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Han Z, Barton KC, Ho LC, Yap KZ, Tan DSY, Lee SS, Neo CXR, Tan AHL, Boey BMY, Soon CJY, Gallagher PJ. Applying narrative medicine to prepare empathetic healthcare providers in undergraduate pharmacy education in Singapore: a mixed methods study. BMC Med Educ 2024; 24:292. [PMID: 38491363 PMCID: PMC10943898 DOI: 10.1186/s12909-024-05254-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 03/04/2024] [Indexed: 03/18/2024]
Abstract
BACKGROUND Narrative medicine demonstrated positive impact on empathy in medicine and nursing students. However, this pedagogical approach had not been evaluated in pharmacy education. This study sought to apply and evaluate the narrative medicine approach in extending empathy in Asian undergraduate pharmacy students. METHODS Narrative medicine was applied through workshops which used narratives of people with different experiences and perspectives. First-year undergraduate pharmacy students who volunteered and attended these workshops formed the intervention group (N = 31) and the remaining first-year cohort formed the control group (N = 112). A sequential explanatory mixed methods approach was adopted in which quantitative methods were first used to measure impact on pharmacy students' empathy using the Jefferson Scale of Empathy- Health Professions Student (JSE-HPS), and qualitative methods (i.e. group interviews) were then used to assess pharmacy students' emotional responses to narratives, and the perspectives of pharmacy students and faculty of this pedagogical approach. RESULTS There was no difference in JSE-HPS scores between intervention and control groups across baseline (i.e. upon matriculation), pre-intervention, and post-intervention timepoints. Pharmacy students in the intervention group had lower scores in Factor 3 ("Standing in People's Shoes") following the intervention. Five themes, guided by internal and external factors in cognition, emerged from the Group Interviews: (1) incongruence between students' motivation and faculty's perception, (2) learning context, (3) academic context, (4) cognitive system, and (5) affective system. Themes 1, 4 and 5 referred to internal factors such as students' motivation, perceived learnings, and feelings. Themes 2 and 3 referred to external factors including workshop materials, activities, content, and facilitation. CONCLUSION This study is the first to demonstrate that pharmacy students engaged with the narrative medicine approach as narratives elicited emotional responses, exposed them to diverse perspectives, and deepened their appreciation of the importance of empathy and complexities of understanding patients' perspectives. Scaffolded educational interventions using narratives and real-life patient encounters, alongside longitudinal measurements of empathy, are necessary to bring about meaningful and sustained improvements in empathy.
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Affiliation(s)
- Zhe Han
- Department of Pharmacy and Pharmaceutical Sciences, Faculty of Science, National University of Singapore, Block S4A, Level 3, 18 Science Drive 4, 117543, Singapore, Singapore.
| | - Keith C Barton
- Department of Curriculum and Instruction, School of Education, Indiana University, 201 N. Rose Avenue, 47405, Bloomington, IN, USA
| | - Li-Ching Ho
- Department of Curriculum and Instruction, School of Education, University of Wisconsin- Madison, 225 N. Mills Street, 53706, Madison, WI, USA
| | - Kai Zhen Yap
- Department of Pharmacy and Pharmaceutical Sciences, Faculty of Science, National University of Singapore, Block S4A, Level 3, 18 Science Drive 4, 117543, Singapore, Singapore
| | - Doreen Su-Yin Tan
- Department of Pharmacy and Pharmaceutical Sciences, Faculty of Science, National University of Singapore, Block S4A, Level 3, 18 Science Drive 4, 117543, Singapore, Singapore
| | - Shuh Shing Lee
- Center for Medical Education, Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Drive, 117597, Singapore, Singapore
| | - Constance Xue Rui Neo
- Department of Pharmacy, Khoo Teck Puat Hospital, 90 Yishun Central, 768828, Singapore, Singapore
| | - Amanda Han Lin Tan
- Department of Pharmacy and Pharmaceutical Sciences, Faculty of Science, National University of Singapore, Block S4A, Level 3, 18 Science Drive 4, 117543, Singapore, Singapore
| | - Brian Ming Yao Boey
- Department of Pharmacy and Pharmaceutical Sciences, Faculty of Science, National University of Singapore, Block S4A, Level 3, 18 Science Drive 4, 117543, Singapore, Singapore
| | - Charis Jia Yan Soon
- Department of Pharmacy and Pharmaceutical Sciences, Faculty of Science, National University of Singapore, Block S4A, Level 3, 18 Science Drive 4, 117543, Singapore, Singapore
| | - Paul J Gallagher
- Department of Pharmacy and Pharmaceutical Sciences, Faculty of Science, National University of Singapore, Block S4A, Level 3, 18 Science Drive 4, 117543, Singapore, Singapore
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Wee J, Tan XR, Gunther SH, Ihsan M, Leow MKS, Tan DSY, Eriksson JG, Lee JKW. Effects of Medications on Heat Loss Capacity in Chronic Disease Patients: Health Implications Amidst Global Warming. Pharmacol Rev 2023; 75:1140-1166. [PMID: 37328294 DOI: 10.1124/pharmrev.122.000782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 04/20/2023] [Accepted: 05/31/2023] [Indexed: 06/18/2023] Open
Abstract
Pharmacological agents used to treat or manage diseases can modify the level of heat strain experienced by chronically ill and elderly patients via different mechanistic pathways. Human thermoregulation is a crucial homeostatic process that maintains body temperature within a narrow range during heat stress through dry (i.e., increasing skin blood flow) and evaporative (i.e., sweating) heat loss, as well as active inhibition of thermogenesis, which is crucial to avoid overheating. Medications can independently and synergistically interact with aging and chronic disease to alter homeostatic responses to rising body temperature during heat stress. This review focuses on the physiologic changes, with specific emphasis on thermolytic processes, associated with medication use during heat stress. The review begins by providing readers with a background of the global chronic disease burden. Human thermoregulation and aging effects are then summarized to give an understanding of the unique physiologic changes faced by older adults. The effects of common chronic diseases on temperature regulation are outlined in the main sections. Physiologic impacts of common medications used to treat these diseases are reviewed in detail, with emphasis on the mechanisms by which these medications alter thermolysis during heat stress. The review concludes by providing perspectives on the need to understand the effects of medication use in hot environments, as well as a summary table of all clinical considerations and research needs of the medications included in this review. SIGNIFICANCE STATEMENT: Long-term medications modulate thermoregulatory function, resulting in excess physiological strain and predisposing patients to adverse health outcomes during prolonged exposures to extreme heat during rest and physical work (e.g., exercise). Understanding the medication-specific mechanisms of altered thermoregulation has importance in both clinical and research settings, paving the way for work toward refining current medication prescription recommendations and formulating mitigation strategies for adverse drug effects in the heat in chronically ill patients.
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Affiliation(s)
- Jericho Wee
- Human Potential Translational Research Programme, Yong Loo Lin School of Medicine (J.W., X.R.T., S.H.G., M.I., M.K.S.L., J.G.E., J.K.W.L.), Department of Pharmacy, Faculty of Science, (D.S.-Y.T), Department of Physiology, Yong Loo Lin School of Medicine (J.K.W.L.), Heat Resilience and Performance Centre, Yong Loo Lin School of Medicine (J.K.W.L.), National University of Singapore, Singapore; Health and Social Sciences, Singapore Institute of Technology, Singapore (X.R.T.); Campus for Research Excellence and Technological Enterprise, Singapore (S.H.G., J.K.W.L.); Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore (M.K.S.L.); Duke-National University of Singapore Medical School, Singapore (M.K.S.L.); Department of Endocrinology, Division of Medicine, Tan Tock Seng Hospital, Singapore (M.K.S.L.); Singapore Institute for Clinical Sciences, Agency for Science, Technology and Research, Singapore (M.K.S.L., J.G.E.); Folkhalsan Research Center, Helsinki, Finland (J.G.E.); Department of General Practice and Primary Health Care, University of Helsinki, and Helsinki University Hospital, University of Helsinki, Helsinki, Finland (J.G.E.); and Department of Obstetrics & Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore (J.G.E.)
| | - Xiang Ren Tan
- Human Potential Translational Research Programme, Yong Loo Lin School of Medicine (J.W., X.R.T., S.H.G., M.I., M.K.S.L., J.G.E., J.K.W.L.), Department of Pharmacy, Faculty of Science, (D.S.-Y.T), Department of Physiology, Yong Loo Lin School of Medicine (J.K.W.L.), Heat Resilience and Performance Centre, Yong Loo Lin School of Medicine (J.K.W.L.), National University of Singapore, Singapore; Health and Social Sciences, Singapore Institute of Technology, Singapore (X.R.T.); Campus for Research Excellence and Technological Enterprise, Singapore (S.H.G., J.K.W.L.); Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore (M.K.S.L.); Duke-National University of Singapore Medical School, Singapore (M.K.S.L.); Department of Endocrinology, Division of Medicine, Tan Tock Seng Hospital, Singapore (M.K.S.L.); Singapore Institute for Clinical Sciences, Agency for Science, Technology and Research, Singapore (M.K.S.L., J.G.E.); Folkhalsan Research Center, Helsinki, Finland (J.G.E.); Department of General Practice and Primary Health Care, University of Helsinki, and Helsinki University Hospital, University of Helsinki, Helsinki, Finland (J.G.E.); and Department of Obstetrics & Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore (J.G.E.)
| | - Samuel H Gunther
- Human Potential Translational Research Programme, Yong Loo Lin School of Medicine (J.W., X.R.T., S.H.G., M.I., M.K.S.L., J.G.E., J.K.W.L.), Department of Pharmacy, Faculty of Science, (D.S.-Y.T), Department of Physiology, Yong Loo Lin School of Medicine (J.K.W.L.), Heat Resilience and Performance Centre, Yong Loo Lin School of Medicine (J.K.W.L.), National University of Singapore, Singapore; Health and Social Sciences, Singapore Institute of Technology, Singapore (X.R.T.); Campus for Research Excellence and Technological Enterprise, Singapore (S.H.G., J.K.W.L.); Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore (M.K.S.L.); Duke-National University of Singapore Medical School, Singapore (M.K.S.L.); Department of Endocrinology, Division of Medicine, Tan Tock Seng Hospital, Singapore (M.K.S.L.); Singapore Institute for Clinical Sciences, Agency for Science, Technology and Research, Singapore (M.K.S.L., J.G.E.); Folkhalsan Research Center, Helsinki, Finland (J.G.E.); Department of General Practice and Primary Health Care, University of Helsinki, and Helsinki University Hospital, University of Helsinki, Helsinki, Finland (J.G.E.); and Department of Obstetrics & Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore (J.G.E.)
| | - Mohammed Ihsan
- Human Potential Translational Research Programme, Yong Loo Lin School of Medicine (J.W., X.R.T., S.H.G., M.I., M.K.S.L., J.G.E., J.K.W.L.), Department of Pharmacy, Faculty of Science, (D.S.-Y.T), Department of Physiology, Yong Loo Lin School of Medicine (J.K.W.L.), Heat Resilience and Performance Centre, Yong Loo Lin School of Medicine (J.K.W.L.), National University of Singapore, Singapore; Health and Social Sciences, Singapore Institute of Technology, Singapore (X.R.T.); Campus for Research Excellence and Technological Enterprise, Singapore (S.H.G., J.K.W.L.); Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore (M.K.S.L.); Duke-National University of Singapore Medical School, Singapore (M.K.S.L.); Department of Endocrinology, Division of Medicine, Tan Tock Seng Hospital, Singapore (M.K.S.L.); Singapore Institute for Clinical Sciences, Agency for Science, Technology and Research, Singapore (M.K.S.L., J.G.E.); Folkhalsan Research Center, Helsinki, Finland (J.G.E.); Department of General Practice and Primary Health Care, University of Helsinki, and Helsinki University Hospital, University of Helsinki, Helsinki, Finland (J.G.E.); and Department of Obstetrics & Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore (J.G.E.)
| | - Melvin Khee Shing Leow
- Human Potential Translational Research Programme, Yong Loo Lin School of Medicine (J.W., X.R.T., S.H.G., M.I., M.K.S.L., J.G.E., J.K.W.L.), Department of Pharmacy, Faculty of Science, (D.S.-Y.T), Department of Physiology, Yong Loo Lin School of Medicine (J.K.W.L.), Heat Resilience and Performance Centre, Yong Loo Lin School of Medicine (J.K.W.L.), National University of Singapore, Singapore; Health and Social Sciences, Singapore Institute of Technology, Singapore (X.R.T.); Campus for Research Excellence and Technological Enterprise, Singapore (S.H.G., J.K.W.L.); Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore (M.K.S.L.); Duke-National University of Singapore Medical School, Singapore (M.K.S.L.); Department of Endocrinology, Division of Medicine, Tan Tock Seng Hospital, Singapore (M.K.S.L.); Singapore Institute for Clinical Sciences, Agency for Science, Technology and Research, Singapore (M.K.S.L., J.G.E.); Folkhalsan Research Center, Helsinki, Finland (J.G.E.); Department of General Practice and Primary Health Care, University of Helsinki, and Helsinki University Hospital, University of Helsinki, Helsinki, Finland (J.G.E.); and Department of Obstetrics & Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore (J.G.E.)
| | - Doreen Su-Yin Tan
- Human Potential Translational Research Programme, Yong Loo Lin School of Medicine (J.W., X.R.T., S.H.G., M.I., M.K.S.L., J.G.E., J.K.W.L.), Department of Pharmacy, Faculty of Science, (D.S.-Y.T), Department of Physiology, Yong Loo Lin School of Medicine (J.K.W.L.), Heat Resilience and Performance Centre, Yong Loo Lin School of Medicine (J.K.W.L.), National University of Singapore, Singapore; Health and Social Sciences, Singapore Institute of Technology, Singapore (X.R.T.); Campus for Research Excellence and Technological Enterprise, Singapore (S.H.G., J.K.W.L.); Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore (M.K.S.L.); Duke-National University of Singapore Medical School, Singapore (M.K.S.L.); Department of Endocrinology, Division of Medicine, Tan Tock Seng Hospital, Singapore (M.K.S.L.); Singapore Institute for Clinical Sciences, Agency for Science, Technology and Research, Singapore (M.K.S.L., J.G.E.); Folkhalsan Research Center, Helsinki, Finland (J.G.E.); Department of General Practice and Primary Health Care, University of Helsinki, and Helsinki University Hospital, University of Helsinki, Helsinki, Finland (J.G.E.); and Department of Obstetrics & Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore (J.G.E.)
| | - Johan G Eriksson
- Human Potential Translational Research Programme, Yong Loo Lin School of Medicine (J.W., X.R.T., S.H.G., M.I., M.K.S.L., J.G.E., J.K.W.L.), Department of Pharmacy, Faculty of Science, (D.S.-Y.T), Department of Physiology, Yong Loo Lin School of Medicine (J.K.W.L.), Heat Resilience and Performance Centre, Yong Loo Lin School of Medicine (J.K.W.L.), National University of Singapore, Singapore; Health and Social Sciences, Singapore Institute of Technology, Singapore (X.R.T.); Campus for Research Excellence and Technological Enterprise, Singapore (S.H.G., J.K.W.L.); Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore (M.K.S.L.); Duke-National University of Singapore Medical School, Singapore (M.K.S.L.); Department of Endocrinology, Division of Medicine, Tan Tock Seng Hospital, Singapore (M.K.S.L.); Singapore Institute for Clinical Sciences, Agency for Science, Technology and Research, Singapore (M.K.S.L., J.G.E.); Folkhalsan Research Center, Helsinki, Finland (J.G.E.); Department of General Practice and Primary Health Care, University of Helsinki, and Helsinki University Hospital, University of Helsinki, Helsinki, Finland (J.G.E.); and Department of Obstetrics & Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore (J.G.E.)
| | - Jason Kai Wei Lee
- Human Potential Translational Research Programme, Yong Loo Lin School of Medicine (J.W., X.R.T., S.H.G., M.I., M.K.S.L., J.G.E., J.K.W.L.), Department of Pharmacy, Faculty of Science, (D.S.-Y.T), Department of Physiology, Yong Loo Lin School of Medicine (J.K.W.L.), Heat Resilience and Performance Centre, Yong Loo Lin School of Medicine (J.K.W.L.), National University of Singapore, Singapore; Health and Social Sciences, Singapore Institute of Technology, Singapore (X.R.T.); Campus for Research Excellence and Technological Enterprise, Singapore (S.H.G., J.K.W.L.); Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore (M.K.S.L.); Duke-National University of Singapore Medical School, Singapore (M.K.S.L.); Department of Endocrinology, Division of Medicine, Tan Tock Seng Hospital, Singapore (M.K.S.L.); Singapore Institute for Clinical Sciences, Agency for Science, Technology and Research, Singapore (M.K.S.L., J.G.E.); Folkhalsan Research Center, Helsinki, Finland (J.G.E.); Department of General Practice and Primary Health Care, University of Helsinki, and Helsinki University Hospital, University of Helsinki, Helsinki, Finland (J.G.E.); and Department of Obstetrics & Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore (J.G.E.)
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Soh XQ, Tan DSY, Chan ECY. Simvastatin, but Not Atorvastatin, Is Associated with Higher Peak Rivaroxaban Serum Levels and Bleeding: an Asian Cohort Study from Singapore. Cardiovasc Drugs Ther 2023; 37:917-925. [PMID: 35567727 DOI: 10.1007/s10557-022-07346-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/04/2022] [Indexed: 11/26/2022]
Abstract
AIMS This study attempts to identify predictors associated with bleeding and stroke and systemic embolism (SSE) in Singaporean Asians taking rivaroxaban and apixaban. METHODS A total of 134 Singaporean patients on either rivaroxaban or apixaban for non-valvular atrial fibrillation were included for this study. Baseline characteristics were recorded at recruitment while bleeding and SSE events were recorded during a 1-year follow-up. Peak and trough drug plasma concentrations were collected based on the dosing interval and pharmacokinetics of the drugs and quantified using high performance liquid chromatography. Characteristics of patients with or without bleeds were compared using relevant statistical tests. Multivariable regression that included covariates with p < 0.1 from an initial univariable regression was performed to analyse predictors that resulted in higher risk of bleeding in patients. RESULTS Median creatinine clearance (CrCl) was significantly lower in patients on rivaroxaban who experienced bleeds as compared to patients who did not experience bleeds (61.5 vs 70.8 mL/min, p = 0.047), while concomitant simvastatin use was found to be independently associated with a sixfold increased risk of bleeding (adjusted OR = 6.14 (95% CI: 1.18-31.97), p = 0.031) for rivaroxaban after controlling for body mass index, CrCl and having experienced a previous SSE. CONCLUSION Our findings suggest that concomitant use of simvastatin with rivaroxaban may be associated with bleeding events in an Asian cohort. Further studies using physiologically based pharmacokinetic modelling are required to investigate the drug-drug interactions between these drugs.
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Affiliation(s)
- Xin Qin Soh
- National University of Singapore, 18 Science Drive 4, Singapore City, 117559, Singapore.
| | - Doreen Su-Yin Tan
- National University of Singapore, 18 Science Drive 4, Singapore City, 117559, Singapore
| | - Eric Chun Yong Chan
- National University of Singapore, 18 Science Drive 4, Singapore City, 117559, Singapore
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Kim JH, Tan DSY, Chan MYY. Cost-effectiveness of CYP2C19-guided antiplatelet therapy for acute coronary syndromes in Singapore. Pharmacogenomics J 2021; 21:243-250. [PMID: 33462345 DOI: 10.1038/s41397-020-00204-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 11/14/2020] [Accepted: 12/04/2020] [Indexed: 11/09/2022]
Abstract
We evaluated the cost-effectiveness of a genotype-guided strategy among patients with acute coronary syndromes using a decision-tree model based on the Singapore healthcare payer's perspective over a 1-year time horizon. Three dual antiplatelet strategies were considered: universal clopidogrel, genotype-guided, and universal ticagrelor. The prevalence of loss-of-function alleles was assumed to be 61.7% and model inputs were identified from the literature. Our primary outcome of interest was incremental cost-effectiveness ratio (ICER) compared to universal clopidogrel. Both genotype-guided (72,158 SGD/QALY) and universal ticagrelor (82,269 SGD/QALY) were considered cost-effective based on a willingness-to-pay (WTP) threshold of SGD 88,991. In our secondary analysis, the ICER for universal ticagrelor was 114,998 SGD/QALY when genotype-guided was taken as a reference. Probabilistic sensitivity analysis revealed that genotype-guided was the most cost-effective strategy when the WTP threshold was between SGD 70,000 to 100,000. Until more data are available, our study suggests that funding for a once-off CYP2C19 testing merits a consideration over 1 year of universal ticagrelor.
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Affiliation(s)
- Ji Heon Kim
- Department of Pharmacy, Khoo Teck Puat Hospital, Singapore, 768828, Singapore.
| | - Doreen Su-Yin Tan
- Department of Pharmacy, Khoo Teck Puat Hospital, Singapore, 768828, Singapore
| | - Mark Yan Yee Chan
- Department of Cardiology, Yong Loo-Lin School of Medicine, National University of Singapore, Singapore, 119228, Singapore
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Chang GSW, Tan DSY. Using Pharmacogenetic Testing to Tailor Warfarin Therapy: The Singapore Experience and What the Future Holds. Eur Cardiol 2020; 15:e53. [PMID: 32684983 PMCID: PMC7362335 DOI: 10.15420/ecr.2019.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 04/03/2020] [Indexed: 11/04/2022] Open
Abstract
Genetic polymorphisms significantly affect individual responses to warfarin, contributing to unpredictability and challenges in managing anticoagulation. Although numerous studies have demonstrated that pharmacogenetic testing improves anticoagulation-related outcomes in the Caucasian population, its effect in the Asian population has not been well studied. This article discusses controversies surrounding tailoring warfarin therapy using pharmacogenetic testing and its role in clinical practice, with a focus on the Asian context. Using the Singapore experience as an example, the authors propose how pharmacogenetic testing can be a means to reduce dose titrations in select patient populations, and how it may be positioned as an enabler to reduce healthcare resources needed for anticoagulation management.
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Affiliation(s)
| | - Doreen Su-Yin Tan
- Department of Pharmacy, Khoo Teck Puat Hospital, Yishun Health Singapore
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Png WY, Wong XY, Kwan YH, Lin YY, Tan DSY. Perspective on CYP2C19 genotyping test among patients with acute coronary syndrome - a qualitative study. Future Cardiol 2020; 16:655-662. [PMID: 32524842 DOI: 10.2217/fca-2020-0036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Identify factors patients consider regarding CYP2C19 genotyping test to guide choice of antiplatelet therapy. Patients & methods: Patient's perception and attitude toward use of CYP2C19 genotyping test was gathered according to an interview guide. Thematic analysis was conducted. Results: A total of 14 patients were interviewed. The main factors found to influence uptake of CYP2C19 genotyping test are, convenience of genotyping test (n = 4), physician's recommendation (n = 11), prior explanation of genetic testing by medical personnel (n = 5) and inclination toward clopidogrel, with three sub-factors; less frequent dosing (n = 3), lower cost (n = 7) and lower risk of bleeding (n = 9). Conclusion: This study provided the information needed to develop a discrete choice experiment to empirically quantify patients' preference and willingness to pay for genetic testing and to simulate uptake.
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Affiliation(s)
- Wan Yu Png
- Department of Pharmacy, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828
| | - Xin Yi Wong
- Department of Pharmacy, National University of Singapore, 18 Science Drive 4, Singapore 117559
| | - Yu Heng Kwan
- Program in Health Services & Systems Research, Duke-NUS Medical School, 8 College Road, Singapore 169857
| | - Ying Ying Lin
- Department of Pharmacy, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828
| | - Doreen Su-Yin Tan
- Department of Pharmacy, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828
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Tan DSY, Aw JWX, Winther M, Goh LL, Ong HY, Wee E, Liu J, Ho HK. CYP2C19 phenotype in South-East Asian Acute Coronary Syndrome patients and impact on major adverse cardiovascular events. J Clin Pharm Ther 2019; 45:52-58. [PMID: 31670842 DOI: 10.1111/jcpt.13062] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 09/17/2019] [Accepted: 09/20/2019] [Indexed: 12/13/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Several Caucasian cohort studies have associated at least one loss-of-function CYP2C19 on Clopidogrel (LoF-Clopidogrel) with major adverse cardiovascular events (MACE), and only a couple have used Clinical Pharmacogenetics Implementation Consortium (CPIC® ) phenotype grouping to study the associations. We primarily aimed to study the impact of use of platelet reactivity testing to escalate antiplatelet therapy and secondarily to study the association of CPIC phenotype with MACE outcomes in South-East Asian Acute Coronary Syndrome (ACS) subjects. METHOD A retrospective genotype study was performed on 238 percutaneous coronary intervention subjects, originally planned for escalation of antiplatelets using platelet reactivity testing. RESULTS AND DISCUSSION There was no difference in MACE between the switched and unswitched groups; however, 'all bleeds' and 'clinically significant bleeds' (CSB) were statistically higher in the patients who were switched to prasugrel. The subgroup of patients who remained on clopidogrel (n = 199) were analysed using phenotype categories and MACE. Eleven percent (11.4%) of CYP2C19 poor metabolizers (PM) suffered MACE, compared with 1.3% of extensive metabolizers (EM). LoF-Clopidogrel patients are significantly more likely to experience MACE compared with non-LoF subjects (8.0% vs 5.4%, P: .041). WHAT IS NEW AND CONCLUSION In our multivariate analysis, LoF-Clopidogrel, malay ethnicity, diabetics and use of proton pump inhibitors were independent predictors of MACE. There were numerically more bleeds in LoF subjects who were on prasugrel compared with Clopidogrel (23.5% vs 11%, P = .082). Our data corroborate with current findings on platelet reactivity testing, suggesting that the assay would not be sensitive enough to pick up sufficient 'at-risk' subjects as compared to the use of CYP2C19 genotyping.
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Affiliation(s)
| | | | | | | | - Hean Yee Ong
- Mount Elizabeth Hospital, Singapore City, Singapore
| | - Eric Wee
- Mount Elizabeth Medical Centre, Singapore City, Singapore
| | - Jianjun Liu
- Genome Institute of Singapore, Singapore City, Singapore
| | - Han Kiat Ho
- National University of Singapore, Singapore City, Singapore
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Wang KL, Lopes RD, Patel MR, Büller HR, Tan DSY, Chiang CE, Giugliano RP. Efficacy and safety of reduced-dose non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation: a meta-analysis of randomized controlled trials. Eur Heart J 2018; 40:1492-1500. [DOI: 10.1093/eurheartj/ehy802] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 08/14/2018] [Accepted: 11/26/2018] [Indexed: 12/12/2022] Open
Affiliation(s)
- Kang-Ling Wang
- General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University School of Medicine, 2400 Pratt Street, Durham, NC 27710, USA
| | - Manesh R Patel
- Duke Clinical Research Institute, Duke University School of Medicine, 2400 Pratt Street, Durham, NC 27710, USA
| | - Harry R Büller
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - Doreen Su-Yin Tan
- Department of Pharmacy, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Chern-En Chiang
- General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Robert P Giugliano
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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9
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Ng Tsai HO, Goh JJN, Aw JWX, Lin Y, Fong AYY, Tiong LL, Tan DSY. Comparison of rivaroxaban concentrations between Asians and Caucasians and their correlation with PT/INR. J Thromb Thrombolysis 2018; 46:541-548. [PMID: 30155672 DOI: 10.1007/s11239-018-1726-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The objectives of this study are to compare steady-state trough (Cmin,ss) and peak (Cmax,ss) concentrations of rivaroxaban between Asians and Caucasians and to evaluate the relationship between rivaroxaban concentrations and prothrombin time/international normalized ratio (PT/INR). Recruited patients were advised on the time to take rivaroxaban. Cmin,ss and PT/INR were taken when patients arrived. Cmax,ss and PT/INR were drawn between 2 and 4 h later after the patient took rivaroxaban with food. Thirty patients were included in the analyses: 57% (n = 17) males and 43% (n = 13) females, 77% (n = 23) on 20 mg and 23% (n = 7) on 15 mg. Median PTtrough and PTpeak are moderately correlated with Cmin,ss (r2 = 0.43) and Cmax,ss (r2 = 0.49), respectively. Patients on 15 mg have lower Cmin,ss and Cmax,ss versus Caucasians [12 ng/ml vs. 57 ng/ml (Cmin,ss); 87 ng/ml vs. 229 ng/ml (Cmax,ss), p < 0.01 for both]. Patients on 20 mg also have lower Cmin,ss and Cmax,ss versus Caucasians [14 ng/ml vs. 44 ng/ml (Cmin,ss); 101 ng/ml vs. 249 ng/ml (Cmax,ss), p < 0.01 for both]. Subgroup analysis shows patients with BMI ≥ 30 have lower Cmax,ss than patients with BMI < 30 [80.47 ng/ml vs. 124 (p = 0.014)]. Cmin,ss and Cmax,ss were lower in Singaporeans than Caucasians. This may have an impact on the effectiveness of rivaroxaban in Singaporeans. Patients with higher BMI may not benefit similarly as patients with lower BMI. Lastly, the Dade Innovin reagent's measure of PT/INR is not sensitive towards changes in rivaroxaban concentrations.
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Affiliation(s)
- Hobart Owen Ng Tsai
- Department of Pharmacy, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore, 768828, Singapore.
| | - Janice Jia Ni Goh
- Department of Pharmacy, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore, 768828, Singapore
| | - Jernice Wan Xin Aw
- Department of Pharmacy, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore, 768828, Singapore
| | - Yingying Lin
- Department of Pharmacy, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore, 768828, Singapore
| | - Alan Yean Yip Fong
- Consultant Cardiologist, Sarawak Heart Centre, Kuching - Samarahan Expressway, 94300, Kota Samarahan, Sarawak, Malaysia.,Clinical Research Centre, Sarawak General Hospital, Jalan Hospital, 93586, Kuching, Sarawak, Malaysia
| | - Lee Len Tiong
- Clinical Research Centre, Sarawak General Hospital, Jalan Hospital, 93586, Kuching, Sarawak, Malaysia
| | - Doreen Su-Yin Tan
- Department of Pharmacy, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore, 768828, Singapore
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Aw JWX, Tan DSY, Goh LL. Letter by Aw et al Regarding Article, "Clinical Outcomes and Sustainability of Using CYP2C19 Genotype-Guided Antiplatelet Therapy After Percutaneous Coronary Intervention". Circ Genom Precis Med 2018; 11:e002253. [PMID: 29987115 DOI: 10.1161/circgen.118.002253] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | - Liuh Ling Goh
- Tan Tock Seng Hospital, Singapore, Singapore (L.L.G.)
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11
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Wee XT, Ho LM, Ho HK, Lee JYC, Yap CW, William H, Chan LCE, Tay HC, Goh CEM, Tan DSY. Incidence of thromboembolic and bleeding events in patients with newly diagnosed nonvalvular atrial fibrillation: An Asian multicenter retrospective cohort study in Singapore. Clin Cardiol 2017; 40:1218-1226. [PMID: 29251769 DOI: 10.1002/clc.22811] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 08/17/2017] [Accepted: 09/07/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Real-world effectiveness and safety of antithrombotics in nonvalvular atrial fibrillation (NVAF) patients in Singapore has not been thoroughly studied. HYPOTHESIS Users of various antithrombotics experience a significantly different risk of stroke and major bleed compared with warfarin users. METHODS This multicenter retrospective cohort study included patients age ≥ 21 years newly diagnosed with NVAF between July 2012 and September 2015. Using electronic medical records, data on patients' demographics, antithrombotics prescribed, and CHA2 DS2 -VASc and HAS-BLED risk factors were collected. Patients were followed for 1 year from diagnosis for the primary effectiveness and safety endpoints of incident stroke or systemic embolism and major bleed, respectively. The secondary safety endpoint was overall bleed. Hazard ratios (HR) were determined from Cox regression. RESULTS Of 743 patients included, 224 were on warfarin, 156 on direct oral anticoagulants (DOACs), 277 on single antiplatelet therapy (SAPT), 28 on dual antiplatelet therapy (DAPT), and 58 on no therapy. Mean age (±SD) was 68.7 ± 13.0 years. Compared with warfarin users, SAPT (adjusted [adj.] HR: 3.70, 95% confidence interval [CI]: 1.21-11.3) and DAPT users (adj. HR: 10.1, 95% CI: 1.51-67.2) were more likely to develop thromboembolic outcomes. Also, DOAC users (adj. HR: 0.304, 95% CI: 0.158-0.585), SAPT users (adj. HR: 0.142, 95% CI: 0.0680-0.295), and DAPT users (adj. HR: 0.112, 95% CI: 0.0146-0.857) were less likely to experience any bleed compared with warfarin users. CONCLUSIONS SAPT and DAPT are less effective than warfarin in NVAF patients. DOACs may be considered in view of lower risk of overall bleed.
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Affiliation(s)
- Xue Ting Wee
- Department of Pharmacy, Khoo Teck Puat Hospital, Singapore
| | - Lih Maan Ho
- Department of Pharmacy, National University of Singapore
| | - Han Kiat Ho
- Department of Pharmacy, National University of Singapore
| | | | - Chun Wei Yap
- Health Services and Outcomes Research, National Healthcare Group, Singapore
| | - Henry William
- Department of Pharmacy, Khoo Teck Puat Hospital, Singapore
| | | | - Hooi Ching Tay
- Department of Pharmacy, Khoo Teck Puat Hospital, Singapore
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12
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Wang KL, Chiu CC, Giugliano RP, Tan DSY, Lin CY, Lai EY, Goto S, Chiang CE. Drug Class, Renal Elimination, and Outcomes of Direct Oral Anticoagulants in Asian Patients: A Meta-Analysis. J Stroke Cerebrovasc Dis 2017; 27:857-864. [PMID: 29239808 DOI: 10.1016/j.jstrokecerebrovasdis.2017.10.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 10/12/2017] [Accepted: 10/21/2017] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) have a better risk benefit profile in Asian patients with atrial fibrillation (AF). Whether treatment effects could be modified by drug class and dependency on renal elimination of studied agents has not yet been explored. METHODS We searched PubMed, CENTRAL, and CINAHL databases through November 2016 for phase III randomized controlled trials comparing DOACs with warfarin in patients with AF. Efficacy and safety outcomes were pooled according to drug class and dependency on renal elimination of DOACs and were compared with the Mantel-Haenszel fixed-effects model. Effect differences were assessed with Bucher's indirect comparisons using common estimates, once heterogeneity was low, and with the Bayesian method. RESULTS Among 6496 Asian patients from 6 trials, both direct thrombin inhibitors and factor Xa inhibitors, compared with warfarin, were associated with lower risks of stroke or systemic embolism and major bleeding (risk ratio [95% confidence interval], 0.51 [0.33-0.78], 0.74 ([0.58-0.96], 0.60 [0.41-0.86], and 0.59 [0.47-0.76], respectively). There was no between-group difference in direct thrombin inhibitors and factor Xa inhibitors or in DOACs with renal elimination less than 50% and 50% or greater (all I2 < 25% and interaction P > .05). Indirect comparisons within strata of drug class and dependency on renal elimination showed no preferential effect of any given regimen over another. There was no difference in effects on ischemic and hemorrhagic stroke, intracranial hemorrhage, myocardial infarction, and all-cause mortality between DOACs stratified by pharmacologic characteristics. CONCLUSIONS DOACs, as a therapeutic class, outperform warfarin in efficacy and safety in Asian patients with AF.
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Affiliation(s)
- Kang-Ling Wang
- General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan.
| | - Chun-Chih Chiu
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Robert P Giugliano
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Doreen Su-Yin Tan
- Department of Pharmacy, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Chun-Yi Lin
- General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - En-Yu Lai
- Institute of Information Science, Academia Sinica, Taipei, Taiwan
| | - Shinya Goto
- Department of Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Chern-En Chiang
- General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
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Wang KL, Chiu CC, Su-Yin Tan D, Lin CY, Lai EY, Goto S, Giugliano RP, Chiang CE. Once- or twice-daily non-vitamin K antagonist oral anticoagulants in Asian patients with atrial fibrillation: A meta-analysis of randomized controlled trials. J Formos Med Assoc 2017. [DOI: 10.1016/j.jfma.2017.05.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Ong KY, Kwan YH, Tay HC, Tan DSY, Chang JY. Prevalence of dysglycaemic events among inpatients with diabetes mellitus: a Singaporean perspective. Singapore Med J 2016; 56:393-400. [PMID: 26243976 DOI: 10.11622/smedj.2015110] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION As the effectiveness of intensive glycaemic control is unclear and recommended glycaemic targets are inconsistent, this study aimed to ascertain the prevalence of dysglycaemia among hospitalised patients with diabetes mellitus in an Asian population and evaluate the current standards of inpatient glycaemic control. METHODS A retrospective observational study was conducted at a secondary hospital. Point-of-care blood glucose (BG) values, demographic data, medical history, glycaemic therapy and clinical characteristics were recorded. Dysglycaemia prevalence was calculated as proportions of BG-monitored days with at least one reading exceeding the cut points of 8, 10 and 15 mmol/L for hyperglycaemia, and below the cut point of 4 mmol/L for hypoglycaemia. RESULTS Among the 288 patients recruited, hyperglycaemia was highly prevalent (90.3%, 81.3% and 47.6% for the respective cut points), while hypoglycaemia was the least prevalent (18.8%). Dysglycaemic patients were more likely than normoglycaemic patients to have poorer glycated haemoglobin (HbA1c) levels (8.4% ± 2.6% vs. 7.3% ± 1.9%; p = 0.002 for BG > 10 mmol/L) and longer lengths of stay (10.1 ± 8.2 days vs. 6.8 ± 4.7 days; p = 0.007 for BG < 4 mmol/L). Hyperglycaemia was more prevalent in patients on more intensive treatment regimens, such as basal-bolus combination therapy and the use of both insulin and oral hypoglycaemic agents (100.0% and 96.0%, respectively; p < 0.001 for BG > 10 mmol/L). CONCLUSION Inpatient glycaemic control is suboptimal. Factors (e.g. type of treatment regimen, discipline and baseline HbA1c) associated with greater prevalence of dysglycaemia should be given due consideration in patient management.
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Affiliation(s)
- Kheng Yong Ong
- Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore ; Specialist Outpatient Clinics, Department of Pharmacy, Singapore General Hospital, Singapore
| | - Yu Heng Kwan
- Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore ; Duke-NUS Graduate Medical School Singapore, Singapore
| | - Hooi Ching Tay
- Department of Pharmacy, Khoo Teck Puat Hospital, Singapore
| | | | - Joanne Yeh Chang
- Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore
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Abstract
Objective: To report a case of erythema multiforme secondary to dimenhydrinate and pamabrom cross-sensitivity. Case Summary: A 22-year-old Chinese female presented with a complaint of lip mucosal ulceration with necrosis and stomatitis, worsening over the past 24 hours and associated with reduced oral intake and incomplete opening of the mouth. Presentation was accompanied by a generalized rash and genital mucosal involvement. The only new systemically ingested agent was dimenhydrinate approximately 4 days prior to admission. She had no significant medical history, but was labeled to be allergic to acetaminophen. She had a positive history of 2 similar presentations secondary to Panadol Menstrual (acetaminophen and pamabrom), once 3 years ago and again 5 months prior to the current admission. An objective causality assessment revealed that the adverse drug event was “probable” to dimenhydrinate. A detailed history revealed a negative drug challenge to acetaminophen. She had previously taken plain acetaminophen and Beserol (acetaminophen and chlormezanone) with no reaction. Discussion: A comprehensive history taking facilitated the diagnosis of erythema multiforme secondary to dimenhydrinate without the need to perform invasive testing, and the removal of erroneous allergy labeling to acetaminophen. Dimenhydrinate and pamabron both contain theophylline-related structures in their chemical composition. Similar reactions to pamabrom strongly suggested cross-sensitivity to theophylline-related structures. Conclusions: To our knowledge, this is the first report of erythema multiforme due to dimenhydrinate with pamabron cross-sensitivity. We recommend that comprehensive medication-history taking be carried out for all drug-allergy patients to ensure greater informed decision making when choosing medications to use for that patient in the future.
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Affiliation(s)
| | - Grant E. Sklar
- National University of Singapore, Singapore
- National University Hospital, Singapore
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