Wednesday, November 21, 2012

Evaluation of Documented Drug Interactions and Contraindications Associated With Herbs and Dietary Supplements


International Journal of Clinical Practice

A Systematic Literature Review

H.-H. Tsai, H.-W. Lin, A. Simon Pickard, H.-Y. Tsai, G. B. Mahady
  Nov 16, 2012 Authors & Disclosures
Int J Clin Pract. 2012;66(11):1056-1078. © 2012  Blackwell Publishing

Abstract and Introduction

Abstract

Background and Aims: The use of herbs and dietary supplements (HDS) alone or concomitantly with medications can potentially increase the risk of adverse events experienced by the patients. This review aims to evaluate the documented HDS-drug interactions and contraindications.

Methods: A structured literature review was conducted on PubMed, EMBASE, Cochrane Library, tertiary literature and Internet.

Results: While 85 primary literatures, six books and two web sites were reviewed for a total of 1,491 unique pairs of HDS-drug interactions, 213 HDS entities and 509 medications were involved. HDS products containing St. John's Wort, magnesium, calcium, iron, ginkgo had the greatest number of documented interactions with medications. Warfarin, insulin, aspirin, digoxin, and ticlopidine had the greatest number of reported interactions with HDS. Medications affecting the central nervous system or cardiovascular system had more documented interactions with HDS. Of the 882 HDS-drug interactions being described its mechanism and severity, 42.3% were due to altered pharmacokinetics and 240 were described as major interactions. Of the 152 identified HDS contraindications, the most frequent involved gastrointestinal (16.4%), neurological (14.5%), and renal/genitourinary diseases (12.5%). Flaxseed, echinacea, andyohimbe had the largest number of documented contraindications.

Conclusions: Although HDS-drug interactions and contraindications primarily concerned a relatively small subset of commonly used medications and HDS entities, this review provides the summary to identify patients, HDS products, and medications that are more susceptible to HDS-drug interactions and contraindications. The findings would facilitate the health-care professionals to communicate these documented interactions and contraindications to their patients and/or caregivers thereby preventing serious adverse events and improving desired therapeutic outcomes.

Introduction

The marketing and consumer use of herbs and dietary supplements (HDS) has risen dramatically in the USA over the past two decades. [1,2] It is estimated that > 50% of patients with chronic diseases or cancers ever use HDS, [3] and nearly one-fifth of patients take HDS products concomitantly with prescription medications. [4,5] Despite their widespread use, the potential risks associated with combining HDS with other medications are poorly understood by these consumers. Although many HDS users believe that HDS are safe, [6] HDS products have been reported to be associated with mild-to-severe adverse effects such as heart problems, chest pain, abdominal pain and headache. [2,7,8]Because a majority of patients often fail to disclose that they have taken HDS products to their healthcare providers, e.g. one study estimated only 30% disclosure, [9] patient-provider communication concerning the risks and benefits of HDS is critically important.
A major challenge for healthcare providers in counselling patients about HDS is that the available clinical evidence may be ambiguous and sometimes conflicting for HDS adverse events and drug interactions. [10,11] Also, there are often practice-based barriers to identifying the evidence on HDS–drug interactions, [12] including lack of familiarity or access to HDS-related textbooks and databases.[13,14] In general, fewer and less rigorous studies are available for HDS than that of prescription drugs, particularly with respect to randomised controlled clinical trials. [15] Many available references for HDS list numerous 'potential HDS–drug interactions' with little clinical significance or risk. Many reference books are replete with errors that serve only to confuse healthcare practitioners or consumers. The aim of this review was to provide healthcare professionals with a resource that concisely summarises the scientific evidence for HDS–drug interactions and contraindications from 2000 to 2010.

Methods

Evidence Resources and Literature Search

This review of HDS–drug interactions and contraindications focused on the evidence in the primary literature and tertiary literature (i.e. textbooks) related to HDS or drug interactions.[16–21] Important online resources about HDS, including the website of National Center for Complementary and Alternative Medicine (NCCAM), [22] and Office of Dietary Supplements [23]were also included. The definition of HDS used for this study was the official definition of dietary supplements as stated in the Dietary Supplement Health and Education Act of 1994 (DSHEA). [24] HDS refers to any herbal product or dietary supplement product containing one of the following ingredients: vitamin, mineral, other botanical, amino acid, or other dietary substance. Thus, traditional foods or fruit products, not listed in the definition (e.g. avocado, grapefruit, and onion, etc.), were not included in this review.
The primary literature was obtained by searching databases, i.e. MEDLINE (via PubMed), EMBASE and Cochrane Library. Search terms included, but were not limited to the medical subject headings (MeSH terms) or key words that encompassed 'herb drug interactions', 'dietary supplements' OR 'vitamins' OR 'minerals' OR 'amino acids' OR 'botanical' OR 'herbal medicine' OR 'phytotherapy' combined with 'contraindications' OR 'drug interactions'. The searches were performed in English only for the period of January 2000 to December 2010. The articles were selected based on the titles and abstracts and reviewed independently by two authors (HHT, HWL). Literature without related information, including studies regarding efficacy of HDS, regulation of HDS or methods of assay, was excluded. All relevant articles were selected without restriction for animal studies, clinical trials, observational studies (including case reports) or review articles.

Data Extraction and Synthesis

Two standardised data abstraction checklists were developed and used to perform the review (one for the HDS–medication interactions and the other for HDS contraindications). All pairs of HDS–drug interactions documented in the retrieved literature sources (except for those interaction pairs with consequences that may benefit to users) were extracted. Because most HDS products or ingredients are not recommended for use during pregnancy or lactation, [25] documented contraindications for these conditions were not further reviewed. All relevant data were extracted, compiled and classified all by one qualified reviewer, and then validated by another. Any disagreements related to the abstraction of data were resolved by consensus.
We grouped HDS products/ingredients into three categories: herb/botanical, vitamin/mineral/amino acid (VMA) and others. The most common drugs were grouped according to the Anatomical Therapeutic Chemical (ATC) classification system. [26] Possible mechanisms and the severity ratings of each pair of interactions were retrieved using the Interactions database in MicroMedex® [27] and 'Natural Product/Drug Interaction Checker' in Natural Medicines Comprehensive Database® (NMCD®). [28] We categorised the mechanisms for pairs of interactions into four types: pharmacokinetics, pharmacodynamics, both (pharmacokinetics plus pharmacodynamics) and unknown. The severity of each documented interaction was categorised as contraindicated, major, moderate and minor based upon MicroMedex®, and major, moderate and minor based upon NMCD®, respectively. The definitions of 'major', 'moderate' and 'minor' were similar in these two databases. For instance, a major interaction may cause life-threatening damage and/or serious adverse effect(s), and a minor interaction would result in a negligible effect(s). However, contraindicated interactions were rated as 'major' severity in NMCD®. The types of contraindications were categorised based on Goldman: Cecil Medicine®. [29] All data were compiled and managed using an Excel spreadsheet. Descriptive analyses to define the frequency or proportion of the evidence associated with the interaction pairs, the corresponding mechanisms and severity ratings of interactions and the types of contraindications for certain populations or patients was performed.

Results

Literature Search

Finally, 461 articles of primary literature were initially identified. Eighty-five articles with full text, including 54 review articles, other than the 6 books and 2 web sites were selected for further review (Figure 1). The summaries of the animal studies, observational studies and clinical trials to retrieve information about HDS–drug interactions and contraindications for the original studies are listed in Table 1 , Table 2 and Table 3 , respectively. The summaries of the retrieved books and reviewed articles to retrieve information about HDS–drug interactions and contraindications were listed in Appendix 1 ,Appendix 2 and Appendix 3 , respectively. Among the original studies ( n = 31), more than half ( n = 16) were clinical trials. All of these articles contained information about HDS–drug interactions, [12,30–113] but only five articles provided descriptive information about HDS contraindications. [55–57,59,102]
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Figure 1.
Flow chart of primary literature search

Quantity of Retrieved Evidence

After excluding the evidence regarding HDS not recommended for human use (i.e. anvirzel, belladonna, chaparral, comfrey, ephedra and pennyroyal) [16,19,21–23] and the duplicates, a total of 1491 unique pairs of documented interactions between HDS and individual drugs were identified. Among these pairs, 814 pairs (54.6%) were retrieved from the primary literature, 1018 pairs (68.3%) from books and only 23 pairs of interactions were identified in the two reviewed web sites. Among these interactions, the corresponding mechanism and severity was determined for 507 pairs (34.0%) using MicroMedex® and 763 pairs (51.2%) in the NMCD® online database. In total, 882 pairs (59.2%) of documented HDS–drug interactions were identified for their potential mechanism and severity. In terms of contraindications, there were 128, 15 and 9 documented HDS contraindications retrieved from books, primary articles and web sites, respectively, for a total of 152.

HDS–drug Interactions

Among all included interactions between HDS and individual drugs, 166 different herbs/botanical products, 28 VMA and 19 other supplements accounted for 890 pairs (59.7%), 529 pairs (35.5%) and 72 pairs (4.8%) of documented interactions, respectively (Figure 2). The top five herbs/botanical products, which were documented to have the most interactions with individual medications, were St John's Wort ( Hypericum perforatum), ginkgo ( Ginkgo biloba), kava ( Piper methysticum), digitalis (Digitalis purpurea) and willow ( Salix alba). For example, St John's Wort, magnesium, calcium, iron and ginkgo have been documented to interact with 147, 102, 75, 71 and 51 individual medications, respectively. Furthermore, a total of 509 unique drugs contributed to the 1491 documented pairs of interactions with HDS. The majority of these medications ( n = 100) were categorised as treatment for central nervous system (CNS), second were those medications affecting the cardiovascular system and then systemic anti-infective drugs ( n = 90 and 75, respectively) (Figure 3). The medications that most contributed to documented interactions with HDS were warfarin, insulin, aspirin, digoxin and ticlopidine. Not surprisingly, warfarin was documented to have interactions with over 100 HDS entities (Figure 4).
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Figure 2.
Herbs and dietary supplements tended to have documented interactions with medications in each caterory. VMA, vitamin/mineral/amino acid; DS, dietary supplements; DHEA, dehydroepiandrosterone
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Figure 3.
Distribution of medications that might have interactions with herbs and dietary supplements. ATC, anatomical therapeutic chemical. The number of total medications was 509
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Figure 4.
Medications with the largest number of interactions with herbs and dietary supplements. HDS, herbs and dietary supplements
Among 882 pairs of interactions with identified mechanisms, a total of 373 pairs (42.3%) were attributable to pharmacokinetic-related mechanisms, i.e. affected the absorption, distribution, metabolism or excretion of the HDS/drug. Approximately 40.1% of all interaction pairs accounted for pharmacodynamic-related mechanisms, and 8.5% were attributed to a combination of both mechanisms. No mechanism was identifiable for the remaining 9.1% of pairs. Among the 373 documented HDS interaction pairs that were pharmacokinetic-related, 87 pairs were associated with St John's Wort (23.3%), whereas calcium supplements were involved in 47 pairs of documented interactions (12.6%), and iron was involved in 42 pairs of interactions (11.3%). St John's Wort was documented to reduce the effectiveness of alprazolam, amitriptyline, imatinib, midazolam, nifedipine and verapamil via the CYP (Cytochrome P450) 3A4 pathway, and the plasma levels of fexofenadine and digoxin via PgP (p-glycoprotein) pathway. Some drugs (i.e. atorvastatin, cyclosporin, indinavir, nevirapine and simvastatin) were documented to interact with St John's Wort through both pathways. [37,99] Among the 354 documented interactions that were pharmacodynamic-related, kava accounted for 4.8% pairs of interactions (17 pairs). St John's Wort and ginkgo were both involved in 15 pairs of interactions (4.2%). Risk of additive serotonergic effects were increased when St John's Wort was used concurrently with monoamine oxidase inhibitors (MAOI), selective serotonin reuptake inhibitors (SSRI), or tryptamine-based drugs causing symptoms of anxiety, dizziness, restlessness, nausea and vomiting. [16–18,20] As a result of their pharmacological actions on the GABA receptor, synergism in CNS adverse events may result from taking barbiturates or benzodiazepines in combination with kava. [16,20,98] Furthermore, kava may worsen the extrapyramidal effects associated with the use of droperidol, haloperidol, metoclopramide or risperidone because of a dopamine. [21,98]
Among the 507 documented interaction pairs identified with a severity rating in MicroMedex®, 69.4% were categorised as the moderate interactions, 17.2% as major interactions, 10.3% as minor interactions and 3.1% were attributable to the contraindications. As for the 763 pairs of documented interactions being identified with the severity rating based on the NMCD®, the majority documented interaction pairs were categorised as moderate (69.2%), major (26.5%) and minor (4.3%). Approximately, 240 documented HDS–drug interactions were categorised as major severity in either database ( Table 4 and Table 5). For example, the following pairs of interactions were considered as being contraindicated for concurrent use in MicroMedex®: l-Tryptophan vs. MAOI (i.e. isocarboxazid, phenelzine and tranylcypromine) or venlafaxine and St John's wort vs. protease inhibitors (i.e. amprenavir, fosamprenavir and indinavir), irinotecan, rasagiline or voriconazole, respectively. Among the 390 documented interaction pairs having severity ratings in both databases, 41.3% were inconsistent. For example, the combination of alfalfa ( Medicago sativa) and warfarin were considered as the minor interaction in MicroMedex®; however, it was rated as the major interaction in NMCD®. The combination of St John's Wort with quetiapine, quinidine, risperidone or sildenafil gave severity ratings major according to NMCD®, and no interaction was reported in MicroMedex®.

HDS Contraindications

Fifty-nine HDS from 152 reports were contraindicated for use among patients with specific disease states. The reports were classified into 19 disease states, including gastrointestinal diseases, neurologic disorders, renal/genitourinary diseases, neoplastic disorders, diseases of the liver/gallbladder/bile ducts and cardiovascular diseases (Figure 5). Flaxseed ( Linum usitatissimum), echinacea ( Echinacea purpurea) and yohimbe ( Pausinystalia yohimbe) had the highest number of documented contraindications. For example, flaxseed was documented to have contraindications associated with gastrointestinal disorders such as acute or chronic diarrhoea, oesophageal stricture, inflammatory bowel disease, hypertriglyceridemia and prostate cancer. [21] Echinacea was contraindicated for use among patients with rheumatoid arthritis, systemic lupus erythematosus, leukosis, multiple sclerosis, tuberculosis and HIV infection. [16,18] Yohimbe was contraindicated in patients with anxiety, bipolar disorder, depression, mania and schizophrenia, as well as benign prostate hypertrophy and kidney disease. [21,22]
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Figure 5.
Common contraindications for HDS use. *Other contraindications of gastrointestinal diseases included fecal impaction for aloe vera and oesophageal stricture for flaxseed. †Other contraindications of neurologic disorders included multiple sclerosis for echinacea and posttraumatic stress disorder for yohimbe. HDS, herbs and dietary supplements

Discussion

In this study, we summarised the evidence of HDS–drug interactions and contraindications that have been reported in the primary and tertiary literature. The existing evidence suggests that some HDS products/ingredients have potentially harmful drug interactions that are predominately moderate in their severity. HDS products containing St John's Wort, magnesium, calcium, iron, and ginkgo had the greatest number of documented interactions with drugs. Medications affecting the CNS and cardiovascular system tended to have more documented interactions with these HDS. Of all listed medications, warfarin was documented to have the greatest number of HDS interactions. HDS products containing herbal remedies were more likely to have documented interactions with medications and the contraindications than vitamins, minerals and other types of dietary supplements.
Some of the commonly used herbal remedies such as echinacea, flaxseed, ginkgo and St John's Wort have featured more prominently in industry or government sponsored clinical trials, academic studies and official monographs. [114,115] Some of these HDS entities have undergone more rigorous scientific evaluations. The clinical evidences for HDS are often mixed in terms of their support for efficacy and/or effectiveness. The benefits of HDS treatment must be balanced against the potential harmful effects including adverse events, and the potential for drug interactions or disease state contraindications. Furthermore, there often may be just a self-medicating 'indication creep', where patients who have a certain disease or condition unrelated to the supportive therapy with these HDS. For example, WHO monographs listed that echinacea products could be used in supportive therapy of colds and infections but were contraindicated for patients with autoimmune diseases. [116] Even though the evidence to support the immunological effects of echinacea was still controversial, [117] 6.4% of patients with arthritis/lupus reportedly used echinacea in the 2002 NHIS. [4] Thus, patients need to understand that advantages of using echinacea products are outweighed by the potential harm if they have a specific disease state.
Patients using medications that have a narrow therapeutic range (i.e. warfarin, digoxin) were at greater risk for adverse outcomes because of HDS–drug interactions. [20] This was particularly important for patients on anticoagulants (i.e. warfarin) who concomitantly took HDS products that had antiplatelet or anticoagulant effects (e.g. danshen, dong quai, garlic, ginger and ginkgo). [70,75] In particular, HDS products that contained vitamin K or metabolites related to vitamin K (e.g. coenzyme Q10) had the potential to reduce the effects of warfarin. [75] However, some conflicting information regarding warfarin–HDS interactions was observed when the evidence was retrieved from different literature sources. For instance, in a case study, the international normalised ratio (INR) decreased in patients when ginseng was administered with warfarin in some case reports, [12,66,118] but other in vitro studies demonstrated that several components of Panax ginseng had anticoagulant effects. [12] Furthermore, a controlled clinical trial of healthy subjects revealed that there was no significant interaction when ginseng was administered with warfarin. [12,17,20,31,64] This discrepancy may be attributed to the fact that there are several different species of ginseng on the market [i.e. Asian ginseng ( Panax ginseng), American ginseng ( Panax quinquefolius), Siberian ginseng ( Eleutherococcus senticosus)], different extract types and different doses used. Another interesting example is the concomitant use of warfarin with green tea. Some studies suggested that green tea may enhance the anticoagulant effects of warfarin. [19,75]However, much of the literature suggested that the content of vitamin K in green tea might antagonise the effect of warfarin. [16,17,68,70,75] Regardless, it is important to regularly monitor the INR levels of warfarin users who also use HDS products that might influence the anticoagulation effect.
In addition, patients on a digoxin regime who have been taking an HDS should check to ensure that their plasma concentration of digoxin is indeed within the therapeutic ranges. If this is not the case, then the pharmacist usually should recommend to their patients to stop taking these HDS or have their digoxin dose adjusted by their healthcare providers; for example, as digoxin serum concentrations are usually measured by fluorescence polarisation immunoassay or microparticle enzyme immunoassay, which may be influenced by ginseng and danshen ( Salvia miltiorrhiza). [20,58] False digoxin levels may confuse laboratory results and result in inappropriate patient management. Furthermore, aloe vera ( Aloe barbadensis), buckthorn ( Rhamnus catartica), cascara ( Rhamnus purshiani), licorice ( Glycyrrhiza glabra) and senna ( Cassia senna) may cause hypokalaemia and result in digoxin toxicity. [16,17,33,47]As a result, digoxin users should be told to avoid taking the aforementioned herbal remedies.
In this study, the documented evidence of HDS–drug interactions and contraindications were systematically reviewed from the published literature. This was done because healthcare professionals, in general, use only textbooks, journal and review articles, as well as Internet as their major information source for HDS. [119] Although the NCCAM and Office of Dietary Supplements are the two most commonly used, free online resources about HDS, [120] only limited information is available related to HDS interactions and contraindications on these sites. Furthermore, only 59% of documented HDS–drug interactions could be identified with either their mechanisms and/or severity in either of the two common drug interaction resources (i.e. MicroMedex® and NMCD®). Among them, over 40% of the interactions differed in their severity rating, which is likely to create confusion among healthcare providers about the potential harmful effects associated with a given HDS–drug interactions. Concerns about disagreements across literature resources and databases for drug interactions have been raised before, [121] and these increase the difficulty in implementing an evidence-based clinical practice for HDS products in clinical care. The intention of this review was to evaluate the evidence of HDS interactions and contraindications and to assist clinical practitioners in identifying patients with specific disease states and drug regimens that are more susceptible to these HDS–drug interactions and contraindications.
One of the limitations of this review was that it included all relevant information identified in the literature, regardless of the evidence types or quality of the studies. Although some HDS–drug interactions with little or no clinical significance were included in this study, their severity grading was based upon the available version of MicroMedex® and NMCD®. In order to reduce any personal bias, only those pairs of interactions with evidence retrieved from the aforementioned two databases were included to categorise the corresponding mechanisms and the severity rating. Consequently, we were unable to evaluate 41% of the interaction pairs for the corresponding mechanisms and severity in this study. Another limitation was the concern of publication bias, which might arise as only HDS products and medications that have been published in the literature on the basis of evidence-based medicine. Therefore, there are many potential HDS–drug or disease interactions that may exist but are simply without documented outcomes. Lastly, only reports, books or articles published in English were included in this review. Those evidence regarding traditional herbal medicine or folk therapies, which were published in other languages (e.g. Chinese, Japanese), might be missing. Thus, it is very likely that the amount of documented HDS–drug interactions and/or contraindications in this review might be under-reported.

Conclusions

This review provides a structured summary of the evidence of the most widely documented HDS interactions and contraindications with medications. Although our findings primarily concern with a relatively small subset of commonly used medications and HDS entities, it is recommended that healthcare professionals should be paid more attention towards those pairs of interactions between any HDS products that contain St John's Wort, magnesium, calcium, iron and ginkgo, and medications that affect the CNS or the cardiovascular system. These findings should be helpful for healthcare professionals to identify the priority areas where communication regarding HDS usages has the greatest potential to prevent adverse events and to improve patient's therapeutic outcomes.

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Tuesday, September 18, 2012

SIMPOSIUM PENOLONG PEGAWAI FARMASI KEBANGSAAN

1. PENGENALAN
1.1 Simposium Penolong Pegawai Farmasi Kebangsaan adalah sesuatu yang di idamkan lama oleh Persatuan Penolong Pegawai Farmasi. Profesion ini telah menjalani penjenamaan semula melalui penukaran gelaran jawatan serta skim iaitu dari Pembantu Farmasi kepada Penolong Pegawai Farmasi.
Ia juga secara tidak langsung memberi pengiktirafan kepada lebih 6,000 Penolong Pegawai Farmasi yang berkhidmat di Kementerian Kesihatan Malaysia, Hospital Universiti, Hospital Swasta dan lain-lain Institusi seperti Pusat Perubatan Badan berkanun dan swasta.

1.2 Pendidikan dan latihan juga telah melalui beberapa peningkatan dan naik taraf dari Sijil Pembantu Farmasi kepada Diploma Pembantu Farmasi dan seterusnya kepada Diploma Farmasi 3 tahun.
Namun selepas melalui beberapa proses peningkatan gelaran jawatan dan naik taraf pendidikan, status profesion, peranan dalam tugas harian serta kepada perkhidmatan Farmasi secara amnya tidak mengalami sebarang perubahan besar sebaliknya semakin berkurang jika dibandingkan dengan peranan besar dahulu semasa taraf sijil.

1.3 Justeru itu Persatuan merasakan Profesion ini sangat memerlukan satu platform untuk membincangkan aspek peranan, halatuju dan peluang dalam memperluaskan skop perkhidmatan kepada semua Penolong Pegawai Farmasi supaya mereka lebih bersemangat, berbangga dan mendapat lebih motivasi dalam kerja seharian. Ia juga secara tidak langsung akan meningkatkan produktiviti Jabatan amnya.

2.  APAKAH DIA SIMPOSIUM ?

Mengikut maklumat dari internet: www.answer.com :
 "A symposium is an educational conference where people get together to discuss thoughts and exchange ideas, rather than to be lectured at".

 Maklumat dari www.dictionary.reference.com : 
"1. A symposium is a meeting or conference for the discussion of some subject,especially a meeting at which several speakers talk on or discuss a topic before an audience".
2. A collection of opinions expressed or articles contributed by several persons on a given subject or topic.

Maksudnya, simposium adalah satu majlis di mana sebilangan orang berkumpul, membincang, bertukar pendapat  kearah satu topik yang sama dan mempunyai pembentang.

3. TUJUAN SIMPOSIUM

3.1  Untuk membincangkan kearah satu topik yang sama iaitu halatuju baru profesion sejak naiktaraf gelaran jawatan Pembantu Farmasi kepada Penolong Pegawai Farmasi pada 1 Jun 2009 dan juga naik taraf sistem pembelajaran dan kelulusan naik taraf anugerah sijil Pembantu Farmasi kepada Diploma Farmasi.
                 
3.2  Memartabatkan Profesion Penolong Pegawai Farmasi Malaysia baik dikalangan Institusi kerajaan ataupun swasta.

3.3  Memulihkan kedudukan status Penolong Pegawai Farmasi dikalangan paramedik yang amat rendah dari segi perkembangan profesion dalam pendidikan, latihan, moral, imej dan peranan kepada jabatan dan negara.

3.4  Melahirkan Penolong Pegawai Farmasi yang cemerlang serta berpeluang untuk menjalankan kajian, berkeupayaan untuk membentang kertas kerja hasil kajian dan berinovasi serta berdaya saing supaya berupaya memberi perkhidmatan yang efektif dan berkualiti


4.        OBJEKTIF

4.1  Mewujudkan budaya kerja yang berpengetahuan tinggi dan sentiasa mengikuti arus perkembangan semasa dalam bidang penjagaan farmaseutikal.

4.2  Berusaha menjadikan Penolong Pegawai Farmasi sebagai anggota yang berkeyakinan tinggi, positif dan berkemampuan menjalankan tugas dengan penuh komited serta kualiti sejajar dengan Misi dan Visi Kementerian Kesihatan Malaysia.

4.3  Bersama menjana transformasi perkhidmatan farmaseutikal dalam bidang teknikal dan berpotensi secara kreatif untuk mencipta inovasi perkhidmatan atau produk untuk perkembangan perkhidmatan Farmasi.

4.4  Menaikkan imej dan moral profesion serta motivasi dalam tugas seharian selaras dengan penukaran gelaran jawatan dan naik taraf Diploma Farmasi.

4.5 Mendedahkan semua peserta dengan kepentingan kerja berpasukan, mengutamakan kehendak pelanggan dan memahami prinsip-prinsip pelaksanaan tugas dan tatacara jabatan dan kementerian demi memperkasakan Perkhidmatan Farmasi.
5.  KEADAAN SEMASA PPF

5.1  Para Penolong Pegawai Farmasi kurang diberi peluang dalam penjagaan farmaseutikal secara menyeluruh kepada pelanggan. Kebanyakan tugas-tugas expanded dan extended role lebih melibatkan Pegawai Farmasi sahaja.

5.2   Tugas-tugas kepakaran yang dilakukan dahulu telah ditarik dan diberikan kepada PRP di hospital-hospital atas alasan Akta. Pendispensan Methadone terpaksa melalui proses yang sukar walaupun tugas mendispen dadah merbahaya masih dilakukan di Klinik-klinik kesihatan sejak 50 tahun lalu tanpa memikirkan hal-hal Akta kerana tiada Pegawai Farmasi berkhidmat di pendalaman.

5.3  Penolong Pegawai Farmasi Kanan Gred U36, U38 dan U40 masih kelihatan tidak mendapat pengiktirafan sebagaimana yang di nikmati oleh paramedik lain di beberapa negeri.

5.4  Ketua Profesion PPF sendiri tidak mempunyai bilik walaupun beliau melakukan tugas-tugas pengurusan dan pentadbiran 100% di Bhg Perkhidmatan Farmasi KKM, Petaling Jaya.
Seorang Penyelia Jururawat di Hospital-hospital seluruh Malaysia, Pen.Pegawai Perubatan U32 diberikan bilik oleh Ketua Jabatan mereka. Kenapa PPF menerima nasib sedemikian???

5.5.  Senarai tugas terlalu bertindih di antara PPF dan Peg.Farmasi yang menyukarkan sebarang tuntutan oleh pihak Kesatuan untuk kebajikan PPF.

5.6  Stress dikalangan PPF amatlah tinggi dan perlu perhatian serta kajian segera untuk mengurangkan kes ini berlanjutan. (bukti melalui kajian oleh kaunselor HKL pada 2005- pembentangan di Mesyuarat Saintifik 2006 di Melaka)

5.7   Kurang peluang pendidikan lanjutan dan sekatan oleh Lembaga Farmasi keatas PPF yang ingin melanjut pelajaran dengan CGPA 3.5 keatas dengan syarat ketat keputusan SPM dengan sekurang-kurangnya 5B tanpa mengambil kira langsung keatas pengalaman dan Diploma Farmasi 3 tahun.

6.  RUMUSAN

Melihatkan status PPF terkini, ia memberi satu justifikasi supaya satu usaha dilakukan untuk mengkaji kesemua hal ehwal PPF dalam aspek pendidikan, senarai tugas, peranan, pengiktirafan, penghormatan, motivasi di tempat kerja dan berusaha mengujudkan keseronokan bekerja serta juga menekankan budaya Kerja Berpasukan secara serius dan ikhlas.

Sekian, semuga PPF lebih cemerlang, dihormati dan kompiten di masa hadapan.

"BERKHIDMAT UNTUK NEGARA"

Ganesan G.Narayanan
Yang DiPertua
Persatuan Penolong Pegawai Farmasi Malaysia




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Saturday, September 8, 2012

Supplement Use in the Prevention and Treatment of Cardiovascular Disease in the Aging Population


From American Journal of Lifestyle Medicine

Ruth A. Reilly, PhD, RD, LD; Colette Janson-Sand, PhD, RD, LD

Abstract and Introduction

Abstract

As the elderly population grows, so does the incidence of cardiovascular disease and the use of medications. Because of the side effects and cost of prescribed medicine, many aging individuals are seeking out alternative treatment options. Complementary and alternative medicine is gaining popularity, with about a third of people older than 60 years currently using one or more of these therapies. Many individuals are using herbs and nutritional supplements to prevent and treat a variety of cardiovascular diseases and their symptoms. Herbs and nutritional supplements are considered food by the Food and Drug Administration and are exempt from mandatory testing for their safety or efficacy. Also, many individuals consider these products as natural and do not recognize the negative impact that these alternative treatments may have on the efficacy of prescribed medications and overall health. To date, research has reported conflicting evidence as to the beneficial effects of these products; health care providers should exercise caution in recommending their use to avoid drug interactions and side effects.

Introduction

Aging increases the risk for many chronic diseases, including cardiovascular disease (CVD). CVD is the leading cause of death and disability in the industrialized world with nearly 82% of Americans older than 65 years dying from this disease.[1,2] Prevention and treatment of CVD includes lifestyle changes and pharmaceutical interventions. People aged 65 years and older are the largest consumers of both prescription and overthe- counter drugs.[3] Medications, although effective, may cause many unwanted side effects. As a result, many elderly individuals are seeking out complementary and alternative medicine (CAM) to augment or substitute for the medications prescribed by their health care provider. The use of CAM has been growing in popularity in recent years and currently more than 15 million people in the United States use herbal or high-dose vitamins for the prevention and treatment of various diseases.[4] Herbal supplement use is high among individuals who are being treated with prescription medications, particularly the elderly.[5] A recent survey reported that approximately 32% of individuals using CAM are older than 60 years.[6] Many people do not realize that herbs and vitamins are considered food and, unlike prescription medications, are not tested for safety or efficacy. Instead, people regard herbs and nutritional supplements as natural substances and therefore consider them safe. Because CAM may interfere with the absorption and metabolism of prescribed medications, the use of CAM can lead to many health risks. The objective of this article is to identify widely used herbs and nutrient supplements and review their efficacy, potential side effects, and risks for the aging population.

The B Vitamins: Folate, B6, B12, and Niacin

Vitamin B6 performs a wide variety of functions in the body and is involved in more than 100 enzyme reactions, most related to protein metabolism.[7] In the late 1960s, a Boston doctor hypothesized that elevated levels of homocysteine could lead to atherosclerosis.[8]Folate, B6, and BB12 were shown to have the ability to enhance homocysteine conversion to methionine, an amino acid used in building proteins, and consequently decrease homocysteine levels in the blood.[9] Several well-designed research studies showed that B vitamins could lower homocysteine levels but did not show any reductions in CVD.[10–12] A systematic review further confirmed that these supplements do not reduce the risk of developing or dying from CVD.[13] Furthermore, the Norwegian Vitamin Trials (NORVIT) reported that the combination of these 3 B vitamins can have harmful effects in those individuals who have already experienced a myocardial infarction or have coronary stents.[14] Niacin, in the form of nicotinic acid, has long been used as a pharmacologic agent to reduce triglycerides and low-density lipoprotein (LDL) levels and to increase high-density lipoprotein (HDL) in the treatment of atherosclerotic CVD.[9] The European Consensus Panel on HDL considered nicotinic acid to be the most potent agent for increasing HDL as well as being very effective in reducing LDL and lipoprotein (a).[15] When combined with statin therapy, nicotinic acid has been shown to have an even greater lipid-reducing effect.[16,17] However, in 2011, a large, National Institutes of Health clinical trial was stopped 18 months early because there was no sign that high-dose niacin coupled with statins reduced cardiovascular problems in people versus using statins alone. Although niacin raised levels of HDL, this did not translate into fewer fatal and nonfatal heart problems.[18,19] Pharmacologic dosages of niacin can cause flushing of the skin, hyperuricemia, abnormal liver function, and hyperglycemia and therefore should be monitored by a physician.[20]

Coenzyme Q10

Coenzyme Q10, commonly referred to as CoQ10, is also known as ubiquinone. It is a vitamin-like substance produced in the mitochondria of cells; as a component of the electron transport chain, CoQ10 generates ~95% of the human body's energy in the form of adenosine triphosphate (ATP).[21] CoQ10 has demonstrated antioxidant properties and therefore has been studied for its effect on cardiovascular health. A recent study showed that CoQ10 plasma concentrations are an independent predictor of mortality in chronic heart failure, with CoQ10 deficiency being a factor in the long-term prognosis of chronic heart failure.[22] CoQ10 and cholesterol share the same biosynthetic pathway, and the production of mevalonate, an intermediate in this pathway, is inhibited by certain beta blockers[23] and statins.[24] Indeed, statins can reduce serum levels of coenzyme Q10 by up to 40%.[25] Therefore, some research studies recommend supplementing statin use with coenzyme Q10as a routine adjunct. In view of the fact that CoQ10 can lower blood pressure and therefore may not be suitable for certain individuals, people should not begin taking this supplement without first consulting with their physician to insure that there are no contraindications to its use.

Fish Oil Supplements

Most epidemiological studies have found a correlation between fish consumption and a lower risk of coronary artery disease. Fish is a rich source of the essential omega-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Fish oil supplements have gained popularity in recent years for the prevention and treatment of many diseases, including CVD, largely because of their anti-inflammatory effects.[26] Fish oil supplements reduce serum triglycerides levels by reducing the hepatic production of very low density lipoproteins (VLDL) and accelerating VLDL clearance.[27]However, the role of omega-3 fatty acids in reducing mortality, heart failure, myocardial infarctions, and arrhythmias has not been established.[26] In a recent metaanalysis, 14 randomized, double-blind placebo-controlled trials indicated that fish oil supplements are ineffective in treating individuals with diagnosed CVD.[28] The US Food and Drug Administration has approved only one dietary omega-3 fatty acid supplement: Lovaza (GlaxoSmith Kline). A 1-g capsule contains 375 mg of DHA and 465 mg EPA.[26] Relative safety has been shown in both primary and secondary prevention of heart disease, but caution should be exercised in individuals taking antiplatelet or anticoagulant drugs, vitamin E, or aspirin.[29 (p351)]

Garlic

Garlic (Allium sativan) has been used for more than 5000 years as a medicine and in cooking. Garlic's proposed cardiovascular effects include controlling blood cholesterol and blood pressure, reducing platelet aggregation, improving circulation, and improving the elasticity of blood vessels.[30 (pp172-187)] Epidemiological evidence has shown that garlic consumption may delay the progression of CVD, but more comprehensive studies need to be conducted to confirm this positive effect.[31] In a recent clinical trial, 192 adults with high LDL were randomly assigned into 3 treatment groups and 1 placebo group. The treatment groups were given raw, powdered, or aged garlic supplements for 6 months. There were no significant effects on LDL concentrations in all groups.[32] A recent metaanalysis examined the effect of garlic on blood pressure and reported that 10 of the 25 studies reviewed showed garlic reduced both systolic and diastolic blood pressure in hypertensive individuals when compared with the placebo group.[33] The active component in garlic, ajoene, has been shown to have antiplatelet effects and it is therefore recommended that individuals on anticoagulant or antiplatelet therapies should avoid garlic supplements. It is also advised that individuals planning surgery should discontinue its use 10 days before surgery.[34] Garlic is well tolerated by most individuals with its greatest side effect being undesirable body odor. It is important to note that an average clove of raw garlic contains ~3 g and most of the research on the therapeutic effects of garlic has used ~2 to 5 g of raw garlic, easily consumed in a normal diet.[35 (p293)]

Grape Seed Extract

Grapes (Vitis vinifera) have been used for centuries for eating, and for making juice, wine, and medicines. Grape seed extract, sold commercially in 50- or 100- mg tablets, comes from the seeds of the red grapes and the active ingredient is a subclass of flavonoids called proanthocyanidins.[36,37] Proanthyocyanidins are powerful antioxidants and also improve vascular elasticity.[30] It has been suggested that grape seed extract could be important in the prevention of atherosclerosis and cancer and in wound healing and also in the treatment of hyperlipidemia. In a recent meta-analysis, Feringa et al[38] evaluated the effects of grape seed extract in both animal and human studies. Although animal studies have suggested cardiovascular benefits from grape seed extract, human studies report conflicting results. Grape seed extract administered to humans lowered systolic blood pressure and heart rate but had no significant effect on diastolic blood pressure, C-reactive protein, or lipid levels.[38] There are few reported side effects from grape seed extract except for allergic reactions.[39]

Green Tea

Tea comes from the Camillia sinensis plant and is consumed in various parts of the world as black, oolong, or green tea.[40] Green tea was first exported from India to Japan in the 17th century and is now produced around the world[41] and available as loose tea (caffeinated or decaffeinated) or as a supplement.[30] Green tea has been used to treat a variety of conditions because of its polyphenol (antioxidant) content. Catechins account for 80% to 90% of the polyphenols found in green tea and are thought to confer most of its health benefits.[42] A recent systematic meta-analysis reported on the effect of green tea on lipid concentrations (LDL, HDL, and triglycerides) in humans. Subjects who consumed green tea (doses 145–3000 mg/d) for 3 to 24 weeks had a 5.46 mg/dL reduction in total cholesterol and a 5.30 mg/dL reduction in LDL when compared with controls, with no significant change in HDL.[30,43] Another review of the literature evaluated the health benefits of green tea in the prevention and treatment of metabolic syndrome, hypertension, cancer, and CVD in humans and animals. There is some evidence that green tea may lower blood pressure and thus reduce the risk of stroke and coronary artery disease, but human studies are still limited and more research is needed to confirm these benefits.[40] Side effects of green tea include allergic reactions (rare), gastrointestinal complaints, irregular heartbeat, and sleeplessness.[39] Consumption of green tea has been shown to reduce the effect of warfarin and so should be used with caution by individuals taking anticoagulants. Green tea extract may interfere with iron absorption and caffeinated green tea or supplements should not be used by individuals taking medications that have negative interactions with caffeine such as amphetamines, clozapine, theophylline, and so on.[30]

Hawthorn

Hawthorn is an herb (Crataegus oxyacantha L. and Crataegus monogyna) that is used to treat angina, congestive heart failure (CHF), and cardiac arrhythmias. A review of 14 studies on the effect of hawthorn use in the treatment of congestive heart failure found beneficial effects of this herb as an adjuvant to standard therapy for patients with CHF.[44,45] Exercise tolerance and oxygen consumption improved in patients with CHF who were consuming the hawthorn extract as compared with the placebo. However, the effect of hawthorn on morbidity and mortality has not been studied.[44]Hawthorn's use in the treatment of hypertension and hyperlipidemia has demonstrated positive outcomes in animals, but its use with humans is speculative.[46] In spite of these positive effects from the use of hawthorn, its efficacy and safety have not been elucidated. Hawthorn should be used with caution by patients taking digitalis as it may result in toxicity.[47] Hawthorn can also increase bleeding time and should not be used by patients taking antiplatelet or anticoagulant drugs.[29] The efficacy of hawthorn use in the treatment of patients with CHF is still unclear and caution should be used with patients currently using digoxin and vasodilating drugs (ie, theophylline). Health care providers should use caution and carefully monitor patients who are using this herb. Reported side effects were mild and included nausea, dizziness, increased heart rate, and gastrointestinal complaints.[45]

Policosanol

Policosanol is a mixture of longchain aliphatic alcohols obtained from sugar cane, beeswax, and wheat germ.[48] Policosanol has been marketed for the treatment of a variety of cardiovascular and circulatory disorders such as hypercholesterolemia, atherosclerosis, and intermittent claudication.[49] The appeal of this drug—its promise to lower cholesterol without significant side effects—has made it one of the fastest growing overthe- counter supplements in the United States.[50] Early studies were done by one research facility in Cuba. These studies claimed that 1 to 20 mg/d of policosanol could produce significant reductions in both total cholesterol and LDL cholesterol. These studies also showed that policosanols were potent antioxidants, beneficial to endothelial cell function, and inhibitors of platelet aggregation and thrombosis.[48] Several randomized, double-blind crossover studies in which participants received low to high doses of policosanol derived from sugar cane and either used alone or with statins, were not able to show significant reduction in LDL or total cholesterol levels.[51–54]Although side effects are mild, such as indigestion, skin rash, headache, insomnia, and weight loss, policosanol may increase the effect of medications that interfere with blood clotting or antiplatelet drugs, such as aspirin, warfarin (Coumadin), heparin, clopidogrel (Plavix), ticlopidine (Ticlid), or pentoxifylline (Trental), or supplements such as garlic, ginkgo, or high-dose vitamin E. Policosanol may also increase the efficacy and side effects of levodopa, a medication used for Parkinson's disease.[29,55]

Red Yeast Rice

Red yeast rice is produced by fermenting red rice with the yeastMonascus purpureus. It was marketed for a number of years under the name Cholestin because it contained the drug lovastatin, known to reduce cholesterol levels and cause small to modest increases in HDL levels.[56] A 1999 US district court ruled Cholestin could be sold without a prescription, but in 2000, the 10th US circuit court reversed the ruling.[57,58] As a result, Cholestin was reformulated to contain policosanol instead of lovastatin although red yeast rice formulations containing lovastatin are still available in other countries online.[59]
For most of the over-the-counter red yeast rice products, there is no indication of statin level: different strains of the Monascus fungus can produce different amounts of statin. There are also some accounts of products being spiked with high doses of lovastatin.[60,61] The safety of red yeast rice products has not been established, and some of the supplements samples have been found to contain high levels of a toxin, citrinin.[62] Statin drugs can cause muscle and liver damage. Rhabdomyolysis, associated with statins, can result in kidney damage and possibly lead to renal failure.[63,64] Therefore, anyone taking statins should be monitored by a physician. People choose red yeast rice over pharmaceuticals because they find it to be a more "natural" form of the drug and because it is much less expensive. Red yeast rice can interact with some 188 different medications, of which 40 have major serious effects. Examples of these include all statins, a large number of antibiotics, antifungal and antiviral agents, as well as niacin supplements.[65]

Vitamin E

Vitamin E is a fat-soluble vitamin whose active form, α-tocopherol, functions as an antioxidant. The oxidation process contributes to the development of atherogenesis.[66,67] Oxidized LDL causes endothelial cells to produce inflammatory markers, and has a role in foam cell formation, destruction of endothelial cells, inhibition of the motility of tissue macrophages, and inhibition of nitric oxide–induced vasodilation.[68] Vitamin E has been shown to decrease oxidative stress in vitro and prevent atherosclerotic plaque formation in mouse models.[69] However, reviews of research studies in humans have concluded that vitamin E is of no benefit in the prevention of CVD. In fact, vitamin E supplementation might be linked to an increase in mortality, heart failure, and stroke.[67,70] It has also been shown to decrease HDL, which has a protective effect on the cardiovascular system.[71] The American Heart Association does not support the use of vitamin E supplements to prevent CVD but does recommend the consumption of foods abundant in vitamin E and other antioxidants.[72] This dietary practice has been associated with a lower risk of heart disease in middle-aged and older men and women.[73,74] Doses exceeding 400 IU per day should be avoided when taking anticoagulants and antiplatelet medications.[75]

Conclusion

Since CAM has gained popularity in recent years, health care professionals should be alert to the fact that their patients, especially their older patients, may be taking herbs and other supplements to treat and prevent a variety of illnesses. The combination of many of these substances, especially with traditional medications, can result in serious side effects. Therefore, asking patients whether they are using any herbals or supplements, and educating patients as to the risks their use may present, should be part of every medical assessment.

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