november-decemBER 2014

New guidelines uphold

levothyroxine as standard of care
for hypothyroidism

news
Why scratching
worsens itching: New
study holds key

BUSINESS
Guardian unveils online
store in Singapore

IN FOCUS
Sore throats can
indicate severe illness

PHARMACY
PRACTICE
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New guidelines uphold levothyroxine

as standard of care for hypothyroidism
Elvira Manzano

evothyroxine (L-T4) should remain as the

standard of care for treating hypothyroid-

ism, according to new hypothyroidism guidelines released by the American Thyroid Association (ATA).
Our guidelines offer reassurance to physicians and their patients [that] no changes are
needed in the current standard of care for hypothyroidism in the majority of patients, said
Dr. Jacqueline Jonklaas, chair of the task force

Reviewers found no robust evidence to support a change

in the current standard of care for hypothyroidism.

that reviewed the latest clinical data on hypothyroidism therapeutics and an associate pro-

concluded there was no robust evidence to

fessor at Georgetown University Medical Cen-

recommend a change in the current standard

ter in Washington, DC, US.

of care.

The taskforce was convened to determine

We found no consistently strong evidence

whether the current standard of care for hypo-

for the superiority of alternative preparations

thyroidism should be revised, and if warranted,

[eg,

to identify potential therapeutic alternatives to

therapy, or thyroid extract therapy] over mono-

L-T4 monotherapy. [Thyroid 2014;doi:10.1089/

therapy with L-T4 in improving health out-

thy.2014.0028]

comes. However, some patients, particularly

levothyroxine-liothyronine

combination

L-T4 is a synthetic form of the hormone thy-

those with a polymorphism or genetic variation

roxine (T4) that is converted to triiodothyronine

in the deiodinase enzyme that converts L-T4 [to

(T3) in the body. While L-T4 is effective in most

T3], may benefit from combination treatments,

patients, some feel unwell when taking the

Jonklaas said.

drug, which is a cause for concern among physicians.

Future research, she said, should focus on

the development of superior biomarkers of eu-

Although some studies suggested combi-

thyroidism to supplement thyroid stimulating

nation therapies may be a valid approach for

hormone (TSH) measurements, mechanistic

patients with hypothyroidism, the taskforce

research on serum T3 levels (including effects

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of age and disease status, relationship with

mation for endocrinologists and physicians on

tissue concentrations, and potential therapeu-

who to treat, why to treat including subclinical

tic targeting), and clinical trials evaluating the

disease and how to treat hypothyroidism.

long-term effects of different combination therapies or thyroid extracts.

Pharmacists for their part can encourage

patients to adhere with their medication un-

Dr. Hossein Gharib, ATA president and pro-

less advised otherwise by their physician and

fessor of medicine at the Mayo Clinic College

to report any adverse effects associated with

of Medicine in Rochester, Minnesota, US said

excessive amounts of thyroid hormone such

while some questions remain unanswered, the

as palpitations, rapid weight loss, restlessness,

new guidelines provide useful up-to-date infor-

sweating, and insomnia.

Long work hours and short sleep

can be toxic
Christina Lau

increased risk of acute MI compared with those

who worked 40-48 hours per week and slept 6-8

ndividuals who work long hours and have

hours per day, said investigator Dr. Ta-Chen Su

short sleep are at significantly increased risks

of the Department of Internal Medicine and Car-

of diabetes, coronary heart disease (CHD) and

diovascular Center, National Taiwan University

acute MI, recent studies have shown.

Hospital, Taipei, Taiwan.

In Taiwan, a recent case-control study

More recently, a meta-analysis (n=222,120)

(n=322) showed that middle-aged men who

showed that individuals who worked more than

worked more than 60 hours per week had a 2.2-

55 hours per week in manual or other low so-

fold increase in the risk of CHD vs those who

cioeconomic status jobs had a 30 percent in-

worked 40-48 hours per week. Study participants

creased risk of diabetes compared with those

who slept less than 6 hours per day had a three-

working 35-40 hours per week. This associa-

fold increased risk of CHD vs those sleeping 6-9

tion was found only in the low socioeconomic

hours per day. [Int J Cardiol 2014;171:419-422]

status group, suggesting sleep as a possible

The risk was highest for those who were

mediator, said Su. [Lancet Diabetes Endocri-

working long hours and had limited sleep, with

nol 2014, e-pub 24 Sep, doi: 10.1016/S2213-

a 5.8-fold increased risk of CHD and an 8.3-fold

8587(14)70178-0]

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Short sleep duration, as well as poor sleep

Light has a role on body fat and appetite-reg-

quality, increased the risk of impaired fasting

ulating hormones, she continued. We showed

glucose, according to a population-based cross-

that exposure to bright light in the evening in-

sectional survey in China (n=15,145). The risk

creased hunger and insulin levels in healthy in-

was highest (odds ratio, 6.37) in those with both

dividuals. Every late hour of mean light exposure

short sleep duration and poor sleep quality. [BMJ

above 500 lux was associated with a 1.28 kg/m2

Open 2014;4:e004436]

increase in BMI. [PLoS One 2014;9:e92251]

Circadian-based metabolic disruption can oc-

Other recent studies showed low morning

cur when the timing of behaviors are misaligned

melatonin levels, indicative of low nocturnal se-

with the endogenous circadian rhythms of insulin

cretion, as a risk factor for insulin resistance and

sensitivity or glucose metabolism, said Professor

diabetes. [Am J Epidemiol 2013;178:231-238;

Phyllis Zee of the Department of Neurobiology,

JAMA 2013;309:1388-1396; JAMA 2013;310:536-

Northwestern University, Chicago, IL, US. Late

537]

sleepers eat later and consume an additional 248

These findings suggest improving circadian

calories per day compared with normal sleep-

rhythms and sleep as targets for disease preven-

ers. [Obesity (Silver Spring) 2011;19:1374-1381]

tion and modification, Zee noted.

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FORUM

Promoting ethical relations

with the pharma industry:
The Mexico Principles
Dr. Yves Saint James Aquino

he Mexico City Principles (MCP) for Voluntary Codes of Business Ethics for the

Biopharmaceutical Sector [1] aims to promote

ethical interactions between the pharmaceutical industry and healthcare professionals. The
guidelines were drafted in Mexico City by 36
experts from 14 member nations of the AsiaPacific Economic Cooperation (APEC), said Dr.
Francisco Tranquilino, a member of the APEC
Expert Working Group and an associate professor at the University of the Philippines, College
of Medicine, at the 2014 Philippine College of
Chest Physicians 2014 Midyear Convention.
quilino. Eventually, patents expired and big
Industry in a negative light
Tranquilino mentioned various factors that
resulted in a pharmaceutical industry having a
negative image in the medical field.
The trend of copycat or me-too drugs and
decreased innovation has caused only a hand-

companies were losing exclusivity to certain formulations.

There was full coverage for generics, partial
for useful brand-name drugs and no coverage
for expensive drugs that offer no added benefit
over cheaper ones, said Tranquilino.

ful of original formulations being developed in

Due to these concerns, the industry re-

recent years. Marketing machineries were devel-

sponded by marketing me-too drugs and push-

oped to compensate for the lack of innovation,

ing harder to extend monopolies on top-selling

focusing on doctors who write the prescriptions.

drugs. The companies also poured more mon-

In 2000, tax revenues of big pharmaceutical

ey into lobbying and political campaigns, said

companies dropped, with health insurers get-

Tranquilino. The marketing strategies involved

ting pushed back against drug costs, said Tran-

handing out free samples and personal gifts, as

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FORUM

well as exclusive advertising contracts with ce-

action with sales representatives was also influ-

lebrities.

ential.

There were also funding or sponsorships of

If you ask us how much influence do sales

travels, vacations and lunches for interns and

representatives have on our prescription, more

residents. The investment on young and future

than 50 percent of us will say it wont affect us,

medical professionals, referred to as food, flat-

said Tranquilino. However, he stated, studies

tery and friendship, created a sense of reciproc-

showed that frequent contact with sales repre-

ity in young doctors that would later prescribe

sentatives was associated with more rapid pre-

medicines, said Tranquilino.

scription of new medicines and less prescribing

of generics.

According to the MCP document,

ethical interactions help ensure that

Core principles for ethical practice

The APEC initiative recognized that commer-

medical decisions are made in the

cial enterprises could promote economic growth

best interests of patients

as long as they are able to operate, trade and

innovate in an ethical manner.
The MCP covers various professional interac-

A period of transition

tions between the health sector and the pharma-

In 2000, the American Medical Association

ceutical industry, including use of promotional

issued guidelines to curb unethical practices. A

information and activities, sponsorship of sym-

few years later, the US Department of Heath and

posia and congresses, educational items and

Human Services warned that excessive gift-giv-

gifts, support for CMEs, company donations for

ing to doctors could be prosecuted under local

charitable purposes, and clinical trials, among

laws.

others.

However, these guidelines mainly dealt with

According to the MCP document, Ethical

extreme practices. Not only are guidelines filled

interactions help ensure that medical decisions

with loopholes, they were also voluntary, said

are made in the best interests of patients. The

Tranquilino.

document espouses six principles that should

Since guidelines typically exempt education

guide companies in the biopharmaceutical sec-

and research activities, it was open to abuse.

tor: healthcare and patient focus, integrity, inde-

There were marketing strategies that masquer-

pendence, legitimate intent, transparency and

aded as education through sponsorship of

accountability.

Continued Medical Education (CME) for medi-

Tranquilino stated that in order to promote

cal doctors. Tranquilino stated that studies have

the core principles, some salient recommenda-

shown CME funding increased the likelihood of

tions were offered.

prescribing sponsors products. Similarly, inter-

In terms of gifts, educational items may

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be deemed acceptable, and in line with local code of ethics, if they are of modest value
and are useful only within the receivers professional healthcare responsibility. Other types
of gifts such as tickets to theater or sporting
events, sporting equipment, or vacation trips
are discouraged to ensure appropriate focus on
educational exchange.

In sponsoring symposia, the MCP

emphasizes that sponsorship to
individual professionals must not
be conditional upon an obligation
to prescribe, recommend or
promote any medicine

In sponsoring symposia, the MCP emphasizes that sponsorship to individual professionals must not be conditional upon an obligation to prescribe, recommend or promote any
medicine. The document also discourages use
of extravagant venues or resorts in hosting congresses, as well as funding individuals who accompany invited healthcare professionals.
1. Available at http://www.fda.gov.ph/attachments/article/103511/The%20Mexico%20City%20Principles.pdf.

FORUM

Case 1: A pharmaceutical company

decides to host a medical symposium
in Boracay, Philippines. Is this acceptable?
The MCP discourages use of extravagant
venues or resorts.
Boracay is a resort location. No matter
what you say, when people go to Boracay,
it is for R&R even if theres Boracay Convention Center, said Tranquilino. Companies are also urged not to provide any
form of entertainment or recreational items
that are not related to the medical and scientific profession. According to the MCP,
such entertainment or recreational benefits should not be offered, regardless of
(1) the value of the items; (2) whether the
Company engages the healthcare professional as a speaker or consultant, or (3)
whether the entertainment or recreation is
secondary to an educational purpose.
Case 2: Dr. X was invited to a dinner
launch for a pharmaceutical product.
He asked if he could bring his family
along, as it was his sons birthday.
The MCP states that inclusion of a healthcare professionals family or other guests
is not appropriate. This applies to hosted
meals accompanied by informational presentation of a company. Offering take-out
meals to be eaten without a company representative is also not acceptable, according to the MCP.

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Why scratching worsens itching:

New study holds key
Elvira Manzano

cratching provides relief for itchy skin but

often only temporary as the itching can

come back again, worse than it was before.

The reason: scratching causes the brain to
release the neurotransmitter serotonin, which
activates the itch receptor and increases itching
sensation, said study investigator Dr. Zhou-Feng
Chen from the Center for the Study of Itch at St.
Louis, Washington University School of Medicine,
St. Louis, Missouri, US.
The findings may provide insights into a previously unrecognized serotonin pathway to break

Scratching triggers the release of serotonin which

exacerbates itching.

the scratch-itch cycle and represent a new thera-

Our study showed that enhancing serotoner-

peutic target for individuals suffering from chronic

gic tone via administration of 5-HT in mice poten-

itch, for example patients with eczema.

tiates GRP [gastrin-releasing peptide] receptor-

The study involved genetically engineered

mediated itch signalling, whereas mice lacking

mice lacking the genes responsible for sero-

5-HT or serotonergic neurons in the brainstem

tonin production and injected with a compound

exhibit markedly reduced scratching behavior,

that would normally cause itching. After injec-

Chen said.

tion of the compound, the mice did not itch as

In addition, the researchers were able to iden-

much. However, when injected with serotonin,

tify 5-beta hydroxytryptamine receptor 1 (5-HT1A)

the mice itched as they would be expected to,

as a key receptor (for serotonin) in facilitating

and scratched badly. [Neuron 2014;doi:http://

GRP-dependent scratching behavior. Blockade

dx.doi.org/ 10.1016/j.neuron.2014.10.003]

of 5HT1A significantly attenuates itch transmis-

Central

serotonin

(5-hydroxytryptophan,

sion and made the mice scratch less.

5-HT) has been shown to modulate somatosen-

We always wondered why this vicious itch-

sory transduction in previous studies, but how it

pain cycle occurs. You scratch, and then it causes

achieves sensory modality-specific modulation

a sensation of pain. When the brain gets those

remains unclear.

pain signals, it responds by producing more

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serotonin to help control the pain. However, it

in humans as this would have far reaching conse-

does more than just inhibiting the pain as it makes

quences. A more practical antipruritic approach,

itching worse by activating the GRP receptor neu-

he said, will be to disrupt the crosstalk between

rons through 5-HT1A receptors, Chen said.

5-HT1A and GRP receptor neurons. Until that can

Although blocking serotonin reduced itch sensation in mice, it may not be a practical strategy

be achieved, Chen said the best advice is not to

scratch.

HSA to transfer regulatory control

of pharmaceutical products
Elvira Manzano

he Health Sciences Authority (HSA) will

transfer the regulatory control of pharma-

ceutical products to the Health Products Act

(HPA) to streamline the regulatory framework for
health products into one Act.
Currently, the legislative control for pharmaceutical products is under the Medicines Act
and Poisons Act. Consolidating the relevant
control under the HPA will provide greater clarity
to stakeholders as they would only need to refer
to a single legislation, the HSA said.
With the proposed legislation, pharmaceutical products will be known as therapeutic
products defined as health products intended
for therapeutic, preventive, palliative or diagnostic purpose, including chemical and biologic
drugs. Regulatory control of cellular and tissue
therapeutic products will continue to be under
the Medicines Act but may be considered for

HPA control of pharmaceuticals should provide clarity to

stakeholders.

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consolidation under the HPA eventually.

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10

advisories and warnings.

Besides transferring fundamental controls,

The HSA said feedback from healthcare

four sets of subsidiary legislation were pro-

professionals and institutions, pharmaceutical

posed to cover areas such as clinical trials,

industry, and the public can be sent through

manufacture, registration, import, supply, pre-

email (hsa_feedback@hsa.gov.sg) or fax (6478

sentation, advertisement, adverse event report-

9076) until November 23, 2014.

ing and enforcement.

Stakeholder feedback will help in refining

Public consultations for advertisement con-

the proposed regulatory framework for thera-

trol and retail pharmacy licensing of therapeu-

peutic products before it is finalized for imple-

tic products are currently ongoing. Proposed

mentation in the third quarter of 2015, the HSA

changes include removal of permits for thera-

said.

peutic product advertisements and inclusion of

Medical devices were the first category

telepharmacy provisions into the HPA. Direct-

of health products to be regulated under

to-consumers advertisements for pharmacy-

the HPA, followed by cosmetic products in

only medicines will be required to include

2008.

Genetic testing for inherited cardiac

conditions now available at NUHCS
Elvira Manzano

and inherited arrhythmias, for example, Brugada

syndrome) are referred to the clinic for genetic

new clinic intended for genetic testing and

testing. Mr. Aziz Marjan, who had lost a son to

counseling of patients with inherited cardiac

ICC, was one of those who underwent the test.

conditions (ICCs) has opened at the National

His daughter was also diagnosed with the same

University Heart Center, Singapore (NUHCS).

condition.

So far, 160 patients have been tested at the

Inherited cardiac diseases predispose indi-

ICC clinic, which is the first of its kind in the coun-

viduals to sudden cardiac death. Genetic testing

try. Patients are initially examined by their car-

can identify those at increased risk for a disease

diologist and those suspected of having some

a family member suffers, or the risk of a couple

types of ICC (cardiomyopathy, aortopathies such

having a child with the same disorder, said As-

as Marfan syndrome and Loeys-Dietz syndrome,

sociate Professor Roger Foo, senior consultant,

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11

Department of Cardiology, NUHCS. The genetic

disease, identifying mutations in a specific gene

information, whether positive or negative, may

can help them make decisions about treatment.

help confirm the diagnosis, allow for a change in

Treatment, he said, will not reverse the condi-

the clinical management, and enable early pre-

tion but is often effective in controlling symptoms,

dictive testing for as yet unaffected family mem-

if done in conjunction with lifestyle changes.

bers, he added.

In Singapore, about 1,000 people die sudden-

Family members of a person with an autoso-

ly each year, and often the causes of death were

mal dominant condition (abnormal gene from

undiagnosed ICC. A genetic test can suggest

one parent) have a 50 percent risk of inheriting

what treatments might be best and how risky

the gene mutation that causes the condition,

the condition is, but it can cost from US$1,000 to

said Foo. The first step to determine if heart dis-

US$3,000 and is difficult to access.

ease runs in the family is through a pedigree

ICC clinics are widely found in Europe, the

showing family members with or without a heart

US and Australia but never before in Singapore. It

condition and those who died unexpectedly.

is important that we now have our own advanced

Sometimes people may not be aware that

genetic tests in the first of such a clinic in Sin-

they have a heart condition because they have

gapore, developed in collaboration with the Ge-

no symptoms, or their findings are mild, said Dr.

nome Institute of Singapore, said Foo.

Raymond Wong, senior consultant, Department

of Cardiology, NUHCS. For those positive for the

Currently, genetic testing is free at the clinic

because of research funding.

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Age, BMI associated with retinal

wear in AMD
Radha Chitale

typical distribution of pigment cells in the

macula, a special region of the retina, to-

gether with a change in thickness in the area

could signal increased risk of age-related macular degeneration (AMD), particularly in older,
overweight people, according to a recent study
of Singaporean Chinese subjects at Khoo Teck
Puat Hospital.

Older, overweight people may be at increased risk of

age-related macular degeneration.

AMD occurs when the macula begins to degrade, creating blurry, distorted vision at the cen-

interval [CI], 1.01-1.13, p=0.04) and body mass

ter of where we focus. While AMD is not painful, it

index (OR 1.17, 95% CI, 1.01-1.34, p=0.03) were

significantly decreases quality of life. AMD is the

significant predictors for atypical macular pig-

third most common cause of blindness among

ment spatial profile with central dip.

Singaporean adults over age 60. Regular eye

screening is not offered in local hospitals.

[Older age and BMI are] the two known risk

factors for AMD, suggesting that atypical macular

The cross-sectional study included 95 Sin-

pigment spatial profile may be associated with

gaporean Chinese subjects with no eye disease

an increased risk of AMD, the researchers said.

at baseline whose mean age was 42 (21 to 68)

Further studies with larger sample sizes are re-

years. [Invest Ophthalmol Vis Sci 2014;55:2376-

quired to confirm these observations.

2383]

The researchers also tested for serum con-

In general, women tend to have lower levels

centrations of lutein (L) and zeaxanthin (Z),

of macular pigment optical density than men and

carotenoids that give the macula its distinct

this was reflected in the study.

yellow color, and found a positive relation-

Eighty-five percent of subjects had a typical

ship between those and macular pigment op-

macular pigment spatial profile. Fifteen-percent,

tical density, although it was only significant

however, had atypical macular pigment spatial

for Z.

profiles featuring a central dip in which the density of macular pigment was lower.
Age (odds ratio [OR] 1.06, 95% confidence

Similar studies on macular pigments in Malay and Indian populations are currently underway.

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13

Probiotics may have a role in IBD

and IBS
Christina Lau

robiotics may have a role in inducing and

maintaining

remission

of

inflammatory

bowel disease (IBD) and in reducing symptoms

of irritable bowel syndrome (IBS).
Recent studies have associated dysbiosis
of the gut microbiota with IBD, IBS, Clostridium
difficile-associated diarrhea, obesity and type 2
diabetes, said Dr. Sunny Wong of the department of medicine and therapeutics, Chinese
University of Hong Kong. Wong was speaking at

Probiotics may help provide relief in people with IBS.

the International Digestive Disease Forum 2014

in Hong Kong.

Dis 2014;20:21-35; Gut 2013;62:787-96)

Therapeutic manipulation of gut microbiota

In IBS patients, two meta-analyses showed

may offer effective treatment for certain gastro-

significant symptomatic improvements with the

intestinal conditions by restoring homeostasis

use of probiotics, while a recent study showed a

of the gut ecosystem. In a study of patients with

significant 35 percent reduction in symptom se-

recurrent C. difficile infection a condition asso-

verity after 12 weeks of probiotic treatment, said

ciated with high rates of antibiotic failure duo-

Wong. (World J Gastroenterol 2008;14:2650-61;

denal infusion of donor feces was significantly

Gut 2010;59:325-32; Aliment Pharmaco Ther

more effective than vancomycin in causing reso-

2014;40:51-62)

lution of infection (93.8 vs 30.8 percent). (N Engl

J Med 2013;368:407-15)

Probiotics are also shown to prevent antibiotic-associated and C. difficile-associated

Understanding of the role of gut microbiota

diarrhea in meta-analyses. (Aliment Pharmaco

in health and diseases has led to great interest

Ther 2012;35:1355-69; Cochrane Database

in the use of probiotics and prebiotics in the

Syst Rev 2013;5:CD006095; Ann Intern Med

medical community, said Wong.

2012;157:878-88) In elderly patients, however,

The use of probiotics is shown, for example,

they are not shown to be effective in preventing

to induce remission in ulcerative colitis and

either type of diarrhea. (Lancet 2013;382:1249-

maintain remission in pouchitis. (Inflamm Bowel

57)

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14

Studies are being conducted to investigate

and clinical use are hampered by heterogeneity

the role of prebiotics, either alone or with pro-

in microbial composition, dosage and formula-

biotics, in the treatment of various diseases,

tion, with a lack of a standard commercialization

said Wong. Nevertheless, their development

process and regulatory framework.

New botulinum toxin approved

for aesthetic use in Singapore
cols that minimize resistance development.

Chuah Su Ping

The immunogenicity of botulinum toxin A is in

ncobotulinumtoxinA (Xeomin , Merz) has

part influenced by the complexing proteins which

been approved for the aesthetic treatment of

are bound to it, which may act as adjuvants and

glabellar frown lines in Singapore. Additionally,

stimulate the bodys immune response. [Bio-

it has also been approved for the treatment of

Drugs 2012;26:e1-e9] As such, manufacturers

abnormal neck position and neck pain associ-

of botulinum toxin preparations have strived to

ated with cervical dystonia, blepharospasm

reduce the content of foreign proteins bound to

and post-stroke spasticity of the upper limbs in

the neurotoxin in order to reduce post-treatment

adults.

immunogenicity.

Botulinum neurotoxin injections are a valu-

IncobotulinumtoxinA is a purified botulinum

able treatment modality for many therapeutic in-

neurotoxin as it is free from complexing proteins

dications as well as in the aesthetic field for facial

and has the lowest foreign protein content per

rejuvenation, said Dr. Med. Welf Prager, head

vial compared with other botulinum toxins cur-

of Aesthetic Dermatology at the Dermatological

rently available on the market. This is important

Practice and Skin Disease Day Clinic in Ham-

as research has shown that a lower concentra-

burg, Germany, during the product launching

tion of foreign proteins in a formulation results

in Singapore. As successful treatment requires

in a lower concentration of antibody formation

repeated injections over a long period of time,

which may affect treatment efficacy in both

secondary resistance to botulinum toxin prepa-

medical as well as aesthetic indications, said

rations after repeated injections is an ongoing

Prager.

concern. He noted that clinicians should be

Furthermore, the low immunogenicity of in-

aware of this risk and implement injection proto-

cobotulinumtoxinA may have implications on

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15

restrictions such as minimum injection intervals

effect (time until muscle action has returned to

of 10 weeks currently in place for maintaining

baseline level), compared with onabotulinum-

successful long-term application of the botuli-

toxinA, he said. [Clin Cosmet Investig Dermatol

num neurotoxin. [BMJ Open 2012;2:e000646]

2013;6:211-219]

Prager also highlighted a prospective, multi-

In my opinion, incobotulinumtoxinA is the

center, randomized trial involving 381 patients,

safest product of its class on the market, both

which showed that incobotulinumtoxinA is as

for medical as well as aesthetic indications. Its

effective as onabotulinumtoxinA in the treat-

not a difficult choice when you compare a prod-

ment of glabellar frown lines. [Dermatol Surg

uct with the smallest possible amount of foreign

2010;36:2146-2154] With regards to time to

body proteins, with other products with higher

onset of treatment effect, incobotulinumtoxinA

concentrations of foreign body proteins which

has been shown to have a shorter time to onset

can increase your patients risk of potential anti-

of treatment, and longer duration of treatment

body reactions, said Prager.

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16

HSA orders recall of drug-tainted

dietary supplement
Elvira Manzano

ingapores Health Sciences Authority (HSA)

has ordered the recall of a health supple-

ment for men containing an undeclared, potent

chemical ingredient.
AMACETM for him, marketed and sold locally

by Acupoint Pte Ltd, tested positive for N-cyclopentyl nortadalfil, an analogue of prescription
medicine tadalafil used for treating male impotence.
The HSA warned that N-cyclopentyl nortadalfil may cause serious adverse effects such
as headache, dizziness, high blood pressure,
chest pain and muscle aches when consumed
without medical supervision. Tadalafil and its analogues are also contraindicated in individuals
with known hypersensitivity to the drug and in
patients with heart problems or are taking heart
medications such as nitrates as cases of death

AMACETM tested positive for N-cyclopentyl nortadalfil,

which can cause serious adverse effects when taken
without medical supervision.

have been reported.

Labeled to contain only natural ingredients

reaction reports associated with the use of the

lingzhi, ginseng, cordyceps and wolfberry,

product, although it is possible that consum-

AMACETM is marketed as a dietary supplement

ers who have experienced side effects may not

and claims to enhance energy level and blood

have told their doctors or pharmacists about the

circulation, strengthen the immune system, and

use of the product.

arouse sexual nerves.

Acupoint has since stopped selling the prod-

Health products containing undeclared in-

uct on HSAs orders. Consumers are also ad-

gredients may cause adverse reactions and

vised to discontinue use and to report immedi-

may interact with other medications.

ately any adverse reactions experienced from

To date, HSA has not received any adverse

using the product. The authority warned that

N OV- DE C 2 0 14

N E WS

17

anyone selling health products containing un-

have any information on the sale of AMACE or

declared potent ingredients will face a penalty or

other illegal products may contact the HSAs En-

fine of up to S$10,000 and/or imprisonment up to

forcement Branch through phone (6866 3485) or

2 years under the Poisons Act. Consumers who

email (hsa_ is@hsa.gov.sg).

Neuroticism, long-term stress linked

to higher risk of Alzheimers in women
Elvira Manzano

omen who worry a lot and cope poorly

with stress may be at an increased risk of

developing Alzheimers disease (AD) later in life,

research suggests.
A study of 800 women in Sweden followed
for 38 years showed that women with the highest scores on neuroticism scale and had experienced long-term distress in midlife were twice
as likely to develop AD than those with the
lowest scores. [Neurology 2014; pii:10.1212/

Neuroticism alone is not a risk factor for stress, but it is

stress that is harmful.

WNL.0000000000000907;E-pub ahead of print]

Neuroticism is the enduring tendency to be in

AD, and that distress mediates this association.

a negative emotional state. People with neurotic

Clearly, there was a clear statistical correlation in

personality may perceive daily run-of-the-mill

those who had been exposed to a long period

situations as alarming or depressing. They suf-

of stress, said Johansson. It is the stress itself

fer from negativity, feelings of guilt, anxiety, envy

that is harmful. A person with a neurotic tenden-

and anger more frequently and more severely

cy is more sensitive to stress than other people,

than other people and have difficulty managing

said lead researcher Dr. Lena Johansson from

stress, although they are in touch with reality.

the Sahlgrenska Academy at Gothenburg Uni-

We have shown in this study that midlife

neuroticism is associated with increased risk of

versity in Molndal, Sweden.

Using the Eysenck Personality Inventory

N OV- D E C 2 0 14

N E WS

18

scale, women were assessed of their dominant

Johansson. However, the finding does not sug-

personality traits (ie, extraversion vs introversion

gest that neuroticism alone could increase the

and neuroticism vs stability). Dementia was di-

risk of AD.

agnosed according to DSM-III-R criteria, based

Personality could determine behavior, life-

on information culled from neuropsychiatric ex-

style and how we react to stress. Ultimately, all

aminations, hospital records, and registry data.

these may significantly affect the risk of develop-

During the study period, 153 women who had

neurotic tendencies at midlife had developed
some types of dementia, 104 of which had AD.

ing AD.
She said future studies should examine whether this group of women will re-

Advancing age, family history, and genetics

spond well to interventions. It remains to be

are known risk factors for AD and other demen-

seen whether neuroticism could be modi-

tia-related disorders. This is the first study to

fied by medical treatment or through lifestyle

show a link between personality and AD, said

changes.

NUS researchers identify potent

anti-obesity compounds
Elvira Manzano

esearchers from the National University of

Singapore (NUS) have identified several

potent inhibitors that selectively target FTO, a

gene that has been associated with fat mass
and obesity in some people.
Using dynamic combinatorial mass-spectrometry, the researchers found that several
compounds were able to selectively inhibit FTO
the most potent being 4-[N-(4-Benzyl-pyridine-3-carbonyl)-hydrazino]-4-oxo-but-2-enoic
acid. [Chemical Science 2014; doi:10.1039/
c4sc02554g]

Singaporeans with certain FTO mutations are good

candidates for new weight loss drugs.

N OV- DE C 2 0 14

N E WS

19

Such remarkable selectivity is rarely

sity risk, but the mechanism behind this link

achieved and is the holy grail in drug discov-

has been unclear until the current study. Previ-

ery, as it potentially translates to significantly

ous studies in children and adults, and in major

reduced side effects, said lead investigator As-

ethnic groups (Chinese, Malay and Indians) in

Singapore, have shown that those with certain

Such remarkable selectivity is rarely

achieved and is the holy grail in drug
discovery, as it potentially translates to
significantly reduced side effects 

variations of the FTO were 70 percent more likely to become obese. This population group is
the target for the development of new drugs for
weight loss, the researchers said.
The research was done in coordination with
scientists from the Agency for Science, Tech-

sociate Professor Esther Woon from the Depart-

nology and Research (A*STAR) and Nanyang

ment of Pharmacy, NUS. This is demonstrated

Technological University. The researchers have

by the promising activities and low cytotoxicity

filed a patent for the inhibitors. They said the next

of some of these inhibitors in cells.

step is to study the effects of these FTO inhibi-

Mutations in the FTO gene have been shown

to be the strongest genetic determinant of obe-

tors on other metabolic diseases, for example in

diabetes.

N OV- DE C 2 0 14

B U S I N E SS

21

Guardian unveils online store

in Singapore

eading health and beauty retailer Guardian

has launched an online store in Singapore

to make shopping more convenient for its customers.

Guardians portal offers door-to-door delivery service of a wide range of health and beauty
products at the customers preferred dates, with
four time slots to choose from. Alternatively,
online purchases can be picked up at any of
Guardians 148 stores islandwide.
The portal is also the first to provide virtual

A media member explores the new Guardian Health &

Beauty e-commerce portal.

healthcare consultations with local doctors

through live chats or video calls. Personal health
diaries with secure logins are also provided for
customers to store and track their health histories. Another feature is the health and wellness
tips by Guardian pharmacists.
Singapore is the first to debut such a comprehensive e-commerce site across the Guardian
Health & Beauty network in Asia, said Ms. Sarah Boyd, chief executive officer, Guardian and
Beauty. The per capita spend on vitamins and
supplements is higher in Singapore than in any
country in the world. This means Singaporean

Guardians CEO Sarah Boyd demonstrates the virtual

health consultation service via a video call with MyDoc
co-founder Dr. Vas Metupalle.

consumers take a very healthy and proactive approach to managing their health. Shoppers here

the same prices online as they would in Guard-

are very busy, and they expect convenience in

ians stores. Our new e-commerce push is part of

getting products and information whenever they

Guardians ongoing efforts to evolve and rebrand.

want it and in the form that they want it. This is

We will continue to be responsive and adapt to

something Guardian can provide online.

the fast-changing health and beauty needs of

Boyd added that customers can get to enjoy

consumers in Singapore.

N OV- D E C 2 0 14

B U S I N E SS

22

The virtual health consultation is in partner-

said online health consultation is cheaper and

ship with MyDoc, an online health consultation

avoids the lengthy wait times during clinic vis-

platform. MyDoc co-founder Mr. Snehal Patel

its.

Dietary whey protein may be good

for weight loss

onsumers are becoming drawn to diets

high in protein, particularly whey protein,

as research suggests they have multiple benefits for healthy aging and weight management.
Experts said the branched-chain amino acids
(BCAAs) leucine, isoleucine, and valine found
in whey can accelerate muscle synthesis and
mimic the longevity benefits of calorie restriction. Whey protein, as part of a high-protein diet,
can help reduce fat and maintain lean muscle,
which are important for weight loss.
A meta-analysis of 14 weight loss studies involving healthy individuals showed that patients
who had consumed whey protein as a replacement for other sources of calories were able to
reduce body weight by 4.20 kg and body fat by
3.74 kg from baseline. There was also a significant increase in lean body mass among patients
who practiced resistance exercise in addition

the use of whey protein as a supplement com-

to whey protein consumption. [J Am Coll Nutr

bined with resistance exercise or as part of a

2014;33:163-175]

weight loss or weight maintenance diet to im-

The authors said current evidence supports

prove body composition parameters.

N OV- DE C 2 0 14

B U S I N E SS

23

FDA greenlights first combo pill

for HCV

he US Food and Drug Administration has

approved ledipasvir-sofosbuvir (Harvoni,

Gilead), for the treatment of hepatitis C virus

(HCV) genotype 1 infection in adults.
Ledipasvir is a potent inhibitor of HCV NS5A,
a viral phosphoprotein that plays a role in viral
replication, assembly, and secretion whereas
sofosbuvir is a nucleotide analogue inhibitor of
HCV NS5B polymerase, the key enzyme mediating HCV RNA replication.
Doctors said the approval was remarkable

studies (ION-1, ION-2, and ION-3) which showed

given that the two-drug regimen is the first FDA-

that treatment with ledipasvir-sofosbuvir over a

approved fixed-dose oral combination pill for

12-week course resulted in sustained virologi-

HCV. Ledipasvir-sofosbuvir also eliminates the

cal response rates of 94 to 99 percent in pa-

need for weekly injections of interferon or a sec-

tients with genotype 1 HCV infection. The most

ond antiviral medication ribavirin, which both

common side effects reported were fatigue and

come with significant side effects, including fa-

headache. However some experts said access

tigue and flu-like symptoms.

to care is a challenge given the high cost of the

The approval was based on three phase III

drug at US$1,125 a pill.

N OV- D E C 2 0 14

B U S I N E SS

24

Google testing video chats with

doctors

oogle is testing a new system that would

allow people searching for information

about their medical problems to video chat with

doctors directly.
All costs for the video chat sessions are covered by Google during the trial phase. It is not
clear, however, if users will have to bear the cost
when the feature is rolled out to the public.
Observers said telemedicine via Google will
be a game-changer as more people are turning to the Internet to obtain information, much
of which is health-related. Having a doctor talk

vice can also be cheaper and more convenient

through symptoms for a remote diagnosis or ad-

compared with an actual physician visit.

N OV- DE C 2 0 14

IN FOCUS

25

Sore throats can indicate severe

illness

ore throats are very common and symptoms can vary from a mild scratchiness at

the back of the throat to severe pain, according

to the Healthcare Handbook 2014 (pp13839).
The patient may also have enlarged lymph
nodes in the neck, difficulty swallowing, a hoarse
voice, coughing, sneezing or a rash, depending
on the cause.
Viruses account for 70 to 90 percent of all
infections. Other causes of sore throats include
streptococcal infection, glandular fever, herpes
simplex, varicella, candidiasis (thrush), adverse
medication reactions, smoking and gastrointestinal reflux.
Examination of the throat in a well-lit area is a
good idea to assess the severity of a sore throat
(Pharmacy Today NZ, June 2003).
Ask the patient to say Ah with the mouth
open as wide as possible. White pus-filled spots
on the tonsils will confirm tonsillitis, which re-

Sore throats are commonly caused by a cold or a flu but

may also indicate a more severe illness.

quires referral to a doctor for assessment and

treatment.
White spots elsewhere in the mouth can be

lethargy. Glandular fever is more common in

adolescents.

caused by candidiasis. Mouth ulcers usually

When it comes to bacterial causes of a sore

indicate the herpes simplex virus as the cause

throat, Group A streptococcal infection (strep

(Pharmacy Today NZ, June 2006).

throat) is the main culprit.

A sore throat lasting 1 to 4 weeks might also

be a symptom of glandular fever, caused by

Treatment essential for strep throat

the Epstein-Barr virus. As well as swollen throat

Strep throat tends to be more severe and

glands, this virus causes swelling in the armpits

persistent than other causes of sore throats,

and pelvic glands, plus fever, headache and

and can lead to rheumatic fever an inflamma-

N OV- D E C 2 0 14

IN FOCUS

26

tory disease that can permanently damage the

causes of throat irritation for people allergic to

heart and kidney disease (Healthcare Hand-

them (Pharmacy Today NZ, June 2004)

book 2014).
Symptoms may include a distinct pattern of
white patches on the back of the throat, a high
fever, or a rash that feels rough to the touch.

Chemical pollutants can also irritate the nose

and throat, with tobacco smoke being the number one cause.
Where a sore throat is severe, or has lingered
longer than the usual course of a cold or flu, and
allergies can be ruled out, patients should be

E
 xamination of the throat in a
well-lit area is a good idea to assess
the severity of a sore throat 

referred to the doctor.

Ear pain is another sign that the infection has
spread and requires referral.
If the patient is having difficulty swallowing,
accompanied with earache or blood in the saliva, a tumor may be present.

Three pharmacies in Hutt Valley and one in

Auckland are trial sites for rheumatic fever re-

Relief for pain and inflammation

sponse clinics, offering throat swabbing and

If the patient has a sore throat associated with

antibiotic prescriptions under standing orders.

a cold or flu, it is important they increase fluids

Patients have to meet a strict set of guidelines,

to offset dehydration and a dry throat (Health-

Unichem Owles Pharmacy in Naenae clinical

care Handbook).

pharmacist Pam Duncan says.

The patients must be aged between four and
19, have a sore throat and a temperature of at
least 38C.
Patients must have elements of high risk for
rheumatic fever, such as Maori or Pacific ethnicity, lower socioeconomic status, crowded homes
or a family history of rheumatic fever.
To help eliminate viral sore throats, patients
with coughs and a runny nose are excluded,
Mrs. Duncan says.
Pharmacies where the clinics are not offered
should refer patients with these symptoms to refer to a doctor for treatment, she advises.
Allergies can also cause a sore throat. Pollens, moulds, dust and cat dander are common

Pharmacies can also recommend products

to help soothe the pain and reduce inflammation.
Pharmacy-only anti-inflammatories include
benzydamine, such as Difflam solutions, sprays
and lozenges.
There is also flurbiprofen, found in Strepfen
lozenges, which is a locally acting, non-steroidal
anti-inflammatory drug (NSAID).
Antiviral agents such as Betadine Sore Throat
Gargle may kill viruses associated with sore
throats, but offer little symptom relief.
Lozenges with antibacterial agents, including
products made by Difflam and Strepsils, help to
relieve symptoms as well as fight the cause.
Locally acting anesthetics contain lignocaine

N OV- D E C 2 0 14

IN FOCUS

27

or benzocaine to soothe and numb sore throats,

Oral analgesics, such as paracetamol, ibu-

but patients must be warned to be careful with

profen or aspirin, can target pain and help keep

hot food or drinks, due to an altered perception

temperature down.

of heat.

Supplements that may help include slippery

Anesthetic products include Cepacine Oral

elm, honey, echinacea, thyme and liquorice.

Solution, Difflam Sugar-Free Lozenges Plus An-

BLIS K12 throat guard products include Strep-

aesthetic and Strepsils Plus lozenges and throat

tococcus salivarivus to help replenish beneficial

spray.

throat bacteria.

PTNZ

N OV- D E C 2 0 14

F E ATU R E

28

Diabetics need encouragement

and advice

hen helping people who have diabetes,

it is important to find out what the patient

understands about their condition, Porirua pharmacist Graeme Blanchard says.

Mr. Blanchards Waitangirua Pharmacy has
around 370 patients with diabetes.
Educating patients is very important, but,
first, it is vital to find out what they know, he says.
Many people are so overwhelmed when they
are first diagnosed with diabetes they forget
what they are told.

Pharmacists have an important role in helping diabetics

with their medication.

Information from the doctor varies but

they forget 90 percent of that in 3 days, Mr.

ery time he sees them, what their glucose read-

Blanchard says.

ing is.

Despite type 2 diabetes being a largely preventable overeating condition, it is important

not to judge, he says.
Asking the patient if they want to be around
for their kids or grandkids helps them to realize
the gravity of the situation, Mr. Blanchard says.
Thats quite a tough one for a lot of parents

It raises the importance of doing the tests

and taking notice of the results, he says.
Normal blood glucose levels are 4.0 mmol/L
to 7.5 mmol/L (Healthcare Handbook 2014).
Mr. Blanchard says just a two or three-minute discussion, each time patients pick up their
scripts, is often all that is needed.

theyre so busy looking after everyone, they

Patients who have a good result get plenty of

dont look after themselves. Its quite emotional:

praise, those who do have a high result might

we get a lot of tears, he says.

need some more one-on-one help, he says.

Diabetics need to be armed with a glucose

Its important to ask open questions: is it

meter, so they can self-manage, Mr. Blanchard

consistently high, are you taking your meds,

says.

what are you eating, are you getting enough ex-

Patients can get the right balance if they un-

ercise?

derstand the three things that affect a glucose

reading: food, medication and activity, he says.
Mr. Blanchard asks his diabetes patients, ev-

Pharmacists have important role

Pharmacists have an important role in help-

N OV- D E C 2 0 14

ing diabetics with their medication, Diabetes

F E ATU R E

Diabetes Types

New Zealand president Chris Baty says.

For many people with diabetes, too often it
comes after theyve had complications they
are often on multiple medicines and they can be
from multiple prescribers.
I do think the pharmacist has got a very real
role in keeping an eye on the medications that
are used, because the greater number of medicines, the greater the risk of things happening.
Mrs. Baty agrees it is important to ensure patients understand what is being said.

P
 atients need to know why it
is important to take certain
medicines with food and potential

Type 1 diabetes
Type 1 diabetes is most commonly diagnosed
in children aged seven to 12 years, although it
can occur at any age.
It is an autoimmune condition where the
immune system rejects or destroys the bodys
insulin-producing cells, leaving the patient with
a life-long dependency on exogenous insulin.
Of all the people with diabetes, around 10
percent have type 1.
Type 2 diabetes
This is the most common type of diabetes.
Unlike people with type 1 diabetes, people with
type 2 diabetes produce insulin. However, it is
either not enough to mop up all the glucose in
the blood or their body is unable to recognize
the insulin and use it properly.
About 7 percent of the adult population in New
Zealand have diabetes, or more than 200,000
people.
People most at risk of developing type 2
diabetes are those who:

it with literacy, but some of the most health illiter-

a
 re of Maori, Asian, Middle Eastern or Pacific
Island descent older than 30 years
are of European descent older than 40 years
are overweight especially if the extra weight
is around the waist
do not exercise regularly
have a family history of diabetes
had gestational diabetes or gave birth to a
baby weighing more than 4 kg.

ate people I know have PhDs, she says.

Diabetes in pregnancy (gestational diabetes)

side effects 

Our levels of health literacy in New Zealand

are very low. Often health professionals confuse

It is important for pharmacists to meet faceto-face with their diabetes patients, and their
families, for a quick consult, Mrs. Baty says.
Patients need to know why it is important to
take certain medicines with food and potential
side effects, she says.
Many also need help with over-the- counter
medicines, such as what cough and cold medicines are safe to take.

Gestational diabetes happens when a pregnant

woman cannot produce enough insulin to
cope with her bodys increased needs during
pregnancy. It usually disappears after the baby
is born but women who have had gestational
diabetes are at greater risk of developing type 2
diabetes later in life.
Gestational diabetes affects 48 percent of
pregnant women, and is routinely screened
for with a polycose test at around 27 weeks
gestation.

29

N OV- DE C 2 0 14

Type 1 diabetes even harder to manage

Mrs. Baty, who is a type 1 diabetic herself,
says patients who are insulin-dependent are
even harder to manage.
All type 1 diabetics, and type 2 diabetics who
have got to the stage that they need insulin,
need a lot of advice, she says.

F E ATU R E

30

Its about diet, and making sure blood pressure and cholesterol are also in range.
Patients with diabetes who are struggling
with adherence may qualify for the Long Term
Conditions (LTC) service, Mrs. Bennett says.
Many benefit from regular reminders about
taking their medicines, she says. However, some

Insulin needs to be refrigerated most of the

diabetics might need more help, such as those

time, particularly if patients are travelling to the

who have been released from hospital after an

Pacific Islands.

incident like a heart attack, Mrs. Bennett says.

Insulin thats cold stings when its put in so

A medicine use review (MUR) gives an op-

taking it out [of the fridge] before you inject it is

portunity for the pharmacist to sit down with a

a good idea, Mrs. Baty says.

patient and go over their medicines in depth,

These patients also need reminding on the

she says.

importance of clean hands when testing and

I found out one woman stopped taking her

injecting, proper disposal of sharps, the need

Lipitor, her cholesterol-lowering medication, be-

to regularly change syringes and lancets, she

cause her neighbor had read an article on side

says.

effects. Its important to find out a patients beliefs and getting agreement from them to buy

Broad advice can be given with LTC and

MUR services
Diabetes goes hand-in-hand with other
chronic conditions. It causes half of all heart attacks and is the single biggest cause of strokes
(Pharmacy Today NZ, November 2012).
It is important diabetics understand the re-

into therapy.
Many patients need help if they are on metformin which is often the first-line medication
to control type 2 diabetes, Mrs. Bennett says.
It can be quite nasty on the tummy youve
got to increase it slowly, so that their body gets
used to having it, she says.

lationship between diabetes and heart health,

Having brochures for people to take home

Auckland pharmacist Marie Bennett from All

and read in their own time is also a good idea,

Seasons Pharmacy, says.

Mrs. Bennett says.

PTNZ

Essential Clinical
Practice Tool
On-The-Go

www.mims.com

The FREE MIMS app delivers critical prescribing information, medical news
and CME articles as well as clinical calculators essential to physicians daily
practice needs.
With MIMS available across multiple platforms and devices, you can now easily
and conveniently find the most up-to-date and relevant drug information you
need anytime, anywhere.

Join over a million MIMS members who have incorporated MIMS

into their daily workflow. Connect with MIMS today.
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N OV- DE C 2 0 14

C L I N I C A L P H A R M ACY

32

Insulin pumps better than

injections for T1D
Elvira Manzano

Optimizing glucose control is essential for

preventing complications in diabetes. Pump

he use of insulin pumps was associated with

therapy, which uses a catheter placed under

lower risks of cardiovascular disease (CVD)

the skin to deliver short-acting doses of insulin,

and death compared with multiple insulin injec-

is an alternative means of providing continuous

tions in patients with type 1 diabetes (T1D), a

insulin infusion to patients who do not achieve

study presented at EASD 2014 has shown.

good glucose control despite multiple daily in-

The study of 18,168 T1D patients from Swe-

sulin injections.

dens national diabetes registry demonstrated

However, Gudbjornsdottir said clinicians

that at a mean follow-up of 7 years, patients on

should exercise caution when interpreting their

pump therapy (n=2,441) were 44 percent less

findings considering the observational nature

likely to develop fatal CVD (hazard ratio [HR],

of the study. A randomized controlled study,

0.56; p=0.003) and 29 percent less likely to

she added, is warranted to determine the long-

die from any cause (HR, 0.71; p=0.003) than

term safety and clinical benefits of using insulin

those receiving multiple daily insulin injections

pumps in patients with T1D.

(n=15,727).

The American Diabetes Association and the

The results were statistically significant, said

EASD, in a separate statement, said insulin

study author Dr. Sofia Gudbjornsdottir from the

pumps are used by an increasing proportion of

University of Gothenburg in Sweden. Pump

patients with T1D, including children, as they

therapy may be associated with a lower risk of fa-

offer adjustable settings and features and are

tal cardiovascular disease and all-cause mortality

relatively small and sophisticated. But consid-

than injections. This was beneficial with regard to

ering the limited regulatory scrutiny of insulin

long-term complications.

infusion sets both in the US and Europe, they

Patients on insulin injections appeared to be

said more robust systems should be estab-

older, with longer diabetes duration, higher blood

lished such as increased requirement for test-

pressure, and higher incidence of CVD than

ing of function over time, more research into

those on pump therapy. The researchers used

the interaction between pump design and hu-

propensity matching to even out the general dif-

man factors, and more well-controlled clinical

ferences between patients receiving insulin injec-

trials on the use of the device under real-world

tions and the pumps.

conditions.

N OV- D E C 2 0 14

C L I N I C A L P H A R MACY

33

SGLT2 inhibitors offer multiple

benefits for patients with T2D:
Meta-analysis
Elvira Manzano

he use of insulin pumps was associated with

lower risks of cardiovascular disease (CVD)

and death compared with multiple insulin injections in patients with type 1 diabetes (T1D), a
study presented at EASD 2014 has shown.
The study of 18,168 T1D patients from Swedens national diabetes registry demonstrated
that at a mean follow-up of 7 years, patients on
pump therapy (n=2,441) were 44 percent less
likely to develop fatal CVD (hazard ratio [HR],
0.56; p=0.003) and 29 percent less likely to

SGLT2 inhibitors effectively lower glucose levels, in

addition to having weight loss and blood pressure
lowering benefits, in T2D patients.

die from any cause (HR, 0.71; p=0.003) than

those receiving multiple daily insulin injections
(n=15,727).

tions and the pumps.

Optimizing glucose control is essential for

The results were statistically significant, said

preventing complications in diabetes. Pump

study author Dr. Sofia Gudbjornsdottir from the

therapy, which uses a catheter placed under

University of Gothenburg in Sweden. Pump

the skin to deliver short-acting doses of insulin,

therapy may be associated with a lower risk of fa-

is an alternative means of providing continuous

tal cardiovascular disease and all-cause mortality

insulin infusion to patients who do not achieve

than injections. This was beneficial with regard to

good glucose control despite multiple daily in-

long-term complications.

sulin injections.

Patients on insulin injections appeared to be

However, Gudbjornsdottir said clinicians

older, with longer diabetes duration, higher blood

should exercise caution when interpreting their

pressure, and higher incidence of CVD than

findings considering the observational nature

those on pump therapy. The researchers used

of the study. A randomized controlled study,

propensity matching to even out the general dif-

she added, is warranted to determine the long-

ferences between patients receiving insulin injec-

term safety and clinical benefits of using insulin

N OV- DE C 2 0 14

pumps in patients with T1D.

C L I N I C A L P H A R M ACY

34

infusion sets both in the US and Europe, they

The American Diabetes Association and the

said more robust systems should be estab-

EASD, in a separate statement, said insulin

lished such as increased requirement for test-

pumps are used by an increasing proportion of

ing of function over time, more research into

patients with T1D, including children, as they

the interaction between pump design and hu-

offer adjustable settings and features and are

man factors, and more well-controlled clinical

relatively small and sophisticated. But consid-

trials on the use of the device under real-world

ering the limited regulatory scrutiny of insulin

conditions.

Timing of meals may impact

effectiveness of TB medication
Greg Town

ating food before taking tuberculosis (TB)

medications may negatively impact the ef-

fectiveness of the treatment, according to new

research presented at ERS 2014.
In a small study, 20 patients with TB were
administered standard drug therapy with isoniazid, rifampicin, pyrazinamide and ethambutol
for the first time, with or without a high-carbohydrate meal. [Abstract P2659]
By analyzing blood samples using liquid
chromatography tandem-mass spectrometry,
the researchers found that within 24 hours of
treatment, the blood concentrations of most of
the drugs administered were significantly lower
when they were given together with a high-carbohydrate meal than when given in a fasting
state.

Food can have an impact on the concentrations of TB

meds in the blood.

N OV- DE C 2 0 14

C L I N I C A L P H A R MACY

35

We found that food intake decreased expo-

variable was the meals and we therefore know

sure of isoniazid, rifampicin and pyrazinamide

that food can have an impact on the concentra-

in treatment-naive TB patients, said lead au-

tions of the drugs in the blood, she said.

thor Dr. Antonia Morita Iswari from the Univer-

Although some existing recommendations

sitas Gadjah Mada, Yogyakarta, Indonesia, and

say that TB drugs can be taken after meals

the University of Groningen, The Netherlands.

or before bed-time to reduce the likelihood of

The main problem was with rifampicin, added

gastrointestinal disturbances, it is unclear how

Iswari. The drugs exposure was much lower

meals may influence the pharmacokinetics of

compared with the fasting state.

such drugs.

Iswari said the study findings suggest eating

The [study] findings may have significant

food before taking TB drugs can render them

implications for clinical practice as we must en-

less effective.

sure that patients are taking the drugs in the

As the research was conducted in the same

people and the same environment, the only

correct way to be as effective as possible,

Iswari said.

P H A R M ACY U P DATE

36

Tiotropium approved for asthma

in Europe
Greg Town

he

long-acting

muscarinic

antagonist

(LAMA) tiotropium (Spiriva), administered

via the novel Respimat soft-mist inhaler, has

been approved in the European Union (EU) to
be used as an add-on maintenance therapy for
patients with asthma.
Consistent with previous studies, latest data
from the phase III UniTinA-asthma clinical trial

Tiotropiums unique mode of action provides physicians

with a new option for managing asthma.

program have shown that tiotropium delivered

by the soft-mist inhaler significantly improved

physician and honorary associate professor,

symptoms in adult patients with a range of asth-

Royal Devon & Exeter Hospital, UK. These sta-

ma severities not well controlled by usual care

tistics clearly highlight the critical need for new

with an inhaled corticosteroid (ICS)/long-acting

and effective asthma treatments.

beta2-agonist (LABA) combination maintenance

therapy regimen. [ERS 2014 Abstract P1894]

Data from the UniTinA-asthma clinical trial

program form the basis of the EU application to

In two replicate randomized controlled phase

authorize the use of tiotropium Respimat as an

III trials involving 912 patients with refractory

add-on maintenance bronchodilator therapy in

asthma despite receiving ICS/LABA mainte-

adult patients with asthma who are currently re-

nance therapy, add-on treatment with tiotropium

ceiving maintenance combination therapy with

5 g/day delivered via a soft-mist inhaler for 48

ICS (at a dosage equivalent to 800 g/day)

weeks significantly reduced the risks of severe

and LABA, and who have experienced 1 se-

asthma exacerbation and asthma worsening by

vere exacerbation in the past year.

21 percent and 31 percent, respectively. [N Engl

J Med 2012;367:1198-1207]
We know that despite taking current treatment options, almost half of those with asthma

Tiotropium had already been granted approval for use in the treatment of asthma in several
countries, including Chile, Colombia, Ecuador,
Norway, Russia, and Thailand.

still experience symptoms, which can put them

Halpin expressed optimism about the poten-

at a significantly increased risk of an asthma at-

tial new treatment option. Over the past de-

tack, said Professor David Halpin, consultant

cade, not much has changed in the range of

P H A R MACY P R AC TI C E

37

therapies that we can offer patients, so this new

improve symptoms and reduce the number of

indication for [tiotropium] Respimat is an im-

patients who experience asthma exacerbations

portant and welcome advance in the treatment

and worsening that are not only frightening and

of asthma. Its unique mode of action in asthma

very unpleasant, but can also be life-threaten-

provides physicians with a new option to help

ing.

Pregnant women need flu, pertussis

innoculations

harmacists giving vaccinations to pregnant

should also be

women is a good strategy, says Dr. Nikki

given to preg-

Turner, director of the Immunisation Advisory

nant

Centre in New Zealand.

Turner says. We

In the past, there was uncertainty over giving

have

women,
a

huge

pregnant women vaccinations, but there is now

problem with se-

very compelling data to give pregnant women

vere

influenza and pertussis vaccines, Turner says.

cough for kids

The flu vaccine reduces a pregnant womans

chances of getting seriously ill.
Youre much more likely to end up in hospital and die [from the flu] if youre pregnant, she
says.
The vaccine also protects the fetus as any
sickness that gives a pregnant woman a fever

whooping
Pharmacists may help to increase

under 1 year. If vaccination in pregnancy.

we give the vac-

cine to pregnant women, they [newborns] get

protected up to 6 months of age.
Getting the message out to pregnant women
is very important, as New Zealand has a very low
uptake of vaccinations in pregnancy, she says.

can be dangerous for her unborn baby. The flu

Just 30 percent of pregnant women have the

vaccine will also protect the newborn baby from

flu vaccine and probably only 20 percent have

getting this common illness in its first few months

the pertussis vaccine, Turner estimates.

of life, she says.

We know from our data that kids at a young
age get a lot of flu.
The pertussis, or whooping cough, vaccine

Getting pharmacists to offer the vaccines to

pregnant women is a good way of increasing the
uptake, she says. I think its definitely a really
great strategy.

PTNZ

N OV- D E C 2 0 14

A F TE R H O U R S

39

Vienna, the capital of Austria, is the birthplace of many famous musicians Wolfgang
Amadeus Mozart, Ludwig van Beethoven and Johannes Brahms. Rich in history and
culture, the city has become synonymous with music and the waltz. Beyond music,
the city oozes charm and romance at every corner, just as Joslyn Ngu discovers.

ow green is Vienna? Well, it is so green that

Johann Strauss to name a few, who lie at rest

there is even a famous green apartment

here. I love how the green landscape seemed to

called the Hundertwasser house. The Viennese

stretch on without an end in sight. The way the

artist who designed it, Friedensreich Hundert-

trees lined up in rows, like armies standing guard

wasser, believed that every home should have

over their precious charges, made it a very ma-

plants or trees in it, so he covered the roof with

jestic place for a walk. Some might find it creepy

soil and grass, and planted large trees growing

to wander around the cemetery, but I found my-

from inside the building.

self enjoying the heavy silence and lush greenery.

Besides green homes for the living, Vienna

The Viennese men and women, young and

has a very green home for the dead as well.

old, rich and poor love to spend time in parks.

The Zentralfriedhof, or Vienna Central Cemetery,

Even in the middle of the city, you can find parks

has about 330,000 graves laid out on 2.5 million

that help you forget the concrete jungle right next

square meters of land. There are many famous

door. Stadtpark is one such park.

Viennese Beethoven, Schubert, Hugo Wolf and

people jogging, doing yoga and walking their

You will see

N OV- D E C 2 0 14

A F TE R H O U R S

40

Zentralfriedhof

dogs in the parks even in the middle of the day. I

joined the crowd and tried to be oh-so-Viennese
by sitting in front of a duck pond, looking contemplative. I became restless within minutes.
Vienna is also well known for its abundance
of history and art both of which I do not appreciate. However, I do enjoy colorful, well-trimmed
gardens. Schnbrunn palace, which used to be
the summer palace of the imperial family, is one
of the most awe-inspiring pieces of Baroque ar-

Hundertwasser house

chitecture in Europe. The Privy Garden in Schnbrunn, also known as the Crown Prince Rudolf

Another beautiful palace and garden I man-

Garden, is surrounded by a horseshoe-shaped

aged to visit was the Belvedere. Its name is very

pergola and five pavilions, with an octagonal pool

apt as there is a panoramic view of the city amidst

in the center. The garden is marvelous. One of the

the stunning background of the palace and gar-

pavilions is accessible to visitors and I went up to

den. The Belvedere was built as the summer pal-

feast my eyes on the amazing view.

ace of Prince Eugene of Savoy. The garden in

N OV- D E C 2 0 14

A F TE R H O U R S

41

The Belvedere

Belvedere connects between two buildings in the

palace, the Upper and Lower Belvedere.
While all the greenery was good for my eyes
and had a lasting impression on me, what stood
out the most were the dog parks scattered
around the city. They are not necessarily well
kept, the flowers may not be as bright and colorful as those in other parks, and the benches may
not be as comfortable, but the four-legged creatures running around the parks make up for all
that. Thanks to the climate, dogs in Vienna are
furrier than those in Southeast Asia. That makes

Stadtpark

them look like adorable, fluffy, cuddly teddy

bears. I spent as many mornings as I could in

Vienna is an amazing city, or as the Austrians

various dog parks, stalking cute dogs and giving

say, Super! It really is the perfect place to go to

them a dose of baby-talk.

for a dose of peace and happiness.

Hon. Editorial Advisory

Board

Publisher

Ben Yeo
Senior Editor

Elvira Manzano
Contributing Editors

Radha Chitale, Chuah Su Ping

(Singapore), Saras Ramiya, Pank Jit
Sin, Joslyn Ngu (Malaysia)
P u b l i c at i o n M a n a g e r

Jason Bernstein

Associate Professor Chui Wai Keung

Head of Depar tment of Pharmacy, Faculty of Science

National University of Singapore (NUS)

Assistant Professor Lita Chew

Chief Pharmacist, Ministry of Health,

Singapore Registrar, Singapore Pharmacy Council
Head, Pharmacy Depar tment, National Cancer
Centre Singapore
Assistant Professor, Depar tment of Pharmacy, NUS

Associate Professor Alexandre Chan

Designers

Lisa Low, Agnes Chieng, Cindy Ang,

Sam Shum
Production

Jasmine Chay
C i r c u l at i o n E x e c u t i v e

Christine Chok

Depar tment of Pharmacy, NUS Associate

Consultant Clinical Pharmacist, Depar tment of
Pharmacy National Cancer Center Singapore

Dr. Joyce Yu-Chia Lee

Assistant Professor of Clinical Pharmacy

Depar tment of Pharmacy,
NUS Principal Clinical Pharmacist, National
Healthcare Group Polyclinics

Acc o u n t i n g M a n a g e r

Minty Kwan
A d v e rt i s i n g C o o r d i n at o r

Angeline Chua
Published by

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