Please find a report put together by Sara Arenas Lopez (and reviewed by Prof. Helena Lutescia Luna Coelho) on the series of meetings and seminars held in Brazil between GRiP and local Formulations experts during November 2013.
Global Research in Paediatrics
Brazil Face to Face Meetings
GRIP Work Package 5 - November 2013
This series of seminars was organized by Prof Helena Lutéscia Luna Coelho (MeMeCri’s Research Group and the Drug Utilisation Research Group for Latin America - DURG-La) together with Sara Arenas-Lopez, Consultant Pharmacist-GRIP for the Scientific Contribution to programme design and delivery of courses. The “Sociedade Brasileira de Farmácia Hospitalar”, (SBRAFH), the Federal University of Ceará and Federal University of Rio de Janeiro supported the courses. Local professionals, students, researchers and authorities, played an important role to achieve its objectives.
São Paulo 14-16th November 2013
The IX Brazilian Hospital Pharmacy and II South American Hospital Pharmacy Congress took place in the city of São Paulo. Approximately 2,000 professionals congregated in this city from around South America. Paediatric Clinical Pharmacy was one of the scientific topics covered during the Congress, with one full day seminar on paediatric medicines and half a day with round table discussions.
The lectures were delivered by Monica Travaglianti, Neonatal Pharmacist (Hospital JP Garrahan, Buenos Aires) and Sara Arenas-Lopez, Consultant Pharmacist (Evelina Children’s Hospital, London) and introduced by Prof Helena Lutéscia Luna Coelho (Universidad Federal do Ceara).
The seminar had 102 attendees, professionals from Academia and Women’s & Children Hospital settings working in paediatrics or in programmes linked to paediatric medicine, there were attendees from all 16 Brazilian States, the best represented was São Paulo followed by Rio de Janeiro and there were even 9 professionals from the remote 3 Amazonic States. In addition participants from Bolivia, Argentina and Uruguay also attended.
Copies of the British National Formulary for Children (BNF-c) were distributed among participants on the basis of departmental needs and their participation on the practical cases.
People showed a real interest on the topic of paediatric clinical pharmacy and formulations and raised the issue of lack of educational programmes on these topics in Latin America. The Children’s Hospital in Buenos Aires runs a Hospital Pharmacy service with a very well developed clinical pharmacy service and it was good for the participants to get to know these professionals as a point of contact in this continent. This hospital was identified as part of the GRIP Network for the WP5 and proposed for the participation in the Seminar and Congress and it is highlighted in the interactive map of the GRIP website. It was suggested that this hospital could be a good role model within this continent to help with development of paediatric clinical pharmacy services.
Rio de Janeiro 17th- 20th of November 2013
A seminar was run at the School of Pharmacy (Universidade Federal do Rio de Janeiro). This meeting was hosted by Prof Guacira Matos and Prof Elisangela da Costa Lima Dellamora from the Department of Pharmacy Practice (Asistência Farmacêutica).
This meeting convened approximately 80 undergraduate and postgraduate students and lecturers from the Universities of Rio and hospital pharmacists from hospitals in the province of Rio de Janeiro.
The Director from the “Farmácia Escola” (Production and Dispensing Department) from the Universidade Federal Fluminense also attended the meeting and was very interested in the GRIP activities of WP5 and shared information about progress in Brazil with paediatric formulations.
The main issues discussed were:
1-Difficulties on formulation information access, the fact that some local professionals have reservations about sharing their formulaes and any research conducted towards their validation. Hence, there is important information from research projects which never gets to the public domain, results do not get published. Some suggestions came up such as publishing them as a book or even working together with the Brazilian Pharmacopeia to include some of this information.
They asked if GRIP could help with compiling information from different centres with regards to their formulations or if they could suggest a way forward. A proposal could be made to the organisers of the second Symposia on Better Medicines for Children, planned for 2015, to get paediatric formulations researchers together
2-Interestingly the collaboration between the School of Pharmacy in Buenos Aires and the one in Rio de Janeiro was thoroughly discussed with the colleagues in Rio, and these two Universities may consider signing off a collaboration agreement.
Fortaleza, Northeast, 27th-28th November 2013
The first meeting was held at the School of Pharmacy of Universidad Federal do Ceará and at the University Hospital Walter Cantidio from the same University. This was organised by Prof Marta Fonteles from the Department of Clinical Pharmacy and Pharmaceutical Care and by the Chief Pharmacist Dr Eugenie Desireé, and supported by the MSc students Marina Garruti and Livia Aline Batista.
The meeting convened around 60 people from local hospitals and the university. Discussions took place around formulation issues, specific examples discussed in details were omeprazole and captopril paediatric formulations and the research of the university on these drugs by Dr Said Fonseca, (Pharmaceutical Technology Department, Universidad Federal do Ceará and member of the MeMeCri group). They also have studies looking at a vehicle to prepare extemporaneous formulations to be tested in different hospitals of Fortaleza and an anti-TB formulation is being developed
Again the similarities in the research lines with those taking place in Buenos Aires became apparent and Dr Fonseca was encouraged to work in collaboration with the other team.
Other research lines at the University were in the areas of Clinical Pharmacy and Pharmacoepidemiology and in the development of Phytotherapy.
Following the seminar at the University, a visit to the hospital paediatric wards and the Neonatal Intensive Care Unit took place with a practical clinical pharmacy session conducted. In the general paediatric wards admissions at the time were whooping cough, leishmaniosis and children with hepatitis.
The visiting GRIP consultant pharmacist reviewed neonatal patients with the local pharmacist and the medical and nursing teams, and formulations issues were identified, challenges and difficulties were discussed. A problem with preparation and administration of IV continuous infusions was extensively debated and this was a typical example:
A neonate (0.9kg) with the following IV Continuous infusions prescribed was reviewed:
Dopamine 1.6ml + Dobutamine 0.7ml +Fentanyl 0.9ml + 6ml of Sodium Chloride 0.9%, all in a 10ml syringe.
The following issues were identified and discussed:
• Prescribing in volume and different strengths of vials that could be available
• Calculations made by doctors but then no other checks take place by nurses or pharmacy. Pharmacy does not visit the ward for clinical support
• Administration of all the drugs in one syringe: Compatibility issues (syringes were made by nurses on the ward early in the morning and changed every 24 hours). Very concentrated solutions and no information available in common information resources, even if they seem compatible it is important to assess the compatibilities in view of the final concentration
• Use of open systems as all the small volumes of each drug drawn up in individual syringes then needed to be transferred into a 10ml syringe and the importance of knowing exactly the final volume as although they were meant to be diluted to 10ml, adding 6ml of sodium chloride was not taking them to the final 10ml, but 9.2ml
• Difficult to titrate the dose, if one drug requirement changes and they have to modify the infusion rate then they have to change the full syringe or all the doses of the rest of the drugs will be modified
• Main reason for this practice is the number of pumps available on the ward per neonate and limited supply of giving sets too. However, they could still look at optimising the pumps if some babies did not require infusions then at least they could separate for example inotropes from analgesia in two different pumps.
Double checking of the doses and doctors to prescribe the dose as units and volume was also important.
Another issue that came up was the constant requirement of manipulation of small volumes and the current work taking place by some GRIP members was shared.
The main dose reference resource used was NeoFax.
On the last day the seminar took place at the General Hospital of Fortaleza. It congregated around 20 doctors and nurses from different paediatric areas. The hosts of this meeting were: Dr Silvana Silton Torres, Consultant Neonatologist, Dr Arthur, Neurologist and Dr Patricia Quirino da Costa, Hospital Pharmacist.
The main issues that arose were around problems with packaging of drugs specially when the patients obtained medicines in community as generic drugs do not seem to be properly packed for heat and humid conditions and the doctors keep readmitting patients due to a suspected lack of efficacy of medicines. They are stabilised in hospital and then on returning to the community the problem is seen again. The neurology team mentioned this specifically for antiepileptic drugs.
Important interest was generated in the audience about GRIP activities and they expressed their interest in participating on research and education work linked to WP5.
During the trip there was an interesting case reported on the Brazilian TV Channel “Globo News” regarding a prescription error for a child made by a Cuban doctor. It was very controversial because the Department of Health has introduced a project to bring doctors from Cuba to provide medical care to the remote areas of Brazil. This has encountered resistance from the Brazilian Medical Association as they are protective of their own medical workforce. The doctor mentioned prescribed the analgesic Dipyrone (Metamizole) as “40 drops/day” despite advising the mother to administer a maximum of 10 drops at the time This was understood as 40 drops/ dose as in Brazil is not usual to prescribe daily doses.
The Dipyrone preparation available is 500mg/ml (20ml) and the common doses 15mg/kg =0.6 drops/kg or in <5 years 3-5 drops in water up to a max of 5 times a day.
This mistake escalated further leading to the temporary suspension of the doctor and demonstrations by the population as they claimed that they did not have a doctor prior to his arrival and wanted him back. A full investigation of the incident is being conducted by the Government as the extent of the error is unclear but this case was discussed during the seminars with regard to the formulation of dipyrone as drops, side effects such as Agranulocytosis, prescribing information for children and how easy it could be to dose inaccurately due to lack of information on the product available to local communities and the presentation. Even a team from the University of São Paulo conducted a study in the community looking at dosing accuracy of over the counter analgesics available containing ibuprofen, paracetamol and Dipyrone (see links) concluding on the risk of overdosing or underdosing with these products.
Overall Brazil is very positive about GRiP and especially about the networking opportunities and their possibility of enrolling in the Masters programme in the future.
Some feed back was received about improvement of the GRiP website as participants were encouraged to navigate the website. Specific ideas to improve the navigation through the website were shared and will be transmitted to the relevant GRIP teams. They found the interactive map really helpful in the WP5 section.
A proposal was made for GRIP WP5 to collaborate with the next DURG-LA meeting, preliminarily planned to take place in Montevideo, Uruguay in 2014. Geographically and economically this could be a strategic place to organize a pediatric formulation workshop for Latin American professionals, researchers, industry, regulators and most DURG-LA members.
Finally all the different professionals with an interest inGRIP unanimously referred to the possibility of translating into Spanish some of the material as English is hardly spoken in Latin America.
• Ricardo Sukiennik, Antitérmicos na emergência pediátrica: estamos usando a dosagem adequada?* http://pediatriasaopaulo.usp.br/upload/html/1176/body/05.htm