November - December 2013

Award for Changi hospital’s medication
management system
Help older patents
understand joint pain
Feature
Expanded role for
pharmacists will
beneft patents
Forum
Aslan raises US$22m
to advance drug
development
Business
Community program can
improve heart health
News
News | Pharmacy Today | November - December 2013 2
Award for Changi hospital’s medication
management system
By Rajesh Kumar
C
hangi General Hospital’s closed loop
medication management system in-
corporating QR codes has won the
prestigious digital healthcare award. The
system aims to enhance patient safety, im-
prove staf productivity and reduce human
error in medication administration.
Unlike the conventional barcode, the QR
Code technology has greater information
storage capacity and is capable of being read
in 360 degrees, from any direction. This elimi-
nates any interference and negative efects
from backgrounds, said Dr. Goh Min Liong,
acting chief medical informatics ofcer at the
Eastern Health Alliance (EHA) that includes
CGH and other health providers.
Medication administration in hospitalized
patients is a complex series of inter-related
processes that involve ordering of medica-
tions, reviewing the order, supplying and
then administering of the medications.
This requires close coordination and com-
munication among all the healthcare provid-
ers to provide drug therapy accurately. There
are several points for human errors that could
results in delayed, omited or incorrect medi-
cation therapy.
Ward nurses manually retrieve medica-
tions from a limited range of ward stocks.
Correct serving of medication depends on
nurses manually checking that the right dose
of the right drug is given to the right patient.
The nurse can pick up the wrong medicine,
pour the wrong amount or may give it to the
wrong patient.
“Certain institutions have tried to address
that by having double checks, i.e. having two
people check every single dose of every single
medication before its administration to pa-
tient. But that is not cost efective,” said Dr.
Goh.
“Two people can easily make two difer-
ent human mistakes. By replacing the second
person with a machine, the error rate can be
drastically cut. We think it is more of a fool
proof system than others.”
The closed loop medication management
system with QR code medication verifcation
at point-of-care eliminates the risk of admin-
istrating a medicine that does not match the
doctor’s prescription.
Once doctor generates the prescription
electronically, the order goes to a central phar-
macy. A robotic dispenser in pharmacy auto-
matically picks up the medicines and packs
them in a bag, with a barcode stuck on it. The
patient also wears a barcode bracelet. The
barcode on the medication bag has to match
with the barcode on the prescription and the
patient.
When the nurse scans the patient’s barcode,
The system ensures that the barcode on the medication pack matches with
the one on the prescription and on the patient’s bracelet before a drug can
be safely administered.
News | Pharmacy Today | November - December 2013 3
it pulls up all the medications and their exact
dosages that the patient is supposed to have
at that particular time. If the medication, dos-
age and its time doesn’t match, the barcode
reader will show up an error.
The system improves healthcare staf’s ef-
fciency, giving them more time for quality
patient care. Data from the system also pro-
vides clinical analytics to improve patient
outcomes.
“What is diferent about the CGH system
is that we pack the medication in unit dosage.
That really improves the accuracy. Some hos-
pitals pack the entire supply of medications
in a single sachet,” said Ms. Phyllis Yap, chief
information ofcer of the Integrated Health
Information Systems (IHiS) that developed
the system for CGH.
This ensures that the right medication in
right dosage goes to the right patient at the
right time, said Yap.
Although nursing homes are also part of
the EHA, the closed loop medication manage-
ment system will not be rolled out for them
due to what Goh and Yap termed as unfavor-
able economies of scale.
“We must have volumes to justify the huge
investment that the (close loop system) war-
rants,” concluded Yap.
The award was presented during the inau-
gural Digital Healthcare Week recently held
in Singapore.
News | Pharmacy Today | November - December 2013 4
Feeling angry? Have a chat
By Rajesh Kumar
W
hen you are angry, simply talking
to someone about it may well pro-
tect you from the negative impact
of stress and anger.
The very act of describing your feeling
can have a signifcant impact on the body’s
physiological response to the situation such
as heart rate and cardiac output, US research
suggested. [PLoS ONE 2013; doi:10.1371/jour-
nal.pone.0064959]
To test the hypothesis, the researchers
asked 102 men and women to complete a
difcult math task in the presence of evalua-
tors trained to ofer negative feedback as they
worked through the assignment.
Negative feedback was designed to elicit
anger in some participants and shame in oth-
ers. At the end of the task, participants were
given a questionnaire that appraised their
feelings (eg. How angry are you right now?),
or a set of neutral questions that did not as-
sess their emotional state.
In the ‘anger’ condition, participants
who completed the questionnaire about
emotional state had diferent physiologi-
cal responses, measured by heart rate
changes, compared to those who answered
neutral questions. Among these, reporting
on one’s emotional state was associated with
a smaller increase in heart rate compared to
others.
“Measurement efects exist throughout the
sciences - the act of measuring ofen changes
the properties of the observed. Our results
suggest that emotion research is no excep-
tion,” wrote authors Drs. Karim Kassam from
Carnegie Mellon University in Pitsburgh,
Pennsylvania, UK and Wendy Mendes from
the University Of California San Francisco,
California, US.
“What impressed us was that a subtle ma-
nipulation had a big impact on people’s phys-
iological response. Essentially, we’re asking
people how they’re feeling and fnding that
doing so has a sizeable impact on their cardio-
vascular response,” said Kassam.
Describing your feeling
can have a signifcant
impact on the body's
physiological response
‘‘
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Forum | Pharmacy Today | November - December 2013 6
T
he expanded role of pharmacists to
help manage the health of patients can
beneft both patients and physicians.
Pharmacists in Canada have recently been
given broader responsibilities including, in
some provinces, prescribing privileges, abil-
ity to order and interpret laboratory tests, and
ability to vaccinate and inject medications.
The Canadian example has the potential
to be replicated in other countries, including
in Singapore. In the United Kingdom, United
States, New Zealand, Australia, and gradu-
ally in Singapore, pharmacists are being in-
volved in collaborative care arrangements.
There is strong evidence that pharmacists’
care can beneft patients, especially in provid-
ing vaccines and managing high blood pres-
sure, diabetes, heart failure, asthma and other
conditions.
As pharmacists more actively participate in
medication management, physicians should
be aware that in inter-professional models of
Expanded role for pharmacists will benefit
patients
Based on a paper jointly writen by a physician and a pharmacist in Canada, summarizing the
opportunities for collaborative care.
Forum | Pharmacy Today | November - December 2013 7
care, every member of the team is accountable
for the care he or she provides and is not to be
held directly liable for the acts of others.
Pharmacists, who have specialized ex-
pertise in drug dosing, drug interactions,
pharmacology and related areas, can help
physicians manage safe prescribing in com-
plex (ofen elderly) patients taking 5 or more
drugs. They can also help in tapering patients
of medications.
Evidence from randomized trials showed
that pharmacist involvement in patient care
can provide beneft, and resulted in favor-
able disease-specifc outcomes for the man-
agement of hypertension, dyslipidemia, heart
failure, anticoagulation therapy, asthma and
diabetes.
Sound evidence
A systematic review of 19 randomized trials
of pharmacist care for hypertension showed a
reduction in systolic blood pressure of 8.1/3.8
mm Hg compared with usual care. Pharma-
cist care for dyslipidemia reduced low densi-
ty lipoprotein cholesterol by 0.28 mmol/L and
helped achieve target lipid values.
Another systematic review of pharmacist
care in patients with heart failure showed
a reduction in hospital admission for heart
failure of 31 percent, compared with usual
physician and nurse care. Collaborative care
by non-specialist pharmacists working with
GPs to manage the treatment of patients with
heart failure also improved prescribing of dis-
ease-modifying medications, but showed no
diference in death or hospital admission for
worsening heart failure.
Improved control of international normal-
ized ratios (INR) and patient satisfaction have
been consistently reported in pharmacist-led
anticoagulation clinics. Asthma and diabetes
care by pharmacists can result in improve-
ments in pulmonary function tests and gly-
cated hemoglobin.
Opportunities to improve care
Once established, collaborative care with
pharmacists will likely yield tremendous
benefts to both patients and physicians. The
expanding scope of pharmacists’ practice of-
fers many opportunities to improve patient
care. However, it is also an ongoing process
that must be evaluated as regulated activities
change, new pharmacists enter practice and
scopes of activities continue to expand
In the interests of patient care and the joint
responsibilities arising from an expanded
scope of pharmacists’ practice, physicians
should refect on the best way to improve
adequate and timely communication with
pharmacists in their practice. Physicians may
wish to communicate with pharmacists by
telephone, because pharmacists can be easily
reached during working hours.
Reciprocal communication arrangements
could be made that allow physicians to be
notifed by pharmacists in a timely fashion
about prescription renewals, modifcations or
initiation of new therapy for their patients.
The use of computer-based prescribing
and electronic health records could facilitate
this task; if these are unavailable, faxes or
emails could be sent directly to the physician.
Communication is a means of not only relay-
ing messages about prescription changes, but
also clarifying who will be responsible for or-
dering tests and acting on the results.
Inter-professional education is the key
The key to establishing an efective collab-
oration between physicians and pharmacists
could be the provision of inter-professional
Forum | Pharmacy Today | November - December 2013 8
education. Many universities are already
making special eforts to bring together un-
dergraduate and graduate students in the
felds of pharmacy and medicine for training
in interdisciplinary care.
At the Université de Montréal and Uni-
versity of Alberta, in Canada, students from
the nursing, medical and pharmacy faculties
are already being jointly exposed to complex
patient cases to prepare for interdisciplinary
functioning in the real-world seting. Region-
al continuing medical education courses on
the expanded scope of pharmacists’ practice
could provide working knowledge to physi-
cians on how to optimize collaborative care.
Paper authored by Dr. Cara Tannenbaum, Faculties of Medicine and
Pharmacy at the Université de Montréal and Dr. Ross Tsuyuki, Faculty
of Medicine and Dentistry, both at the University of Alberta in Alberta,
Canada. [CMAJ 2013; doi:10.1503/cmaj.121990]
Smart Rx. Every Time.
www.MIMS.com
News | Pharmacy Today | November - December 2013 9
Community program can improve heart
health
By Radha Chitale
A
n afordable community program
improved key vitals including cho-
lesterol, body fat and stamina among
over 200 participants at risk for cardiovascu-
lar events, according to data from researchers
at the National University of Singapore (NUS)
department of pharmacy and the Singapore
Heart Foundation.
The Heart Wellness Programme at the
Singapore Heart Foundation’s Heart Well-
ness Centre in Bishan was designed to assist
patients who were recovering from heart at-
tack or stroke or who were at high risk for
having these to making the lifestyle changes
necessary to improve health and delay dis-
ease progression.
The researchers, led by Assistant Professor
Joanne Yeh Chang, Mr. Ong Kheng Yong and
Mr. Kwan Yu Heng of the NUS Department
of Pharmacy, surveyed 207 patients who par-
ticipated in the program for 12 months be-
tween 2010 to 2011.
Of these, 137 were cardiovascular rehabil-
itation patients. The rest were primary pre-
vention patients who had, for example, hy-
pertension, diabetes, or other cardiovascular
risk factors.
The program, to which participants were
referred by their physicians afer being
deemed stable for community-based exer-
cise, ofered individualized exercise plans,
advice on diet and smoking cessation, and
psychosocial counseling for $3 per session as
well as fexible scheduling.
The most signifcant improvement was
for low-density lipoproteins (LDL), which
improved about 12 percent from baseline.
Participants also improved their total choles-
terol and their 6-minute walking test.
These measures improved more cardiac
rehabilitation patients than among the pri-
mary prevention patients, although Chang
noted this was probably because these pa-
tients were relatively healthy at baseline.
Notably, while primary prevention patients
showed no change in their high-density li-
poprotein levels, the cardiac rehabilitation
group improved about 8 percent from base-
line.
Though smaller, the health gains among
primary prevention patients would prob-
ably translate into signifcant cardiovascular
improvement in the long term, Chang said,
efectively preventing future cardiovascular
events.
Patients in both groups failed to im-
The program aims to assist patients rehabilitating from heart atack or
stroke or at high risk for both events.
News | Pharmacy Today | November - December 2013 10
prove certain measures including visceral
fat density and abdominal circumference,
though this may have been a function of
their advancing age and the short duration
of the trial period. Ong said they might see
greater improvement as they gather more
data.
This positive pilot study to confrm the ef-
fectiveness of the Heart Wellness Programme
should be followed up with future studies to
assess patients’ long-term heart health and
quality of life and the impact on healthcare
costs. Importantly, Chang said further anal-
yses should include paterns and efects of
medication use among patients at cardiovas-
cular risk, which was not included in the cur-
rent data.
“Cardiovascular disease is one of the top
causes of death in Singapore,” Ong said.
“Future expansion to the program has po-
tential in improving the cardiovascular well-
ness and longevity of Singaporeans.”
By Elvira Manzano
T
here is no beneft to using ibuprofen
over paracetamol in most patients with
upper respiratory tract infections (UR-
TIs). Steam inhalation therapy also does not
ofer any advantage, research has shown.
“Clinicians should probably not advise
patients to use steam inhalation in daily
practice as it does not provide symptomatic
beneft for acute respiratory infections. Simi-
larly, routinely advising ibuprofen, rather
than as required, is not likely to be efec-
tive,” said lead study author Professor Paul
Litle from the University of Southampton in
Southampton, UK. “For most patients, clini-
cians should not ofer ibuprofen rather than
paracetamol as there is litle beneft.”
The study of 889 patients across 25 GP
practices in the UK showed that treatment
with ibuprofen or steam inhalation rath-
er than paracetamol did not help improve
URTI symptoms (cold, sore throat, cough, si-
nusitis and otitis media). Four of 207 patients
receiving steam inhalation experienced mild
Ibuprofen may be no better than
paracetamol for URTI symptoms
Ibuprofen, however, may be considered in patients with chest infections and
in children <16 years of age.
News | Pharmacy Today | November - December 2013 11
scalding. [BMJ 2013;347:f6041]
There was also no diference in symptom
control between patients taking ibuprofen/
paracetamol combination and those receiv-
ing only paracetamol. Patients treated with
ibuprofen were also more likely to return to
their GPs within a month of starting thera-
py for new or worsening symptoms. There
were 17 complications overall – two in the
paracetamol group, 11 in the ibuprofen
group and four in the ibuprofen/paracetamol
combination group, although most were not
serious and mainly self-limiting.
Litle said it is possible that ibuprofen is
interfering with an important part of the im-
mune response, resulting in the progression
of symptoms in some individuals. “We must
be a bit cautious as the fndings are surpris-
ing. For the moment, I would personally not
advise most patients to use ibuprofen for
control of cough and colds and sore throat,”
he said. “However, ibuprofen may be con-
sidered in patients with chest infections and
in children <16 years of age for short-term
control of symptoms.”
Paracetamol is a mild analgesic and anti-
pyretic commonly used for headache, other
minor aches and pain. It is also a major in-
gredient in many cold and fu remedies. The
medicine is generally safe when taken at
therapeutic doses (up to 4,000 mg per day for
adults), but small overdoses can cause liver
damage.
Ibuprofen is a non-steroidal infamma-
tory drug (NSAID) indicated for arthritis,
fever, dysmenorrhea and pain. It has both
analgesic and antiplatelet efects. While its
painkilling efect begins as soon as a dose
is taken, its anti-infammatory efect takes
longer to begin (up to 3 weeks to get the
desired results). Ibuprofen is contraindi-
cated in people with ulcer due to increased
bleeding risk, those taking steroids or other
NSAIDs.
By Rajesh Kumar
S
ingapore’s Health Sciences Authority
(HSA) is alerting the public to an unreg-
istered medicinal product called “Oxy-
ELITE Pro” which has been linked to numer-
ous cases of serious liver injuries in the US
and one case in Hong Kong.
Although not approved for sale in Singa-
pore, OxyELITE Pro is being sold illegally
through the internet and some members of
the public may have purchased the product
from overseas, an HSA spokesperson said.
Labeled to contain herbal extracts, the
product is marketed as a dietary supplement
and fat burner to achieve rapid weight loss.
Preliminary laboratory tests conducted by
HSA on the capsules bought online found
the product to contain 1,3-dimethylamyla-
mine (DMAA) and yohimbine which are po-
HSA warns of serious liver injuries with
‘OxyELITE Pro’
News | Pharmacy Today | November - December 2013 12
tent western medicinal ingredients that are
not allowed to be present in supplements
sold locally.
Health products containing such ingredi-
ents require registration as medicinal prod-
ucts and can cause serious adverse efects
when consumed without medical supervi-
sion. Investigations are ongoing to detect
other potentially undeclared ingredients
which may have caused the liver injuries.
The US Food and Drug Administration
(FDA) recently reported 29 cases of acute
non-viral hepatitis in the state of Hawaii. Al-
though the actual cause of the liver injuries
has not been identifed, investigations have
found that 24 of these cases were associated
with the use of this medicinal product.
Eleven of the 29 cases have been hospi-
talized with acute liver injury: two of these
cases have resulted in liver transplants and
one person has died as a result of the com-
plication of serious liver injuries. The most
commonly reported symptoms of liver inju-
ries experienced by the patients include loss
of appetite, jaundice, dark urine and light-
colored stools.
The US Centers for Disease Control and
Prevention (CDC) is currently investigat-
ing other cases of liver injury in other US
states that may be related to these events in
Hawaii. The US FDA is also investigating
the contents of the product OxyELITE Pro
and its manufacturing premises, as well as
whether counterfeit products or any other
ingredients could be related to these cases
of acute liver injuries.
To date, HSA has not received any adverse
reaction reports associated with the use of
the product, although it could be possible
that consumers who have sufered side ef-
fects may not have told their doctors or phar-
macists about the use of this product.
HSA is warning that anyone selling Oxy-
ELITE Pro will face a fne of up to $10,000
and/or imprisonment for up to 2 years under
the Poisons Act.
Over 20 cases of acute non-viral hepatitis in the US and one in Hong Kong
have been linked to OxyELITE Pro.
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Feature | Pharmacy Today | November - December 2013 14 Aged Care
P
harmacists play a vital role in manag-
ing elderly osteoarthritis suferers’ pain
by helping them to understand their
treatment options and the condition itself.
Of the 140 types of arthritis, osteoarthritis
– a weakness in the joints – is the most com-
mon. Almost half of people over the age of 60
sufer from osteoarthritis and the majority of
people over the age of 80 have it.
People should see a health professional if
they are experiencing the following symp-
toms for more than two weeks to check for
osteoarthritis: stif joints afer geting out of
bed or siting for a long time, pain in or near
the joints, swelling in or near the joint, mus-
cle weakness or creaking sensation with bone
movement, according to the Arthritis New
Zealand website (www.arthritis.org.nz).
Arthritis New Zealand educator Mr. Lulia-
no Tinielu says, pharmacists play a vital role
in explaining to patients why they need to
take their osteoarthritis medication and the
correct way to take it.
“GPs only have 15 minutes with their pa-
tients and that’s it. That’s where the pharma-
cist comes in; by helping them understand
the logic behind taking their medications
properly.”
Osteoarthritis suferers most ofen experi-
ence joint pain in the knees, hips, spine and
hands. The main treatment for this condition
is pain relief, such as paracetemol. As the
condition is classifed as a non-infammatory
form of arthritis, nonsteroidal anti-infamma-
tory drugs are generally going to be inefec-
tive.
In cases of extreme pain, health profes-
sionals may recommend a medication which
Help older patients understand joint pain
Osteoarthritis is common and progresses with age, so pharmacies are well placed to assist people
who need pain relief, reports Pharmacy Today New Zealand
GPs only have 15 minutes with their patients, and that's where pharmacists come in.
Feature | Pharmacy Today | November - December 2013 15 Aged Care
combines paracetamol and codeine. Howev-
er, as the condition progresses, some people
do experience infammation in the joints. In
these instances, the pharmacist can recom-
mend ibuprofen or a cream or gel to rub into
the skin to reduce the pain and swelling.
Feedback Arthritis New Zealand receives
from osteoarthritis suferers is that, when
pharmacists explain the importance of tak-
ing their medication, and provide cues, such
as taking medication at meal times, this helps
them to stick to a medication regimen, Tinielu
says.
“If patients understand the logic then they
are more likely to take their medications
properly,” Mr. Tinielu says.
He believes pharmacists are underutilised
in arthritis management and says having
pharmacists based at family doctors’ practic-
es who could spend time discussing the con-
dition with the patient, would be benefcial.
Supplements not widely efective
Alternatives to medication, such as natu-
ral health products, including glucosamine,
chondroitin and fsh oil, are sometimes rec-
ommended for treating arthritis, but there is
no frm evidence to support their use, Tinielu
says.
The supplements are thought to reduce
stifness and pain in the joints. A 2009 Co-
chrane summary on the use of glucosamine
for improving pain in osteoarthritis sufer-
ers showed afer 6 months pain improved at
about the same level in people taking fake
pills as it did in the people taking glucos-
amine supplements.
However, one brand of supplements, Rot-
ta, did appear to show slightly greater pain
relief in the people taking them, compared
with those not taking them. A BPAC resource,
Symptomatic Management of Osteoarthri-
tis, states a capsaicin cream, which contains
a chilli pepper extract, could help to relieve
joint pain.
BPAC advises people to assess the efec-
tiveness of capsaicin cream or glucosamine
and discontinue use if it is not efective afer
three months. It also states there is no clini-
cal evidence for the efectiveness of multi-
vitamin and mineral supplements, copper
bracelets and acupuncture on treating osteo-
arthritis symptoms. On the other hand, some
suferers report these supplements are efec-
tive, but pharmacists should be aware this is
an expensive treatment for people to main-
tain.
Exercise, diet help to improve joint pain
While age is a major trigger for osteo-
arthritis, excessive weight can also trigger
this condition because it puts strain on the
joints. Pharmacists should encourage people
with osteoarthritis to exercise regularly and
maintain a healthy diet to help control their
weight.
Exercises which involve stretching,
strengthening and aerobics are essential to
maintain and restore joint movement, reduce
pain and stifness, improve muscle strength,
manage weight and increase energy and
wellbeing.
Feature | Pharmacy Today | November - December 2013 16 Aged Care
Elderly at risk of food-drug interactions
T
he more drugs people are on, the more
chances there are of interactions with
food, which may inhibit their vitamin
and mineral uptake, a professor of pharma-
ceutical nutrition says.
As the elderly tend to be on more medica-
tions, they tend to fall into the high-risk catego-
ry for drug and nutrition interactions, said Pro-
fessor Gil Hardy of the University of Auckland
School of Pharmacy, Auckland, New Zealand.
Around 50 percent of the elderly population
are on omeprazole and other protein-pump in-
hibitors, which can impair their absorption of
vitamins C, B12 and iron, Professor Hardy says.
Patients on these drugs can beneft from
supplements, including a B12 intramuscular
injection.
Proactive community pharmacists ought to
at least point out the possibility of interactions
to patients when they pick up their prescrip-
tions, although, as this is such a new area of
research, neither they nor GPs tend to be too
well versed in the subject, Hardy says.
Professor Hardy thinks pharmacists are
probably already suggesting supplements to
counteract interactions of some drugs with
food.
According to the New Zealand Nutrition
Foundation about 5 percent of older people
at home, 25 percent in acute and rehabilita-
tion hospitals and over 50 percent in nursing
homes are undernourished.
One of the ways to combat this is by ofer-
ing extra-fortifed drinks during the day, such
as Complan, Sustagen and Ensure, the founda-
tion says in a 14 June bulletin.
Old-age psychiatrist Dr Chris Perkins says
reasons elderly people may not be eating well
include living on their own, sufering from
dementia and forgeting to eat or how to cook,
not being able to get to the shops, not having
good teeth and being served uninspiring food
in some residential care.
Community pharmacists can help remind
their customers living in their own homes
to eat regularly by initiating a conversation
about food, Perkins says.
Evidence on the value of supplements for
elderly residential care patients is inconclu-
sive but, if supplements are used, it is impor-
tant, for adherence and absorption, to give
them at meal times.
Research into the impact of vitamins C, E,
B6, B12 and folate on reducing dementia has
produced some positive results, but the evi-
dence is inconsistent.
The more drugs people are on,
the more chances there are of interactions
with food, which may inhibit their
vitamin and mineral uptake
‘‘
Feature | Pharmacy Today | November - December 2013 17 Aged Care
U
se it or lose it. That moto can be ascribed
to many things – not least the health of
the aging human body and mind.
Keeping ft and active is recognised as the
best way to stay well as people age and the
idea has been incorporated into government
health policy.
The Singapore Ministry of Health has pub-
lished detailed guide lines recommending at
least 30 minutes of aerobic physical activity
fve days a week as well as fexibility, balance
and “resistance” activities.
Exercise can include any thing from walk-
ing to the shops and doing the vacuum ing to
bowls, t’ai chi and ball room dancing.
“It’s never too late to start becoming phys-
ically active,” Age Concern New Zealand
chief executive Ms. Ann Martin says.
“Whatever your age, regu lar activity will
improve your health, make you feel beter
and make it easier to do every day tasks.”
Staying active can help older people by:
increasing their strength to lif and carry gro-
ceries, improving fexibil ity to tie shoe laces,
wash hair or hang up washing, aiding bal-
ance to climb stairs or get on and of a bus or
simply giv ing them the energy to play with
grandchildren.
Other health benefts include: reducing the
risk of developing high blood pres sure, car-
diovascular disease, cancer, osteoporosis and
dia betes; easing the pain of arthri tis and oth-
er physical disabili ties, and improving sleep.
Exercise also benefts mental health
Exercise can also improve mood and
self esteem, while lowering stress levels
and reducing the risk of depression, Mar-
tin says.
“There are immediate and long- term ben-
efts – physically, mentally and socially. There
is also the beneft of helping to maintain in-
dependence in eve ryday living and broaden-
ing social networks, leading to new friends
and a sense of purpose.”
Even people who are cur rently the least
active are like ly to receive a boost from an in-
crease in activity.
“It is wise to start gently and build up
gradually. Finding something enjoyable at
a level that is comfortable is a good place to
start,” Martin says.
People with chronic health conditions
or injuries should discuss physical activity
options with their doctor frst, and anyone
who feels unwell or has pain during exercise
should stop immediately and seek medical
Active aging brings health benefits
Staying active while aging makes everyday tasks easier and improves health
overall.
It is wise to start gently
and build up gradually
‘‘
Feature | Pharmacy Today | November - December 2013 18 Aged Care
advice, she advises.
Some doctors or practice nurses may pre-
scribe a Green Prescription, which includes
advice on staying active.
Martin says Age Concern welcomes any
ini tiatives to encourage people to engage in
healthy physical activity as they age.
It’s never too late to make a diference
– geriatrician
Dr. John Scot is a geriatrician with Wait-
emata DHB, divid ing his time between North
Shore and Waitakere hospitals and outpatient
clinics in New Zealand.
Scot works with older people who are frail
and strug gling with the demands of daily life,
either because of their age or due to illnesses,
such as stroke or emphysema.Some exercise
programmes are tailored for the therapeu tic
needs of individual patients and then there
are programmes to encourage people to be
more active generally.
“The health benefts of exercise are enor-
mous,” Scot says. “It’s not just about being
stronger and being able to walk further with-
out fall ing over. There are also bene fts for
mental health, mood, digestion, cardiac func-
tion and lung function. A huge part is geting
people to maximize their function.
“There is no upper age limit. I see people
well into their nineties and even the odd cen-
tenarian. There is no point at which you stop
being able to derive a beneft.”
Scot believes society’s view on what it
means to be “old” is changing.
“Someone in their seventies doesn’t really
seem that old these days.”
Scot also encourages younger people to
become more active to insure their health in
older age.
“The trick is making it a habit – and fnding
something you enjoy,” he says.
Feature | Pharmacy Today | November - December 2013 19 Aged Care
By Rajesh Kumar
M
en and women with hypertension
were 1.3 times to 2.4 times less likely
to take their prescription medications
afer retirement, according to a study. Men, but
not women, with diabetes had the same rate of
medication non-adherence.
Poor adherence to prescription medication
is common and can afect the ability to man-
age hypertension and diabetes, two illnesses
linked with heart disease and death. Although
substantial research has been conducted on
factors that infuence medication adherence
such as patient demographics, physician and
pharmacist characteristics and other factors,
litle is known about the efects of life changes
on medication adherence.
Researchers from Finland, the United King-
dom and Sweden looked at the efect of retire-
ment on medication adherence in a cohort of
21,052 retired government employees in Fin-
land. They linked data on flled prescriptions
from national registers to each patient, follow-
ing them 3 years before retirement to 4 years
afer retirement. Of the 21,052 retirees, 3,468
people had hypertension and 412 had type 2
diabetes in the period before retirement. Me-
dian age at retirement was 61 years, and 75
percent women of the total 3,880 people were
women.
“For men and women with hypertension
and men with type 2 diabetes, retirement
was linked to 1.3- to 2.4-fold increases in
poor medication adherence,” said Professor
Mika Kivimäki of the Department of Epi-
Retired people less likely to take
medications for hypertension, diabetes
Loss of routine or believing poor health will improve can lend retirees to
stop medications.
demiology and Public Health at University
College London (UCL), London, UK.
“We saw no signifcant diference in this
adherence patern between age groups, socio-
economic strata or patients with and without
depression or co-morbid cardiovascular dis-
ease. These paterns suggest that our fnd-
ings were robust and not limited to a specifc
group.”
The researchers suggested several reasons
for the drop in taking medications. The per-
ception that poor health will get beter with re-
tirement, loss of a familiar daily routine or the
transition from workplace to non-workplace
health care in Finland could all be factors.
“These fndings suggest that retirement
may increase medication non-adherence, a
timely issue given that the proportion of peo-
ple aged 65 years or older is growing rapidly.
Further research is needed to determine the
generalizability of our fndings across mul-
tiple setings and in other populations,” the
authors concluded.
Business | Pharmacy Today | November - December 2013 20
Aslan raises US$22m to advance drug
development
By Rajesh Kumar
S
ingapore frm Aslan Pharmaceuticals
has raised US$22 million in the second
round of funding to advance its drug
development activities.
Aslan licenses preclinical and early clini-
cal compounds from global pharmaceutical
companies, focusing on oncology and in-
fammation diseases, and uses development
resources available across Asia to progress
the drugs through clinical development.
The company currently has three drugs in
the pipeline, including the lead compound
ASLAN001 a small-molecule pan-HER (hu-
man epidermal growth factor receptor) in-
hibitor licensed from Array BioPharma, US,
which is being developed for gastric cancer.
The drug candidate showed positive data in
a phase II study completed earlier this year.
ASLAN002 is a cMET inhibitor, licensed
from Bristol Myers Squibb, which is in phase
I trials for solid tumours. It is likely to enter
phase II clinical trials in 2014.
ASLAN003, licensed from Almirall, is a
novel potent and selective inhibitor of the
DHODH enzyme that could potentially be
a safer and more efective therapy than cur-
rent treatments for rheumatoid arthritis. It is
scheduled to enter a multiple ascending dose
phase I study in Singapore to assess its safety
profle, tolerability and pharmacokinetics.
The new money will not only fund the
ongoing clinical development of the above
drugs, but will also support the licensing of
additional compounds in 2013 and 2014, said
a company spokesperson.
The fnancing was led by Cenova Ventures
and included new investors, Morningside
Group of Hong Kong and XinChen Ventures
from Taiwan, in addition to existing inves-
tors BioVeda Capital of Singapore and Saga-
more Bioventures of the US.
“We are proud to have assembled such a
strong group of investors from China, Tai-
wan and the US that can support the devel-
opment of our portfolio through efcient and
high quality clinical centers in the region,”
said company chief executive Dr. Carl Firth.
“This round will allow us to complete at least
fve further studies and deliver robust proof
of concept data on several of our programs.”
The company was established in April 2010
by a group of industry experts – Dr. Firth,
Dr. Alan Barge, Dr. Mark McHale and Mr.
Jef Tomlinson. The following year, it raised
US$12m in a funding round led by Bioveda
and Sagamore, along with a number of pri-
vate investors. Its frst drug is likely to reach
the market in 2017.
Oncology and infammation diseases are the focus of the company's current
activities.
Business | Pharmacy Today | November - December 2013 21
Servier, SIgN team up to develop targeted
therapies
By Rajesh Kumar
F
rance’s largest pharmaceutical com-
pany Servier has entered into a re-
search collaboration with A*STAR’s
Singapore Immunology Network (SIgN) to
discover and develop targeted immunother-
apeutic drugs to tackle cancer and autoim-
mune disorders.
“SIgN’s strong expertise in translational
human immunology and Servier’s in-depth
knowledge in drug discovery and develop-
ment will push the frontiers of immunother-
apy for complex and difcult-to-treat dis-
eases,” said SIgN acting executive director
Associate Professor Laurent Rénia.
The two parties earlier collaborated under
similar public-private partnership in 2011 to
develop anti-cancer drugs that can suppress
tumor-initiating cells (TICs), also known as
cancer stem cells. Several human monoclonal
antibodies directed at restricting the growth
of TICs have since been generated for further
development into therapeutic antibodies.
The success of that frst collaborative proj-
ect prompted Servier to expand its partner-
ship with SIgN with three more research col-
laboration agreements. Neither Servier nor
SIgN have disclosed the fnancial details of ei-
ther the previous or the three new agreements
citing commercial sensitivities.
By expanding this partnership, the compa-
ny is expressing its goal to collaborate closely
with leading scientists worldwide, to discov-
er and develop innovative medicines, particu-
larly in the feld of cancer, said Servier Chief
Executive Dr. Jean-Philippe Seta.
“We believe that high quality of the re-
search done at the SIgN is a unique opportu-
nity to achieve this goal,” said Seta.
Incidentally, Servier recently entered into
a similar agreement with Shanghai Institute
of Materia Medica in Shanghai, China, to col-
laborate on the development of lucitanib, a
targeted antitumor drug candidate with anti-
angiogenic efects.
Neither Servier nor SIgN have
disclosed the fnancial details
of the agreements citing
commercial sensitivities
‘‘
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Infectious Disease in Pregnancy
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Your partner in paediatric and O&G practice NOV/DEC 2012 Vol. 38 No. 6 Your partner in paediatric and O&G practice
NowAccredited
For CME Points
by the Singapore Medical Council
See page iii for details
PAEDI ATRI CS
CME ARTI CLE
JOURNAL WATCH
OBSTETRI CS
NOV/DEC 2012 Vol. 38 No. 6 Your partner in paediatric
and O&G practice
NowAccredited
For CME Points
by the Singapore Medical Council
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Clinical Pharmacy | Pharmacy Today | November - December 2013 23
Introduction
In the South East Asian region in 2011,
there were 71.4 million people with diabetes,
representing 9.4 percent of the population.
Projections estimate that by 2030, this will
rise to 120.9 million – an increase of 69 per-
cent. [International Diabetes Federation. IDF
Diabetes Atlas. Fifh edition, 2012]
The defning feature of type 2 diabetes is
insulin resistance, where muscle and liver
cells become progressively less responsive to
the hormone’s efect. Initially the pancreas
responds by producing more insulin, but
eventually beta-cells become exhausted and
insulin production ceases. Normally insulin
stimulates the uptake of glucose into cells,
but in diabetes plasma glucose levels rise.
The consequence of elevated glucose levels
long term is damage to blood vessels. This
leads to complications, both microvascular
(eg, retinopathy, neuropathy) and macrovas-
cular (eg, myocardial infarction). Complica-
tions due to diabetes are a major cause of dis-
ability, reduced quality of life, and death.
Lifestyle modifcation – a healthy diet and
regular exercise – is the foundation of diabe-
tes management. As the disease progresses,
oral medication and eventually insulin injec-
tions become necessary to maintain plasma
glucose levels in a normal range. Several
classes of oral antidiabetic medications are
available. Metformin is the preferred frst-
line therapy, as it has a long-standing evi-
dence base for efcacy and safety, is inexpen-
Saxagliptin/metformin: Novel once-daily
oral antidiabetic drug combination for
type 2 diabetes
Drug Profile
Type 2 diabetes is a major cause of morbidity and mortality worldwide. It usually occurs in
adults but is increasingly seen in younger people. Lifestyle modifcation is the foundation
of diabetes management, but as the disease progresses patients eventually require treatment
with oral medications and eventually insulin injections. Several classes of oral antidiabetic
medications are now available, diferent combinations of which may be tried if frst-line
metformin monotherapy fails to control blood glucose. This report describes the burden of
diabetes and profles a novel once-daily oral antidiabetic drug combination – saxagliptin/
metformin.
Clinical Pharmacy | Pharmacy Today | November - December 2013 24
sive and may reduce risk of cardiovascular
events. [Diabetes Care 2013;36(Suppl 1):S11-
S66] When metformin fails to maintain con-
trol of plasma glucose levels, another agent
is added. Options include oral therapies
– sulfonylureas, thiazolidinediones, DPP-4
inhibitors – and injected GLP-1 receptor ago-
nists and insulin (available in a variety of for-
mulations). If a combination of two glucose-
lowering drugs is inefective, a third may be
added or the oral medications replaced by a
regimen of multiple daily doses of insulin.
[Diabetes Care 2012;35:1364-1379]
Saxagliptin/metformin
Pharmacology
Saxagliptin is a competitive dipeptidyl
peptidase-4 (DPP-4) inhibitor, a recently in-
troduced class of oral drugs for type 2 dia-
betes. It prevents the deactivation by DDP-4
of glucagon-like peptide-1 (GLP-1) and glu-
cose-dependent insulinotropic polypeptide.
These incretin hormones are secreted from
the gut in response to food intake and de-
crease postprandial glucose levels by stimu-
lating insulin secretion, inhibiting glucagon
secretion and delaying gastric emptying. [J
Pharmacol Pharmacother 2011;2:230-235]
Metformin is an insulin sensitizer. It is
thought to act by activating AMP-kinase to
decrease hepatic glucose production. [Diabe-
tes Care 2012;35:1364-1379]
Pharmacokinetics
Upon oral ingestion saxagliptin is rapidly
absorbed, with a bioavailability of around 67
percent. It is principally hydrolyzed by cyto-
chrome (CYP) 3A4/5. The major metabolite
(5-hydroxy saxagliptin) is also active, with
half the potency of saxagliptin. Peak plasma
concentrations of saxagliptin are reached
within 2 hours, and within 4 hours for the
major metabolite. Elimination is via both re-
nal and hepatic pathways, with 75 percent
excreted in the urine and 22 percent in the fe-
ces. None of the pharmacokinetic parameters
are afected by gender, body weight, age, or
race; however a dose reduction is required in
moderate to severe renal impairment. [Kom-
biglyze-XR Prescribing Information]
When metformin is taken in extended-
release formulation peak plasma concen-
trations are achieved in 4-8 hours (median
7). Absorption increases when taken with
food (ie, AUC); however there is no efect
upon peak plasma concentration or its tim-
ing. Metformin is excreted unchanged in the
urine. [Kombiglyze-XR Prescribing Informa-
tion]
Clinical efcacy
In clinical trials of up to 24 weeks’ duration,
saxagliptin monotherapy lowered HbA1c by
0.4 to 0.9 percent. When used together with
metformin, HbA1c is reduced by up to 2.53
percent. The saxagliptin/metformin combi-
nation has been shown to be efective in both
treatment-naïve patients as well as in those
inadequately controlled by metformin alone.
[J Pharmacol Pharmacother 2011;2:230-235] A
long-term study over 52 weeks showed that
saxagliptin/metformin was non-inferior to a
glipizide/metformin combination while less
likely to cause weight gain or hypoglycemia.
[Int J Clin Pract 2010;64:1619-1631]
Adverse efects
While the long-term safety profle of sax-
agliptin remains to be determined, typical
adverse events include infections (respira-
tory and urinary tract) and headache. Ad-
verse events atributable to metformin are
Clinical Pharmacy | Pharmacy Today | November - December 2013 25
predominantly gastrointestinal, including
diarrhea, nausea and vomiting. [Kombig-
lyze-XR Prescribing Information] Important-
ly, there is no change in body weight with
the combination of saxagliptin plus metfor-
min. [NPS Radar February 2013. Sitagliptin,
vildagliptin and saxagliptin — dipeptidyl
peptidase-4 inhibitors (‘gliptins’) for add-on
therapy in type 2 diabetes mellitus. Website:
www.nps.org.au] This is signifcant given that
overweight/obesity has deleterious efects
on plasma glucose control in type 2 diabe-
tes. There is also a low risk of hypoglycemia
with saxagliptin either as monotherapy or in
combination with metformin.
The US regulatory authorities require that
the cardiovascular (CV) risk associated with
new antidiabetic drugs must be estimated.
To satisfy this requirement, a meta-analysis
of phase II and phase III trials of saxagliptin
was undertaken. No evidence of an in-
creased CV risk was found. On the contrary,
saxagliptin was associated with benefcial
changes to CV risk factors (blood pressure,
lipid profle, body weight), suggesting that
saxagliptin may in fact reduce the risk of ma-
jor adverse CV events. [Cardiovascular Diabe-
tol 2012:11:6]
Dosing
In patients with type 2 diabetes, the rec-
ommended dose of saxagliptin is either 2.5
or 5 mg/day. The commercially available for-
mulation combining saxagliptin with met-
formin extended-release (Kombiglyze-XR) is
available in strengths of 5 mg saxagliptin /
500 mg metformin, 5 mg saxagliptin / 1,000
mg metformin, and 2.5 mg saxagliptin / 1,000
mg metformin. One combination pill should
be taken daily with the evening meal. The
starting dose should be individualized based
on the patient’s current regimen, with the
dosage then adjusted according to efective-
ness and tolerability.
In patients also taking a strong inhibitor
of CYP3A4/5 (eg, ketoconazole, atazanavir,
clarithromycin, indinavir, itraconazole, ne-
fazodone, nelfnavir, ritonavir, saquinavir or
telithromycin) the dosage should be limited
to 2.5 mg saxagliptin / 1,000 mg metformin
once daily.
Place within guidelines
The recent Position Statement of the
American Diabetes Association (ADA) and
the European Association for the Study of
Diabetes (EASD) recommends that glucose
targets and medications should be individ-
ualized to the particular patient. Lifestyle
interventions, including diet, exercise and
education, are the foundation of any man-
agement strategy for type 2 diabetes. The
optimal choice for frst-line therapy is met-
formin (unless contraindications are pres-
ent). [Diabetes Care 2012;35:1364-1379] Type
2 diabetes is a progressive chronic disease
and frequently additional medications are
required to maintain control of plasma glu-
cose levels. [Diabetes Care 2012;35:1364-1379]
There are few data to guide the choices of
second- and third-line therapies; however it
is important to minimize side efects where
possible. [Diabetes Care 2012;35:1364-1379]
Patients frequently prefer oral to injectable
therapies, and given the favorable profle
of DPP-4 inhibitors with respect to weight
gain and risk of hypoglycemia, novel combi-
nations such as saxagliptin/metformin may
be an optimal choice for a wide range of pa-
tients.
Clinical Pharmacy | Pharmacy Today | November - December 2013 26
Teriparatide, denosumab combo better
at improving BMD
By Rajesh Kumar
A
combination of teriparatide and de-
nosumab might be more efective
than either agent alone at increasing
bone mineral density (BMD) in postmeno-
pausal women at high risk of fractures, ac-
cording to a randomized controlled trial.
Some therapies licensed to treat osteoporo-
sis work by inhibiting bone turnover (anticat-
abolic agents) and others by stimulating bone
formation (anabolic agents) to increase BMD.
These therapies lower but don’t complete-
ly eliminate fracture risk. The researchers
found that combining the anticatabolic drug
denosumab and anabolic drug teriparatide
increased BMD more than either agent on its
own, and more than what has been reported
with other approved therapies. [Lancet 2013;
doi:10.1016/S0140-6736(13)60856-9]
They enrolled 100 postmenopausal women
with osteoporosis between September, 2009
and January, 2011and assigned them in a 1:1:1
ratio to receive 20 µg teriparatide daily, 60 mg
denosumab every 6 months, or both. BMD
was measured at baseline and 3, 6, and 12
months. Of them, 94 women who completed
at least one study visit afer baseline were as-
sessed in a modifed intention-to-treat analy-
sis.
At 12 months, posterior-anterior lumbar
spine BMD increased more in the combina-
tion group (9.1%, [SD 3.9]) than in the teripa-
ratide (6.2% [4.6], p=0.0139) or denosumab
(5.5% [3.3], p=0.0005) groups.
Femoral-neck BMD also increased more
in the combination group (4·.2% [3.0]) than
in the teriparatide (0·8% [4.1], p=0.0007) and
denosumab (2.1% [3.8], p=0.0238) groups, as
did total-hip BMD (combination, 4.9% [2.9];
teriparatide, 0.7% [2.7], p<0.0001; denosumab
2.5% [2.6], p=0·0011).
“Our fndings are in contrast to those of
previous trials that assessed the efect of
bisphosphonates combined with teripara-
tide or parathyroid hormone (PTH). In ran-
domised controlled trials of postmenopausal
women who received alendronic acid and
teriparatide or PTH for various durations, ef-
fcacy did not difer between the combination-
therapy and individual-therapy groups,” said
the researchers Dr. Joy Tsai and Dr. Alexander
Uihlein of the endocrine unit at Massachusets
General Hospital, Boston, Massachusets, US,
and colleagues.
“Similarly, combined teriparatide and zole-
dronic acid given for 12 months was not as-
sociated with beter results than each drug
individually. In a study in which alendronic
acid was added to previously started teripara-
tide therapy, however, the results were more
promising.”
Combined teriparatide and denosumab reduced the risk of esteoporosis-
related fractures beter than either drug alone.
Clinical Pharmacy | Pharmacy Today | November - December 2013 27
Although more studies are needed to as-
sess reductions in fracture risk and to explore
the efects of diferent doses and durations of
treatment, the researchers said their results
suggested that this specifc combination of
drugs could be a useful option in the treat-
ment of patients with osteoporosis at espe-
cially high risk of fracture.
In an accompanying commentary, Drs
Richard Eastell and Jennifer Walsh of the aca-
demic unit of bone metabolism at the North-
ern General Hospital in Shefeld, UK, said
the fndings provide proof of concept for the
additive efect of the combined therapy, but
its safety needs to be confrmed and the re-
duction in fracture risk needs to be quantifed
so that cost-efectiveness can be assessed.
Also, what will happen when teriparatide
is stopped since the current license only sup-
ports its use for a maximum of 24 months,
the commentators asked. [Lancet 2013;
doi:10.1016/S0140-6736(13)60984-8]
Pharmacologic interventions for
ankylosing spondylitis
By Elvira Manzano
A
nkylosing spondylitis (AS), a form of
arthritis that starts in young adults, is
a chronic progressive condition for which
there is currently no cure. In Singapore, about
5,000-10,000 people sufer from AS, which af-
fects both spinal and peripheral joints.
Chronic back pain may not be the frst
manifestation of the disease, said Dr. Lui Nai
Lee, consultant rheumatologist at the Singa-
pore General Hospital (SGH). Occasionally,
peripheral joint pain or extra-articular mani-
festations such as anterior uveitis, psoriasis,
infammatory bowel disease and dactylitis
may be the presenting symptoms.
In the advanced stages, patients develop
butock atrophy, loss of lumbar lordosis, and
thoracic kyphosis, with a stooped forward
neck or a question mark posture. The condi-
tion afects men two to three times more com-
monly than women.
NSAIDs frst line-treatment for AS
Regular physiotherapy (ie, supervised ex-
ercises) and education are the cornerstone of
non-pharmacological treatments for AS. Non-
steroidal anti-infammatory drugs (NSAIDs),
including coxibs, are the recommended frst-
line drugs.
About 75 percent of patients respond to
NSAIDs, 20 to 50 percent nevertheless remain
on active disease while on treatment. Those
with persistently active, symptomatic dis-
ease may require continuous treatment with
AS treatment is the key in high-risk, rapidly declining patient.
Clinical Pharmacy | Pharmacy Today | November - December 2013 28
NSAIDs to control their symptoms (pain and
stifness). Long-term use of NSAIDs however
can cause serious side efects, Lui warned.
“Cardiovascular and gastrointestinal risks
should be taken into account when prescrib-
ing NSAIDs. This is because NSAIDs, in time,
can cause heart burn, gastritis, ulcers and
bleeding.” He added patients, particularly
those who self-medicate, use non-prescrip-
tion NSAIDs beyond the recommended dos-
age, or those at high-risk for NSAID-toxicity
should be made aware of this. Physicians and
pharmacists have a role to play, he added.
Other pharmacologic options
Corticosteroid injections to the local site of
musculoskeletal infammation may be con-
sidered, said rheumatology professor Robert
Landewé from the Academic Medical Center,
University of Amsterdam, the Netherlands,
who was in Singapore for a short visit.
“For axial disease, the use of systemic
corticosteroids and disease modifying anti-
rheumatic drugs (DMARDs), including sul-
fasalazine and methotrexate, is not supported
by evidence.” Possible side efects with the
drugs include nausea, diarrhea, increased
risk of infections, liver damage, lung damage,
and bleeding. Sulfasalazine, however, may
be considered in patients with peripheral ar-
thritis.
For patients with persistently high-disease
activity despite conventional treatments, bio-
logics such as anti- tumour necrosis factor
therapy (ie, adalimumab, etanercept, infix-
imab and golimumab) should be given, he
said. Biologics are given as a subcutaneous
injection or as an intravenous injection over a
period of time. Response should be assessed
at least 12 weeks of treatment, Landewé add-
ed.
Adalimumab has been shown to be efec-
tive in reducing signs and symptoms of AS
and infammation (as shown by MRI), im-
proving work productivity and quality of life,
with positive efects on bone mineral density
and concomitant diseases. [Ann Rheum Dis
2008;67:1218-1221]
“As for patients with axial disease, there is
no evidence to the obligatory use of DMARDs
prior to or concomitant with anti-TNF thera-
py,” said Landewé.
Considerations for taking TNF-blockers
Lui’s message to physicians: “TNF-block-
ers can potentially cause a fare-up of tuber-
culosis (TB). Hence, patients are routinely
screened for past history of TB prior to start-
ing therapy. Patients on this medication also
have an increased risk for serious infections.”
Those with infammatory back pain, but not
mechanical low back pain, should be treated
with long term NSAIDs because of NSAID’s
good efcacy record for acute symptoms and
potential to retard long-term damage. Pa-
tients with active disease despite treatment
with NSAIDs may be put on TNF-blocking
agents, he added.
At the Autoimmunity and Rheumatology
Centre, Singapore General Hospital (SGH),
where Lui is consultant rheumatologist, ma-
jority of patients diagnosed with AS, are on
long-term NSAIDs, 10 percent need biologic
therapy, while six patients do not require any
pharmacological treatment. Eighty-percent
of those with AS are ethnic Chinese, 6 per-
cent and 4 percent are Indians and Malays,
respectively.
People respond to diferent medications
with varying levels of efectiveness. At the end
of the day, efective early treatment should
focus on patients with high disease activity
and those who are likely to have radiologi-
cal progression and rapid functional decline
during the natural course of AS, both experts
said.
Clinical Pharmacy | Pharmacy Today | November - December 2013 29
Microencapsulation key to uniform drug
release
M
icrocapsules containing brain tu-
mor drug may simplify treatment
and provide more tightly con-
trolled therapy for the disease, according to
research. [Adv. Mater. 2013;25: 4529]
“Brain tumors are one of the world’s deadli-
est diseases,” said researcher Mr. Mohammad
Reza Abidian, assistant professor of bioengi-
neering, chemical engineering and materials
science and engineering at Penn State Univer-
sity in Pennsylvania, US. “Typically doctors
resect the tumors, do radiation therapy and
then chemotherapy.”
The majority of chemotherapy is done in-
travenously. But the drugs are very toxic and
are not targeted, resulting in a lot of side ef-
fects. Another problem with intravenous
drugs is that they go everywhere in the blood-
stream and do not easily cross the blood brain
barrier so litle gets to the target tumors. To
counteract this, high doses are necessary.
“We are trying to develop a new method
of drug delivery,” said Abidian. “Not intrave-
nous delivery, but localized directly into the
tumor site.”
Current treatment already includes leav-
ing wafers infused with the anti-tumor agent
BCNU in the brain afer surgery, but when
the drugs in these wafers run out, repeating
invasive placement is not generally recom-
mended.
“BCNU has a half-life in the body of 15
minutes,” said Abidian. “The drug needs pro-
tection because of the short half-life. Encap-
sulation inside biodegradable polymers can
solve that problem.”
Encapsulation of BCNU in microspheres
has been tried before, but the resulting prod-
uct did not have uniform size and drug distri-
bution or high drug-encapsulation efciency.
With uniform spheres, manufacturers can
design the microcapsules to precisely control
the time of drug release by altering polymer
composition. The tiny spheres are also inject-
able through the skull, obviating the need for
more surgery.
The researchers looked at using an electro-
jeting technique to encapsulate BCNU in poly
(lactic-co-glycolic) acid, an approved biode-
gradable polymer. In electrojeting, a solution
containing the polymer, drug and a solvent are
rapidly ejected through a tiny nozzle with the
system under a voltage as high as 20 kilovolts
but with only microamperage. The solvent in
A scanning electron micrograph of BCNU loaded microspheres (black and
white background) with 3D rendered images of brain cancers cells (yellow)
and released BCNU (purple).
P
h
o
t
o

c
r
e
d
i
t
:

M
o
h
a
m
m
a
d

R
e
z
a

A
b
i
d
i
a
n
.

We are trying to develop a
new method of drug delivery
‘‘
Clinical Pharmacy | Pharmacy Today | November - December 2013 30
the liquid quickly evaporates leaving behind
anything from a perfect sphere to a fber.
“Electrojeting is a low cost, versatile ap-
proach,” said Abidian. “We can produce
drug-loaded micro/nano-spheres and fbers
with same size, high drug-loading capacity
and high drug-encapsulation efciency.”
The researchers tested solutions of poly-
mer from 1 percent by weight to 10 percent by
weight and found that at 1 to 2 percent they
obtained fatened microspheres, at 3 to 4 per-
cent they had microspheres, at 4 to 6 percent
they had microspheres and microfbers, at 7
to 8 percent they had beaded microfbers and
above 8 percent they obtained only fbers.
“Depending on the desired applications,
all the shapes are useful except for the beaded
fbers,” said Abidian. “While fbers are not
good for drug delivery, they are good for tis-
sue engineering applications.”
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After Hours | Pharmacy Today | November - December 2013 32
TIMOR LESTE:
A PATH LESS TRODDEN
P
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By Rajesh Kumar
T
he small beach facing the deep blue
Banda sea in Baucau, north eastern
part of Timor Leste, is arguably one of
the most unspoilt beaches in Asia.
Its vernacular name, Imia-Mata Bundura,
literally means powdery white sand beach
and it delivers on what it promises. Then
some. Crystal clear waters, thriving coral beds
kissing the shoreline, awe inspiring views
and star-saturated night skies. Above all, no
throng of tourists. For now, at least.
For intrepid travelers always on the look-
out for a path less trodden, Timor Leste may
well be the next big fx. As the country re-
turns to peace afer decades of violence and
destruction and slowly builds its economy,
the government is hoping its unspoilt beach-
es like Imia-Mata Bundura, natural beauty,
abundant marine life and great diving and
hiking spots would atract enough visitors to
kick start its tourism sector.
Located between Indonesia and Australia,
Timor Leste is part of the Coral Triangle (in-
cluding tropical marine waters of Indonesia,
Malaysia, Papua New Guinea, Philippines
and Solomon Islands) that contains hundreds
of species of reef building corals.
The sheer diversity of marine life in the
region has earned it the nickname “Amazon
of the seas.” For this very reason, Atauro and
Jaco islands are fast becoming popular with
die hard divers looking for exotic locales.
“Just four days ago, we had three adult blue
whales coming through the lagoon. Nowhere
else in the world can you see them this close
to the shore,” said Mr. Kevin Austin, chief ex-
ecutive of Sustainable Marine Industry Devel-
opment Facility that runs Baucau Beaches, a
tourism project to help the impoverished lo-
cal community with high unemployment.
“Most of the time, we spot green turtles,
sharks, reef sharks, and occasionally manta
rays,” Austin told me and other visiting media
persons.
That aside, the World War II era Japanese
bomb shelters in Venilale, Lekirika Mana sta-
lactites/stalagmites cave system high in the
eastern tropical forests and remnants of the
After Hours | Pharmacy Today | November - December 2013 33
centuries of Portugese colonial rule add just
a dash of history to what, for us, was quite
an adventurous voyage into the unspoilt un-
knowns.
We were told that Lekirika Mana cave was
used as a shelter by rebel forces hiding from
the Indonesian military during the later’s
brutal occupation of Timor Leste soon afer
the Portugese lef in 1975. The occupation
continued until the country’s self determina-
tion in 1999, followed by UN administration
until December 2012.
In the capital city Dili, the Jesus Statue
(Cristorae) located atop Cape Fatucama on
the eastern tip, Cathedral of Immaculate Con-
ception and the Presidential Palace seemed
popular with domestic and international visi-
tors alike.
About 8 kilometers west of Dili lie Tasitolu
Wetlands, a protected area comprising three
salt lakes, an esplanade, and a beach. The area
was designated Tasitolu Peace Park in 2002
due of its cultural and historical signifcance.
Tasitolu is notorious as the site where Indo-
nesian soldiers allegedly killed and dumped
many young rebels during the country’s
bloody independence struggle.
Nearby is Pope John Paul II monument
that commemorates the pontif’s visit to the
country in 1989, during the Indonesian oc-
cupation. The catholic country of 1.2 million
proud, friendly people comprises the eastern
half of the island of Timor the nearby islands
of Atauro and Jaco, and Oecusse, an exclave
on the northwestern side of the island within
Indonesian West Timor. The two halves were
occupied by the Dutch and the Portuguese
respectively, the Dutch half now with Indo-
nesia.
Timor Leste has embarked on a slow and
painful path to progress, thanks to money
from its oil and natural gas bounty. But it is
proving to be a long and arduous journey.
In its eforts to atract tourists, Timor Leste
will not emulate Bali with its night clubs, neon
signs and unchecked urban sprawl. Instead,
the focus will be on sustainable eco-tourism
with particular regard for the fragile envi-
ronment, the country’s tourism minister said.
One can only hope so.
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Hon. Editorial Advisory Board
Associate Professor Chui Wai Keung
Head of Department of Pharmacy, Faculty of Science,
National University of Singapore (NUS)
Assistant Professor Lita Chew
Chief Pharmacist, Ministry of Health, Singapore
Registrar, Singapore Pharmacy Council
Head, Pharmacy Department, National Cancer Centre Singapore
Assistant Professor, Department of Pharmacy, NUS
Associate Professor Alexandre Chan
Department of Pharmacy, NUS
Associate Consultant Clinical Pharmacist, Department of Pharmacy, National
Cancer Center Singapore.
Dr. Joyce Yu-Chia Lee
Assistant Professor of Clinical Pharmacy, Department of Pharmacy, NUS
Principal Clinical Pharmacist, National Healthcare Group Polyclinics