Ketrampilan panum farmako (modul) Case 3:` Marta, 10 tahun, berat badan 35kg, sejak 3 hari yang lalu menderitadiare 5 kali perhari, feses cair, berlendir, tidak ada darah. Mulai tadi pagi Marta -6 mengeluh badannya demam, buang air besar sedikit-dikit dan kotoran terlihat darah. Saat buang air besar terasa sakit. Pagi ini buang air besar sudah 8 kali. Pada pemeriksaan kesadaran, keadaan umum dan aktivitas masih baik. Suhu tubuh 38°C. Abdomen rata, supel, nyeri tekan distal u bilicus, bising usus m sedikit meningkat. Marta, 10 years old with body weight 35kg, suffers from 5-6 episodes of diarrhea per day since 3 days ago. The feces are watery and slimy without blood. Since this morning, Marta complains of fever, small amount of defecation and bloody feces. She also felt pain while passing motion and have 8 episodes of bowel discharges since this morning. Upon examination; consciousness, general condition, and activeness remain normal; body emperature 38°C; t abdomen is flat, soft, pain in distal of the umbilicus when pressed, bowel sound slightly increased. STEP 1: Define the patient's problem y Watery diarrhea since 3 days ago (5-6 episodes per day) y Fever, pain while passing motion, and small amount bloody feces since this morning (8 episodes of bowel discharges s ince this morning) y 38°C in body temperature, pain in distal of umbilicus when pressed, and slight increased bowel sound STEP 2: Specify the therapeutic objective y Diagnosis: Acute infectious (inflammatory) diarrhea y The therapeutic objectives include prevent dehydration / replacement of fluid loss, terminate diarrhea, and relieve fever and pain STEP 3: Verify the suitability of your P-drug P-drug i. Define the diagnosis y Acute infectious (inflammatory) diarrhea ii. Specify the therapeutic objective y The therapeutic objectives include prevent dehydration / replacement of fluid loss, terminate diarrhea, and relieve fever and pain iii. Make an inventory of effective groups of drugs y Rehydration / Replacement of loss: Oral Rehydration Solutions (ORS) y Terminate diarrhea: Antimotility, Absorbents, Antisecretory y Relieve of fever and pain: NSAID iv. Choose an effective group according to criteria y Antidiarrheal: Efficacy +++ ++ +++ Safety ++ +++ ++ Suitability +++ +++ +++ Cost Group Antimotility (+) Absorbents (+) Antisecretory (+) y Antipyretic / analgesic Group Efficacy NSAID Pharmacodynamics: Inhibits cyclooxygenase prostaglandin synthesis Pharmacokinetics: PO / PR Safety Suitability Cost Side effects: Contraindications: 1 and Hypersensitivity, GI upset and bleeding (besides Bleeding disorders, peptic ulcer disease paracetamol), salicylism (aspirin) (besides paracetamol) Group NSAID v. Efficacy +++ Safety +++ Suitability +++ Cost +++ Choose a P-drug y Antidiarrheal: Antisecretory Efficacy Bismuth subsalicylate +++ Safety ++ Suitability +++ Cost Stobiol 262 mg x 120's (Rp24000) NSAID: NSAID Efficacy Safety Suitability Cost Acetaminophen Acetaminophen possesses analgesic and Does not cause GI upset / bleeding G6PD deficiency, Panadol antipyretic activities with few antihypersensitivity Cap 500mg X inflammatory effects Occasionally, maculopapular rash or 100 = y Aspirin Syrup 160mg/5ml 60ml Allergic reactions Rp9,200 Aspirin is an analgesic, antipyretic, and anti- GI upset and bleeding, allergic reactions, Hypersensitivity, bleeding Aspirin Bayer inflammatory agent increased risk of Reye s Syndrome in disorder, peptic ulcer Tab 500mg children, salicylism disease 15 X 8 Anti-inflammatory properties are related to Rp36,930 the inhibition of prostaglandin biosynthesis Aspirin non selectively inhibits cyclooxygenase1 (COX-1), which is associated with GI and renal effects and inhibition of platelet aggregation, and cyclooxygenase-2 (COX-2), which is associated with the inflammatory response It is a nonselective inhibitor of cyclo- Gastric distress, blood loss, diarrhea, oxygenase-1 (COX-1) and cyclo-oxygenase-2 vomiting, dizziness, and skin rash occur (COX-2) and reversibly alters platelet function occasionally and prolongs bleeding time Better tolerated than aspirin by most patient urticarial skin reactions occur; methemoglobinemia, neutropenia, and thrombocytopenic purpura are rarely reported Rp19,000 X = X = Ibuprofen Syndrome of nasal polyps; angioedema; bronchospastic reactivity to aspirin or other NSAIDs Bufect / Bufect Forte Syrup 100mg/5ml X 60ml = Rp10,765 Syrup 200mg/5ml 60ml Rp15,100 X = NSAID Acetaminophen Aspirin Ibuprofen y Efficacy ++ +++ +++ Safety +++ + ++ Suitability +++ ++ ++ Cost +++ ++ +++ Conclusion: o Active substance, dosage form: Bismuth subsalicylate, PO Tab 262mg Ibuprofen, PO syrup 100mg/5ml X 60ml o Dosage schedule: Bismuth subsalicylate, ½-1 tablet every 30-60 minutes as needed Ibuprofen, 20mg/kg/day divided into 3 doses for about 10 days o Duration: length of monitoring interval / until the dispensed drug is finished STEP 4: Write a prescription Dr. johnson Jl. Saturnus 3, Malang Telp. 0341582110 SIP. 446.DU/012/35.73.306/2007 Malang, 27 April 2011 R/ Bismuth subsalicylate 262mg tab No. XX q1h dd tab 1, max 5 tab/day - - - - ,, - - - Ibuprofen 200mg syrup fl No. II 3 dd cth 1 pc. - - - - ,, - - - ORS sachet No. XX 1 sachet setiap kali sesudah BAB, 1 sachet diencer dengan 1 gelas air putih, prn. - - - - ,, - - - Id Pro: Adik Marta Umur: 10th. Alamat: Jl. Muthafukar No. 117, Malang STEP 5: Give information, instructions and warnings i. Effects of the drug y Bismuth subsalicylate treats symptoms of diarrhea y Ibuprofen relives the fever and pain y All the symptoms will be reduced and finally disappear y The effect is expected to start after the first 2 doses y The symptoms will remained if the drug is not taken correctly / not at all ii. Side effects y Bismuth subsalicylate may cause darkening of tongue &/or feces, and toxic if overdose y Ibuprofen might cause gastric distress, blood loss, diarrhea, vomiting, dizziness, or skin rash y If felt excessive side effects, stop the medication, and immediately refer to doctor iii. Instructions y Bismuth subsalicylate is taken ½-1 tablet every 30-60 minutes as needed up to 5 tablets a day y Ibuprofen is taken a spoon (5ml) 3 times daily y ORS is taken a sachet that have been diluted in a glass of clean water every time after passing motion y The treatment should be continue as long as it is effective / after the dispensed drug is finished iv. Warnings y The drug should be taken as instructed, do not increase / reduce the amount to be taken, and do not increase / reduce the frequency of the drug that should be taken as instructed v. Future consultations y Come back for follow up after 2 days of treatment, if the diarrhea persists y Come back to doctor earlier if experiencing side effects Everything clear? y Repeat the important information and clarified the doubts STEP 6: Monitor (and stop?) the treatment y Treatment effectiveness: o Effective: continue the drug o Minimal effect: reconsider dosage / drug choice o Not effective: verify all steps Case 4: Seorang anak berusia 4 tahun, dibawa ke dokter dengan keluhan panas 3 hari ini. Sudah diberi parasetamol, panas turun sebenta kemudian naik lagi. Pagi r ini anak tersebut batuk-batuk, tanpa diikuti pilek. Nafsu makan anak menurun, tapi masih mau bermain. Pada pemeriksaan didapat data: BB: 20kg. suhu tubuh: 38.5°C. Tenggorokan: Pharynx merah, sekret +, kental, warna kekuningan. Selain itu tidak ada kelainan lain. A 4 years old child was brought to the doctor with complaint of fever since 3 days ago. After the child was given paracetamol, the fever subsided but returned again. This morning, the child starts coughing without flu / cold. The child still wanted to play. Upon examinations, the child s body weight is 20kg, body temperature is 38.5°C, pharynx appeared red, and thick yellowish secrete is present. Other physical examinations resultsare within the normal range. STEP 1: Define the patient's problem y Complaint of fever since 3 days ago y Fever subsided temporally with paracetamol but returned shortly after that y This morning, the child has cough without flu / cold y Moderate fever, pharynx appeared red, and present of thick yellowish secrete STEP 2: Specify the therapeutic objective y Diagnosis: bacterial pharyngitis y The therapeutic objectives for this patient are to eradicate bacterial infection, relieve fever and inflammation, and remove secrete STEP 3: Verify the suitability of your P-drug P-drug i. Define the diagnosis y Bacterial pharyngitis ii. Specify the therapeutic objective vi. iii. iv. y The therapeutic objectives for this patient are to eradicate bacterial infection, relieve fever and inflammation, and remove secrete Make an inventory of effective groups of drugs y Eradication of bacterial infection: Beta-lactams (Penicillin, cephalosporin), macrolide y Relieve of fever and inflammation: NSAID y Removal of secrete: Acetylcysteine, guaifenesin, bromhexine Choose an effective group according to criteria y Antibiotics Group Efficacy BetaPharmacodynamics: lactams Inhibits cross-linking of cell wall components Pharmacokinetics: PO / IM / IV Macrolide Pharmacodynamics: Inhibits protein synthesis (prevents translocation of polypeptide chain by binding to the P site of the ribosomal 50s subunit) Pharmacokinetics: PO / IV Group Beta-lactams Macrolide Efficacy +++ +++ Safety +++ ++ Safety Suitability Cost Side effects: Contraindications: 1 (amoxicillin) & 3 Hypersensitivity, rare nerve, liver or kidney Known hypersensitivity of (cephalexin) toxicity beta lactams, resistant of causative bacteria Side effects: Contraindications: GI upset, increase plasma level of many Hypersensitivity, drugs, toxicity may results when co- dysfunction administered with theophylline, anticoagulants, carbamazepine 2 (erythromycin) hepatic Suitability +++ ++ Cost +++ / + ++ y NSAID Group Efficacy NSAID Pharmacodynamics: Safety Side effects: Suitability Contraindications: Cost 1 Inhibits cyclooxygenase prostaglandin synthesis Pharmacokinetics: PO / PR Group NSAID y and Hypersensitivity, GI upset and bleeding (besides Bleeding disorders, peptic ulcer disease paracetamol), salicylism (aspirin) (besides paracetamol) Efficacy +++ Safety +++ Suitability +++ Cost +++ Expectorants Group Efficacy Acetylcysteine Pharmacodynamics: Acetylcysteine exerts its mucolytic action through its free sulfhydryl group, which opens the disulfide bonds and lowers mucus viscosity Pharmacokinetics: PO / inhalation Guaifenesin Pharmacodynamics: Guaifenesin is proposed to have an expectorant action through an increased output of respiratory tract fluid, enhancing the flow of less viscid secretions, promoting ciliary action, and facilitating the removal of inspissated mucus Pharmacokinetics: PO Bromhexine Pharmacodynamics: It increases the production of serous mucus in the respiratory tract and makes the phlegm less sticky and thinner, which leads to secretomotoric effect Safety Suitability Side effects: Contraindications: Bronchospasm, GI disturbances, GI upset stomatitis, rhinorrhea, headache, tinnitus, urticaria, shivering, fever, hemoptysis. Anaphylactic shock (rare) Cost 1 Side effects: Contraindications: 2 Occasional nausea and vomiting, Hypersensitivity to guaifenesin Probat especially with excessive dosage; Tab dizziness; headache 100mg X 30 = Rp8,500 Side effects: Diarrhea, nausea, vomiting, and other GI disturbances, allergic reaction (include rash, urticaria, bronchospasm, Contraindications: 3 Hypersensitivity to bromhexine, history of peptic ulceration; asthmatic patients, that helps the cilia transport the phlegm out of angioedema, anaphylactic shock), severe hepatic the lungs increase antibiotic (amoxicillin, impairment Pharmacokinetics: erythromycin) concentration in lungs PO / inhalation Group Acetylcysteine Guaifenesin Bromhexine v. Efficacy +++ ++ ++ Safety ++ +++ ++ Suitability +++ +++ ++ Cost +++ +++ +++ or renal Choose a P-drug y Beta-lactams Beta-lactams Efficacy Safety Penicillin Inhibits cross-linking of cell wall components Nausea, diarrhea, rash (amoxicillin) Amino side group makes it hydrophilic enough to penetrate the porins in gram negative organisms Penicillin is the drug of choice in the treatment of Group A streptococcal pharyngitis Suitability Cost Known hypersensitivity of Amoxil beta lactams, resistant of Cap 250mg X causative bacteria 100 = Rp185,009 Syrup 125mg/5ml 60ml Rp21,620 Syrup 250mg/5ml 60ml Rp37,358 GI Known hypersensitivity of Ospexin X = X = Cephalosporin Inhibits cross-linking of cell wall components Hypersensitivity reactions, (cephalexin) Beta-lactam binds penicillin binding proteins Inhibits cell wall synthesis and may in turn activate autolysins In patients allergic to penicillin, a macrolide such as erythromycin or a first-generation cephalosporin such as cephalexin (if the reaction is non immunoglobulin E-mediated hypersensitivity) can be used Beta-lactams Efficacy Penicillin (amoxicillin) +++ Cephalosporin ++ (cephalexin) y disturbances, hematologic beta lactams, resistant of Tab 500mg X 10 abnormalities, nephrotoxicity and causative bacteria X 10 = hepatic enzyme abnormalities Rp616,000 Syrup 250ml/5ml 60ml Rp48,500 X = Safety +++ ++ Suitability +++ +++ Cost +++ ++ NSAID NSAID Efficacy Safety Suitability Cost Acetaminophen Acetaminophen possesses analgesic and Does not cause GI upset / bleeding G6PD deficiency, Panadol antipyretic activities with few antihypersensitivity Cap 500mg inflammatory effects Occasionally, maculopapular rash or 100 urticarial skin reactions occur; Rp19,000 methemoglobinemia, neutropenia, and thrombocytopenic purpura are rarely Syrup reported 160mg/5ml 60ml Allergic reactions Rp9,200 X = X = Aspirin Aspirin is an analgesic, antipyretic, and anti- GI upset and bleeding, allergic reactions, Hypersensitivity, bleeding inflammatory agent increased risk of Reye s Syndrome in disorder, peptic ulcer children, salicylism disease Anti-inflammatory properties are related to the inhibition of prostaglandin biosynthesis Aspirin non selectively inhibits cyclooxygenase1 (COX-1), which is associated with GI and renal effects and inhibition of platelet aggregation, and cyclooxygenase-2 (COX-2), which is associated with the inflammatory response It is a nonselective inhibitor of cyclo- Gastric distress, blood loss, diarrhea, oxygenase-1 (COX-1) and cyclo-oxygenase-2 vomiting, dizziness, and skin rash occur (COX-2) and reversibly alters platelet function occasionally and prolongs bleeding time Better tolerated than aspirin by most patient Aspirin Bayer Tab 500mg X 15 X 8 = Rp36,930 Ibuprofen Syndrome of nasal polyps; angioedema; bronchospastic reactivity to aspirin or other NSAIDs Bufect / Bufect Forte Syrup 100mg/5ml X 60ml = Rp10,765 Syrup 200mg/5ml 60ml Rp15,100 X = NSAID Acetaminophen Aspirin Ibuprofen Efficacy ++ +++ +++ Safety +++ + ++ Suitability +++ ++ ++ Cost +++ ++ +++ Expectorant o *Refer to iv* y Conclusion: o Active substance, dosage form: Amoxicillin, PO syrup 250mg/5ml X 60ml Ibuprofen, PO syrup 100mg/5ml X 60ml Guaifenesin, PO tab 100mg o Dosage schedule: Amoxicillin, 40-50mg/kg/day divided into 3 doses for about 10 days Ibuprofen, 20mg/kg/day divided into 3 doses for about 10 days Guaifenesin, 50-100mg every 4 hours, maximum 1200mg/day o Duration: length of monitoring interval / until the dispensed drug is finished STEP 4: Write a prescription Dr. johnson Jl. Saturnus 3, Malang Telp. 0341582110 SIP. 446.DU/012/35.73.306/2007 Malang, 27 April 2011 R/ Amoxicillin 250mg syrup fl No. II 3 dd cth 1 pc. - - - - ,, - - - Ibuprofen 100mg syrup fl No. II 3 dd cth 1 pc. - - - - ,, - - - Guaifenesin 100mg tab No. XX 3 dd tab 1 pc. - - - - ,, - - - y Id Pro: Adik Adam Umur: 4th. Alamat: Jl. Muthafukar No. 117, Malang STEP 5: Give information, instructions and warnings i. Effects of the drug y Amoxicillin eradicates the causative bacterial y Ibuprofen relives the fever and inflammation y Guaifenesin facilitates the removal of secrete / mucus / phlegm y All the symptoms will be reduced and finally disappear y The effect is expected to start after the first 2 doses y The symptoms will remained if the drug is not taken correctly / not at all ii. Side effects y Amoxicillin might cause nausea, diarrhea, or rash y Ibuprofen might cause gastric distress, blood loss, diarrhea, vomiting, dizziness, or skin rash y Guaifenesin might cause nausea, vomiting, dizziness, or headache y If felt excessive side effects, stop the medication, and immediately refer to doctor iii. Instructions y Amoxicillin and ibuprofen are taken a spoon (5ml) each 3 times daily y Guaifenesin is taken 1 tablet 3 times daily y It is recommended to be taken with food y The treatment should be continue until the dispensed drug is finished iv. Warnings y The drug should be taken as instructed, do not increase / reduce the amount to betaken, and do not increase / reduce the frequency of the drug that should be taken as instructed v. Future consultations y Come back for follow up after the drug is finished / when the effect of the drug is still absent / minimal after 2 doses y Come back to doctor earlier if experiencing side effects Everything clear? y Repeat the important information and clarified the doubts STEP 6: Monitor (and stop?) the treatment y Treatment effectiveness: o Effective: end of treatment o Minimal effect: reconsider dosage / drug choice o Not effective: verify all steps 7. Seorang anak berumur 12 thn, sejak 3 hr menderita BAB 6-7X 1hr, cair, ada lender, tidak ada darah. Mulai tadi pagi terasa demam (menggigil) dan pada kotoran terliaht ada darah dan frequency BAB pagi tadi adalah 8X. Kesadaran, keadaan umum dan aktifitas fisik masih cukup baik. i. Define the diagnosis : - Dysentry (Acute bloody diarrhea) caused by infection of lower GIT ii. Specific therapeutic obj : - Stop the dysentery by curing infection. -Hydrate the patient. iii. Make inventory of effective groups y Anti diarrhea with antibiotic y Opiat (Non antibiotic) y Adsorben y Anti Cholinergic y Oralit iv. Choose a drug according to criteria y Anti diarrhea with antibiotic Efficacy Safety Suitability Cost Menghambat sistesis Hypersensitivity , mual Indikasi: infeksi saluran Tablet 500mg; : Rp dinding sel microba muntah. cerna 1300 Kontraindikasi: hypersensitivity and allergy penicilin ++ ± + +++ vi. Opiat (Non antibiotic) Efficacy Safety Konstipasi / anit Mual, muntah, diarrhea epigastric distress y + y Adsorben Safety Mual muntah, nyeri epigastric kanstipasi dan dehidrasi - Suitability Hypersensitivity, not suitable for dehydrated patient - Cost - - Efficacy Menyerap toksin bakteri dan mengikat bakteri + y Suitability Hypersensitivity Cost - - - Anti Cholinergic Efficacy Safety Anti muscarinik, Dry, hot skin, impared menghambat sekresi GI mortality, saluran cerna dan hypertension, peristaltik tachycardia ect + y Suitability Hypersensitivity hepatic diseaseobstructive GI disease - Cost - - Oralit Safety overhydrated Suitability Indication : for minor or severe dehydration Cost Oralit 1L : Rp710 Efficacy Hydrate the body by providing electrolytes for reabsorbtion ++ ± + ++ v. Choose a P-drug y Ampisilin Efficacy Safety -Menghambat Hypersensitivity, mual, mucopeptida untuk muntah sintesis didding sel mikroba -peroral -H.L :1,3 jam urine ++ ± Makrolida (erithromysin) Efficacy Safety Menghambat sintesis Hypersensitivity, mual, protein kuman dgn muntah, nyeri mengikat ribosom epigastrium -H.L 1,6 jm hepar + ± y Suitability Kontraindikasi : alergi penicillin, hypersensitivity Indikasi : infeksi saluran cerna. ± Cost 500mg : Rp1300 Sirup 60ml, 125mg/5ml : Rp6000 +++ Suitability Ganguan hepar Cost 500mg; Rp 1900 - ++ Glikopeptida (vankomisin) Efficacy Safety Menghambat sintesis Sangat toksik didding sel -HL : 6-10hr filtrasi glomelurus + y Suitability hypersinsivitas Cost 500mg: Rp70000 - - Conclusion Active substance dosage from : Ampisilin peroral sirup, oralit peroral Dosage : ampisilin-125mg(5ml)x4/day, oralit 1L x2 / day Dr. Kishern Jln Wonogiri 4, Malang Telp :081805167956 SIP :446.DU/0121/25.47.588 Malang 26 kepala sudah satu minggu dan minum obat paramex, tetapi sakit teta Pasien baru alih dari IUD 8. Ibu Tina, 45 thn, dating ke dokter dengan keluhan sakitapril 2011 p. ke Pil KB dan punya riwayat hipertensi ringan. Selain itu ada riwayat ibunya meningal akibat kanker payudara. Pada pemeriksaan T= 160/95mmHg, N= R/ Ampisilin 125mg NO 1 80/min. Lain pada batas normal. i. Define the 4dd I peroral diagnosis : hypertension due to hormonal pill causing headache KISH ii. Specific therapeutic obj : - Control the hypertension R/iii. Make inventory of effective groups Oralit 1L NO2 2 dd y peroral Blocker I Beta KISH y ACE inhibitor y Vasodilators Px : anak xxx y Diuretics Umur : 12 thn iv. Choose a drug according to criteria y Beta Blocker Alamat: xxx, Malang Efficiensy Safety Suitability Cost Mengurangi Bradicardi, pusing, Indikasi : hipertensi Propanolol kontraktilitas jantung, kelemahan otot, lelah K.indikasi:Block AV PO 10mg tab mengurangi frekeunsi derajat 2 &3, Rp 1012/biji denyut jantung cardiiogenic Shock, met. acidosis +++ +++ +++ ++ y ACE inhibitor Efficiensy Mengurangi volume n tekanan pengisian ventrikel Meningkatkan curah jantung ++ Diuretics Efficiensy Menghambat Na n Cl Safety Takikardi, batuk kering , demam Suitability Cost Indikasi : hipertensi Captopril 50mgx5x10 : K.indikasi:hypersensitive Rp 10700 hamil, laktasi, gagal ginjal ++ +++ + y Safety Hipokelemi, hiponatremi, dehidrasi, hiperglikemi. + ++ v. Choose a P-drug y Propanolol Efficiensy Mengurangi kontraktilitas jantung, mengurangi frekeunsi denyut jantung Suitability Indikasi : hipertensi K.indikasi: hamil and laktasi gagal ginjal ++ Cost Furosemid Rp21753 ++ Safety Efek: gangguan pencernaan, lelah Suitability Indikasi : hipertensi K.indikasi:Block AV derajat 2 &3, cardiiogenic Shock, met. acidosis Cost PO 10mg tab. Rp1.012/biji y +++ Atenolol Efficiensy Mengurangi kontraktilitas jantung, mengurangi frekeunsi denyut jantung +++ +++ Safety Efek: bradicardi, gangguan pencernaan, lelah +++ Suitability Indikasi : hipertensi K.indikasi:Block AV derajat 2 &3, sinus bradicardi ++ +++ Cost PO 10mg tab. Rp1.400/biji Rp2.250/biji ++ ++ Conclusion Active substance dosage from : Propanolol Dosage : 40mg orally twice a day Dr. Kishern Jln Wonogiri 4, Malang Telp :081805167956 SIP :446.DU/0121/25.47.588 Malang 26 april 2011 R/ Propanolol 10mg NO.II Modul 11 2dd 4tab menderita kanker colon stadium akhir. Keluarganya meminta ia dirawat di rumah dandokter mengunjunginya seminggu sekali. Hari ini KISH Pak Ucup (53 th) PO istrinya menelpon dokter agar datang ke rumah karena Pak Ucup kesakitan. Pada pemeriksaan didapat Pak Ucup tidak bisa tidur s emalaman karena merasa Px : Ibu Tina nyeri dan sudah berlangsung seminggu ini. Obat penghilang nyeri yang telah diminum selama ini tidak dapat mengurangi nyerinya. Pak Ucup juga menderita diabetes tipe 2. Umur : 45 thn Alamat: xxx, Malang Problem: nyeri akibat kanker colon stadium akhir dan menderita diabetes tipe 2. Tujuan terapi: meredakan nyeri dan tidak memperberat diabetes tipe2 P-treatment a. Advis: mengurangi makanan yang berlemak, daging (terutama daging merah) Menghindari makanan yang dibakar b. Terapi non-obat: kemoterapi P-drug Efficacy Acetaminophen atau paracetamol Safety Suitability Farmakodinamik: Analgesik&antipiretik Iritasi gaster (-) Hambatan agregasi trombosit () Farmakokinetik: Absorpsi tergantung pengosongan lambung Kadar puncak 30-60 menit Terikat protein plasma 20-50% Metabolisme di hati T1/2=1-3 jam Metampiron atau antalgin FD: Menghambat enzim siklooksigenase sehingga konversi asam arakhidonat menadi PGG2 terganggu Efek analgetik dan antipiretik baik sedangkan anti inflamasi rendah Efek samping: Eritema Utikaria Lesi pada mukosa Anemia hemolitik pada penggunaan kronis autoimun Nekrosis hati pada 10-15gram Nekrosis tubulus renalis Indikasi: Moderete pain and fever Kontraindikasi: G6PD deficiency Interaksi obat: Barbiturates Abuse hepatotoksik meningkat Memperkuat efek warfarin Dosis: Dewasa 325-650 mg tiap 4-6 jam atau 1000 mg 3-4x/hr tidak melebihi 4 gram Indikasi: nyeri kepala, neuralgia, sakit pinggang, nyeri pasca bedah, dismeneroe, nyeri kolik, demam Kontraindikasi: Hipersensitivitas gol.pirazolon Deficiency G6PD Profiria Interaksi obat: Menurunkan kadar siklosporin dalam darah, meningkatkan efek alkohol Sediaan: Tab 500 mg dan larutan IV 500 mg/mL Efek samping: Kadang menimbulkan agranulositosis, anemia aplastik dan trombositopeni Dosis: Dewasa 3x1 tab/hr sesudah makan Anak 8-12 tahun (1-2)x1/2 tab/hr sesudah makan Pilihan golongan obat: acetaminophen Nama obat: paracetamol 500mg 3x/hr Modul 5 1. Define the diagnosis : stage 1 essential hypertension 2. Goal of Diagnosis : i) reduce blood pressure without aggravating asthma attack 3. Therapeutic Intervention : A) Non Pharmaco - Reduce food intake that is high in salf and caffeine - Exercise regularly B) Pharmaco i) To reduce blood pressure Drug group Efficacy Safety Suitability Cost Beta Blocker ++ + + + Diuretics ++ ++ ++ ++ angiotensin++ ++ ++ + converting enzyme inhibitor Group of choice is Diuretics Drugs Efficacy Thiazide ++ Loop diuretic ++ Potassium ++ sparing diuretic Safety ++ + + Suitability ++ + + Cost ++ + + y Drug of choice is thiazide 4.Resep 5.KIE - Take in the morning once - Patient might regularly have the urge to urinate - Eat balanced food without excessive salt intake - Ask the patient to return if is experiencing any side effects such as dizziness 6. Monitoring pt -Monitor the patient by asking the patient to return within the 1st week for check up . MODUL 6 1.Define the diagnosis : Cough-Variant Asthma 2.Goal of Diagnosis : To maintain the state of cleared airway and breathing 3.Therapeutic Intervention : A) Non Pharmaco - Avoid cold drinks and food - Use enough clothes to keep warm - Refer to Rehab Medic lab for coughing exercises B) Pharmaco - Already given in case that the drug is theophylline IV and for maintenance theophylline oral tablets. 4. Resep 5. KIE -Return to doctor if the is any side effects such as allergy reaction,fast or irregular breathing or heartbeat. - Do not smoke cigarette or marijuana - Patient should have a fast acting reliever if having sudden shortness of breath as theophylline does not effect immediately - Do not consume other drugs without informing the doctor 1st ( cimetidine,phenytoin ) 6. Monitoring -Throughout the usage of the medicine Modul 12 Bu Ati (38 th), 3 hari ini mengeluh sering kencing, sedikit-sedikit. Setiap kencing dirasakan tidak tuntas dan diakhir kencing terasa sakit dan panas di daerah kemaluan. Warna kencing kuning bening. Badan terasa demam dan tidak ada keluha lain. Lain-lain dalam batas normal. Problem: keluhan kencing yang mengarah pada uretritis Tujuan terapi: y Membunuh kuman penyebab timbulnya keluhan kencing y Menghilangkan gejala P-treatment a. Advis: menjaga kebersihan urogenital, menggunakan kondom pada sat berhubungan untuk mencegah penularan b. Terapi non-obat: P-drug Efficacy Tetrasiklin FK: Absorpsi: 30-80% diserap dalam saluran cerna yang sebagian besar berlangsung di lambung dan usus halus bagian atas. Adanya makanan menghambat penyerapannya. Selain itu, absorpsi akan berjalan lambat bila terbentuk kompleks tetrasiklin dengan zat lain yang sukar diserap, seperti aluminium hidroksida, garam kalsium dan Safety Efek samping: Reaksi kepekaan: tjd reaksi kulit seperti erupsi morbiliformis, utikaria, dermatitis eksfoliatif. Reaksi yang lbh hebat yaitu edema angioneurotik dan syok anafilaksis. Selain itu juga demam dan eusinofilia tjd pd saat terapi. Reaksi toksik dan iritatif: iritasi lambung bil diberikan dlm dosis besar. Diare timbul akibat iritasi Suitability Indikasi: riketsiosis, infeksi klamidia, uretritis non spesifik, infeksi mycoplasma pneumonia, infeksi basil, infeksi kokus, infeksi venerik, acne vulgaris, infeksi lain (Actinomycosis, frambusa, leptospira, infeksi GIT) Kontraindikasi: Pd px yang hipersensitifitas, gagal ginjal Interaksi obat: Tetrasiklin+metoksifluoran nefrotoksik Tetrasiklin+penicilin aktivitas magnesium. Tetrasiklin diberikan sebelum makan atau 2 jam setelah makan. Distribusi: terikat dengan protein plasma dalam jumlah yang bervariasi. Pemberian oral 250mg tetrasiklin tiap 6 jam menghasilkan kadar sekitar 2-2,5 mcg/ml. Dalam CSS, kadar tetrasiklin hanya 10-20% kadar serum. Penetrasi ke jaringan baik. Obat yang ditimbun dalam sistem retikuloendotelial di hati, limpa, dan sumsum tulang, dentin, email dari gigi yang belum bererupsi. Obat ini juga menembus sawar uri dan berada dalam ASI dalam kadar yang relatif tinggi. Ekskresi: diekskresikan melalui urine, filtrasi glomerolus, dan melalui empedu. Sebagian obat yang diekskresi melalui usu ini mengalami siklus enterohepatik, dan masih terdapat dalam darah meskipun terapi sudah dihentikan. FD: Bersifat bakteriostatik, td. Tromboplebitis akibat antimikrobanya dihambat pemberian tetrasiklin Sediaan: intravena. Reaksi toksik yg plg Dosis: sering tjd yaitu hepatotoksisitas, tetrasiklin akan akumulasi di dalam tubuh. Kontraindikasi pada pasien dgn gangguan ginjal. Pertumbuhan tulang akan terhambat, tjd terutama pada pertengahan masa hamil smp anak umur 3 thn. Pada gigi susu maupun gigi tetap, tetrasiklin menimbulkan disgenesis, perubahan warna dan karies. Efek samping akibat perubahan biologis: tjd nya super infeksi oleh kumanyg resisten. Enterokolitis streptokokus dapat timbul setiap saat pada waktu terapi. Kandidiasis intestinal dan kolitis pseudomembranosa. menghambat sintesis protein bakteri pada ribosomnya. Merupakan antibiotika spektrum luas, yang efektif untuk kuman gram negatif, positif, aerob dan anaerob Doxycyclin FK: Sama dengan tetrasiklin, hanya doksisiklin boleh diberikan pada Absorpsi: diserap >90%, pasien gagal ginjal sebagian besar di lambung dan usus halus bagian atas. Makanan dalam lambung tidak menghambat penyerapan doksisiklin Distribusi: masa paruh doksisiklin tidak pada insuficiency ginjal sehingga boleh diberikan pd org dgn gagal ginjal. Daya penetrasi ke jaringan kurang baik dibandingkan tetrasiklin Ekskresi: Sebagian obat yang diekskresi melalui usu ini mengalami siklus enterohepatik, dan masih terdapat dalam darah meskipun terapi sudah dihentikan. FD: Bersifat bakteriostatik, menghambat sintesis protein Indikasi: riketsiosis, infeksi klamidia, uretritis non spesifik, infeksi mycoplasma pneumonia, infeksi basil, infeksi kokus, infeksi venerik, acne vulgaris, infeksi lain (Actinomycosis, frambusa, leptospira, infeksi GIT) KI: hipersensitivitas Sediaan: Kapsul atau tablet 100mg; tablet 50 mg; sirup 10mg/ml Dosis: Dewasa: oral dosis awal 200mg; selanjutnya 100-200mg/hr Anak: oral hari pertama 4mg/kgBB/hr, selanjutnya 2mg/kg/hr dosis tunggal bakteri pada ribosomnya. Merupakan antibiotika spektrum luas, yang efektif untuk kuman gram negatif, positif, aerob dan anaerob Sulfamethoxazole/trimethoprim FK: Absorption: Oral: Almost complete (90-100%). Time to peak, serum: Within 1-4 hr. Distribution: Protein binding: Sulfamethoxazole: 68%; Trimethoprim: 45%. Metabolism: Sulfamethoxazole: N-acetylated and glucuronidated; Trimethoprim: Metabolised to oxide and hydroxylated metabolites. Excretion: Both are removed in urine as metabolites and unchanged drug. FD: Co-trimoxazole exhibits the synergistic actions of its components (sulfamethoxazole and trimethoprim) by 10-fold. Sulfamethoxazole inhibits dihydrofolic acid formation from PABA, thus interfering with Efek samping: Renal failure, nausea, vomiting, diarrhoea, anorexia; skin rashes, urticaria. Potentially Fatal: StevensJohnson syndrome, agranulocytosis, toxic epidermal necrolysis, hepatic necrosis. Indikasi: Susceptible infection, UTI, GI infection, respiratory tract infection, pneumocystis jiroveci pneumonia, hepatic impairment, profilaksis infeksi pada pasien AIDS KI: Hypersensitivity; severe renal or hepatic insufficiency; infants <4 wk; megaloblastic anaemia; pregnancy and lactation. G6PD deficiency; potential folate deficiency; hepatic and renal impairment; elderly; porphyria; thyroid dysfunction; maintain adequate hydration. IO: Reduced ciclosporin concentrations in blood when used concurrently. Increases toxicity of methotrexate. Inhibitsphenytoin clearance. Potentiates warfarin and oral hypoglycaemics. synthesis and growth of bacterial folic acid. Trimethoprim inhibits enzymes folic acid pathway, preventing the reaction of the dihydrolic acid to tetrahydrofolate. Co-trimoxazole possesses bactericidal effects against E coli, Klebsiella spp, Enterobacter spp, M morganii, P mirabilis, P vulgaris, H influenzae, Strep pneumoniae, Pneumocystis (carinii) jiroveci,Cyclospora spp Pilihan golongan obat: sulfamethoxazole/trimethoprim Nama obat: cotrim Potentially Fatal: Co-admin with pyrimethamine causes megaloblastic anaemia. Enhancement of renal damage by ciclosporin. Sediaan: Dosis: Modul 15. pak samin, umur 45 tahun, pekerjaan tukang becak, datang ke poliklinik dengan keluhan sering merasa nyeri otot dan sendi (peg el-linu), terutama pada sendi2 tangan. Rasa sakit ini diderita sudah 3 bulan terakhir, kadang muncul, kadang tidak. Walaupun tidak terlalu berat, tapi penderita merasa te rganggu kegiatan sehari2nya. Rasa nyeri juga disertai kaku sendi tangan, terutama pagi hari. Kalau sedang kumang sering diberi anta lgin, teteapi tidak banyak menolong. Pemeriksaan fisik lain dalam batas normal. A. Problem: nyeri otot dan sendi2 tangan yang mengarah pada RA (rheumatoid arthritis) B. Tujuan terapi: 1. Mengurangi nyeri NSAiD 2. Mengurangi inflamasi NSAiD 3. Menghentikan kerusakan sendi DMARDs 4. Mencegah cacat 5. Memperbaiki fungsi sendi 6. Memperbaiki kualitas hidup 7. Mencegah kematian dini C. Intervensi Terapi: a. Non-farmakologis : i. Advice : mengistirahatkan sendi2 yang sakit ii. Non drug : 1. rehabilitasi (fisioterapi) u/ meningkatkan kualitas hidup pasien Segera setelah rasa sakit pada sendi berkurang/minimal : terapi mekanik, pemanasan(hidrotherapy maupun electrotherapy), occupational therapy 2. pemakaian alat yg diperlukan seperti : bidai, walking machine, kursi roda, alat protetik lainnya 3. jika fisioterapi tdk berhasil tindakan operatif b. Farmakologis : i. NSAID : obat simptomatik untuk mengurangi rasa sakit dan inflamasi tetapi tidak memperlambat kemajuan RA. ii. Disease-modifying antirheumatic drugs (DMARDs) membantu memperlambat atau menghentikan perkembangan RA. DMARD yang paling umum digunakan untuk mengobati rheumatoid arthritis adalah metotreksat. DMARDs lainnya termasuk Arava, Azulfidine, Cytoxan, Imuran, Neoral, Plaquenil, sulfasalasin, kloroquin dapat digunakan. Namun kek urangan dari penggunaan obat tersebut adalah efek samping yang ditimbulkan cukup besar, prosedur penggunaan cukup rumit, efek lambat, dan angka kegagalan yang cukup besar. iii. Yang perlu diingat adalah bahwa kunci keberhasilan pengobatan RA yaitu diagnosa dinidan pengobatan awal yang prograsif, yaitu sesegera mungkin menggunakan obat pengubah perjalanan penyakit (DMARD) bila diagnosa telah ditegakkan. - Farmakologis Golongan Mekanisme Nama Obat Indikasi Dosis Efek Samping Cost NSAiD Menghambat Piroxicam 20mg/hari dosis - Gangguan & 20 mg x 10 Efficacy:+++ sintesa tunggal terbagi pendarahan GI x10 (Rp Suitability:++ prostaglandin dlm 3 hari - Ruam, pruritus 29.000) Safety:+++ dg memblokir Cost:++++ ke2 jalur Ketoprofen 200mg 3-4x/hari - alergi Tab salut Efficacy:+++ cyclooxygenasi - pruritus enterik Suitability:++ DMARDs (Diseasemodifying antirheumatic drugs) membantu memperlambat atau menghentikan perkembangan RA dengan melindungi proses destruksi akibat RA Klorokuin - Klorokuin fosfat 250 mg/hari - Hidroksikloroku in 400mg/hari eritema lokal 50mgx3x10 (Rp44.000) Senyawa emas/AST (auro sodium tiomolat gold standar yg b fungsi memperlamba t terjadinya kelainan bentuk tulang. I: KI : tdk diberikan pada px penyakit hati dan ginjal, penyakit darah -penurunan penglihatan, dermatitis makulopapular, nausea, diare dan anemia hemolitik - Suntikan IM ruam kulit, gatal mingguan dan berkurangnya diberikan sampai sejumlah sel darah. tercapai dosis total 1 gram atau sampai timbulnya efek samping atau terjadinya perbaikan yang berarti. - Jika obat ini efektif, dosisnya dikurangi secara bertahap. Safety:+++ Cost:++ Efficacy:++ Suitability:++ Safety:++ Cost:++++ Efficacy:+++ Suitability:+++ Safety:++ Cost:++ Penisilamin digunakan jika senyawa emas tidak efektif atau -250-300mg/hari, kemudian ditingkatkan setiap 2-4minggu sebesar 250- - penekanan terhadap pembentukan sel darah di dalam sumsum tulang, Efficacy:+ Suitability:++ Safety:+ Cost:++ menyebabkan efek samping yang tidak dapat ditoleransi. 300mg/hari u/mencapai dosis total 4x250-300 mg/hari. kelainan ginjal, penyakit otot, ruam kulit dan rasa tidak enak di mulut. - Obat ini juga bisa menyebabkan miastenia gravis, sindroma Goodpasture dan sindroma yang menyerupai lupus. gangguan pencernaan, kelainan hati, kelainan sel darah dan ruam kulit. Efficacy:++ Suitability:+++ Safety:+++ Cost:++ Sulfasalazine. Dosisnya dinaikkan secara bertahap dan perbaikan biasanya terjadi dalam 3 bulan Agen biologis Kortikosteroid memblokir sebuah protein inflamasi pada RA yaitu tumor necrosis factor (TNF) Menghambat fosfolipase, shg shg TNF blocker Efficacy:++++ Suitability:++ Safety:++++ Cost:+ Prednison penipisan kulit, memar, osteoporosis, Efficacy:+ Suitability:++++ Safety:+ pembenukan prostaglandin dan leukotrien terhambat. Obat ini paling efektif untuk mengurangi peradangan di bagian tubuh manapun, namun cenderung kurang efektif digunakan dalam jangka panjang, padahal RA adl penyakit yang biasanya aktif selama bertahun-tahun. Immunosupresif cyclophosphami de) efektif untuk mengatasi artritis rematoid yang berat menekan pembentukan tekanan darah tinggi, kadar gula darah yang tinggi dan katarak. Cost:+++ Oral: 50200mg/hari IV 1015mg/kg/hari setiap 3-7hari penyakit hati, peradangan paruparu, mudah terkena infeksi, penekanan terhadap pembentukan sel darah di sumsum Efficacy:+++ Suitability:+++ Safety:+++ Cost:+ Ab Methotrexat RA stadium awal Dosis awitan 57,5 mg /minggu. Bila dlm 4 bln tdk ada perbaikan, dosis ditingkatkan tulang dan perdarahan kandung kemih (karena cyclophosphamide) . Selain itu cyclophosphamide bisa meningkatkan resiko terjadinya kanker Penurunan imunitas tubuh bahaya pd px TB -bersifat hepatotoxic Tab 2.5mgx100 (Rp.278.000) Efficacy:++ Suitability:+++ Safety:++++ Cost:++ D. Resep dr. Uca SIP : 0710710068 Praktek : Jl.Berlian 1234 Malang Telp: 0341 1234567 _______________________________________________________ Malang, 27 April2011 R/chloroquine tab 250mg no.VII 1 dd 1 h.s Paraf R/ Piroxicam tab 20mg no.VII 1 dd 1 h.s Paraf Pro Umur Alamat : Pak Samin : 45 tahun : Jl Emas Kuning 4567 Malang E. Komunikasi obat (KIE) Bapak, Saya buatkan resep untuk anda. Ada 2 macam obat : Pertama : chloroquine, untuk memperlambat/menghentikan perusakan peradangan pada sendi bapak, sehingga rasa nyerinya juga akan hilang, diminum 1 kali sehari sebelum tidur Kedua : piroxicam, menekan rasa nyeri, diminum 1 kali sehari sebelum tidur Setelah mengkonsumsi obat ini, mungkin anda akan mengalami gatal-gatal dan nyeri perut spt mag (efek samping obat),Jika terjadi efek samping tersebut, maka segera kembali dan konsultasi ke dokter F. Monitoring dan Evaluasi Setelah meminum obat ini jika bertambah parah, atau timbul efek samping yang sangat mengganggu atau gejalatidak berkurang segera kembali ke dokter.