Many years ago BI would irregularly receive donations of sutures. There were always many medical teams that have wanted sutures, and BI has continued to receive pleas for sutures quite frequently. For that reason, Blessings has embarked an effort to carry purchased sutures. Due to the great abundance of suture types, lengths, and needles this is being done with much fear and trembling because what does a pharmacologist know about sutures? The answer is nothing by means of academic training. But by handling the donated sutures years ago, I learned enough, hopefully, to avoid some huge mistakes and hopefully BIs first venture into purchased sutures will not be too far off the mark for the most widely needed sutures.

The sutures now in stock can be seen in the hospital/surgical supply area of our bulletin. These sutures and needles were manufactured in India and are sterile. BI chose to allow teams to decide whether they would prefer to purchase needles and sutures separately or sutures with pre-attached needles. Needles alone come in assorted boxes of either cutting or round point needles. Presently BI has sutures with out needles consisting of various lengths of either chromic catgut or synthetic absorbable (ployglycolic acid coated, braided, like Vycryl). Finally silk sutures with cutting point needles of various sizes, and synthetic absorbable sutures with a choice of round point, or cutting point needles of various sizes are listed.

If you choose to order some of these sutures, I ask that you let me know how well they work out for you. That is the only way we will know if these sutures meet the needs of physicians and surgeons that use them. Finally if this current selection does not meet your needs, please share with me your preferred suture material, sizes, and needles with me. This is the only way we can be of greater service to you.

A few years ago BI began to stock Fluconazole tablets 150 mg carded as a single tablet for use in treating vaginal candidiasis. The cost for a single tablet was about 30 cents. While this cost is not that high, we found that many teams required large quantities, sometimes 500 to 1000 tablets. This represents a considerable amount of bulky material which with the decreased weight allowance per bag let BI to begin stocking small bottles of fluconazole tablets to save space and weight. One 60 cc size bottle contains 100 tablets and a 250 cc bottle contains 500 tablets. Using such packaging allows a pharmacist on site to administer one tablet at a time for a woman to take orally immediately without having to also use a separate zip lock bag to package one tablet.

As a pharmacologist, I am highly motivated to introduce new interventions for treating severe infections and hard to manage chronic diseases. In the spring of 2009, BI introduced the drug combination of artemether + lumefantrine as a powder for oral suspension to for the treatment of malaria in infants 5 to 15 kg. Treating malaria in infants is a difficult proposition and one that I personally faced in Southern Sudan in 2005. BI can now provide an effective oral treatment for treating infants diagnosed with malaria. BI now also carries artemether for injection to treat patients who are unconscious or unable to take oral medication for malaria.

For several years, BI has had requests for newer antihypertensive drugs, in particular for Cozaar (losartan) tablets. Recently one of BIs former board members who is now a missionary was frantic for BIs assistance to obtain some Cozaar which is presently only available as a proprietary brand name drug. But by April 2010, the Cozaar will be off patent just in time for the arrival of BIs first production run of generic Cozaar known as losartan in 50 mg tablets. As with all other drugs that BI imports, every lot has two certificates of analysis, one by the manufacturer, and a second one by an international Swiss laboratory to confirm the manufacturers assay. BI also has made up tablet punches having an imprint of COZR to serve as a tablet identifier for safety reasons.

Losartan potassium tablets join atenolol tablets as the second drug that BI offers among its import for export medicines indicated for the treatment of hypertension. BI would also have offered enalapril were it not for a limitation of the expiration date to two years by the Indian government.

Losartan potassium is among the first of a new class of angiotensin II receptor (type AT1) antagonist. ACE inhibitors such as captopril or enalapril inhibit the conversion of angiotensin I to angiotensin II by binding to angiotensin converting enzyme II to block formation of angiotensin II,. In contrast Losartan and its primary metabolite block the vasoconstrictor and aldosterone-secreting effects of angiotensin II by selectively blocking the binding of angiotensin II to the AT1 receptor found in many tissues, (e.g., vascular smooth muscle, adrenal gland). There is also an AT2 receptor found in many tissues, but it is not known to be associated with cardiovascular homeostasis. While both losartan and its active metabolite have about a 1000 fold greater affinity for the AT1 receptor over the AT2 receptor, neither exhibits any partial agonist activity for the AT1 receptor. In vitro binding studies have indicated that losartan binding is a reversible, competitive inhibitor of the AT1 receptor. Being 10 to 40 times more potent (by weight) than losartan, the primary metabolite appears to be a non-competitive, irreversible inhibitor of the AT1 receptor. When losartan potassium alone is insufficient to control hypertension, low doses of hydrochlorothiazide (12.5 mg) may be safely used in combination with losartan. The antihypertensive effects of losartan and HCTZ are additive.

Warning: In pregnancy during the second and third trimesters, drugs that act directly on the renin-angiotensin system can cause injury and even death to the developing fetus. When pregnancy is detected, losartan should be discontinued as soon as possible.

Losartan potassium will become available for shipment from BI around 1 May 2010.

When ciprofloxacin was introduced, it had an enormous impact in improving the treatment of UTIs, skin infections, and respiratory infections. While BI still ships out large quantities of generic Bactrim/Septra under our own name of Cotrimoxazole for use in many nations where such infections remain sensitive to this important combination, there are many countries where ciprofloxacin has replaced sulfamethoxazole + trimethoprim due to the development of resistance. Likewise, response rates to ciprofloxacin have begun to fall in some developing nations in the same way it had in developed countries. This is especially serious when treating lower respiratory infections when azithromycin is also not as effective. For these reasons, and to stay ahead of the problems of increased resistance in developing nations, BI will add levofloxacin to its pharmaceutical armamentarium sometime in 2010. Let us know if you have a need or an interest in obtaining levofloxacin for use in your medical clinics.

Blessings International has stocked A Comprehensive Guide to Missions by Karen Bean, R.N. for many years. Karens book is an excellent introduction in the preparation and management of short- and long-term mission teams. An excellent companion to Karen Beans book is A Complete Guide to Medical Missions, a Turn-Key Manual for Short-Term Medical Teams by James A. Lindgren, MD. This manual is an updated version in a three ring binder to facilitate removal of many forms that would be very useful in operating a short-term medical clinic. Dr. Lindgren has compiled an extensive variety of forms and suggested lists of everything to consider having or using in a primary care clinic including medicines as well as medical supplies. In addition, he has included a list of most common presenting complaints/diagnoses encountered and a table with columns listing complaints, associated signs/symptoms, differential diagnoses, and finally treatment recommendations. There are many additional lists and tables that every leader of a medical mission effort will eager to possess to facilitate preparation and the smooth operation of a primary care clinic. We highly recommend this new guide!

For a very long time the treatment of scabies has consisted to the topical application of products including benzyl benzoate, sulfur in petrolatum, the insecticide lindane (lotion), premethrin cream, and more recently a non-toxic solution of enzymes that Blessings calls Itch B Gone. The lesser expensive products require soaking/bathing in the solutions for which compliance may be poor. Premethrin is quite costly if many people need treatment. Now ivermectin can be used as a one dose oral therapy for treatment of scabies.

Background: Ivermectin is an drug (related to macrolide antibiotics) that has been around for many years and has very broad use in veterinary medicine and many know if its use to prevent heart worms in dogs. For many years, Merck has donated this drug for the treatment and prevention of onchocerciasis (river-bend blindness) and more recently lymphatic filariasis (elephantiasis). Annual treatment is required because the drug does not kill the adult worms, but rather only the immature microfilaria. Because the human is primary host for these diseases, it is thought that by keeping the circulating microfilaria levels very low in treated subjects, transmission by the intermediate vectors (a fly for onchocerciasis, and mosquito for filariasis), would greatly reduced or blocked altogether. Eventually the incidence and prevalence of these diseases should drop. The goal is to the eventual complete elimination of these diseases. Therefore Merck is to be commended for its donations of ivermectin (Mectizan) in support of mass drug administration programs. However Merck donates ivermectin for such programs only to countries where onchocerciasis and lymphatic filariasis are co-endemic.

Treatment of scabies: The dosage recommend for treatment of scabies is with ivermectin a 200 mcg/kg taken once. A 70 kg adult dose would be 14mg, or 2.5 tablets of 6 mg each. Tablets are scored for ease of administration to patients having various weights. Children as small as 15kg (90 cm in height) can be treated with ivermectin. There are no studies on safety of using ivermectin in infants.

Safety, side effects, pregnancy, nursing mothers: Ivermectin is generally very well tolerated in well adults. Most side effects occur as a result of actions of the drug on the parasites; dying microfilaria that can cause severe reactions. Such reactions do not occur in treating scabies. Ivermectin is not mutagenic by the Ames assay and by other tests. No studies have been conducted on carcinogenicity. The drug is not embryo toxic, but at repeated maternally toxic doses, it is teratogenic in mice, rats and rabbits. Therefore it is rated a Pregnancy Category C drug. Even though very little drug is secreted into breast milk, the nursing of infants should be avoided for several days after treatment. There have been no known deaths caused overdoses of ivermectin.

Therapeutic Response: The response rate to treatment of scabies with ivermectin may be characterized as better than that with topical 1% lindane lotion, but somewhat less that with topical 5% premethrin. Those failing to respond two weeks after treatment can be retreated at the same dose and again after another two weeks if necessary. The need for retreatment is not unexpected in massive or incrusted infections. Finally long-term cure depends upon good hygienic practices, especially washing all clothes and bedding of an infected family in hot water and bleach at the time of treatment regardless of the choice of drug used for treatment.

Cost per treatment: For adults, the cost per treatment is between 30 to 45 cents (15 cents/tablet) which is only about 5-7% of the cost of treatment with 5% premethrin.

Final tip from the pharmacologist on ivermectin: While ivermectin is active against many intestinal helminthes other than hookworms, I do not advise using ivermectin for treating intestinal worms other than Strongyloides (threadworm) for two reasons. First, the administration of albendazole and mebendazole is much easier because the dose is the same for adults and children of all weights. Second the incidence of side effects (intestinal discomfort) is less with mebendazole or albendazole than with ivermectin. Finally dont be tempted to use Blessings ivermectin for your dog because it cost less; Blessings ivermectin is intended for use only outside the USA.

For many years Blessings International has desired to have these newer macrolid antibiotics in its formulary. Among other indications, both of these drugs are very useful for treating moderately severe lower respiratory Infections in ambulatory patients which are resistant to older antibiotics. And with Azithromycin, the duration of treatment of moderate acute bacterial exacerbations of chronic obstructive pulmonary disease is much shorter, being 3 days (500mg QD x 3d) instead of the typical 10 days for Clarithromycin (500mg b.i.d. x 10 d). Community-acquired pneumonia can be treated with 500mg of Azithromycin once on day 1 followed by 250mg on days 2 through day 5. I would encourage every team to consider having at least a supply of one of these drugs for every trip. Twice daily treatment with Clarithromycin 500mg, Amoxicillin 1 gram, and Omeprazole 20mg for treatment of duodenal ulcers caused by H. pylori infections. Blessings also has Omeprazole 10mg in its formulary.

Everyone is a creature of habit. When amoxicillin is the antibiotic chosen to treat an adult infection, it is well known that the standard dose is 500mg t.i.d. (every 8 hours or three times daily). Yet both people in underdeveloped nations and here in the US are apt to be much more compliant when a b.i.d. dose schedule is possible. Well this is very readily achieved by prescribing 750 mg of amoxicillin b.i.d. (every 12 hours or twice daily). Of course this cannot be achieved using 500 mg capsules. However it is easily and readily accomplished using three 250mg capsules b.i.d. I encourage medical teams to take only 250mg capsules of amoxicillin instead of both 250mg and 500mg capsules because the 250mg dose size can easily be used for treating both the school age children and adults.

Another habit clinicians are accustomed to is treating vaginal candidiasis with clotrimazole cream. Of course treatment with this cream must be done for several days and requires an additional accessory or an inserter. A number of years ago, a single150mg tablet of fluconazole taken once was demonstrated to cure this common infection. Not only is it much more convenient and compliance is 100%, the cost of a single tablet is about one tenth the cost of a tube of clotrimazole. I have been encouraging prescribing medical professionals for perhaps two years or more to switch to fluconazole 150mg tablets not just because it is less expensive, but also because it is a tiny fraction of the weight of a 45gm tube of clotrimazole and it requires almost no space by comparison. These are often important considerations when carrying medicines into other nations. So be a better steward of your pharmacy budget, and kick this old habit in favor of oral treatment which should be more acceptable for all patients except those having liver problems.

For almost 20 years common intestinal worm infections were treated with mebendazole 100mg b.i.d. for three days. Indeed, this was and is effective for treatment of common round worms, pin worms, hookworms and whipworms. More recently mebendazole 500mg tablets have been formulated for the purpose of single tablet treatment programs with much fanfare that compliance would be 100%. True enough. However, the efficacy of single tablet treatment remained in question until a few years ago when a study reported that while roundworms (ascariasis) are effectively treated by the 500mg single tablet dose, the efficacy of treatment of whipworm was greatly reduced and the efficacy of treating hookworm was very poor (7.6% cure rate vs 96% cure rate using 100mg tablets bid x 3 days). So where a population is known to be infected with whipworms and hookworm, use of the 100mg dose of mebendazole bid x 3 day is mandatory.

Albendazole is an anthelmintic that is similar to mebendazole except that more is absorbed than mebendazole. A single 400mg tablet is effective in the treatment of roundworms, pinworms, hookworms in children (2 years and older) and adults. The advantage of albendazole is that it is also useful for treating non-intestinal worm infections. Both whipworm and cutaneous larva migrans infections can be treated with 400mg for 3 days. Even neurocysticercosis (larval infection of Taenia solium) can be treated using the 400mg albendazole bid for 8-30 days. Even though most short-term medical teams lack the ability to diagnose tissue worm effectively, the use of albendazole will no doubt increase with time.

Metronidazole, better known as Flagyl, has been in use a very long time for the treatment of amebiasis, giardiasis, trichomoniasis, as well as anerobic infections. The big problem with metronidazole is that it results in a strong metallic taste due to secretion in saliva and it tends to cause most people unpleasant CNS symptoms that make compliance a major effort, especially for treating amebiasis (750mg tid x 5-7 days or 45-63 250mg tabets). Back in the mid 1980s, while in Guatemala, I came across tinidazole under the Pfizer name of Fasgyn that was being used instead of metronidazole for the same indications. Tinidazole is an imidazole similar to metronidazole. But it is vastly better than metronidazole for at least two reasons. First the incidence of side effects is vastly lower though similar to metronidazole. Second the duration of treatments are much shorter or a single dose treatment.

Dosages for using tinidazole for various indications:

Trichomoniasis: a single 2 gram dose taken with food to minimize side effects.

Giardiasis: A single 2 gram dose with food in adults; in children 3 years and older, a single oral dose of 50mg/kg up to 2 g with food.

Amebiasis: 2 grams per day for three days taken with food or 50mg/kg/day for children older than 3 years

Conclusion: The once a day treatment schedule combined with a shorter duration of treatment using tinidazole make it an obviously better choice of drugs in treating amebiasis

Announcement: Blessings has added tinidazole 500mg in bottles of 100 tablets to its formulary.