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Indri Widyastuti 1 , Diana Lyrawati 1,2 1 Department of Pharmacy, Dr. Saiful Anwar General Hospital Malang, Indonesia 2 Laboratory of Pharmacy, Faculty of Medicine, Brawijaya University, Malang, Indonesia Health Insurance for Poorer Family (ASKESKIN) issued National Drug Formulary comprising drugs required for therapeutic management of major diseases in Indonesia. Drugs listed there are provided for poorer patients at no cost. The choice of drugs, however, were limited, hence presents challenges, both for the health carer and patients, in therapeutic management for certain diseases. Three weeks after underwent renal surgery, a 60-year-old man, was admitted to this hospital with chief complaints of fever for 5 days, pain in the right-sided of his abdomen, nausea, loss of appetite and general weak.ness. The patients was diagnosed with end stage renal disease, urosepsis and nephrolithiasis. Hematological data showed that patient had severe hyperkalemia with serum potassium level 8.4 mmol/L (Table Data). Calcium-polystirene sulfonate is one of the preferred drug for hyperkalemia management. It is a resin that exchanges calcium ions for potassium and other ions in the gastrointestinal tract, thereby enhances potassium excretion. The drug, however, is not listed in ASKESKIN Drug Formulary, and for this reason need to be substituted. The goals of therapy of hyperkalaemia are to antagonize adverse cardiac effects, reverse any symptoms that may be present, and to return the serum and total body stores of potassium to normal In this case patient was given a combination therapy of calcium gluconas; 40% In management of hyperkalemia, physicians in Dr. Saiful Anwar Hospital Malang typically use oral calcium polystyrene sulfonate. The drug, however not covered in the ASKESKIN. The case we report here showed that there were alternatives drugs listed in the ASKESKIN which worked well for hyperkalamia. potassium to normal. In this case, patient was given a combination therapy of calcium gluconas; 40% dextrose; insulin and sodium bicarbonate to correct hyperkalemia. Intravenous calcium gluconas is used to protect the heart from life-threatening arrhythmias. It antagonizes the cardiac membrane effect of hyperkalemia. Administration of insulin and dextrose is an effective method to reduce serum potassium. Insulin has synergistic effect with Na-K-ATPase pump, distributing potassium from extracellular into intracellular; whereas dextrose was administered to counter insulin effect to kept the serum glucose level within normal range. Sodium bicarbonate is to correct metabolic acidosis in patient. In this manner, hyperkalemia of the patient could be resolved, substantiated by his laboratory data on day 5 serum potassium level, 3.2 mmol/L. Variable Normal value Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Blood pressure 120/ 100/ 110/ 120/ 110/ 120/ 120/ 120/ 120/ 120/ 120/ 130/ 110/ 110/ 130/ A bi ti f Blood pressure 120/ 70 100/ 80 110/ 70 120/ 80 110/ 70 120/ 80 120/ 80 120/ 70 120/ 80 120/ 80 120/ 60 130/ 70 110/ 60 110/ 60 130/ 80 Heart rate 120 90 82 90 74 74 84 74 84 84 88 120 120 89 Respiratory rate 24 20 24 20 20 20 20 20 20 30 30 30 24 Temp. (°C) 36 GCS 456 456 456 456 456 456 456 456 456 456 Hematologic and blood chemical data Hb 13-18 g/dL 10.9 9.9 8.9 9.9 9.6 11 7.9 9.7 Leucocytes 4000-10,000/μL 11,800 6,100 14,800 9,900 11,100 14,000 12,100 6,500 Thrombocytes 150-450 (10 3 /mm 3 ) 505 509 457 442 327 305 256 222 PCV/HCT 40-54% 32.5 29 25.9 28.9 29.6 34.2 23.8 27.4 Ureum 20-40mg/dL 117 119.6 57.1 57.2 80.9 Creatinine 1-2mg/dL 7.14 4.25 2.05 3.03 3.17 Glucose 70-110mg/dL 147 183 Potassium 3.5-5.0mmol/L 8.4 5.7 5 3.2 3.77 3.63 A combination of calcium gluconas; 40% dextrose; insulin and sodium bicarbonate could serve as alternative for calcium-polystirene sulfonate to correct hyperkalaemia. Such measures were proven to normalize patient’s serum potassium level and patient did not have to worry the cost of the drugs Table 1. Clinical Data D I S C H A Potassium 3.5 5.0mmol/L 8.4 5.7 5 3.2 Sodium 136-145mmol/L 126 131 132 134 136 133 Chloride 98-106mmol/L 103 107 107 106 114 111 Albumin 3.5-5.5g/dL 3.13 3.17 PTT 12.6 APTT 18.8 Blood gas analysis pH 7,35 - 7,45 7.27 7.29 pCO2 35 – 45 mmHg 14 23.9 pO2 80-100 mmHg 96.8 107.5 HCO3 21 – 28 mmol/L 6.3 11.8 O2 saturation 85-95% 96 98.5 Base excess -3 - +3 -18.4 -12.4 Urine analysis the cost of the drugs. This case also highlights the role of pharmacists who know well ASKESKIN drugs in providing information of alternatives drugs so that drugs can be substituted with the appropriate alternatives swiftly. Acker C.G., Johnson J.P., Palevsky, P.M., R G E D pH 6 Leucocytes - +++ Therapeutic intervention Drugs Dosage Normal saline (NS) 500mL/24h √ Dextrose 5% (D5) 500mL/24h √ NS:D5 (1:1) 2 flasks √ √ Ceftriaxone 2x1g √ Zibac (ceftazidime) 3x1g √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ Ciprofloxacin 2x500mg √ √ Omeprazole 2x40mg √ Omeprazole 1x40mg √ √ √ √ √ √ Ca-gluconas 10mL √ Dextrose 40% 50mL √ Acker C.G., Johnson J.P., Palevsky, P.M., Greenberg, A., 1998. Hyperkalemia in Hospitalized Patients. Arch Intern Med. 158 Brophy, D. F. and Gehr T.W.D., 2005. Disorders of Potassium and Magnesium Homeostasis. In: Pharmacotherapy A Pathopysiologic Approach 6 th ed. (Dipiro et al. Eds.) USA: McGraw Hill. p.967-981 Evans, K., 2005. Hyperkalemia : A Review. Journal of Intensive Care Medicine. 20(5): 272. Pagana, K., 2002. Manual of Diagnostic Actrapid (insulin) 10IU √ Na bicarbonate 100meq drip √ Na bicarbonate 75 meq IV √ PRC 2 flasks √ Plasbumin 25% 100mL √ Kalnex 3x500mg √ √ √ √ √ Antrain 3x1amp √ √ √ Remopain 2x10mg √ √ Mefenamic acid 3x500mg √ √ Surgery √ 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 and Laboratory tests. USA : Mosby. p.372-375 This study was funded by: DFID British Council- United Kingdom, DelPHE Project: Indonesia (Faculty of Medicine, Brawijaya University)-UK (School of Pharmacy, University of London).
