PSBIM Passers 2011

Philippine College of Physicians
PHILIPPINE SPECIALTY BOARD OF INTERNAL MEDICINE
January 30, 2011
Bayanihan Hall, Unilab Building, Pasig City

LIST OF EXAMINEES WHO PASSED

The production of counterfeit or substandard anti-infective drugs is a widespread and under-recognized problem that contributes to morbidity, mortality, adverse drug reactions, drug resistance, enormous financial consequences for companies producing the genuine product and loss of confidence in the health care systems and the drug regulatory authorities. Counterfeit drugs particularly affect the most disadvantaged people in poor countries, like the Philippines. A wide array of different counterfeit types based on packaging, sophisticated fake holograms styles on blisterpacks and spurious tablets that contain no active drug have been found in Southeast Asia.

To counter such threats, simple field tests and advances on Forensic Analysis and Chemical Characterization of counterfeit and substandard anti-infectives can be done. Among of which are High Performance Liquid Chromatography (HPLC); Gas Chromatography coupled with optical, electrochemical or mass spectrometric detectors; Thin-Layer Chromatography (TLC); and Colourimetry.

There can be no simple solution to the problem of counterfeit drugs. A comprehensive, pragmatic plan of action, linking various organizations, health workers, industry, and civil society is essential. The increasing evidence that the trade in counterfeit drugs is linked to transnational organized crime presage the necessity to harmonize definitions and penalties between countries, apply strict police and customs action, intensify inspection and drug regulation, increase public awareness, and reinforce a strong political will and openness among countries.

1) the drug itself or the container or labeling thereof or any part of such drug, container or labeling bearing without authorization the trademark, trade name or other identification mark or imprint or any likeness to that which is owned or registered in the Bureau of Patent, Trademark and Technology Transfer (BPTTT) in the name of another natural or juridical person;

2) a drug product refilled in containers by unauthorized persons if the legitimate labels or marks are used;

3) an unregistered imported drug product, except drugs brought in the country for personal use as confirmed and justified by accompanying medical records;

4) a drug which contains no amount of or a different active ingredient or less than eighty percent (80%) of the active ingredient it purports to possess as distinguished from an adulterated drug including reduction or loss or efficacy due to expiration.”

Hence, a substandard quality medicine is a counterfeit medicine by definition.

For the internist, the following can be indicators for fake drugs:

• Patients are not getting well or getting sicker– therapeutic failures. We have observed quite a few cases of attempted suicides with benzodiapezines, taking as much as over 50 tablets without any toxic effects. These drugs were sourced from undisclosed drug stores or from the streets. Hence, no active ingredients, patient do not get well or deteriorates and there is delay in treatment.
• Patient may report unusual side effects that are not known in current literature. Ask the patients where they had sourced their medicines. If they hesitate or refuse, suspect that the source is not from a legal channel. Please remember that even legal channels (i.e. licensed drug stores sometimes source medicines from illegal channels). Counterfeit medicines may contain nothing of the original active principles but something else (e.g. branded antihypertensive drugs were used, patients developed bleeding, while the diagnosis might be hypertensive bleed, the differential may be coumarin chemicals). Hence, wrong active ingredients can kill.
• The packaging is not in its original package, they do not have the requisite BFAD registration numbers andexpiry dates, printing is misaligned, labels easily destroyed or removed, discoloration of the package, no package inserts, tablets crumble, parenteral or bottle for reconstitution is tampered (i.e. needle holes seen in the rubber stopper) and the contents cannot be dissolved easily, evidence of contamination, foreign particles.

What the doctors must not do:

• With knowledge of substandard or fake drugs and of less than active ingredients, the doctor must not double the dose.
• Refusal to share information with other colleagues and hence missed out on patterns.
• Refusal to consider substandard drugs or counterfeit medicines as differentials to deterioration of patien conditions.
• Refusal to cooperate with the concerned drug industry in the investigation of counterfeit drugs.
• Buy drugs from questionable sources or abroad on their own and sell these in their clinics.

References:

Newton PN, Dondorp A, Green MD, et.al. Counterfeit artesunate antimalarials in Southeast Asia. The Lancet. 2003; 362:169.

The landscape of the medical profession has changed dramatically over the recent decades. While the more traditional roles of health-care provider and scientist remain, challenging roles such as steward of patient resources, community educator, and patient advocate have emerged. To be able to fulfill such roles, we as today’s Filipino physicians have to be constantly aware of ourselves and our environments, define our boundaries, limitations and comfortable spheres, and be willing to go beyond them.

As internists, our comfort zones are more often confined to our own selves and our immediate families, and our own medical practice, be it general internal medicine or any of its subspecialties. The Philippine College of Physicians, hence, challenges its members to go beyond their comfort zones and extend beyond the concerns of self, family, or private practice, and be involved in the concerns of the community, nation and beyond. While there is an increasing burden of chronic illness and complexity of medical care, there is also an astounding development in the field of information and communication technology that has blurred geographic borders, enabling us to coordinate care across various settings and health care providers. While disparities in healthcare access among various groups continue to exist, the Filipino internist is given the chance to reaffirm his own relevance by becoming part of the solution to this inequity.

The PCP also urges its members to practice medicine beyond medicine – to scrutinize the nature and effects of the patient’s illness, to understand the complexity of clinical judgments and the ethical dimensions of physician–patient, physician-physician and physician-industry encounters, and to utilize the multifaceted dimensions of health to further improve patient care.

We therefore envision the PCP 2010 Annual Convention to be a venue wherein we, as Filipino internists, may explore our own territories, examine our own follies and strengths, and rediscover our own relevance. We will be redefining ourselves and our profession – beyond our traditional roles as clinicians, beyond the biomedical definition of health, beyond geographic boundaries, all within the bounds of medical ethics, all for the improvement of our patients’ welfare.  http://www.pcp.org.ph

This space is reserved for the PSBIM 2010 Written Certifying Examinations in Internal Medicine Results.

>>>Complete list here

A. Pre-exposure Measures

1. The most effective preventive measure is the avoidance of high-risk exposure (i.e. wading in floods and contaminated water, contact with animal body fluids).
2. If high risk exposure is unavoidable, appropriate protective measures include wearing boots, goggles, overalls, and rubber gloves.
3. Pre-exposure antibiotic prophylaxis is NOT ROUTINELY RECOMMENDED. However, in those individuals who intend to visit highly endemic areas AND get exposed, pre-exposure prophylaxis may be considered.

Pre-exposure prophylaxis regimen for non-pregnant, non-lactating adult: Doxycycline 2 capsules of 100 mg/ capsule once weekly, to begin 1 to 2 days before exposure and continuing through the period of exposure Currently, there is NO recommended pre-exposure prophylaxis that is safe for pregnant and lactating women.

B. Post-Exposure Measures

1. Antibiotic prophylaxis in the prevention of leptospirosis is NOT 100% effective.
2. Factors that may affect prophylactic effectiveness include the quality of the drug, timing of intake of the antibiotic, drug interaction, the presence or absence of skin wounds, and degree and extent of exposure.
3. Antibiotic prophylaxis of leptospirosis may be achieved by administration of doxycycline depending on the risk category of exposure.
1. LOW RISK is defined as those individuals with a single history of wading in flood or contaminated water but with absence of wounds, cuts or open lesions of the skin.

2. Doxycycline (hydrochloride or hyclate) at 2 capsules of 100 mg/capsule single dose within 24 to 72 hours of exposure. MODERATE RISK is defined as those individuals with a single history of wading in flood or contaminated water and the presence of wounds, cuts, or open lesions of the skin, OR accidental ingestion of contaminated water.

3. Doxycycline (hydrochloride or hyclate) at 2 capsules of 100 mg/capsule once a day for 3-5 days to be started immediately within 24 to 72 hours of exposure. HIGH RISK is defined as those individuals with continuous exposure (i.e., those with more than a single exposure; those exposed for several days, e.g., residents in flooded areas, rescuers and relief workers). People who wade in flooded or contaminated water everyday – with or without wounds, cuts or open lesions of the skin; those who swim in flooded water and ingest contaminated water are also considered high risk.

Doxycycline (hydrochloride or hyclate) at 2 capsules of 100 mg/capsule once weekly until the end of exposure
4. The use of such prophylaxis REQUIRES PRIOR CONSULT WITH A PHYSICIAN. It should not be taken unless prescribed and fully explained by a physician, including common side-effects and contraindications.
5. SINCE ANTIBIOTIC PROPHYLAXIS IS NOT 100% EFFECTIVE, INDIVIDUALS SHOULD CONTINUE TO MONITOR THEMSELVES FOR FEVER AND OTHER FLU-LIKE SYMPTOMS.

C. Algorithm on the Risk Category and Prophylactic Regimen

ANNEX
Doxycycline8-10

Contraindications

* Do not use this medication if you are pregnant. It could cause harm to the unborn baby, including permanent discoloration of the teeth later in life.
* Do not take this medication without telling your doctor if you are breast-feeding a baby. Doxycycline passes into breast milk and may affect bone and tooth development in a nursing baby.
* Do not give doxycycline to a child younger than 8 years old. Doxycycline can cause permanent yellowing or graying of the teeth, and it can affect a child’s growth
* Do not use this medication if you are allergic to doxycycline, or to similar medicines such as demeclocycline, minocycline, or tetracycline.

Precautions

* Before taking doxycycline, tell your doctor if you have liver or kidney disease. You may not be able to take doxycycline, or you may need a dose adjustment or special tests during treatment
* Doxycycline can make birth control pills less effective. Use a second method of birth control while you are taking doxycycline to keep from getting pregnant.
* Avoid exposure to sunlight or artificial UV rays (sunlamps or tanning beds). Doxycycline can make your skin more sensitive to sunlight and sunburn may result. Use a sunscreen (minimum SPF 15) and wear protective clothing if you must be out in the sun.
* Do not take iron supplements, multivitamins, calcium supplements, antacids, or laxatives within 2 hours before or after taking doxycycline
* Store this medication at room temperature away from moisture and heat
* Throw away any unused doxycycline when it expires or when it is no longer needed. Do not take any doxycycline after the expiration date printed on the bottle. Expired doxycycline can cause a dangerous syndrome resulting in damage to the kidneys.

Drug Interactions

* Drug interactions: antacids; minerals such as iron, zinc, calcium, magnesium, and over-the-counter vitamin and mineral supplements cholesterol-lowering medications such as cholestyramine or colestipol; isotretinoin; tretinoin; product that contains bismuth subsalicylate; warfarin; penicillin antibiotic such as amoxicillin, penicillin, dicloxacillin, oxacillin (Bactocill), and others.

Adverse Reactions

* Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat.
* Antibiotic medicines can cause diarrhea, which may be a sign of a new infection. If you have diarrhea that is watery or has blood in it, call your doctor. Do not use any medicine to stop the diarrhea unless your doctor has told you to.

Other alarming side effects:

* severe headache, dizziness, blurred vision; fever, chills, body aches, flu symptoms; severe blistering, peeling, and red skin rash; urinating less than usual or not at all; pale or yellowed skin, dark colored urine, fever, confusion or weakness; severe pain in your upper stomach spreading to your back, nausea and vomiting, fast heart rate; loss of appetite, jaundice (yellowing of the skin or eyes); or easy bruising or bleeding, unusual weakness.

Less serious side effects may include:

* swollen tongue, trouble swallowing; mild nausea, vomiting, diarrhea, or stomach upset; white patches or sores inside your mouth or on your lips; sores or swelling in your rectal or genital area; or vaginal itching or discharge.

How to Reduce Doxycycline Side Effects

* Ensure that your physician is aware of all medications and over-the-counter vitamin supplements or herbal remedies that you are taking. Antacids and certain vitamins and minerals are known to interfere with doxycycline absorption.
* Take doxycycline with food or following a meal. If you have taken doxycycline on an empty stomach before and gotten away with it, the next time may be different. Doxycycline induced nausea is quite unpleasant and more serious stomach irritation can occur.
* Don’t lie down for an hour following doxycycline intake to prevent one of the most formidable doxycycline side effects, esophageal damage. If reclined, the medication may dissolve in the esophagus instead of the stomach. If this doxycycline side effect occurs, a patient may gag on something as innocuous as sips of water. Treatment may take days for this condition to abate, depending on the extent of the irritation or damage.
* Avoid, if possible, taking doxycycline along with other medications that are known to bother the stomach. Space out the medications accordingly and add more food intake if needed. Pain medications and NSAIDs (e.g., ibuprofen) combined with doxycycline may cause significant stomach distress.
* Talk to your physician about the benefits of acid reducers, rather than antacids, as these may be helpful in reducing or eliminating some doxycycline side effects.
* Discuss any recommended treatments for yeast infection should these occur. Some patients find lactobacillus helpful in preventing yeast infections. This healthy bacteria is found in some foods, including yogurt and cheese. It is also available as a supplement in capsule form.
* Take doxycycline 100 mg capsule BID if 200 mg OD is not tolerated.

References

1. San Lazaro Hospital Guideline on Prophylaxis for Leptospirosis 2009
2. DOH- Health Emergency Management Staff Manual on Treatment Protocols of Common Communicable Diseases and other Ailments During Emergencies and Disasters
3. Mandell’s Principles and Practice of Infectious Diseases 2005 6th ed chapter 237:2789-2795
4. Mandell’s Principles and Practice of Infectious Diseases 2009 7th ed
5. New England Journal of Medicine Feb 23, 1984 Volume 310 (8):497-500
6. Int J Antimicrob Agents 2000 Feb; 13 (4): 249-55. Randomized controlled trial of doxycycline prophylaxis against leptospirosis in an endemic area
7. Revista do Instituto de Medicina Tropical de Sao Paulo 1998; 40: 59-61. Use of doxycycline for leptospirosis after high-risk exposure in Sao Paulo, Brazil
8. http://health.yahoo.com/infectiousdisease
medications/doxycycline/healthwised00037a1.html#d00037a1-drugs
9. http://www.drugs.com/pro/doxycycline.html.
10. http://www.ehow.com/how_2165217_avoid-doxycycline-side-effects.html?ref=fuel&utm_source=yahoo&utm_medium=ssp&utm_campaign=yssp_art

Task Force Committee
Marissa M. Alejandria, MD
Rhona G. Bergantin, MD
Manolito L. Chua, MD
Raul P. Destura, MD
Raquel Victoria M. Ecarma, MD
Ma. Cecilia S. Montalban, MD
Mario M. Panaligan, MD
Minette O. Rosario, MD
Paul Salandanan, MD
Rontgene M. Solante, MD
Maria Fe R. Tayzon, MD
Dionisio M. Tiu, MD
Catherine Yu, MD

To Philippine College of Physician (PCP) members,

The North Luzon chapter under the leadership of Dr. Manny Bautista had met
with his team to have an accurate assessment of the impact of the recent
disaster on the prospect of holding the PCP mid-year convention in Baguio
as scheduled. They have wisely deemed it prudent and appropriate to cancel
the mid-year convention that they had earnestly prepared for. At this
time, focus has to be put on the on-going relief operations.
The Board of Regents  agrees with their assessment of the situation and
has approved the recommendation to cancel the 2009 mid-year convention in
Baguio. The recommendation to cancel the convention is thus carried out.

Meanwhile, the people of north Luzon need help. We will be figuring out in
the next few days the best way to help. We are one with the people of
North Luzon – especially our colleagues there – and we intend to help
where help can make a difference. Their preparations in Baguio to welcome
us next week during the scheduled convention need not go to waste. The
comfort and relaxation that we would have enjoyed, we definitely wouldn’t
mind giving up in exchange for the comfort and relief of our unfortunate
brothers and sisters who have lost a lot more in the last few days.

The recent disasters have taught us important lessons; we have become more
sensitive to the misfortune of others. We should also learn one important
thing: WE ARE LEADERS. WHAT WE HAVE HAD IN THE LAST FEW DAYS ARE
OPPORTUNITIES TO LEAD.

Kudos to all!

Eugene Ramos