risk reduction was only applicable to women without benign breast disease or a family history of breast cancer1. Consequently.16.2 years as analysis of the data showed that the health risks of the combined HRT exceeded its benefits15.35% per year. This trial was terminated early after a mean follow-up period of 5. there was a reduction in total mortality in women of this age group using HRT. The initial report of this WHI study stated an increased risk in breast cancer and was publicised in the media which resulted in fear and a negative impact on the use of HRT. in 1992. the American College of Physicians issued a position statement based on a landmark meta-analysis of observational studies. The WHI trial of estrogen-only HRT in women with hysterectomy was also terminated earlier due to an increase in risk of stroke1.608 women with an intact uterus who were given either a combined estrogen and progestin (contained conjugat- .10.29 Pharmacy Practice | Pharmacy Today | June 2013 ed equine estrogen 0. An extended follow-up of this WHI trial found that the use of estrogen-only HRT for a median of 5. but declined dramatically in 1975 when estrogeninduced endometrial cancer was reported19. the use of estrogen climbed again after the emergence of evidence of protective effects of progestogens on estrogen-induced endometrial changes and reports of improved bone mass with conjugated estrogen. 95% CI 0. However. Consequently. In addition.77. Use of estrogen increased steadily in the mid-1960s to mid-1970s due to initiation of oral contraceptives in young women. while Premarin® (1. However. hazard ratio (HR) 0. HRT was widely used during the 1990s although there were insufficient randomized controlled trials to support its benefits and also its safety during that time12.95.27% versus 0.5 mg) or a matching placebo15. which contained more positive results on HRT. approximately 15 million US women were using HRT5. However. Findings from the Postmenopausal Estrogen-Progestin Interventions (PEPI) trial in 1995 showed favorable lipoprotein changes in estrogen users.625 mg and medroxyprogesterone acetate 2. the first HRT approved by the US FDA in 1941 for the treatment of menopausal symptoms was diethylstilbestrol.02). a subsequent report by the WHI study in 2007. The Women’s Health Initiative (WHI) randomized controlled trial on postmenopausal women between the ages of 50 and 79 years in the US involved 16.9 years was associated with lower incidence of invasive breast cancer compared with placebo (0. Consequently. with the cessation of long-term use of HRT in many users and a drop in HRT use rate of 40 to 80%3. and this reinforced the cardioprotective effects of HRT19. which recommended that all postmenopausal women should be offered HRT to prevent cardiac problems19.
may have been inappropriately deprived of the benefits of HRT and some had to suffer unnecessarily3. a 59% reduction in Alzheimer’s disease was observed if HRT is initiated in early menopause and continued for more than 10 years12. this could then translate into enormous health and economic consequences. following the WHI publication in 20025. Similarly. . if HRT. the addition of a progestogen in combined HRT reduces such risk in women with an intact uterus4. A recent systematic review concluded that a reduction in the risk of fracture with the use of HRT was the only beneficial outcome which has strong evidence12. later years. Unopposed estrogen in women with intact uterus is associated with an increase in risks of endometrial hyperplasia at all doses and this may develop into endometrial cancer4. However. If one million women entered menopause each year in the US alone. a cardioprotective effect was observed9. as menopausal symptoms also occur around this age9. but were too afraid to start HRT. Therefore. women who wish to stop HRT should consult their healthcare providers so that alternative treatment for the prevention of osteoporosis and bone fractures could be given6. women who discontinued HRT were at 55% greater risk of hip fracture compared with those who continued using HRT6. Protection from hip fracture in postmenopausal women seemed to tail off within two years of cessation of HRT. Similarly. Decades ago. This can be seen from a study in Australia which demonstrated a fall in the prevalence and duration of use of HRT from 28% in women over 50 in the year 2000 to an estimated 10.5 years of followup. Risks associated with the use of HRT include: • Endometrial hyperplasia which may lead to endometrial cancer • Breast cancer • Ovarian cancer • Gallbladder disease • Stroke • Thromboembolism.2% in 200211.955 postmenopausal women aged 60 and on HRT found that after 6. A longitudinal study on 80. especially those with severe symptoms of menopause. Some women.23. a drastic drop in HRT use was observed in the US. The risks associated with the use of HRT are shown in Table 1. especially estrogen-only HRT. Consequently. However. it was already known that the incidence of bone fractures was twice as common in postmenopausal women compared to their male contemporaries and.16. Risks of HRT Controversies over the risks and benefits of HRT have been debated continuously over the past two decades. hence.8. there was an increased use of non-evidence-based complementary medicines for the management of menopausal symptoms although these had not been proven safe and/or more effective than the placebo used in HRT trials14. was started in women under 60 years and closer to the start of menopause.12. Low-dose estrogen-only HRT is especially beneficial for the prevention of fractures in women if initiated before age 60 years.11. The systematic review by Marjoribanks and colleagues also found that HRT was not indicated for the prevention of cardiovascular disease or dementia in postmenopausal women aged around 6012. it was suggested that small doses of estrogen should be given to retard the deterioration of bones in postmenopausal women20.30 Pharmacy Practice | Pharmacy Today | June 2013 and there was a 50% increased risk of bone fracture associated with a 50% decrease in HRT use.
93 (95% CI. reviews of randomized controlled trials of HRT have shown that estrogen-only HRT does not increase the risk of breast cancer9. if given appropriately2. In addition. it is agreed that the risk-benefit ratio of HRT depends on the age of the woman. types of HRT. this risk of ovarian cancer increased with the use of estrogen-only HRT in a duration-dependent manner7 and appeared to be attenuated by the presence of progestogens.33) and the absolute excess risk was − 2 per 10.12. The elevated risk in coronary heart disease Summary . exercise.000 person-years. The WHI trial found that for postmenopausal women aged 50 to 59.65-1. On the contrary.9. medical profile of the woman. only low doses of transdermal estrogen-only HRT should be used in women with risk factors for stroke. this association was not consistently observed in different studies.12. A systematic review of mainly observational studies indicated that both estrogen-only and combined HRT was associated with an increase in risk of ovarian cancer12. Rossouw et al reported that the risk of stroke did not vary significantly with age of the woman or time of initiation of the HRT since menopause16. However.13.12.17: • Use the lowest effective dose of HRT • Duration of use should be determined by Several observational studies have associated a drop in the incidence of breast cancer during the period when there was a decline in the use of HRT6. these problems may be reduced by tailoring the use of HRT to individual needs and following some general principles4. Generally. most of the physicians believed that the benefits of HRT outweigh its risks. Although there are potential side effects and risks associated with the use of HRT. An increase in risks of ovarian cancer had been seen mostly in women who have undergone hysterectomy with ovarian conservation and have been on estrogen-only HRT for more than five years9.19. dose of HRT and duration of HRT use2. Women should attempt non-pharmacological management first since there is evidence to show that some symptoms may be alleviated with lifestyle modifications such as a healthy and balanced diet. but this protective effect reduced with an increase in the age of women given HRT leading to an increase instead of a reduction in risk among women aged 70 to 7916. if indicated. high risk for venous thromboembolism and for older postmenopausal women18. The recommendation is that women with menopausal symptoms need to be informed that the symptoms are transient and also the risks and benefits of using HRT. Thromboembolism is the main serious short-term risk associated with the use of HRT especially during the first year or two of use9. cessation of smoking. The risk is highest among those with thrombophilia and/or obesity9. 0. reduction in alcohol intake and reduction of psychosocial stress10. However. A study in five European countries and the US showed that the majority of physicians had not lost confidence in HRT as most of them were of the opinion that the negative publicity of HRT by the media was not justified and that HRT remained an effective treatment for the alleviation of climacteric symptoms and could significantly improve the quality of life of some menopausal women. It has been recommended that. There appeared to be an increase in risk of stroke in women initiated with HRT many years after menopause9. the hazard ratio (HR) for CHD was 0.10.31 Pharmacy Practice | Pharmacy Today | June 2013 (CHD) was most apparent and significant in the first year of HRT use12. The review also found a statistically significant association between HRT and gallbladder disease. However.
17.6 1 21 (16 – 28) 32 (25 – 40) 24 (19 – 31) 102 (91 – 112) 1.15 – 3.94 (0.6 5.26* (1.68) 0.08 – 1.02 – 1.6 7 7 7 AR = Absolute risk.74 – 1. CI = Confidence interval.89* (1.75) 1. and possibly also cognitive benefits9. These may outweigh the risks which are less likely to occur in women aged below 609.com.74) 1. MI = myocardial infarction.79 (0. HRT should be initiated as near the time of menopause as possible for symptom control when it will also have other additional beneCombined continuous HRT Events Duration of use (year) AR per 1000 (95% CI) RR (95% CI) Coronary (MI or cardiac death) Venous thromboembolism (DVT or PE) Stroke Breast cancer All clinical fractures 1 4 (3 – 7) 22 (18 – 27) 7 (4 – 11) 18 (14 – 23) 23 (19 – 29) 86 (79 – 94) 1. especially in women with only symptoms of vulvar and vaginal atrophy • Initiate HRT in symptomatic women near menopause.78* (0.56) 0.32 Pharmacy Practice | Pharmacy Today | June 2013 fits such as a reduction in fracture and cardiovascular risks. PE = pulmonary embolism. DVT = deep vein thrombosis. the duration of use of estrogenonly HRT is more flexible compared to the combination HRT which should not be used beyond 3 to 5 years17. Estrogen-only HRT Duration of use (year) AR per 1000 (95% CI) RR (95% CI) the estimated risks and benefits for each individual • Minimize or eliminate systemic progestogens (by using intrauterine progestogen delivery systems) • Use non-oral routes or local estrogen-only preparations.1) 7 1. Therefore. please go to www.38* (1.52) 4.61 – 1.98 – 1.34) 1.01) 0.6 5.07 – 1.65 – 0.17. Estrogen-only HRT has a more favorable benefit-risk profile than the combination HRT (except for those with an intact uterus and a high risk of endometrial hyperplasia) which appears to be associated with an earlier appearance of increased breast cancer risk.8) 5. RR = risk ratio Table 1: Risks of HRT in relatively healthy postmenopausal women12 To answer the quiz for your CPD points.28* (2.73* (0.49 – 7.71 – 0.85) 7 38 (32 – 46) 0.34* (1.my .32* (1 – 1. HRT = hormone replacement therapy.22 (0.13) 5.mims-cpd.
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