孕妇可以吃药吗？

每一个准妈妈的怀孕历程都不同。有的和平时一样， 就像美国一个距离预产期两个星期的孕妇竟然还能挺着大肚子举重。 可是有的孕妇却在怀孕期间吃尽了苦头，身体不断出状况。而在怀孕期间生病能吃药吗？

其实，并不是所有的药物都对胎儿有害。根据世界卫生组织网站2014年1月的资料显示，每33个婴儿当中，有一个会患有先天性疾病或身体缺陷。药物所导致 的先天性异常只占了少数一部分。其他因素如营养不良，遗传，传染病，化学品，高剂量辐射，烟，酒和环境等因素其实更为普遍。而这当中有一半以上都很难找出 具体的原因。

为了孕妇的安全，不同国家把药物在怀孕期间分类的方法都不同。我国根据美国食品和药物管理局 (FDA) 的标准，把药物分类成A, B, C, D, X 五个等级。A和B级的药物一般都可安全使用，C和D级的药物则可能会对胎儿造成损害，可是却对孕妇的病况有益。而X级的药品属于怀孕中禁止被使用的药物如口服暗疮药isotretinoin。

除了药物的等级，其他因素如药物的剂量，持续服用的时间和在哪一个怀孕周期服用都会对胎儿有影响。在卵子受精后20至55天，或停经后5至10周是胎儿器 官成型期 (organogenesis) 。在这时期，孕妇不应擅自服药。有的时候，同样的一种药物在怀孕早期的和晚期会带来不同的影响。 比如在怀孕早期，孕妇并不适合服用有pseudoephedrine成分的感冒药。但是在怀孕晚期如果短暂如一至两天使用却可以被接受。

孕妇也不应擅自停药。如果在怀孕前就患有慢性疾病如高血压，糖尿病，癫痫，气喘等，此类疾病如果控制不当所带来的不良影响远比服用药物还来得高。举个例子，许多常见的高血压药物如perindopril, losartan等并不适合在怀孕期使用，必须得换成另一种药物。患有高血压的准妈妈不应擅自停药，而应在计划怀孕前就咨询医生或药剂师，她们所服用的药物是否适合？

其他怀孕期常见的疾病如孕吐，感冒，胃灼热，便秘，痔疮，头疼， 妊娠期糖尿病和高血压，有许多A和B级的药物可以使用。比如发烧药paracetamol,感冒药loratadine,咳嗽药diphenhydramine,胃药ranitidine，antacids和胰岛素等等。孕妇可向医生或药剂师询问药物的等级并商量到底她们的情况是否该服药。

 

旅游六大常用药品

旅行是一个让身心充电的好方法。不管您是独自上路还是全家老少一齐出动，请记得携带一些简单的药品以备不时之需。以下是六种旅游常用药品供大家参考。

1）感冒药

感冒病毒容易在人潮多和空气不流通的地方传播。除此以外，面对大幅度气候及温度转换也会容易让人患上感冒。备有退烧药如 paracetamol,能有效退热和减轻咽喉不适。令外， antihistamines能舒缓流鼻水和打喷嚏等症状。

2）口服补液盐

如果不慎吃了不卫生的食物而导致轻微的腹泻和呕吐，及时补充口服补液盐，oral rehydration salt能帮助补充身体流失的盐分和水分。此外，一些能吸附毒素的药品如charcoal和smectites，和减少肠胃蠕动的药品如loperamide 和atropine diphenoxylate 能暂停腹泻的症状，都是不错的旅游良伴。

3）胃药

品尝美食是旅途中不可或缺的。如果吃了太多辛辣，煎炸和油腻的食物，再加上因为赶路而没有定时进食，经常会引起消化不良，造成上腹部疼痛及不适。这时候胃药如小包装方便携带的液状antacids,或者胃片能帮助减少疼痛。其他口服胃药如ranitidine, famotidine 药效持续时间较长，适合旅途使用。

4）过敏药

若旅途中接触一些新物品，如穿戴新饰品或者碰触动植物而出现皮肤红肿，可以口服antihistamines和擦上消炎药膏如hydrocortisone。

5） 晕车药

感觉晕头转向，随即伴有噁心和呕吐的症状不只发生在车里，也常见于其他交通工具如飞机，船和火车上。旅客可在乘搭交通工具半小时前服用dimenhydrynate 和meclozine 等药品以避免不适。只是此类药物能导致昏昏欲睡。

6） 外用药品（外用止痛药，驱蚊剂，防晒霜）

外用止痛药如含有ketoprofen,diclofenac 成分的药膏和贴片能减轻因常久保持同一坐姿或步行太多而引起的肩膀酸痛和肌肉疼痛。此类外用的止痛药不逊于口服止痛药，而且能够避免口服止痛药所带来的胃痛和胀气等不适。另外，若到郊外露营或者郊游要避免被蚊虫叮咬，旅客们可穿上长袖衣裤并在衣服上喷上驱蚊剂。药剂行出售的驱蚊剂琳琅满目，而且多由天然的植物制作而成。最后，防晒霜能够保护我们的皮肤免受紫外线的伤害。出门时记得在半小时前擦上，并在太阳曝晒下每两个小时内重复使用。

以上所列的药品，纯属参考。旅客们也须记得携带日常服用的其他慢性疾病药物。如果发现自身或旅伴的症状在服用药物后没有改善，并有加剧的象征，请即刻到邻近的医院就医。

 

How far can clinical pharmacists go?

I have been working as a clinical pharmacist for 3 years plus. The daily job of a clinical pharmacist including following doctor's ward round, answering drug related enquiries,  examining medication charts, elicit patient's medication history, counsel patients who need to be started on new devices or new drugs and dispensing the discharge medications to the ward patients. We also work in an ambulatory clinic such as warfarin medication adherence clinic (MTAC), diabetic clinic, chronic kidney disease clinic, methadone clinic, respiratory clinic and etc.

It has been a while since I feel that working as a ward pharmacist is "looking good but going nowhere". Reading articles from David Gibson at http://www.pjonline.com/clinical-pharmacist/2014_feb/piece_of_the_jigsaw makes me wonder how far can a clinical pharmacist go in the future and whether the profession as clinical pharmacists will disappear in the near future.

In view of we are trained as pharmacists, we deal with medications and not diagnosing patients. Although in recent years, there are guides and books coming out in the US to teach pharmacist in physical examination of patients, what has been provided in the university or workplace is still not adequate to replace an actual diagnosis. Our recommendation rely very much on the doctor's diagnosis. The management plan can be not working not that our recommendation is inappropriate, but it is just because the diagnosis is wrong.

An experience doctor who know how to diagnose usually will know how to manage the patients and how to monitor the result after the management was perform on the patient. Maybe what we do was just fine-tuning on dosing, and selection of certain drugs, but  In view of the increasing in numbers of specialists with so many different types of sub-specialty, consultants, are the clinical pharmacist actually redundant??? Where are the clinical pharmacists heading to? What are we trying to achieve? Is it necessary that we go through the training by doctors to understand the patients more? If we really go through doctor's training, then why don't we change our title to doctor???

Liver abscess

There is this Indian uncle who had admitted to my ward complaining of fever for 3 days and worsening abdominal pain for 1 week. Patient is an alcoholic. Initially he was suspected to have acute calculus cholecystitis and meliodosis. However, CT scan showed that he actually had liver abscess. (a pus filled cavity in the liver).

His blood culture and sensitivity taken on admission showed present of Enterobacter Sakazakii. As there is multiple loculi, and the size of each of the loculus was small, there is no indication for surgical drainage of the abscess. Therefore the surgeons plan to start on conservative management, which is starting antbiotics treatment. So, for how long should we give the antibiotics???

There are 3 types of liver abscess, namely pyogenic, amebic and also fungal liver abscess. In this article, lets discuss pyogenic and amebic liver abscess. Pyogenic abscess is usually present as multiple loculi on the CT scan and commonly cause by gram negative enteric organism such as Klebsiella pneumonia, Enterobacteriacae, enterococcus, anaerobics. On the other hand, amebic liver abscess is usually present as single loculus caused by parasite Entamoeba histolytica. The antibiotics required for this 2 types are different.

Patient in this case received antibiotics (IV cefoperazone 1g BD and IV metronidazole) for 5 days and later discharge with Tab cefuroxime 250mg BD and Tab metronidazole 400mg TDS for 6 weeks. The careless houseman in charge only prescribed 1 week antibiotics for him. Luckily the error was later amended after being informed by us. (this HO did not even show a slight appreciation!!!!! OMG, seriously beh tahan with her "DO I CARE" face. Can't she just say THANK YOU???)

Come back to the case, the national antibiotics guidline in Malaysia back in 2008 is not clear... The guideline only mentioned that patient should be treated until clinical improvement achieved. In pyogenic liver abscess, the choice of IV antibiotics include:
IV Ampicilin + IV Metronidazole + IV Gentamicin, x 2 weeks (Effective but resistant toward ampicilin increased and Gentamicin may cause nephrotoxicitiy)
or
IV Ampicillin/sulbactam alone x 2 weeks. (metronidazole may be added if cant rule out amebic)

Then, the alternative agents include:
IV 3rd gen cephalosporin + IV Metronidazole x 2 weeks or
IV ciprofloxacin + IV Metronidazole x 2 weeks.

For amoebic liver abscess, IV metronidzole 500mg TDS may be started for 10 days and Tab Tinidzole 2g OD for 3-5 days.

Then from Sanford guideline, pyogenic liver abscess may be treated with:
IV metronidazole + (IV ceftriazone or IV ciprofloxacin or IV Pip/Tazo or IV Amp/Sulbactam)
and amebic liver abscess with metronidazole, however the duration was not mentioned.

A search on the total duration of antibiotics patient should received is unclear and inconclusive. The suggested duration include IV antibiotics for 2 to 3 weeks followed by oral anitbiotics for 3 to 12 weeks. The common practice in Hospital Selayang as informed by one of the doctor is IV antibiotics for 2 weeks followed by 6 weeks oral antibiotics.

In the Malaysia ICU antibiotic guideline, pyogenic liver abscess required 6 weeks of oral antibiotics while amebic liver abscess only require 7 to 10 days of therapy followed by a luminal agent for gut colonisation. Suggested regimen for those who is hemodynamically unstable are:
IV Pip/Tazo + IV metronidazole  ---- prefered
IV Cefepime + IV metronidazole ---- prefered
IV Meropenem + IV metronidazole ---- alternative
IV Imipenem/Cilastatin + IV metronidazole ---- alternative

Then for those who is hemodynamically stable are:
IV Ceftriaxone + IV metronidazole
IV Pip/Tazo + IV metronidazole

The SD number for patient is SD330816 for future reference.

Onychomycosis (Nail infection)

My doctor asked me regarding the choice of drug in onychomycosis (nail fungal infection) today. She informed that patient's condition was severe and topical antifungal did not help and oral antifungal may be needed in this patient.

Itraconazole can be use in this kind of patient. The dose and duration for this infection is very unique and it worth to be keep in mind.

1. For onychomycosis which involve fingernail only:
200mg BD x 1 week, then off for 3 weeks, followed by 200mg BD for another week.

2. For onychomycosis which involve toenail (Trichophyton rubrum or T. mentagrophytes):
200mg BD x 12 consecutive weeks

3. For onycomycosis (toenails with or without fingernail involvement):
200mg OD x 12 weeks OR 200mg BD x 1 week, repeat 1 week course twice with 3 week off time between each course.