QUIT

SMOKING
CLINIC
Inside this issue:
Tobacco use is recognized as the
Quit Smoking
Clinic 1-3
main cause of premature and pre-
ventable death in our country. It is
Methadone Clin- 4
ic estimated that 20,000 deaths in
Amendment in 5-6 Malaysia are attributed to smoking
Drug Formulary annually. In Malaysia, smoking
Hospital Sungai
Siput kills 20,000 Malaysians every year
Differences be-
and will increase to 30,000 by the
tween Inhaler 7 year 2020 if the pattern of smok-
Foster and Sym-
bicort
ing does not change.
Differences be-
tween Erythro- 7
mycin and
Objective of Quit
Azithromycin

Seebri Breezhaler 8
Smoking Clinic:
Technique
 Provide professional
MDI Foster Tech- 9
advice, materials to
nique
help quit smoking and
Editorial Board:
enlisting the smoker’s
own willpower.
Chief Editor:
Nurul Akhmam Binti
Abdullah

Editor:
Teoh Lee Rhui

Contributors:
Kong Hui Shan
Nor Izzati Binti Saiful
Affendi
Soon Yung Xin
Page 2 Issue 02/2018

Flowchart of Quit Smoking Service

Client Registration
Brief Clinical Intervention
(5 A’s):
Assessment of Nicotine Dependence
Step 1: Ask about tobacco smoking
(FAGERSTROM Score)
Step 2: Advice to quit
Step 3: Assess willingness to make a quit attempt Physical and Clinical Assessment of
Step 4: Assist in quit attempt Client
Step 5: Arrange follow up
Client Visits

Motivational Intervention Non-pharmacological Pharmacological In-

Intervention tervention (NRT/
(5R’s) :
CHAMPIX)
Relevance:
 Encourage the patient to indicate why
quitting is personally relevant. Follow-up Visits

Risks:
 Ask the patient to identify potential Reference
negative consequences of tobacco use.
Rewards:
 Ask the patient to identify potential benefits Activities for Maintaining Non-
of stopping tobacco use. smoking Status

Roadblocks:
 Ask the patient to identify barriers or
Monitoring
impediments to quitting and provide
treatment that could address barriers.
Repetition:
 The motivational intervention should be
repeated every time an unmotivated patient
visits the clinic setting.
Page 3 Issue 02/2018

Pharmacological Intervention:
A) Nicotine replacement therapies (NRT)

Nicotine patch Nicotine gum Nicotine lozenge Nicotine inhaler

B) Non-nicotine based
 Varenicline
 Sustained release (SR) bupropion

Varenicline (Champix)
Dosing: Technique of Administration:
Day 1-3: 0.5mg OD  Take with food (non-oily food)
Day 4-7: 0.5mg BD  Take a full glass of water
Day 8 to end of treatment: 1mg BD  Take at the same time everyday

Side effects: Interaction:

 May impair the ability to drive or operate heavy  Antipsychotic drugs, opioid, antihyper-
machinery tensive, insulin, blood thinning drugs
 Nausea—Take on a full stomach and theophylline: Increased level or
effect of drug.
 Insomnia—Take second pill at supper time or
after dinner
 Trouble sleeping, abnormal/ vivid/ strange
dreams, abdominal pain, flatulence, headache.
Page 4 Issue 02/2018

KLINIK RAWATAN TERAPI GANTIAN

METHADONE

FLOWCHART FOR PROCEDURE OF METHADONE

TREATMENT

Objectives: Patient (opioid drug addict) arrived at

the clinic
 To reduce blood -borne infec-
Not
tions among IV drug users Qualified
Early as- Check criteria of qualifications for
 To help and treat patients sessment
methadone treatment
who have addiction problem,
especially opioids and then *Qualified
increase the patient’s quality
No Patient: Sign on the agreement after
of life Dis- Agree explanation from staffs
charge

Government started methadone Yes

treatment program as part of the Early assessment of patient:
component harm reduction in Screening test for HIV, Hep B and C,
Liver Function Test, Urinalysis for
October 2005 in the effort of the
Drug Screening
country in handling HIV among IV
drug users and opioid addiction .
Methadone clinic was started in No Medical Practitioner:
Pass the
Do physical examination
Hospital Sungai Siput in year screening
2008.
Operation hour:
Yes
Weekdays 8 to 9.30a.m Medical Practitioner:
Weekend 8 to 9 a.m. Start methadone treatment
Venue: Pharmacist:
Dispense the methadone
Klinik Rawatan Terapi Gantian
Patient:
Methadone Go through treatment and counsel-
ing session
Stable

Yes
Patient—continue follow-up treat-
ment and psychosocial interven-
tion (Maintenance Phase)
Page 5 Issue 02/2018

AMENDMENT IN DRUG FORMULARY HOSPITAL SUNGAI SIPUT

There are some amendments in Drug Formulary Hospital Sungai Siput. The following is the list of
medicines newly added into Drug Formulary HSS:

DRUG CATEGORY INDICATION

MDI Beclomethasone Dipropionate A/KK 1Regular treatment of asthma where use of a

100mcg/Formoterol Fumarate Dihy- combination product (inhaled corticosteroid and
drate 5mcg (Foster®) long-acting beta2 agonist) is appropriate in:

i) Patients not adequately controlled with inhaled

corticosteroids and "as needed" inhaled short
acting beta2 agonist, or

ii) Patients already adequately controlled on both

inhaled corticosteroids and long-acting beta2-
agonists.

Azithromycin 250mg Tablet A* Category of prescriber A/KK is only approved for

indication (i):

i) Adult treatment of uncomplicated genital infec-

tions due to Chlamydia richomatis or susceptible
Neisseria gonorrhea.

The following indication is still under category of

prescriber A*:

i) Treatment of complicated respiratory tract in-

fection not responding to standard macrolides;

ii) Prophylaxis against Mycobacterium

avium complex in patients with advanced HIV.

Polyethylene Glycol/Macrogol 4000 A Bowel cleansing prior to colonoscopy, radiological

Powder (FORTRANS) examination or colonic surgery. Suitable for pa-
tients with heart failure or renal failure.

Glycopyrronium 50mcg, Inhalation- A/KK For maintenance bronchodilator treatment to

Powder Hard Capsules relieve symptoms in adult patients with chronic
obstructive pulmonary disease (COPD). COPD
diagnosis is confirmed by spirometry.
Page 6 Issue 02/2018

AMENDMENT IN DRUG FORMULARY HOSPITAL SUNGAI SIPUT

There are some amendments in Drug Formulary Hospital Sungai Siput. The following is the list of
medicines that have been removed from Drug Formulary HSS:
GENERIC NAME CATEGORY INDICATION

Olive Oil Ear Drops C Impacted wax softener.

Gutt Gentamicin 0.3% A/KK Broad spectrum antibiotic in superficial eye infections
and also for Pseudomonas aeruginosa.

Irbesartan 150mg & 300mg A/KK Hypertension, diabetic nephropathy (in patient who
Tablet cannot tolerate ACE inhibitors because of cough).

Bacampicillin 400mg Tablet B Infections caused by ampicillin-sensitive gram positive

and gram negative microorganisms.

Vancomycin 500mg Injec- A* Only for the treatment of MRSA and CAPD peritonitis.
tion
Naloxone 0.02mg/ml Injec- B For the complete/ partial reversal of narcotic depres-
tion sion including respiratory depression induced by opi-
oids such as natural and synthetic narcotics. Diagnosis
of suspected acute opioids overdosage.

Monobasic sodium phos- A Bowel cleansing prior to colonoscopy, radiological ex-

phate 48%, dibasic sodium amination or bowel surgery.
phosphate 18% solution

Tiotropium 2.5mcg/puff so- A/KK i) Maintenance bronchodilator treatment to relieve

lution for inhalation symptoms of patients with chronic obstructive pulmo-
nary disease (COPD) in which the diagnosis of COPD is
confirmed by spirometry.

Ii) As add-on maintenance bronchodilator treatment in

adult patients with asthma who are currently treated
with the maintenance combination of inhaled cortico-
steroids (≥800mcg budesonide/day or equivalent) and
long acting-β2-agonist and who experienced one or
more severe exacerbations in the previous year.
Page 7 Issue 02/2018

MDI Foster Symbicort

Actives Beclometasone dipropionate 100 mcg, formoterol Budesonide 160 mcg, formoterol 4.5 mcg OR
fumarate dihydrate 6 mcg Budesonide 320 mcg, formoterol 9 mcg
Dose Asthma Asthma
A. Maintenance therapy: A. Maintenance therapy:
Adult ≥18 yr: 1 or 2 puff BD Adults (≥12 yr): 1-2 puff BD
Max daily dose: 4 puff Max daily dose: 4 puff BD
Children (6-11 yr): Lower strength (80/4.5
mcg 2 puff bd)
<6 yr: not recommended
B. Maintenance and reliever therapy(MART): B. Maintenance and reliever therapy(MART):
Adult ≥18 yr: 1 puff BD, 1 or 2 puff PRN Adult ≥18 yr: 2 puff per day
Max daily dose: 8 puffs 1 puff PRN. Max daily dose: 12 puffs

Childn & adolescent <18 yr : not recommended

COPD COPD
Adult ≥18 yr: 2 puff BD Adult ≥18 yr: 2 puff BD
Pharma- •NO involvement of cytochrome P450  Metabolism via cytochrome P450 isoenzyme 3A4
cology (CYP3A4)
 Avoided in ketoconazole and other strong CYP3A4
inhibitors (e.g., ritonavir, atazanavir,
clarithromycin, indinavir, itraconazole, nefazodone,
nelfinavir, saquinavir, telithromycin)

Macro- Erythromycin Ethinylsuccinate Azithromycin

lides
400mg q6h or 800mg q12h. Max: 4g/day C trachomatis, N 1 g as single dose.
gonorrhea
Dose All other indications 500 mg OD for 3 days or
500 mg on day 1, then
250 mg on day 2-5.
Interac- **Contraindicated: •does not interact significantly with the he-
tions EES is CYP3A4 inhibitor patic cytochrome P450 system
•increase concentrations of HMG-CoA reductase inhibitors
(e.g. lovastatin and simvastatin).

Increase QT interval
•Terfenadine, quinidine, astemizole, indapamide

**Caution:
Increase concentration of:
Carbamazepine, cyclosporin, digoxin, ergotamine,
methylprednisolone, midazolam, omeprazole, phenytoin,
rifabutin, sildenafil, tacrolimus, domperidone,
tertheophylline, triazolam, valproate, vinblastine and
antifungals and warfarin.
Adverse hepatic dysfunction, prolongation of QT interval, ventricular abnormal liver function, prolongation of QT
effect arrhythmias interval
Page 8
SEEBRI BREEZHALER TECHNIQUE
Pull of the cap
Hold the base of the inhaler
firmly and tilts the mouth-
piece to open the inhaler
Separate one of the blister
from blister card by tearing at
the perforation. Take one
blister and peel away the
protective backing to exposed
the capsule
Capsules should always be
stored in the blister and only
removed immediately before
use.
Do not swallow the capsule
Place the capsule into the
capsule chamber.
Never place a capsule directly
into the mouthpiece
Close the inhaler until you
hear a “click”
REMEMBER TO GARGLE
AFTER EACH USE
Issue 02/2018
Hold the inhaler upright
with the mouthpiece
pointing up.
Press both button together
firmly. You will hear a
“click” sound
Release the buttons fully
Before placing the mouth-
piece into your mouth,
breathe out fully
Never blow into the
mouthpiece
Before breathing in, hold
the inhaler with button to
the left and right. Place the
mouthpiece in your mouth
and close firmly.
Breathe in rapidly but
steadily
As you breathe in through
the inhaler, the capsule
spins around in the cham-
ber and you should hear a
whirring sound. You will
experience a sweet taste of
medicine goes into your
lungs
Continue to hold your
breath for 5—10 second or
as long as you can while
removing the inhaler from
your mouth.
Then breathe out.
Open the mouthpiece and
removed the empty cap-
sule. Close the cap back
into its place.
Page 9 Issue 02/2018

MDI FOSTER TECHNIQUE

Tilt your head

1
Remove the cap
from the inhaler 5 back slightly

Shake the inhaler Exhale away from

the inhaler
2 well for 5 seconds

Hold the inhaler Put the inhaler in

3 firmly by placing
your index finger on
7 your mouth. Press
the inhaler and
top to the canister start breathing in
and thumb on the at the same time.
bottom of the Take a slow and
mouthpiece deep breath

Sit straight or Hold your breath

stand up for 10 seconds.
4 Exhale slowly
through your
8 mouth or nose

REMEMBER TO GARGLE AFTER EACH USE