SlideShare a Scribd company logo

Philippine National Formulay 8th Ed.pdf

•
•
H
HErSONLU

t

Health & Medicine
1 of 800
Download to read offline
1
Philippine National Formulary 8th Edition Published by Department of Health Manila, Philippines 2019
DISCLAIMER The list of medicines and the prescribing information contained in this edition of the Formulary were collated as meticulously as possible through the collaborative efforts of the Formulary Executive Council (FEC), pharmacists, medical specialists, and specialty societies applying the standard clinical practice current at the time of the undertaking. Thus, the medicines and the accompanying prescribing information in this edition are the most recent only insofar as the dates of the actual collaboration are concerned. There is no guarantee, therefore, that after the final drafting for this edition, the new medicines or new information that may subsequently become available will be included. While diligent effort has been made to ensure the accuracy of each entry, it is essential to bear in mind that the information presented here is a synopsis of key points in the official product labeling, and that the complete labeling contains additional precautionary information that may be of significance in specific cases. Thus, the editors do not warrant that the information contained herein is in every aspect accurate. Since a manual of this volume cannot be as exhaustive, the editors have included only the information which they consider to be essential, and the most relevant and useful for rapid reference by the physicians. It is the hope of the editors that this Formulary is perceived as a readily accessible, easily understandable, up-to-date source of independent medicine information. Nevertheless, this Formulary should be supplemented, where necessary, by more recent and comprehensive materials and publications. Moreover, the recommendations incorporated into this Formulary are intended to serve only as guides that will supplement and not replace the best clinical judgment of the prescribing clinicians. Readers are enjoined to confirm the information contained herein with other sources, particularly with regard to new or the latest updates. ISBN 978-621-95540-3-9 All rights reserved 2019 The Formulary Executive Council Pharmaceutical Division, Health Regulation Team Published by: Department of Health San Lazaro Compound, Rizal Ave., Sta. Cruz, Manila, Philippines, 1003 Any part or the whole book may be reproduced or transmitted without any alteration, in any form or by any means, with permission from DOH provided it is not sold commercially.
THE PHILIPPINE NATIONAL FORMULARY 8th Edition 2019 DEPARTMENT OF HEALTH FRANCISCO T. DUQUE III, MD, MSc Secretary of Health ROLANDO ENRIQUE D. DOMINGO, MD, DPBO Undersecretary of Health Health Regulation Team ANNA MELISSA S. GUERRERO, MD, MPH (HTA) Chief Pharmaceutical Division FORMULARY EXECUTIVE COUNCIL Froilan A. Bagabaldo, RPh, Ll.B. Cleotilde H. How, MD, FPSECP, FPPS Cecilia A. Jimeno, MD, FPCP, FPSEDM Cecilia C. Maramba-Lazarte, MD, MScID, MScCT, FPPS, FPIDSP, FPSECP Paul Matthew Pasco, MD, FPNA Imelda G. Peña, RPh, MS, DrPH John Q. Wong, MD, MSc
THE PHILIPPINE NATIONAL FORMULARY 8th Edition 2019 EDITORIAL TEAM Yolanda R. Robles, RPh, MPharm, PhD Shiela Mae J. Nacabu-an, RPh, MHPEd Christine Aileen C. Benosa, RPh, MPH Ian Theodore G. Cabaluna, RPh, MD GDip (Epi) Editors Jeanne Genevive A. Pillejera, RPh Associate Editor Joshua Elijah M. Chavez, RPh Ena Elizabeth L. Naoe, RPh Kristel Keith N. Nieva, RPh Frances Lois U. Ngo Jarvin Enosh T. Tan, RPh Rose Charisse L. Traballo, RPh Ryan Joseph C. Tuzon Mikaella B. Santos Martha O. de la Paz Arizaldo E. Castro, MSc Leo Miguel S. Vergeire Technical Writers Irene V. Florentino-Fariñas, RPh, MD, MNSA Joyce Anne D. Ceria-Pereña, RPh, MPM Johanna B. Mallari, RPh Kate D. Dunlao, RPh April Rose B. Macandog, RPh Members of the Editorial Team John Michael L. Roque Technical Assistant
C O N T R I B U T O R S DOH Disease Prevention and Control Bureau DOH Family Health Office National Antiobiotic Guidelines Committee National Center for Mental Health Rodney Ribleza Boncajes, MD National Kidney and Transplant Institute Jean Anne B. Toral, MD, MSc Lynn B. Bonifacio, MD Chrystal Catli Burog, MD Teresita Dumagay, MD Roxan Perez, MD National Poison Management and Control Center Pediatric Infectious Disease Society of the Philippines Philippine Academy of Ophthalmology Philippine Academy of Pediatric Pulmonologists Philippine Children’s Medical Center Marilou A. Abrera, MD Cecilia Cruz, MD Philippine College of Chest Physicians Philippine College of Geriatric Medicine Philippine College of Radiology Philippine Dermatological Society Philippine Heart Association Philippine Heart Center Maria Teresa B. Abola, MD Eden A. Gabriel, MD
Philippine Neurological Association Philippine Obstetrical and Gynecological Society Philippine Orthopaedic Association Philippine Psychiatric Association Philippine Rheumatology Association Philippine Society of Allergy, Asthma and Immunology, Inc. Philippine Society of Anesthesiologists, Inc. Angel M. Gomez, MD Philippine Society of Endocrinology, Diabetes and Metabolism Philippine Society of Gastroenterology Philippine Society of Hematology and Blood Transfusion Philippine Society of Medical Oncology Mary Claire V. Soliman, MD, FPCP, FPSMO Marcelo Severino B. Imasa, MD, FPCP Philippine Society for Microbiology and Infectious Diseases Philippine Society of Nephrology Philippine Society of Newborn Medicine Philippine Society of Otolaryngology, Head and Neck Surgery Philippine Society of Parenteral and Enteral Nutrition Philippine Society of Pediatric Metabolism and Endocrinology Philippine Society of Pediatric Oncology Philippine Urological Association Stroke Society of the Philippines
Department of Health - Office of the Secretary Message The revitalization of the Fourmula One Plus for Health as the framework of the healthcare reform agenda of the national government is anchored on the values of equitable and inclusive health system, transparent and accountable provision of quality health services, and efficient use of resources. The 8th edition of the Philippine National Formulary (PNF) is a tool to exercise these values while contributing to the achievement of the objectives of financial protection and better health outcomes. Its previous editions have been the basis of tailored procurement of medicines in public health facilities while providing efficient use of limited resources. It is also the basis of the Philippine Health Insurance Corporation (PhilHealth) in reimbursing claims to end-users for medicines use. With its new format and content, the PNF 8th edition can now maximize the PNF’s contribution to the rational use of medicines. Its abridged content is intended to provide concise evidence-based drug information which is vital in medical practice. The latest PNF is a useful tool to ensure rational prescribing, dispensing, and administration of medicines. I would like to encourage our health professionals to fully utilize it in their medicines procurement as well as in their day-to-day clinical decision- making. Let us continue to work for our shared vision of all for health towards health for all! Mabuhay! FRANCISCO T. DUQUE III, MD, MSc Secretary of Health
Department of Health – Health Regulation Team Message Greetings! The Philippine National Formulary (PNF) plays a vital role in promoting the rational use of medicines in the country. As mandated by Republic Act 9502, otherwise known as the “Universally Accessible Cheaper and Quality Medicines Act of 2008,” and in accordance with Republic Act 9184, also known as “Government Procurement Reform Act,” the PNF serves as the basis of procurement of medicines in all government agencies, including government units. PNF requires continuous revisions and updating to ensure its relevance. It is part of the important role of the Department of Health (DOH) in regulating health products and services and providing technical assistance to health providers and stakeholders. While the FDA ensures that only quality medicines are available in the market, the PNF helps assure that only safe, effective, and affordable medicines are procured by public health facilities. The 8th edition of the PNF includes critical revisions that would facilitate the work of physicians, nurses, pharmacists, and other healthcare professionals. Thus, in behalf of the DOH, particularly the Health Regulation Team, I would like to commend the movers behind the PNF in promoting rational prescribing, dispensing, and use of medicines. Their valuable efforts in revising the National Formulary enable the country to ACHIEVE better health outcomes. Congratulations! ROLANDO ENRIQUE D. DOMINGO, MD, DPBO Undersecretary of Health Health Regulation Team
ACKNOWLEDGMENTS This Formulary is adapted from the World Health Organization (WHO) Model Formulary (2008) with the publisher’s permission. We acknowledge, with sincere thanks, the work of the WHO in producing the Model Formulary so that countries and organizations can compile and produce their own national formularies. For their invaluable contribution to the current edition of the Philippine National Formulary (PNF), sincere gratitude is also due to the following: Members of the Formulary Executive Council (FEC) who thoroughly reviewed the list of essential medicines and the Formulary monographs: Atty. Froilan Bagabaldo, Dr. Cleotilde H. How, Dr. Cecilia A. Jimeno, Dr. Hilton Y. Lam, Dr, Cecilia C. Maramba- Lazarte, Dr, Paul Matthew Pasco, Dr. Imelda G. Peña, and Dr. John Q. Wong; Hospitals who participated in the pilot run of the formulary: Philippine Children’s Medical Center, Philippine Heart Center, Lung Center of the Philippines, National Kidney and Transplant Institute, Luis Hora Memorial Regional Hospital, Bicol Medical Center, and San Lazaro Hospital; and All the experts from the national health programs (NHA), specialty hospitals, and professional medical societies who participated in the review of the content of the Formulary and provided valuable and indispensable comments and corrections.
TABLE OF CONTENTS GENERAL GUIDE ON THE USE OF THIS FORMULARY ......................................................................................... i MEDICINE MONOGRAPH KEY ............................................................................................................................ ii FDA PREGNANCY RISK CATEGORIES .................................................................................................................. iii SYMBOLS AND ABBREVIATIONS ........................................................................................................................ iv GENERAL GUIDE TO PRESCRIBING A. RATIONAL APPROACH TO THERAPEUTICS ............................................................................................. v B. VARIATION IN DOSE RESPONSE 1. PHYSIOLOGICAL AND PHARMACOKINETIC VARIABLES ................................................................. vii 2. MEDICINE DISTRIBUTION ................................................................................................................ ix 3. MEDICINE METABOLISM AND EXCRETION ................................................................................... ix 4. PHARMACODYNAMIC VARIABLES ................................................................................................... ix 5. DISEASE VARIABLES ........................................................................................................................ ix 6. ENVIRONMENTAL VARIABLES ......................................................................................................... x C. ADHERENCE TO (COMPLIANCE WITH) MEDICINE TREATMENT .............................................................. x 1. PATIENT-RELATED REASONS .......................................................................................................... x 2. DISEASE-RELATED REASONS ......................................................................................................... xi 3. DOCTOR-RELATED REASONS .......................................................................................................... xi 4. THE DOCTOR-PATIENT INTERACTION ............................................................................................. xi 5. PRESCRIPTION-RELATED REASONS .............................................................................................. xi 6. PHARMACIST-RELATED REASONS ................................................................................................. xi 7. RECOMMENDATIONS TO THE PRESCRIBERS ............................................................................... xi D. ADVERSE EFFECTS 1. ADVERSE DRUG REACTIONS (ADR) ................................................................................................ xii 2. MAJOR FACTORS PREDISPOSING TO ADVERSE EFFECTS ............................................................ xii E. PRESCRIPTION WRITING 1. PRESCRIPTION FORM ....................................................................................................................... xiii 2. INCORRECT PRESCRIPTIONS .......................................................................................................... xiv 3. NARCOTICS AND CONTROLLED SUBSTANCES .............................................................................. xiv F. PATIENT COUNSELING ............................................................................................................................... xv 1. WHAT TO COUNSEL ......................................................................................................................... xv 2. WHO AND WHEN TO COUNSEL ....................................................................................................... xv 3. COUNSELING: PROCESS STEPS ..................................................................................................... xvi ANTIMICROBIAL RESISTANCE ............................................................................................................................. xvii MEDICINE AND THERAPEUTIC INFORMATION A – ALIMENTARY TRACT AND METABOLISM 1 DRUGS FOR ACID RELATED DISORDERS ................................................................................................... 1 DRUGS FOR FUNCTIONAL GASTROINTESTINAL DISORDERS .................................................................. 8 ANTIEMETICS AND ANTINAUSEANTS ......................................................................................................... 11 BILE AND LIVER THERAPY .......................................................................................................................... 13 DRUGS FOR CONSTIPATION ....................................................................................................................... 14 ANTIDIARRHEALS, INTESTINAL ANTIINFLAMMATORY/ANTIINFECTIVE AGENTS .................................... 17 DRUGS USED IN DIABETES ........................................................................................................................ 22 VITAMINS ..................................................................................................................................................... 26 MINERAL SUPPLEMENTS ........................................................................................................................... 33 OTHER ALIMENTARY TRACT AND METABOLISM PRODUCTS ................................................................... 41 B – BLOOD AND BLOOD FORMING ORGANS 43 ANTITHROMBOTIC AGENTS ........................................................................................................................ 43 ANTIHEMORRHAGICS ................................................................................................................................. 57 ANTIANEMIC PREPARATIONS ..................................................................................................................... 61 BLOOD SUBSTITUTES AND PERFUSION SOLUTIONS ............................................................................... 66 C – CARDIOVASCULAR SYSTEM 94 CARDIAC THERAPY ...................................................................................................................................... 94 AGENTS ACTING ON ARTERIOLAR SMOOTH MUSCLE............................................................................... 112 AGENTS ACTING ON THE RENIN-ANGIOTENSIN SYSTEM......................................................................... 115 BETA-BLOCKING AGENTS............................................................................................................................ 124 CALCIUM CHANNEL BLOCKERS ................................................................................................................. 129 CENTRALLY ACTING ANTIADRENERGIC AGENTS....................................................................................... 139 DIURETICS.................................................................................................................................................... 140
LIPID MODIFYING AGENTS ......................................................................................................................... 148 D – DERMATOLOGICALS 152 ANTIFUNGALS FOR DERMATOLOGICAL USE ............................................................................................. 152 EMOLLIENTS AND PROTECTIVES ............................................................................................................... 156 ANTIPRURITICS, INCLUDING ANTIHISTAMINES, ANESTHETICS, ETC. ...................................................... 156 ANTIPSORIATICS ......................................................................................................................................... 156 ANTIBIOTICS AND CHEMOTHERAPEUTICS FOR DERMATOLOGICAL USE ............................................... 158 CORTICOSTEROIDS, DERMATOLOGICAL PREPARATIONS ........................................................................ 160 ANTISEPTICS AND DISINFECTANTS ........................................................................................................... 162 ANTI-ACNE PREPARATIONS ........................................................................................................................ 165 G – GENITO URINARY SYSTEM AND SEX HORMONES 167 ANTIINFECTIVES AND ANTISEPTICS, EXCLUDING COMBINATIONS WITH CORTICOSTEROIDS ...... ……. 167 OTHER GYNECOLOGICALS ........................................................................................................................ 167 SEX HORMONES AND MODULATORS OF THE GENITAL SYSTEM ............................................................. 170 UROLOGICALS ............................................................................................................................................. 184 H – SYSTEMIC HORMONAL PREPARATIONS, EXCLUDING SEX HORMONES AND INSULINS 187 PITUTARY AND HYPOTHALAMIC HORMONES AND ANALOGUES .............................................................. 187 CORTICOSTEROIDS FOR SYSTEMIC USE ................................................................................................... 189 THYROID THERAPY ...................................................................................................................................... 197 J – ANTIINFECTIVES FOR SYSTEMIC USE 202 ANTIBACTERIALS FOR SYSTEMIC USE ....................................................................................................... 202 ANTIFUNGALS FOR SYSTEMIC USE ............................................................................................................ 250 ANTIMYCOBACTERIALS .............................................................................................................................. 255 ANTIVIRALS FOR SYSTEMIC USE ................................................................................................................ 266 IMMUNE SERA AND IMMUNOGLOBULINS ............................................................................................... 280 VACCINES .................................................................................................................................................... 287 L – ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS 312 ANTINEOPLASTIC AGENTS ........................................................................................................................ 312 ENDOCRINE THERAPY ................................................................................................................................ 366 IMMUNOSTIMULANTS ................................................................................................................................ 374 IMMUNOSUPPRESSANTS ........................................................................................................................... 381 M – MUSCULO-SKELETAL SYSTEM 397 ANTIINFLAMMATORY AND ANTIRHEUMATIC PRODUCTS ......................................................................... 397 MUSCLE RELAXANTS .................................................................................................................................. 406 ANTIGOUT PREPARATIONS ......................................................................................................................... 415 DRUGS FOR TREATMENT OF BONE DISEASE ............................................................................................ 417 OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM............................................... 420 N – NERVOUS SYSTEM 424 ANESTHETICS .............................................................................................................................................. 424 ANALGESICS ................................................................................................................................................ 438 ANTIEPILEPTICS .......................................................................................................................................... 465 ANTI-PARKINSON DRUGS ........................................................................................................................... 481 PSYCHOLEPTICS ......................................................................................................................................... 487 PSYCHOANALEPTICS .................................................................................................................................. 519 OTHER NERVOUS SYSTEM DRUGS ............................................................................................................ 529 P – ANTIPARASITIC PRODUCTS, INSECTICIDES, AND REPELLENTS 540 ANTIPROTOZOALS ....................................................................................................................................... 540 ANTHELMINTICS ......................................................................................................................................... 548 ECTOPARASITICIDES, INCLUDING SCABICIDES, INSECTICIDES, AND REPELLENTS .............................. 551 R – RESPIRATORY SYSTEM 553 NASAL PREPARATIONS ............................................................................................................................... 553 THROAT PREPARATIONS ............................................................................................................................ 554 DRUGS FOR OBSTRUCTIVE AIRWAY DISEASES ......................................................................................... 555 COUGH AND COLD PREPARATIONS ........................................................................................................... 571 ANTIHISTAMINES FOR SYSTEMIC USE ...................................................................................................... 572 OTHER RESPIRATORY SYSTEM PRODUCTS ............................................................................................. 575 S – SENSORY ORGANS 579 OPHTHALMOLOGICALS .............................................................................................................................. 579 OTOLOGICALS ............................................................................................................................................. 601 EAR, NOSE, AND THROAT PREPARATIONS ................................................................................................ 603 V – VARIOUS 605 ALL OTHER THERAPEUTIC PRODUCTS ...................................................................................................... 605 DIAGNOSTIC AGENTS ................................................................................................................................ 631
GENERAL NUTRIENTS ................................................................................................................................. 633 CONTRAST MEDIA ....................................................................................................................................... 640 DIAGNOSTIC RADIOPHARMACEUTICALS ................................................................................................... 650 THERAPEUTIC RADIOPHARMACEUTICALS ................................................................................................. 651 X – HERBAL PREPARATIONS 653 APPENDICES SUMMARY STATISTICS .............................................................................................................................. A1 LIST OF DRUG MOLECULES ADDED TO THE PNF 8TH EDITION................................................................ A2 LIST OF DRUG MOLECULES DELETED FROM THE PNF 7th EDITION....................................................... A4 LIST OF ESSENTIAL MEDICINES INCLUDED IN THE PNF BUT NOT REGISTERED WITH THE FDA .......... A6 LIST OF DANGEROUS DRUG PREPARATIONS INCLUDED IN THE PNF.................................................... A9 LIST OF CONTROLLED CHEMICALS INCLUDED IN THE PNF.................................................................... A10 LIST OF ESSENTIAL MEDICINES WITH NARROW THERAPEUTIC RANGE................................................. A11 LIST OF RESTRICTED ANTIMICROBIALS ................................................................................................... A12 LIST OF MEDICINAL PLANT PRODUCTS REGISTERED WITH THE FDA AND INCLUDED IN THE PNF A13 DEFINITION OF DOSAGE FORMS .............................................................................................................. A14 FDA ADVERSE DRUG REACTION (ADR) REPORTING FORM ...................................................................... A17 DIRECTORY ........................................................................................................................................................... A20 REFERENCES ........................................................................................................................................................ A22 ISSUANCES ........................................................................................................................................................... A26 INDEX .................................................................................................................................................................... A93
GENERAL GUIDANCE
i GENERAL GUIDANCE ON THE USE OF THIS FORMULARY The Philippine National Formulary 8th Edition allows healthcare practitioners – physicians, dentists, pharmacists, nurses, and other allied healthcare professionals – to find important medicine information to guide them in the rational use of medicines. In this new edition of the PNF, the essential medicines list and monographs have been integrated into a single manual. The medicines are arranged using the Anatomical Therapeutic Chemical (ATC) Classification System. Medicines with more than one therapeutic indication appear in more than one category. Each monograph consists of: •Generic Name •Dosage Form/Strength •Indications •Contraindications •Dosage (weight and/or age-specific dosage recommendations) •Dose Adjustments (for patients with renal or hepatic disease; or the elderly patients) •Precautions/Warnings •Adverse Drug Reactions •Drug Interactions •Administration Guide •Pregnancy Category •ATC Code The therapeutic information in this Formulary have been adapted from various current and comprehensive references (refer to Appendix M. This edition also followed and adapted previously approved format and contents of the Philippine National Formulary Manual for Primary Healthcare.
ii MEDICINE MONOGRAPH KEY The medicine monograph key summarizes and describes the types of information contained in this edition that the physicians and dentists can utilize in prescribing medicines for their patients. This key also shows the format of how the prescribing information is arranged. GENERIC NAME DOSAGE FORM/STRENGTH INDICATION/S: This section only includes Philippine FDA-approved indications. In addition, the indications listed for the Anti-Infective Agents are restricted to those included in the most current local clinical practice guidelines that were made available to the editors and/or the latest published recommendations of the Philippine Antimicrobial Resistance Surveillance Program (ARSP). CONTRAINDICATION/S: This section details disease states where and patient populations for whom the medicine should not be used. DOSE: This section lists dosages of the medicines for adult, child and elderly patients, if specified, as indicated in the official FDA-approved labeling and/or other main references. DOSE ADJUSTMENT/S: This section gives dosage adjustment recommendations for the elderly, or for patients with renal or hepatic impairment. PRECAUTIONS: This section details (1) harmful conditions related to the use of the medicine (e.g., exacerbations, increased risk of adverse effects), and (2) disease states or patient populations where caution is advised. This may also include precautions for breastfeeding mothers and nursing infants. Black Box Warnings are included. ADVERSE DRUG REACTIONS: This section denotes side effects and adverse drug reactions (ADRs) listed in the official FDA-approved labeling. Only Common ADRs are listed in this Formulary. A complete listing of ADRs can be viewed on the online copy of the formulary. DRUG INTERACTION/S: This section includes the effects and implications of the concomitant administration of different medicines, or their use together with food. ADMINISTRATION: This section lists recommendations on the proper intake or administration of the medicines. PREGNANCY CATEGORY: This section is based on the US FDA Pregnancy Risk Categories. ATC CODE: This section is based on the WHO ATC/DDD Index 2016. (WHO Collaborating Centre for Drug Statistics Methodology).
iii US FDA PREGNANCY RISK CATEGORIES The FDA-assigned pregnancy categories as used in the Drug Formulary are as follows: Category Interpretation A CONTROLLED STUDIES SHOW NO RISK. Adequate and well-controlled studies in pregnant women have failed to demonstrate a risk to the fetus in the first trimester of pregnancy (and there is no evidence of risk in later trimesters). B NO EVIDENCE OF RISK IN HUMANS. Animal reproduction studies have failed to demonstrate a risk to the fetus and there are no adequate and well-controlled studies in pregnant women. C RISK CANNOT BE RULED OUT. Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks. D POTENTIAL EVIDENCE OF RISK. There is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience or studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks. X CONTRAINDICATED IN PREGNANCY. Studies in animals or humans have demonstrated fetal abnormalities and/or there is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience, and the risks involved in the use of the drug in pregnant women clearly outweigh potential benefits.
iv SYMBOLS AND ABBREVIATIONS ACE - Angiotensin-converting enzyme ADR - Adverse drug reaction AIDS - Acquired Immunodeficiency Syndrome a.m. - Morning; before noon Amp - Ampule AV - Atrioventricular BCG - Bacille Calmette-Guérin BP - Blood pressure BSA - Body surface area cap., caps - Capsule(s) CNS - Central Nervous System comp. - Compound cr., crm. - Cream CR - Controlled-release CSF - Cerebrospinal fluid D5NS - Glucose (dextrose) 5% in normal saline (0.9%) D5W - Glucose (dextrose) 5% solution DOTS - Directly observed treatment, short-course DMARD - Disease modifying agents in rheumatoid disorders DPI - Dry powder inhaler EC - Enteric-coated ECG - Electrocardiogram emuls. - Emulsion EPS - Extrapyramidal syndrome ER - Extended Release FC - Film-coated G - Gram GFR - Glomerular Filtration Rate GI - Gastrointestinal gtt(s) - Drop(s) h, hr. - Hour HAI - Hospital-Acquired Infections HIV - Human Immunodeficiency Virus HRT - Hormone Replacement Therapy (ID) - Intradermal (IM) - Intramuscular Inj. - Injection INR - International Normalized Ratio IU - International Unit(s) (IV) - Intravenous L - Liter LA - Long-Acting lin. - Liniment lot. - Lotion MAOI - Monoamine Oxidase Inhibitor MDI - Metered Dose Inhaler MDR-TB - Multidrug-resistant tuberculosis mEq - Milliequivalent Mg - Milligram mL - Milliliter Mmol - Millimole MR - Modified release [includes CR, ER, SR, LA] nebul. - Spray NSAID - Non-steroidal Anti- Inflammatory Drugs p.m. - Afternoon / Evening RE - Retinol Equivalent Resp. Soln. - Respiratory Solution Rx - Prescription (SC) - Subcutaneous (SL) - Sublingual; under the tongue sig. - Signa / write on label Soln. - Solution spp. - Species SR - Sustained Release SSRI - Selective Serotonin Reuptake Inhibitor supp. - Suppository susp. - Suspension syr. - Syrup tab., tabs. - Tablet(s) TB - Tuberculosis top. - Topical XDR-TB - Extensively Drug-resistant Tuberculosis
v GENERAL GUIDE TO PRESCRIBING A RATIONAL APPROACH TO THERAPEUTICS Rational use of medicines (RUM) is the fundamental concept where patients receive medicines, when these are needed, that are appropriate for the clinical needs, in doses that meet the individual requirements, for an adequate period of time, at the lowest possible cost, and administered correctly by the right person. The problem of irrational use of medicines concerns the following: a. This is one of the most critical causes of unsuccessful treatment outcomes, health hazards that include antimicrobial resistance (AMR), wastage of resources, and increased health costs. b. Worldwide, 50% of medicines are prescribed, dispensed or sold inappropriately; moreover, half of the patient population fails to take them correctly. c. In the Philippines, many irrational practices are prevalent such as rationing (often termed as “diby-diby”), prescribing of inappropriate alternative medicines, “shotgun” therapy, misuse and overuse of antibiotics, dispensing of antibiotics without a prescription, self-medication, buying medicines piecemeal (“tingi”), and failure to complete treatment. d. The problems that underlie the irrational practices are far-reaching and include inadequate supplies of medicines that are in turn due to the sheer number of patients coming for consultation, the lack of funds or poor support from the government officials, poverty, inherent limitations of the National Formulary, anomalous transactions, geographical isolation and poor health literacy of patients and even some health care providers. The solutions for many of the causes of irrational practices are often beyond the control of the physicians. However, the physicians, as stewards of the people’s health, must lead by example the efforts to adhere faithfully to the principles of RUM. The basic tenets of RUM include: a. Prescribing medicines only when these are necessary; b. Prescribing appropriately; and, c. Considering the benefits of administering medicines in relation to the risks involved. The key points of the systematic processes that will assist in determining the proper treatment are: a. Defining the patient’s problem; b. Specifying the therapeutic objective; and, c. Selecting the therapeutic strategy. The selected strategy for achieving a health outcome should be agreed upon with the patient. The total costs for all therapeutic options should be considered. Strategies can either be non-pharmacologic and/or pharmacologic. 1) Non-pharmacologic Treatment This implies that patients do not always need medicine for the treatment of their conditions. This includes changes in lifestyle or diet, use of physiotherapy or exercise, provision of adequate psychological support, and other non-pharmacologic treatments. This is of equal importance as prescription medicines; instructions for such treatments must be written, explained, and monitored in the same way.
vi 2) Pharmacologic Treatment a) Selecting the correct group of medicines: There are two fundamental principles for rational therapeutics: i. Knowledge about the pathophysiology involved in the clinical situation of each patient ii. Pharmacodynamics of the chosen group of medicines b) Verifying the suitability of the chosen pharmaceutical treatment: i. Is the active substance chosen suitable for the patient? ii. Is the dosage form suitable for the patient? iii. Is the standard dosage schedule suitable for the patient? iv. Is the standard duration of treatment suitable for the patient? c) Prescription Writing: i. This serves as the link between the prescriber, the pharmacist (or dispenser), and the patient. ii. This is vital to the successful management of presenting medical conditions (see detailed Prescription Writing below). iii. In the Philippines, only validly registered medical doctors and dentists (as well as veterinarians) are allowed to prescribe. d) Giving information, instructions, and warnings: This is essential in ensuring patient adherence. e) Monitoring treatment: i. The evaluation of the follow-up and the outcome of treatment allows for possible termination of treatment (if the patient’s problem is solved), or its reformulation when necessary. ii. This step gives rise to important information about the effects of medicines, contributing to the pool of knowledge on pharmacovigilance; that in turn is needed to promote the rational use of medicines. B VARIATION IN DOSE-RESPONSE Correct dose regimen is necessary for the success in medicine treatment. The use of standard doses in the marketing literature suggests that standard responses are the rule, but in reality there is considerable variation in medicine response. The reasons for the variation include: adherence (see Adherence with Medicine Treatment), medicine formulation, body weight and age, composition, variation in medicine absorption, distribution, metabolism, and excretion, variation in pharmacodynamics, disease variables, and genetic and environmental variables. MEDICINE FORMULATION a. Poorly formulated medicines may fail to disintegrate or to dissolve. b. Enteric-coated medicines may pass through the GI tract intact. Changes in absorption can produce sudden changes in medicine concentrations of medicines with a narrow therapeutic-to-toxic ratio. For such medicines, quality control surveillance should be carried out. BODY WEIGHT AND AGE Although the concept of varying the dose with the body weight or age of children has long been a tradition, adult doses have been assumed to be the same irrespective of size or shape. However, adult weights vary 2- to 3-folds. Furthermore, a patient with
vii a large fat mass can store large excesses of highly lipid-soluble medicines compared with a lean patient of the same weight. Age can also be important. Adolescents may metabolize some medicines relatively more rapidly than adults, while the elderly may have reduced renal function and eliminate some medicines more slowly. DOSE CALCULATION IN CHILDREN Many children’s doses are standardized by weight (and therefore require multiplying by the body-weight in kilograms to determine the child’s dose). Occasionally, the doses have been standardized by body surface area (BSA) in m2. To calculate a child’s medication based on BSA, use the formula: child′ s BSA 1.73 × adult dose = child′ s dose with the BSA computed as follows: A = � W × H 3600 where: A – patient’s BSA (m2) W – patient’s weight in kg H – patient’s height in cm 3600 – conversion / correction factor (kg/m2) If the weight is expressed in pounds (lbs) and the height in inches (in): A = � W × H 3131 o Young children may require a higher dose for each kilogram than adults because of their faster metabolic rates. o Calculation by body weight in an overweight child may result in higher than necessary doses being administered. In such cases, doses should be calculated using an ideal weight, related to height and age. o Nomograms can also be used to calculate body surface values based on a child’s height and weight. o Where the dose for children is not readily available, prescribers should seek specialist advice before prescribing for a child. PHYSIOLOGICAL AND PHARMACOKINETIC VARIABLES a. Pharmacokinetics This area of study deals with changes of concentration in the drug product, or in a drug and its metabolites, in the body, after it has been administered. This includes the time course of drug absorption, distribution, metabolism, and elimination. A basic understanding of the factors which control drug concentration at the site of action (e.g., bioavailability, area under the curve, and half-life) is important for the optimal use of drugs. 1) Bioavailability This refers to the amount of medicine from an administered dosage form which enters the systemic circulation, and the rate at which it appears in the bloodstream. Changes in a drug’s bioavailability may be thought of in terms of changes in
viii exposure to the drug which, if substantial, can relate to safety and efficacy concerns. 2) Bioequivalence This indicates that a drug in two or more similar dosage forms reaches the general circulation at the same relative rate and the same relative extent (i.e., that the plasma level profiles of the drug obtained using the two dosage forms are the same). This is an important consideration in several key situations involving lot-to-lot consistency, innovator to generic product therapeutic equivalence, and situations where a marketed product undergoes changes in certain aspects (formulation, manufacturing process, and dosage strength). 3) Half-life This indicates the time required to reduce the amount of medicine in the body or the plasma concentration by 50%. This is a clinically useful pharmacokinetic parameter because this indicates when the next dose of a medicine needs to be administered, and thus helpful in determining an optimal dosing regimen. b. Medicine absorption rates may vary widely among individuals and in the same individual at different times and in different physiological states. Medicines taken after a meal are delivered to the small intestine more slowly than in the fasting state, leading to much lower medicine concentrations. In pregnancy, gastric emptying is also delayed, while some medicines may increase or decrease gastric emptying, and affect absorption of other medicines. MEDICINE DISTRIBUTION a. Fat-soluble medicines (vitamins A, D, E, and K) are stored in adipose tissues. b. Water-soluble medicines are distributed chiefly in the extracellular space. c. Acidic medicines bind strongly to plasma albumin. d. Basic medicines go to muscle cells. e. Hence, variations in plasma albumin concentration, fat content, or muscle mass may all contribute to dose variation. MEDICINE METABOLISM AND EXCRETION a. Medicine metabolism is affected by genetic, environmental, and disease-state factors. b. Medicine acetylation shows genetic polymorphism, where individuals fall clearly into either fast or slow acetylator types. This means that some patients can metabolize medicines more rapidly (fast acetylators) than the others (slow acetylators). c. Medicine oxidation, however, is polygenic. Although a small proportion of the population can be classified as very slow oxidizers of some medicines, there is a normal distribution of medicine- metabolizing capacity for most medicines and most subjects. d. Many medicines are eliminated by the kidneys without being metabolized. e. Renal disease or toxicity of some medicines on the kidney can slow excretion of some medicines. f. Hepatic disease or toxicity of some medicines on the liver can slow excretion of some medicines.
ix PHARMACODYNAMIC VARIABLES Significant variations in receptor response to some medicines (especially CNS responses, such as pain and sedation) are attributed to genetic factors, tolerance, medicine interactions, and medicine dependence. DISEASE VARIABLES a. Both liver and kidney diseases can have major effects on metabolism and elimination, respectively (resulting in increasing toxicity), but also through effects on plasma albumin (resulting in increasing free medicine and thus toxicity). b. Heart failure can also affect metabolism of medicines with rapid hepatic clearance (e.g., lidocaine). c. Respiratory disease and hypothyroidism can impair oxidation of drugs. ENVIRONMENTAL VARIABLES a. Many medicines and environmental toxins can induce the hepatic microsomal enzyme oxidizing system or cytochrome P450 oxygenases, leading to more rapid metabolism and elimination, and thus less effective treatment. b. Environmental pollutants, anesthetic medicines, and other compounds, such as pesticides, can also induce metabolism. c. Diet and nutritional status also affect pharmacokinetics: 1) In malnourished infantile and elderly populations, medicine oxidation rates are decreased. 2) High protein diets, charcoal-cooked foods, and certain other foods act as metabolizing enzyme inducers. 3) Chronic alcohol use induces oxidation of some medicines; but in the presence of high circulating alcohol concentrations, medicine metabolism may be inhibited. C ADHERENCE TO (COMPLIANCE WITH) MEDICINE TREATMENT One of the most important reasons for treatment failure is poor adherence to (compliance with) the treatment plan. Reasons for non-compliance may be related to: (1) the patient, (2) the disease, (3) the doctor, (4) the prescription, (5) the pharmacist, or (6) the health system. o For instance, patients' perceptions of the risk and severity of adverse drug reactions may differ from those of the healthcare provider and may affect adherence. o Poor prescribing or a dispensing error may also create a problem, which patients may have neither the insight nor the courage to question. Even with good prescribing though, failure to adhere to treatment is common. Valid reasons for poor adherence include the ff.: the medicine may be poorly tolerated, may cause obvious adverse effects, or may be prescribed in a toxic dose. Failure to adhere with such a prescription has been described as “intelligent non-compliance”. Low-cost strategies for improving adherence increase effectiveness of health interventions and reduce costs. Such strategies must be tailored to the individual patient. Healthcare providers should be familiar with techniques for improving adherence and they should employ systems to assess adherence and to determine what influences it.
x 1. PATIENT-RELATED REASONS a. Women tend to be more adherent than men. b. Younger patients and the very elderly tend to be less adherent. c. People living alone are less adherent than those living with partners or spouses. d. Specific education interventions have been reported and shown to improve adherence and compliance. e. Some patient disadvantages include illiteracy, poor eyesight, or cultural attitudes, which includes preference for traditional or alternative medicines, and distrust of modern medicines. f. Economic factors affect patient adherence, compliance and maintenance. 2. DISEASE-RELATED REASONS Conditions with a known worse prognosis (e.g., cancer) or painful conditions (e.g., rheumatoid arthritis) elicit better adherence than asymptomatic “perceived as benign” conditions such as hypertension. 3. DOCTOR-RELATED REASONS a. Failure to inspire confidence in the treatment offered b. Little or no explanation provided c. Too many medicines prescribed d. Errors in prescribing e. Overall attitude to the patient 4. THE DOCTOR-PATIENT INTERACTION a. Quality of the doctor–patient interaction is crucial to adherence and compliance. b. “Satisfaction with the interview” is one of the best predictors of good adherence. c. If they are in doubt or dissatisfied, they may turn to alternative options, including complementary medicine. 5. PRESCRIPTION-RELATED REASONS a. Illegible or inaccurate prescriptions may discourage patients to adhere to medications. b. Lost prescriptions may delay patients to start or continue medications. c. Prescriptions not refilled as intended or instructed for a chronic disease may reduce maintenance. d. Too complex prescriptions (greater number of different medicines, poorer adherence). e. Multiple doses decrease adherence and compliance especially if more than two doses per day are given. f. Adverse effects, like drowsiness, impotence, or nausea, reduce adherence. 6. PHARMACIST-RELATED REASONS a. Manner and professionalism b. Pharmacist information and counseling can serve as a valuable reinforcement, as long as they agree with the physician’s advice. 7. RECOMMENDATIONS TO THE PRESCRIBERS a. Review the prescription to make sure it is correct. b. Spend time explaining the health problem and the reason for the medicine. c. Establish good rapport with the patient. d. Explore problems, such as difficulty with reading the label or getting the prescription filled.
xi e. Encourage patients to bring their medication to the clinic so that tablet counts can be done to monitor compliance. f. Encourage patients to learn the names of their medicines, and review their regimen with them. Write notes for them. g. Keep treatment regimens simple. h. Communicate with other healthcare professionals to develop a team approach and to collaborate on helping and advising the patient. i. Involve the partner or another family member. j. Listen to the patient. D ADVERSE EFFECTS AND INTERACTIONS 1. ADVERSE DRUG REACTIONS (ADR) Any response to a medicine which is noxious, unintended and occurs at doses normally used for prophylaxis, diagnosis, or therapy. These reactions are different from accidental OR deliberate excessive dosage or medicine maladministration. 2. MAJOR FACTORS PREDISPOSING TO ADVERSE EFFECTS a. EXTREMES OF AGE 1) The very old and the very young populations are more susceptible to ADRs. Examples of which are: hypnotics, antihypertensives, Non-Steroidal Anti- inflammatory Drugs (NSAIDs), psychotropics, diuretics, and digoxin. 2) All children, particularly neonates, differ from adults in their response to medicines. Some medicines are likely to cause problems in o Neonates, but are generally tolerated in children o Children of all ages, who are at increased risk of ADRs for other medicines b. INTERCURRENT ILLNESSES/COMORBIDITIES This occurs when a patient suffers from another disease aside from the current condition being treated (kidney, liver or heart disease). The genetic make-up of the individual patient plays a role. c. MEDICINE INTERACTIONS These may occur among medicines which compete for the same receptor, or which act on the same physiological system. 1) These may occur indirectly when a medicine-induced disease, or a change in fluid/electrolyte balance, alters the response to another medicine. 2) These may occur when one medicine alters the absorption, distribution, or elimination of another medicine, such that the amount which reaches the site of action is either increased or decreased. Drug–drug interactions are some of the most common causes of adverse effects. When two medicines are administered to a patient, they may either act independently of each other, or interact with each other. Interaction may increase or decrease the effects of the medicines concerned and may cause unexpected toxicity. As newer and more potent medicines become available, the frequency of serious drug interactions is likely to increase. NOTE: Interactions which modify the effects of a medicine may involve non-prescription medicines, non-medicinal chemical agents, and social drugs such as alcohol, marijuana and tobacco, and traditional remedies, as well as certain types of food. The physiological changes in individual patients, caused by such factors as age and sex, also influence the predisposition to ADRs resulting from drug interactions.
xii d. INCOMPATIBILITIES BETWEEN MEDICINES AND IV FLUIDS Medicines should not be added to blood, amino acid solutions, or fat emulsions. o Certain medicines, when combined with intravenous fluids, may be inactivated by pH changes, precipitation, or chemical reaction. e. ADVERSE EFFECTS CAUSED BY TRADITIONAL MEDICINES Patients who have been, or are taking, traditional herbal remedies may develop ADRs. In these types of preparation, it is not always easy to identify the responsible constituents. Refer to the medicine and toxicology information service if available or to suitable literature. f. EFFECT OF FOOD ON MEDICINE ABSORPTION Food delays gastric emptying and reduces the rate of absorption of many medicines; however, the total amount of medicine absorbed may or may not be reduced. On the other hand, some medicines are taken with food, either to increase absorption or to decrease the irritant effect on the stomach. E PRESCRIPTION WRITING 1. PRESCRIPTION FORM Administrative Order No. 62 (series of 1989) on the rules and regulations to implement prescribing requirements under the Generics Act defines a prescription as a written order and instruction of a validly-registered physician, dentist or veterinarian for the use of a specific medicine (or medical device) for a specific patient. The most important requirement for a prescription is that it should be clear. It should be legible and indicate precisely what should be given. The language used may be in English, Filipino, or the local dialect. In accordance with R.A. 5921, or the Pharmacy Act as amended, all prescriptions should contain the following information: o The patient’s name, age and sex; o The prescriber’s name, office address, professional registration number, and professional tax receipt number; and, o Date of the prescription In addition, Section 3 of the Generics Act lists the following specific guidelines to prescribing: o Generic names shall be used in all prescriptions. For drugs with a single active ingredient, the generic name of that active ingredient shall be used in prescribing. For drugs with two or more active ingredients, the generic name as determined by the Philippine FDA shall be used. o The generic name must be written in full, but the salt or chemical form may be abbreviated. The symbol Rx means prescription which originated in medieval manuscripts as an abbreviation of the Latin verb recipe. The imperative form is recipere which means “to take” or “take thus.”) o The generic name must be clearly written immediately after the Rx symbol or on the order chart. o The pharmaceutical form (e.g., “tablet”, “oral solution”, “eye ointment”) should also be stated. o The strength of the medicine should be stated in standard units using abbreviations which are consistent with the Système International (SI) [Refer to Appendices for abbreviations and symbols].
xiii o Avoid decimals whenever possible. If this is unavoidable, a zero should be written before the decimal point. 2. INCORRECT PRESCRIPTIONS Three types of incorrect prescriptions may be identified: a. Erroneous prescription: o Where the brand name precedes the generic name o Where the generic name is the one in parenthesis o Where the brand name is not in parenthesis b. Violative prescription: o Where the generic name is not written o Where the generic name is not legible, and a brand name which is legible is written o Where the brand name is indicated and instructions added (such as the phrase “no substitution”) which tend to obstruct, hinder or prevent proper dispensing c. Impossible prescription: o When only the generic name is written, but it is not legible o When the generic name does not correspond to the brand name o When both the generic and brand names are not legible o When the drug product prescribed is not registered with the Philippine Food and Drug Administration If an erroneous prescription is received, the prescription may be filled but it should be kept and reported to the nearest Department of Health (DOH) office for appropriate action. In contrary, violative and impossible prescriptions are not to be filled and should also be kept and reported to the nearest DOH office. 3. NARCOTICS AND CONTROLLED SUBSTANCES The prescribing of a medicinal product which is liable to abuse requires special attention and may be subjected to specific statutory requirements. Practitioners may need to be authorized to prescribe controlled substances. In such cases, it might be necessary to indicate details of the authority on the prescription. In particular, the strength, directions, and the quantity of the controlled substance to be dispensed should be stated clearly, with all quantities written in words, as well as in figures to prevent alteration. Other details, such as patient particulars and date, should also be filled in carefully to avoid alteration. F PATIENT COUNSELING One-to-one, dynamic interaction between a health care practitioner and a patient and/or caregiver, which should include an assessment if the information was received as intended, and that the patient understands how to use the information to improve the probability of positive therapeutic outcomes. 1. WHAT TO COUNSEL Routinely, effectively and appropriately educate patients on the following: (1) when dispensing prescription and non-prescription drugs, (2) when counseling on discharge medications, and (3) when providing recommendations about management of specific drug-related problems: a. The medication’s name (generic), indication and when appropriate to use;
xiv b. The medication’s expected onset of action and what to do if the action does not occur; c. The medication’s route, dosage form, dosage and administration schedule (including duration of therapy); d. Directions for use including education about drug devices; e. Proper storage requirements; f. Common or important drug-drug or drug-food interactions; g. Potential common and severe adverse effects, and actions to prevent or minimize their occurrence; h. What the patient should do to monitor his/her therapeutic response or when side effects develop; i. What actions the patient should take if the intended therapeutic response is not obtained or if side effects develop; and, j. Proper disposal of contaminated, discontinued or unused medications. 2. WHO AND WHEN TO COUNSEL a. Patients who should always be counseled together with their families and caregivers: o Confused patients; o Patients who are sight- or hearing-impaired; o Patients with poor literacy; o Patients whose profiles show change in medications or dosing; o New patients, or those receiving a medication for the first time; and, o Patients who have medications with significant side effects, specific storage requirements, and complicated directions. b. Patients who should be counseled at certain intervals: o Asthmatic patients; o Diabetic patients; o Patients taking four (4) or more prescribed medications; o Patients who are mentally ill; o Epileptic patients; and, o Patients with skin complaints. 3. COUNSELING: PROCESS STEPS Steps in patient education and counseling process will vary according to the health system’s policies and procedures, environment, and practice setting. Generally, the following steps are appropriate for patients receiving new medications or returning for refills: a. Establish caring relationship with the patient as appropriate to the practice setting, and stage in the patient’s health care management. Show interest in the patient verbally and non-verbally o Explain the purpose and expected length of sessions. o Obtain the patient’s agreement to participate. b. Assess the patient’s knowledge about his or her health problems, medications, physical and mental capability to use the medications appropriately, and attitude towards the health problems and medications. o Ask why the patient is being prescribed with the medication (if known), or the medication’s use, expected benefits and action. o Provide information orally, and use demonstrations or visual aids to fill the patient’s gaps in knowledge and understanding.
xv o Open the medication containers and show patient what the medication looks like, or demonstrate use. Explain how to take the medication. o Discuss when to take and how long to take the medication. o Plan what to do if a dose is missed. o Determine any special precautions to heed and follow. Explain how to store the medication. o Demonstrate if the prescription can be refilled, and if so, determine when it is done. o Give specific details on how the patient will know if the medication is working. c. Verify patient’s knowledge and understanding of medication use. o Ask the patient to describe (or show) how the medication should be used, and its effects. o Ask the patient if they have any questions.
xvi ANTIMICROBIAL RESISTANCE A. DEFINITION OF ANTIMICROBIAL RESISTANCE 1. Antimicrobial Resistance (AMR) refers to the resistance of a micro-organism (including bacteria, viruses and some parasites) to an antimicrobial agent to which it was previously sensitive. Resistant organisms withstand attack by antibacterials, antivirals, or antimalarials. Thus, standard treatments become ineffective, allowing infections to persist and spread. 2. AMR which is a consequence of the use or misuse of antimicrobials develops when the organism mutates or acquires a resistance gene. B. CAUSES OF ANTIMICROBIAL RESISTANCE 1. Although the ultimate causes of AMR are microbial, clinical, and programmatic in nature, it is essentially a man-made occurrence. 2. The proliferation of drug-resistant strains is associated with various management, healthcare provider, and patient-related issues. Table 1 enumerates several of the causes leading to drug resistance. 3. The general categories of the causes, i.e., therapeutic protocols, drug characteristics, and drug selling and purchasing practices, provide opportunities where potential strategies to combat AMR arise. Table 1. Causes of inadequate treatment which may contribute to emergence of drug resistance Healthcare providers: Inadequate regimens Drugs: Inadequate supply/quantity Patients: Inadequate drug intake - Inappropriate guidelines - Noncompliance with guidelines - Absence of guidelines - Poor training - No treatment monitoring - Poorly organized or funded control programs - Poor quality - Unavailability of certain drugs (stock-outs or delivery disruptions) - Poor storage conditions - Wrong dose or combinations - Poor adherence (or poor directly observed therapy) - Lack of information - Lack of money (no treatment available free of charge - Lack of transportation - Adverse effects - Social barriers - Malabsorption - Substance dependency disorders Source: Final Report, Country Situation Analysis on Antimicrobial Resistance, Philippines, 2012. C. ANTIMICROBIAL RESISTANCE: A GROWING GLOBAL CONCERN 1. The WHO cites the following alarming reasons: AMR is already a global concern, AMR kills, AMR challenges control of infectious disease, AMR threatens a return to the pre-antibiotic era, AMR increases the costs of health care, AMR jeopardizes healthcare gains to society, and AMR compromises health security, and damages trade and economy. 2. Furthermore, the following facts collated by WHO1 indisputably demonstrate the potential and real dangers that AMR causes and has caused: a. About 440,000 new cases of multi-drug resistant TB (MDR-TB which is defined as resistance to Rifampicin and Isoniazid) emerge annually, causing at least
xvii 150,000 deaths. Therapy of MDR-TB requires 18-24 months of treatment with expensive second-line drugs, like capreomycin and kanamycin. b. Extensively drug-resistant TB (XDR-TB defined as MDR plus resistance to any member of the quinolone family and at least to any second-line anti-TB injectable, such as kanamycin, capreomycin or amikacin) is a global threat with a case-fatality rate of 50%. XDR-TB is a big problem because there are very few options for treatment, which probably accounts for the high mortality rate among them. c. Resistance to earlier generation antimalarial medicines such as chloroquine and sulfadoxine-pyrimethamine is widespread in most malaria-endemic countries. Falciparum malaria parasites resistant to artemisinins are emerging in Southeast Asia; infection showed delayed clearance after the start of treatment (indicating resistance). d. Ciprofloxacin is the only antibiotic currently recommended by WHO for the management of bloody diarrhea due to Shigella, now that wide-spread resistance has developed to any previously effective antibiotics. But rapidly increasing prevalence of resistance to Ciprofloxacin in Shigellosis is reducing the options for safe and efficacious treatment especially for children. New antibiotics suitable for oral use are badly needed. e. AMR has become a serious problem for treatment of gonorrhea (caused by Neisseria gonorrhoea), involving even “last-line” oral cephalosporins, and this is increasing in prevalence worldwide. In multidrug-resistant N. gonorrhoea, resistance is found against tetracyclines, macrolides (including azithromycin), sulfonamide and trimethoprim combinations and more recently, to quinolones. Untreatable gonococcal infections will result in higher rates of illness and death thus reversing the gains made in the control of the sexually transmitted infections. f. ESBLs (extended-spectrum beta-lactamases) are resistant to third-generation cephalosporins (ceftazidime, cefotaxime and cefpodoxime) as well as monobactams (aztreonam); common in the Enterobacteriaceae, particularly E.coli and K. pneumoniae. g. New resistance mechanisms, such as the beta-lactamase NDM-1 (New Delhi metalo- beta-lactamase 1), have emerged among several gram-negative bacilli. This is considered as a new superbug that has resistance to broad spectrum antibiotics that are often the last defense against multi-resistant bacterial strains. h. A high percentage of hospital acquired infections is caused by highly resistant bacteria such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin resistant enterococci. i. Resistance is an emerging concern for treatment of HIV infection, following the rapid expansion in access to anti-retroviral medicines in recent years. D. STATUS OF ANTIMICROBIAL RESISTANCE IN THE PHILIPPINES 1. The need to approach the problem of AMR in the Philippines with a sense of urgency is clearly elucidated by several evidence of the dangers it poses. a. The most dreaded recognized AMR gene, the NDM-1, was identified in the Escherichia coli isolated from the urine of a 33 year old female in 2011. The gene can render even the most powerful antibiotics ineffective. b. Many of the causative bacterial pathogens that cause infections included in the Top Ten causes of morbidity in the Philippines have already become resistant to multiple antibiotics. At the forefront is TB, with MDR-TB and even XDR-TB already present in the Philippines which ranked 6th among 27 identified countries with MDR-TB. In 2006, the occurrence of MDR-TB was 4% among new cases and a high 27% among previously treated patients.
xviii 2. The DOH established in 1988 the Antimicrobial Resistance Surveillance Program (ARSP) to determine the current status and developing trends of antimicrobial resistance of selected bacteria to specific antimicrobials. The ARSP, which now has 24 sentinel sites hospital bacteriology laboratories in 16 regions of the Philippines and 2 gonococcal surveillance sites, submits and publishes annual summary reports focusing on aerobic bacterial pathogens of public health importance causing common infectious diseases. All readers are enjoined to refer to the yearly published ARSP surveillance data provided by RITM for updated information and proper guidance. 3. The ARSP found alarming rates of resistance among various bacterial pathogens. 1,2 a. The ESBL enzyme, which can render pathogens resistant to many antibiotics, has been identified in Escherichia coli and Klebsiella spp. b. Multi-drug resistant Pseudomonas aeruginosa and Acinetobacter spp. which account for 43% of all hospital-acquired pneumonia have been identified. c. The percent resistance, in all ARSP sites from January-December of 2013 of Streptococcus pneumonia (which causes acute respiratory tract infections) to penicillin was 5% compared to 0 in 2010. Resistance to cotrimoxazole was 20% in 2013.² d. The percent resistance of non-typhoidal Salmonella from January-December, 2013, to ampicillin and cotrimoxazole were 56% and 34%, respectively. ² e. There is a steady increase in the resistance rates of Staphylococcus aureus and consequently higher prevalence of MRSA which is also an important cause of hospital acquired infections. f. In the period 2012-2013, there were very high resistance rates of Neisseria gonorrhoea to ciprofloxacin (74%), penicillin (80%), and tetracycline (55%). ² 4. These alarming increasing trends of AMR in the country are clearly demonstrated in Table 2 which summarized the results of a comparison of the antimicrobial resistance of selected organisms in 1993 and 2011. Please refer to the Antimicrobial Resistance Surveillance Program (ARSP) Summary Report for antimicrobial resistance patterns of specific organisms. E. RECOMMENDATIONS OF THE PHILIPPINE ANTIMICROBIAL RESISTANCE SURVEILLANCE PROGRAM Below are the recommendations of the ARSP regarding antibiotic treatment for aerobic bacterial pathogens of public health importance based on the reported antimicrobial resistance surveillance data for 2013 (Carlos, C, 2013): 1. Respiratory Bacterial Pathogens: a. Infections secondary to Streptococcus pneumoniae can still be covered with penicillin or one of the anti-pneumococcal macrolides, although there is a need to closely monitor the changing trends of resistance among pneumococci. Improved local data on serotype distribution will allow for better surveillance information especially needed for vaccination recommendations. b. Due to high resistance rate of Haemophilus influenzae to ampicillin, this antibiotic is no longer recommended for empiric therapy for infections secondary to the pathogen. c. Recommended empiric treatment for suspected H. influenzae infections may consist of beta-lactam-beta-lactamase inhibitor combinations, extended spectrum oral cephalosporins and the newer macrolides.
xix 2. Bacterial Enteric Pathogens: a. For suspected uncomplicated enteric fever, empiric treatment can still consist of either chloramphenicol or cotrimoxazole or amoxicillin/ampicillin. There are increasing reports of nalidixic acid resistance and ciprofloxacin non- susceptibility which may result to clinical treatment failures when treating enteric fever using fluoroquinolones. Microbiological data is recommended for pathogen directed therapy. b. In Salmonella gastroenteritis, increasing rates of ciprofloxacin resistance should remind clinicians to use antibiotics judiciously as this is usually a self-limiting disease. c. Due to the emerging resistance of Shigellae to the quinolones and limited data available, more vigilant surveillance of the resistance pattern of this organism should be pursued by encouraging clinicians to send specimens for culture. d. For cholera, tetracycline, chloramphenicol and cotrimoxazole remain to be good treatment options. 3. Sexually-Transmitted Bacterial Pathogens: a. Limited data is available on N. gonorrhoeae in recent years, but based on reported isolates, ceftriaxone remains as empiric antibiotic of choice for gonococcal infections. More vigilant surveillance of the resistance patterns of this organism must be pursued by encouraging clinicians to send specimens for culture. 4. Gram-positive Cocci: a. In view of the continuous high rates of methicillin/oxacillin resistance among staphylococci, there may be an indication to shift empiric treatment of suspected staphylococcal infections from oxacillin to alternative agents such as cotrimoxazole, doxycycline, clindamycin, linezolid or vancomycin. 5. Gram-negative Bacilli: a. Hospitals should base their treatment recommendations for the Enterobacteriaceae on their institution’s prevailing resistance patterns as these have been found to be variable from hospital to hospital. The high percentage of possible ESBL-producing isolates complicates treatment of serious infections caused by these organisms and may lead to the increased use of carbapenems that may favor the spread of the carbapenem-resistant Enterobacteriaceae. b. Increasing resistance among the bacterial organisms Pseudomonas aeruginosa and Acinetobacter baumannii continue to be a concern as both carry intrinsic resistance to a number of antimicrobial classes and acquisition of additional resistance severely limits the available treatment options. c. Prudent antimicrobial use, monitoring of resistance patterns and antimicrobial use, and improved standards of infection control are essential in addressing the clinical and public health concerns. All readers are enjoined to refer to the yearly published ARSP surveillance data provided by RITM for updated information and proper guidance. F. DRIVING FORCES BEHIND ANTIMICROBIAL RESISTANCE 1. The inappropriate and irrational use of medicines provides favorable conditions for resistant microorganisms to emerge and spread. WHO enumerates the following as the underlying factors that drive AMR: a. Inadequate national commitment to a comprehensive, coordinated response, ill-defined accountability, and insufficient engagement of communities;
xx b. Weak or absent surveillance and monitoring systems; c. Inadequate systems to ensure quality and uninterrupted supply of medicines; d. Inappropriate and irrational use of medicines, in both clinical practice and animal husbandry, and aquaculture; e. Poor infection prevention and control practices; and, f. Depleted arsenals of diagnostics, medicines, and vaccines as well as insufficient research and development of new products. G. THE RESPONSE OF THE NATIONAL GOVERNMENT TO THE RISING ANTIMICROBIAL RESISTANCE 1. Creating an Inter-Agency Committee on AMR (ICAMR). 2. Developing a National Plan that will include, but not limited to, the following strategies: a. Establishing short and long term programs to address the different aspects of response to AMR; b. Strengthening the surveillance system and laboratory detection capacity of AMR in both humans and animals; c. Ensuring accessibility, affordability, availability and quality of antimicrobial drugs for humans and its appropriate use in food producing animals including banning the use of antibiotics as growth promoters; d. Developing relevant and utilizable essential medicines list for human and veterinary use; e. Monitoring the rational use of antimicrobials in humans, animal husbandry and aquaculture; f. Advocating the rational use of antimicrobials to consumers and community through media and the academe; g. Training and educating on, and promotion of infection prevention and control measures in health care facilities and the community; h. Conducting researches to develop new antimicrobials and innovative technology to improve diagnosis and treatment; i. Monitoring and evaluating compliance with existing policies and on the proper execution of the AMR control plan; j. Engaging all relevant stakeholders such as government agencies, healthcare providers, non-government institutions, professional organizations, drug industry, veterinary and aquaculture groups, consumer groups, researchers and civil societies; and, k. Ensuring that activities are well financed for sustainability. H. ACTION PLANS, WHICH THE PRIMARY PHYSICIANS AND DENTISTS CAN ADOPT TO HELP COMBAT ANTIMICROBIAL RESISTANCE 1. Assuring the judicious use of antimicrobial agents through faithful adherence to the principles of rational use of medicines and utilizing antimicrobial agents only for the appropriate indications as recommended by the Antimicrobial Resistance Surveillance Program (ARSP) or the task force for Clinical Practice Guidelines and included in the Philippine National Formulary. The choice of antibiotics must strictly conform to the best standard treatment guidelines or clinical practice guidelines (e.g., National Antibiotic Guidelines), and guided by the latest findings and recommendations of the ARSP; 2. Keeping abreast of the latest information on AMR through reviews of the latest antibiotic susceptibility data published by the ARSP, literature search, attendance in seminars, and participation in continuing medical education programs; 3. Devoting sufficient time to educate the patients and their families and caregivers about the appropriate use of antibiotics and the reasons behind the need for strict adherence to the
xxi prescribed dosage schedule and completion of full course of treatment as well as to educate them on the prevention of AMR; 4. Careful monitoring of the patients’ compliance and their response to the antimicrobial agents; 5. Submitting specimen for culture when indicated (e.g., for suspected gonococcal infections); 6. Complying with the rules on prescribing, and other regulations in the Pharmacy Law; 7. Developing better communication with pharmacists and other dispensers; 8. Educating other healthcare providers (nurses, midwives, barangay health workers) about the RUM and prevention of AMR; and, 9. Educating the community continually on the need for and proper ways of maintaining good personal hygiene and sanitation, avoidance of vices or unhealthy habits, sanitation, and prevention of infections, including maintaining cleanliness of their surroundings.
MEDICINE AND THERAPEUTIC INFORMATION
A ALIMENTARY TRACT AND METABOLISM 1 ALIMENTARY TRACT AND METABOLISM DRUGS FOR ACID-RELATED DISORDERS ANTACIDS OTC ALUMINUM HYDROXIDE + MAGNESIUM HYDROXIDE Oral: 200 mg aluminum hydroxide + 100 mg magnesium hydroxide tablet 225 mg aluminum hydroxide + 200 mg magnesium hydroxide per 5 mL suspension, 60 mL and 120 mL An antacid that combines aluminum hydroxide and magnesium hydroxide to reduce effect on bowel movement and to relieve epigastric pain from peptic ulcer through acid neutralization. Indication: Symptomatic relief of symptoms related to hyperacidity from heartburn, hiatal hernia, upset stomach, peptic ulcer, peptic esophagitis, or gastritis. Contraindications: Severe renal impairment; hypophosphatemia; undiagnosed GI and rectal bleeding; porphyria; appendicitis. Dose: Hyperacidity, by mouth, ADULT, 10-20 mL 4 times daily (maximum 80 mL daily). Dose Adjustment: Renal Impairment: Use with caution due to risk of accumulation and toxicity. For mild-to-moderate renal impairment, dose reduction is warranted. For severe impairment, avoid use and refer patient to a specialist. Precautions: WARNING: Aluminum and magnesium salts may be hazardous in patients with renal insufficiency. If intensive antacid therapy is to be used, only non- systemic (non-absorbable) antacids should be considered because of the potential danger of alkalosis with systemic therapy. Acute porphyria; prolonged antacid therapy may result in hypophosphatemia (i.e., decreased phosphate absorption in the GI tract); dehydration; fluid restriction; constipation; diarrhea; hepatic impairment; renal impairment; GI disorders associated with decreased bowel motility or obstruction; some products may contain phenylalanine. Elderly (may be predisposed to diarrhea or constipation); children. Adverse Drug Reactions: Common: Constipation, diarrhea, GI irritation. Less Common: Chalky taste, fecal discoloration, hypophosphatemia, nausea, vomiting. Rare: Anemia, encephalopathy, fecal impaction, hypermagnesemia, hypophosphatemia, intestinal obstruction, osteomalacia, proximal myopathy. Drug Interactions: Monitor closely with: Increases excretion due to urine alkalinization: Acetylsalicylic Acid Reduces absorption of the following drugs: Azithromycin, Chloroquine, Digoxin, Enalapril, Isoniazid, Rifampicin Avoid concomitant use with: Reduces therapeutic effect of the following drugs Bisphosphonates e.g., Alendronate, Iron, Ketoconazole, Quinolones e.g., Nalidixic acid, Rosuvastatin, Tetracyclines, e.g., Doxycycline. [Separate dosing by at least 2 hours before, or 4–6 hours after the antacid]: Administration: Shake well before use. Best given 1–3 hours after the last meal to neutralize and buffer the acid produced. NOTE: Antacids should preferably not be taken at the same time as other oral drugs since they may impair absorption (interactions may be avoided by having an interval of at least 2 hours between taking an antacid and the other drug). Pregnancy Category: B ATC Code: A02AD01 OTC SODIUM BICARBONATE Oral: 325 mg and 650 mg tablet A short-acting, potent systemic antacid that rapidly neutralizes gastric acid to form sodium chloride, carbon dioxide, and water. After absorption of sodium bicarbonate, plasma alkali reserve is increased, and excess sodium and bicarbonate ions are excreted in urine, rendering urine less acid. Indications: Symptomatic relief of hyperacidity (belching, heartburn, indigestion, gas pains), gastritis, and peptic ulcer; urine alkalinizer. Contraindications: Diuretics known to produce hypochloremic alkalosis; edema; hypertension; hypocalcemia; hypochloremia; hypernatremia; impaired renal function; metabolic alkalosis; respiratory alkalosis or acidosis; any situation where administration of sodium could be clinically detrimental. Dose: Antacid, by mouth, ADULT, 2–8 tablets every 4 hours (maximum, 48 tablets in 24 hours); ADULT ≥60 years, 2– 4 tablets every 4 hours (maximum, 24 tablets in 24 hours.
A ALIMENTARY TRACT AND METABOLISM 2 Urine alkalinizer, by mouth, ADULT, initially 3.94 g, then 0.97–1.95 g every 4 hours; CHILD, 84–840 mg/kg daily, in divided doses. Dose Adjustment: Geriatric, Renal and Hepatic Impairment: Dose adjustment may be required. Precautions: WARNING: Ask attending physician before use if on a sodium restricted diet. Do not use maximum dose for more than 2 weeks. Cardiac, liver, or renal disease; Fluid or solute overload; Postoperative patients with cardiovascular or renal insufficiency (e.g., sodium or water retention and edema which may result in serious pulmonary edema); Arrested patients with preexisting metabolic acidosis, hyperkalemia, or tricyclic or barbiturate overdose; Elderly; Pregnancy (restrict intake in hypertension and toxemia). Adverse Drug Reactions: Common: Belching, gastric distention, flatulence, metabolic alkalosis, electrolyte imbalance, (sodium overload, hypocalcemia, hypokalemia, milk-alkali syndrome, dehydration), reduction in CSF pressure, intracranial hemorrhage, severe tissue damage following extravasation of IV solution, renal calculi or crystals, impaired kidney function Drug Interactions: Monitor closely with: Decreases the absorption of Ketoconazole Decreases therapeutic effect of the following drugs: Chlorpropamide, Lithium Carbonate, Salicylates, Tetracyclines Increases therapeutic effect of the following drugs: Appetite Suppressants (e.g., Amphetamines), Flecainide, Mecamylamine, Quinidine, Sympathomimetics (e.g., Ephedrine, Dopamine) NOTE: Sodium bicarbonate raises intra-gastric pH, which may affect the absorption of certain drugs. Administration: Should be taken on an empty stomach. Tablets may be swallowed whole or dissolved in water prior to use. Do NOT add oral preparation to calcium-containing solutions. Pregnancy Category: C ATC Code: A02AH FOR PEPTIC ULCER AND GASTRO-ESOPHAGEAL REFLUX DISEASE (GERD) H2-RECEPTOR ANTAGONISTS Rx (Inj.) OTC (Oral) FAMOTIDINE Oral: 20 mg tablet Inj.: 10 mg/mL, 2 mL ampule / vial (IM, IV) A competitive inhibitor of histamine H2­receptor, inhibiting both daytime and nocturnal basal gastric acid secretion, as well as food-stimulated and pentagastrin-stimulated gastric acid secretion. Indications: Relief and prevention of heartburn; treatment and maintenance of active duodenal ulcers, pathological hypersecretory conditions (e.g., Zollinger-Ellison Syndrome or multiple endocrine adenomas), Gastroesophageal Reflux Disease (GERD) and active benign gastric ulcer. Contraindications: Cirrhosis of the liver; impaired renal or hepatic function; lactation; other H2 antagonists. Dose: Duodenal ulcer, acute therapy, by mouth, ADULT, 40 mg daily at bedtime (or 20 mg twice daily) for 4-8 weeks. Duodenal ulcer, maintenance therapy, by mouth, ADULT, 20 mg daily at bedtime. Gastric ulcer, acute therapy, by mouth, ADULT, 40 mg daily at bedtime. Peptic ulcer, by mouth, CHILD 1-16 years, 0.5 mg/kg daily at bedtime or divided twice daily (maximum dose, 40 mg daily) (doses of up to 1 mg/kg daily have been used in clinical studies); by IV injection, CHILD 1-16 years, 0.25 mg/kg every 12 hours (maximum dose, 40 mg daily) (doses of up to 0.5 mg/kg have been used in clinical studies). GERD, by mouth, ADULT, 20 mg twice daily for 6 weeks; CHILD 1-16 years, 1 mg/kg daily divided twice daily (maximum dose, 40 mg twice daily) (doses of up to 2 mg/kg/day have been used in clinical studies); CHILD 3- 12 months, 0.5 mg/kg twice daily; CHILD <3 months, 0.5 mg/kg once daily. Esophagitis and accompanying symptoms due to GERD, by mouth, ADULT, 20 mg or 40 mg twice daily for up to 12 weeks. Hypersecretory conditions, by mouth, ADULT, initially, 20 mg every 6 hours, may increase in increments up to 160 mg every 6 hours. Patients unable to take oral medication, by IV injection, ADULT, 20 mg every 12 hours. Dose Adjustment: Renal Impairment: For creatinine clearance <50, reduce dose by half or increase dosing interval to 36–48 hours. Precautions: Increases risk of community-acquired pneumonia with prolonged use; prolonged treatment (≥2 years) may lead to vitamin B12 malabsorption and subsequent vitamin B12 deficiency; gastric malignancy.
A ALIMENTARY TRACT AND METABOLISM 3 Elderly >50 years. Lactation (excreted into breast milk). Adverse Drug Reactions: Common: Headache, dizziness, constipation, diarrhea, nausea and vomiting, anxiety, confusion. Less Common: Acne, pruritus, urticaria, dry skin, fever, hypertension, flushing, musculoskeletal pain, arthralgia, tinnitus Drug Interactions: Monitor closely with: Decreases absorption of the following drugs: Cefpodoxime, Cefuroxime, Iron salts Decreases serum concentration of the following drugs: Indinavir, Multivitamins / Minerals with ADEK, Folate, Iron Increases the absorption of: Methylphenidate Increases serum concentration of Famotidine: Bupropion Avoid concomitant use with: Decreases absorption of Famotidine: Antacid Decreases absorption of Diazepam Decreases serum concentration of the following drugs: Atazanavir, Cefditoren, Itraconazole Ketoconazole (systemic) Increases serum concentration of Risedronate Administration: For oral administration, may be taken with or without food For IV injection or IV push, inject over at least 2 minutes. If administered by IV infusion, administer over 15–30 minutes. Pregnancy Category: B ATC Code: A02BA03 Rx RANITIDINE Oral: 150 mg and 300 mg tablet (as hydrochloride) 75 mg/5 mL syrup (as hydrochloride), 60 mL and 150 mL Inj.: 25 mg/mL, 2 mL ampule / vial (IM, IV, IV infusion) (as hydrochloride) A competitive inhibitor of histamine H2­receptor, inhibiting both daytime and nocturnal basal gastric acid secretion, as well as food- and pentagastrin-stimulated gastric acid secretion. Ranitidine is also a weak cytochrome P-450 enzyme inhibitor. Indications: Relief and prevention of heartburn. Management of duodenal ulcer, erosive esophagitis, gastric ulcer, GERD, pathological hypersecretory conditions (e.g., Zollinger-Ellison syndrome, systemic mastocytosis) Contraindications: Cirrhosis of the liver; impaired renal or hepatic function; acute porphyria Dose: Duodenal ulcer, acute therapy, by mouth, ADULT, 150 mg twice daily, or 300 mg once daily after the evening meal or at bedtime; INFANT, CHILD, and ADOLESCENT ≤16 years, 4-8 mg/kg daily divided twice daily (maximum, 300 mg daily). Duodenal ulcers, maintenance therapy, by mouth, ADULT, 150 mg once daily at bedtime; INFANT, CHILD, and ADOLESCENT ≤16 years, 4–8 mg/kg daily divided twice daily; 2–4 mg/kg once daily (maximum, 150 mg daily); by IM injection, ADULT, 50 mg every 6–8 hours; by IV intermittent bolus or IV infusion, ADULT, 50 mg every 6–8 hours (if increased doses are necessary utilize more frequent administration up to a maximum of 400 mg daily); by IV injection, INFANT, CHILD, and ADOLESCENT ≤16 years, 2–4 mg/kg daily divided every 6–8 hours (maximum dose, 50 mg/dose); by continuous IV infusion, ADULT, 6.25 mg/hour. Benign gastric ulcer, acute therapy, by mouth, ADULT, 150 mg twice daily; INFANT, CHILD, and ADOLESCENT ≤16 years, 4-8 mg/kg daily divided twice daily (maximum, 300 mg daily). Benign gastric ulcer, maintenance therapy, by mouth, ADULT, 150 mg once daily at bedtime; INFANT, CHILD, and ADOLESCENT ≤16 years, 2-4 mg/kg once daily (maximum, 150 mg daily). Erosive esophagitis, acute therapy, by mouth, ADULT, 150 mg 4 times daily, INFANT, CHILD, and ADOLESCENT ≤16 years, 5-10 mg/kg daily divided twice daily (maximum, 300 mg daily). Erosive esophagitis, maintenance therapy, by mouth, ADULT, 150 mg twice daily. Gastroesophageal reflux disease (GERD), by mouth, ADULT, 150 mg twice daily; INFANT, CHILD, and ADOLESCENT ≤16 years, 5-10 mg/kg daily divided twice daily (maximum, 300 mg daily). Heartburn, prevention, by mouth, CHILD ≥12 years, 75-150 mg 30-60 minutes before eating food or drinking beverages that cause heartburn (maximum, 2 doses daily), not to be used for more than 14 days. Pathological hypersecretory conditions (e.g. Zollinger Ellison Syndrome), by mouth, ADULT, 150 mg twice daily, adjust dose or frequency as clinically indicated (doses of up to 6 g daily have been used in patients with severe disease); by IM injection, ADULT, 50 mg every 6–8 hours; by continuous IV infusion, ADULT, 6.25 mg/hour, initially, 1 mg/kg per hour (measure gastric acid output at 4 hours, if >10 mEq or if patient is symptomatic, increase dose in increments of 0.5 mg/kg per hour) (doses of up to 2.5 mg/kg per hour (220 mg/hour) have been used by IV intermittent bolus or infusion); 50 mg every 6–8 hours (if increased doses are necessary utilize more frequent administration up to a maximum of 400 mg daily). Patients not able to take oral medication, by IM injection, ADULT, 50 mg every 6–8 hours;
A ALIMENTARY TRACT AND METABOLISM 4 by IV intermittent bolus or infusion, ADULT, 50 mg every 6–8 hours; 50 mg every 6–8 hours (if increased doses are necessary utilize more frequent administration up to a maximum of 400 mg daily); by continuous IV infusion, ADULT, 6.25 mg/hour; by IV injection, INFANT, CHILD, and ADOLESCENT <16 years, 2–4 mg/kg daily divided every 6–8 hours (maximum dose, 50 mg/dose). Dose Adjustment: Renal Impairment: For patients with creatinine clearance <50 mL/minute, adjust dose cautiously. Adjust dosing schedule to not coincide with the end of hemodialysis. Precautions: WARNING: NOT to be used if there is trouble or pain when swallowing food, vomiting with blood, or bloody or black stools. NOT to be used in combination with other acid reducers. Avoid the use of 150 mg tablet for patients with kidney disease. Relief of symptoms does not preclude the presence of a gastric malignancy. Rare cases of reversible confusion have been associated with use, usually among elderly or severely ill patients, or in patients with renal or hepatic impairment. Prolonged treatment (≥2 years) may lead to vitamin B12 malabsorption and subsequent vitamin B12 deficiency. Decreased renal or hepatic function (use with caution). Elderly (use with caution) Pregnancy; lactation (excreted into breast milk; use with caution). Adverse Drug Reactions: Common: Headache, abdominal pain, constipation, diarrhea, nausea, and vomiting. Less Common: Asystole, atrioventricular block, bradycardia (with rapid IV administration), premature ventricular beats, tachycardia, vasculitis. Drug Interactions: Monitor closely with: Decreases absorption of the following drugs: Cephalosporins, Iron salts [except ferric carboxymaltose, ferric citrate, ferric gluconate, ferric pyrophosphate citrate, iron dextran complex, iron sucrose] Enhances therapeutic effect of: Procainamide Reduces therapeutic effect of: Warfarin (decreased prothrombin time) Avoid concomitant use with: Decreases absorption of the following drugs: Cyanocobalamin / Vitamin B12 Decreases serum concentration of Azoles, e.g., Ketoconazole Decreases therapeutic effect of Ranitidine: Cigarette smoking Decreases therapeutic effect of Diazepam Administration: For IM administration, no dilution is required. For IV administration, solution must be diluted. May be administered by intermittent bolus, intermittent IV infusion, or continuous IV infusion. Pregnancy Category: B ATC Code: A02BA02 PROTON PUMP INHIBITORS Rx LANSOPRAZOLE Oral: 15 mg and 30 mg capsule 15 mg and 30 mg MR tablet A substituted benzimidazole, which acts as a proton pump inhibitor (PPI), by blocking the final step of acid production. It acts by inhibiting the H+/K+–ATPase system at the parietal cells of the stomach, suppressing both basal and stimulated gastric acid secretion. Indications: Management of acid-related dyspepsia, erosive esophagitis, Gastroesophageal Reflux Disease (GERD), peptic ulcer, Helicobacter pylori infection, NSAID- associated ulcer, Zollinger-Ellison syndrome. Contraindication: Known severe hypersensitivity to lansoprazole or any ingredient in the formulation Dose: Acid-related dyspepsia, by mouth, ADULT, 15–30 mg once daily in the morning for 2–4 weeks. GERD, acute therapy, by mouth, ADULT, 15–30 mg once daily in the morning for 4–8 weeks. GERD, maintenance therapy, by mouth, ADULT, maintenance therapy, 15–30 mg once daily (adjust dosing according to response); CHILD 12–17 years, 15 mg once daily for up to 8 weeks; CHILD 1–11 years (≤30 kg), 15 mg once daily in the morning for up to 12 weeks; CHILD >30 kg, 30 mg once daily in the morning for up to 12 weeks (may increase doses up to 30 mg twice daily if patient is still symptomatic after 2 or more weeks of treatment). Erosive esophagitis, acute therapy, by mouth, ADULT, 30 mg once in the morning for up to 8 weeks; by IV injection, ADULT, 30 mg over 30 minutes for up to 7 days; CHILD 12–17 years, 30 mg once daily for up to 8 weeks; CHILD 1–11 years (≤30 kg), 15 mg once daily in the morning for up to 12 weeks; CHILD >30 kg, 30 mg once daily in the morning for up to 12 weeks (may increase doses up to 30 mg twice daily if patient is still symptomatic after 2 or more weeks of treatment). Erosive esophagitis, maintenance therapy, by mouth, ADULT, 15 mg once daily. Peptic ulcer, acute therapy, by mouth, ADULT, 15 mg once daily. Peptic ulcer, maintenance therapy, by mouth, ADULT, 30 mg once daily in the morning for up to 4 weeks (for duodenal ulcer) or up to 8 weeks (for gastric ulcer).
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf
Philippine National Formulay 8th Ed.pdf

Recommended

Medication Related Problems
Medication Related ProblemsMedication Related Problems
Medication Related Problemswef
 
Philippine National Formulary
Philippine National FormularyPhilippine National Formulary
Philippine National FormularyAdrianne Gabucan
 
Pndf vol1ed7 2008
Pndf vol1ed7 2008Pndf vol1ed7 2008
Pndf vol1ed7 2008Wingielyn Baldoza
 
AO 56 revised presentation
AO 56 revised presentationAO 56 revised presentation
AO 56 revised presentationFoodanddrug Regionone
 
Hospital and community pharmacy
Hospital and community pharmacyHospital and community pharmacy
Hospital and community pharmacyDileepKumar866
 
Define clinical pharmacy
Define clinical pharmacyDefine clinical pharmacy
Define clinical pharmacyRafi Bhat
 
hospital formulary
hospital formularyhospital formulary
hospital formularyvarshitha Nakka
 
Intro pharma
Intro pharmaIntro pharma
Intro pharmanowienajoyce
 

Recommended

Medication Related Problems
Medication Related ProblemsMedication Related Problems
Medication Related Problemswef
 
Philippine National Formulary
Philippine National FormularyPhilippine National Formulary
Philippine National FormularyAdrianne Gabucan
 
Pndf vol1ed7 2008
Pndf vol1ed7 2008Pndf vol1ed7 2008
Pndf vol1ed7 2008Wingielyn Baldoza
 
AO 56 revised presentation
AO 56 revised presentationAO 56 revised presentation
AO 56 revised presentationFoodanddrug Regionone
 
Hospital and community pharmacy
Hospital and community pharmacyHospital and community pharmacy
Hospital and community pharmacyDileepKumar866
 
Define clinical pharmacy
Define clinical pharmacyDefine clinical pharmacy
Define clinical pharmacyRafi Bhat
 
hospital formulary
hospital formularyhospital formulary
hospital formularyvarshitha Nakka
 
Intro pharma
Intro pharmaIntro pharma
Intro pharmanowienajoyce
 
History of pharmacy
History of pharmacyHistory of pharmacy
History of pharmacyVirginia Commonwealth University School of Pharmacy
 
14ab1t0019 drug distribution
14ab1t0019 drug distribution14ab1t0019 drug distribution
14ab1t0019 drug distributionRamesh Ganpisetti
 
Good Dispensing Practice
Good Dispensing PracticeGood Dispensing Practice
Good Dispensing PracticeFoodanddrug Regionone
 
Introduction to hospital pharmacy
Introduction to hospital pharmacyIntroduction to hospital pharmacy
Introduction to hospital pharmacyAnas Bahnassi أنس البهنسي
 
14ab1t0030 hospital formulary
14ab1t0030 hospital formulary14ab1t0030 hospital formulary
14ab1t0030 hospital formularyRamesh Ganpisetti
 
Pharmacy layout ppt
Pharmacy layout pptPharmacy layout ppt
Pharmacy layout pptMaham Shafiq
 
Hospital pharmacy procedural manual
Hospital pharmacy procedural manualHospital pharmacy procedural manual
Hospital pharmacy procedural manualDevyani Joshi
 
Checklist of Requirements
Checklist of RequirementsChecklist of Requirements
Checklist of RequirementsFoodanddrug Regionone
 
Pharmacy practice
Pharmacy practicePharmacy practice
Pharmacy practiceAsraful Islam Rayhan
 
Drug Distribution Methods
Drug Distribution MethodsDrug Distribution Methods
Drug Distribution MethodsHealth Forager
 
Communication skill for the pharmacist
Communication skill for the pharmacistCommunication skill for the pharmacist
Communication skill for the pharmacistMerin Babu
 
Patient counselling
Patient counsellingPatient counselling
Patient counsellingRamesh Ganpisetti
 
Hospital pharmacy service
Hospital pharmacy serviceHospital pharmacy service
Hospital pharmacy serviceMuhammad Maroof Ahmad
 
54278982 ra6675-generics-act-of-1988
54278982 ra6675-generics-act-of-198854278982 ra6675-generics-act-of-1988
54278982 ra6675-generics-act-of-1988Wingielyn Baldoza
 
Good Dispensing Practice
Good Dispensing PracticeGood Dispensing Practice
Good Dispensing PracticeJavis Von Onias
 
Hospital pharmacy functions,organisation and responsibilities
Hospital pharmacy functions,organisation and responsibilitiesHospital pharmacy functions,organisation and responsibilities
Hospital pharmacy functions,organisation and responsibilitiesajitha27
 
Community pharmacy
Community pharmacyCommunity pharmacy
Community pharmacyVikas Soni
 
Forensic pharmacy (pharmaceutical jurisprudence)
Forensic pharmacy (pharmaceutical jurisprudence)Forensic pharmacy (pharmaceutical jurisprudence)
Forensic pharmacy (pharmaceutical jurisprudence)Sanjiv Pandey
 
Pharmaceutical care
Pharmaceutical carePharmaceutical care
Pharmaceutical careAkram Ahmad
 
Chapter 16 hospital pharmacy
Chapter 16 hospital pharmacyChapter 16 hospital pharmacy
Chapter 16 hospital pharmacyAnn Bentley
 
znf.pdf
znf.pdfznf.pdf
znf.pdfDeLondre1
 
World Pharmacist Day 2020
World Pharmacist Day 2020World Pharmacist Day 2020
World Pharmacist Day 2020RAHUL PAL
 

More Related Content

What's hot

14ab1t0019 drug distribution
14ab1t0019 drug distribution14ab1t0019 drug distribution
14ab1t0019 drug distributionRamesh Ganpisetti
 
14ab1t0030 hospital formulary
14ab1t0030 hospital formulary14ab1t0030 hospital formulary
14ab1t0030 hospital formularyRamesh Ganpisetti
 
Pharmacy layout ppt
Pharmacy layout pptPharmacy layout ppt
Pharmacy layout pptMaham Shafiq
 
Hospital pharmacy procedural manual
Hospital pharmacy procedural manualHospital pharmacy procedural manual
Hospital pharmacy procedural manualDevyani Joshi
 
Drug Distribution Methods
Drug Distribution MethodsDrug Distribution Methods
Drug Distribution MethodsHealth Forager
 
Communication skill for the pharmacist
Communication skill for the pharmacistCommunication skill for the pharmacist
Communication skill for the pharmacistMerin Babu
 
54278982 ra6675-generics-act-of-1988
54278982 ra6675-generics-act-of-198854278982 ra6675-generics-act-of-1988
54278982 ra6675-generics-act-of-1988Wingielyn Baldoza
 
Good Dispensing Practice
Good Dispensing PracticeGood Dispensing Practice
Good Dispensing PracticeJavis Von Onias
 
Hospital pharmacy functions,organisation and responsibilities
Hospital pharmacy functions,organisation and responsibilitiesHospital pharmacy functions,organisation and responsibilities
Hospital pharmacy functions,organisation and responsibilitiesajitha27
 
Community pharmacy
Community pharmacyCommunity pharmacy
Community pharmacyVikas Soni
 
Forensic pharmacy (pharmaceutical jurisprudence)
Forensic pharmacy (pharmaceutical jurisprudence)Forensic pharmacy (pharmaceutical jurisprudence)
Forensic pharmacy (pharmaceutical jurisprudence)Sanjiv Pandey
 
Pharmaceutical care
Pharmaceutical carePharmaceutical care
Pharmaceutical careAkram Ahmad
 
Chapter 16 hospital pharmacy
Chapter 16 hospital pharmacyChapter 16 hospital pharmacy
Chapter 16 hospital pharmacyAnn Bentley
 

What's hot (20)

History of pharmacy
History of pharmacyHistory of pharmacy
History of pharmacy
 
14ab1t0019 drug distribution
14ab1t0019 drug distribution14ab1t0019 drug distribution
14ab1t0019 drug distribution
 
Good Dispensing Practice
Good Dispensing PracticeGood Dispensing Practice
Good Dispensing Practice
 
Introduction to hospital pharmacy
Introduction to hospital pharmacyIntroduction to hospital pharmacy
Introduction to hospital pharmacy
 
14ab1t0030 hospital formulary
14ab1t0030 hospital formulary14ab1t0030 hospital formulary
14ab1t0030 hospital formulary
 
Pharmacy layout ppt
Pharmacy layout pptPharmacy layout ppt
Pharmacy layout ppt
 
Hospital pharmacy procedural manual
Hospital pharmacy procedural manualHospital pharmacy procedural manual
Hospital pharmacy procedural manual
 
Checklist of Requirements
Checklist of RequirementsChecklist of Requirements
Checklist of Requirements
 
Pharmacy practice
Pharmacy practicePharmacy practice
Pharmacy practice
 
Drug Distribution Methods
Drug Distribution MethodsDrug Distribution Methods
Drug Distribution Methods
 
Communication skill for the pharmacist
Communication skill for the pharmacistCommunication skill for the pharmacist
Communication skill for the pharmacist
 
Patient counselling
Patient counsellingPatient counselling
Patient counselling
 
Hospital pharmacy service
Hospital pharmacy serviceHospital pharmacy service
Hospital pharmacy service
 
54278982 ra6675-generics-act-of-1988
54278982 ra6675-generics-act-of-198854278982 ra6675-generics-act-of-1988
54278982 ra6675-generics-act-of-1988
 
Good Dispensing Practice
Good Dispensing PracticeGood Dispensing Practice
Good Dispensing Practice
 
Hospital pharmacy functions,organisation and responsibilities
Hospital pharmacy functions,organisation and responsibilitiesHospital pharmacy functions,organisation and responsibilities
Hospital pharmacy functions,organisation and responsibilities
 
Community pharmacy
Community pharmacyCommunity pharmacy
Community pharmacy
 
Forensic pharmacy (pharmaceutical jurisprudence)
Forensic pharmacy (pharmaceutical jurisprudence)Forensic pharmacy (pharmaceutical jurisprudence)
Forensic pharmacy (pharmaceutical jurisprudence)
 
Pharmaceutical care
Pharmaceutical carePharmaceutical care
Pharmaceutical care
 
Chapter 16 hospital pharmacy
Chapter 16 hospital pharmacyChapter 16 hospital pharmacy
Chapter 16 hospital pharmacy
 

Similar to Philippine National Formulay 8th Ed.pdf

World Pharmacist Day 2020
World Pharmacist Day 2020World Pharmacist Day 2020
World Pharmacist Day 2020RAHUL PAL
 
Hospital HEALTHCARE WASTE Management MANUAL.pdf
Hospital HEALTHCARE WASTE Management MANUAL.pdfHospital HEALTHCARE WASTE Management MANUAL.pdf
Hospital HEALTHCARE WASTE Management MANUAL.pdfMimiGT
 
6.pndfs april 14 2010- Dr. Marife Yap
6.pndfs april 14 2010- Dr. Marife Yap6.pndfs april 14 2010- Dr. Marife Yap
6.pndfs april 14 2010- Dr. Marife Yappsecp
 
Polypharmacy resource_JAN 15_NINA BARNETT
Polypharmacy resource_JAN 15_NINA BARNETTPolypharmacy resource_JAN 15_NINA BARNETT
Polypharmacy resource_JAN 15_NINA BARNETTZeshan Ahmed
 
Revitalizing the role of pharmacists
Revitalizing the role of pharmacistsRevitalizing the role of pharmacists
Revitalizing the role of pharmacistsMeghana Nadendla
 
Problems and challenges faced in consumer reporting of adverse drug reactions...
Problems and challenges faced in consumer reporting of adverse drug reactions...Problems and challenges faced in consumer reporting of adverse drug reactions...
Problems and challenges faced in consumer reporting of adverse drug reactions...Mohammed Alshakka
 
Logan Hospital - Chastina Hack
Logan Hospital - Chastina HackLogan Hospital - Chastina Hack
Logan Hospital - Chastina HackEthanFrench1
 
Connecting with colleagues | Chastina Heck
Connecting with colleagues | Chastina HeckConnecting with colleagues | Chastina Heck
Connecting with colleagues | Chastina HeckNACCHOpresentations
 
Assessment of dispensing practice in Khartoum state teaching hospitals.pdf
Assessment of dispensing practice in Khartoum state teaching hospitals.pdfAssessment of dispensing practice in Khartoum state teaching hospitals.pdf
Assessment of dispensing practice in Khartoum state teaching hospitals.pdfJennifer Strong
 
Clinical pharmacist Managed Oncology Clinic In University Hospital
Clinical pharmacist Managed Oncology Clinic In University HospitalClinical pharmacist Managed Oncology Clinic In University Hospital
Clinical pharmacist Managed Oncology Clinic In University Hospitalfathy alazhary
 
The truth between the lines – Community pharmacists in improving the health o...
The truth between the lines – Community pharmacists in improving the health o...The truth between the lines – Community pharmacists in improving the health o...
The truth between the lines – Community pharmacists in improving the health o...inemet
 

Similar to Philippine National Formulay 8th Ed.pdf (20)

znf.pdf
znf.pdfznf.pdf
znf.pdf
 
World Pharmacist Day 2020
World Pharmacist Day 2020World Pharmacist Day 2020
World Pharmacist Day 2020
 
Hospital HEALTHCARE WASTE Management MANUAL.pdf
Hospital HEALTHCARE WASTE Management MANUAL.pdfHospital HEALTHCARE WASTE Management MANUAL.pdf
Hospital HEALTHCARE WASTE Management MANUAL.pdf
 
6.pndfs april 14 2010- Dr. Marife Yap
6.pndfs april 14 2010- Dr. Marife Yap6.pndfs april 14 2010- Dr. Marife Yap
6.pndfs april 14 2010- Dr. Marife Yap
 
Data Speaks; What We Missed
Data Speaks; What We MissedData Speaks; What We Missed
Data Speaks; What We Missed
 
research 1
research 1research 1
research 1
 
Polypharmacy resource_JAN 15_NINA BARNETT
Polypharmacy resource_JAN 15_NINA BARNETTPolypharmacy resource_JAN 15_NINA BARNETT
Polypharmacy resource_JAN 15_NINA BARNETT
 
Revitalizing the role of pharmacists
Revitalizing the role of pharmacistsRevitalizing the role of pharmacists
Revitalizing the role of pharmacists
 
ROLE OF PHARMACIST IN HEALTH CARE SYSTEM.
ROLE OF PHARMACIST IN HEALTH CARE SYSTEM.ROLE OF PHARMACIST IN HEALTH CARE SYSTEM.
ROLE OF PHARMACIST IN HEALTH CARE SYSTEM.
 
Problems and challenges faced in consumer reporting of adverse drug reactions...
Problems and challenges faced in consumer reporting of adverse drug reactions...Problems and challenges faced in consumer reporting of adverse drug reactions...
Problems and challenges faced in consumer reporting of adverse drug reactions...
 
Logan Hospital - Chastina Hack
Logan Hospital - Chastina HackLogan Hospital - Chastina Hack
Logan Hospital - Chastina Hack
 
Connecting with colleagues | Chastina Heck
Connecting with colleagues | Chastina HeckConnecting with colleagues | Chastina Heck
Connecting with colleagues | Chastina Heck
 
Regulatory agencies
Regulatory agenciesRegulatory agencies
Regulatory agencies
 
Clinical 1
Clinical 1Clinical 1
Clinical 1
 
Nutraceuticals
NutraceuticalsNutraceuticals
Nutraceuticals
 
Assessment of dispensing practice in Khartoum state teaching hospitals.pdf
Assessment of dispensing practice in Khartoum state teaching hospitals.pdfAssessment of dispensing practice in Khartoum state teaching hospitals.pdf
Assessment of dispensing practice in Khartoum state teaching hospitals.pdf
 
Clinical pharmacist Managed Oncology Clinic In University Hospital
Clinical pharmacist Managed Oncology Clinic In University HospitalClinical pharmacist Managed Oncology Clinic In University Hospital
Clinical pharmacist Managed Oncology Clinic In University Hospital
 
Consumer health: time for a regulatory re-think?
Consumer health: time for a regulatory re-think?Consumer health: time for a regulatory re-think?
Consumer health: time for a regulatory re-think?
 
Drug information services by BNP.pdf
Drug information services by BNP.pdfDrug information services by BNP.pdf
Drug information services by BNP.pdf
 
The truth between the lines – Community pharmacists in improving the health o...
The truth between the lines – Community pharmacists in improving the health o...The truth between the lines – Community pharmacists in improving the health o...
The truth between the lines – Community pharmacists in improving the health o...
 

Recently uploaded

Artifacts in Nuclear Medicine with Identifying and resolving artifacts.
Artifacts in Nuclear Medicine with Identifying and resolving artifacts.Artifacts in Nuclear Medicine with Identifying and resolving artifacts.
Artifacts in Nuclear Medicine with Identifying and resolving artifacts.MiadAlsulami
 
VIP Call Girls Pune Vani 9907093804 Short 1500 Night 6000 Best call girls Ser...
VIP Call Girls Pune Vani 9907093804 Short 1500 Night 6000 Best call girls Ser...VIP Call Girls Pune Vani 9907093804 Short 1500 Night 6000 Best call girls Ser...
VIP Call Girls Pune Vani 9907093804 Short 1500 Night 6000 Best call girls Ser...Miss joya
 
VIP Call Girls Pune Vrinda 9907093804 Short 1500 Night 6000 Best call girls S...
VIP Call Girls Pune Vrinda 9907093804 Short 1500 Night 6000 Best call girls S...VIP Call Girls Pune Vrinda 9907093804 Short 1500 Night 6000 Best call girls S...
VIP Call Girls Pune Vrinda 9907093804 Short 1500 Night 6000 Best call girls S...Miss joya
 
Call Girls Doddaballapur Road Just Call 7001305949 Top Class Call Girl Servic...
Call Girls Doddaballapur Road Just Call 7001305949 Top Class Call Girl Servic...Call Girls Doddaballapur Road Just Call 7001305949 Top Class Call Girl Servic...
Call Girls Doddaballapur Road Just Call 7001305949 Top Class Call Girl Servic...narwatsonia7
 
Russian Call Girls in Chennai Pallavi 9907093804 Independent Call Girls Servi...
Russian Call Girls in Chennai Pallavi 9907093804 Independent Call Girls Servi...Russian Call Girls in Chennai Pallavi 9907093804 Independent Call Girls Servi...
Russian Call Girls in Chennai Pallavi 9907093804 Independent Call Girls Servi...Nehru place Escorts
 
Russian Call Girls Chennai Madhuri 9907093804 Independent Call Girls Service ...
Russian Call Girls Chennai Madhuri 9907093804 Independent Call Girls Service ...Russian Call Girls Chennai Madhuri 9907093804 Independent Call Girls Service ...
Russian Call Girls Chennai Madhuri 9907093804 Independent Call Girls Service ...Nehru place Escorts
 
Call Girls Horamavu WhatsApp Number 7001035870 Meeting With Bangalore Escorts
Call Girls Horamavu WhatsApp Number 7001035870 Meeting With Bangalore EscortsCall Girls Horamavu WhatsApp Number 7001035870 Meeting With Bangalore Escorts
Call Girls Horamavu WhatsApp Number 7001035870 Meeting With Bangalore Escortsvidya singh
 
Call Girls Colaba Mumbai ❤️ 9920874524 👈 Cash on Delivery
Call Girls Colaba Mumbai ❤️ 9920874524 👈 Cash on DeliveryCall Girls Colaba Mumbai ❤️ 9920874524 👈 Cash on Delivery
Call Girls Colaba Mumbai ❤️ 9920874524 👈 Cash on Deliverynehamumbai
 
Call Girls Service Chennai Jiya 7001305949 Independent Escort Service Chennai
Call Girls Service Chennai Jiya 7001305949 Independent Escort Service ChennaiCall Girls Service Chennai Jiya 7001305949 Independent Escort Service Chennai
Call Girls Service Chennai Jiya 7001305949 Independent Escort Service ChennaiNehru place Escorts
 
Low Rate Call Girls Ambattur Anika 8250192130 Independent Escort Service Amba...
Low Rate Call Girls Ambattur Anika 8250192130 Independent Escort Service Amba...Low Rate Call Girls Ambattur Anika 8250192130 Independent Escort Service Amba...
Low Rate Call Girls Ambattur Anika 8250192130 Independent Escort Service Amba...narwatsonia7
 
VIP Call Girls Tirunelveli Aaradhya 8250192130 Independent Escort Service Tir...
VIP Call Girls Tirunelveli Aaradhya 8250192130 Independent Escort Service Tir...VIP Call Girls Tirunelveli Aaradhya 8250192130 Independent Escort Service Tir...
VIP Call Girls Tirunelveli Aaradhya 8250192130 Independent Escort Service Tir...narwatsonia7
 
High Profile Call Girls Jaipur Vani 8445551418 Independent Escort Service Jaipur
High Profile Call Girls Jaipur Vani 8445551418 Independent Escort Service JaipurHigh Profile Call Girls Jaipur Vani 8445551418 Independent Escort Service Jaipur
High Profile Call Girls Jaipur Vani 8445551418 Independent Escort Service Jaipurparulsinha
 
Sonagachi Call Girls Services 9907093804 @24x7 High Class Babes Here Call Now
Sonagachi Call Girls Services 9907093804 @24x7 High Class Babes Here Call NowSonagachi Call Girls Services 9907093804 @24x7 High Class Babes Here Call Now
Sonagachi Call Girls Services 9907093804 @24x7 High Class Babes Here Call NowRiya Pathan
 
Call Girls Service Pune Vaishnavi 9907093804 Short 1500 Night 6000 Best call ...
Call Girls Service Pune Vaishnavi 9907093804 Short 1500 Night 6000 Best call ...Call Girls Service Pune Vaishnavi 9907093804 Short 1500 Night 6000 Best call ...
Call Girls Service Pune Vaishnavi 9907093804 Short 1500 Night 6000 Best call ...Miss joya
 
Call Girls Whitefield Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Whitefield Just Call 7001305949 Top Class Call Girl Service AvailableCall Girls Whitefield Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Whitefield Just Call 7001305949 Top Class Call Girl Service Availablenarwatsonia7
 
VIP Mumbai Call Girls Hiranandani Gardens Just Call 9920874524 with A/C Room ...
VIP Mumbai Call Girls Hiranandani Gardens Just Call 9920874524 with A/C Room ...VIP Mumbai Call Girls Hiranandani Gardens Just Call 9920874524 with A/C Room ...
VIP Mumbai Call Girls Hiranandani Gardens Just Call 9920874524 with A/C Room ...Garima Khatri
 
Aspirin presentation slides by Dr. Rewas Ali
Aspirin presentation slides by Dr. Rewas AliAspirin presentation slides by Dr. Rewas Ali
Aspirin presentation slides by Dr. Rewas AliRewAs ALI
 
Call Girl Coimbatore Prisha☎️ 8250192130 Independent Escort Service Coimbatore
Call Girl Coimbatore Prisha☎️ 8250192130 Independent Escort Service CoimbatoreCall Girl Coimbatore Prisha☎️ 8250192130 Independent Escort Service Coimbatore
Call Girl Coimbatore Prisha☎️ 8250192130 Independent Escort Service Coimbatorenarwatsonia7
 
Kesar Bagh Call Girl Price 9548273370 , Lucknow Call Girls Service
Kesar Bagh Call Girl Price 9548273370 , Lucknow Call Girls ServiceKesar Bagh Call Girl Price 9548273370 , Lucknow Call Girls Service
Kesar Bagh Call Girl Price 9548273370 , Lucknow Call Girls Servicemakika9823
 

Recently uploaded (20)

Artifacts in Nuclear Medicine with Identifying and resolving artifacts.
Artifacts in Nuclear Medicine with Identifying and resolving artifacts.Artifacts in Nuclear Medicine with Identifying and resolving artifacts.
Artifacts in Nuclear Medicine with Identifying and resolving artifacts.
 
VIP Call Girls Pune Vani 9907093804 Short 1500 Night 6000 Best call girls Ser...
VIP Call Girls Pune Vani 9907093804 Short 1500 Night 6000 Best call girls Ser...VIP Call Girls Pune Vani 9907093804 Short 1500 Night 6000 Best call girls Ser...
VIP Call Girls Pune Vani 9907093804 Short 1500 Night 6000 Best call girls Ser...
 
VIP Call Girls Pune Vrinda 9907093804 Short 1500 Night 6000 Best call girls S...
VIP Call Girls Pune Vrinda 9907093804 Short 1500 Night 6000 Best call girls S...VIP Call Girls Pune Vrinda 9907093804 Short 1500 Night 6000 Best call girls S...
VIP Call Girls Pune Vrinda 9907093804 Short 1500 Night 6000 Best call girls S...
 
Call Girls Doddaballapur Road Just Call 7001305949 Top Class Call Girl Servic...
Call Girls Doddaballapur Road Just Call 7001305949 Top Class Call Girl Servic...Call Girls Doddaballapur Road Just Call 7001305949 Top Class Call Girl Servic...
Call Girls Doddaballapur Road Just Call 7001305949 Top Class Call Girl Servic...
 
Russian Call Girls in Chennai Pallavi 9907093804 Independent Call Girls Servi...
Russian Call Girls in Chennai Pallavi 9907093804 Independent Call Girls Servi...Russian Call Girls in Chennai Pallavi 9907093804 Independent Call Girls Servi...
Russian Call Girls in Chennai Pallavi 9907093804 Independent Call Girls Servi...
 
Russian Call Girls Chennai Madhuri 9907093804 Independent Call Girls Service ...
Russian Call Girls Chennai Madhuri 9907093804 Independent Call Girls Service ...Russian Call Girls Chennai Madhuri 9907093804 Independent Call Girls Service ...
Russian Call Girls Chennai Madhuri 9907093804 Independent Call Girls Service ...
 
Call Girls Horamavu WhatsApp Number 7001035870 Meeting With Bangalore Escorts
Call Girls Horamavu WhatsApp Number 7001035870 Meeting With Bangalore EscortsCall Girls Horamavu WhatsApp Number 7001035870 Meeting With Bangalore Escorts
Call Girls Horamavu WhatsApp Number 7001035870 Meeting With Bangalore Escorts
 
Call Girls Colaba Mumbai ❤️ 9920874524 👈 Cash on Delivery
Call Girls Colaba Mumbai ❤️ 9920874524 👈 Cash on DeliveryCall Girls Colaba Mumbai ❤️ 9920874524 👈 Cash on Delivery
Call Girls Colaba Mumbai ❤️ 9920874524 👈 Cash on Delivery
 
Call Girls Service Chennai Jiya 7001305949 Independent Escort Service Chennai
Call Girls Service Chennai Jiya 7001305949 Independent Escort Service ChennaiCall Girls Service Chennai Jiya 7001305949 Independent Escort Service Chennai
Call Girls Service Chennai Jiya 7001305949 Independent Escort Service Chennai
 
Low Rate Call Girls Ambattur Anika 8250192130 Independent Escort Service Amba...
Low Rate Call Girls Ambattur Anika 8250192130 Independent Escort Service Amba...Low Rate Call Girls Ambattur Anika 8250192130 Independent Escort Service Amba...
Low Rate Call Girls Ambattur Anika 8250192130 Independent Escort Service Amba...
 
VIP Call Girls Tirunelveli Aaradhya 8250192130 Independent Escort Service Tir...
VIP Call Girls Tirunelveli Aaradhya 8250192130 Independent Escort Service Tir...VIP Call Girls Tirunelveli Aaradhya 8250192130 Independent Escort Service Tir...
VIP Call Girls Tirunelveli Aaradhya 8250192130 Independent Escort Service Tir...
 
High Profile Call Girls Jaipur Vani 8445551418 Independent Escort Service Jaipur
High Profile Call Girls Jaipur Vani 8445551418 Independent Escort Service JaipurHigh Profile Call Girls Jaipur Vani 8445551418 Independent Escort Service Jaipur
High Profile Call Girls Jaipur Vani 8445551418 Independent Escort Service Jaipur
 
Sonagachi Call Girls Services 9907093804 @24x7 High Class Babes Here Call Now
Sonagachi Call Girls Services 9907093804 @24x7 High Class Babes Here Call NowSonagachi Call Girls Services 9907093804 @24x7 High Class Babes Here Call Now
Sonagachi Call Girls Services 9907093804 @24x7 High Class Babes Here Call Now
 
Call Girls Service Pune Vaishnavi 9907093804 Short 1500 Night 6000 Best call ...
Call Girls Service Pune Vaishnavi 9907093804 Short 1500 Night 6000 Best call ...Call Girls Service Pune Vaishnavi 9907093804 Short 1500 Night 6000 Best call ...
Call Girls Service Pune Vaishnavi 9907093804 Short 1500 Night 6000 Best call ...
 
sauth delhi call girls in Bhajanpura 🔝 9953056974 🔝 escort Service
sauth delhi call girls in Bhajanpura 🔝 9953056974 🔝 escort Servicesauth delhi call girls in Bhajanpura 🔝 9953056974 🔝 escort Service
sauth delhi call girls in Bhajanpura 🔝 9953056974 🔝 escort Service
 
Call Girls Whitefield Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Whitefield Just Call 7001305949 Top Class Call Girl Service AvailableCall Girls Whitefield Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Whitefield Just Call 7001305949 Top Class Call Girl Service Available
 
VIP Mumbai Call Girls Hiranandani Gardens Just Call 9920874524 with A/C Room ...
VIP Mumbai Call Girls Hiranandani Gardens Just Call 9920874524 with A/C Room ...VIP Mumbai Call Girls Hiranandani Gardens Just Call 9920874524 with A/C Room ...
VIP Mumbai Call Girls Hiranandani Gardens Just Call 9920874524 with A/C Room ...
 
Aspirin presentation slides by Dr. Rewas Ali
Aspirin presentation slides by Dr. Rewas AliAspirin presentation slides by Dr. Rewas Ali
Aspirin presentation slides by Dr. Rewas Ali
 
Call Girl Coimbatore Prisha☎️ 8250192130 Independent Escort Service Coimbatore
Call Girl Coimbatore Prisha☎️ 8250192130 Independent Escort Service CoimbatoreCall Girl Coimbatore Prisha☎️ 8250192130 Independent Escort Service Coimbatore
Call Girl Coimbatore Prisha☎️ 8250192130 Independent Escort Service Coimbatore
 
Kesar Bagh Call Girl Price 9548273370 , Lucknow Call Girls Service
Kesar Bagh Call Girl Price 9548273370 , Lucknow Call Girls ServiceKesar Bagh Call Girl Price 9548273370 , Lucknow Call Girls Service
Kesar Bagh Call Girl Price 9548273370 , Lucknow Call Girls Service
 

Philippine National Formulay 8th Ed.pdf

  • 1. 1
  • 2.
  • 3. Philippine National Formulary 8th Edition Published by Department of Health Manila, Philippines 2019
  • 4.
  • 5. DISCLAIMER The list of medicines and the prescribing information contained in this edition of the Formulary were collated as meticulously as possible through the collaborative efforts of the Formulary Executive Council (FEC), pharmacists, medical specialists, and specialty societies applying the standard clinical practice current at the time of the undertaking. Thus, the medicines and the accompanying prescribing information in this edition are the most recent only insofar as the dates of the actual collaboration are concerned. There is no guarantee, therefore, that after the final drafting for this edition, the new medicines or new information that may subsequently become available will be included. While diligent effort has been made to ensure the accuracy of each entry, it is essential to bear in mind that the information presented here is a synopsis of key points in the official product labeling, and that the complete labeling contains additional precautionary information that may be of significance in specific cases. Thus, the editors do not warrant that the information contained herein is in every aspect accurate. Since a manual of this volume cannot be as exhaustive, the editors have included only the information which they consider to be essential, and the most relevant and useful for rapid reference by the physicians. It is the hope of the editors that this Formulary is perceived as a readily accessible, easily understandable, up-to-date source of independent medicine information. Nevertheless, this Formulary should be supplemented, where necessary, by more recent and comprehensive materials and publications. Moreover, the recommendations incorporated into this Formulary are intended to serve only as guides that will supplement and not replace the best clinical judgment of the prescribing clinicians. Readers are enjoined to confirm the information contained herein with other sources, particularly with regard to new or the latest updates. ISBN 978-621-95540-3-9 All rights reserved 2019 The Formulary Executive Council Pharmaceutical Division, Health Regulation Team Published by: Department of Health San Lazaro Compound, Rizal Ave., Sta. Cruz, Manila, Philippines, 1003 Any part or the whole book may be reproduced or transmitted without any alteration, in any form or by any means, with permission from DOH provided it is not sold commercially.
  • 6.
  • 7. THE PHILIPPINE NATIONAL FORMULARY 8th Edition 2019 DEPARTMENT OF HEALTH FRANCISCO T. DUQUE III, MD, MSc Secretary of Health ROLANDO ENRIQUE D. DOMINGO, MD, DPBO Undersecretary of Health Health Regulation Team ANNA MELISSA S. GUERRERO, MD, MPH (HTA) Chief Pharmaceutical Division FORMULARY EXECUTIVE COUNCIL Froilan A. Bagabaldo, RPh, Ll.B. Cleotilde H. How, MD, FPSECP, FPPS Cecilia A. Jimeno, MD, FPCP, FPSEDM Cecilia C. Maramba-Lazarte, MD, MScID, MScCT, FPPS, FPIDSP, FPSECP Paul Matthew Pasco, MD, FPNA Imelda G. Peña, RPh, MS, DrPH John Q. Wong, MD, MSc
  • 8. THE PHILIPPINE NATIONAL FORMULARY 8th Edition 2019 EDITORIAL TEAM Yolanda R. Robles, RPh, MPharm, PhD Shiela Mae J. Nacabu-an, RPh, MHPEd Christine Aileen C. Benosa, RPh, MPH Ian Theodore G. Cabaluna, RPh, MD GDip (Epi) Editors Jeanne Genevive A. Pillejera, RPh Associate Editor Joshua Elijah M. Chavez, RPh Ena Elizabeth L. Naoe, RPh Kristel Keith N. Nieva, RPh Frances Lois U. Ngo Jarvin Enosh T. Tan, RPh Rose Charisse L. Traballo, RPh Ryan Joseph C. Tuzon Mikaella B. Santos Martha O. de la Paz Arizaldo E. Castro, MSc Leo Miguel S. Vergeire Technical Writers Irene V. Florentino-Fariñas, RPh, MD, MNSA Joyce Anne D. Ceria-Pereña, RPh, MPM Johanna B. Mallari, RPh Kate D. Dunlao, RPh April Rose B. Macandog, RPh Members of the Editorial Team John Michael L. Roque Technical Assistant
  • 9. C O N T R I B U T O R S DOH Disease Prevention and Control Bureau DOH Family Health Office National Antiobiotic Guidelines Committee National Center for Mental Health Rodney Ribleza Boncajes, MD National Kidney and Transplant Institute Jean Anne B. Toral, MD, MSc Lynn B. Bonifacio, MD Chrystal Catli Burog, MD Teresita Dumagay, MD Roxan Perez, MD National Poison Management and Control Center Pediatric Infectious Disease Society of the Philippines Philippine Academy of Ophthalmology Philippine Academy of Pediatric Pulmonologists Philippine Children’s Medical Center Marilou A. Abrera, MD Cecilia Cruz, MD Philippine College of Chest Physicians Philippine College of Geriatric Medicine Philippine College of Radiology Philippine Dermatological Society Philippine Heart Association Philippine Heart Center Maria Teresa B. Abola, MD Eden A. Gabriel, MD
  • 10. Philippine Neurological Association Philippine Obstetrical and Gynecological Society Philippine Orthopaedic Association Philippine Psychiatric Association Philippine Rheumatology Association Philippine Society of Allergy, Asthma and Immunology, Inc. Philippine Society of Anesthesiologists, Inc. Angel M. Gomez, MD Philippine Society of Endocrinology, Diabetes and Metabolism Philippine Society of Gastroenterology Philippine Society of Hematology and Blood Transfusion Philippine Society of Medical Oncology Mary Claire V. Soliman, MD, FPCP, FPSMO Marcelo Severino B. Imasa, MD, FPCP Philippine Society for Microbiology and Infectious Diseases Philippine Society of Nephrology Philippine Society of Newborn Medicine Philippine Society of Otolaryngology, Head and Neck Surgery Philippine Society of Parenteral and Enteral Nutrition Philippine Society of Pediatric Metabolism and Endocrinology Philippine Society of Pediatric Oncology Philippine Urological Association Stroke Society of the Philippines
  • 11. Department of Health - Office of the Secretary Message The revitalization of the Fourmula One Plus for Health as the framework of the healthcare reform agenda of the national government is anchored on the values of equitable and inclusive health system, transparent and accountable provision of quality health services, and efficient use of resources. The 8th edition of the Philippine National Formulary (PNF) is a tool to exercise these values while contributing to the achievement of the objectives of financial protection and better health outcomes. Its previous editions have been the basis of tailored procurement of medicines in public health facilities while providing efficient use of limited resources. It is also the basis of the Philippine Health Insurance Corporation (PhilHealth) in reimbursing claims to end-users for medicines use. With its new format and content, the PNF 8th edition can now maximize the PNF’s contribution to the rational use of medicines. Its abridged content is intended to provide concise evidence-based drug information which is vital in medical practice. The latest PNF is a useful tool to ensure rational prescribing, dispensing, and administration of medicines. I would like to encourage our health professionals to fully utilize it in their medicines procurement as well as in their day-to-day clinical decision- making. Let us continue to work for our shared vision of all for health towards health for all! Mabuhay! FRANCISCO T. DUQUE III, MD, MSc Secretary of Health
  • 12. Department of Health – Health Regulation Team Message Greetings! The Philippine National Formulary (PNF) plays a vital role in promoting the rational use of medicines in the country. As mandated by Republic Act 9502, otherwise known as the “Universally Accessible Cheaper and Quality Medicines Act of 2008,” and in accordance with Republic Act 9184, also known as “Government Procurement Reform Act,” the PNF serves as the basis of procurement of medicines in all government agencies, including government units. PNF requires continuous revisions and updating to ensure its relevance. It is part of the important role of the Department of Health (DOH) in regulating health products and services and providing technical assistance to health providers and stakeholders. While the FDA ensures that only quality medicines are available in the market, the PNF helps assure that only safe, effective, and affordable medicines are procured by public health facilities. The 8th edition of the PNF includes critical revisions that would facilitate the work of physicians, nurses, pharmacists, and other healthcare professionals. Thus, in behalf of the DOH, particularly the Health Regulation Team, I would like to commend the movers behind the PNF in promoting rational prescribing, dispensing, and use of medicines. Their valuable efforts in revising the National Formulary enable the country to ACHIEVE better health outcomes. Congratulations! ROLANDO ENRIQUE D. DOMINGO, MD, DPBO Undersecretary of Health Health Regulation Team
  • 13. ACKNOWLEDGMENTS This Formulary is adapted from the World Health Organization (WHO) Model Formulary (2008) with the publisher’s permission. We acknowledge, with sincere thanks, the work of the WHO in producing the Model Formulary so that countries and organizations can compile and produce their own national formularies. For their invaluable contribution to the current edition of the Philippine National Formulary (PNF), sincere gratitude is also due to the following: Members of the Formulary Executive Council (FEC) who thoroughly reviewed the list of essential medicines and the Formulary monographs: Atty. Froilan Bagabaldo, Dr. Cleotilde H. How, Dr. Cecilia A. Jimeno, Dr. Hilton Y. Lam, Dr, Cecilia C. Maramba- Lazarte, Dr, Paul Matthew Pasco, Dr. Imelda G. Peña, and Dr. John Q. Wong; Hospitals who participated in the pilot run of the formulary: Philippine Children’s Medical Center, Philippine Heart Center, Lung Center of the Philippines, National Kidney and Transplant Institute, Luis Hora Memorial Regional Hospital, Bicol Medical Center, and San Lazaro Hospital; and All the experts from the national health programs (NHA), specialty hospitals, and professional medical societies who participated in the review of the content of the Formulary and provided valuable and indispensable comments and corrections.
  • 14.
  • 15. TABLE OF CONTENTS GENERAL GUIDE ON THE USE OF THIS FORMULARY ......................................................................................... i MEDICINE MONOGRAPH KEY ............................................................................................................................ ii FDA PREGNANCY RISK CATEGORIES .................................................................................................................. iii SYMBOLS AND ABBREVIATIONS ........................................................................................................................ iv GENERAL GUIDE TO PRESCRIBING A. RATIONAL APPROACH TO THERAPEUTICS ............................................................................................. v B. VARIATION IN DOSE RESPONSE 1. PHYSIOLOGICAL AND PHARMACOKINETIC VARIABLES ................................................................. vii 2. MEDICINE DISTRIBUTION ................................................................................................................ ix 3. MEDICINE METABOLISM AND EXCRETION ................................................................................... ix 4. PHARMACODYNAMIC VARIABLES ................................................................................................... ix 5. DISEASE VARIABLES ........................................................................................................................ ix 6. ENVIRONMENTAL VARIABLES ......................................................................................................... x C. ADHERENCE TO (COMPLIANCE WITH) MEDICINE TREATMENT .............................................................. x 1. PATIENT-RELATED REASONS .......................................................................................................... x 2. DISEASE-RELATED REASONS ......................................................................................................... xi 3. DOCTOR-RELATED REASONS .......................................................................................................... xi 4. THE DOCTOR-PATIENT INTERACTION ............................................................................................. xi 5. PRESCRIPTION-RELATED REASONS .............................................................................................. xi 6. PHARMACIST-RELATED REASONS ................................................................................................. xi 7. RECOMMENDATIONS TO THE PRESCRIBERS ............................................................................... xi D. ADVERSE EFFECTS 1. ADVERSE DRUG REACTIONS (ADR) ................................................................................................ xii 2. MAJOR FACTORS PREDISPOSING TO ADVERSE EFFECTS ............................................................ xii E. PRESCRIPTION WRITING 1. PRESCRIPTION FORM ....................................................................................................................... xiii 2. INCORRECT PRESCRIPTIONS .......................................................................................................... xiv 3. NARCOTICS AND CONTROLLED SUBSTANCES .............................................................................. xiv F. PATIENT COUNSELING ............................................................................................................................... xv 1. WHAT TO COUNSEL ......................................................................................................................... xv 2. WHO AND WHEN TO COUNSEL ....................................................................................................... xv 3. COUNSELING: PROCESS STEPS ..................................................................................................... xvi ANTIMICROBIAL RESISTANCE ............................................................................................................................. xvii MEDICINE AND THERAPEUTIC INFORMATION A – ALIMENTARY TRACT AND METABOLISM 1 DRUGS FOR ACID RELATED DISORDERS ................................................................................................... 1 DRUGS FOR FUNCTIONAL GASTROINTESTINAL DISORDERS .................................................................. 8 ANTIEMETICS AND ANTINAUSEANTS ......................................................................................................... 11 BILE AND LIVER THERAPY .......................................................................................................................... 13 DRUGS FOR CONSTIPATION ....................................................................................................................... 14 ANTIDIARRHEALS, INTESTINAL ANTIINFLAMMATORY/ANTIINFECTIVE AGENTS .................................... 17 DRUGS USED IN DIABETES ........................................................................................................................ 22 VITAMINS ..................................................................................................................................................... 26 MINERAL SUPPLEMENTS ........................................................................................................................... 33 OTHER ALIMENTARY TRACT AND METABOLISM PRODUCTS ................................................................... 41 B – BLOOD AND BLOOD FORMING ORGANS 43 ANTITHROMBOTIC AGENTS ........................................................................................................................ 43 ANTIHEMORRHAGICS ................................................................................................................................. 57 ANTIANEMIC PREPARATIONS ..................................................................................................................... 61 BLOOD SUBSTITUTES AND PERFUSION SOLUTIONS ............................................................................... 66 C – CARDIOVASCULAR SYSTEM 94 CARDIAC THERAPY ...................................................................................................................................... 94 AGENTS ACTING ON ARTERIOLAR SMOOTH MUSCLE............................................................................... 112 AGENTS ACTING ON THE RENIN-ANGIOTENSIN SYSTEM......................................................................... 115 BETA-BLOCKING AGENTS............................................................................................................................ 124 CALCIUM CHANNEL BLOCKERS ................................................................................................................. 129 CENTRALLY ACTING ANTIADRENERGIC AGENTS....................................................................................... 139 DIURETICS.................................................................................................................................................... 140
  • 16. LIPID MODIFYING AGENTS ......................................................................................................................... 148 D – DERMATOLOGICALS 152 ANTIFUNGALS FOR DERMATOLOGICAL USE ............................................................................................. 152 EMOLLIENTS AND PROTECTIVES ............................................................................................................... 156 ANTIPRURITICS, INCLUDING ANTIHISTAMINES, ANESTHETICS, ETC. ...................................................... 156 ANTIPSORIATICS ......................................................................................................................................... 156 ANTIBIOTICS AND CHEMOTHERAPEUTICS FOR DERMATOLOGICAL USE ............................................... 158 CORTICOSTEROIDS, DERMATOLOGICAL PREPARATIONS ........................................................................ 160 ANTISEPTICS AND DISINFECTANTS ........................................................................................................... 162 ANTI-ACNE PREPARATIONS ........................................................................................................................ 165 G – GENITO URINARY SYSTEM AND SEX HORMONES 167 ANTIINFECTIVES AND ANTISEPTICS, EXCLUDING COMBINATIONS WITH CORTICOSTEROIDS ...... ……. 167 OTHER GYNECOLOGICALS ........................................................................................................................ 167 SEX HORMONES AND MODULATORS OF THE GENITAL SYSTEM ............................................................. 170 UROLOGICALS ............................................................................................................................................. 184 H – SYSTEMIC HORMONAL PREPARATIONS, EXCLUDING SEX HORMONES AND INSULINS 187 PITUTARY AND HYPOTHALAMIC HORMONES AND ANALOGUES .............................................................. 187 CORTICOSTEROIDS FOR SYSTEMIC USE ................................................................................................... 189 THYROID THERAPY ...................................................................................................................................... 197 J – ANTIINFECTIVES FOR SYSTEMIC USE 202 ANTIBACTERIALS FOR SYSTEMIC USE ....................................................................................................... 202 ANTIFUNGALS FOR SYSTEMIC USE ............................................................................................................ 250 ANTIMYCOBACTERIALS .............................................................................................................................. 255 ANTIVIRALS FOR SYSTEMIC USE ................................................................................................................ 266 IMMUNE SERA AND IMMUNOGLOBULINS ............................................................................................... 280 VACCINES .................................................................................................................................................... 287 L – ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS 312 ANTINEOPLASTIC AGENTS ........................................................................................................................ 312 ENDOCRINE THERAPY ................................................................................................................................ 366 IMMUNOSTIMULANTS ................................................................................................................................ 374 IMMUNOSUPPRESSANTS ........................................................................................................................... 381 M – MUSCULO-SKELETAL SYSTEM 397 ANTIINFLAMMATORY AND ANTIRHEUMATIC PRODUCTS ......................................................................... 397 MUSCLE RELAXANTS .................................................................................................................................. 406 ANTIGOUT PREPARATIONS ......................................................................................................................... 415 DRUGS FOR TREATMENT OF BONE DISEASE ............................................................................................ 417 OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM............................................... 420 N – NERVOUS SYSTEM 424 ANESTHETICS .............................................................................................................................................. 424 ANALGESICS ................................................................................................................................................ 438 ANTIEPILEPTICS .......................................................................................................................................... 465 ANTI-PARKINSON DRUGS ........................................................................................................................... 481 PSYCHOLEPTICS ......................................................................................................................................... 487 PSYCHOANALEPTICS .................................................................................................................................. 519 OTHER NERVOUS SYSTEM DRUGS ............................................................................................................ 529 P – ANTIPARASITIC PRODUCTS, INSECTICIDES, AND REPELLENTS 540 ANTIPROTOZOALS ....................................................................................................................................... 540 ANTHELMINTICS ......................................................................................................................................... 548 ECTOPARASITICIDES, INCLUDING SCABICIDES, INSECTICIDES, AND REPELLENTS .............................. 551 R – RESPIRATORY SYSTEM 553 NASAL PREPARATIONS ............................................................................................................................... 553 THROAT PREPARATIONS ............................................................................................................................ 554 DRUGS FOR OBSTRUCTIVE AIRWAY DISEASES ......................................................................................... 555 COUGH AND COLD PREPARATIONS ........................................................................................................... 571 ANTIHISTAMINES FOR SYSTEMIC USE ...................................................................................................... 572 OTHER RESPIRATORY SYSTEM PRODUCTS ............................................................................................. 575 S – SENSORY ORGANS 579 OPHTHALMOLOGICALS .............................................................................................................................. 579 OTOLOGICALS ............................................................................................................................................. 601 EAR, NOSE, AND THROAT PREPARATIONS ................................................................................................ 603 V – VARIOUS 605 ALL OTHER THERAPEUTIC PRODUCTS ...................................................................................................... 605 DIAGNOSTIC AGENTS ................................................................................................................................ 631
  • 17. GENERAL NUTRIENTS ................................................................................................................................. 633 CONTRAST MEDIA ....................................................................................................................................... 640 DIAGNOSTIC RADIOPHARMACEUTICALS ................................................................................................... 650 THERAPEUTIC RADIOPHARMACEUTICALS ................................................................................................. 651 X – HERBAL PREPARATIONS 653 APPENDICES SUMMARY STATISTICS .............................................................................................................................. A1 LIST OF DRUG MOLECULES ADDED TO THE PNF 8TH EDITION................................................................ A2 LIST OF DRUG MOLECULES DELETED FROM THE PNF 7th EDITION....................................................... A4 LIST OF ESSENTIAL MEDICINES INCLUDED IN THE PNF BUT NOT REGISTERED WITH THE FDA .......... A6 LIST OF DANGEROUS DRUG PREPARATIONS INCLUDED IN THE PNF.................................................... A9 LIST OF CONTROLLED CHEMICALS INCLUDED IN THE PNF.................................................................... A10 LIST OF ESSENTIAL MEDICINES WITH NARROW THERAPEUTIC RANGE................................................. A11 LIST OF RESTRICTED ANTIMICROBIALS ................................................................................................... A12 LIST OF MEDICINAL PLANT PRODUCTS REGISTERED WITH THE FDA AND INCLUDED IN THE PNF A13 DEFINITION OF DOSAGE FORMS .............................................................................................................. A14 FDA ADVERSE DRUG REACTION (ADR) REPORTING FORM ...................................................................... A17 DIRECTORY ........................................................................................................................................................... A20 REFERENCES ........................................................................................................................................................ A22 ISSUANCES ........................................................................................................................................................... A26 INDEX .................................................................................................................................................................... A93
  • 18.
  • 20.
  • 21. i GENERAL GUIDANCE ON THE USE OF THIS FORMULARY The Philippine National Formulary 8th Edition allows healthcare practitioners – physicians, dentists, pharmacists, nurses, and other allied healthcare professionals – to find important medicine information to guide them in the rational use of medicines. In this new edition of the PNF, the essential medicines list and monographs have been integrated into a single manual. The medicines are arranged using the Anatomical Therapeutic Chemical (ATC) Classification System. Medicines with more than one therapeutic indication appear in more than one category. Each monograph consists of: •Generic Name •Dosage Form/Strength •Indications •Contraindications •Dosage (weight and/or age-specific dosage recommendations) •Dose Adjustments (for patients with renal or hepatic disease; or the elderly patients) •Precautions/Warnings •Adverse Drug Reactions •Drug Interactions •Administration Guide •Pregnancy Category •ATC Code The therapeutic information in this Formulary have been adapted from various current and comprehensive references (refer to Appendix M. This edition also followed and adapted previously approved format and contents of the Philippine National Formulary Manual for Primary Healthcare.
  • 22. ii MEDICINE MONOGRAPH KEY The medicine monograph key summarizes and describes the types of information contained in this edition that the physicians and dentists can utilize in prescribing medicines for their patients. This key also shows the format of how the prescribing information is arranged. GENERIC NAME DOSAGE FORM/STRENGTH INDICATION/S: This section only includes Philippine FDA-approved indications. In addition, the indications listed for the Anti-Infective Agents are restricted to those included in the most current local clinical practice guidelines that were made available to the editors and/or the latest published recommendations of the Philippine Antimicrobial Resistance Surveillance Program (ARSP). CONTRAINDICATION/S: This section details disease states where and patient populations for whom the medicine should not be used. DOSE: This section lists dosages of the medicines for adult, child and elderly patients, if specified, as indicated in the official FDA-approved labeling and/or other main references. DOSE ADJUSTMENT/S: This section gives dosage adjustment recommendations for the elderly, or for patients with renal or hepatic impairment. PRECAUTIONS: This section details (1) harmful conditions related to the use of the medicine (e.g., exacerbations, increased risk of adverse effects), and (2) disease states or patient populations where caution is advised. This may also include precautions for breastfeeding mothers and nursing infants. Black Box Warnings are included. ADVERSE DRUG REACTIONS: This section denotes side effects and adverse drug reactions (ADRs) listed in the official FDA-approved labeling. Only Common ADRs are listed in this Formulary. A complete listing of ADRs can be viewed on the online copy of the formulary. DRUG INTERACTION/S: This section includes the effects and implications of the concomitant administration of different medicines, or their use together with food. ADMINISTRATION: This section lists recommendations on the proper intake or administration of the medicines. PREGNANCY CATEGORY: This section is based on the US FDA Pregnancy Risk Categories. ATC CODE: This section is based on the WHO ATC/DDD Index 2016. (WHO Collaborating Centre for Drug Statistics Methodology).
  • 23. iii US FDA PREGNANCY RISK CATEGORIES The FDA-assigned pregnancy categories as used in the Drug Formulary are as follows: Category Interpretation A CONTROLLED STUDIES SHOW NO RISK. Adequate and well-controlled studies in pregnant women have failed to demonstrate a risk to the fetus in the first trimester of pregnancy (and there is no evidence of risk in later trimesters). B NO EVIDENCE OF RISK IN HUMANS. Animal reproduction studies have failed to demonstrate a risk to the fetus and there are no adequate and well-controlled studies in pregnant women. C RISK CANNOT BE RULED OUT. Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks. D POTENTIAL EVIDENCE OF RISK. There is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience or studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks. X CONTRAINDICATED IN PREGNANCY. Studies in animals or humans have demonstrated fetal abnormalities and/or there is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience, and the risks involved in the use of the drug in pregnant women clearly outweigh potential benefits.
  • 24. iv SYMBOLS AND ABBREVIATIONS ACE - Angiotensin-converting enzyme ADR - Adverse drug reaction AIDS - Acquired Immunodeficiency Syndrome a.m. - Morning; before noon Amp - Ampule AV - Atrioventricular BCG - Bacille Calmette-Guérin BP - Blood pressure BSA - Body surface area cap., caps - Capsule(s) CNS - Central Nervous System comp. - Compound cr., crm. - Cream CR - Controlled-release CSF - Cerebrospinal fluid D5NS - Glucose (dextrose) 5% in normal saline (0.9%) D5W - Glucose (dextrose) 5% solution DOTS - Directly observed treatment, short-course DMARD - Disease modifying agents in rheumatoid disorders DPI - Dry powder inhaler EC - Enteric-coated ECG - Electrocardiogram emuls. - Emulsion EPS - Extrapyramidal syndrome ER - Extended Release FC - Film-coated G - Gram GFR - Glomerular Filtration Rate GI - Gastrointestinal gtt(s) - Drop(s) h, hr. - Hour HAI - Hospital-Acquired Infections HIV - Human Immunodeficiency Virus HRT - Hormone Replacement Therapy (ID) - Intradermal (IM) - Intramuscular Inj. - Injection INR - International Normalized Ratio IU - International Unit(s) (IV) - Intravenous L - Liter LA - Long-Acting lin. - Liniment lot. - Lotion MAOI - Monoamine Oxidase Inhibitor MDI - Metered Dose Inhaler MDR-TB - Multidrug-resistant tuberculosis mEq - Milliequivalent Mg - Milligram mL - Milliliter Mmol - Millimole MR - Modified release [includes CR, ER, SR, LA] nebul. - Spray NSAID - Non-steroidal Anti- Inflammatory Drugs p.m. - Afternoon / Evening RE - Retinol Equivalent Resp. Soln. - Respiratory Solution Rx - Prescription (SC) - Subcutaneous (SL) - Sublingual; under the tongue sig. - Signa / write on label Soln. - Solution spp. - Species SR - Sustained Release SSRI - Selective Serotonin Reuptake Inhibitor supp. - Suppository susp. - Suspension syr. - Syrup tab., tabs. - Tablet(s) TB - Tuberculosis top. - Topical XDR-TB - Extensively Drug-resistant Tuberculosis
  • 25. v GENERAL GUIDE TO PRESCRIBING A RATIONAL APPROACH TO THERAPEUTICS Rational use of medicines (RUM) is the fundamental concept where patients receive medicines, when these are needed, that are appropriate for the clinical needs, in doses that meet the individual requirements, for an adequate period of time, at the lowest possible cost, and administered correctly by the right person. The problem of irrational use of medicines concerns the following: a. This is one of the most critical causes of unsuccessful treatment outcomes, health hazards that include antimicrobial resistance (AMR), wastage of resources, and increased health costs. b. Worldwide, 50% of medicines are prescribed, dispensed or sold inappropriately; moreover, half of the patient population fails to take them correctly. c. In the Philippines, many irrational practices are prevalent such as rationing (often termed as “diby-diby”), prescribing of inappropriate alternative medicines, “shotgun” therapy, misuse and overuse of antibiotics, dispensing of antibiotics without a prescription, self-medication, buying medicines piecemeal (“tingi”), and failure to complete treatment. d. The problems that underlie the irrational practices are far-reaching and include inadequate supplies of medicines that are in turn due to the sheer number of patients coming for consultation, the lack of funds or poor support from the government officials, poverty, inherent limitations of the National Formulary, anomalous transactions, geographical isolation and poor health literacy of patients and even some health care providers. The solutions for many of the causes of irrational practices are often beyond the control of the physicians. However, the physicians, as stewards of the people’s health, must lead by example the efforts to adhere faithfully to the principles of RUM. The basic tenets of RUM include: a. Prescribing medicines only when these are necessary; b. Prescribing appropriately; and, c. Considering the benefits of administering medicines in relation to the risks involved. The key points of the systematic processes that will assist in determining the proper treatment are: a. Defining the patient’s problem; b. Specifying the therapeutic objective; and, c. Selecting the therapeutic strategy. The selected strategy for achieving a health outcome should be agreed upon with the patient. The total costs for all therapeutic options should be considered. Strategies can either be non-pharmacologic and/or pharmacologic. 1) Non-pharmacologic Treatment This implies that patients do not always need medicine for the treatment of their conditions. This includes changes in lifestyle or diet, use of physiotherapy or exercise, provision of adequate psychological support, and other non-pharmacologic treatments. This is of equal importance as prescription medicines; instructions for such treatments must be written, explained, and monitored in the same way.
  • 26. vi 2) Pharmacologic Treatment a) Selecting the correct group of medicines: There are two fundamental principles for rational therapeutics: i. Knowledge about the pathophysiology involved in the clinical situation of each patient ii. Pharmacodynamics of the chosen group of medicines b) Verifying the suitability of the chosen pharmaceutical treatment: i. Is the active substance chosen suitable for the patient? ii. Is the dosage form suitable for the patient? iii. Is the standard dosage schedule suitable for the patient? iv. Is the standard duration of treatment suitable for the patient? c) Prescription Writing: i. This serves as the link between the prescriber, the pharmacist (or dispenser), and the patient. ii. This is vital to the successful management of presenting medical conditions (see detailed Prescription Writing below). iii. In the Philippines, only validly registered medical doctors and dentists (as well as veterinarians) are allowed to prescribe. d) Giving information, instructions, and warnings: This is essential in ensuring patient adherence. e) Monitoring treatment: i. The evaluation of the follow-up and the outcome of treatment allows for possible termination of treatment (if the patient’s problem is solved), or its reformulation when necessary. ii. This step gives rise to important information about the effects of medicines, contributing to the pool of knowledge on pharmacovigilance; that in turn is needed to promote the rational use of medicines. B VARIATION IN DOSE-RESPONSE Correct dose regimen is necessary for the success in medicine treatment. The use of standard doses in the marketing literature suggests that standard responses are the rule, but in reality there is considerable variation in medicine response. The reasons for the variation include: adherence (see Adherence with Medicine Treatment), medicine formulation, body weight and age, composition, variation in medicine absorption, distribution, metabolism, and excretion, variation in pharmacodynamics, disease variables, and genetic and environmental variables. MEDICINE FORMULATION a. Poorly formulated medicines may fail to disintegrate or to dissolve. b. Enteric-coated medicines may pass through the GI tract intact. Changes in absorption can produce sudden changes in medicine concentrations of medicines with a narrow therapeutic-to-toxic ratio. For such medicines, quality control surveillance should be carried out. BODY WEIGHT AND AGE Although the concept of varying the dose with the body weight or age of children has long been a tradition, adult doses have been assumed to be the same irrespective of size or shape. However, adult weights vary 2- to 3-folds. Furthermore, a patient with
  • 27. vii a large fat mass can store large excesses of highly lipid-soluble medicines compared with a lean patient of the same weight. Age can also be important. Adolescents may metabolize some medicines relatively more rapidly than adults, while the elderly may have reduced renal function and eliminate some medicines more slowly. DOSE CALCULATION IN CHILDREN Many children’s doses are standardized by weight (and therefore require multiplying by the body-weight in kilograms to determine the child’s dose). Occasionally, the doses have been standardized by body surface area (BSA) in m2. To calculate a child’s medication based on BSA, use the formula: child′ s BSA 1.73 × adult dose = child′ s dose with the BSA computed as follows: A = � W × H 3600 where: A – patient’s BSA (m2) W – patient’s weight in kg H – patient’s height in cm 3600 – conversion / correction factor (kg/m2) If the weight is expressed in pounds (lbs) and the height in inches (in): A = � W × H 3131 o Young children may require a higher dose for each kilogram than adults because of their faster metabolic rates. o Calculation by body weight in an overweight child may result in higher than necessary doses being administered. In such cases, doses should be calculated using an ideal weight, related to height and age. o Nomograms can also be used to calculate body surface values based on a child’s height and weight. o Where the dose for children is not readily available, prescribers should seek specialist advice before prescribing for a child. PHYSIOLOGICAL AND PHARMACOKINETIC VARIABLES a. Pharmacokinetics This area of study deals with changes of concentration in the drug product, or in a drug and its metabolites, in the body, after it has been administered. This includes the time course of drug absorption, distribution, metabolism, and elimination. A basic understanding of the factors which control drug concentration at the site of action (e.g., bioavailability, area under the curve, and half-life) is important for the optimal use of drugs. 1) Bioavailability This refers to the amount of medicine from an administered dosage form which enters the systemic circulation, and the rate at which it appears in the bloodstream. Changes in a drug’s bioavailability may be thought of in terms of changes in
  • 28. viii exposure to the drug which, if substantial, can relate to safety and efficacy concerns. 2) Bioequivalence This indicates that a drug in two or more similar dosage forms reaches the general circulation at the same relative rate and the same relative extent (i.e., that the plasma level profiles of the drug obtained using the two dosage forms are the same). This is an important consideration in several key situations involving lot-to-lot consistency, innovator to generic product therapeutic equivalence, and situations where a marketed product undergoes changes in certain aspects (formulation, manufacturing process, and dosage strength). 3) Half-life This indicates the time required to reduce the amount of medicine in the body or the plasma concentration by 50%. This is a clinically useful pharmacokinetic parameter because this indicates when the next dose of a medicine needs to be administered, and thus helpful in determining an optimal dosing regimen. b. Medicine absorption rates may vary widely among individuals and in the same individual at different times and in different physiological states. Medicines taken after a meal are delivered to the small intestine more slowly than in the fasting state, leading to much lower medicine concentrations. In pregnancy, gastric emptying is also delayed, while some medicines may increase or decrease gastric emptying, and affect absorption of other medicines. MEDICINE DISTRIBUTION a. Fat-soluble medicines (vitamins A, D, E, and K) are stored in adipose tissues. b. Water-soluble medicines are distributed chiefly in the extracellular space. c. Acidic medicines bind strongly to plasma albumin. d. Basic medicines go to muscle cells. e. Hence, variations in plasma albumin concentration, fat content, or muscle mass may all contribute to dose variation. MEDICINE METABOLISM AND EXCRETION a. Medicine metabolism is affected by genetic, environmental, and disease-state factors. b. Medicine acetylation shows genetic polymorphism, where individuals fall clearly into either fast or slow acetylator types. This means that some patients can metabolize medicines more rapidly (fast acetylators) than the others (slow acetylators). c. Medicine oxidation, however, is polygenic. Although a small proportion of the population can be classified as very slow oxidizers of some medicines, there is a normal distribution of medicine- metabolizing capacity for most medicines and most subjects. d. Many medicines are eliminated by the kidneys without being metabolized. e. Renal disease or toxicity of some medicines on the kidney can slow excretion of some medicines. f. Hepatic disease or toxicity of some medicines on the liver can slow excretion of some medicines.
  • 29. ix PHARMACODYNAMIC VARIABLES Significant variations in receptor response to some medicines (especially CNS responses, such as pain and sedation) are attributed to genetic factors, tolerance, medicine interactions, and medicine dependence. DISEASE VARIABLES a. Both liver and kidney diseases can have major effects on metabolism and elimination, respectively (resulting in increasing toxicity), but also through effects on plasma albumin (resulting in increasing free medicine and thus toxicity). b. Heart failure can also affect metabolism of medicines with rapid hepatic clearance (e.g., lidocaine). c. Respiratory disease and hypothyroidism can impair oxidation of drugs. ENVIRONMENTAL VARIABLES a. Many medicines and environmental toxins can induce the hepatic microsomal enzyme oxidizing system or cytochrome P450 oxygenases, leading to more rapid metabolism and elimination, and thus less effective treatment. b. Environmental pollutants, anesthetic medicines, and other compounds, such as pesticides, can also induce metabolism. c. Diet and nutritional status also affect pharmacokinetics: 1) In malnourished infantile and elderly populations, medicine oxidation rates are decreased. 2) High protein diets, charcoal-cooked foods, and certain other foods act as metabolizing enzyme inducers. 3) Chronic alcohol use induces oxidation of some medicines; but in the presence of high circulating alcohol concentrations, medicine metabolism may be inhibited. C ADHERENCE TO (COMPLIANCE WITH) MEDICINE TREATMENT One of the most important reasons for treatment failure is poor adherence to (compliance with) the treatment plan. Reasons for non-compliance may be related to: (1) the patient, (2) the disease, (3) the doctor, (4) the prescription, (5) the pharmacist, or (6) the health system. o For instance, patients' perceptions of the risk and severity of adverse drug reactions may differ from those of the healthcare provider and may affect adherence. o Poor prescribing or a dispensing error may also create a problem, which patients may have neither the insight nor the courage to question. Even with good prescribing though, failure to adhere to treatment is common. Valid reasons for poor adherence include the ff.: the medicine may be poorly tolerated, may cause obvious adverse effects, or may be prescribed in a toxic dose. Failure to adhere with such a prescription has been described as “intelligent non-compliance”. Low-cost strategies for improving adherence increase effectiveness of health interventions and reduce costs. Such strategies must be tailored to the individual patient. Healthcare providers should be familiar with techniques for improving adherence and they should employ systems to assess adherence and to determine what influences it.
  • 30. x 1. PATIENT-RELATED REASONS a. Women tend to be more adherent than men. b. Younger patients and the very elderly tend to be less adherent. c. People living alone are less adherent than those living with partners or spouses. d. Specific education interventions have been reported and shown to improve adherence and compliance. e. Some patient disadvantages include illiteracy, poor eyesight, or cultural attitudes, which includes preference for traditional or alternative medicines, and distrust of modern medicines. f. Economic factors affect patient adherence, compliance and maintenance. 2. DISEASE-RELATED REASONS Conditions with a known worse prognosis (e.g., cancer) or painful conditions (e.g., rheumatoid arthritis) elicit better adherence than asymptomatic “perceived as benign” conditions such as hypertension. 3. DOCTOR-RELATED REASONS a. Failure to inspire confidence in the treatment offered b. Little or no explanation provided c. Too many medicines prescribed d. Errors in prescribing e. Overall attitude to the patient 4. THE DOCTOR-PATIENT INTERACTION a. Quality of the doctor–patient interaction is crucial to adherence and compliance. b. “Satisfaction with the interview” is one of the best predictors of good adherence. c. If they are in doubt or dissatisfied, they may turn to alternative options, including complementary medicine. 5. PRESCRIPTION-RELATED REASONS a. Illegible or inaccurate prescriptions may discourage patients to adhere to medications. b. Lost prescriptions may delay patients to start or continue medications. c. Prescriptions not refilled as intended or instructed for a chronic disease may reduce maintenance. d. Too complex prescriptions (greater number of different medicines, poorer adherence). e. Multiple doses decrease adherence and compliance especially if more than two doses per day are given. f. Adverse effects, like drowsiness, impotence, or nausea, reduce adherence. 6. PHARMACIST-RELATED REASONS a. Manner and professionalism b. Pharmacist information and counseling can serve as a valuable reinforcement, as long as they agree with the physician’s advice. 7. RECOMMENDATIONS TO THE PRESCRIBERS a. Review the prescription to make sure it is correct. b. Spend time explaining the health problem and the reason for the medicine. c. Establish good rapport with the patient. d. Explore problems, such as difficulty with reading the label or getting the prescription filled.
  • 31. xi e. Encourage patients to bring their medication to the clinic so that tablet counts can be done to monitor compliance. f. Encourage patients to learn the names of their medicines, and review their regimen with them. Write notes for them. g. Keep treatment regimens simple. h. Communicate with other healthcare professionals to develop a team approach and to collaborate on helping and advising the patient. i. Involve the partner or another family member. j. Listen to the patient. D ADVERSE EFFECTS AND INTERACTIONS 1. ADVERSE DRUG REACTIONS (ADR) Any response to a medicine which is noxious, unintended and occurs at doses normally used for prophylaxis, diagnosis, or therapy. These reactions are different from accidental OR deliberate excessive dosage or medicine maladministration. 2. MAJOR FACTORS PREDISPOSING TO ADVERSE EFFECTS a. EXTREMES OF AGE 1) The very old and the very young populations are more susceptible to ADRs. Examples of which are: hypnotics, antihypertensives, Non-Steroidal Anti- inflammatory Drugs (NSAIDs), psychotropics, diuretics, and digoxin. 2) All children, particularly neonates, differ from adults in their response to medicines. Some medicines are likely to cause problems in o Neonates, but are generally tolerated in children o Children of all ages, who are at increased risk of ADRs for other medicines b. INTERCURRENT ILLNESSES/COMORBIDITIES This occurs when a patient suffers from another disease aside from the current condition being treated (kidney, liver or heart disease). The genetic make-up of the individual patient plays a role. c. MEDICINE INTERACTIONS These may occur among medicines which compete for the same receptor, or which act on the same physiological system. 1) These may occur indirectly when a medicine-induced disease, or a change in fluid/electrolyte balance, alters the response to another medicine. 2) These may occur when one medicine alters the absorption, distribution, or elimination of another medicine, such that the amount which reaches the site of action is either increased or decreased. Drug–drug interactions are some of the most common causes of adverse effects. When two medicines are administered to a patient, they may either act independently of each other, or interact with each other. Interaction may increase or decrease the effects of the medicines concerned and may cause unexpected toxicity. As newer and more potent medicines become available, the frequency of serious drug interactions is likely to increase. NOTE: Interactions which modify the effects of a medicine may involve non-prescription medicines, non-medicinal chemical agents, and social drugs such as alcohol, marijuana and tobacco, and traditional remedies, as well as certain types of food. The physiological changes in individual patients, caused by such factors as age and sex, also influence the predisposition to ADRs resulting from drug interactions.
  • 32. xii d. INCOMPATIBILITIES BETWEEN MEDICINES AND IV FLUIDS Medicines should not be added to blood, amino acid solutions, or fat emulsions. o Certain medicines, when combined with intravenous fluids, may be inactivated by pH changes, precipitation, or chemical reaction. e. ADVERSE EFFECTS CAUSED BY TRADITIONAL MEDICINES Patients who have been, or are taking, traditional herbal remedies may develop ADRs. In these types of preparation, it is not always easy to identify the responsible constituents. Refer to the medicine and toxicology information service if available or to suitable literature. f. EFFECT OF FOOD ON MEDICINE ABSORPTION Food delays gastric emptying and reduces the rate of absorption of many medicines; however, the total amount of medicine absorbed may or may not be reduced. On the other hand, some medicines are taken with food, either to increase absorption or to decrease the irritant effect on the stomach. E PRESCRIPTION WRITING 1. PRESCRIPTION FORM Administrative Order No. 62 (series of 1989) on the rules and regulations to implement prescribing requirements under the Generics Act defines a prescription as a written order and instruction of a validly-registered physician, dentist or veterinarian for the use of a specific medicine (or medical device) for a specific patient. The most important requirement for a prescription is that it should be clear. It should be legible and indicate precisely what should be given. The language used may be in English, Filipino, or the local dialect. In accordance with R.A. 5921, or the Pharmacy Act as amended, all prescriptions should contain the following information: o The patient’s name, age and sex; o The prescriber’s name, office address, professional registration number, and professional tax receipt number; and, o Date of the prescription In addition, Section 3 of the Generics Act lists the following specific guidelines to prescribing: o Generic names shall be used in all prescriptions. For drugs with a single active ingredient, the generic name of that active ingredient shall be used in prescribing. For drugs with two or more active ingredients, the generic name as determined by the Philippine FDA shall be used. o The generic name must be written in full, but the salt or chemical form may be abbreviated. The symbol Rx means prescription which originated in medieval manuscripts as an abbreviation of the Latin verb recipe. The imperative form is recipere which means “to take” or “take thus.”) o The generic name must be clearly written immediately after the Rx symbol or on the order chart. o The pharmaceutical form (e.g., “tablet”, “oral solution”, “eye ointment”) should also be stated. o The strength of the medicine should be stated in standard units using abbreviations which are consistent with the Système International (SI) [Refer to Appendices for abbreviations and symbols].
  • 33. xiii o Avoid decimals whenever possible. If this is unavoidable, a zero should be written before the decimal point. 2. INCORRECT PRESCRIPTIONS Three types of incorrect prescriptions may be identified: a. Erroneous prescription: o Where the brand name precedes the generic name o Where the generic name is the one in parenthesis o Where the brand name is not in parenthesis b. Violative prescription: o Where the generic name is not written o Where the generic name is not legible, and a brand name which is legible is written o Where the brand name is indicated and instructions added (such as the phrase “no substitution”) which tend to obstruct, hinder or prevent proper dispensing c. Impossible prescription: o When only the generic name is written, but it is not legible o When the generic name does not correspond to the brand name o When both the generic and brand names are not legible o When the drug product prescribed is not registered with the Philippine Food and Drug Administration If an erroneous prescription is received, the prescription may be filled but it should be kept and reported to the nearest Department of Health (DOH) office for appropriate action. In contrary, violative and impossible prescriptions are not to be filled and should also be kept and reported to the nearest DOH office. 3. NARCOTICS AND CONTROLLED SUBSTANCES The prescribing of a medicinal product which is liable to abuse requires special attention and may be subjected to specific statutory requirements. Practitioners may need to be authorized to prescribe controlled substances. In such cases, it might be necessary to indicate details of the authority on the prescription. In particular, the strength, directions, and the quantity of the controlled substance to be dispensed should be stated clearly, with all quantities written in words, as well as in figures to prevent alteration. Other details, such as patient particulars and date, should also be filled in carefully to avoid alteration. F PATIENT COUNSELING One-to-one, dynamic interaction between a health care practitioner and a patient and/or caregiver, which should include an assessment if the information was received as intended, and that the patient understands how to use the information to improve the probability of positive therapeutic outcomes. 1. WHAT TO COUNSEL Routinely, effectively and appropriately educate patients on the following: (1) when dispensing prescription and non-prescription drugs, (2) when counseling on discharge medications, and (3) when providing recommendations about management of specific drug-related problems: a. The medication’s name (generic), indication and when appropriate to use;
  • 34. xiv b. The medication’s expected onset of action and what to do if the action does not occur; c. The medication’s route, dosage form, dosage and administration schedule (including duration of therapy); d. Directions for use including education about drug devices; e. Proper storage requirements; f. Common or important drug-drug or drug-food interactions; g. Potential common and severe adverse effects, and actions to prevent or minimize their occurrence; h. What the patient should do to monitor his/her therapeutic response or when side effects develop; i. What actions the patient should take if the intended therapeutic response is not obtained or if side effects develop; and, j. Proper disposal of contaminated, discontinued or unused medications. 2. WHO AND WHEN TO COUNSEL a. Patients who should always be counseled together with their families and caregivers: o Confused patients; o Patients who are sight- or hearing-impaired; o Patients with poor literacy; o Patients whose profiles show change in medications or dosing; o New patients, or those receiving a medication for the first time; and, o Patients who have medications with significant side effects, specific storage requirements, and complicated directions. b. Patients who should be counseled at certain intervals: o Asthmatic patients; o Diabetic patients; o Patients taking four (4) or more prescribed medications; o Patients who are mentally ill; o Epileptic patients; and, o Patients with skin complaints. 3. COUNSELING: PROCESS STEPS Steps in patient education and counseling process will vary according to the health system’s policies and procedures, environment, and practice setting. Generally, the following steps are appropriate for patients receiving new medications or returning for refills: a. Establish caring relationship with the patient as appropriate to the practice setting, and stage in the patient’s health care management. Show interest in the patient verbally and non-verbally o Explain the purpose and expected length of sessions. o Obtain the patient’s agreement to participate. b. Assess the patient’s knowledge about his or her health problems, medications, physical and mental capability to use the medications appropriately, and attitude towards the health problems and medications. o Ask why the patient is being prescribed with the medication (if known), or the medication’s use, expected benefits and action. o Provide information orally, and use demonstrations or visual aids to fill the patient’s gaps in knowledge and understanding.
  • 35. xv o Open the medication containers and show patient what the medication looks like, or demonstrate use. Explain how to take the medication. o Discuss when to take and how long to take the medication. o Plan what to do if a dose is missed. o Determine any special precautions to heed and follow. Explain how to store the medication. o Demonstrate if the prescription can be refilled, and if so, determine when it is done. o Give specific details on how the patient will know if the medication is working. c. Verify patient’s knowledge and understanding of medication use. o Ask the patient to describe (or show) how the medication should be used, and its effects. o Ask the patient if they have any questions.
  • 36. xvi ANTIMICROBIAL RESISTANCE A. DEFINITION OF ANTIMICROBIAL RESISTANCE 1. Antimicrobial Resistance (AMR) refers to the resistance of a micro-organism (including bacteria, viruses and some parasites) to an antimicrobial agent to which it was previously sensitive. Resistant organisms withstand attack by antibacterials, antivirals, or antimalarials. Thus, standard treatments become ineffective, allowing infections to persist and spread. 2. AMR which is a consequence of the use or misuse of antimicrobials develops when the organism mutates or acquires a resistance gene. B. CAUSES OF ANTIMICROBIAL RESISTANCE 1. Although the ultimate causes of AMR are microbial, clinical, and programmatic in nature, it is essentially a man-made occurrence. 2. The proliferation of drug-resistant strains is associated with various management, healthcare provider, and patient-related issues. Table 1 enumerates several of the causes leading to drug resistance. 3. The general categories of the causes, i.e., therapeutic protocols, drug characteristics, and drug selling and purchasing practices, provide opportunities where potential strategies to combat AMR arise. Table 1. Causes of inadequate treatment which may contribute to emergence of drug resistance Healthcare providers: Inadequate regimens Drugs: Inadequate supply/quantity Patients: Inadequate drug intake - Inappropriate guidelines - Noncompliance with guidelines - Absence of guidelines - Poor training - No treatment monitoring - Poorly organized or funded control programs - Poor quality - Unavailability of certain drugs (stock-outs or delivery disruptions) - Poor storage conditions - Wrong dose or combinations - Poor adherence (or poor directly observed therapy) - Lack of information - Lack of money (no treatment available free of charge - Lack of transportation - Adverse effects - Social barriers - Malabsorption - Substance dependency disorders Source: Final Report, Country Situation Analysis on Antimicrobial Resistance, Philippines, 2012. C. ANTIMICROBIAL RESISTANCE: A GROWING GLOBAL CONCERN 1. The WHO cites the following alarming reasons: AMR is already a global concern, AMR kills, AMR challenges control of infectious disease, AMR threatens a return to the pre-antibiotic era, AMR increases the costs of health care, AMR jeopardizes healthcare gains to society, and AMR compromises health security, and damages trade and economy. 2. Furthermore, the following facts collated by WHO1 indisputably demonstrate the potential and real dangers that AMR causes and has caused: a. About 440,000 new cases of multi-drug resistant TB (MDR-TB which is defined as resistance to Rifampicin and Isoniazid) emerge annually, causing at least
  • 37. xvii 150,000 deaths. Therapy of MDR-TB requires 18-24 months of treatment with expensive second-line drugs, like capreomycin and kanamycin. b. Extensively drug-resistant TB (XDR-TB defined as MDR plus resistance to any member of the quinolone family and at least to any second-line anti-TB injectable, such as kanamycin, capreomycin or amikacin) is a global threat with a case-fatality rate of 50%. XDR-TB is a big problem because there are very few options for treatment, which probably accounts for the high mortality rate among them. c. Resistance to earlier generation antimalarial medicines such as chloroquine and sulfadoxine-pyrimethamine is widespread in most malaria-endemic countries. Falciparum malaria parasites resistant to artemisinins are emerging in Southeast Asia; infection showed delayed clearance after the start of treatment (indicating resistance). d. Ciprofloxacin is the only antibiotic currently recommended by WHO for the management of bloody diarrhea due to Shigella, now that wide-spread resistance has developed to any previously effective antibiotics. But rapidly increasing prevalence of resistance to Ciprofloxacin in Shigellosis is reducing the options for safe and efficacious treatment especially for children. New antibiotics suitable for oral use are badly needed. e. AMR has become a serious problem for treatment of gonorrhea (caused by Neisseria gonorrhoea), involving even “last-line” oral cephalosporins, and this is increasing in prevalence worldwide. In multidrug-resistant N. gonorrhoea, resistance is found against tetracyclines, macrolides (including azithromycin), sulfonamide and trimethoprim combinations and more recently, to quinolones. Untreatable gonococcal infections will result in higher rates of illness and death thus reversing the gains made in the control of the sexually transmitted infections. f. ESBLs (extended-spectrum beta-lactamases) are resistant to third-generation cephalosporins (ceftazidime, cefotaxime and cefpodoxime) as well as monobactams (aztreonam); common in the Enterobacteriaceae, particularly E.coli and K. pneumoniae. g. New resistance mechanisms, such as the beta-lactamase NDM-1 (New Delhi metalo- beta-lactamase 1), have emerged among several gram-negative bacilli. This is considered as a new superbug that has resistance to broad spectrum antibiotics that are often the last defense against multi-resistant bacterial strains. h. A high percentage of hospital acquired infections is caused by highly resistant bacteria such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin resistant enterococci. i. Resistance is an emerging concern for treatment of HIV infection, following the rapid expansion in access to anti-retroviral medicines in recent years. D. STATUS OF ANTIMICROBIAL RESISTANCE IN THE PHILIPPINES 1. The need to approach the problem of AMR in the Philippines with a sense of urgency is clearly elucidated by several evidence of the dangers it poses. a. The most dreaded recognized AMR gene, the NDM-1, was identified in the Escherichia coli isolated from the urine of a 33 year old female in 2011. The gene can render even the most powerful antibiotics ineffective. b. Many of the causative bacterial pathogens that cause infections included in the Top Ten causes of morbidity in the Philippines have already become resistant to multiple antibiotics. At the forefront is TB, with MDR-TB and even XDR-TB already present in the Philippines which ranked 6th among 27 identified countries with MDR-TB. In 2006, the occurrence of MDR-TB was 4% among new cases and a high 27% among previously treated patients.
  • 38. xviii 2. The DOH established in 1988 the Antimicrobial Resistance Surveillance Program (ARSP) to determine the current status and developing trends of antimicrobial resistance of selected bacteria to specific antimicrobials. The ARSP, which now has 24 sentinel sites hospital bacteriology laboratories in 16 regions of the Philippines and 2 gonococcal surveillance sites, submits and publishes annual summary reports focusing on aerobic bacterial pathogens of public health importance causing common infectious diseases. All readers are enjoined to refer to the yearly published ARSP surveillance data provided by RITM for updated information and proper guidance. 3. The ARSP found alarming rates of resistance among various bacterial pathogens. 1,2 a. The ESBL enzyme, which can render pathogens resistant to many antibiotics, has been identified in Escherichia coli and Klebsiella spp. b. Multi-drug resistant Pseudomonas aeruginosa and Acinetobacter spp. which account for 43% of all hospital-acquired pneumonia have been identified. c. The percent resistance, in all ARSP sites from January-December of 2013 of Streptococcus pneumonia (which causes acute respiratory tract infections) to penicillin was 5% compared to 0 in 2010. Resistance to cotrimoxazole was 20% in 2013.² d. The percent resistance of non-typhoidal Salmonella from January-December, 2013, to ampicillin and cotrimoxazole were 56% and 34%, respectively. ² e. There is a steady increase in the resistance rates of Staphylococcus aureus and consequently higher prevalence of MRSA which is also an important cause of hospital acquired infections. f. In the period 2012-2013, there were very high resistance rates of Neisseria gonorrhoea to ciprofloxacin (74%), penicillin (80%), and tetracycline (55%). ² 4. These alarming increasing trends of AMR in the country are clearly demonstrated in Table 2 which summarized the results of a comparison of the antimicrobial resistance of selected organisms in 1993 and 2011. Please refer to the Antimicrobial Resistance Surveillance Program (ARSP) Summary Report for antimicrobial resistance patterns of specific organisms. E. RECOMMENDATIONS OF THE PHILIPPINE ANTIMICROBIAL RESISTANCE SURVEILLANCE PROGRAM Below are the recommendations of the ARSP regarding antibiotic treatment for aerobic bacterial pathogens of public health importance based on the reported antimicrobial resistance surveillance data for 2013 (Carlos, C, 2013): 1. Respiratory Bacterial Pathogens: a. Infections secondary to Streptococcus pneumoniae can still be covered with penicillin or one of the anti-pneumococcal macrolides, although there is a need to closely monitor the changing trends of resistance among pneumococci. Improved local data on serotype distribution will allow for better surveillance information especially needed for vaccination recommendations. b. Due to high resistance rate of Haemophilus influenzae to ampicillin, this antibiotic is no longer recommended for empiric therapy for infections secondary to the pathogen. c. Recommended empiric treatment for suspected H. influenzae infections may consist of beta-lactam-beta-lactamase inhibitor combinations, extended spectrum oral cephalosporins and the newer macrolides.
  • 39. xix 2. Bacterial Enteric Pathogens: a. For suspected uncomplicated enteric fever, empiric treatment can still consist of either chloramphenicol or cotrimoxazole or amoxicillin/ampicillin. There are increasing reports of nalidixic acid resistance and ciprofloxacin non- susceptibility which may result to clinical treatment failures when treating enteric fever using fluoroquinolones. Microbiological data is recommended for pathogen directed therapy. b. In Salmonella gastroenteritis, increasing rates of ciprofloxacin resistance should remind clinicians to use antibiotics judiciously as this is usually a self-limiting disease. c. Due to the emerging resistance of Shigellae to the quinolones and limited data available, more vigilant surveillance of the resistance pattern of this organism should be pursued by encouraging clinicians to send specimens for culture. d. For cholera, tetracycline, chloramphenicol and cotrimoxazole remain to be good treatment options. 3. Sexually-Transmitted Bacterial Pathogens: a. Limited data is available on N. gonorrhoeae in recent years, but based on reported isolates, ceftriaxone remains as empiric antibiotic of choice for gonococcal infections. More vigilant surveillance of the resistance patterns of this organism must be pursued by encouraging clinicians to send specimens for culture. 4. Gram-positive Cocci: a. In view of the continuous high rates of methicillin/oxacillin resistance among staphylococci, there may be an indication to shift empiric treatment of suspected staphylococcal infections from oxacillin to alternative agents such as cotrimoxazole, doxycycline, clindamycin, linezolid or vancomycin. 5. Gram-negative Bacilli: a. Hospitals should base their treatment recommendations for the Enterobacteriaceae on their institution’s prevailing resistance patterns as these have been found to be variable from hospital to hospital. The high percentage of possible ESBL-producing isolates complicates treatment of serious infections caused by these organisms and may lead to the increased use of carbapenems that may favor the spread of the carbapenem-resistant Enterobacteriaceae. b. Increasing resistance among the bacterial organisms Pseudomonas aeruginosa and Acinetobacter baumannii continue to be a concern as both carry intrinsic resistance to a number of antimicrobial classes and acquisition of additional resistance severely limits the available treatment options. c. Prudent antimicrobial use, monitoring of resistance patterns and antimicrobial use, and improved standards of infection control are essential in addressing the clinical and public health concerns. All readers are enjoined to refer to the yearly published ARSP surveillance data provided by RITM for updated information and proper guidance. F. DRIVING FORCES BEHIND ANTIMICROBIAL RESISTANCE 1. The inappropriate and irrational use of medicines provides favorable conditions for resistant microorganisms to emerge and spread. WHO enumerates the following as the underlying factors that drive AMR: a. Inadequate national commitment to a comprehensive, coordinated response, ill-defined accountability, and insufficient engagement of communities;
  • 40. xx b. Weak or absent surveillance and monitoring systems; c. Inadequate systems to ensure quality and uninterrupted supply of medicines; d. Inappropriate and irrational use of medicines, in both clinical practice and animal husbandry, and aquaculture; e. Poor infection prevention and control practices; and, f. Depleted arsenals of diagnostics, medicines, and vaccines as well as insufficient research and development of new products. G. THE RESPONSE OF THE NATIONAL GOVERNMENT TO THE RISING ANTIMICROBIAL RESISTANCE 1. Creating an Inter-Agency Committee on AMR (ICAMR). 2. Developing a National Plan that will include, but not limited to, the following strategies: a. Establishing short and long term programs to address the different aspects of response to AMR; b. Strengthening the surveillance system and laboratory detection capacity of AMR in both humans and animals; c. Ensuring accessibility, affordability, availability and quality of antimicrobial drugs for humans and its appropriate use in food producing animals including banning the use of antibiotics as growth promoters; d. Developing relevant and utilizable essential medicines list for human and veterinary use; e. Monitoring the rational use of antimicrobials in humans, animal husbandry and aquaculture; f. Advocating the rational use of antimicrobials to consumers and community through media and the academe; g. Training and educating on, and promotion of infection prevention and control measures in health care facilities and the community; h. Conducting researches to develop new antimicrobials and innovative technology to improve diagnosis and treatment; i. Monitoring and evaluating compliance with existing policies and on the proper execution of the AMR control plan; j. Engaging all relevant stakeholders such as government agencies, healthcare providers, non-government institutions, professional organizations, drug industry, veterinary and aquaculture groups, consumer groups, researchers and civil societies; and, k. Ensuring that activities are well financed for sustainability. H. ACTION PLANS, WHICH THE PRIMARY PHYSICIANS AND DENTISTS CAN ADOPT TO HELP COMBAT ANTIMICROBIAL RESISTANCE 1. Assuring the judicious use of antimicrobial agents through faithful adherence to the principles of rational use of medicines and utilizing antimicrobial agents only for the appropriate indications as recommended by the Antimicrobial Resistance Surveillance Program (ARSP) or the task force for Clinical Practice Guidelines and included in the Philippine National Formulary. The choice of antibiotics must strictly conform to the best standard treatment guidelines or clinical practice guidelines (e.g., National Antibiotic Guidelines), and guided by the latest findings and recommendations of the ARSP; 2. Keeping abreast of the latest information on AMR through reviews of the latest antibiotic susceptibility data published by the ARSP, literature search, attendance in seminars, and participation in continuing medical education programs; 3. Devoting sufficient time to educate the patients and their families and caregivers about the appropriate use of antibiotics and the reasons behind the need for strict adherence to the
  • 41. xxi prescribed dosage schedule and completion of full course of treatment as well as to educate them on the prevention of AMR; 4. Careful monitoring of the patients’ compliance and their response to the antimicrobial agents; 5. Submitting specimen for culture when indicated (e.g., for suspected gonococcal infections); 6. Complying with the rules on prescribing, and other regulations in the Pharmacy Law; 7. Developing better communication with pharmacists and other dispensers; 8. Educating other healthcare providers (nurses, midwives, barangay health workers) about the RUM and prevention of AMR; and, 9. Educating the community continually on the need for and proper ways of maintaining good personal hygiene and sanitation, avoidance of vices or unhealthy habits, sanitation, and prevention of infections, including maintaining cleanliness of their surroundings.
  • 42.
  • 44.
  • 45. A ALIMENTARY TRACT AND METABOLISM 1 ALIMENTARY TRACT AND METABOLISM DRUGS FOR ACID-RELATED DISORDERS ANTACIDS OTC ALUMINUM HYDROXIDE + MAGNESIUM HYDROXIDE Oral: 200 mg aluminum hydroxide + 100 mg magnesium hydroxide tablet 225 mg aluminum hydroxide + 200 mg magnesium hydroxide per 5 mL suspension, 60 mL and 120 mL An antacid that combines aluminum hydroxide and magnesium hydroxide to reduce effect on bowel movement and to relieve epigastric pain from peptic ulcer through acid neutralization. Indication: Symptomatic relief of symptoms related to hyperacidity from heartburn, hiatal hernia, upset stomach, peptic ulcer, peptic esophagitis, or gastritis. Contraindications: Severe renal impairment; hypophosphatemia; undiagnosed GI and rectal bleeding; porphyria; appendicitis. Dose: Hyperacidity, by mouth, ADULT, 10-20 mL 4 times daily (maximum 80 mL daily). Dose Adjustment: Renal Impairment: Use with caution due to risk of accumulation and toxicity. For mild-to-moderate renal impairment, dose reduction is warranted. For severe impairment, avoid use and refer patient to a specialist. Precautions: WARNING: Aluminum and magnesium salts may be hazardous in patients with renal insufficiency. If intensive antacid therapy is to be used, only non- systemic (non-absorbable) antacids should be considered because of the potential danger of alkalosis with systemic therapy. Acute porphyria; prolonged antacid therapy may result in hypophosphatemia (i.e., decreased phosphate absorption in the GI tract); dehydration; fluid restriction; constipation; diarrhea; hepatic impairment; renal impairment; GI disorders associated with decreased bowel motility or obstruction; some products may contain phenylalanine. Elderly (may be predisposed to diarrhea or constipation); children. Adverse Drug Reactions: Common: Constipation, diarrhea, GI irritation. Less Common: Chalky taste, fecal discoloration, hypophosphatemia, nausea, vomiting. Rare: Anemia, encephalopathy, fecal impaction, hypermagnesemia, hypophosphatemia, intestinal obstruction, osteomalacia, proximal myopathy. Drug Interactions: Monitor closely with: Increases excretion due to urine alkalinization: Acetylsalicylic Acid Reduces absorption of the following drugs: Azithromycin, Chloroquine, Digoxin, Enalapril, Isoniazid, Rifampicin Avoid concomitant use with: Reduces therapeutic effect of the following drugs Bisphosphonates e.g., Alendronate, Iron, Ketoconazole, Quinolones e.g., Nalidixic acid, Rosuvastatin, Tetracyclines, e.g., Doxycycline. [Separate dosing by at least 2 hours before, or 4–6 hours after the antacid]: Administration: Shake well before use. Best given 1–3 hours after the last meal to neutralize and buffer the acid produced. NOTE: Antacids should preferably not be taken at the same time as other oral drugs since they may impair absorption (interactions may be avoided by having an interval of at least 2 hours between taking an antacid and the other drug). Pregnancy Category: B ATC Code: A02AD01 OTC SODIUM BICARBONATE Oral: 325 mg and 650 mg tablet A short-acting, potent systemic antacid that rapidly neutralizes gastric acid to form sodium chloride, carbon dioxide, and water. After absorption of sodium bicarbonate, plasma alkali reserve is increased, and excess sodium and bicarbonate ions are excreted in urine, rendering urine less acid. Indications: Symptomatic relief of hyperacidity (belching, heartburn, indigestion, gas pains), gastritis, and peptic ulcer; urine alkalinizer. Contraindications: Diuretics known to produce hypochloremic alkalosis; edema; hypertension; hypocalcemia; hypochloremia; hypernatremia; impaired renal function; metabolic alkalosis; respiratory alkalosis or acidosis; any situation where administration of sodium could be clinically detrimental. Dose: Antacid, by mouth, ADULT, 2–8 tablets every 4 hours (maximum, 48 tablets in 24 hours); ADULT ≥60 years, 2– 4 tablets every 4 hours (maximum, 24 tablets in 24 hours.
  • 46. A ALIMENTARY TRACT AND METABOLISM 2 Urine alkalinizer, by mouth, ADULT, initially 3.94 g, then 0.97–1.95 g every 4 hours; CHILD, 84–840 mg/kg daily, in divided doses. Dose Adjustment: Geriatric, Renal and Hepatic Impairment: Dose adjustment may be required. Precautions: WARNING: Ask attending physician before use if on a sodium restricted diet. Do not use maximum dose for more than 2 weeks. Cardiac, liver, or renal disease; Fluid or solute overload; Postoperative patients with cardiovascular or renal insufficiency (e.g., sodium or water retention and edema which may result in serious pulmonary edema); Arrested patients with preexisting metabolic acidosis, hyperkalemia, or tricyclic or barbiturate overdose; Elderly; Pregnancy (restrict intake in hypertension and toxemia). Adverse Drug Reactions: Common: Belching, gastric distention, flatulence, metabolic alkalosis, electrolyte imbalance, (sodium overload, hypocalcemia, hypokalemia, milk-alkali syndrome, dehydration), reduction in CSF pressure, intracranial hemorrhage, severe tissue damage following extravasation of IV solution, renal calculi or crystals, impaired kidney function Drug Interactions: Monitor closely with: Decreases the absorption of Ketoconazole Decreases therapeutic effect of the following drugs: Chlorpropamide, Lithium Carbonate, Salicylates, Tetracyclines Increases therapeutic effect of the following drugs: Appetite Suppressants (e.g., Amphetamines), Flecainide, Mecamylamine, Quinidine, Sympathomimetics (e.g., Ephedrine, Dopamine) NOTE: Sodium bicarbonate raises intra-gastric pH, which may affect the absorption of certain drugs. Administration: Should be taken on an empty stomach. Tablets may be swallowed whole or dissolved in water prior to use. Do NOT add oral preparation to calcium-containing solutions. Pregnancy Category: C ATC Code: A02AH FOR PEPTIC ULCER AND GASTRO-ESOPHAGEAL REFLUX DISEASE (GERD) H2-RECEPTOR ANTAGONISTS Rx (Inj.) OTC (Oral) FAMOTIDINE Oral: 20 mg tablet Inj.: 10 mg/mL, 2 mL ampule / vial (IM, IV) A competitive inhibitor of histamine H2­receptor, inhibiting both daytime and nocturnal basal gastric acid secretion, as well as food-stimulated and pentagastrin-stimulated gastric acid secretion. Indications: Relief and prevention of heartburn; treatment and maintenance of active duodenal ulcers, pathological hypersecretory conditions (e.g., Zollinger-Ellison Syndrome or multiple endocrine adenomas), Gastroesophageal Reflux Disease (GERD) and active benign gastric ulcer. Contraindications: Cirrhosis of the liver; impaired renal or hepatic function; lactation; other H2 antagonists. Dose: Duodenal ulcer, acute therapy, by mouth, ADULT, 40 mg daily at bedtime (or 20 mg twice daily) for 4-8 weeks. Duodenal ulcer, maintenance therapy, by mouth, ADULT, 20 mg daily at bedtime. Gastric ulcer, acute therapy, by mouth, ADULT, 40 mg daily at bedtime. Peptic ulcer, by mouth, CHILD 1-16 years, 0.5 mg/kg daily at bedtime or divided twice daily (maximum dose, 40 mg daily) (doses of up to 1 mg/kg daily have been used in clinical studies); by IV injection, CHILD 1-16 years, 0.25 mg/kg every 12 hours (maximum dose, 40 mg daily) (doses of up to 0.5 mg/kg have been used in clinical studies). GERD, by mouth, ADULT, 20 mg twice daily for 6 weeks; CHILD 1-16 years, 1 mg/kg daily divided twice daily (maximum dose, 40 mg twice daily) (doses of up to 2 mg/kg/day have been used in clinical studies); CHILD 3- 12 months, 0.5 mg/kg twice daily; CHILD <3 months, 0.5 mg/kg once daily. Esophagitis and accompanying symptoms due to GERD, by mouth, ADULT, 20 mg or 40 mg twice daily for up to 12 weeks. Hypersecretory conditions, by mouth, ADULT, initially, 20 mg every 6 hours, may increase in increments up to 160 mg every 6 hours. Patients unable to take oral medication, by IV injection, ADULT, 20 mg every 12 hours. Dose Adjustment: Renal Impairment: For creatinine clearance <50, reduce dose by half or increase dosing interval to 36–48 hours. Precautions: Increases risk of community-acquired pneumonia with prolonged use; prolonged treatment (≥2 years) may lead to vitamin B12 malabsorption and subsequent vitamin B12 deficiency; gastric malignancy.
  • 47. A ALIMENTARY TRACT AND METABOLISM 3 Elderly >50 years. Lactation (excreted into breast milk). Adverse Drug Reactions: Common: Headache, dizziness, constipation, diarrhea, nausea and vomiting, anxiety, confusion. Less Common: Acne, pruritus, urticaria, dry skin, fever, hypertension, flushing, musculoskeletal pain, arthralgia, tinnitus Drug Interactions: Monitor closely with: Decreases absorption of the following drugs: Cefpodoxime, Cefuroxime, Iron salts Decreases serum concentration of the following drugs: Indinavir, Multivitamins / Minerals with ADEK, Folate, Iron Increases the absorption of: Methylphenidate Increases serum concentration of Famotidine: Bupropion Avoid concomitant use with: Decreases absorption of Famotidine: Antacid Decreases absorption of Diazepam Decreases serum concentration of the following drugs: Atazanavir, Cefditoren, Itraconazole Ketoconazole (systemic) Increases serum concentration of Risedronate Administration: For oral administration, may be taken with or without food For IV injection or IV push, inject over at least 2 minutes. If administered by IV infusion, administer over 15–30 minutes. Pregnancy Category: B ATC Code: A02BA03 Rx RANITIDINE Oral: 150 mg and 300 mg tablet (as hydrochloride) 75 mg/5 mL syrup (as hydrochloride), 60 mL and 150 mL Inj.: 25 mg/mL, 2 mL ampule / vial (IM, IV, IV infusion) (as hydrochloride) A competitive inhibitor of histamine H2­receptor, inhibiting both daytime and nocturnal basal gastric acid secretion, as well as food- and pentagastrin-stimulated gastric acid secretion. Ranitidine is also a weak cytochrome P-450 enzyme inhibitor. Indications: Relief and prevention of heartburn. Management of duodenal ulcer, erosive esophagitis, gastric ulcer, GERD, pathological hypersecretory conditions (e.g., Zollinger-Ellison syndrome, systemic mastocytosis) Contraindications: Cirrhosis of the liver; impaired renal or hepatic function; acute porphyria Dose: Duodenal ulcer, acute therapy, by mouth, ADULT, 150 mg twice daily, or 300 mg once daily after the evening meal or at bedtime; INFANT, CHILD, and ADOLESCENT ≤16 years, 4-8 mg/kg daily divided twice daily (maximum, 300 mg daily). Duodenal ulcers, maintenance therapy, by mouth, ADULT, 150 mg once daily at bedtime; INFANT, CHILD, and ADOLESCENT ≤16 years, 4–8 mg/kg daily divided twice daily; 2–4 mg/kg once daily (maximum, 150 mg daily); by IM injection, ADULT, 50 mg every 6–8 hours; by IV intermittent bolus or IV infusion, ADULT, 50 mg every 6–8 hours (if increased doses are necessary utilize more frequent administration up to a maximum of 400 mg daily); by IV injection, INFANT, CHILD, and ADOLESCENT ≤16 years, 2–4 mg/kg daily divided every 6–8 hours (maximum dose, 50 mg/dose); by continuous IV infusion, ADULT, 6.25 mg/hour. Benign gastric ulcer, acute therapy, by mouth, ADULT, 150 mg twice daily; INFANT, CHILD, and ADOLESCENT ≤16 years, 4-8 mg/kg daily divided twice daily (maximum, 300 mg daily). Benign gastric ulcer, maintenance therapy, by mouth, ADULT, 150 mg once daily at bedtime; INFANT, CHILD, and ADOLESCENT ≤16 years, 2-4 mg/kg once daily (maximum, 150 mg daily). Erosive esophagitis, acute therapy, by mouth, ADULT, 150 mg 4 times daily, INFANT, CHILD, and ADOLESCENT ≤16 years, 5-10 mg/kg daily divided twice daily (maximum, 300 mg daily). Erosive esophagitis, maintenance therapy, by mouth, ADULT, 150 mg twice daily. Gastroesophageal reflux disease (GERD), by mouth, ADULT, 150 mg twice daily; INFANT, CHILD, and ADOLESCENT ≤16 years, 5-10 mg/kg daily divided twice daily (maximum, 300 mg daily). Heartburn, prevention, by mouth, CHILD ≥12 years, 75-150 mg 30-60 minutes before eating food or drinking beverages that cause heartburn (maximum, 2 doses daily), not to be used for more than 14 days. Pathological hypersecretory conditions (e.g. Zollinger Ellison Syndrome), by mouth, ADULT, 150 mg twice daily, adjust dose or frequency as clinically indicated (doses of up to 6 g daily have been used in patients with severe disease); by IM injection, ADULT, 50 mg every 6–8 hours; by continuous IV infusion, ADULT, 6.25 mg/hour, initially, 1 mg/kg per hour (measure gastric acid output at 4 hours, if >10 mEq or if patient is symptomatic, increase dose in increments of 0.5 mg/kg per hour) (doses of up to 2.5 mg/kg per hour (220 mg/hour) have been used by IV intermittent bolus or infusion); 50 mg every 6–8 hours (if increased doses are necessary utilize more frequent administration up to a maximum of 400 mg daily). Patients not able to take oral medication, by IM injection, ADULT, 50 mg every 6–8 hours;
  • 48. A ALIMENTARY TRACT AND METABOLISM 4 by IV intermittent bolus or infusion, ADULT, 50 mg every 6–8 hours; 50 mg every 6–8 hours (if increased doses are necessary utilize more frequent administration up to a maximum of 400 mg daily); by continuous IV infusion, ADULT, 6.25 mg/hour; by IV injection, INFANT, CHILD, and ADOLESCENT <16 years, 2–4 mg/kg daily divided every 6–8 hours (maximum dose, 50 mg/dose). Dose Adjustment: Renal Impairment: For patients with creatinine clearance <50 mL/minute, adjust dose cautiously. Adjust dosing schedule to not coincide with the end of hemodialysis. Precautions: WARNING: NOT to be used if there is trouble or pain when swallowing food, vomiting with blood, or bloody or black stools. NOT to be used in combination with other acid reducers. Avoid the use of 150 mg tablet for patients with kidney disease. Relief of symptoms does not preclude the presence of a gastric malignancy. Rare cases of reversible confusion have been associated with use, usually among elderly or severely ill patients, or in patients with renal or hepatic impairment. Prolonged treatment (≥2 years) may lead to vitamin B12 malabsorption and subsequent vitamin B12 deficiency. Decreased renal or hepatic function (use with caution). Elderly (use with caution) Pregnancy; lactation (excreted into breast milk; use with caution). Adverse Drug Reactions: Common: Headache, abdominal pain, constipation, diarrhea, nausea, and vomiting. Less Common: Asystole, atrioventricular block, bradycardia (with rapid IV administration), premature ventricular beats, tachycardia, vasculitis. Drug Interactions: Monitor closely with: Decreases absorption of the following drugs: Cephalosporins, Iron salts [except ferric carboxymaltose, ferric citrate, ferric gluconate, ferric pyrophosphate citrate, iron dextran complex, iron sucrose] Enhances therapeutic effect of: Procainamide Reduces therapeutic effect of: Warfarin (decreased prothrombin time) Avoid concomitant use with: Decreases absorption of the following drugs: Cyanocobalamin / Vitamin B12 Decreases serum concentration of Azoles, e.g., Ketoconazole Decreases therapeutic effect of Ranitidine: Cigarette smoking Decreases therapeutic effect of Diazepam Administration: For IM administration, no dilution is required. For IV administration, solution must be diluted. May be administered by intermittent bolus, intermittent IV infusion, or continuous IV infusion. Pregnancy Category: B ATC Code: A02BA02 PROTON PUMP INHIBITORS Rx LANSOPRAZOLE Oral: 15 mg and 30 mg capsule 15 mg and 30 mg MR tablet A substituted benzimidazole, which acts as a proton pump inhibitor (PPI), by blocking the final step of acid production. It acts by inhibiting the H+/K+–ATPase system at the parietal cells of the stomach, suppressing both basal and stimulated gastric acid secretion. Indications: Management of acid-related dyspepsia, erosive esophagitis, Gastroesophageal Reflux Disease (GERD), peptic ulcer, Helicobacter pylori infection, NSAID- associated ulcer, Zollinger-Ellison syndrome. Contraindication: Known severe hypersensitivity to lansoprazole or any ingredient in the formulation Dose: Acid-related dyspepsia, by mouth, ADULT, 15–30 mg once daily in the morning for 2–4 weeks. GERD, acute therapy, by mouth, ADULT, 15–30 mg once daily in the morning for 4–8 weeks. GERD, maintenance therapy, by mouth, ADULT, maintenance therapy, 15–30 mg once daily (adjust dosing according to response); CHILD 12–17 years, 15 mg once daily for up to 8 weeks; CHILD 1–11 years (≤30 kg), 15 mg once daily in the morning for up to 12 weeks; CHILD >30 kg, 30 mg once daily in the morning for up to 12 weeks (may increase doses up to 30 mg twice daily if patient is still symptomatic after 2 or more weeks of treatment). Erosive esophagitis, acute therapy, by mouth, ADULT, 30 mg once in the morning for up to 8 weeks; by IV injection, ADULT, 30 mg over 30 minutes for up to 7 days; CHILD 12–17 years, 30 mg once daily for up to 8 weeks; CHILD 1–11 years (≤30 kg), 15 mg once daily in the morning for up to 12 weeks; CHILD >30 kg, 30 mg once daily in the morning for up to 12 weeks (may increase doses up to 30 mg twice daily if patient is still symptomatic after 2 or more weeks of treatment). Erosive esophagitis, maintenance therapy, by mouth, ADULT, 15 mg once daily. Peptic ulcer, acute therapy, by mouth, ADULT, 15 mg once daily. Peptic ulcer, maintenance therapy, by mouth, ADULT, 30 mg once daily in the morning for up to 4 weeks (for duodenal ulcer) or up to 8 weeks (for gastric ulcer).