GUIDELINES FOR USING PANTOPRAZOLE HUSM

Mucosal break
lesion Upper GIT bleed

Treatment

Prophylatic/suspected

Upper GIT bleed confirm

IV Pantoprazole 40 mg BD

Chronic
Acute

IV Pantoprazole 80 mg stat then T. Pantoprazole 40 mg BD 6/52

IV Pantoprazole 80 mg/hour for 72 hour then
IV Pantoprazole 40 mg BD for 7/7 then
T. Pantoprazole 40 mg BD 6/52

OGDS

If not properly heal

Maintenance T. Pantoprazole 40 mg OD - 3-6/12 therapy

1
 FLOW CHART USAGE OF PPI IN HUSM
ENDOSCOPY MEETING ON 4/10/07

Bleeding cases (Non variceal bleed)

1st Endoscopic procedure, then

2nd Proton pump inhibitor, then
3rd Mucosal protective therapy, then
4th I/V Somatostatin analog 25 mg/hr 1 kg, then
5th Surgival intervention

PPI

1st line I/V Pantoprazole 80 mg stat, then

I/V Pantoprazole 8 mg/hr for 3 5/7, then
I/V Pantoprazole 40 mg BD

Follow-up by t.Pantoprazole 40 mg BD 8 12/52 and to repeat endoscopy if

rebleed or after complete treatment.

I/V Esomeprazole can be used as second choice.

Mucosal break lesion (Prophylaxis)

1st line I/V Esomeprazole 40 mg BD or

2nd line I/V Pantoprazole 40 mg BD or
3rd line I/V Ranitidine or Tablet
4th line Mucosal protection agent (Sulcalfate)

Peptic Ulser disease (PUD)

1st line Tab. Lansoprazole 30 mg OD/BD, then

2nd line Tab. Esomeprazole 40 mg OD/BD, then
3rd line Tab. Pantoprazole 40 mg OD/BD, then
4th line Tab. Rabeprazole 20 mg OD/BD, then
5th line Tab. Omeprazole 40 mg OD/BD, then
6th line Tab. Ranitidine 150 mg OD/BD, then
7th line Tab. Cimetidine 300 g OD

2
In cases of PUD (No. OGDS) (No. PPI test)

T. Ganaton 50 mg BD/TDS with

1st line T. Lansoprazole 30 mg OD/BD

2nd line T. Esomeprazole 40 mg OD/BD

If not improve after 2/52 refer results endoscopy investigation (Gastro/Surgical)

In cases of no OGDS for PPI test

1st line T. Lansoprazole 30 mg BD 2/52 then decision OR

2nd line T. Esomeprazole 40 mg BD 2/52 then decision.

In Cases of Biliary gastritis/recurrent GERD/GERD (Gastrooesophageal disease)

1) T. Ganaton 50 mg BD/TDS with } 1st line

T. Esomeprazole 40 mg BD/TDS }

2) T. Ganaton 50 mg BD/TDS with } 2 nd line

T. Rabeprazole 20 mg BD }

In Cases of PUD with normal OGDS/NERD (non erosive gastritis)

T. Ganaton 50 mg BD/TDS WITH

1st line Esomeprazole 40 mg OD/BD

2 nd line T. Lansoprazole 30 mg OD/BDs

3 rd line T. Pantoprazole 40 mg OD/BD

4th line T. Rabeprazole 20 mg OD/BD

3
 LIPID LOWERING THERAPY
USM GUIDELINES

Indications for use

1. Coronary heart disease (CHD)

2. CHD disease equivalent
a) Diabetes Mellitus
b) Carotid artery disease
c) Peripheral artery disease
d) Abdominal aortic aneurysm
3. Familial hyperlipidaemia (or total chol > 8, LDL chol > 6)
4. CHD high risk individuals
a) Individuals with 2 or more risk factors
5. CHD low risk
a) Individuals with less than 2 risk factors
6. If asymptomatic but total cholesterol 5.0 mmol/l, LDL cholesterol 3.0
mmol/l and total CVD risk of projected CVD risk at 60 years of age is 5%.
7. Others
a) Individuals with chronic renal disease (Creatinine > 133 umol/L or
GFR < 60 ml/min/1.73 m2)
b) Metabolic syndrome

Drug Dose range LDL reduction Cost for 1/12 rx

( mg ) RM
Pravastatin 10 - 40 19 40 %
Simvastatin 10 - 80 28 - 48 %
Lovastatin 20 - 80 29 48 %
Atorvastatin 10 - 80 38 54 %
Rosuvastatin 10 - 40 52 63 %

4
 Indications 1-4

Aggressive lipid lowering therapy required

High dose and high potency drug required
Suggestion

1. Coronary heart disease (CHD)

2. CHD disease equivalent
i) Diabetes Mellitus
ii) Carotid artery disease
iii) Peripheral artery disease
iv) Abdominal aortic aneurysm
3. Familial hyperlipidaemia (or total chol > 8, LDL, chol >6)
4. CHD high risk individuals- Individuals with 2 or more

Check FLP

Start atorvastatin
10 20 mg od TLC

Check FLP after

3/12

Total C > 4.5 or Total C < 4.5 or

LDL > 2.5 LDL < 2.5

Intensification of Rx Continue medication or

Increase dose of consider de-escalation of Rx
Atovarstatin or change TLC ie change to Simvastatin or
to Rosuvastatin Pravastatin as per indicated

TLC = Therapeutic lifestyle changes

5
 Indications 5-7:

Lipid lowering therapy can be step wise intensification

Suggestions

1. CHD low risk

a) Individuals with less than 2 risk factors
2. If asymptomatic but total cholesterol 5.0 mmol/l, LDL cholesterol 3.0
mmol/l and total CVD risk of projected CVD risk at 60 years of age is 5 %.
3. Others
a) Individuals with chronic renal disease
(Creatinine > 1.33 umol/L or GFR < 60 ml/min/1.73 m2)
b) Metabolic syndrome

Total chol

Risk score: 10 year risk for CV death

Total risk <5 % Total risk 5 %

TLC FLP
Includes:
T chol/ LDL/HDL
Total chol < 5.0
LDL chol < 3.0
TLC for 3/12

FLP
F/ up 5 yearly Includes :
T chol/LDL/HDL

Total chol ,5.0 Total chol > 5.0

LDL chol < 3.0 LDL chol > 3.0

Continue TLC Continue TLC

TLC = Therapeutic
lifestyle changes Reassess risk yearly
Start drug
therapy
If risk 5 % and
Total chol < 4.5 and
LDL chol < 2 5

Consider drug
therapy

6
 Drug therapy indicated

Total chol 5.0 5.9 Total chol 6.0 6.9 Total chol 7.0
LDL chol 2.5 3.5 LDL chol 3.5- 4.5 LDL chol 4.5

Pravastatin or Simvastatin or Atorvatatin or

simvastatin atorvastatin rosuvastatin

If targets not achieved : Total chol > 4.5 or LDL > 2.5
CHECK COMPLIANCE TO TLC AND DRUG THERAPY
Consider intensifying treatment

Combination therapy
Simvastatin
Ezetimide Atorvastatin
Or Or
Atorvastatin Rosuvastatin
Or And or
Rosuvastatin Ezetimibe
And or
Fibrates etc

Prepared by Dr Tee Meng Hun & AP Dr Zulkurnai Yusof, Med Dept

7
 Indication of Using Amlodipine (and Felodipine) in HUSM (suggestion)

1. Introduction

Calcium channel blockers work by blocking the initial calcium influx into myocytes
and vascular smooth muscle cells. Amlodipine and felodipine are long acting second
generation dihydropyridine that have vascular smooth muscle relaxing activity with
no or minimal negative inotropic effects. They have a greater selectivity for vascular
smooth muscle compared to the myocardium. They vasodilate coronary arteries
reduce coronary resistance, increase coronary blood flow and may enhance the
development of coronary collaterals.

2.Indication of using calcium channel blocker (CCB)

2a. The use of CCB as anti-ischemic agent

-calcium channel blocker has been shown to exert anti-angina properties in various
ways such as reduction in heart rate, reduction in contractility, reduction in afterload
and direct vasodilatation.
-calcium channel blocker should be considered if there are contraindications or
adverse reactions to either beta blockers of nitrates or if symptoms are not well
controlled with a combination of these agents.

2b.The use in acute coronary syndrome (ACS) patients.

- The potential benefits of either amlodipine or felodipine in acute MI has not

been examined directly.
- Amlodipine is often used in patients with acute MI when hypertension is not
adequately controlled by other therapy of proven benefit (beta blockers and ACE
inhibitors ).
- Study in stable coronary heart disease (PREVENT trial) found no or little
benefit of amlodipine but also has no harm.
- Therefore amlodipine is not indicated as first line therapy on ACS patients
unlike ACE inhibitors and beta blockers.

2c. The use of CCB in patients with heart failure

- The potential benefit of either amlodipine or felodipine in acute MI has not

been examined directly. However, clinical trial that have evaluated these drugs in
heart failure (V- HeFT III and the PRAISE trials) found no or little benefit but also no
harm.
- In patient with heart failure, amlodipine in at a drug choice as compared to
ACE inhibitors, beta blockers and aldosterone antagonist.

8
2d.The use of CCB in hypertension patients.

- Although recommendations for initiating medical therapy in essential

hypertension have been proposed, there is no uniform agreement on which
antihypertensive agent should be given as initial therapy. A variety of different classes
of drugs can be used in this setting. These include the thiazide diuretics, beta blockers,
angiotensin converting enzyme (ACE) inhibitors, angiotensin II receptor blockers and
calcium channel blockers.
- There have been limited data as to whether different antihypertensive drugs
have variable effects upon patient outcomes, particularly cardiovascular morbidity
and mortality. However, an increasing number of trials have provided evidence that at
the same level of blood pressure control, most antihypertensive drugs provide the
same degree of cardiovascular protection provided there are no other compelling
indications.
- The choice of drug should be based on the patients individual risk profile and
the tolerability of the drugs.
- First-line drugs should have the following properties :
1. reduce long-term morbidity and mortality
2. high efficacy of once-daily administration
3. no adverse effects on concomitant risk factor
4. good tolerability

- based on JNC VII guidelines, hypertensive nave patient should receive

diuretics as first line drug.

2e. The use of CCB in anti-arrythmic agents

-the use of amlodipine as anti- arrythmic agents therapy was not well studied unlike
verapamil and diltiazem, therefore it is not recommended as anti-arrythmic therapy.

2f. The use of CCB in patients with renal disease/nephropathy

- Hypertension is common in chronic renal disease and is risk factor for

progression of renal damage, and reduction of blood pressure (BP) is an efficient way
of preventing or slowing the progression of this damage. BP lowering effects are
common to all antihypertensive drugs, but intra-renal effects differ between classes
and between individual drugs within certain classes. Angiotensin converting
enzyme (ACE) inhibitors and angiotensin receptors blockers (ARB) have beneficial
effects on proteinuria and declining renal function that appear to be mediated by
factors additional to their effects on BP. These RAS inhibitors are recommended as
first-line antihypertensive approach in patients with chronic kidney disease.
- Calcium channel antagonist are highly a heterogenous class of compounds,
and it appears that some agents are more suitable for use in patients with chronic renal
disease than others. Most common calcium channel blockers are nondihydropyridine
group like verapamil and diltiazem.
- Dihydropyridine calcium channel blockers (eg nifedipine and amlodipine)
may worsen proteinuria and accelerate the progression of disease in patients with
nondiabetic or diabetic nephropathy.

9
2g. The use of CCB in peripheral vascular disease (PVD) patient.

- Unlike verapamil, the use of amlodipine and felodipine in treating peripheral

vascular disease patients are not well studied. Therefore, it is not
recommended to use these drugs to treat PVD patients.

2h. The use of CCB in Pulmonary Artery Hypertension patients.

- The oral vasodilators of choice are the calcium channel blockers nifedipine
and diltiazem. Verapamil is not recommended, since it tends to posses
significant negative inotropic properties.
- Amlodipine has been a useful alternative for patients who are intolerant of the
other agents (eg. Because of edema, bradycardia, tachycardia, or hypotension)
- The use of Felodipine in pulmonary artery hypertension is not well studied.

3. Advantages of Amlodipine (and felodipine) above other antihypertensive.

3a.Single daily dose, therefore this will improve patient compliance.

3b. No need for renal function monitoring.
3c. Among the least side effects compared to other anti-hypertensive.
3d. In comparison between amlodipine and felodipine, on of the retrospective study
has shown that amlodipine has better patients adherence compared to felodipine.

4. Disadvantages of CCB above other antihypertensive.

4a. The potential benefit of either amlodipine or felodipine in ACS has not been
examined directly in ACS patients. A systematic analysis of all randomized calcium
blocker trials in unstable angina suggests calcium channel blockers that as a class do
not prevent the development of acute myocardial infarction or reduce mortality, and it
also has no harm to these group of patients.
4b. Short-acting CCB (i.e. Nifedipine) has a relatively high incidence of adverse side
effects, including peripheral edema (not related to heart failure), flushing, headaches,
and lightheadedness, which is due to peripheral vasodilatation.
4c. There was a study (cross sectional) showed that there was a higher rate of
depression among hypertensive patients who were on calcium channel blocker as
compared to other anti-hypertensive.
4d. Both amlodipine and felodipine are long acting calcium channel blockers,
therefore it is not recommended as first line therapy for hypertensive urgency.

10
List of Tables

Table 1 Comparative pharmacokinetics of selected dihydropyridine calcium channel

antagonists

Nifedipine Nisoldipine Felodipine Amlodipine Diodipine

Oral absorption >90 >90 >90 >90 >90
Oral 30-50 5-15 10-25 60-65 5-15
bioavailability
Elimination 3-5 4-10 2-8 35-50 3-15
half-life

Table-Dosing and costs of the Calcium Channel Blockers

Drug Initial Dose Usual Dosage Range Cost x 30 days

Verapamil
- regular (Isoptia generic) 80mg TID 80-160 mg TID $37.33-$68.15
- long acting (Isoptin SR) 180 mg 120 mg daily-240mg $37.52-$99.94
(Varelan) daily BID $32.87-$85.92
180 mg 120-480 mg daily
daily
Diltiazem
- regular (Cardizem 30mg TID 30mg TID-90 mg QID $28.51- $83.61
generic) 60 mg BID 60-80 mg BID $51.63- $126.31**
- long acting (Cardizem 120 mg 120 mg-300mg daily $47.12- $95.89
SR)** daily
(Cardizem

CD )
Felodipine (Plendil, 5mg daily 2.5-20 mg daily $23.13-$83.61
Renedil)
Nifedipine
- regular capsules 10mg TID 10mg TID-30 mg QID $27.25-$89.52
(Adalatgeneric) 10 mg BID 10-40mg BID $37.90-$104.72**
- long acting (Adalat PA)** 30 mg daily 30-120 mg daily $37.81-$104.72
(Adalt XL) 5 mg daily 5-10 mg daily $46.14-$65.34
Amlodipine (Norvasc) 10mg TID 20-40 mg TID $62.04-$117.58
Nicardipine (Cardene)
**Base on wholesale acquisition cost Feb. 1995 of least expensive product and professional
fee of $6.50 as April 1, 1995. Pharmcare no longer covers Cardizem SR and Adalat PA

11
5. References

1. Antiischemic Agents in the Management of Unstable Angina and Acute Non-

ST Elevation (Non-Q Wave) Myocardial Infarction. Michael Simons, MD. Up
to date version 13.3

2. Calcium Channel Blockers in Acute Myocardial Infarction. Robert S

Rosenson, MD Harold L Keneddy, MD, MPH. Up to date version 13.3.

3. Calcium Channel Blockers in the Management of Stable Angina Pectoris.

Joseph P. Kannam, MD. Julian M Aroesty, MD. Bernard J Gersh, MB, ChB,
DPhil, FRCP. UpToDate version 13.3.

4. Choice of Therapy in Essential Hypertension: Clinical Trials. Norman M

Kaplan, MD, Burton D Rose, MD. UpToDate version 13.3.

5. Wenzel, Rene R. Renal Protection in Hypertensive Patients: Selection of

Antihypertensive Therapy. (Review). Dugs. 65 (Suppl 2):29-39, 2005.

6. JNC VII guidelines.

7. Medical Management of Claudication. UpToDate version 13.3.

8. Non Diabetic Kidney Disease (Andrew S) N Engl J Med. VOl 347. No 19.
November 7, 2002.

9. Nephropathy in Patient with Type 2 Diabetes. Remuzzi et al. N Engl J Med.

Vol. 346, No. 15 April 11, 2002.

10. Adherence to Calcium Channel Blocker Therapy in Older Adults: A

Comparison of Amlodipine and Felodipine. Menzin J et al. J Int Med Res.
2004 May-June; 32(3) :233-9.

12
 FLOW CHART

Diagnosis of hypertension

Initiate lifestyle modification

If still not achieve BP target (<140/90 mmHg or <130/80 mmHg for those with
diabetes or chronic kidney disease)

Initiate drug of choice

Without compelling indication With compelling indication

Stage I Hypertension Stage 2 hypertension Use appropriate

BP(140-159/90-99) (SBP > 160 or DBP anti-hypertensive
Thiazide is a first choice. >100mmHg) agent
May consider consider 2 drugs
ACEI/ARB/BB/CCB or
combination.
If CCB is used amlodipine
is preferred due to good
blood pressure control
compared to felodipine.
If cost is an issue,
felodipine can be used
instead of amlodipine.
If patient has side-effects
to amlodipine such as
headache, postural
hypotension, changed to
felodipine is justified.

13
 PROPOSAL
GUIDELINES ON PLAVIX PRESCRIPTION FOR CARDIOLOGY PATIENTS
HUSM

ACUTE CORONARY PERCUTANEOUS INTRACEPT ASD CABG

SYNDROME CORONARY INTERVENTION CLOSURE DEVICE
(PCI)
NSTEMI/UA = 9 months Bare metal stent = 3-4 Plavix x 3 months No indication
STEMI = 8 days weeks
Drug eluting stent (DES)
= 6-12 months

* Contraindication for aspirin, ticlopidine is a substitution

14
 PROTOCOL NOVOSEVEN OR RECOMBINANT FACTOR 7 FOR JABATAN NEUROSAINS HUSM.

Level for recommendations:

1. recommended (by experts) better than other measures (evidence based and expert opinion)
2. optional other measures can be as good as novoseven/lacking solid evidence.

Drug name Indication Dose Amount stored Criteria

1. NOVOSEVEN 1. Polytrauma/Trauma patient in severe DIVC -1 vial (1.2 mg) but if 3 vials per session of Non standard
or coagulopathy, requires severely deranged use. and require
urgent/emergency life saving surgery. coagulopathy or obese, specialist
2 or 3 vials can be approval.
given initially.
Level of recommendation (0.2-0.9 mg/kg)
Recommended (1)
-Paediatrics also can be
given. (0.2-0.9 mg/kg)

-can be repeated after

2-5 hours.(the INR and
APTT should be
repeated after those 2-5
hours of therapy).

2. Coagulopathy is resistant to other Same

therapeutic measures and requires
urgent/emergency or life saving surgery.

Level of recommendation
Recommended (1)

15
3. Patients known to suffer from Same/Novoseven made
coagulopathy disorders (eg Haemophilia) available
who requires urgent/emergency life
saving surgery which can or can not cause
post operative DIVC.( if patient developed
severe coagulopathy prior to surgery, please
refer to indication 1)

Level of recommendation
Recommended (1)
Note: alternative is the haemophilic factor (8/9)

4. Warfarin/Liver diseases induced Same

intracranial haematoma (abnormal INR)
that causing neurological
deficits/neurological deterioration which is
supported by radiological findings.

Level of recommendation
Optional (2)

Note 1: FFP, Vitamin K are the alternatives.

Note 2: Patient who is candidate for emergency

life saving surgery, the Novoseven is the choice
made available intraoperatively because of fast
effect (FFPs are the alternatives
intraoperatively)

16
 5. Patient who has within 4 hours of Same
intracranial haematoma causing
neurological deficits/deterioration but is not
a candidate for surgery yet.

Level of recommendation
Optional (2)

Note 1: the BP-controlled management and

correction of coagulopathy if presence with
other measures are the alternatives.

Note 2: routine use of Novoseven for post

surgical evacuation of intracranial clots for
patient with persistent post operative abnormal
clotting parameters is not recommended, the
FFP and/or cryoprecipitate are the primary
alternatives.

Note: Clinical management among cases may differ, depending on some other clinical scenarios/factors.

17
FLOW CHART

1. (POLY) TRAUMA PATIENT

IN SEVERE DIVC OR COAGULOPATHY,

PLANS FOR URGENT/EMERGENCY
LIFE-SAVING SURGERY
(NEUROSURGERY)

GIVE NOVOSEVEN

DIVC CORRECTED

SURGERY

Level of recommendation: Recommended (1)

18
2.
(POLY) TRAUMA OR NON TRAUMA PATIENT

IN SEVERE DIVC OR COAGULOPATHY, DIVC

IS NOT CORRECTED BY OTHER MEANS AND
REQUIRED URGENT/EMERGENCY OR LIFE
SAVING SURGERY.

GIVE NOVOSEVEN

DIVC OR COAGULOPATHY CORRECTED

SURGERY

Level of recommendation: Recommended (1)

19
3.
KNOWN COAGULOPATHY (Eg Haemophiliac) PATIENT
WITH/WITHOUT TRAUMA

PLAN FOR EMERGENCY LIFE SAVING

SURGERY (CRANIOTOMY/CRANIECTOMY)

NOVOSEVEN MADE AVAILABLE

SURGERY

NOVOSEVEN GIVEN IF COAGULOPATHY WORSENING.

- novoseven should be given earlier, if severe coagulopathy occurs prior to
surgery and patient requires life saving surgery (see flow chart 1)

Level of recommendation: Recommended (1)

Note: alternatives is the haemophiliac factor (8/9)

20
4. WARFARIN/LIVER DISEASES INDUCES INTRACRANIAL
HAEMATOMAS (ABNORMAL INR)
THAT CAUSING NEUROLOGICAL DEFICITS/DETERIORATION

IMAGING BRAIN: SIGNIFICANT HAEMATOMA/S WITH RADIOLOGICAL

FEATURES OF RAISED INTRACRANIAL PRESSURE AND/OR CLINICAL
EVIDENCE OF RAISED INTRACRANIAL PRESSURE.

GIVE NOVOSEVEN

Level of recommendation: Optional (2)

Note 1: FFP, Vitamin K are the alternatives.
Note
5. 2: Patient who is a candidate for emergency life saving surgery, the Novoseven is the choice made available intraoperatively
because of fast effect (FFPs are the alternatives)

21
 5.
PATIENTS WITHIN 4 HOURS OF DEVELOPING INTRACRANIAL
HAEMATOMA/S WITH NEUROLOGICAL DEFICITS/DETERIORATION.

IMAGING BRAIN: SIGNIFICANT HAEMATOMA/S WITH VOLUME 30 MLS

OR ABOVE BELIEVES CAUSING NEUROLOGICAL
DEFICITS/DETERIORATION

NOVOSEVEN CAN BE GIVEN TO HALT THE PROGRESSION OF

DEFICITS/DETERIORATION IN CONSERVATIVELY TREATED PATIENT
WHO IS NOT YET A SURGICAL CANDIDATE.
-ROUTINE USE IS NOT RECOMMENDED.

Level of recommendation: Optional (2)

Note 1: the BP-controlled managemant and correction of coagulopathy if presence with other measures are the alternatives.
Note 2: routine use of Novoseven for post surgical evacuation of intracranial clots for patient with persistent post operative
abnormal clotting parameters are not recommended, the FFP, Cryoprecipitate are the primary alternatives.

22
ABSOLUTE CONTRAINDICATION

1. Known allergy to Novoseven.

2. Allergy to mouse, hamster and bovine proteins.

RELATIVE CONTRAINDICATIONS

1. Known thrombotic tendencies.

2. Prosthetic heart valves requiring warfarin.
3. Recent angioplasty, stent insertion, MI thrombotic CVA, PE or DVT.

COMPLICATIONS

1. Thromboembolic events
2. Anaphylaxis

23
References:

1. Malaysian Society of Anaesthesiologist : Novoseven recommendations 2006.

2. Mayer FA, Rincon F: Ultra-early hemostatic therapy for acute intracerebral haemorrhage.
Semin Hematol.2006 Jan; 43 (1 Supp): S70-6.

3. Neurosurgery : Coagulopathy in Neurosurgery and recombinant Factor 7: series articles: Jun 2006

4. DeLoughery T.G : Management of bleeding emergencies : when use recombinant activated Factor VII: Expert Opinion ; a
review article.Pharmacotherapy 7(1): 2006.

5. Novoseven Product cataloge 2006.

THIS PROTOCOL MEANT TO CLINICAL DOCTORS IN NEUROSCIENCES OR ALLIED NEUROSCIENCES.

ACCURATE INTERPRETATION /UNDERSTANDING MAY REQUIRE EXPERT EXPLAINATIONS.

Prepared by Dr Zamzuri Idris

Date: 29/10/2006

24
 GUIDELINES FOR OUTPATIENT TREATMENT OF CHRONIC ASTHMA
DEPARTMENT OF MEDICINE HOSPITAL USM

CLASSIFICATION BY SEVERITY1
CLASSIFY SEVERITY
Clinical Feature Before Treatment

Symptoms Nocturnal FEV1 or PEF

Symptoms
STEP 4 Continuous Limited Frequent 60% predicted
Severe physical activity Variability > 30%
Persistent
STEP 3 Daily > 1 time a week 60-80% predicted
Moderate attack affect activity Variability > 30%
Persistent
STEP 2 > 1 time a week > 2 times a month 80% predicted
Mild Persistent but < 1 time a day Variability 20-30%
STEP 1 < 1 time a week 2 times a month 80% predicted
Intermittent Asymptomatic Variability < 20%
and normal PEF
between attacks

TREATMENT

STEP 1- Salbutamol Inhaler as required

STEP 2- Move to step 2 if symptoms as above or failure of step 1
T. Montelukast 10 mg daily2
Does the patient has: Yes Salbutamol inhaler as required
Allergic rhinitis?
Definite aspirin allergy?
Exercise induced asthma? No
Budesonide MDI/Turbuhaler 100-
800ug BD
Beclomethasone MDI 50-500 ug
BD/TDS
Ciclesonide MDI 160 ug OD/BD
Salbutamol MDI as required
Start steroid at high dose, taper down
later1
STEP 3- Move to step 3 if symptoms as above or failure of step 2
Treatment options: Consider Symbicort if patient is educated
Formoterol/ Budesonide because
4.5/160Turbuhaler (Symbicort) 1 inh BD the dose can be adjusted according
or to the patients need i.e. 1 inhalation
Salmeterol/ Fluticasone 50/250 Accuhaler BD when symptomatic and 1
(Seretide) 1 inhalation BD inhalation daily if stable3
Salbutamol inhaler
STEP 4 move toas required
step 4 if step 3 fails Symbicort may be used as rescue
medication

25
STEP 4 Move to step 4 if step 3 fails

Treatment options:
Formoterol/ Budesonide Plus
4.5/160Turbuhaler (Symbicort) 1 inh BD Montelukast 10 mg daily
or
Salmeterol/ Fluticasone 50/250 Accuhaler KIV
(Seretide) 1 inhalation BD Theophyline SR 250 mg BD
Salbutamol inhaler as required

Still symptomatic

Add
Prednisolone 5-10 mg OD

Please note:

Do reversibility test if diagnosis of asthma is questionable

Do spirometry as baseline before starting any treatment
Do spirometry before any change of treatment regime
Discuss with chest physician before starting daily prednisolone

References:

1. Global Initiative For Asthma 2002. www.ginaasthma.com

2. Mastalertz L, et al. Clin Exp Allergyu 2002 Sep;32(9):1360-5
3. Aalbers R, et al. Curr Med Res Opin 2004;20:225-240

Prepared by:

Dr. Che Wan Aminud-din Hashim

Respiratory Physician
Department of Medicine
Version 1 Nov 2006

26
 GUIDELINES FOR USING INFLUENZA VACCINE

Indication:

Patients with the following criteria:-

1. Moderate to severe Chronic Obstructive Pulmonary Disease (Defined by

GOLD guideline, HUSM guideline)
2. Asthma with recurrent exacerbation due to flu / URTI
3. Moderate to severe bronchiectasis with recurrent exacerbation
4. Any other chronic lung disease eg. Post-tuberculosis infection, insterstitial
lung disease, etc with recurrent secondary infection.

Management Plan:

Influenza vaccine will be administered as yearly basis.

Prepared by:

Dr. Che Wan Aminud-din b Hashim

Repiratory Physician
HUSM

27
 FLOW CHART PENGGUNAAN DRUG UNTUK RAWATAN ATTENTION
DEFICIT HYPERACTIVITY DISORDER (ADHD)

METHYLPHENIDATE IR (IMMEDIATE RELEASE)

METHYLPHENIDATE SR (SLOW RELEASE)
METHYLPHENIDATE LA (LONG ACTING)
METHYLPHENIDATE (EXTENDED RELEASE) OR CONCERTA
ATOMOXETINE (STRATERA)

Pesakit dirujuk ke klinik

Diagnosa ADHD

Pure ADHD ADHD with comorbidities

Adult ADHD

Umur di atas 6 tahun Umur di bawah 6 tahun

Epilepsy

Tics

Gilles de la
Tourette

IR Methylphenidate (dly-tds) Behavior modification Complicated

Methyphenidate (dly-bd) Pervasive SR
Development
Disorders

Severe untoward
events due to
methyllphenidate
Methyphenidate LA (single dose)
Concerta (single dose)

Atomoxetine (Stratera)

Disediakan oleh:

Dr Mohd Jamil Yaacob,

Klinik Psikiatri Kanak-kanak & Remaja.

28
 Lampiran A

DEPARTMENTAL POLICY ON THE USE OF ANTIPSYCHOTIC DRUGS

AND REQUEST FOR NON-STANDARD DRUGS

1. The typical or conventional antipsychotics are encouraged as the first line,

especially for unproductive and chronic patients who had not benefited much
from their improvement. However, if patients developed side-effect with the
conventional drugs, changing to atypical antipsychotic is recommended.
2. The use of atypical antipsychotic drugs in Malaysia and throughout the world
is increasing from year to year. In order to cut the cost, risperidone the
cheapest atypical antipsychotic is recommended as the first line. However,
exception to the rule is when patients clinical features are more favors for
other available antipsychotics. In dealing with psychogeriatric cases that are
sensitive to drug side-effect, Quatiapine may be considered as first line.
3. The used of atypical antipsychotic in poor compliance patients is discouraged:
typical antipsychotics or depot preparation of typical group such Fluphenazine
Decanoate and Flupentixol Decanoate should be strongly considered.
4. All the available drugs in the formulary must be tried with adequate dose (at a
lower dose if patients developed side-effects) and duration before considering
for non-standard drug. The request (LP) will be rejected if it does not follow
the standard procedure.
5. Not all the non-standard antipsychotics could be requested through L.P, the
list of non-standard drugs approved by the department will be circulated from
time to time. If patients need non-standard drug which is not approved by the
department, drug company should supplied to the patients or they should
bought by their own.
6. An additional form which contained information such as the detail of drugs
used (dose, duration and side-effect), benefit from the patient improvement
and socioeconomic background of the patients family must be attached to the
standard LP form when applying for non-standard drug.
7. The staffs from pharmacy department may counter-check patients folder when
they are doubtful about the accurateness of the information given in the LP
form. The request could not be processed if the information given was
misleading.
8. The pharmacy department will give the feedback to the treating doctor
whether the application for the non-standard drug is approved or not.

29
 Lampiran B

FLOW CHART OF USING ATYPICAL ANTIPSYCHOTICS FOR GENERAL

PSYCHIATRIC PATIENTS

Risperidone

No side-effect Developed intolerated Required dosage >4 mg daily

Side-effect <4 mg daily

Continued Olanzapine/ Olanzapine/ Continued

the drug Aripiprazole Aripiprazole the drug

Side-effect Poor response

LP

Quatiapine Clozapine/
drug combinations

Note: try to keep maintaining dose of olanzapine and aripiprazole not exceeding 15
mg daily; otherwise review the diagnosis and medication to minimize the dose.

30
GUIDELINE ON THE USE OF ANTIPSYCHOTICS

A. SCHIZOPHRENIA AND RELATED DISORDERS (NON-EFFECTIVE

PSYCHOSES)

1. UNPRODUCTIVE PATIENTS

Used typical antipsychotics as a first line

Developed moderate to severe side- Developed mild side-effects

effect

Continued the drug

Change to risperidone

* Unproductive means the patients could not contribute to the socio-economic

development of the family, community or nation even after they improved;
e.g, jobless patients. It is not cost-effectiveness of giving expensive drugs to
these groups of patients.

31
 2. PRODUCTIVE PATIENTS

Used risperidone as first line

No side-effect Developed intolerable side- Required dosage >3 mg daily

effect in the dose < 3 mg daily

Continued the drug Changed to olanzapine or other Change to olanzapine or

atypical antipsychotics increased the dose

* Examples of productive patients are students, government servants, self-employer

and active house-wives.

32
B. AFFECTIVE DISORDERS

Used olanzapine as first line for new cases

Poor compliance or Good compliance or

developed side-effect responding well

Change to other drug

Continued the drug

OLD CASES
1. unproductive patients on atypical antipsychortics, especially involved
olanzapine, try to change to typical drugs if it does not compromise with
efficacy of the treatment and side-effects.
2. Any patient, who has evidence of poor drug compliance regardless of the
diagnosis, should change to a cheaper drug, e.g conventional antipsychotics.

33
 ALZHIMERS DISEASE
TREATMENT STRATEGY

Mild to moderate cases

a) F.D.A. Approval drugs

1) Donepezil 5-10mg/day
(cholinestherase inhibitors)
2) Rivastigmine 6-12mg/day
3) Galantamine 16-24mg/day

b) Use Supported by Clinical Trials

1) Seligeline 5mg BD.
2) Vit. E 2000I.U./day

Moderate to severe cases

a) NMDA. Antagonist- Memantine 10-20mg/day

b) Combination of cholinestherase inhibitors + N.M.D.A. Antagonist

34
 PARKINSON DISEASE
Early stage with minimal symptoms-
sign
Moderate motor symptoms
interfering with activities
Severe Symptoms-Motor
Complications of L. Dopa
Very advanced motor
Complications of Levodopa Therapy
1 Defer use of Levodopa if age below
60
2 Seligeline
3 Amantadine
4 Dopamine Receptor Agonists
Ropinerol
Pramipexol
Peribedil
5 Anti-cholinergics
1 Add small titrating dose of
Levodopa- dopa de carboxylase
Inhibitor Combination
(L-Dopa-Carbidopa) Madopar
(L-Dopa-Benzeraside)-Sinement
1 Add on Dopamine Receptor
agonist and reduce dose of
Levodopa
2 Add on COMT Inhibitor Ento
Capone (COMTAN)
3 Starton STALLEVO a
combination of Levodopa-
carbidopa Entocaps
4 Adjunctivies Amantadine Anti-
Cholinergics
1 Consider Surgical Treatment
Deep Brain Stimulation
35
 FLOW CHART FOR TREATMENT HEPATITIS B IN TREATMENT NAVE
PATIENTS

HBSAg positive

HBeAg status

Positive HBeAg Negative HBeAg

Is ALT Elevated Is ALT Elevated

YES NO NO YES

ALT more than ALT less No treatment. ALT less 2x ALT more than
2x normal 2x normal Monitor ALT normal 2x normal
every 1-3
months.

HBVDNA (PCR) HBVDNA (PCR)

Quantitative >log105 Quantitative
>log104

Liver Biopsy
Ishak Score >2.0 Liver Biopsy
Ishak Score >2.0

Oral therapy 18 months (minimum) Oral therapy

First choice: Minimum duration 2
1. Entecavir 0.5 mg OD years
2. Adefovir 10 mg OD
3. Telbivudine 600 mg OD
Second choice: American/Europian/Asia Pasific Guidelines
1. Lamivudine 100mg Od no longer use lamivudine as first line due to
2. Interferon Alpha (injection) high viral resistance of 25% at 1 year, 45% at
2 years and 65% resistance at 3 years
treatment duration.

End points of treatment 1. ALT Normalisation

2. HBeAg Seroconversion/ HBeAntibody
3. HBVDNA (PCR) supression

36
 FLOW CHART OF CHRONIC VIRAL HEPATITIS B
PRE CORE MUTANT HBEAG NEGATIVE

HBSAg POSITIVE MORE THAN 6 MONTHS

LIVER ENZYME
ALT > 2 NORMAL

HBVDNA (PCR) QUANTITATIVE

HBVDNA > 10,000 COPIES/ML

LIVER BIOPSY
HPE BIOPSY SCORE > 2 ISHAR SCORE

THERAPY FOR MINIMUM 18 MONTHS

1. LAMIVUDINE 100 MG OD
2. TELBIVUDINE 600 MG OD

HBVDNA (PCR) QUANTITATIVE

MONITORED AT 24, 48, 72 WEEKS

THERAPY STOPPED AFTER MINIMUM 18 MONTHS

IF HBVDNA (PCR) UNDETECTABLE

Prepared by:

Dr. Amry A. Rahim

Physician / Clinical Specialist
Gastroenterology / Hepatology
HUSM

37
 FLOW CHART FOR GENITAL ULCER SYNDROME

Patient complains of GENITAL ULCER or SORE

Take history and examine

INVESTIGATIONS NEEDED:-
1. Dark ground microscopy for syphilis (IF AVAILABLE)
2. Gramstain for haemophilus ducreyi
3. Tzancks smear
4. VDRL, TPHA
5. HIV Ab.

Multiple superficial erosions or vesicular lesions

Ulser present? PRESENT?

Treat for SYPHILIS and CHANCROID

Educate for behaviour change Health Education
Partner management Educate for behaviour change
Follow-up regime YES TCA x 2 weeks and review
For confirmed syphilis results of inv.
2 weeks for results
monthly x 3 visits
3 monthly x 3 visits
3 monthly x 2 visits
Genitial herpes management
3 months repeat HIV Ab. And
Educate for behaviour change
VDRL/TPHA if initial results were negative
TCA x 2 weeks and review results

Treatment Protocol For Genital Ulcer Syndrome

TREATMENT FOR SYPHILIS AND CHANCROID

1ST FIRST CHOICE: IM BenzathinePenicillin 2.4 million units weekly x 2

(once a week x 2 weeks)
PLUS
Azythromycin 1.0 gm single oral dose
2nd SECOND CHOICE: IM Benzathine Penicilin 2.4 million units weekly x 2
(once a week x 2 weeks)
PLUS
Cotrimoxazole 2 tablets orally twice daily x 7 days
3rd THIRD CHOICE: IM Benzathine Penicillin 2.4 million units weekly x 2
(once a week x 2 weeks)
PLUS
IM Ceftriaxone 250mg single dose

Note: If patient develops allergic reaction to the 1st dose of IM Benzathine Penicillin, DO NOT give the
second dose.
If patient is allergic to Penicillin, use EITHER
Doxycycline 100mg orally bd x 15 days OR Erythromycin ES 800 mg bd x 15 days.

38
 FLOW CHART FOR VAGINAL DISCHARGE SYNDROME
Patient complains of VAGINAL DISCHARGE

Take history and do physical examination

INVESTIGATION NEEDED:-
Vaginal swab
Wet mount for trichomonas vaginalis
Gram stain for candidia albicans and clue cells
Cervical swab
Gram stain for gonococci and pus cells
Culture for gonococci ( using Amies charcoal transport media )

VDRL, TPHA, and HIV ab.

YES Patient has LOWER

Refer to NEAREST Hospital ABDOMINAL PAIN?
NO Treat for VAGINITIS
RISK FACTORS NO Educate for behaviour
1. Less than 21 years old RISK ASSESSMENT change
2. Single Partner has symptoms OR
3. Recent partner ( less than 3
Follow up for 2 weeks
monts)
Risk factor positive for results
4. Multiple partners
YES

Treat for CERVICITIS and Vaginitis

Educate for behaviour change
Partner management
Follow- up ---2 weeks for result
3 months to repeat VDRL, TPHA & HIV Ab,
IF INITIAL TEST WERE NEGATIVE

Treatment Protocol For Vaginal Discharge Syndrome

(Cervicitis And Vaginitis)
Treatment for Vaginal Discharge Syndrome ( Cervicitis)
1st FIRST CHOICE: Azithromycin 1 gm single oral dose
2nd SECOND CHOICE: IM Ceftriaxone 250 mg single dose
+
Doxycycline 100 mg bd x 10 14 days
3rd THIRD CHOICE: IM Ceftriaxone 250 mg single dose
+
Erythromycin ES 800 mg bd x 10 14 days
PLUS
Treatment for Vaginal Discharge Syndrome ( Cervicitis)
Metronidazole 2 gm STAT
PLUS
Nystatin pessaries 100,000 units daily x 14 days
On follow-up: If no improvement or not effective to continue Metronidazole 400 mg bd x 7 days
OR TREATMENT FOR VAGINITIS ONLY

39
 FLOW CHART FOR URETHRAL DISCHARGE SYNDROME IN MEN
Patient complains of Urethal
Discharge/Dysuria or irritation

Take history and examine (milk URETHRA

if necessary)

INVESTIGATIONS NEEDED:-
- Urethral smear
Gram stain for gonococci & pus cells
Culture for gonococci (use AMIES
charcoal transport media)
- 2 glass urine test
- VDRL,TPHA & HIV Ab

No
Discharge No 1. Do 2 glass test
PRESENT? 2. result POSITIVE? ULCER PRESENT?

Yes
Yes
Treat for GONORRHEA and
CHLAMYDIA No REFER TO
Educate for behaviour change Appropriate
Partner management flow chart
Follow-up
Two weeks for result Health Education
Three months to repeat Yes Follow-up for 2 weeks
VDRL, TPHA & HIV Ab.

Traetment for CHLAMYDIA

Treatment Protocol for Urethral Discharge Syndrome

Treatment for Gonorhea and Chlamvdia

1st CHOICE: Azithromycin 1gm orally single dose

2nd CHOICE: IM Ceftriaxone 250mg single dose
+
Erythromycin ES800mg orally bd x 10-14 days
3rd CHOICE: IM Ceftriaxone 250mg single dose
+
Erythromycin ES 800mg orally bd x 10-14 days
If Patient is allergic to penicillin and azithromycin is not available

IM Spectinomycin 2gm STAT

+
Doxycycline 100mg orally bd x 10-14 days
OR
IM Spectinomycin 2gm STAT
+
Erythromycin ES 800 mg orally bd x 10-14 days

40
TREATMENT PLAN
OUTPATIENT
TREATMENT OF CAP

DIAGNOSIS
Does history, physical
PRIMARY CARE OF EMERGENCY DEPT Exam & chest x-ray NO
VISIT confirm CAP ?
Patient presents w/ symptoms suggestive of ALTERNATIVE
community-acquired pneumonia (CAP) YES DIAGNOSIS
Treat patient appropriately

Yes, 2 core
No core adverse SITE OF CARE DECISION
adverse prognostic
prognostic factors Does patient have any of the
core adverse prognistic factors are present
are present
factors?
EVALUATION
Does patient have
preexisting adverse
prognostic factors? YES Yes, 1 core adverse prognostic
factors are present
NO

HOSPITAL
ADMISSION
OUTPATIENT TREATMENT
Non-pharmacological
Patient education
Avoid smoking CLINICAL DECISION
Adequate hydration & Should patient be admitted to YES
nutrition hospital? Base decision on clinical
judgement, additional adverse
Pharmacotherapy prognostic factors, the patients
Symptomatic therapy NO social circumstances & patient
Analgesics for pleuritic preferences
pain
Antibiotics therapy

41
TREATMENT PLAN (CONTD)
EMPIRIC OUTPATIENT CAP
ANTIBIOTIC THERAPY

EMPIRIC ORAL ANTIBIOTICS

Local epidemiologic patterns need to be considered to target the antimicrobial therapy against the likely pathogens
Previously healthy individual
Any one of the following :
High-dose Amoxycillin
Doxycycline
Macrolide Erythromycin
Preferred agent in many guidelines
Comorbidity is present (DM, renal insufficiency, CHF, alcohol abuse, COPD)
Any one of the following :
Advanced macrolide - Azithromycin
Beta-lactam or beta lactam-beta-lactamase inhibitor
Quinolone
Patient has multiple medical condirions , has COPD & received antibiotics or oral steriods in the last 3 months or any other risk factors for Gram ve organisms
Macrolide (Azithromycin) + beta lactam or beta-lactam (beta lactamase inhibitor)
Quinolone (alone)
Suspected aspiration pneumonia
Any one of the following :
Beta-lactam, beta-lactamase inhibitor w/ or w/o macrolide (Azithromycin)
(Clindamycin or metronidazole w/ quinolone)

FOLLOW UP
Follow up will depend on initial severity assessment
Recommended follow up in 48-72 hr
If patient fails to improve consider the following :
Chest X-ray
Hospital admission
Possible reasons for failure to improve
Host factors associated w/ a delayed response
Inadequate antimicrobial selection (eg. Resistant organism or bacteria not covered by initial antibiotic therapy)
Metastatic infections (eg. Meningitis, endocarditis, empysema etc)
Noninfections illness

42
 FLOW CHART OF USING SULPERAZONE IN ICU

ICU Patient

Ventilated/NonVentilated

Nosocomial Infection

Non Acinetobacter Acinetobacter

Quinolones Multi-Drug Resistance (MDR) Non-Drug Multi

or Resistance
3rd Generation
or
4th Generation
or
Carbapename
Sulperazone Unasyn

Aminoglycoside
Aminoglycoside

Responding
Non-Responding
Within 24-48 Hr or
Suspicious of MDR

Continue Treatment

43
 GUIDELINES FOR USING NOVOMIX 30 FLEXPEN
HOSPITAL UNIVERSITI SAINS MALAYSIA

PRE-MIXED INSULIN

Mixtard 30 Penfill NovoMix 30

FlexPen

OADs OADs failure Patients on Mixtard (switch

failures 1. elderly to)
2. hypoglycaemic prone 1. frequent hypoglycaemia
3. fasting (ramadhan) or puasa 2. poor control
sunat) 3. post prandial
hyperglyacemic
4 fasting (ramadhan) or puasa

44
FLOWCHART FOR USE OF GLUCOPHAGE XR

Type 2 Diabetes Mellitus

Metformin (immediate release) BID/TID

Poor compliance or
Gastro-intestinal side-effects

Metformin (extended release)

(Glucophage XR) once daily

45
FLOWCHART FOR USE OF INSULIN DETEMIR

Insulin requiring diabetes mellitus

NPH insulin

Hypoglycemia

Insulin Detemir/Glargine

46
ALGORITHM FOR THE MANAGEMENT OF POSTMENOPAUSAL
OSTEOPOROSIS

Clinical Assessment

Patients with risk General measures: Patients with prior

factor but no - Calcium intake (B) incidental low
fracture - Physical activity (B) trauma fracture

In the elderly:
- Vitamin D + calcium (A)
- Prevention of falls (B)

BMD measurement

T score: T score: T score:

-1 <-1 to > -2.5 -2.5

NORMAL OSTEOPENIA* OSTEOPOROSIS OSTEOPOROSIS

(BMD if available)

Monitor If multiple risk

factor present (C) Treatment options: Treatment options:
-Strontium ranelate -Strontium ranelate
-SERMs/ - Bishosphonate (A)
-Bishosphonates (A) -SERMs (A)
-Activated vitamin D (A) -Activated vitamin D (A)
-Calcitonin (A)
-rPTH**(A)
Reassess
with BMD after
2 years (A) NO YES
Follow up with BMD if available

If BMD
deteriorates
Reassess Treatment options:
BMD yearly (C) - Strontium ranelate
- SERMs (A)
- Alendronate (A)
- HRT (A)

47
 ZOLENDRONIC ACID PRESCRIPTION FLOW CHART

Bone Metastasis Confirmed By Bone Scan

Primary By:

1) Breast Carcinoma
2) Nasopharyngeal Carcinoma
3) Lung Carcinoma (NSCLC)
4) Prostate Carcinoma

Symptoms of Pain

Severe Hypercalcaemia Mild To Moderate Pain Severe pain. Scale > 7/10

1st Line +/- Hypercalcaemia

IV Pamidronate 90 mg
Over 2 hours every 4/52
For 6 months

Palliative Intension.
To stop and reduce bone
metastases/damage
Further pain +/- especially when bone
Hypercalcaemia involvement is wide
spread

2nd Line
IV Zolendronic Acid 4 1st Line
mg over 15 minutes IV Zolendronic Acid 4 mg
every 4 weeks for 6 over 15 minutes every 4
months weeks for 6 months.

48
 FLOW CHART FOR USING IMATINIB IN CHRONIC MYELOID
LEUKEMIA (CML), PH+ ACUTE LYMPHOBLASTIC LEUKEMIA (ALL)

Patients with Ph+CML (all phases)

Begin imatinib at 400mg daily

Assess response at 3, 6, 12, 18 months as

per European Leukemia Net guidelines

Good response Suboptimal Poor / No

response response

Continue imatinib Increase imatinib to Stop imatinib

400 mg daily 600-800 mg daily Consider alternative
treatment

Good response Poor / No

response

Continue imatinib Stop imatinib

600-800 mg daily Consider alternative
treatment

NB
1. Chronic phase CML patients responding to imatinib should continue
treatment indefinitely until disease progression (expected rate of
progression 1-5 %/year)

2. In accelerated, blast phase CML and Ph+ALL imatinib is usually used

as induction +/- chemotherapy prior to more definitive treatment like
stem cell with an anticipated duration of imatinib use of 4-8 weeks.

49
 Lampiran1
Dr. Shamsul Kamaruljan

ARCOXIA PRESCRIPTION FLOW CHART

Acute/chronic pain

History of Gastritis

Yes
No

1st line: 1st line:

NSAIDS e.g Voltaren, Mefenamic T. Celebrex 200-400mg dly
acid, Ibuprofen T. Meloxicam 7.5mg bd
T. Tramadol 50-100mg tds
Oral opiods e.g. T. DF118,
Oral morphine

Pain not Pain not

relieved relieved

2nd line: 2nd line:

T. Celebrex 200-400mg dly T. Arcoxia 60-120mg dly
T. Meloxicam 7.5mg bd T. Oxycontin 10-40mg bd
Oral opiods e.g. T.DF118, Oral
morphine

Pain not
relieved

3rd line:
T. Arcoxia 60-120mg dly
T. Oxycontin 10-40mg bd

*Prescription: Maximum only for 3/52

Dose: 60mg, 90mg and 120mg
(Depends on severity of the pain and condition of the pain)

50
 Lampiran 2
Setelah diubahsuai oleh Jabatan Ortopedik

OUTPATIENT PAIN PRESCRIPTION FLOW CHART

Acute/chronic pain

History of Gastritis

Yes
No

1st line: 1st line:

AC: Voltaren, Mefenamic acid, AC: T. Celebrex 200-400mg dly
Ibuprofen AC Gouty arthritis : T Arcoxia
CHR: Feldene, Neprosyn 120mg daily
CHR: T. Meloxicam 7.5mg dly
T Celebrex 200mg dly

Pain not Pain not

relieved relieved

2nd line: 2nd line:

AC: Oral opiods e.g. T.DF118, Oral opiods e.g. T.DF118,
T. Arcoxia 120mg dly T. Arcoxia 60-120mg dly
CHR: T. Celebrex 200 dly
T. Meloxicam 7.5mg dly

Pain not
relieved

rd 3rd line:
3 line: Oral morphine
Oral morphine T. Oxycontin 10-40mg bd
T. Oxycontin 10-40mg bd

*COX2 Prescription for acute pain: Maximun only for 3/52

Arcoxia Dose: 60mg (OA), 90mg (RA) and 120mg (Acute pain e.g. gouty arthritis)
(Depends on severity of the pain and condition of the pain)
3rd line is same in both pathways

AC acute
CHR - chronic

51
FLOWCHART OF PATIENTS DIAGNOSED WITH BACTERIAL
CONJUNCTIVITIS

Bacterial Conjunctivitis

1st line:
Gutt. Chloramphenicol

Perform Culture and

Sensitivity test Not resolved

2nd line:
Gutt. Ciprofloxacin
(Ciloxan)

Not resolved

3rd line:
Gutt. Moxifloxacin
(Vigamox)

52
FLOWCHART OF PATIENTS DIAGNOSED WITH BACTERIAL
KERATITIS

Bacterial Keratitis

1st line:
Gutt. Ciprofloxacin
(Ciloxan)

Perform Cornea
Scrapping/ Culture Not resolved
and Sensitivity test

2nd line:
Gutt. Moxifloxacin
(Vigamox)

53
 FLOWCHART OF PATIENTS REQUIRING PRE AND POST CATARACT
SURGERY ANTIBIOTIC PROPHYLAXIS

Cataract Surgery
Prophylaxis

Preop prophylaxis:
Gutt. Moxifloxacin 0.5 % (Vigamox) 1 drop every 15 minutes 1
hour prior to surgery.
5 % Povidone iodine ( 1 drop ) on the ocular surface.

Intra-cameral injection:
1mg in 0.1 mL cefuroxime*
or
0.1 mL Gutt. Moxifloxacin 0.5% (Vigamox)1
- at the end of surgery

*Dilution is required as standard ceruroxime

injection is 100 mg/mL.

Postop prophylaxis:
Gutt. Moxifloxacin 0.5% (Vigamox) 3-4 times
daily for 1 month.

Reference:
1) CRG Espiritu et. al. Safety of Prophylactic Intracameral Moxifloxacin 0.5%
Opthalmic Solution in Cataract Surgery Patients. J Cataract Refract Surg 2007: 33:
63-68

54
 FLOW CHART FOR USING OLOPATADINE 0.1% AND SODIUM
CROMOGLYCATE

i. Kegunan ubat tersebut adalah untuk rawatan kes Allergic

conjunctivitis terutama Vernal Allergic conjunctivitis di kalangan
kanak-kanak dan remaja.
ii. Kerana mempunyai kesan kedua-dua iaitu mast cell stabilizer dan
anti histamines
iii. Ubat titis sodium cromoglycate yang dahulu digunakan untuk kes di
atas, akan dikurangkan kegunaannya.

Flow chart penggunaan kedua-dua drug bagi membezakan kes-kes tersebut seperti
berikut;

Pesakit

Pesakit Allergic conjunctivitis Selainnya

terutama Vernal Allergic
conjunctivitis

Ubat titis Sodium

Ubat titis Olopatadine Cromoglycate 2%

55
 TREATMENT ALGORITHM OF ALLERGIC RHINITIS (AR)

Diagnosis of AR

Allergen Avoidance

Drug Therapy
(Antihistamines)

Intermittent Symptoms Persistent Symptoms

Moderate - Mild Moderate -

Mild
Severe Severe

Xyzal Xyzal Xyzal * Xyzal *

1st & 2nd generation 1st & 2nd generation

antihistaminics antihistaminics (No clinical data
available to support this
indication

Xyzal * (Bachert C et al. J. Allergy Clin. Immunol 2004; 114: 838-844) The XPERT,
Xyzal in Persistent Allergic Rhinitis Trial Published RCT data. Indication approved
by FDA / DCA.

56
 FLOW CHART OF THALASSAEMIA PATIENT WITH IRON OVERLOAD

DIAGNOSIS OF THALASSAEMIA ON REGULAR BLOOD TRANSFUSION

REGULAR 3-4 MONTHLY FOLLOW-UP IN PAEDIATRIC HAEMATOLOGY

CLINIC

REGULAR 3-4 WEEKLY FOLLOW-UP IN THALASSAEMIA DAY CARE UNIT

FOR BLOOD TRANSFUSION

3 MONTHLY MONITORING SERUM FERRITIN LEVEL

EVIDENCE OF IRON OVERLOAD, SERUM FERRITIN > 1000 MCG/L

INTRODUCE TO SUBCUTANEOUS DESFERAL (deferoxamine) WITH

TRAINING AND MONITORING

ASSESSMENT OF COMPLIANCE TO DESFERAL (Growth, Se Ferritin, yearly

echo of heart)

POOR COMPLIANCE GOOD COMPLIANCE

TO DESFERAL TO DESFERAL

Se Ferritin Se Ferritin
< 2500mcg/L > 2500mcg/L CONTINUE DESFERAL

DEFERASIROX DEFERIPRONE

57
 INTERFERON BETA-1B FLOWCHART

Multiple Sclerosis

1) Remitting and Relapsing type.

2) Clinically Isolated syndrome with MRI evidence of multiple

plaques.

DIAGNOSIS ESTABLISHED AS PER Mc DONALD CRITERIA

TREAT THE ACUTE EPISODE WITH I.V METHYL PREDNISOLONE

THEN CONSIDER THE THERAPEUTIC OPTION OF STARTING BETA-

INTERFERON THERAPY.

(Beta interferon is the only evidence based treatment for the above condition, to
reduce the risk of relapses and slow down the disease progression).

58