HERBAL MEDICINE

dr. HARDHI PRANATA

P.D.H.M.I

Perkembangan herbal medicine di

indonesia

National Commitment

• 27 Mei 2008: President of Indonesia (SBY) declare “Gelar Kebangkitan Jamu” to integrate Jamu in formal health system and jamu as a national heritage

• UU no.36 – 2009: Traditional health should be included in National Health Care

• Permenkes 2010: Scientification of Jamu

Global Commitment

• 2009, Ranggoon (Myanmar): WHO regional meeting on the use of herbal medicine in primary health care

• 2010, Hanoi (Vietnam): 2nd conference on traditional medicine in asian countries “Integration of traditional medicine into the National Healthj Care Systems:

CLINICAL GUIDE

ROLE OF HERBAL MEDICINE (Medical Plant)

Promotive Preventive Curative Rehabilitative Palliative

Food +

Supplement + +

Complement + + + + +

Drug + + + +

HERBAL MEDICINE (Medicinal Plant)

• 54,3 % Indonesian people use it as traditional medicine

• Hippocrates (Father of Modern Medicine):“ Let food be your medicine and medicine be your food”

• Medicinal plant in Indonesia use aso Food (ginger, turmeric, chili, garlic, celery, etc)o Supplement (garlic, white curcuma, etc)o Complementary (guava, Phaleria macrocarpa)o Drug (Phyllantus niruri, gotukola, andrographis paniculata,

celeri)

SWOT Analysis of Medicinal Plant

• STRENGTH– Biological more compatible to human body– Could be used as food supplement, complement, drug– Less side effect, one herbs, multi compound, that acts

synergistically– Indonesia is the fifth mega biodiversity– About 33.000 potentially plant could be used as medicine– Traditionally used for thousand years– Cheap– Broad indication as health promotion, preventive, curative,

rehabilitative, palliative of diseases

• WEAKNESS– Raw material contamination with bacterial, mold, heavy

metal– Quality and quantity depend on soil, environment, season,

climate changes– Has a complex formula – depends on people’s experience– Less evidence based and Mostly empirical based

experience– In Indonesia only a few phytopharmaca

• OPPORTUNITY– Trend of ‘Back to Nature’– Economical value potential– Indonesia is a mega diversity country– Degenerative disease and metabolism disorder tends to be

increased in this millenium ages

• THREAT– Global warming and climate changes– Environment contamination with pesticide, heavy metal,

and pollution– Less numbers of medicinal plants caused by urban

development

PRINCIPLE USE OF MEDICINAL PLANT

• RIGHT DOSE– Empirical herbs depends on people’s tradition like the numbers

of use of leaf, stem, or root in making medicinal herbs– The product made by manufacturer should be consumed in a

right dose as its written on the back of the product’s side

• RIGHT TIME– Irritating-stomach Herbs should be taken after a meal

e.g: Rosella tea, morinda, ginger, garlic, orange, andrographis paniculata, chili

− Herbs that reduce uterine contraction like cabai jawa (Piper retrofractum) should not be used in the late pregnancy

• RIGHT ROUTE OF USE– Herbs like cajuput oil should be used externally– Datura metel Leaf (kecubung) should be smoked for asthmatic

patient

• RIGHT PATIENTS– Most of medicinal plant like chemical drug must be used

carefully for the pregnant, lactating women

• RIGHT INDICATION– Catharantus roseus (Tapak dara) could reduce numbers of

leucocyte in blood

MEDICINAL PLANT CHARATERISTIC

• COMPLEMENTARY EFFECT– Thyme (Thymus vulgaris) contains thymol, calvacrol, and

polymethoxyflavon * Thymol acts as an expectorant* Calvacrol acts as an antibacterial* Flavon enhances immune system

• SYNERGIC EFFECT– Misai Kucing (Orthosiphon stamineus) contains

polymetoxyflavon, saponin, potassium that synergicly act as diuretic

• ANTAGONISTIC EFFECT– Tobacco leaf (Rheum officinale) contains anthraquinone as

laxans but also contains tannin as an antidiarrhea

• SIDE EFFECT ELIMINATING SUBSTANCES (SEES)– Sugar cane (Saccharum officanarum L) that produces sugar

contains Sacharant as an anti diabetic

INTERACTION BETWEEN MEDICINAL PLANT AND CHEMICAL DRUG

• ACTION ON P450– Hypericin, Garlic, Ginseng, Silymarin, Melatonin

• SYNERGIC EFFECT– Misai Kucing/ Kumis Kucing (Orthosiphon stamineus) contains

polymetoxyflavon, saponin, potassium that synergicly act as diuretic

• ACTION ON CYP3A4 and CYPP2O6– Curcuma heyneana, Piper nigrum, Punica granatum, Catharantus

roseus, Piper cabeba, Alyxia reinwardtii, andrographis paniculata, Cymbopogon nardus, Glycyrrhiza glabra, Rheum palmatum, Santalun album, Syzygum aromaticum, Tinospora crispa, Alstonia scholaris, Zingiber aromaticum

SIDE EFFECT OF HERBAL MEDICINE

1. GASTROINTESTINAL– Stomachache– Diarrhea– Nausea– Vomiting

2. NERVE SYSTEM– Headache– Dizziness– Insomnia– Sleepy

3. CARDIOVASCULAR SYSTEM– Increasing or decreasing of blood pressure– Palpitation– Syncope– Cold sweat

4. ALLERGIC REACTION– Anaphylactic– Urticaria– Steven Johnson Syndrome

5. METABOLISM– Drop of glucose level in blood

NO Nama Tanaman Bagian Indikasi Potensi

1. Garlic (Alium savitum) Umbi lapis Candidiasis, hyperlipidemia

2. Benalu Teh (Loranthus spec) Batang Megarah ke antikanker

3. Brotowali (Tinospora rumphii) Batang Antimalaria, diabetes

4. Ceguk (Quisqualis indica) Biji Askariasis, oksiuriasis

5. Daun ungu (Graptophylum pictum) Daun Haemorrhoid

6. Delima putih (Punica granatum) Kulit buah Antiseptik. Antidiare

7. Dlingo (Acorus calamus) Rimpang Sedativa

8. Inggu (Ruta graveolens) Daun Analgetika, antipiretika

9. Jahe (Zingiber officinale) Rimpang Analgetika, antipiretik, antiinflamasi

10. Jambu biji (Psidium guajava) Daun Antidiare, DBD

11. Jambumede (Anacardium occidentale) Daun Analgetika

12. Jati belanda (Guazuma ulmifolia) Daun Hiperlipidemia

13. Jeruk nipis (Citrus aurantifolia) Buah Antitusif

14. Katuk (Sauropus androgynus) Daun Meningkatkan produksi ASI

15. Kejibeling (Strobilantus crispus) Daun Nefrotiliasis, diuretika

DAFTAR TANAMAN OBAT PROSPEKTIF UNTUK FITOFARMAKA

NO Nama Tanaman Bagian Indikasi Potensi

16. Kumis kucing (Ortosiphon stamineus) Daun Diuretika

17. Kunyit (Curcuma domestica) Rimpang Hepatitis, artritis, antiseptik

18. Labu merah (Cucurbita moschata) Biji Taenasiasis

19. Pegagan (Centella asiatica) Herba Diuretika, antiseptik, antikeloid

20. Pala (Myristica fragrans) Buah Sedativa

21. Pare (Momordica charantia) Buah/ biji Diabetes

22. Pepaya (Carica papaya) Getah, daun, biji Sumber papain, antimalaria

23. Saga telik (Abrus precatorius) Daun Stomatis, aftosa

24. Sambiloto (Andrographis panicullata) Herba Antiseptik, diabetes

25. Seledri (Apium graveolens) Daun Hipertensi

26. Sembung (Blumea balsamifera) Daun Analgetika, antipiretika

27. Sidowayah (Woodfordia floribunda) Bunga Antiseptika, diuretica

28. Sirih (Piper betle) Daun Antiseptic

29. Tempuyung (Sonchus arvensis) Daun Nefrotiliasis, diuretica

30. Temulawak (Curcuma xantorrhiza) Rimpang Hepatitis, artritis

DAFTAR TANAMAN OBAT PROSPEKTIF UNTUK FITOFARMAKA

No. Organ Affected Herbs

1. Heart Digitalis leaf, Oleander leaf

2. Autonomous nervous system Datura metel (kecubung), Saga seed,Jatroba seed

3. Central nervous system Cocaine leaf

4. Digestive system Widuri leaf

5. Repiratory system Cashew skin

6. Female reproduction system (Abortivum) Maja leaf, Kelor root, young pineaple,

7. Male reproduction system - Decrease libido: cotton seed- weakens spermatozoa: Pare seed

8. Urethra - Strong diuretic: Meniran, kejibeling- Renal stone: Spinach, Pineapple

9. Liver Comfrei, mimba and fermented alcohol

10. Increasing level of uric acid in blood Beans

11. Decreasing numbers of leucocytes Vinca rosea (Tapak dara)

CAUTIOUSLY SIDE-EFFECT HERBS

HERBS THAT HAVE NARROW LD50

NO RAW HERBS FAMILIA LD50

1. Daun Majakan(Quercus lucitanica Roxb.) Fagaceae 16,45 mg/kgBB

2. Bunga Nagasari(Mesua ferea L.) Guttiferae 20,93 mg/kgBB

3. Buah sukmadiluwih(Gunera macrophyla Bl.) Halorrhagidaceae 21,91 mg/kgBB

4. Bunga Sidowayah(Woodfordia floribunda) Litraceae 24,22 mg/kgBB

5. Kulit buah delima (Punica granatum L.) Punicaceae 29,0 mg/kgBB

• Immunomodulator: Meniran, Lidah buaya, Sambiloto, Temulawak

• Anti-Inflammation : Temulawak, Lempuyang, jahe, Lengkuas

• Anti-Parasite : Leuchena leucocephala, Tinospora (brotowali), Temuireng for treating:Brugia malayi, Brugia timori, Wuchereria bancrofti

• Anti-viral : Meniran, Pasak Bumi, Beluntas, dan Jambu Biji

• Anti-biotic : Meniran, Beluntas, Lengkuas dan Tabat Barito,

• Anti Hypercholesteremia : Labu Siam, Temulawak, Salam, Kunyit, Sambiloto, dan Mengkudu

• Anti Hypertension : Belimbing Wuluh, Seledri, Garlic, Leunca, Kayu Manis, Rosella, Pegagan

• Anti Oxydant : Temulawak, Cabai, Buah Mengkudu, Lengkuas, Daun Salam, Teh, Lada Hitam

• Diabetes mellitus : Pare, Salam, Jamblang, Kayu Manis, Brotowali, Mengkudu, Sambiloto, Kunyit

• Uric acid: Sidaguri, Anting-anting, Kepel, Salam

• Fever : Sambiloto, Pule, Temulawak

• Tooth ache : Cengkeh, Jambu Mede

• Obesity : Kemuning, Gamboge, Jati Belanda

• Anorexia : Lempuyang wangi, temulawak, temu mangga, temu ireng, temu kunci

• Nephrolithiasis: Tempuyung, keji beling, Meniran, Sembung

• Dyspepsia : Pare, Pala, Jahe, Temulawak, Kunyit

• Nausea & vomitting : Jahe , ketumbar

• Cancer palliative & supportive : Sirsak, pegagan, kunyit putih, sambiloto, ceplukan, manggis, keladi tikus

• Heart & Vascular disease : Pegagan, garlic, dewa, temulawak, kunyit

• Gastritis: Kunyit, Temulawak, Pegagan

• Arthritis : Cabe, Sereh, Kayu putih, Cengkeh, Jahe, Temulawak, Tapak liman, salam

• Constipation: Lidah buaya, senna, wungu

• Cough: Saga, Adas, Kencur, Jahe

• Gastroentritis: Jambu biji, Tapak liman, Sambiloto

• Insomnia: Pala, Valeria

• Hepatoprotector: Temulawak, Paliasa, Kunyit, Meniran, Sambiloto

• Erectile dysfunction : Purwoceng, Som jawa, Cabe jawa

• Hemorrhoid: Wungu

• Upper Respiratory Tract Infection: Adas, Sambiloto

• Skin disease: Lengkuas, Ketepeng Cina, Pegagan

REGULATION

The Core PROGRAM• Implementation of MoH’s Decree No 3/2010 regarding Jamu

Scientification + No. 1109/2007 regarding CAM practitioner leading to Govt Regulation’s draft of Trad.Med (as mandatedby Health Act No 36/09) + revitalization of SP3T

• SJ DIAGNOSTIC : “down-stream” approach by developing dual JAMU’s skilled researcher + practitioner (physician+dentist) + scientific labeling of JAMU MEDICAL ("concentrate")

• SJ THERAPEUTICALS : "up-stream“ approach by developing community/clinical pharmacist + JAMU’s producer using local wisdom potency

• Escorted by the National Commission and Regional Commission of SJ

• Central Java as a pioneer model

Dasar yuridis (UU KES baru)

• OT = bag sediaan farmasi (ttp khusus) – ps 1(4)• Obat tradisional adalah bahan atau ramuan

bahan yang berupa bahan tumbuhan, bahan hewan, bahan mineral, sediaan sarian (galenik), atau campuran dari bahan tersebut yang secara turun temurun telah digunakan untuk pengobatan, dan dapat diterapkan sesuai dengan norma yang berlaku di masyarakat – ps 1 (9)

Dasar yuridis yankestra

• Pelayanan kesehatan tradisional adalah pengobatan dan/atau perawatan dengan cara dan obat yang mengacu pada pengalaman dan keterampilan turun temurun secara empiris yang dapat dipertanggungjawabkan dan diterapkan sesuai dengan norma yang berlaku di masyarakat – ps 1 (16)

• Ps 48 : yankestra = salah satu upaya kes• Jamu : salah satu ramuan yankestra (ps 59 -1.b) yg

hrs AMAN & MANFAAT n memerlukan PP

Yankestra (2)

• Orang (Dr/Non Dr) yankestra pakai alkestek perlu ijin dinkes (ps 60) perlu standar tindakan yankestra

• Masyarakat blh meningkatkan yankestra via a.l. “Rumah Sehat” (ps 61)

• BB TOOT jamin bahan baku OT (ps 100 – ay 1)• GP Jamu atas dasar PP membuat JAMU

MEDIK/konsentrat = sbg sediaan farmasi utk kuratif sbg sinergi/integrasi yankes formal (SELAIN JAMU NON MEDIK/OTC utk promotif-preventif-rehab)

INDONESIAN JAMU Practitioners & Health Act 36/2010

• JAMU’s Dr use empirical - rational herbs (art. 104 para 2) TRAD.HEALTH standards

• Competence based of professionalism : using JAMU’s research method : qualitative method =/> quantitative (Art 105) 50 HOURS special TRAINING (Permenkes SJ No 3/2010)

• Trad.Health Standard ethicolegal approach by establishing specific subdivisions in MKEK IDI leading to forming JAMU’s College recoqnized by KKI

• Advocating the establishing : THE BOARD OF LECTURER as college of JAMUOLOGI by IDI / PDGI after CAM EB of IDI

• Making JAMU Medical/concentrates led by clinical/community pharmacist (art. 108) supported by JAMU MANUFACTURER as partner of network of DUAL-ID BOARD practitioner (Permenkes No. 1109/2007)

KOMNASSJ

KualiINDIVIDU

kuantiPrevent Infection

PreventivePUBLIC HEALTH

Prevent Infection

PreventivePUBLIC HEALTH

OTONOM INTEGRASI

BATTRA

YANMEDHOSPITAL

BINKES

SENTRA

P3T

Medicinal

Materials

GPJAMU

IAI

GPFARMAS

I

Metode Riset

GRANDDESIGN

Physician/dentist

FASYANKESRPP BATTRA

Dual Clinic’s NetworkRes through Services

Hierarchy of health worker

S.J. NAS

REVITALIZATION

Kohort prospektif-Mass Clinical observation

Meta-sintesis-Deskriptif-exploratif

JAMU for FITNESSAESTHETIC’s JAMUANTI-AGING’s JAMU

Meta-analysis

Clin Trial

Label SaintifikIDI

PDGI

35

Formal Health Care System

Indigenous Health Care

System (Jamu)

Folk Health Care System

Synergizing & Integrating TRAD.MED. into Formal Health care System

JAMU SCIENTIFICATION NETWORK of dual-profession : JAMU researcher + practitioner and SCIENTIFIC LABELIZATION

of MEDICAL JAMU + NON MEDICAL JAMU

JAMU SCIENTIFICATION NETWORK of dual-profession : JAMU researcher + practitioner and SCIENTIFIC LABELIZATION

of MEDICAL JAMU + NON MEDICAL JAMU

Jamu Medik/Concentrate

Jamu saintifik Nas Jamu Saintifik Lokal

JAMU NON MEDIK/OTC

OHTFITO

FARMAKA

JAMKESMAS

JAMKESDA ??

CURRENT PARADIGM

HIGEST LEVEL EBM :DB, RCT, MA

Is RI has aninfrastructure??

HOW MUCH RI’S PHYTOFARMAKA ARE “BESTSELLER”

VALUE :HOW JAMU AS AHOST IN RI???

GOVERNMENT GUARANTEE THE DEVELP & MTANANCE Batra & Raw MaterialsUSE OF TRADITIONAL MEDICINE SOURCE - article 100 of Law 36/09 of Health

Obat Herbal

Jamu

Herbal Terstandar

Fitofarmaka

FUTURE PARADIGM

OPINION EXPERTFROM THOUSANDOF EXPERT ?

KONTEKS DUET : DR PENELITI + YAN

RI BUILDING ANRESEARCH’SINFRASTRUCTURE+CREATING MARKET

5 “W” + 1 “H” JAMU BECOMEA KEY COMPONENT IN FORMAL HEALTH SYSTEM

BATTRA CAM MUDAH dan MURAH

Biomedik

Diluar ilmu Kedokteran Dan Keperawatan Belum diakui

PREPATOGENESIS

JAMU HERBAL Terstandar Patologi = Konvensional

ALUR PENGOBATAN HERBAL

GOLDEN STANDARD FITOFARMAKA

JAMU’S DR : BROAD-MINDED & PROFESSIONAL

KONVENSIONALHereditary = peer review Doctor herbal researcher

PALIATIFHOME CARE

Contextual featuresPatient’s preference

REHABILITASI

Quality of Life

IDI / PDGI AREA SHOULD HORIZONS& CARE OF INTEREST NATION

Integrasi Yankes• Penyatuan/penggabungan sebagian atau

seluruh aspek pengobatan komplementer-alternatif pada pelayanan kesehatan di semua tingkatan fasilitas pelayanan kesehatan, termasuk aspek regulasi, pembiayaan, serta kebijakan mengenai penyelenggaraan pelayanan dan obat yang digunakan.

– Pasal 1- butir 8 Permenkes 1109/2007

DUET YAN-LITBANG : PERLU DR/G & NAKES BERWAWASAN LITBANG

BATTRA – SALAH SATU UPAYA KES – ps 48 UU Kes no 36/09 Tata cara & jenis = RPP Battra (ps 59)

Sinergi yankes – ps 1-7 Permenkes 1109/07

• Penggabungan metoda pengobatan non konvensional dengan pengobatan konvensional yang akan memberikan manfaat/khasiat pengobatan yang lebih baik dibandingkan dengan manfaat satu jenis pengobatan saja.

Implisit : multi-metodologi dlm litbang pendampingan dlm yankes (integrasi)Juga : KE-JANGAN-SOMBONG-AN kedokteran konvensional

Getting JAMU’s scientific evidences among skilled and practicing doctors (and dentists) as the noble & oath-taking professions, as the complementary & alternative medicine for promotive, preventive, rehabilitative, palliative remedies and finally curative as well at formal health care facilities.

Networking dual function practitioners : research through service in various JAMU clinic at primary and secondary care facilities.

Principles of SAINTIFIKASI JAMU PERMENKES 3/2010& 1109/2007

Sentra P3T (as dev & implementing clinic of trad.med) – Permenkes 584/95

• Screening, doing research of trad.med’s herbs material (JAMU) NIHRD’s function

• Educating & training the safe & effective JAMU BPSDM’s function

• Providing JAMU as approved model DG of Medical Services

• Fitofarmaka’s clinical trial NIHRD’s function

jamu Manufacturer

Riset

Dokter Dokter

Rumah Sakit

Rumah SakitMitra

Dokter UmumKonvensional

Non Dokter/ SP3T

Non Dokter/ SP3T

Praktisi Jamu

Self Treatment Self Treatment

Standar Rumah Sakit

MEDICAL-JAMU R & D System Based on Health Services - Permenkes 3 / 10Article 7

Komite IlmiahKomite etik

Rumah SehatTradisional/ CAM

Holistik

Unit Teknis Sentra P3TBP, PUSKESMAS, RS, SWASTA

BKTM & LKTM

BBTOOT TIPE A

Dual research-service =Double ID-board

.

BIOLOGI KIMIA FISIKA

ANATOMIFISIOLOGI BIOKIMIAHISTOLOGI

PSIKONEUROIMUNOENDOKRINOLOGI

PATOLOGIKD/ KLINIS

TH/ KLINIS

FISIK MENTAL SOSIO SPIRITUAL

THERAPI HOLISTIK

ETIKOLEGAL - PROFESIONALISM

DIAGNOSTIK HOLISTIK KEBUGARANWellness

Index

SJMETPEN

NETWORK

LEVELINDEP LINGK

50 jam

100 jam

BK-KA IDI +BALITBANG

BK-KA IDI + MKEK

HOLISTIC MR

DOUBLE ID BOARD

Konsep Diklat SJ – 50 jam awal Sinergi Praktek Konvensional – Non Konvensional

.

DOKTERSJ

BLOK 1METODOLOGI PENELITIAN

BLOK 4MEDIKO-ETIKOLEGAL

BLOK 3FARMAKODINAMIK JAMU

BLOK 2DIAGNOSTIK HOLISTIK

SAINTIFIKASI DR JAMU(LANGKAH AWAL NAKES JAMU)

SAINTIFIKASI JAMU(OBAT TRAD – BRAND RI)

PRAKTISI KRITIS + JEJARING PENELITI

PRAKTISI LEGAL PROFESIONAL

Persyaratan PerizinanJenis Registrasi

NakesIzin Nakes Registrasi

Komplementer- Alternatif

Surat Tugas/Surat Izin Kerja

Komplementer-Alternatif

Dokter-dokter gigi, apoteker

STR/STRA SIP SBR-TPKA ST-TPKA

Tenaga kesehatan lainnya

SURAT IZIN /REGISTRASI (DINKES PROV)

SIP/SIK SBR-TPKA ST-TPKA/SIK-TPKA

Batra (jamu) Surat Terdaftar Batra di Dinkes Kab/Kota

STR+SBR

TPKA, ps 16

SIP+ST TPKA, ps 22 ay1

PETA PERIJINAN UUPK/Pmks 512,725,1109-07Konsep Ijin Ganda krn “blm diakui metodenya”

Dalam Faskes Konvensional :INTEGRASI

SINERGI

Dinkes Prop a/n MenkesPs 17

PKKAI

IjazahSumpah

SertifikatKompetensi

Rekomen-dasi IDI

SehatKompetenPDSp

PDSmEtis Anggota

FK-FKG

Kolegium +/- Kol CAM

KKI

DINKES KAB/IKOTA

tataran individu Nakesmulti-metodologi, ps 1 ay 7

KEWENANGAN TOLAKPs 24

UJI KOMPMTK P/KAB

Berlaku 5 thn (ps 20)TPKA ASING : 1 th (ps 33 ay 6

KTP (-)

KAJIAN INSTITUSI, ps 5(1)

RS ps 9

KLINIK, ps 8

Ps 16 ay 6KAPUSRENGUN

CATATAN REGISTRASI NAS

PoltekesAkademi

Nakes

WNA/LULUSAN LN, ps 19

Berlaku 1 th (ps. 25)

KUOTA MAX : 3 TPBADAN KAJIAN KA

??…

`::,..,. ` ` “ “ ,::`”.,.

, `:`“

,::`”.,. , `:`“ ,::`”.,.

, `:`“ ,::`”.,.

, `:`“ ,::`”.,.

, `:`“

,::`”.,. , `:`“

,::`”.,. , `:`“

,::`”.,. , `:`“