Saturday, September 5, 2009

Simple Ways of Maintaining Health

At times, we are too obsessed about our health; or we just simply ignore our health.

Either way, it's not going to help us to stay healthy and enjoy our life.

Health is a lifestyle, a process. It's not an end-product.

The key points:
  • Eat less
  • Move more (Exercise more)
  • Sleep more
Eating is a pleasure in life. But it will slowly kill us if we eat too much. Especially, when we are eating sugar.

You might think I am crazy for saying we are eating sugar.

But think about it, each time you eat a full bowl of rice (be it white, brown, red), you are actually eating a full bowl of sugar (after digesting, rice will turn to sugar: starch turns sucrose turns glucose).

What more, the fat we are consuming, plus all those preservatives and coloring agents.

We are killing ourselves by eating more.

How about to move more? Each day, we are very static.

The amount of foods we are eating, are providing us a lot of energy. But by moving less, we are not using the energy, and it will turns into fat, deposited in our body, and slowly clogging around our bodies, causing a variety of chronic diseases.

And talking about sleeping. We are having too many activities going on in our life. We forgot we are made of flesh and bones, not iron.

Our body need rest, so as our brain.

So, instead of being over-productivity, please, sleep more.

If we can live our life according to these 3 principles, we are moving towards healthy lifestyle.

The rest, are just details, and we can pick it up through the process of living healthy.

Enjoy it.

Saturday, August 22, 2009

WHO Guideline on Pharmacological Management of Pandemic (H1N1) Influenza

WHO had just issued (20th August, 2009) the guideline for the use of antivirals in the management of patients infected with H1N1 pandemic virus.

The emphasis of the guideline was on the use of oseltamivir and zanamivir to prevent severe illness and deaths, reduce the need for hospitalization, and reduce the duration of hospital stays.

The H1N1 virus is currently still susceptible to both oseltamivir and zanamivir (neuraminidase inhibitors), but resistant to the M2 inhibitors (rimantadine and amantadine).

So far, worldwide, most patients infected with the virus experienced typical influenza symptoms and fully recover within a week, even without any form of medical treatment. Healthy patients with uncomplicated illness need not be treated with antivirals.

However, this is just a weak recommendation with low quality evidence. It should be based on clinical assessment and how the virus is spreading throughout the community.

In areas where the virus is circulating widely in the community, doctors seeing patients with influenza-like illness (ILI) should assume the H1N1 is the cause. Treatment decisions should not wait for laboratory confirmation.

'At risk' group defined by WHO included:
  • Infants and children aged less than 5
  • The elderly (>65 years)
  • Nursing home residents
  • Pregnant women
  • Patients with chronic co‐morbid conditions such as cardiovascular, respiratory or liver disease, diabetes
  • Those with immunosuppression related to malignancy, HIV infection or other diseases
For 'at risk' population, WHO recommends treatment with either oseltamivir or zanamivir. They should receive treatment as soon as possible after symptom onset, without waiting for laboratory confirmation.

For patients present with severe illness or whose condition begins to deteriorate, WHO recommends treatment with oseltamivir as soon as possible, preferably within 48 hours after symptom onset. However, even after 48 hours, treatment should also be provided.

This recommendation covers all patients groups. The dose of oseltamivir can be given up to 150mg twice daily and longer than 5 days based on clinical response.

Clinical deterioration is characterized by primary viral pneumonia, which destroys the lung tissue and does not respond to antibiotics (sometimes, with the failure of multiple organs, including the heart, kidneys and liver). This type of patients require management in ICU in addition to antiviral (oseltamivir).

How about children?

They are classified as 'at-risk' group, however, they should be treated if presented with severe or deteriorating illness, or if they are at risk of more severe or complicated illness.

For pregnant women, WHO recommends treatment should be started once the symptom onset. (Although the studies on oseltamivir in pregnant women not yet established)

Below is the table to summarize the recommendations:

Healthcare professionals need to be alert to danger signs that signal progression to more severe disease. The progression can be very rapid, medical attention is needed when any of the following signs appear in a patient with confirmed or suspected H1N1 infection:
  • Shortness of breath
  • Difficulty in breathing
  • Turning blue
  • Bloody or coloured sputum
  • Chest pain
  • Altered mental status
  • High fever that persists beyond 3 days
  • Low blood pressure
As zanamivir is the only alternative to oseltamivir, it should be used when the patient show signs of resistant to oseltamivir.

Personal remark is:

Oseltamivir is not without adverse effects.

Common ones are:
  • Diarrhea
  • Nausea
  • Stomach pain
  • Vomiting
  • And of course, allergic reaction (can be mild like rashes, to severe like anaphylactic shock)
Noted that it has effects on central nervous system as well. So, please observe the patient if they are having such symptoms while taking oseltamivir (it might cause fatal outcome like suicide):
  • Abnormal behaviour
  • Confusion
  • Hallucinations
  • Mood or mental changes

Thursday, August 20, 2009

Protecting yourself from H1N1

Now we talk about how to protect yourself from H1N1 virus (and also normal flu virus).

In your everyday life, you should:
  • Cover your nose and mouth with tissue paper when you cough or sneeze. Immediately throw the tissue into thrash after using it. (Do not keep them!)
  • Wash your hand often with soaps and water, especially after you cough or sneeze.
  • Avoid touching your eyes, noses and mouth.
  • Try to avoid sick people.
  • If you are sick, please stay at home for at least 24 hours after the fever is gone, except if you are going to seek medical help.
  • Put on face mask if you are sick and really have to go out (seeking medical help, etc)
  • Boost your immune system, take foods with high vitamin C. If not possible, then take vitamin C supplement, with zinc. Plus, have enough sleep!
  • Hydrate youself.
If the government announces about school closures, avoiding crowds, and other social distancing measures, please do follow the instruction!

Doing all these, is not only protecting yourself, but to help spread the flu.

Don't be selfish. Act now!


Oseltamivir is now the blockbuster drug in whole world, including Malaysia.

It is a neuraminidase inhibitor.

The influenze neuraminidase releases newly formed viruses from infected cells, allowing them to spread from cell to cell. This inhibitor mimic the natural substrate of the influenze neuraminidase and bind to the active site, preventing neuraminidase from cleaving host-cell receptors and releasing new virus.

As H1N1 virus attacking Malaysia, out-of-control-ly, nothing preventive can we do now. The last resort is to prescribe (by doctor) and dispense (by pharmacist) oseltamivir (also known as Tamiflu) to those having influenze-like-illness (ILI), especially those having co-morbidities (obesity, diabetes, asthma, etc).

As oseltamivir is being used so extensively, antimicrobial resistance is our concern now.

First, we look at the rational use of oseltamivir.

The sooner the drug is taken after the onset of symptoms (within 48 hours), the better the clinical efficacy (subside of the symptoms in shorter period). If the virus has replicated and infected many cells, the effectiveness of this drug will be severely diminished.

And it should be used in recommended dosage and duration (normally is 75mg twice daily for 5 days; but now the MOH guideline increased the dosing regime up to 150mg twice daily up to 10 days for children more than 12-year-old and more than 40kg).

The over-extensive use of oseltamivir will cause the shortage of supply. That will inspire the sharing of supply, resulting in adequate treatment.

Another problem is the compliance issue. If counselling on this drug is not done appropriately, patients tend to stop taking once the symptoms are gone, regardless the course of treatment already completed, or not (a well-established tendency seen in antibiotic treatment).

The other problem is rather simple: the more you use one antimicrobial on one microorganism, the higher probability the microorganism will develop resistance towards the antimicrobial.

These will lead to the development of oseltamivir-resistance-strain of H1N1 virus.

It's just a matter of when, rather than will it happen or not (there were case of H5N1 virus resistant to oseltamivir already).

We should ensure the proper use of oseltamivir, rather than just providing unlimited supply of it to the public.

Human papillomavirus (HPV) vaccination

HPV vaccination is getting more and more popular these days.

It is not limited to female, but to male, now, to provide protection against human papillomavirus (HPV). (For male, it's still an unlabelled use, and they claimed that it will help spread the HPV if the vaccination extended to male population)

HPV can cause cervical cancer is discovered by Zur Hansen, the winner of Noble Prize in Physiology or Medicine in 2008.

So, the pharmaceutical companies started to develop vaccines for HPV. The theory is: If you can prevent HPV, you can prevent cervical cancer, too.

So simple? I wish so.

However, there are more than 100 types of HPV (and a study discovered that some of them are linked with development of hypertension too, so, that means vaccination for hypertension in the future?), and at least 15 of them are oncogenic.

Current vaccines only cover some of them:
  • Gardasil (from Merck & Co) covers type 16, 18, 6 and 11
  • Cervarix (from GSK) covers type 16, 18
HPV is the most prevalence sexually transmitted disease, however, the virus does not appear to be very harmful as most of them can be cleared by our immune system.

Only for some women, the infection will persist, and eventually develop into cervical cancer. However, till now, we do not have any tool or method to predict what type of woman will have such tendency.

As we cannot predict who will develop cervical cancer, we also cannot predict the effect of vaccine on the young girls and women, 20 or 40 years from now. We can only see the effect using long term clinical trial or follow-up.

Right now, what we have is studies on prevalence of cervical intraepithelial neoplasias grades 2 and 3.

There were adverse events reported on HPV vaccines, mostly on dizziness, headaches, and fever. Not very serious. There were also some serious events such as anaphylaxis, Guillain-Barre syndrome, transverse myelitis, pancreatitis, and venous thromboembolic events. However, we cannot conclude whether these adverse reactions were caused solely by the vaccines, or not.

The situations we are facing now, are:
  1. We do not know the net benefit of the HPV vaccines
  2. We do not know the long term harmful effect of these vaccines either
For medical professional judgement, we tend to weigh between benefits and risks, then to conclude whether a medical decision is sound, or not.

Now, how can we decide?

Economically, we look at the incentives.

If you are a woman/man, plan to live sexually active in the future (having multiple sex partners), taking the vaccine is definitely a good choice. But who will know what kind of life you will have in the future anyway?

And if you are already sexually active, it's already too late to have the vaccines.

And even if you already took the vaccine, it's not a guarantee that you are free from cervical cancer 100% throughout your life. You still need to do regular screening.

So, you should think about the cost (including the potential harmful effects) of the vaccines. before you take it.

How about consulting healthcare professionals?

Well, they are judging whether to take the vaccine, by weighing benefits vs risks as well. And it is important to ask who takes the risk, and who gets the benefits. Indeed.

(Take note that the so-called healthcare professionals' judgement are always clouded by the promotion strategies by pharmaceutical companies)

So, what's the conclusion?

The truth is, I don't have one for you. Sorry.

Saturday, August 1, 2009


Diarrhea = Increase frequency of bowel movement relative to normal for an individual

I don't have to explain to you what is normal in the definition mentioned above. Everyone has their own normal frequency of passing motion.

Why I am talking about diarrhea here?

Because it may cost your life if you don't manage it properly!


Loss of fluid through diarrhea can cause severe dehydration, and loss of electrolytes (sodium, potassium) and other nutriets.

It's fatal, especially for little children (or we call them infants).

Many factors can cause diarrhea, food poisoning is the most popular one.

Others include: Inflammatory bowel disease, irritable bowel syndrome, malabsorption problems, cancers, and drug-related.

The drugs that commonly cause diarrhea are:
  • Acarbose
  • Metformin
  • Antibiotics
  • Colchicine
  • Cytotoxic agents (Chemotherapy)
  • Sorbitol, mannitol, fructose, and lactose
  • Laxatives (of course)
  • Magnesium-containing antacids
  • NSAIDs
All patients presenting with diarrhea, should be questioned about the relationship between symptoms and changes of drug or initiation of of any drug therapy.

If it's drug-related, management of diarrhea should be focused on the cause (the drug), rather than treating the diarrhea with another drug therapy.

For chronic diarrhea, the management also should be focused on the cause (the underlying disease), rather than keep giving drug therapy.

For acute diarrhea, first thing to do is the fluid replacement: Oral rehydration therapy!

Oral rehydration solution (ORS) is made of water, with salts (potassium, sodium) and glucose.

Commercial-packed is available in most (I should say All) pharmacy stores.

Simple instruction will be:
  • Everytime after having loose stool (during the period you are having diarrhea), mix a packet of ORS into a cup of warm water, and drink it.
  • Of course, you need to further rehydrate yourself with your normal daily intake of fluids.
It sounds simple, but it saves lifes.

How about drug therapy?

Well, it's not really recommended, cause diarrhea is a symptom your body to 'detox'. To stop the diarrhea, is to stop the toxins that causing the diarrhea from clearing off your body. It might delay the recovering process.

It is recommended only for social convenience (you need to work, or go to an important meeting, conference, and so on).

The drug therapy is the antimotility. It's not (never) indicated for infants and children.
  • Loperamide
4mg orally initially, then followed by 2mg for each loose stool. (Maximum: 16mg daily)
  • Diphenoxylate 5mg + atropine 0.05mg (popularly known as Lomotil despite of the availability of various generic versions)
1 tablet orally 3 to 4 times daily.

The drug therapy should be stop if there is no more loose stool. It should not be taken for long term.

Sometimes, you can supplement the drug therapy with activated charcoal, to help adsorb the toxins and cleared from the GI tract. But it should not be taken with the drug, as it may reduce the absorption of the drugs.

Remember to see the doctor if you get any of these symptoms:
  1. Bloody diarrhea or pus in the stool
  2. Headache, stiff neck and fever
  3. Fever that lasts more than 24 hours
  4. Faintness, rapid heart rate, or dizziness after sitting or standing up suddenly
  5. Diarrhea that not improved (recovering) after 3 days
  6. Weakness, numbness, or tingling, usually in the arms or legs, but sometimes around the mouth

Friday, July 24, 2009

In reality

In reality, the medications that you are taking, are not only the products of the decisions of the healthcare team. There are many 'commercial' factors.

Let's say in hypertension guidelines, it's listed that ACEI or ARB will be the first line treatment. But which one in these groups are to be used?

Unless you are having other diseases, like kidney failure, or chronic liver disease, which will affect the choice of drug in more precise way, I don't think the healthcare team really have the clear idea of which one to give you.

So in the end, which one to use?

To use those more familiar one.

Well, that's the trick behind it. Those you are familiar with, are either those very established, existed for a long long time, and appeared to be very safe; or, those new drugs that the drug companies keep promoting to the healthcare team.

Normally, the healthcare team will tend to forget about the drugs that are existed very long time with good safety profile. Those, will be only extensively mentioned in text book. It is kind of 'uncool' of the young doctors or pharmacists to deal with them.

So, which left the latter one: Those new drugs that the drug companies keep promoting about.

New drugs mean: New, with lesser safety profile, and slightly (sometimes significantly, but quite rare) more effective than the old drugs; and of course, claimed to be having lesser side effects.

How intensive is the promoting?

Well, you can see the name of the drugs on the pens, the folders, notebooks, reference books, and even guidelines printed by drug companies.

The healthcare team is basically brainwashed by the drug companies every day.

Plus, the obviously biased data provided by the drug companies, with nicely designed charts and figures.

To some lucky ones, they might have incentives if they prescribe more than certain amount of the certain drugs.

How nice. The healthcare team has so so much to gain.

What about the price that the public bear?

More expensive, but just slightly better, with unknown risk ahead.

Who cares?