Understanding Ketogenic Nutrition Support For Cancer Patients

Ketogenic nutrition support terminology  either parenteral nutrition or enteral feedings concept  is applied to  patients with intractable seizure and some cases in inborn error of metabolism like carbohydrate disorder metabolism and characterized by high fat, low carbohydrate, and maintenance protein contents.

The goal of nutrition support in cancer patients is to minimize wasting but not for ideally nutrition repletion and gaining weight.

Furthermore, the goal of nutrition support in a patient with cancer (adult) maintenance support which is between 23- 25 Kcal/kg/day, not anabolic support as theoretically high calories providing may feed cancer cells as stated in some studies.

The idea behind ketogenic diets is relatively simple. If glucose is the primary fuel for cancer, then lower carbohydrate intake and replace carbohydrates with other sources of fuel, such as fats, in order to push the body’s metabolism into ketosis.

Preclinical and case report studies indicated that the restricted ketogenic diet can be an effective “metabolic therapy” for managing malignant cancer in children and adults.

Addition of Carnitine should be considered along with a high-fat or ketogenic PN solution. Carnitine is a nonessential amino acid that facilitates the transport of fatty acids from long-chain fats into the mitochondria. It is also essential in certain conditions, such as liver disease, trauma, sepsis, and organ failure, and is advised when the major source of calories are derived from fat.

Selenium is an essential trace mineral that is generally included in PN solutions when used longer than four weeks.

I hope this helps.

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Should A Pharmacist Holds PN During Blood Transfusion

The practice of holding Parenteral Nutrition during blood transfusion is to avoid fluid load in short time that may affect cardiopulmonary system.

The average of blood transfusion is between 1 to 4 hrs depending on the number of units. Except platelets that may take just less than one hour. In case of blood transfusion, you have to taper PN rate by half for at least one hour depends on the dextrose concentration in PN. ( no need if patient receiving peripheral PN)

Furthermore, you may recommend fingerstick at the mid of blood transfusion. Regarding, IV lipids you may advise the nurse to commence I.V. lipids after blood transfusion is completed.

So to make it simpler:

  1. Make sure not to infuse Lipid and PN through the same line as Blood; Using the same line of PN and Blood is an absolute contraindication and might cause Blood Dyscrasias.
  2. There is no absolute contraindication of infusing blood with the same time with PN and Lipids using different lumen unless if the patient is fluid overloaded.
  3. Most patients can tolerate the low infusion rate of lipid same time with Blood transfusion; however, most clinicians don’t favor discontinuation and manipulation of lipid.
  4. If the patient is at risk of fluid overload, then hold PN; hold lipid and resume after blood transfusion.
  5. If you know the time of blood transfusion in advance, try to start lipid after completion of blood transfusion. So you avoid holding and restarting.

Hope this helps.

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Patient using Coversyl + Celebrex

Decreasing Prostaglandins by inhibiting COX-2. Celecoxib does not inhibit cyclooxygenase-1 (COX-1) with normal doses.

CELECOXIB MOA

How celecoxib works


when angiotensin 1 is converted to angiotensin 2, it results in strong vasoconstriction.

Perindopril prevents conversion of ang1 to ang2, but blocking Angiotensin converting Enzyme (ACE)

CELECOXIB MOA

How Perindopril works


Coversyl may enhance the adverse/toxic effect of Celebrex. The combination of Celebrex and Coversyl may result in a significant decrease in renal function. Celecoxib may diminish the antihypertensive effect of coversyl.

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Protocol Of Treatment Of Confirmed COVID19 Infection

This is just trials done by the CDC MICC team, thought you might want it shared:

Treatment of COVID19 upper respiratory tract infection (fever, runny nose, cough without lung infiltrate + positive PCR)

MED

ROUTE

DOSE

Chloroquine Phosphate

Oral

500MG BID for 5 Days

Oseltamivir

Oral

150MG BID for 5 Days

Treatment of COVID19 Pneumonia

MED

ROUTE

DOSE

Chloroquine Phosphate

Oral

500MG BID for 5 days

Darunavir / cobicistat

Oral

Darunavir 800MG + Cobicistat 150MG daily for 2 weeks

Or

Atazanavir

Oral

400MG once daily for 2 weeks

Oseltamivir

Oral

150MG BID for 5 Days

Corticosteroids 

Intravenous

Methylprednisolone 40MG bid for 5 days


SUPPORTIVE CARE AND ANTIVIRAL TREATMENT OF SUSPECTED OR CONFIRMED COVID-19 INFECTION

Last Updated on 

Disclaimer: This is a personal guidance that is subject to change as more data rise. It will be updated regularly whenever needed. The following data should be used to assist healthcare practitioners against COVID-19 infection and is not intended to replace clinical judgment but rather enhanced.

Common orders and procedures: CBC, Urea/Electrolytes, Creatinine, CRP, LFTs, Chest X-Ray, COVID-19 PCR tests.

Ambulatory Care Settings

Guidance for Pharmacies

Guidance for Dental Settings

COVID-19 Antiviral Options with Dosages

G6PD screening if Hydroxychloroquine or chloroquine will be used

Hydroxychloroquine:
Adults: 200 mg 3 times daily for 10 days (Gautret 2020) or 400 mg twice daily on day 1 followed by 200 mg twice daily for 4 days (CDC 2020; Yao 2020) or 400 mg twice daily on day 1 followed by 400 mg once daily for 5 days or 600 mg twice daily on day 1 followed by 400 mg once daily for 4 days (CDC 2020).
Children and Adolescents: 6.5 mg/kg/dose hydroxychloroquine sulfate twice daily on day 1; maximum day 1 dose: 400 mg/dose; followed by 3.25 mg/kg/dose hydroxychloroquine sulfate twice daily on days 2 through 5; maximum dose: 200 mg/dose (ASTCT 2020).

Chloroquine: 
Adults: 1 g (600 mg base) once on day 1 followed by 500 mg (300 mg base) once daily for a total treatment duration of 4 to 7 days (FDA 2020).
Infants, Children, and Adolescents: 8.3 mg/kg/dose chloroquine phosphate every 12 hours for 10 days; maximum dose: 500 mg/dose (ASTCT 2020)

Hydroxychloroquine/Chloroquine toxicity: QT interval at baseline: Follow-up ECG monitoring and adjustments in medical management are dependent on clinical scenario (eg, baseline risk, concomitant medications, overall clinical status)

Lopinavir 400 mg/ritonavir 100 mg twice daily.
can be taken as once daily dose of 800/200 but not with pregnant women.
Once-daily dosing is not recommended in those receiving efavirenz, fosamprenavir, nevirapine, nelfinavir, carbamazepine, phenobarbital, or phenytoin.

Remdesivir (CHECK FOR ELIGIBILITY CRITERIA)
Adults: IV: 200 mg as a single dose on day 1, followed by 100 mg once daily for a total duration of 5 to 10 days. (GILEAD 2020)
Children and Adolescents ≤17 years: 
<40 kg: IV: 5 mg/kg/dose as a single dose on day 1, followed by 2.5 mg/kg/dose once daily.
≥40 kg: IV: 200 mg as a single dose on day 1, followed by 100 mg once daily.

COVID-19

1.

Patient is suspected to have COVID19 but with no shortness of breath, admission is only recommended if emergency situation at hand. We should treat symptoms as they arise and there is no antiviral treatment recommended at this stage. We can use Paracetamol to treat pain and fever, and try to avoid NSAIDS

Common orders and procedures to be followed (medications, radiology and labs).

2.

Patient is suspected to have COVID19 with high risk comorbidities  but with shortness of breath, admission is only recommended if emergency situation at hand. We should treat symptoms as they arise, admit to an isolation room with negative pressure and there is adequate evidence to start empirical antiviral treatment at this stage till the lab results is obtained. We can use Paracetamol to treat pain and fever, and try to avoid NSAIDS

Common orders and procedures to be followed (medications, radiology and labs).

3.

Patient is confirmed to have COVID19 with no symptoms, admission is only recommended if emergency situation at hand. We should treat symptoms as they arise, admit to an isolation room with negative pressure if undergoing any aerosol generating procedure and there is no need to start empirical antiviral treatment at this stage . We can use Paracetamol to treat pain and fever, and try to avoid NSAIDS

Common orders and procedures to be followed (medications, radiology and labs).

4.

Patient is confirmed to have COVID19 with mild symptoms without pneumonia or ventilation, admission is recommended. We should treat symptoms as they arise, admit to an isolation room with negative pressure and start empirical antiviral treatment promptly. Consider antifungals and antibiotics to treat secondary infections. We can use Paracetamol to treat pain and fever, and try to avoid NSAIDS

Common orders and procedures to be followed (medications, radiology and labs).

5.

Patient is confirmed to have COVID19 with severe symptoms: 

  • Respiratory rate 30/min(adults); 40/min (children)
  • Blood oxygen saturation 93%
  • PaO2/FiO2 ratio <300
  • Lung infiltrates >50% if the lung field within 24 to 48 hours

admission to ICU to an isolation room with negative pressure. We should treat symptoms as they arise, admit and start empirical antiviral treatment promptly. Consider antifungals and antibiotics to treate secondary infections. We can use Paracetamol to treat pain and fever, and try to avoid NSAIDS

Common orders and procedures to be followed (medications, radiology and labs).

6.

Patient is confirmed to have COVID19 with critical symptoms:

  • Acute respiratory distress syndrome
  • Sepsis
  • Altered consciousness
  • Multi-Organ failure

admission to ICU to an isolation room with negative pressure. We should treat symptoms as they arise, admit and start empirical antiviral treatment promptly. Consider antifungals and antibiotics to treate secondary infections. We can use Paracetamol to treat pain and fever, and try to avoid NSAIDS

Common orders and procedures to be followed (medications, radiology and labs).

COVID-19 TESTING

CATEGORY

SUPPORTIVE CARE

ANTIVIRAL THERAPY

PRECAUTIONS

Suspicious cases 


Mild to moderate:
Symptoms with no shortness of breath

  • Treat symptoms
  • If no hospital admission required, need to follow instructions and recommendations posted by CDC

NOT REQUIRED

  • Use acetaminophen
  • Avoid ibuprofen
  • Labs and work-up: CBC, Urea/Electrolytes, Creatinine, CRP, LFTs, Chest X-Ray, COVID-19 PCR tests.

Mild to moderate:
Symptoms with shortness of breath in high risk patients

  • Treat symptoms
  • If no hospital admission required, need to follow instructions and recommendations posted by CDC
  • Consult infectious disease specialist

Case needs to be discussed with infectious disease specialist, to initiate an empirical antiviral therapy, based on the potential delay to obtain results.

  • Admission to negative pressure room
  • Labs and work-up: CBC, Urea/Electrolytes, Creatinine, CRP, LFTs, Chest X-Ray, COVID-19 PCR tests.

Mild to moderate:
Symptoms with no shortness of breath in high risk patients

Confirmed cases

Asymptomatic

Follow instructions and recommendations posted by CDC

NOT REQUIRED

  • Use acetaminophen
  • Avoid ibuprofen
  • Labs and work-up: CBC, Urea/Electrolytes, Creatinine, CRP, LFTs, Chest X-Ray, COVID-19 PCR tests.

Mild to moderate:
Symptoms (no O2 requirement and no evidence of pneumonia)

  • Treat symptoms
  • Consult infectious disease specialist

- consider starting Hydroxychloroquine 400mg BID for 1 day, followed by 200mg BID up to 5 days

- If Hydroxychloroquine is not available, consider Chloroquine 600mg (10mg/kg) at diagnosis and 300mg(5mg/kg) 12 hours later, followed by 300mg (5mg/kg) BID up to day 5, or Chloroquinephosphate 1000mg at diagnosis and 500mg 12 hours later, followed by 300mg BIDup to day 5

Hydroxychloroquine and Chloroquine:

- Labs and work-upL Same as above with additional G6PD screening if chloroquine will be used

- Perform ECG daily if initial QTc 450 -  500msec, and biochemistry according to underlying disease

Sever:

Symptoms as 1 of the following:

- Respiratory rate 30/min(adults); 40/min (children)

- Blood oxygen saturation 93%

- PaO2/FiO2 ration <300

- Lung infiltrates >50% if the lung field within 24 to 48 hours

  • Treat symptoms
  • ICU admission, decision by ICU treating team
  • Consult infectious disease specialist
  • consider antibiotics or antifungals according to local antibiogram and institutional pneumonia management guidelines.

- consider starting Hydroxychloroquine 400mg BID for 1 day, followed by 200mg BID up to 5 days

- If Hydroxychloroquine is not available, consider Chloroquine 600mg (10mg/kg) at diagnosis and 300mg(5mg/kg) 12 hours later, followed by 300mg (5mg/kg) BID up to day 5, or Chloroquine phosphate 1000mg at diagnosis and 500mg 12 hours later, followed by 300mg BIDup to day 5

- consider combination therapy (Lopinavir/Ritonavir) 400/100mg (2 tabs of 200/50mg) BID and (Hydroxy)chloroquine up to 10 days

Lopinavir/Ritonavir:

- Labs and work-upL Same as above with additional G6PD screening if chloroquine will be used

- Perform ECG daily if initial QTc 450 -  500msec, and biochemistry according to underlying disease

- Avoid coadministration with drugs that are highly dependent on CYP3A fod clearance or with potent CYO3A inducers

- precautions with patient with renal or liver impairments 

Critical:

Symptoms as 1 of the following:

- Acute respiratory distress syndrome

- Sepsis

- Altered consciousness

- Multi-Organ failure

  • Treat symptoms
  • ICU admission, decision by ICU treating team
  • Mechanical ventilation
  • Consult infectious disease specialist
  • Specific prevention and treatment of ARDS
  • Secondary bacterial and opportunistic (Aspergillus) infection according to local antibiogram and institutional pneumonia management guidelines
  • - Prevention of subsequent lung fibrosis

- consider combination therapy (Lopinavir/Ritonavir) 400/100mg (2 tabs of 200/50mg) BID and (Hydroxy)chloroquine up to 10 days, crushed in NGT and the same dosage and monitoring as above

- Remdesivir (compassionate use, once available) 200mg loading dose (IV, within 30 min), followed by 100mg once daily for 2 to 10 days

- however, since the clinical efficacy of (Hydroxy)chloroquine isn't demonstrated, caution is required in case of kidney / liver / cardiac failure and abstention in such situations is preferred

Remdesivir:

- Inclusion criteria for the use of Remdesivir: ICU + confirmation of SARS-cov-2 by PCR + mechanical ventilation

- Exclusion criteria for the use of Remdesivir:

Evidence of multi-organ failure, need of inotropic, creatinine clearance < 30ml/min, dialysis/hemofiltration, transaminases > 5 x  ULN of concomitant use of Lopinavir/Ritonavir

- This means that most(if not all) patient in ICU will not be eligible


update 26-03-2020:  Role of Pharmaceutical companies against COVID-19

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Update 31-03-2020:

Concluding Remarks ...

  • COVID 19 has caused the worst pandemic since the Spanish influenza
  • The virus spreads rapidly and efficiently
  • Droplet and contact precautions are recommended by WHO except for aerosol generating procedures where airborne isolation is necessary
  • In countries where rigorous measures were taken such as Hong Kong and Singapore containment was achieved (banned gathering, work from home, social distancing. HCWS practices)
  • Vaccine trials are underway
  • Treatment options include chloroquine/hydroxychloroquine +/- azithromycin; need to be verified in randomized controlled trials 
  • Lopinavir/Ritonavir to be considered early in the treatment course but needs to be studied further
  • Antiviral medications (remdesivir, favipiravir) are not currently available in the Middle East but for compassionate use 
  • IL-6 antagonists to be considered for severe cases with cytokine storm
Few COVID-19Facts

Last Updated on

Who named Months?

Month

Origin of it's name

January

Janus, the Roman god of beginnings.

February 

Februa, an ancient Roman festival of purification held on February 15.

March

Latin word Mārtius, meaning “of Mars,” as in, the Roman god of war.

April

Latin name is aprīlis, which is related to the Latin word aperīre, meaning “to open,” a reference to the blooming flowers of spring.

May

Maia, the Roman goddess of fertility.

June

Juno, the queen of the Roman gods.

July

Jūlius in honor of Julius Caesar.

August

Caesar’s grandnephew, the emperor Augustus.

September

Septem, the Latin word for “seven.”

October

Latin word octō means “eight.”

November

Latin, novem means “nine.”

December

Latin word for 10, which is decem.

Last Updated on

First Ebola Virus Vaccine

On December 19, 2019, the US FDA approved Ervebo(R) (ebola zaire vaccine, live) intramuscular suspension indicated for the prevention of disease caused by Zaire ebolavirus in individuals 18 years of age and older. Approval is based off of a study conducted during the 2014-2016 outbreak in Guinea where Ervebo was determined to be 100% effective in preventing Ebola cases with symptom onset greater than 10 days after vaccination. Additionally, no cases of ebola virus disease with symptom onset greater than 10 days after vaccination were observed in the group immediately given the vaccine as opposed to 10 cases of ebola virus disease in the group who received a delayed vaccination.

Prescribing information can be found https://www.merck.com/product/usa/pi_circulars/e/ervebo/ervebo_pi.pdf.

Full Article

Last Updated on

FORTIFIED EYE DROPS

“How to create a fortified eye drop?”

- Some answers here

Fortified Eye Drop

Materials Needed

Procedure

Fluconazole eye drops 2mg/ml

1 vial Fluconazole 2mg/ml

1 bottle Tears Naturale eye drops

10CC syringe

1.Discard Tears Naturale content.

2.Put 10ml of Fluconazole soln. into the empty bottle.

3.Label the bottle properly.

Fortified Gentamicin 15mg/ml

1 bottle Gentamicin (0.3%) E.D.

1 amp.Gentamicin 80mg/2ml

2 pieces 3CC syringes

1. Add the 2 ml of Gentamicin amp.(80mg) to 4 ml of Gentamicin eye drops.

2. Label the bottle properly.

Fortified Amikacin 20mg/ml

1 amp.Amikacin 100mg/2ml

1 bottle tears natural E.D.

1 piece 10CC syringe

1 piece 3CC syringe

1. Discard 12 ml of tears naturalE.D.

2. Add the 2 ml Amikacin to the remaining 3 ml of tears natural E.D. 

3. Label the bottle properly

Fortified Cefuroxime 50mg/ml

1 vial Cefuroxime 750mg (Zinacef 750mg)

1 amp. water for injection

1 bottle tears natural E.D.

2 pieces 3CC syringe

1. Dilute Cefuroxime with 2.5 ml sterile water

2. Discard 2.5 ml of teras natural E.D.

3. Add the diluted Cefuroxime to the remaining 12.5 ml tears natural E.D.

4. Label the bottle properly 

Fortified Cefazolin/Ceftazidime 50mg/ml

1 vial Cefazolin/Ceftazidime 500mg

1 amp water for injection

1 bottle tears natural E.D.

1 piece 10CC syringe

1 piece 3CC syringe 

1. Dilute the antibiotic with 2.5 ml sterile water

2. Discard 7.5 ml of teras natural E.D.

3. Add the diluted antibiotic to the remaining 7.5 ml of tears natural E.D.

4.Label the bottle properly

Fortified Vancomycin 50mg/ml

1 vial Vancomycin 0.5 gm

1 amp water for injection

1 bottle teras natural E.D.

1 piece 10CC syringe

1. Dilute Vancomycin with 10 ml sterile water

2. Discard all the content of tears natural E.D.

3. Put the diluted Vancomycin into the empty bottle of tears natural E.D.

4. Label the bottle properly

Cyclosporine Eye Drop 10mg/ml

1 capsule Cyclosporine 100mg

1 bottle teras natural E.D.

1 piece disposable needle

1. Pick the capsule with sterile needle 

2. Mix the content of the capsule with 10 ml tears natural E.D.

3. Label the bottle properly

Anti-vascularization Treatment

2 bottle tears natural E.D.

4 vials Kenacort 40mg/ml

2 capsules Doxydar (Tabocine 100mg)

1. Add 4 ml of Kenacort to 4 ml of tears natural E.D.

2. Add the content of 2 capsule of Doxydar to 10 ml of tears natural E.D.

3. Label the two bottle properly 

EXPIRATION DATE: 24 HOURS AT ROOM TEMPERATURE, 96 HOURS IN REFRIGERATOR.

Last Updated on

A baby comes to the ER

Question...


Mother brought her baby to the ER

Patient history and chief complains:

  • 8m old baby boy.
  • 2 soft stools per day.
  • Recent trip to Brazil.
  • After trip mother noticed 4 loose stools per day (smelly and different colors than usual).
  • Healthy appetite and lifestyle.
  • No current illness in siblings and parents. (No diarrhoea)
  • Working mother (baby attends day care center while mother works)

Physical examination:

  • Healthy baby.
  • Soft abdomen.
  • No masses felt.
  • A. What would be the diagnosis?
  • B. Investigations and advice!?

Continue reading

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Can KCL and MgSO4 be mixed together?

Can kcl and mgso4 be mixed together?

Today Pharmacy received an order for electrolytes (kcl and mgso4). the patient had severe electrolytes imbalance and the ICU physician ordered some corrective measures.

The order came as follows:
[20MEQs of KCL + 2GM of MgSO4] mixed to 200ML of D5W in 0.45% NACL.

Our pharmacy stock of Potassium chloride is from PSI factory in Jeddah, and it comes as 20MEQs in 10ML, Magnesium sulphate comes as 2.5GM in 5ML. The needed preparation was supposed to be mixed as follow:

  1. 1
    10ML of KCL that gives 20MEQs.
  2. 2
    4ML of MgSO4 that gives 2GM.
  3. 3
    186ML of D5W 0.45% NACL.

Physical Compatibility: Physically compatible. No visible haze or particulate formation, color change, or gas evolution.
Chemical Stability: Chemically stable. Less than 5% change in measured potassium and magnesium concentrations occurred in 24 hours.
Storage: Room temperature of 22 °C.

Reference:

Quay I, Tan E: Compatibility and stability of potassium chloride and magnesium sulfate in 0.9% sodium chloride injection and 5% dextrose injection solutions. Int J Pharmaceut Compound: 2001. 5: 323-4.
https://www.ncbi.nlm.nih.gov/pubmed/23981924

Last Updated on

Perpetual Motion Machines

Perpetual Motion Machines

devices that can do work indefinitely without any external energy source have captured many inventors’ imaginations because they could totally transform our relationship with energy. There’s just one problem: they don’t work. Why not?

  1. 1
     Energy can't be created or destroyed - you can't create more energy than you put in within a device.
  2. 2
    Friction
  3. 3
    Machine must be operated in vacuum
  4. 4
    Machine must be soundless, as sound is a way of lost energy!!
  5. 5
    Something more?!!!

Last Updated on

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