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ATIIO
ONN MALAYSIA
MALAYSIA •• JANUARY/FEBRUARY
JANUARY/FEBRUARY 2020
2020

SARS-CoV-2 outbreak:
FIP issues guidelines for
pharmacists

Office, workshop
workers at high risk for
vitamin D deficiency
Strength in numbers:
Lim Jack Shen on
pharmacy management
and banner groups

How to ward off

medication errors:
Experts' perspectives
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In Malaysia, coronary artery disease (CAD) and stroke are
leading causes of death in 2017. Patients with established
CAD and stroke who are at risk of secondary thrombotic
events can be more effectively managed with the help of
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with the goal of understanding the current landscape of CAD
– particularly acute coronary syndrome (ACS) – and stroke, as
well as highlighting the role of pharmacists in preventing and
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Acne vulgaris (also known as ‘acne’) is one of the most
common and burdensome dermatological disorders, affecting
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occurs more prominently in young adolescents and adults. The
management of acne is based on the severity of acne and type
of acne lesions. As acne remains a common problem, many
patients undoubtedly seek the advice of community pharmacists
for its management, especially in mild-to-moderate acne.

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 | Y O U R T R U S T E D S O U R C E O F P H A R M A C Y I N F O R M AT I O N Publisher

CONTENTS
Yasunobu Sakai

Country Vice President

(Marketing Platform & Medcomms)
 Aundrey Yeoh

JANUARY/FEBRUARY ISSUE Contributing Editors

Malaysia: Saras Ramiya, Pank Jit Sin,
Rachel Soon
Singapore: Elvira Manzano, Roshini Claire
NATIONAL NEWS Anthony, Pearl Toh, Audrey Abella
4 MPS, GSK issue joint commitment to patient safety focus Hong Kong: Christina Lau,
Dr Joseph Delano Fule Robles
Philippines: Stephen Padilla, Jairia Dela
6 Programme to promote community pharmacy-based diabetes management Cruz, Elaine Soliven

Business Managers
7 SARS-CoV-2 outbreak: FIP issues guidelines for pharmacists
Kam Zhi Yan,
Rathika Nagarajan, Sugalia Santhira,
8 Research in brief: emergency errors, curry leaves, and TKIs Xavier Wee, Krystle Lim
• Medication errors identified in one-third of emergency admissions at training
Designer
hospital Razli Rahman
• Curry leaf extracts demonstrate antibacterial potential
Circulation Executive
• Afatinib may offer survival benefit over gefitinib, erlotinib in advanced lung
Pauline Hoe
cancer
Accounting Manager
Christine Goh
10 Symposium showcases industrial pharmacy opportunities
Published by
11 How safe are herbal medicines? MIMS Medica Sdn Bhd
2nd Floor, West Wing, Quattro West,
No.4, Lorong Persiaran Barat
46200 Petaling Jaya
Selangor, Malaysia
Email: enquiry.my@mims.com
Tel: (603) 7623 8000

6 11

FRONT PAGE
14 How to ward off medication errors: Experts' perspectives

FROM ABROAD HOW TO CONTACT US

18 Office, workshop workers at high risk for vitamin D deficiency
To subscribe:
enquiry.my@mims.com
19 No link between talc powder and ovarian cancer risk in large study To contact the editor:
rachel.soon@mims.com
20 Pre-pregnancy acetaminophen use tied to increased adverse birth outcomes To submit an article:
risk rachel.soon@mims.com

AUSTRALIA • MALAYSIA • HONG KONG

INDIA • INDONESIA • CHINA • MYANMAR
NEW ZEALAND • PHILIPPINES • VIETNAM
SINGAPORE • SOUTH KOREA • THAILAND
14 19

1 JANUARY/FEBRUARY ISSUE
 | Y O U R T R U S T E D S O U R C E O F P H A R M A C Y I N F O R M AT I O N MIMS Pharmacist is published 6 times a

CONTENTS
year by MIMS Medica. MIMS Pharmacist
is a controlled circulation publication to
pharmacists and members of allied pro-
fessions in Malaysia. Editorial matter pub-
lished herein has been prepared by profes-
sional editorial staff. Views expressed are
not necessarily those of MIMS Medica.
JANUARY/FEBRUARY ISSUE
Although great effort has been made in
compiling and checking the information
given in this publication to ensure that
22 Little evidence to support use of common antidepressant in autism it is accurate, the authors, the publisher
and their servants or agents shall not be
responsible or in any way liable for the
23 Relugolix relieves pain symptoms in women with uterine fibroids
continued currency of the information or
for any errors, omissions or inaccuracies in
25 Ivermectin-doxycycline combo superior to monotherapy in severe rosacea this publication whether arising from negli-
gence or otherwise howsoever, or for any
consequences arising therefrom; the pub-
26 Vitamin C-thiamine-hydrocortisone combo yields no improvement in septic lisher bears no responsibility or liability for
shock patent ownership or patent legality of any
medical product mentioned or featured,
nor is it responsible for verifying the own-
27 Reduced gout incidence with SGLT-2 inhibitors vs GLP-1 receptor agonists ership or originality of the product which,
therein infringes upon the intellectual prop-
erty rights or other rights of any third party.
The inclusion or exclusion of any product
does not mean that the publisher advo-
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©2020 MIMS Medica. All rights reserved.

No part of this publication may be repro-
22 25 duced in any language, stored in or intro-
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FEATURE mechanical, photocopying, recording or
29 Strength in numbers: Lim Jack Shen on pharmacy management and banner otherwise), without the written consent of
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27 29

PP17931/12/2013(033147) ISSN 2076-5738

2 JANUARY/FEBRUARY ISSUE
 Message from the
Dear readers,
2020 has arrived with new controversies
and challenges facing pharmacists and
the general public. Towards the end of
2019, a major backlash erupted over
proposed amendments to the Poisons
Act 1952 that would penalize doctors
who refused to give prescription slips
upon request by patients, leading to
the postponement of the Act’s second
tabling to March 2020, with results
pending.
At the beginning of the year, the
emergence of the 2019 novel
coronavirus (2019-nCoV), now named
severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2), outbreak
in Wuhan, China also began to
dominate the headlines, with fears
of a global health crisis leading to
mass quarantines, shortages of
medical supplies, and the spread of
information—verified or not—about
the disease over social media and the
Internet.
Team:
We’d like to hear about your
experiences. Have you been affected
by the coronavirus outbreak in
your place of practice? What are
some of the precautions you’ve taken?
Have there been any changes in daily
operating procedures? How have you
dealt with concerns from incoming
patients or members of the public?
Feel free to write in with your stories
(50–200 words) at rachel.soon@mims.
com. As always, longer contributions in
the form of news, stories and opinions
are also welcome in our inbox.
As previously announced, MIMS
Pharmacist is now a digital magazine
as of the beginning of 2020, with
6 issues per year on a bimonthly
schedule. If you’d like to receive monthly
emailers whenever new issues of MIMS
Pharmacist are out, you can register an
account for free at www.mims.com and
select “Pharmacy” as your specialty of
interest to do so.
3 JANUARY/FEBRUARY ISSUE
You can also download previous issues
from the MIMS Specialty News –
Pharmacy website at specialty.mims.
com/pharmacy in portable PDF format
for your device of choice. If you or your
organization would be interested in a
special print run of a specific MIMS
Pharmacist issue, do contact our
business team at MYBM@mims.com.
Sincerely,
The MIMS Pharmacist team
Our MIMS Pharmacist Readership
Survey has closed with over 300
submissions! Thank you to everyone
who contributed your feedback, and
congratulations to our three lucky draw
winners Chew Seaw Wei, Phang Earn
Loo and Ying Han Chin! Each of them
will be receiving a physical copy of the
MIMS Pharmacy Patient Counselling
Guide 2019/2020.
 NATIONAL NEWS

MPS, GSK issue joint commitment to patient

safety focus
Rachel Soon

I
n conjunction with World Phar-
macists Day 2019, the Malaysian
Pharmaceutical Society (MPS)
and GlaxoSmithKline (GSK) Consumer
Healthcare Sdn Bhd have reaffirmed a
mutual commitment to high standards
of patient safety in products and supply
chains.

An estimated 1,000 pharmacists

from the MPS have pledged to display
commitment stickers at their individual
premises. The stickers are intended to
remind both patients and pharmacists
that patient safety—through proactive
and clear communication on correct use
of medicines, and adherence to them—
must be prioritised.

“Traditionally, pharmacists served as
the bridge between patient and doctor
by checking the prescriptions from phy-
sicians before dispensing the medication
to the patients,” said Amrahi Buang, MPS
president. “That role has not changed;
pharmacists are now also responsible
for helping patients to manage minor ail-
ments with medicines by responding to
their symptoms, and even offering health
advice on their diet and lifestyle.”
According to Amrahi, a pharmacist’s
role revolves around patient safety, es-
pecially with growing evidence of Ma-
laysians turning to pharmacists for as-
sistance with managing their health. He
added that for pharmacists to effectively
carry out their roles within the communi-
ty, more open communication was need-
ed between them and their patients.
In 2015, the MOH Pharmaceutical
Services Division released the results of
the National Survey on the Use of Med-
icines by Malaysian Consumers (NSUM
2015), a cross-sectional survey of urban
and rural consumers aiming to inves-
tigate current patterns of medicine use
A pharmacist holds up the note of appreciation from GSK for joining the pledge for safe and effective
medicines.
and knowledge across all states and
federal territories. [Available at www.
pharmacy.gov.my/v2/sites/default/files/
document-upload/national-survey-use-
medicine-iii-nsum-iii.pdf]
Among the survey’s findings were
that despite evidence of extensive use of
pharmaceutical products, many respon-
dents admitted to knowledge gaps relat-
ed to safe usage, compliance issues, as
well as a need for additional information
on medicines and medication-related
issues (see infographic). When respon-
dents were asked regarding their first
persons of contact for medicine-related
concerns, doctors (49.6%) and pharma-
cists (31.1%) were the top choices.
“Through this pledge with GSK, we
want to show that we, the pharmacy
community, are committed to initiate
conversations with our patients to en-
courage proper adherence to their med-
ication and to discuss what is best for
them,” said Amrahi. “For various reasons,
some patients may not be able to adhere
to instructions, thus affecting their safety.
We want patients to voice out their con-
cerns about their medication, so that we
can advise on the right course of action.”
“At GSK, we have extensive safety
controls throughout our production and
supply chain, and these are enforced
throughout all the markets in which we
operate,” said Bryan Wong, GSK Con-
sumer Healthcare’s general manager.
“All these measures are part of our re-
sponsibility as a global pharmaceutical
company to ensure that the health of our
consumers is not compromised in any
way.”
“Our pledge with the MPS also
serves to remind consumers that they
have a role to play in medicinal safety.
They should not be shy about asking
their pharmacists about the right medi-
cation for them, alternative options, and
what to do in cases where they are un-
able to adhere completely,” he added.

4 JANUARY/FEBRUARY ISSUE
NATIONAL NEWS

5 JANUARY/FEBRUARY ISSUE

Programme to promote community pharmacy-
based diabetes management
Rachel Soon
I
n conjunction with World Diabetes
Day 2019, health biotech compa-
ny Holista CollTech Ltd (Holista)
and CARiNG Pharmacy Group Bhd an-
nounced a 10-year collaboration on a
pharmacy-based platform for better di-
abetes management.
Under the Live Well with Diabetes
programme, the two companies will
jointly contribute to several initiatives to
educate the public on preventing and liv-
ing with the disease. In the short term,
these will include regular live health talks
in the first half of 2020, information shar-
ing events via radio and the Internet, and
the co-launching of Holista’s prediabetic
and diabetic food products in CARiNG
outlets. The partners also aim to distrib-
ute a set of comprehensive guidelines for
a healthier lifestyle to patients with diabe-
tes and their family members.
In addition to public education efforts,
Holista will also contribute to continu-
ing professional development (CPD) for
Chong Yeow Siang (second from left), and Dato’ Dr Rajen Manicka (centre) with CARiNG Pharmacy
staff at the launch of the Live Well With Diabetes collaboration between the two companies.
NATIONAL NEWS
CARiNG pharmacists via the company’s
Pharmacist Diabetes Forum, according
to company representatives. The part-
nership aims to highlight the roles and
responsibilities of community pharma-
cists as health advisors, particularly in
the area of diabetes management.
Pharmacists have the
potential to provide
valuable services to
patients and families
with diabetes in terms
of lifestyle coaching,
not just screening and
treatment.
According to Chong Yeow Siang,
managing director, CARiNG Pharmacy
Group Bhd., the collaboration is a fur-
ther step in a series of ongoing diabe-
tes management efforts provided by the
pharmacy group since 2014. These ef-
forts have included multiple awareness
campaigns, focus group workshops,
one-stop corners for diabetes resources
6 JANUARY/FEBRUARY ISSUE
in 33 outlets, an in-house virtual diabe-
tes management system, and a pilot
3-month nutritional therapy programme
to address HbA1c reduction and weight
loss, he said.
Speaking at the official launch of the
collaboration, Dato’ Dr Rajen Manicka,
Holista founder and chief executive offi-
cer, said pharmacists have the potential
to provide valuable services to patients
and families with diabetes in terms of
lifestyle coaching, not just screening and
treatment.
“Modern medicine is good at tell-
ing people what their health situation is
and what medicines to take, but when
it comes to how to live with diabetes,
we’re lousy,” said Rajen. “For many,
when they become a diabetic, it’s akin
to a death sentence … there is no one
to guide them through what comes next.
I believe that pharmacists can play im-
portant roles in that space.”
Rajen added that Holista had chosen
partnership with CARiNG due to its be-
ing the current largest employer of phar-
macists in the private sector, with over
238 pharmacists actively covering 132
outlets nationwide.
In a statement issued at the launch,
Datin Mariani Ahmad Nizaruddin, vice
president I of the Malaysian Pharmaceu-
tical Society (MPS), said that an estimat-
ed 20% of more than 16,000 registered
pharmacists in Malaysia are engaged
in community pharmacy practice. Over
2,300 community pharmacies were reg-
istered at the end of 2018, of which 746
were chain pharmacies.
“Community pharmacists play an
active role in advising patients on nutri-
tion, healthy diets, and diabetes condi-
tion management, as well as providing
screening services and self-care tests,”
Mariani added.

SARS-CoV-2 outbreak: FIP issues guidelines
for pharmacists
Rachel Soon
T
he International Pharmaceutical
Federation (FIP) has released a
29-page health advisory doc-
ument to guide pharmacists worldwide
on how to manage the 2019-nCoV, now
named severe acute respiratory syn-
drome coronavirus 2 (SARS-CoV-2), out-
break within their spaces.
Titled ‘Coronavirus 2019-nCoV out-
break: Information and interim guide-
lines for pharmacists and the pharmacy
workforce’, the document shared by the
Malaysian Pharmaceutical Society (MPS)
Facebook page gives a comprehensive
overview of clinical information regarding
onset, symptoms, treatment, stock man-
agement, and prevention of the disease.
It also provides an extensive list of
recommendations for pharmacy mediat-
ed preventive measures, recommended
equipment to stock, advice for pharma-
cists to give to members of the public,
triage and referral procedures, and labo-
ratory testing measures.
The full document from the FIP can
be downloaded online in six languages
at https://www.fip.org/coronavirus and is
subject to updates given ongoing devel-
opments in the global situation.
The FIP document was developed
by an emergency taskforce, with contri-
butions from the experiences of the Chi-
nese Pharmaceutical Association.
“Since pharmacies are often the first
point of contact with the health system
and given that cases have already been
seen in a number of countries, it is im-
portant that the whole pharmacy work-
force is well informed and prepared,”
said Jane Dawson, FIP taskforce chair
and secretary of FIP’s Military and Emer-
gency Pharmacy Section.
NATIONAL NEWS
Severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2): How can pharmacists advise?
(adapted from “FIP Poster: Decision tree for community pharmacist advice”
at https://www.fip.org/coronavirus)
NO symptoms • Offer reassurance
(cough/fever/ • Very unlikely to have SARS-CoV-2 infection risk
breathing difficulties) • Highlight preventive measures
NO travel history to • Provide evidence-based information and advice
affected areas/contact (oral and/or written)
with infected people
HAS symptoms • Offer reassurance
NO travel history to • Very unlikely to have SARS-CoV-2 infection risk
affected areas/contact • Highlight preventive measures
with infected people • Provide evidence-based information and advice
(oral and/or written)
NO symptoms • Offer reassurance
Recent travel history • Risk of SARS-CoV-2 infection may exist
to affected areas/ • Highlight preventive measures and recommend
contact with infected home quarantine for 14 days
people • Trace contacts history
• Provide evidence-based information and advice
(oral and/or written)
• If symptoms appear in 14 days after return from
travel/contact with infected person, contact
emergency services/reference hospital
HAS travel plans to • Offer reassurance
affected areas/contact • Risk of SARS-CoV-2 infection may exist
with infected people • Recommend home quarantine for 14 days upon
return from travel
• Inform about situation and ways of transmission
• Highlight preventive measures
• Provide evidence-based information and advice
(oral and/or written)
HAS symptoms • Offer reassurance
Recent travel history • Risk of SARS-CoV-2 infection may exist
to affected areas/ • Contact authorities to initiate care protocol. In
contact with infected Malaysia, at-risk patients are referred to designated
people hospitals for screening, with a full list available at
http://www.moh.gov.my/moh/resources/Penerbitan/
Garis%20Panduan/Pengurusan%20KEsihatan%20
&%20kawalan%20pykit/2019-nCOV/Annex_3_
Senarai_Hospital_for_nCoV_2020.pdf.
• Inform about procedure of isolation, diagnosis and
treatment
• Highlight measures to prevent further transmission
• Provide evidence-based information and advice
(oral and/or written)
7 JANUARY/FEBRUARY ISSUE
 NATIONAL NEWS

Research in brief: emergency errors, curry

leaves, and TKIs
consuming approximately US$42 bil-
lion annually in healthcare expenditure,”
wrote the study authors, who added that
emergency departments were high-risk
areas for ME occurrences.

“Patients with a higher number of

medications prescribed during [their] visit
to the ED were found to be particularly
at risk. Identification of such factors may
guide intervention measures to prevent
medication errors in this setting,” they
added.

Curry leaf extracts

demonstrate antibacterial
potential

Rachel Soon patient visit (adjusted OR, 0.34; 95% CI,
0.52–0.75). [Hospital Pharmacy 2019;
Medication errors doi:10.1177/0018578719890092]
identified in one-third of
emergency admissions at “Medication errors continue to pose
training hospital a significant problem to healthcare sys-
tems across the world, not only caus-
E
xtracts of Murraya koenigii (curry
leaf) may point the way to new
antimicrobial compounds for
common pathogens, according to an in
vitro study.
In a joint collaboration among re-
searchers from Universiti Sains Malaysia,
International Islamic University Malaysia,
and the Kebbi State University of Science

A
recent cross-sectional study at ing harm and death in patients but also and Technology, Nigeria, it was found that
Hospital Universiti Sains Ma-
laysia (HUSM) found almost a
third of emergency department visits in a
9-week period experienced at least one
medication error (ME).

Of 547 patients who visited HUSM’s

emergency department during normal
working hours (between 8 am and 5 pm)
and who were enrolled in the study, 311
were selected at random for analysis. Of
these, 95 patients (30.5%) experienced
at least one ME.

The main factors associated with

ME were identified as number of medi-
cations (adjusted odds ratio [OR], 1.91;
95% confidence interval [CI], 1.51–
2.41), triage (adjusted OR, 0.11; 95%
CI, 0.04–0.27), gender (adjusted OR,
0.50; 95% CI, 0.26–0.93), and time of

8 JANUARY/FEBRUARY ISSUE

a minimum inhibitory concentration (MIC)
of 15.63 μg/mL of ethyl acetate M. koe-
nigii leaf extract was enough to disrupt
cell walls in human pathogens such as
Staphylococcus aureus, Escherichia coli,
Vibrio alginolyticus, Vibrio parahaemo-
lyticus and Yersinia enterocolitica. [Eur
J Integr Med 2020;doi:10.1016/j.eu-
jim.2019.101010]
The researchers also compared the
MICs of M. koenigii extract against pure
versions of potentially antimicrobial flavo-
noids previously identified in the species
from other studies, ie, quercetin, myrice-
tin and rutin, as well as tetracycline as a
control.
Overall, M. koenigii leaf extract
(15.63–1000 μg/mL) and stem extract
(15.63–125 μg/mL) were needed in high-
er concentrations to reach antibacterial
activity comparable to tetracycline (0.06–
31.25 μg/mL). However, higher concen-
trations of the flavonoids were needed to
match the M. koenigii extracts (quercetin,
62.5–1000 μg/mL; myricetin, 31.25–500
μg/mL; rutin, 125–250 μg/mL).
Nine strains of bacteria pathogenic
NATIONAL NEWS
to humans were tested in the study,
consisting of four gram-negative strains
(Listeria monocytogenes, S. aureus, E.
coli O157:H7, E. coli ATCC 25922) and
five gram-positive strains (V. alginolyt-
icus, V. parahaemolyticus, Salmonella
paratyphi, Salmonella typhi, Y. enteroco-
litica).
The present study
demonstrates that
the ethyl acetate leaf
extract of Murraya
koenigii has a
broad spectrum of
antibacterial activity
against the tested
bacteria.
However, the extracts did not appear
to affect Salmonella species tested in the
study, while Listeria monocytogenes was
affected only by hexane and chloroform
extracts from M. koenigii stems.
“The present study demonstrates
that the ethyl acetate leaf extract of Mur-
raya koenigii has a broad spectrum of
9 JANUARY/FEBRUARY ISSUE
antibacterial activity against the tested
bacteria,” wrote the researchers. “Clinical
trials are recommended to verify novel
therapeutic agents. The bioactive phe-
nolic compounds that are contained in
the extract might be responsible for the
antibacterial activities.”
Afatinib may offer survival
benefit over gefitinib,
erlotinib in advanced lung
cancer
S
econd-generation EGFR-TKI*
afatinib may provide longer
progression-free survival over
first-generation EGFR-TKIs gefitinib or
erlotinib in first-line treatment of EGFR
mutant advanced lung adenocarcinoma,
according to a new study.
In a retrospective analysis of 113 pa-
tients treated with first-line afatinib, gefi-
tinib or erlotinib (n=24, 63, 26, respective-
ly) at University Malaya Medical Centre
between 2015 and 2018, researchers
found that median progression-free
survival (mPFS) of patients treated with
afatinib (13.1 months) exceeded that of
gefitinib or erlotinib (10.9 months and
7.8 months, respectively; p=0.479).
[Ann Oncol 2019; doi:10.1093/annonc/
mdz437.013]
Patients on afatinib had consistently
longer PFS than those on gefitinib for the
first 17 months and erlotinib for the first
20 months. The overall response rate
was higher in patients on afatinib (75.0%)
than those on gefitinib (63.5%) or erlo-
tinib (53.8%). However, there was no
difference in disease control rate among
the three treatments.
The authors attributed the lack of
statistical significance in the study to the
small number of patients on afatinib, as
well as the more frequent use of afati-
nib over the other two options for rare
or complex EGFR mutations and more
symptomatic brain metastases.
* EGFR-TKI: epidermal growth factor receptor-
tyrosine kinase inhibitor

Symposium showcases industrial pharmacy
opportunities
Rachel Soon
P
harmaceutical industry represen-
tatives highlighted lesser-known
career opportunities for licensed
pharmacists at the recent Pharmaceuti-
cal Industries Pharmacists Insights 3.0
(PIPI 3.0) symposium in Petaling Jaya.
Themed ‘Beyond “A”normous: all
pharmacists’ values beyond Poison A
license holders’, PIPI 3.0 saw experi-
enced industry representatives touch on
various aspects of professions in indus-
trial pharmacy including pharmaceutical
innovations, drug development, tran-
sitions from the hospital or community
pharmacy to industry, business manage-
ment, and global direction.
“Although the liberalization of pro-
visionally registered pharmacist (PRP)
training has been in effect since 2012,
many are still not familiar with opportu-
nities in the industry,” said Sharon Ding,
PIPI 3.0 advisor, at the opening ceremony.
“Most have the impression that phar-
macists in the industry mainly work in
sales and marketing, or manufacturing.
In fact, there are more non-convention-
al roles that need qualified pharmacists,
such as clinical research in oncology, bi-
ologics development, radiopharmaceuti-
cals, validation, stability, quality control,
testing, and [data] interpretation,” she
added.
Ding emphasized the importance
of pharmacy graduates expanding their
view of employment opportunities, not-
ing that medium- and high-skilled jobs
accounted for only 10.5% of national job
vacancies as of early 2019, according to
government statistics.
“The pharmacy profession, once
seen to be stable, is no longer a guar-
anteed job-getter,” said Ding. “You’re not
guaranteed a position in a hospital.”
NATIONAL NEWS
L-R: Andrew Roy Pereira, pharmacist, Hospital Melaka; Soo Li Ping, senior manager regulatory
affairs, Roche Malaysia; and Loke Jee Chung, manager, international business, Duopharma, speaking
at a dialogue session at PIPI 3.0.
Hosted at Taylor’s University Lake-
side Campus in partnership with the
Malaysian Pharmaceutical Society (MPS)
Industrial Chapter, the conference saw
an estimated 120 participants—primar-
ily pharmacy students and recent grad-
uates—attend to gain more insights
into misconceptions about the industry,
the differences between frontline and
back-end professions, career advance-
ment potential, and professional respon-
sibilities.
At a dialogue session titled ‘Food for
Thought: The Journey with Opportunities
or Obstacles?’, Roche Malaysia’s senior
manager regulatory affairs Soo Li Ping
and Duopharma’s international business
department manager Loke Jee Chung
fielded questions from the audience re-
garding their experiences as industrial
pharmacists.
On being asked about whether PRP
made a difference to employability with-
in the industry, Soo and Loke advised
young graduates to complete their PRPs
where possible.
“Don’t be too choosy; apply for
multiple placements to make sure you
10
complete your PRP and get your phar-
macy license first,” said Soo. “It’s difficult
to re-enter PRP if you enter the work-
force immediately [after graduating] and
then change your mind.”
They also added that pharmacy de-
grees should not define what range of
professional roles to consider, but rather
be considered as a supporting asset to
any role.
“Don’t limit yourself to a specific
department within a pharmaceutical
company; try working in different de-
partments to gain more exposure and to
contribute your own experiences there,”
said Loke.
Soo added, “From a multinational
[company’s] perspective, pharmacists
were traditionally hired for roles that
needed higher science degrees, while
commercial roles were designated for
those with business degrees, and so on.
But today, more pharmacists are going
into commercial roles. Having a phar-
macy degree actually helps you grow
into any role within the industry that
you’re interested in … it’s an enabler, not
a limiter.”
JANUARY/FEBRUARY ISSUE
 NATIONAL NEWS

How safe are herbal medicines?

We often hear sales pitches from promoters and friends regarding herbal products: “This is
natural, so it is safe.” Well, as the argument goes, cyanide is also natural since it can be derived
from the pits and seeds of common fruits such as apricots and apples. Professor Gan Siew Hua,
head of the School of Pharmacy, Monash University, speaks to MIMS regarding the safety of
herbal medications and their possible side effects.

What is traditional and lifetime is high in certain developed coun- Some drugs, such as digoxin which
complementary medicine? tries: Belgium (38%), US (42%), Australia is used to treat heart failure and irregular

T
raditional and complementa-
ry medicine (T&CM) is a term
generally used to describe the
practice of medicine which is not the
conventional scientific type. According
to the Ministry of Health (MOH), it en-
compasses traditional Malay, Chinese
and Indian medicine, homeopathy, com-
plementary therapies, and herbal medi-
cines, but excludes medical or dental
practices by registered medical or dental
practitioners. [Available at: http://tcm.
moh.gov.my/ms]
Herbal medicine is widely utilized in
many developed countries. In fact, utili-
zation of T&CM is the norm in Europe,
North America and Australia. To date,
herbal medicines contribute to about
40% of all healthcare services provided
in China. The proportion of inhabitants
which has been reported to have utilized
herbal medicines at least once in their
(48%), Canada (70%) and France (75%).
[J Am Geriatr Soc. 2000;48(12):1560–
1565; WHO/EDM/TRM/2002]
Many modern drugs
are designed based
on the molecular
structure of the active
constituents present
in natural products.
Are herbal medicines truly
herbal?
Herbal medicines are normally sold as
tablets, capsules, powders, teas, ex-
tracts, fresh or dried plants, or dietary
supplements. Although many people
believe that products labelled as ‘natural’
are always safe and good for them; this
is not necessarily true.
heartbeat, is extracted from Digitalis pur-
purea and can cause death if taken in ex-
cessive amounts. In fact, many modern
drugs are designed based on the molec-
ular structure of the active constituents
present in natural products. For example,
aspirin (acetylsalicylic acid) is developed
based on the molecular structure of sal-
icylic acid, a substance extracted from
the bark of the willow tree.
Dietary supplements do not have to
go through rigorous testing that mod-
ern drugs do. Additionally, product reg-
istration is more relaxed. In our country,
registered products are recognized by a
hologram label on its packing indicating
its registration number which begins with
the word ‘MAL’ (which represents Malay-
sia) followed by eight digits that end with
the alphabet ‘T’ for traditional medicines.
Therefore, only registered products
should be purchased.

11 JANUARY/FEBRUARY ISSUE

A study conducted on 260 drugs pat-
ented in Asia reported that many prod-
ucts, especially Ayurvedic medicines,
contained heavy metals like mercury
(14%), arsenic (14%), and lead (10%).
Heavy metals may be intentionally intro-
duced into the product or are present
in contaminated environment during the
manufacturing process. The US Centers
for Disease Control (CDC) reported that
heavy metals like lead present in Indian
Ayurvedic herbal medicines can cause
deafness, paralysis, growth retardation
(in children), seizures, and death. [Ex-
pert Opin Drug Saf 2005;4(4):769–778;
https://www.cdc.gov/mmwr/preview/
mmwrhtml/mm5326a3.htm]
Other than heavy metals, herbal
medicines may also be adulterated with
modern drugs. In fact, it has been re-
ported that 7% of herbal medicines were
intentionally adulterated with steroids
(including dexamethasone and prednis-
olone), sexual stimulants (such as silde-
nafil), drugs for losing weight (like sibutra-
mine) or drugs used in the treatment of
allergies (like chlorpheniramine). [Leg
Med (Tokyo) 2007;9(5):258–264]
Steroids are commonly the culprit
because it is the “panacea for all ills”.
Adulteration is hazardous since users
may be oblivious to the presence of
these substances thinking that they are
NATIONAL NEWS
“natural and safe”. If consumed unknow-
ingly with modern drugs, there is a pos-
sibility of exposure to adverse effects and
drug interactions.
Besides heavy metals and adulter-
ation with modern drugs, herbal med-
icines can also be contaminated with
pesticides (like malathion and paraquat),
microorganisms (like various bacteria
and fungi), or other herbal ingredients
especially during their production. The
manufacturing process, if done in a con-
taminated environment or vesicle, can be
a source of contamination.
Some fungi, like aflatoxin, which are
naturally present in herbal products and
are not properly removed, may pose a
cancer risk.
Herbal preparations: what
and when to avoid?
Some herbs contain naturally occur-
ring substances known as coumarins, a
group of anticoagulants that includes the
drug warfarin. One should stop consum-
ing herbal medicines at least 7–14 days
before undergoing a major surgery due
to a higher risk of uncontrolled bleeding
during or after the surgery.
Examples of herbs which may af-
fect blood clotting and cause excessive
bleeding are:
12
• Hempedu bumi (Andrographis pa-
niculata), especially if consumed
in high doses (more than 1.2 g/
day). [Int J Nutr Pharmacol Neurol
Dis.2013;3(1):3–10]
• Garlic may help with blood pressure
and cholesterol lowering in some in-
dividuals but consuming more than
4 g/day may cause excessive bleed-
ing. [Braun, L., et al. Herbs & Natural
Supplements: An evidence-based
guide. Sydney: Churchill Livingstone
Elsevier; 2007.]
• Ginseng, usually taken as an an-
ti-ageing herb, to boost immunity
or improve sex. To date, no exact
dose has been reported that can
cause excessive bleeding. [Evid
Based Complement Alternat Med
2011;doi:10.1155/2011/612150]
• Dong quai (Angelica sinensis) con-
tains coumarins as well—no exact
dose reported.
• Ginkgo biloba, a Chinese herbal
medicine consumed to improve blood
circulation and memory, may also
pose some risk of increased bleeding
in combination with warfarin. [AMIA
Annu Symp Proc 2015;1174–1183]
Examples, uses, and adverse
effects
Asian ginseng, also known as Korean
ginseng or red ginseng (Panax ginseng),
is native to the Far East (including China
JANUARY/FEBRUARY ISSUE
 NATIONAL NEWS

and Korea) and used as a tonic to replen-

ish energy and increase concentration;
stimulate the immune function, slow the
ageing process, ameliorate anxiety and
erectile dysfunction; improve menopaus-
al symptoms, and overall, to improve
general well-being.

Asian ginseng roots have been

reported to contain active constituents
known as ginsenosides, which are be-
lieved to contribute to its purported
medicinal claims. Nevertheless, some
evidence indicates that the herb may al-
ter blood pressure and blood sugar, and
therefore should be avoided in individu-
als with diabetes or high blood pressure.
Another type of ginseng, the American
ginseng (Panax quinquefolius) is not re-
ported to cause the same effects.

Pregnant and
breastfeeding women,
as well as children,
should abstain
from using herbal
medicines since their
safety is not proven in
controlled trials.
Fenugreek, mostly used as a spice
in cooking, has been traditionally used to
induce childbirth. In modern times, it is
used as a dietary supplement to enhance
lactation and control diabetes. Neverthe-
less, fenugreek has oestrogen-like prop-
erties, and therefore may be dangerous
in women with hormone-sensitive can-
cers like ovarian and breast cancers.
Additionally, fenugreek may also
cause uterine contractions in pregnant
women. Other adverse effects of fenu-
greek include diarrhoea, smelly urine and
sweat, and worsening of asthma.
Safety and validity of herbal
medicines
Herbal medicines should be purchased
from reliable sources. Patients should be
reminded that herbal medicines can be
regarded as similar to modern drugs with
important active constituents. Therefore,
they pose similar risk of interaction with
other drugs, with adverse effects.
There is still a lack of validity and
safety data for many herbal medicines.
Therefore, if herbal medicines are used
for the treatment of diseases, it is best
to not use them for a long duration. Ad-
ditionally, recommended doses (if any)
should be followed to prevent any po-
tential adverse effects or interactions. If
a patient experiences any adverse ef-
fects when using herbal medicines, they
should be advised to check with a doctor
immediately.
Pregnant and breastfeeding women,
as well as children, should abstain from
using herbal medicines since their safety
is not proven in controlled trials. This is
because it is unethical to include these
groups in clinical trials. Therefore, their
effects (and safety) are not well-estab-
lished in these populations.
Patients should be advised to inform
their doctor or pharmacist if they are tak-
ing herbal medicines, so that they can
check for potential drug interactions.
It has been reported that 40% of pa-
tients do not reveal the use of herbal
supplements or alternative medicines
to their doctor. The Malaysian herbal
industry, valued at approximately RM29
billion, unfortunately contributes to drug-
induced liver failure in 42% of cases.
[Available at https://www.thestar.com.
my/news/nation/2018/11/26/not-so-
good-remedy-for-your-health-herbal-
medicine-may-have-deadly-side-effects-
say-medical-experts.]
It is believed that the number of cas-
es has been underreported since pa-
tients may refuse a liver biopsy and the
cause of liver failure remains unknown.
Besides liver failure, the report stat-
ed that substances found in traditional
medicine may also cause kidney failure,
urinary tract cancer, and heart compli-
cations. Therefore, herbal medicines—
though generally regarded by the public
as ‘safe’—should be used with caution.
Ed: Prof Gan has authored a book titled
‘Tips on Using Common Medicines Safely’
published by MPH.

13 JANUARY/FEBRUARY ISSUE
FRONT PAGE

How to ward off

medication errors:
Experts' perspectives

14 JANUARY/FEBRUARY ISSUE

Pearl Toh
A
lmost three-quarters of adverse
events (AEs) related to medica-
tion errors in over-the-count-
er (OTC) cough and cold medications
(CCMs) for paediatrics required evalu-
ation by healthcare facility and majority
of the cases were due to dosing errors,
a Singaporean surveillance study has
found, highlighting the need for interven-
tions to mitigate medication errors.
With the advent of the digital age, the
potential of new technologies can be har-
nessed to help detect medication errors
and allow for medication reconciliation at
transition points such as at hospital ad-
mission, as shown in a separate study.
What we do is a two-
people verification
and check of
medications. In [the]
polyclinic, there are
pharmacy technicians
to cross check.
When asked on how medication
errors can be prevented in the primary
care setting, Dr Serene Wee from Park-
FRONT PAGE
way Shenton, Singapore, who was not
affiliated with the studies, responded:
“What we do is a two-people verification
and check of medications. In polyclinic,
there are pharmacy technicians to cross
check.”
“We also have drug information op-
tion available on [clinic management
software system] to check drug dosag-
es, indications [and other drug informa-
tion],” she added.
Dosing errors most common
In the national surveillance study, 513
paediatric cases with a significant AE
related to OTC CCM identified were due
to medication errors. Almost all cases
(93.2%) were due to the wrong dose
of medication administered. Of these,
dose volume error constituted 86.6% of
the dosing error, while 19.2% involved
dose frequency error. [Acad Pediatr
2019;doi:10.1016/j.acap.2019.09.006]
Although no deaths were report-
ed from the medication errors, near-
ly three-quarters (74.3%) of the cases
needed to be evaluated at healthcare
facility, and 24.6% were admitted.
“Continued standardization of mea-
suring devices, concentrations, and units
15
of measure along with consumer educa-
tion are needed to further decrease med-
ication errors from CCMs,” the research-
ers suggested.
Continued
standardization of
measuring devices,
concentrations, and
units of measure
along with consumer
education are needed
to further decrease
medication errors
from CCMs.
Diphenhydramine (30.2%) and dex-
tromethorphan (50.9%) were the most
common ingredients responsible for
most medication errors, regardless of
formulations used. They also account-
ed for most of the medication errors
requiring evaluation at healthcare facility
(29.1% and 52.0%, respectively).
“While identifying the root cause of
medication errors may help target inter-
ventions to improve safe use, nearly a third
of medication error cases involved chil-
dren <4 years old for whom CCM use is
not recommended,” said the researchers.
JANUARY/FEBRUARY ISSUE

Almost half of the medication errors
(45.8%) involved children aged 2 to <6
years.
“The child is growing. Their weights
are moving targets. Sometimes parents
may underdose the child by giving the
same volume months ago,” commented
Associate Professor Andrea Kwa, assis-
tant director of Health Services Related
Research Unit at Department of Phar-
macy, Singapore General Hospital, Sin-
gapore, who was unrelated to the study.
“The key is to empower the parents
how to dose, what to use these medi-
cations for, and the knowledge of what
is available in the local market,” she
stressed.
Labelling, counselling,
education
Many errors come about from not know-
ing that some medications given were
similar types to others given, and this
arises because of leftover medications
from previous visits to pharmacies and
clinics, according to Kwa.
Patients should be counselled on what other drugs they
receive and how to identify drugs with similar active
ingredients locally and online.
FRONT PAGE
In such cases, counselling and de-
tailed labelling can help keep medication
errors at bay, be it in the setting of OTC
pharmacies, primary care, or hospitals,
she said. Patients should be counselled
on what other drugs they receive and
how to identify drugs with similar active
ingredients locally and online.
“I will add on and explain the follow-
ing details, teaching the parents how to
apply should [the child] need the same
medication many months down the
road,” said Kwa, alluding to keeping de-
tails such as the patient’s weight by the
date recorded, the appropriate dose by
weight (mg per kg), and the associated
dose (in volume) in the label.
“Further education to healthcare pro-
viders on the recommended safe use
of these medications in young children,
in addition to understanding caregiver
awareness of labelled warnings and rea-
sons why they continue to use CCMs
despite these warnings may lead to ad-
ditional improvements in safety,” the re-
searchers added.
16
Also, modern technology can pro-
mote medication adherence and avoid
dosing medication errors—especially in
cases involving multiple caregivers—by
improving communication between dif-
ferent parties and avoid repeat dosing,
the researchers pointed out.
Electronic tool for medication
reconciliation
A separate study showed that an elec-
tronic pharmaceutical record (EPR) of
past medications used by a patient can
help detect prescription errors and allow
for medication reconciliation at hospital
admission. [Presse Med 2019;48:999–
1000]
“In our study, EPR has proved to be
an essential tool to detect prescription
errors. Indeed, it has enabled to detect
them, frequently more than other sourc-
es of information [such as] patient's in-
terview [and] contact with community
pharmacy,” said the researchers.
Of the 70 prescription errors detect-
ed, drug omission was the most com-
mon types of errors (65.7%), followed by
discrepant dose (27.1%) and discrepant
frequency (2.9%).
When the researchers looked into
the information sources used to detect
these errors, most of them were detect-
ed based on EPR (77.1%), followed by
patient’s interview (64.3%), contact with
community pharmacy (42.9%), and pre-
vious drug prescriptions (41.4%).
In fact, six prescription errors (8.6%)
would not have been detected if not for
the source of information from EPR.
“The EPR represents therefore a very
interesting source of information, espe-
cially for patients for which limited infor-
mation is available about their personal
treatment,” said the researchers. “It has
the advantage to list self-medications,
which could interact with the current
treatment. It also allows a better coordi-
nation between healthcare facilities and
community.”
JANUARY/FEBRUARY ISSUE
 ON THE SHELF

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17 JANUARY/FEBRUARY ISSUE

Office, workshop workers at high risk for
vitamin D deficiency
Elaine Soliven
O
ffice and workshop workers
were at a greater risk for vita-
min D deficiency compared with
control room workers, according to a re-
cent Singapore study.
“Little is known about the effect of
working conditions on vitamin D status
in Southeast Asia, where vitamin D defi-
ciency is common despite the presence
of sunlight all year round in most places,”
said the researchers.
A previous study reported that 90%
of vitamin D is synthesized in the skin
upon exposure to ultraviolet B (UV-B)
radiation from sunlight, while 10% is ob-
tained from food such as oily fish, egg
yolks, fortified milk and juices, and di-
etary supplements. [J Clin Endocrinol
Metab 2011;96:1911–1930]
The researchers analysed 213 par-
ticipants (mean age 42.5 years, 76.5%
male) who were office (n=109), work-
shop (n=50), and control room workers
(n=54) from four workplaces in Singa-
pore between August 2016 and January
2017. Blood samples were collected for
FROM ABROAD
determination of serum 25-hydroxyvita-
min D [25(OH)D] concentration to assess
vitamin D status.
Self-administered questionnaires
were given to evaluate work-related fac-
tors and other covariates. At the time of
data collection, the UV index value in Sin-
gapore was ~7.5 (high). Subjects were
followed up at 3 and 12 months. [Int J
Environ Res Public Health 2020;17:164]
Results showed that the overall
prevalence of vitamin D deficiency* was
at 32.9%, which was considered lower
than the general population of Singapore
at 42.1%.
In a multivariate analysis, a signifi-
cantly higher risk of vitamin D deficien-
cy was observed among workers in the
office (prevalence ratio [PR], 2.16, 95%
confidence interval [CI], 1.12–4.16;
p=0.021) or workshop (PR, 2.25, 95%
CI, 1.05–4.81; p=0.037) than those in
the control room.
In addition, those who worked on
night shift (median, one-night shift per
month) showed a significantly increased
18
risk of vitamin D deficiency (PR, 1.31,
95% CI, 1.03–1.67; p=0.027).
“Night shift workers, due to their
working hours and daytime sleeping, are
generally exposed less to solar UV-B ra-
diation,” the researchers noted.
“Other work-related factors[, partic-
ularly working hours per day,] were not
significantly associated with vitamin D
deficiency, … [which is in contrast to pre-
vious studies, wherein] those who work
for long hours indoors are likely to have
low sunlight exposure, and thus are more
prone to vitamin D deficiency,” they add-
ed. [Br J Nutr 2013;109:493–502; Oc-
cup Environ Med;2011;68:902–907]
The researchers noted that the study
has some limitations, including the small
sample size with limited power to detect
a significant difference between the as-
sociation of working hours and vitamin D
deficiency.
“[In conclusion,] office and workshop
workers (vs control room workers) and
night shift workers were at a higher risk
for vitamin D deficiency,” the research-
ers said, who suggested that “work-
place policies and wellness program[me]
s should incorporate regular screening
program[me]s for vitamin D in office,
workshop, and night shift workers.”
“Workers[, especially those doing
night shift,] should [also] be encouraged
to take breaks to go outdoors for sun-
light exposure and to consume adequate
amounts of vitamin D-rich food to main-
tain optimal vitamin D levels, although the
role of supplements remains controver-
sial,” said the researchers.
“Future studies with larger sample
size are required to confirm our study
findings,” they added.
* Vitamin D deficiency: Defined as serum 25(OH)D
concentration of <50 nmol/L
JANUARY/FEBRUARY ISSUE

No link between talc powder and ovarian
cancer risk in large study
Pearl Toh
T
here was no evidence that the
use of talc powder in the geni-
tal area was associated with an
increased risk of ovarian cancer, a large
pooled analysis of four prospective co-
hort studies shows.
“[The study] represents the largest
cohort to date to examine whether an as-
sociation exists between powder use in
the genital area and ovarian cancer risk,
and the findings are overall reassuring,”
stated Drs Dana Gossett and Marcela del
Carmen from the University of California,
San Francisco and Harvard University
Medical School in Boston, Massachu-
setts, US, respectively in an accompa-
nying editorial. [JAMA 2020;323:29–31]
The analysis pooled data from
252,745 women (median age 57 years)
from four large US-based cohorts:
NHS (n=81,869), NHSII (n=61,261),
SIS (n=40,647), and WHI-Observational
Study* (n=73,267). Thirty-eight percent
of the women reported use of powder in
the genital area, of which 10% of the ever
users were long-term (≥20 years) users
and 22% were frequent users (at least
once per week).
During a median follow-up of 11.2
years, 2,168 women developed ovarian
FROM ABROAD
cancer, equating to an incidence rate of
58 cases/100,000 person-years overall.
[JAMA 2020;323:49–59]
Specifically, the incidence of ovar-
ian cancer was 61 cases/100,000 per-
son-years among ever users compared
with 55 cases/100,000 person-years
among never users–which translates to
a 0.09% difference in estimated risk at
70 years between the two groups and
did not reach statistical significance (esti-
mated hazard ratio [HR], 1.08, 95% con-
fidence interval [CI], 0.99–1.17).
Similar results were seen when users
were stratified by frequent use (estimat-
ed HR, 1.09, 95% CI, 0.97–1.23) and by
long-term use (estimated HR, 1.01, 95%
CI, 0.82–1.25), compared with never
use.
“There were no clear dose-response
trends for duration and frequency of
powder use in the genital area in rela-
tion to ovarian cancer risk,” said the re-
searchers.
When the analysis was restrict-
ed to women with patent reproductive
tracts**—a susceptible subgroup—the
HR was 1.13 (95% CI, 1.01–1.26), com-
pared 0.99 among those with nonpatent
reproductive tracts (p=0.15 for heteroge-
neity).
19
“This is the key finding of the study,”
said Gossett and del Carmen. “It is not
possible to equate a patent reproductive
tract with exposure and a nonpatent re-
productive tract with nonexposure … [as
the nonpatent subgroup who] use pow-
ders in the genital area cannot be as-
sumed to have started using them only
after their surgeries.”
“The fact that there are no significant
differences in the HRs in the patent and
nonpatent subgroups confirms the over-
all conclusion that there is no demonstra-
ble statistically significant association be-
tween use of powder in the genital area
and ovarian cancer risk,” they added.
While the HR was 1.19 for frequent
vs never use of powder among the wom-
en with patent reproductive tracts, Gos-
sett and del Carmen commented that
the difference “is below the effect size
that epidemiologists generally consider
important,”–and thus, “should not be
selectively highlighted by the statistically
unsophisticated reader as evidence of a
relationship.”
Previous case-control studies have
suggested positive associations be-
tween powder use in the genital area and
risk of ovarian cancer, but these studies
are susceptible to recall bias in view of
the recent upsurge of talc-related law-
suits and media coverage, the research-
ers noted.
“Although the study was underpow-
ered to detect small changes in risk, this
is, to our knowledge, the largest study of
this topic to date, and it is believed that
no other large prospective cohorts have
collected data on powder exposure in
the genital area,” the researchers high-
lighted.
* NHS: Nurses’ Health Study, SIS: Sister Study, WHI:
Women’s Health Initiative
** having an intact uterus and no tubal ligation
JANUARY/FEBRUARY ISSUE

Pre-pregnancy acetaminophen use tied to
increased adverse birth outcomes risk
Elaine Soliven
T
he use of acetaminophen 3
months prior to pregnancy was
associated with an increased
risk of adverse birth outcomes, such as
low birth weight (LBW), preterm birth
(PTB), and small-for-gestational-age
(SGA), according to a recent study.
Using data from the Ontario Birth
Study (OBS), the researchers conduct-
ed a prospective study involving 1,200
women (mean age 33.8 years, mean
BMI 23.2 kg/m2) who gave birth between
January 2013 and June 2017 at Mount
Sinai Hospital in Ontario, Canada.
Information on acetaminophen use
and other lifestyle factors across the
three periods of pregnancy were docu-
mented in a questionnaire, and was cat-
egorized into pre-pregnancy (3 months
before pregnancy), early pregnancy (first
12–16 weeks), and mid-to-late pregnan-
cy (completion of the first questionnaire
and 28–32 weeks of gestation). [Pediat-
ric Research 2019;doi:10.1038/s41390-
019-0726-8]
After adjusting for potential confound-
ers, children born to mothers who were
exposed to acetaminophen for ≥1/week
pre-pregnancy were at an increased risk
of being LBW (<2,500 g; adjusted risk ra-
tio [adjRR], 2.16, 95% confidence inter-
val [CI], 1.02–4.54), SGA* (adjRR, 1.84,
95% CI, 1.14–2.98), or PTB** (adjRR,
1.86, 95% CI, 0.96–3.63), which was not
statistically significant.
An increased risk of SGA was also
observed among children of mothers
who consumed acetaminophen <1/
week pre-pregnancy (RR, 1.46, 95% CI,
1.02–2.11).
However, the researchers found
no associations between acetamino-
phen intake during early or mid-to-late
FROM ABROAD
pregnancy and risk of adverse birth out-
comes.
With regard to the frequency of ac-
etaminophen use, women who were
only exposed to acetaminophen during
pre-pregnancy or early pregnancy
demonstrated an increased risk of their
infants being born SGA (RR, 1.54, 95%
CI, 1.02–2.34).
“[Of note,] we were … able to in-
corporate information on frequency of
acetaminophen use, to detect a dose
response relationship between maternal
acetaminophen use during the pre-preg-
nancy period and the offspring being
born SGA.
In addition, we limited the possibility
of confounding by other pain medica-
tions by adjusting for the use of other
commonly used pain medications includ-
ing NSAIDs,” noted the researchers.
On the other hand, those who used
acetaminophen across the three preg-
nancy periods showed no increased risk
of PTB (RR, 1.29, 95% CI, 0.58–2.88),
LBW (RR, 1.18, 95% CI, 0.47–2.95), or
SGA (RR, 0.80, 95% CI, 0.41–1.53).
20
“[W]e found that maternal acetamin-
ophen use in the 3 months prior to preg-
nancy is associated with an increased
risk of adverse birth outcomes,” the re-
searchers highlighted. “As data on lon-
ger-term outcomes in the OBS cohort
are not yet available, PTB, LBW, and
SGA serve as intermediary outcomes
that have been implicated in later nega-
tive developmental outcomes. Follow-up
of offspring in the OBS cohort is ongoing
and future studies to investigate child de-
velopmental outcomes are planned.”
“To our knowledge, acetaminophen
remains the safest analgesic for use
during pregnancy as per the current lit-
erature. However, further research is
warranted to evaluate and validate our
results, and to investigate the effects of
pre-conception acetaminophen use,”
said the researchers, noting that “the
results … should not be overstated so
as to not unnecessarily burden preg-
nant women and those planning for
pregnancy.”
* SGA: Defined as a birthweight of <10th centile for
gestational age, relative to a Canadian reference
population
** Preterm birth: Live birth before 37 weeks of
gestation
JANUARY/FEBRUARY ISSUE
EMPOWERING
HEALTHCARE
COMMUNITIES

Little evidence to support use of common
antidepressant in autism
Pearl Toh
W
hile the SSRI* fluoxetine ap-
peared to improve obses-
sive-compulsive behaviours
at 16 weeks compared with placebo in
children and adolescents with autism
spectrum disorders (ASD) in the initial
analysis, the difference between groups
became nonsignificant after correcting
for potential confounding factors and
imbalances in baseline characteristics,
reveals the FAB** study.
“More than half of children and ado-
lescents with ASD are prescribed med-
ication, with up to one third receiving
antidepressants despite inconclusive ev-
idence of their effectiveness,” said lead
author Professor Dinah Reddihough from
the Royal Children’s Hospital in Parkville,
Australia.
“[The results] will challenge the field
to reconcile the limited performance of
the drug with long-standing utilization
patterns,” wrote Professor Bryan King of
UCSF Weill Institute for Neurosciences,
University of California, San Francisco in
San Francisco, California, US in a linked
editorial. [JAMA 2019;322:1557–1558]
In the primary analysis, fluoxe-
tine decreased the scores for obses-
sive-compulsive behaviours on the
CYBOCS-PDD*** more than place-
bo at 16 weeks (mean change from
baseline, -3.72 vs -2.53 points), with a
corresponding between-group mean
difference of -2.01 (p=0.03). [JAMA
2019;322:1561–1569]
However, the difference between
groups was nullified (mean, -1.17;
p=0.21) after further adjustments for
potential confounding factors and base-
line imbalances in prespecified analyses,
which according to the authors, weak-
ened the strength of evidence from the
primary analysis above.
FROM ABROAD
In addition, interpretation of the pri-
mary finding was further limited by the
high dropout rate as well as confidence
intervals that included the minimal clini-
cally important difference of 2 points for
CYBOCS-PDD scores.
There were also no significant dif-
ferences between groups for other
secondary measures, including Repet-
itive Behaviour Scale-Revised, Spence
Children’s Anxiety Scale, Aberrant Be-
haviour Checklist-Community Version,
Clinical Global Impression Scale-Global
Improvement and Efficacy Index, and
disruptiveness assessment.
Adverse events (AEs) were reported
in 45% of participants in the fluoxetine
arm and 42% in the placebo arm. Sleep
disorders were the most common AE
(n=13 vs 16), followed by gastrointesti-
nal issues such as diarrhoea and nausea
(n=10 vs 7), and mood disturbance, in
particular irritability (n=9 vs 12).
The multicentre FAB trial random-
ized paediatric participants aged 7.5–18
years (mean age 11.2 years, 85% male)
with ASD and total CYBOCS-PDD score
≥6 to receive fluoxetine# or placebo for
16 weeks.
According to the researchers, the
high dropout rate was due to families
who were unwilling to risk being as-
signed to receive placebo as fluoxetine
22
was available from their community pae-
diatricians off-label.
“Despite the limitations, the outcome
of the trial … is consistent with similar
trials and contributes new evidence that
SSRIs do not add any value over placebo
for repetitive behaviours in children and
adolescents with ASD as captured in the
CYBOCS-PDD,” commented King.
He noted that frequent use of these
drugs has persisted despite a Cochrane
review has concluded that “there was no
evidence of effect of SSRIs in children,
limited evidence in adults, and even
emerging evidence of harm”, which was
recently highlighted in practice guidelines
for ASD. [Cochrane Database Syst Rev
2013;(8):CD00467; J Psychopharmacol
2018;32:3–29]
“Additional rigorous studies are
needed, both to identify other potential
treatments for core symptoms and, for
SSRIs, to determine whether clinical indi-
cations other than repetitive behaviours
might account for their persistent wide-
spread use in ASD,” said King.
* SSRI: Selective serotonin reuptake inhibitor
** FAB: Fluoxetine for Autistic Behaviors
*** CYBOCS-PDD: Children’s Yale-Brown Obsessive
Compulsive Scale–modified for pervasive
developmental disorders
# fluoxetine dosing: Started at 4 mg/day if <40 kg or 8
mg/day if ≥40 kg for the first week; and then titrated
to a maximum dose of 20 or 30 mg/day, depending
on weight, over 4 weeks
JANUARY/FEBRUARY ISSUE

Relugolix relieves pain symptoms in women
with uterine fibroids
Jairia Dela Cruz
T
reatment with the oral gonad-
otropin-releasing hormone
(GnRH) receptor antagonist re-
lugolix in women with uterine fibroids is
well tolerated and produces significant
reductions in pain symptoms, according
to data from a phase III trial.
“Furthermore, consistent with the
positive results from another phase III
study in Japanese women with uterine
fibroids that reported reductions in heavy
menstrual bleeding, this study confirms
the benefits of 40 mg/d relugolix on
symptom severity and quality of life and
suggests that relugolix can be a potential
treatment option for women with uterine
fibroids,” the investigators said. [Obstet
Gynecol 2019;133:423–433]
In the trial, 65 premenopausal Jap-
anese women with moderate-to-severe
uterine fibroid–associated pain were
randomized to receive relugolix 40 mg
(n=33; mean age, 40.5 years) or place-
bo (n=32; mean age, 42.6 years) once
daily for 12 weeks. The Numerical Rating
Scale (NRS) score was used to record
FROM ABROAD
pain symptoms every day from screen-
ing to week 12 or early termination by
patients.
The mean maximum NRS score was
6.6 in the relugolix group and 6.3 in the
placebo group. Intramural was the most
common type of uterine fibroid (66.7%
vs 90.6%, respectively), followed by sub-
serosal (51.5% vs 28.1%). None of the
patients had the submucosal or cervical
type. [Fertil Steril 2019;112:922–929.e2]
Significantly more patients in the ac-
tive vs placebo arm achieved the primary
endpoint of a maximum NRS score of
≤1 during the 28-day period before the
final dose of study drug (57.6% vs 3.1%;
odds ratio [OR], 42.1, 95% confidence
interval [CI] 5.1–346.2; p<0.0001).
Likewise, relugolix yielded better re-
sults for all secondary endpoints: pro-
portion of patients with no pain (NRS, 0;
48.5% vs 3.1%) and percentage of days
without pain (96.4% vs 71.4%).
Pain relief occurred with parallel re-
ductions in myoma (37.4%) and uterine
volumes (42.2%), as well as improve-
23
ments in Uterine Fibroid Symptom and
Quality of Life (UFS-QOL) symptom se-
verity, regardless of the type of uterine
fibroid, the investigators pointed out.
In terms of safety, treatment-emer-
gent adverse events (TEAEs) occurred
with greater frequency with relugolix than
with placebo (87.9% vs 56.3%), although
the rate of treatment discontinuation was
low and similar in the treatment arms.
Most TEAEs were mild to moderate and
included hot flush, metrorrhagia, hyper-
hidrosis, menorrhagia and viral upper re-
spiratory tract infection.
A novel oral nonpeptide GnRH re-
ceptor antagonist, relugolix competitively
inhibits GnRH receptors on the anterior
lobe of the pituitary, thus inhibiting secre-
tion of follicle-stimulating hormone (FSH)
and luteinizing hormone (LH). [J Med
Chem 2011;54:4998–5012; Eur J Phar-
macol 2014;723:167–174]
“As a result, relugolix decreases
blood concentrations of exogenous oes-
tradiol (E2) and progesterone (P) within
days and induces amenorrhea. This is in
contrast to GnRH agonists, which initially
stimulate LH, FSH, E2 and P levels,” the
investigators explained.
“GnRH antagonists do not cause
clinical flares and have a faster onset
of action than GnRH agonists. Further-
more, because of its oral formulation and
half-life, relugolix allows a faster recovery
of normal hormonal levels and menstru-
ation after discontinuation of treatment,
leading to a more rapid recovery of fertil-
ity than the injectable depot formulations
of GnRH agonists,” they added.
The investigators acknowledged
several study limitations, including the
absence of an active control, such as a
GnRH agonist, and the issue of gener-
alizability of the results to non-Japanese
populations.
JANUARY/FEBRUARY ISSUE

Ivermectin-doxycycline combo superior to
monotherapy in severe rosacea
Stephen Padilla
T
he combination of ivermectin
1% cream (IVM) and doxycy-
cline 40-mg modified-release
capsules (DMR) delivers faster respons-
es, better response rates and greater
satisfaction compared with monotherapy
in patients with severe rosacea, a recent
study has shown.
“Faster onset of visible improvement,
greater efficacy, a reduction in flush-
ing episodes, and a decrease in facial
stinging and burning were all observed,
offering the opportunity to reach skin
clearance in more patients while not
compromising safety,” the researchers
said.
A total of 273 adults with severe ro-
sacea (Investigator’s Global Assessment
[IGA] score, 4) participated in this 12-
week, multicentre, randomized, investi-
gator-blinded, parallel-group compara-
tive study and were randomly assigned
to receive either IVM and DMR (30-mg
immediate-release and 10-mg de-
FROM ABROAD
layed-release beads; combination arm)
or IVM and placebo (monotherapy).
The combination therapy was superi-
or to monotherapy in terms of reduction of
inflammatory lesions (–80.3% vs –73.6%;
p=0.032) and IGA score (p=0.032). On-
set of action as of week 4 was also faster
with the combination therapy. In addi-
tion, significantly more patients receiv-
ing both IVM and DMR achieved an IGA
score of 0 (11.9% vs 5.1%; p=0.043) and
100-percent lesion reduction (17.8% vs
7.2%; p=0.006) at week 12. [J Am Acad
Dermatol 2020;82:336–343]
On the other hand, both treatments
were well tolerated and were effective
in reducing the Clinician’s Erythema As-
sessment score, stinging and burning,
flushing episodes, Dermatology Life
Quality Index score, and ocular signs or
symptoms.
“A surprising outcome from this study
was the improvement in ocular signs and
symptoms,” the researchers said. “De-
spite instructions to avoid application of
25
IVM to the eyelid area, both treatments
resulted in a significant reduction in ocu-
lar signs and symptoms.”
Another significant outcome was
the reduction in stinging and burning,
which was also seen in previous clinical
trials. [Br J Dermatol 2015;172:1103–
1110; J Eur Acad Dermatol Venereol
2016;30:829–836; J Drugs Dermatol
2014;13:316–323]
A surprising
outcome from
this study was the
improvement in
ocular signs and
symptoms.
Although these symptoms could
worsen patient discomfort, physicians
often underestimated their impact, ac-
cording to the researchers.
“[T]hese … results suggest that us-
ing a combination of IVM and DMR, each
once daily, along with a properly selected
skin care regimen, can improve treat-
ment [outcomes],” the researchers said.
“Ultimately, overall patient satisfaction
was achieved more frequently in those
… who utilized the combination therapy.”
Limitations of the current study in-
cluded a lack of a control group, short
study duration, which did not allow for
the evaluation of possible recurrences,
and that diagnosis of the severity of ocu-
lar rosacea was not undertaken by oph-
thalmologists.
“[F]urther studies of ocular rosa-
cea are necessary, as highlighted by a
recent Cochrane review that identified
only two studies with usable data yet
with a low-quality level of evidence,” the
researchers said. [Cochrane Database
Syst Rev 2015;4:CD003262]
JANUARY/FEBRUARY ISSUE

Vitamin C-thiamine-hydrocortisone combo
yields no improvement in septic shock
Roshini Claire Anthony
A
combination of intravenous (IV)
vitamin C, hydrocortisone, and
thiamine did not reduce mortali-
ty or dependence on vasopressors in pa-
tients with septic shock* in the intensive
care unit (ICU), according to results of the
VITAMINS** trial presented at the recent
Critical Care Reviews meeting (CCR20).
“[T]here appears to be no immediate
justification for adoption of high-dose vi-
tamin C, alone or in combination, as a
component of treatment for sepsis,” said
Professor Andre Kalil from the Universi-
ty of Nebraska Medical Center in Oma-
ha, Nebraska, US, in an accompany-
ing editorial. [JAMA 2020;doi:10.1001/
jama.2019.22438]
A total of 211 adults (mean age 61.7
years, 63% male) with septic shock
(within 24 hours pre-enrolment) at 10
ICUs in Australia, New Zealand, and Bra-
zil completed the trial. They had been
randomized 1:1 to receive a combination
of IV vitamin C (1.5 g every 6 hours), hy-
drocortisone (50 mg every 6 hours), and
thiamine (200 mg every 12 hours) or IV
hydrocortisone alone (50 mg every 6
hours) for up to 10 days (or until septic
shock resolution). Mean treatment dura-
tion was 3.4 days in both groups.
Duration of time alive and ≥4 hours
free from vasopressor use at day 7 did
not significantly differ between those
who received the combination or hy-
drocortisone alone (median, 122.1 vs
124.6 hours; median of all paired dif-
ferences between groups, -0.6 hours;
p=0.83). [JAMA 2020;doi:10.1001/
jama.2019.22176]
All-cause mortality rate was compa-
rable between patients who received the
combination and hydrocortisone alone at
28 days (22.6% vs 20.4%; p=0.69) and
90 days (28.6% vs 24.5%; p=0.51), with
FROM ABROAD
a hazard ratio of death of 1.18 (p=0.54)
for the combination vs hydrocortisone
alone.
ICU mortality (19.6% vs 18.3%;
p=0.80) and hospital mortality (23.4%
vs 20.4%; p=0.60) also did not differ
between combination and hydrocorti-
sone-alone recipients, nor did duration
of hospitalization (median 12.3 days in
both groups). There was also no be-
tween-group difference in time free from
mechanical ventilation or renal replace-
ment therapy at 28 days.
A post hoc analysis showed that
death (15.9% vs 14.4%; p=0.77) or
re-dependence on vasopressors (33.3%
vs 26.7%; p=0.33) by day 7 did not differ
between combination and hydrocorti-
sone-alone recipients.
Adverse events (AEs) reported were
one incident each of fluid overload and
hyperglycaemia in the combination
group and one incident of gastrointesti-
nal bleeding in the hydrocortisone-only
group. No serious AEs were reported.
Previously, a small study suggested
that a hydrocortisone-thiamine-high-dose
IV vitamin C combo reduced in-hospital
mortality risk and vasopressor use in pa-
tients with severe sepsis or septic shock.
However, as corticosteroids alone have
26
also reduced mortality and vasopressor
use, it remained unknown if the com-
bination was a superior option. [Chest
2017;151:1229–1238; N Engl J Med
2018;378:809–818]
“[The present study] suggests that
treatment with IV vitamin C, hydrocor-
tisone, and thiamine does not lead to
a more rapid resolution of septic shock
compared with IV hydrocortisone alone,”
said the researchers.
Additionally, the use of the combi-
nation could also have unwanted con-
sequences including “perpetuating false
hopes for patients, families, and clini-
cians, and delaying proven lifesaving
therapies,” noted Kalil.
“The findings of the VITAMINS trial
are clear: In patients with septic shock
from Australia, New Zealand, and Bra-
zil, there was no signal of benefit with
the high dose vitamin C, thiamine, and
hydrocortisone cocktail. The search for
treatments that might improve the out-
come of these very sick patients must
now focus on other interventions,” point-
ed out study lead investigator Professor
Rinaldo Bellomo, from Austin Hospital in
Heidelberg, Victoria, Australia.
* as per the Sepsis-3 definition
** VITAMINS: Vitamin C, Hydrocortisone and Thiamine
in Patients With Septic Shock
JANUARY/FEBRUARY ISSUE

Reduced gout incidence with SGLT-2 inhibitors
vs GLP-1 receptor agonists
Roshini Claire Anthony
I
ndividuals with type 2 diabetes (T2D)
who are prescribed an SGLT2* in-
hibitor may have a reduced risk for
developing gout compared with those
who are prescribed a GLP-1** receptor
agonist, according to a study from the
US.
Using a US commercial insurance
database, the researchers identified
295,907 adults (mean age 54 years,
52% female) with T2D who were newly
prescribed either an SGLT-2 inhibitor or a
GLP-1 receptor agonist between March
2013 and December 2017 (n=119,530
patients in each group after propensity
score matching). Patients were followed
up for a mean 302 (SGLT-2 inhibitors)
and 261 (GLP-1 receptor agonists) days,
respectively.
Incidence of gout was lower among
patients with T2D who received an SGLT-
2 inhibitor compared with those who re-
ceived a GLP-1 receptor agonist (4.9 vs
7.8 per 1,000 person-years; adjusted
hazard ratio [adjHR], 0.64, 95% confi-
dence interval [CI], 0.57–0.72). [Ann In-
tern Med 2020;doi:10.7326/M19-2610]
FROM ABROAD
The reduced incidence with SGLT-
2 inhibitors vs GLP-1 receptor agonists
was consistent regardless of sex (adjHR,
0.69 and 0.57 in men and women, re-
spectively), age (adjHR, 0.64 and 0.67
in individuals aged ≤60 and >60 years,
respectively), and baseline diuretic use
(adjHR, 0.45 and 0.74 in users and
non-users, respectively).
There was also a reduced risk of
heart failure hospitalizations in patients
prescribed an SGLT-2 inhibitor com-
pared with those prescribed a GLP-1
receptor agonist (1.7 vs 2.7 per 1,000
person-years; adjHR, 0.63, 95% CI,
0.51–0.77).
When compared with new users of
DPP4*** inhibitors in a sensitivity anal-
ysis (n=97,442 in each group), gout in-
cidence was still lower among SGLT-2
inhibitor users (5.35 vs 8.08 per 1,000
person-years; adjHR, 0.66, 95% CI,
0.58–0.75).
The researchers pointed out a re-
cent meta-analysis of 62 studies that
demonstrated a reduction in serum uric
acid levels following SGLT-2 inhibitor use.
However, many of the studies included
in the meta-analysis comprised patient
27
populations without hyperuricaemia at
baseline, and as such, the clinical rele-
vance of this reduction in uric acid levels
was unclear, they said. [Diabetes Obes
Metab 2018;20:458–462]
Furthermore, GLP-1 receptor ag-
onists are not known to reduce uric
acid levels, making them the “ideal
comparator” to assess if this effect of
SGLT-2 inhibitors translates to a reduc-
tion in gout risk. [Diabetes Obes Metab
2018;20:1235–1245]
“Logically, patients with hyperuricae-
mia and higher serum uric acid levels at
baseline have a greater potential for re-
ducing uric acid levels. If proven, this will
be relevant for adults with diabetes who
also have hyperuricaemia, and one day
may also be relevant for adults with hy-
peruricaemia who do not have diabetes,”
the researchers said.
Aside from the need for additional
research to confirm the gout-reducing
characteristics of SGLT-2 inhibitors, the
researchers recommended studies to
assess this outcome in individuals with
or at high-risk for developing gout.
With a recent study showing an ele-
vated risk of cardiovascular and all-cause
mortality with the gout treatment febux-
ostat, [N Engl J Med 2018;378:1200–
1210], there is an increased need to
identify new treatments for this condition,
they added.
“If SGLT-2 inhibitors are found to
lower the risk for gout, they may be the
ideal treatment for patients with diabetes
who are at high risk for gout, because
SGLT-2 inhibitors also reduce the risk for
cardiovascular mortality and, potentially,
all-cause mortality,” they said.
* SGLT2: Sodium-glucose cotransporter-2
** GLP-1: Glucagon-like peptide-1
*** DPP4: Dipeptidyl peptidase 4
JANUARY/FEBRUARY ISSUE
 FEATURE

Strength in numbers:
Lim Jack Shen on pharmacy
management and banner groups
As a pharmacist, Lim Jack Shen wears many hats: vice-president
of the Federation of Asian Pharmaceutical Associations (FAPA),
honorary treasurer of the Malaysian Pharmaceutical Society
(MPS), assistant general manager of business development at
Berjaya Corporation, and ‘passionate evangelist for pharmacy’
at Tigas Alliance Pharmacy. For this issue of MIMS Pharmacist,
Lim talks about his experiences with developing MyTigas
Alliance, a collaboration of independent community pharmacies
for providing group healthcare services.

Rachel Soon they later realized it would give them

the opportunity to be freed from issuing
Could you explain what the medications every month.
MyTigas Alliance is?

W
e’re what would be called
a ‘banner group’ in Austra-
lia. It’s not exactly a co-op;
those imply a sharing of equity. A banner
group is a loose alliance of pharmacies
where a central company helps provide
branding, products, and services for in-
dividual fee-paying members, who then
have the ability to operate and be identi-
fied as part of the group.
In the case of MyTigas Alliance, our
banner group branding is essential as
we are considered a panel for deliver-
ing pharmacy benefits services for cor-
porations in Malaysia. We do this by
aggregating prescriptions from clinics,
providing corporations with better di-
rect-to-employee dispensation for long-
term medication. We can deliver at least
30% in cost savings for corporations
which reimburse employees' chronic ill-
ness medications.
Was there pushback
from existing healthcare
providers?
There’s a company, which we currently
work with to help them manage [employ-
ees] with long-term medication; when we
first went in with a proposal, the doctors
on their panel were initially unhappy, but
As we only work with long-term
medications, which are driven by repeat
prescriptions, we now work quite closely
with them; the doctors issue prescrip-
tions with one to two repeats depending
on the case, and we issue the medica-
tions.
In the long run, it’s not only proven
more cost-effective for the corporations
in terms of direct drug costs, but also al-
lows the doctor to spend more time in
consultation. Admittedly this is what has
frustrated me about the pushback from
doctors about [dispensing separation].
They’re worried about the loss of income
from providing medications. But the re-
ality is that they’re already losing out,
because many companies and patients
themselves want to stretch their funds.
Many companies are putting caps
on medical benefits at maybe RM1,000
per year, so patients will go see a doctor,
get the initial round of medication, then
go to some of [the low-cost pharmacies]
and just buy the subsequent rounds from
them without a prescription. They don’t
go back to the doctor.
What happens then is three bad
things: one, the doctor loses the patient,
because they’re buying medication on
their own without a prescription. Two,
proper pharmacies who want to control
medication safety also lose out to the
low-cost pharmacies. Three—and the
most important—long-term medication
needs monitoring and optimal doses
change. What you take today may not be
what you need for your blood pressure
control in a year’s time.
Ultimately what happens is the pa-
tient is more likely to be admitted to a
hospital for further treatment for a poorly
controlled condition, and the cost then
goes back to the company, and the
medical costs are blown out of the water.
That’s the reason why we do what
we do at MyTigas Alliance. What we’re
trying to do is create an environment or
ecosystem where the doctor prescribes,
the pharmacists dispense, but they
come together to manage medications
for the patients and the companies in a
more cost-effective way for everyone.
Having small independent community
pharmacies join the programme provides
accessibility to pharmacy services. It’s
a small-scale model of what dispensing
separation could look like if it were imple-
mented at a larger scale.

29 JANUARY/FEBRUARY ISSUE

A community pharmacy in Kuching, Sarawak. MyTigas aims to build a collaborative ecosystem
among independent community pharmacies.
Lim (first from right) with other representatives of the Malaysian Pharmaceutical Society (MPS)
officiating the opening of the Pharmaceutical Industries Pharmacists Insights 3.0 (PIPI 3.0)
conference.
What’s the difference
between MyTigas Alliance
and the Tigas Alliance
Pharmacy?
MyTigas Alliance is driven by a member-
ship-cooperative framework, with a pro-
prietary dispensing platform that allows
pharmacy members to participate in the
dispensing of prescriptions collected
from corporate employees for long-term
medications.
The concept started in 1999 as a joint
buying/wholesale organization which
then went into community marketing and
FEATURE
branding, so there was a time where you
would see member pharmacies take on
the Tigas associative branding. We’ve
also made it so that members can keep
their own store names; they just need
to add some smaller decals indicating
‘MyTigas Alliance Member’ at their lo-
cations. The decals link employees to
nominated pharmacies where their med-
ication may be dispensed.
On the other hand, the ‘Tigas Alliance’
brand may also be directly licensed, and
in the case of Berjaya Pharmacy Sdn
Bhd, a subsidiary under Berjaya Corpo-
30
ration, its core chain pharmacies operate
as Tigas Alliance Pharmacy by way of
a brand licence. These selected stores
were spun off from Cosway (M) Sdn Bhd,
where I was head of pharmacy when
[those stores] were named Cosway
Pharmacy.
What does Berjaya get out of
the MyTigas arrangement?
The main benefit is getting to build an
ecosystem. In my role within Berjaya,
I’m looking more towards professional
engagement, government engagement,
and professional services.
We realize that pharmacy shouldn’t
be a commodity or a retail trade. Phar-
macy should be all about patient-centred
care based on the patient-pharmacist
relationship. And while we could build
pharmacies of our own around that
philosophy, another route is building an
ecosystem where everyone—healthcare
providers, patients, organizations—can
benefit.
For us, it’s also easier to bring multi-
ple members together and talk to corpo-
rations. Instead of saying, “We own this
number of stores,” we can say, “Here’s
the network we have within this ecosys-
tem.” You’ll notice we’re hardly in malls;
MyTigas alliance pharmacy members
tend to be more community-situated
standalone pharmacies.
How could umbrella members
be assured they wouldn’t be
undercut by the core chain?
That’s a fair enough question. For one,
Berjaya Pharmacy [Tigas Alliance Phar-
macy] has a limited number of stores—
around a dozen—and no intention of
expanding at present. How to put their
mind at ease ... that’s tough to answer.
What I can say is that when we do things
[as MyTigas], it’s for mutual benefit.
For example, when we have cor-
porate programmes, we channel the
customer base from those to the MyTi-
gas Alliance member’s independent
pharmacy. It’s a win-win situation for
JANUARY/FEBRUARY ISSUE

the pharmacist, who now has patients
from corporate programmes going to
them without needing to go and do the
negotiations directly with that corpora-
tion. They’ll know there’s a set cost, and
they’ll know exactly what they’re going
to get when they treat a patient. So the
independent [pharmacies] are also ex-
posed to less risk.
As for Berjaya Pharmacy, we simply
don’t have to build so many stores to
achieve a certain level of order fulfilment.
My work is to instead focus on managing
the customer base within the companies
involved.
Another thing is that MyTigas Alliance
is currently in the process of acquiring
and launching our own branded prod-
ucts, or products exclusive to the MyTi-
gas Alliance network. We’re not compel-
ling members to buy them, but if they
think it’s worthwhile they can sell them at
their stores, with no worries about price
war on those items because they would
be part of the ecosystem.
Tell us a bit about your
background.
My father is an industrial pharmacist him-
self who worked for multinational phar-
maceutical companies before starting his
own manufacturing plant. He was also
a former vice president of the Malaysian
FEATURE
Pharmaceutical Society (MPS) and one
of its longest-serving council members,
being there 17 years or so.
I graduated in 2003 from Monash
University in Melbourne and worked for
a couple of years there; my first job was
in hospital pharmacy at Western Health.
When I came back to Malaysia, it was in
the last year before compulsory training
started. I worked in a factory doing for-
mulation and lab work, as well as dis-
pensing active ingredients, before mov-
ing to sourcing, sales, and marketing.
After that, I started working in medi-
cal affairs for a nutrition company based
in Bangi before starting my own compa-
ny selling dietary supplements with my
own product range. I joined the Berjaya
Group in 2011 and was assigned to
Cosway Pharmacy, which in 2016 was
split off [from Cosway] and took on the
brand of Tigas Alliance Pharmacy.
Was there family pressure to
become a pharmacist?
Of course! There was definitely an ex-
pectation although I must admit I al-
most became a medical doctor. It may
be surprising to many but my first love is
architecture. But you know, growing up
in a typical Chinese family, there was al-
ways pressure to do something more in
the normal ‘professional’ vein … this was
31
also in the 90s when the financial crash
had just hit, so it seemed like a bad time
to get into construction-related fields.
My academic choice had always
been medicine. But at the last minute,
my dad gave me a speech about how
the pharmacy degree is more interesting
and more widely usable … “as a doctor
you’ll always work as a doctor, but with
pharmacy you can go into industry, pro-
duction, and many other places.” That’s
why I chose pharmacy.
Have you regretted that
decision?
As a matter of fact, no. You could say I
took another route, because instead of
becoming a doctor I married a doctor.
Did you make a conscious
choice to go into
management over frontline
work?
In a way, it’s how things ended up. I did
enjoy my frontline experience, especially
in clinical pharmacy. Every case was an
interesting puzzle you had to put togeth-
er and take apart … I think that’s why a
lot of Malaysian pharmacists look at clin-
ical pharmacy as their area of interest. I
just ended up being in management over
the years.
I’m not sure I would go back to clini-
cal pharmacy at this point. If I did, in Ma-
laysia, it would be in a government hos-
pital, because as far as I know—and I do
stand to be corrected—not a lot of phar-
macy services in private hospitals offer
expanded clinical roles for pharmacists.
The roles are still very supply-based
rather than having expanded pharma-
ceutical services like medication thera-
py adherence clinics (MTACs). Whereas
in Australia, we were doing services like
therapeutic drug monitoring (TDM), ad-
justing doses of antibiotics.
Maybe the next step for me is to
move from management to public
health—which is an area of interest for
me.
JANUARY/FEBRUARY ISSUE
 EVENT CALENDAR

MARCH MARCH MARCH

6-8
FRIDAY–SUNDAY
8
FRIDAY
27-29
FRIDAY–SUNDAY

International Research
Conference on Pharmaceutical
and Allied Sciences (IRCPAS
2020)
Location: Le Quadri Hotel, Kuala Lumpur
Info: UCSI University
Tel: (018) 665 3642
Email: IRCPAS@ucsiuniversity.edu.my
URL: apps.ucsiuniversity.edu.my/
ircpas2020
Myths & Facts about Sexual
Health & Family Planning
Workshop
Location: G Hotel Gurney, Penang
Info: Malaysian Pharmaceutical Society
(MPS) Penang, Malaysian Community
Pharmacy Guild (MCPG)
Email: mpspenang@gmail.com
URL: facebook.com/
events/2439891649473815
12th Diabetes Complications
Conference & Grand Rounds
Location: Hotel Istana, Kuala Lumpur
Info: National Diabetes institute (NADI)
Tel: (03) 7876 1676 / 1677
Fax: (03) 7876 1679
Email: enquiry@nadidiabetes.com.my
URL: diabetesmalaysia.com.my

APRIL APRIL 2020 JUNE

10-12
FRIDAY–SUNDAY
17-19
FRIDAY–SUNDAY
13-15
SATURDAY–MONDAY

National Heart Association of National Pharmacists Convention 25th Malaysian Dietitians

Malaysia (NHAM) Congress 2020
Location: Kuala Lumpur Convention Centre
Info: Congress Secretariat
Tel: (03) 7931 2131
URL: www.malaysianheart.org
(NPC) 2020 Association (MDA) National
Location: Hotel Istana, Kuala Lumpur Conference 2020
Info: Malaysian Pharmaceutical Society Location: Hotel Istana, Kuala Lumpur
(MPS)
Info: MDA Secretariat
Tel: (03) 8079 1861
Email: conference@dietitians.org.my
Email: mps.online@gmail.com
URL: mps.org.my URL: conference.dietitians.org.my

JULY AUGUST OCTOBER

6-9
MONDAY–THURSDAY
18-20
TUESDAY–THURSDAY
20-24
TUESDAY–SATURDAY

11th National Pharmacy R&D Asian Symposium on Medicinal Federation of Asian

Conference 2020
Location: TBA
Info: Pharmaceutical Research &
Development Branch, Pharmacy Policy
& Strategic Planning Division, Ministry of
Health (MOH)
URL: research.pharmacy.gov.my/
rndconf2020
Plants and Spices (ASOMPS)
2020
Location: Zenith Hotel, Putrajaya
Info: Malaysian Natural Products Society
(Prof Dr Faridah Abas)
Email: asomps2020@gmail.com
URL: asompsxvii.org
Pharmaceutical Associations
(FAPA) Congress 2020
Location: KL Convention Centre
Info: FAPA Secretariat
URL: www.facebook.com/FAPA2020

To notify us of any events of interest to pharmacists, please submit details to rachel.soon@mims.com.

32 JANUARY/FEBRUARY ISSUE
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