Part I: Understanding Gastric

Gastric pain is a common problem in our community. Try to look around you, perhaps you can discover some of your family members or friends are having this irritable problem. But, what is gastric? Generally, GASTRIC, sometimes called as DYSPEPSIA (indigestion) is a type of stomach discomfort and pain (stomach fullness, bloating, and nausea). Gastric can be termed as gastrointestinal esophageal reflux disease (GERD) if it is related to acid reflux and heartburn. Gastric can be persistent or recurrent.

Note: The LOWER ESOPHAGEAL SPHINCTER muscles opens (relaxes) to allow food to pass through stomach and closes (contracts) to prevent food entry into stomach. Acid reflux occurs when the sphincter muscle does not contracts completely, allowing gastric acid and semi-digested food to push back into the oesophagus. Eventually, it causes heartburn, a feeling of discomfort and burning sensation in the chest and throat, sometimes accompanied with nausea.

What is the triggers of gastric/GERD? Who is at risk of gastric/GERD?

Diet with high content of fats, oils, coffee, alcohol, and citrus fruits can trigger gastric. Persistent and intense stressful lifestyle (anger and hostility) can increase the amount of acid in the stomach. With most of the people living their stressful and hectic working lives, people tends to have irregular meal that will make harm to the stomach. People with weakened immune system (kidney failure, viral infection) have higher risk to suffer from gastric. Long-term use of certain medication (particularly pain killers known as NSAIDs) can increase the risk of gastric incidence. Acid reflux (GERD) and asthma are sometimes interrelated, meaning they may trigger one another. Certain asthma medication (theophylline and bronchodilators e.g. salbutamol) can cause esophageal sphincter muscle to relax, allowing the stomach contents to flow back into the throat. The stomach contents may then enter the lungs (aspiration) and irritate the airways.

How to know which type of gastric you are having? If you have the symptoms of gastric pain, your pharmacist might dispense you some medication but you are advised to go for a checkup to find out the cause of gastric. The first approach of the checkup will be endoscopy so that the doctor can observe whether there is any presence of stomach ulcer and inflammation along the digestive tract. In this procedure, you will required to fast or have at least 8 hours without having any meals in order to clear your digestive tract for better visualisation. You might require to be hospitalised in order to perform the procedure whereby a thin, flexible telescope will put into your throat to your stomach.

 If the test result is normal with no ulcer shown, this type of gastric is termed as FUNCTIONAL DYSPEPSIA. There is no particular cause for this gastric and mainly due to weakened lower oesophageal sphincter, causing an acid reflux problem (can refer to the risk/triggers of gastric above). Majority of the people suffered from functional dyspepsia  but they usually do not benefit from gastric medication for examples H2 blockers or proton pump inhibitors (PPI). However, they  can consider antacid, which is available over-the-counter to relieve the pain rapidly if needed. If there is inflammation on the wall of gullet, this indicates that you are having acid reflux (GERD). On the other hand, NON-FUNCTIONAL DYSPEPSIA can be classified if the result shows the presence of peptic (stomach) ulcers. In this case, gastric medication will be beneficial and further test of Helicobacter pylori (H. pylori) will be carried out.

What is H. pylori?  H. pylori is a stubborn bacteria that have hairs to punch holes in our stomach, causing ulcers (as shown in the picture above). This bacteria can be detected through urea breath test, blood test or even stool sample or a biopsy sample taken during an endoscopy. In most of the case, if H. pylori is found, then it is likely to be the cause of the ulcer. H2 blockers or proton pump inhibitors (PPI) for acid suppression will be given along with the antibiotic as a whole course of H. pylori treatment (at least 1 week).

If H. pylori is absent, doctor will collect some information from you and identify the triggers of your gastric. For instance, if you are taking pain killers for long-term, you have higher risk in developing gastric problem and it may worsen your pre-existing gastric problem. Pain killers (non-steroidal anti-inflammatory drugs (NSAIDs)) for example aspirin, ibuprofen, diclofenac, mefenamic acid, and naproxen may be the cause of your gastric. To avoid gastric problem, you are advised to take pain killers only when necessary and not on regular basis.

If the cause is still unknown with persistent stomachache, accompanied with some alarming symptoms (difficulty swallowing, weight loss, black stools and persistent vomiting with blood), more investigation is needed. The condition can be presence of gallstone or even throat cancer (Barrett’s esophagus), stomach cancer and liver cancer. Infection with H. pylori seems to be a major cause of stomach cancer. Other risk factors could be: family history, tobacco use, and unhealthy diet.

Alright, that’s all for now. A full detailed of gastric medication (highlighted in light blue) will be further discussed in Part II. Stay tuned.

Author:

Lok Ker Yee

B Pharm (Hons) (IMU)

Editors:

Ong Jijien

B Pharm (Hons) (IMU)

Tan Sue Fern

B Pharm (Hons) (IMU)

Jordy Wong Der Yuan

B Pharm (Hons) (IMU)

Oral Contraceptive Pills - Part 2

To all the ladies who had been taking oral contraceptive pills (OCPs) for quite some time, have you all ever wondered what you are actually taking? 

Do you know what these little pill contains and its potential side effects?

Do you know that there will be a risk of deep vein thrombosis (DVT) if you are taking the OCPs as a smoker? 

It sounds insane but this is the truth!

But first, let’s understand the whole picture of the oral contraceptive pill.

So, we had discussed on the ''morning after pills'' in the previous article entitled "Oral Contraceptive Pills - Part 1". If you are interested to know more or had not gone through it, please click into the link:

Link: http://storyofdrugs.blogspot.my/2016/05/oralcontraceptive-pills-part-1-how-much.html

This article will mainly discuss on the combined oral contraceptives (COCs). The Progestin-only pills (POPs) will be discussed in next article "Oral Contraceptive Pill - 3".

The combined oral contraceptives (COCs), also known as the regular birth control pills, consists of two female hormones, namely oestrogen and progesterone while progestin-only pills (POPs) has only progesterone in it. As the POPs do not contain any oestrogen, it may not have as many side effects compared to the regular birth control pills. Do take note that Progestin and progesterone are the same hormone, so get confused when you come across these 2 throughout the article.

The combined oral contraceptives (COCs) are highly effective. Among all women who correctly and precisely used the COCs, less than 1 percent of them will actually get conceived during their first year of using COCs.

The following pictures are examples of the combined oral contraceptives (COCs).

Questions Frequently Asked

1. When should you consider a regular birth control pill?

      When you need to take more than 2 course of "Escapelle/Postinor2" in a month or more than one Ella pill in a month.

      When other contraception methods, such as using condom or diaphragm, are not desired.

2. This is my first time taking the daily birth control pill. How should I take it?

It is recommended to take the first tablet on the first day of your menses because it will protect you from getting pregnant after your menses. Besides that, it should be taken daily at the same time if possible to avoid fluctuations of your hormones.

One strip of COCs usually contains 21 tablets for 21 days of administration. Once you had finished the 21 days course, there should be 7-pills-free-days and your menses should come within this period. A new pack should be continued after the free pills period.

Meanwhile, there are also the "EveryDay pills" which have 28 pills in a strip, with a 21 active tablets and 7 tablets with inactive ingredient.

It is your own choice on whether to take the inactive tablets but it will definitely help people who tend to be forgetful. So, if you had decided to take both active and inactive tablets, you must take the tablets in a right order. For example, you should take the pills according to the numbers stated on the strip as shown in the picture to avoid mistakes from occurring and you continue a new pack straight away after you had finished the strip.

3. What should I do when I take the pill later than my usual administration time (less than 24 hours)?

If you usually take the regular birth control pill at 8 a.m. (morning) and you only realized that you had forgotten to take it only in the afternoon or in the evening. Please take the pill as soon as you remember and continue your routine on the next day.

4. What should I do when I missed my pills?

Missed 1 pill: More than 24 hours but less than 48 hours without taking the pill.

Missed 2 pills or more: More than 48 hours without taking the pill.

Missed 3 pills or more: More than 72 hours without taking the pill.

5. Is it safe to take the regular birth control pills while I am an active smoker?

The answer definitely is a big "NO" because there will be an increased risk of deep vein thrombosis (DVT). Let's read further to understand what DVT is and why is that so.

DVT is a condition in which blood clots are formed in the vein, most commonly in deep vein of lower limbs.

Why is this condition dangerous?

The blood clots often dislodge from the deep vein and enter into the bloodstream to become an embolus (mobile blood clot). The mobile blood clot may end up obstructing the blood vessels in other areas and cause other complications, for example, in brain (stroke) and in lungs (pulmonary embolism - obstructed blood vessels in lungs).

How does smoking increases DVT risks in people taking birth control pill?

Cigarette contains numerous toxic chemicals, which will damage the blood vessels and will thicken the blood, leading to an increased risk of blood clot formation in an undamaged blood vessel.

Moreover, taking the oestrogen-containing birth control pill, which definitely increases the stickiness of the blood, which is a well-established risk factor for DVT. Hence, there will be further increased risk of DVT in an active smoker who are taking COCs. Aside from the DVT risks, an active smoker who are taking COCs will be at risk of heart attack and stroke due to the same reason as well.

6. Is it safe to take the regular birth control pills while I have high blood pressure?

Most of the COCs can cause a small increase in blood pressure. In fact, using regular birth control pills in a patient with high blood pressure can increase the risk of heart attack and stroke. So, please consult the doctor before starting any birth control pills especially if you have high blood pressure.

However, there are certain brands with Drospirenone (new generation of progesterone hormone) which can be used in patient with high blood pressure. Due to the fact that Drospirenone has diuretic (removing water from the body) effect, it will be more suitable than other COCs to be used in this group of patient. However, you still consult your doctor or pharmacist before choosing any birth control pills for yourself.

After reading these, are you more familiar with your regular birth control pills right now? We welcome any questions that pops out from your mind so don’t feel shy and go ahead and share it with us. Our team will try our very best to clarify your doubts in our next post "Oral Contraceptive Pills - Part 3".

Meanwhile, are you curious on what our next article will be about?

 If you ever experienced any "heartburn" - upper abdominal discomfort with burning feeling, please stay tune to our next article to know more about the gastric medications available for immediate relief and control.

Have a great week ahead!

Written by:

Jordy Wong Der Yuan

BPharm (Hons) (IMU)

Edited by:

1. Chang Jen Nee

    BPharm (Hons) (IMU)

2. Ong Jijien

    BPharm (Hons) (IMU)

Misconceptions on Eye Drops

By Jen Nee Chang

Edited by Jijien and Jordy Wong

Misconception #1

I can use my eye drops after the expiry date

It is not recommended to use any medications after the expiry date or 1 month since the opening of the eyedrop container as its stability might change and the medication may not be effective as before. Besides that, the preservative inside the eyedrop will be ineffective after the expiry date or 1 month since the opening of the eyedrop container. Hence, this will lead to contamination of the eyedrops and usage of the contaminated eyedrops might lead to increased risk of bacterial infection.

For normal eye drops (Systane Ultra, Refresh, Natural Tears and others), it is highly advisable to dispose it 1 month after the opening date even though it is placed in the fridge. There are certain brands of eye drops, namely Optive or Hylo-Comod, are allowed to be kept for 6 months. Hence, it is important to read the consumer’s leaflet or discuss with your pharmacist on anything that you are unsure about.

Misconception #2

I can share my eye drops with anyone

Not everything can be shared especially eye drops as you may accidentally spread your eye infection to someone else. Even though you are unable to finish the whole bottle of your eye drops, disposing it is always the best choice rather than passing it to your family member who have the same condition. Besides that, not all eye drops are meant for the same indication. There are some eye drops that are available with different concentrations, such as Timolol (0.25% and 0.5%) for glaucoma.

*Timolol 0.25% eye drop is not available in Malaysia.

Misconception #3

The more I drop the drops into my eye, it more it will absorb

The recommended drops for normal eye drops are usually 2-3 drops every 3-4 hours or when necessary. There is no point for you to drop half the bottle at one go as your eye does not have such huge storage capacity and it will go to a waste from dripping down to your face. However, please use the medicated eye drops according to the instructions from the pharmacists or your physician because medicated eye drops may have a different instruction compared to the normal moisturizing eye drops.

Misconception #4

I can store my eyedrops anywhere I want

All medications has its own storage stability. In case you haven’t noticed about it, most medications are recommended to be placed away from direct sunlight or hot places such as the car or in the kitchen. As for eyedrops, it is best to be placed in a cool place or in a refrigerator. Please follow the instructions on the eye drop container.

Misconception #5

I can just use normal lubricant eye drops for itchy eyes

There are many causes for itchy eyes. It can be due to bacterial infection or allergies. Lubricant eye drops, namely Eye Glo or Optrex, are basically for normal tired or to refresh the eyes. Those lubricant-type eye drops are not medicated.

Meanwhile, medicated eye drops, such as Naphcon A, is suitable for itchy and redness in the eye. Naphcon A, containing pheniramine which is topical antihistamine (an agent to reduce allergic response, such as itchiness) and naphazoline which is a vasoconstrictor (an agent to narrow the eye blood vessels to reduce eye redness). However, it is important to remember that red eyes with itchiness are not necessary only caused by allergic responses. Hence, Naphcon A might not be useful in all types of patients with both red and itchy eyes.

If you experience matting of your eyelid especially when you wake up in the morning, having swollen eyelid or yellowish discharge from the eye, it is highly due to bacterial infection. You will need antibiotic eye ointments such as Terramycin ointment or Chloramphenicol ointment during the night time. The reason why it is recommended to use during the night is because it may cause blurring of your vision. Antibiotics eyedrops on the other hand such as the Nicol (Chloramphenicol) or Xepanicol (Chloramphenicol) eye drops can be used throughout the day because it is usually not associated with blurriness of the eyes.

Misconception #6

It is okay for me to apply the eye drops while wearing contact lens

Generally, all the medicated eye drops must not be used while wearing contact lens. However, there are only certain brands of non-medicated MOISTURIZING eye drops that are compatible with contact lens. Hence, it is very important to read the labels of the eye drops on whether it is compatible with your lens.

If your eye(s) is/are itchy or dry due to long period from wearing your contact lens, it is best for you to remove your lens before placing your eye drops. Contact lens also will prevent the absorption of the eyedrops.

If you are diagnosed with bacterial eye infections, it is necessary to dispose or throw away your current contact lens because your current contact lens are contaminated. Besides that, it is advisable that contact lens should not be worn until the eye infections are gotten rid of.

*Important note* for EVERYONE:

Do not use or apply any medicated eye drops/ointment without consulting to the pharmacists/ophthalmologist/your physician.

Precaution: look at the label of the bottle, many mistaken ear drops for eye drops.

Proper steps on how to apply eye drops:

1. Before using the eye drops, make sure your hands are clean by washing your hands with soap and warm water. Dry them with a clean towel.
2. While tilting your head back and look up, pull the lower lid of your eye down with one hand while holding the eye drops bottle or tube in your other hand (you may rest your hand on your forehead to keep it steady).
3. Place one eye drop or a small amount (about ⅓ length of your lower lid) of ointment inside your lower lid. The tip of the medicine bottle or tube should not touch your eye.
4. Blink and dab away the excess eye drop fluid with a tissue. For eye ointment, close your eyes and move the eyeball up and down few times before open eyes.
5. If you are prescribed both eye drops and eye ointment, use the eye drops first, otherwise the ointment may block the absorption of the eye drops.
6. If you have more than one type of eye drop to put in your eyes, wait about five minutes after the first medicine before putting in the second eye drop medicine.
7. Keeping the eyes closed (without continued blinking) for a few minutes may allow better penetration of the medication.

If symptom persists for more than 3 days, please consult your ophthalmologist (eye doctor).