Mr. S, 50 yo, was admitted to the hospital with productive cough, dyspnea, short of brethness, icteric and pruritus since 1 month ago. He was treated with cathegory 1 TB medicine, but there was no good response. The doctor asked the pharmacist about the most possible drug which could be resistant to this patient and about the best theraphy. R/ inj SNMC

R/ HP Pro 1 x 1 tab

R/ GG 3 x 1 tab

R/ codein 1 x 1 tab

R/ omeprazole

S O A P

Productive cough

Dyspnea

Short of breathness

TB PARU• Pengobatan batuk produktif :

GG

• Pengobatan TB untuk sementara dihentikan sampai fungsi hati normal dan dilanjutkan dengan pengobatan TBC second line

Icteric

Pruritus

Increase of total bilirubin

ALT 650,

AST 498

Gangguan hepar• Inj SNMC 2 ampul (@20

ml)/hari selama 2 minggu, dilanjutkan 80 mg 2x/minggu selama 24 minggu

• HP pro 1 x 1 tab

• Domperidone untuk mengatasi gejala mual muntah karena gangguan hati

TB Paru adalah infeksi Mycobacterium tuberculosis yang menyerang paru-paru

PATOFISIOLOGY

ETIOLOGI

TBC Mycobacterium tuberculosis yang sebagian besar (80%) menyerang paru-paru.

Penyebaran kuman melalui percikan dahak (droplet) di udara oleh penderita TB.

GANGGUAN HEPAR Penggunaan obat-obat TB seperti PZA, Inh Tanpa ada hepatoprotektor

FAKTOR RESIKO

TBC Umur

Status sosial dan ekonomi

Keadaan tempat tinggal

Prilaku / kebiasaan:merokok

Daya tahan tubuh

Status gizi

Penyakit lain

GANGGUAN HEPAR

Umur

Kebiasaan hidup: miras

Penggunaan obat dengan efek samping pada hepar

PENATALAKSANAAN TERAPI TBC

Kategori 1 : 2HRZE/4H3R3

Tablet Isoniazid @ 300 mg

Kaplet Rifampisin @ 450 mg

Tablet Pirazinamid @ 500 mg

Tablet Etambutol @ 250 mg

Obat ini diberikan untuk:

Penderita baru TB Paru BTA Positif Penderita baru TB Paru BTA negatif Röntgen Positif yang “sakit berat

Penderita TB Ekstra Paru berat

Kategori 2 : 2HRZES/HRZE/5H3R3E3

Tablet Isoniazid @ 300 mg

Kaplet Rifampisin @ 450 mg

Tablet Pirazinamid @ 500 mg

Tablet Etambutol @ 250 mg

Tablet Etambutol @ 500 mg

Vial Streptomisin @ 1,5 gr

Obat ini diberikan untuk penderita TB paru BTA(+) yang sebelumnya pernah diobati, yaitu:

Penderita kambuh (relaps) Penderita gagal (failure)

Penderita dengan pengobatan setelah lalai (after default).

Kategori 3 : 2 HRZ/4H3R3

Tablet Isoniazid @300 mg

Kaplet Rifampisin @ 450 mg

Tablet Pirazinamid @ 500 mg

Obat ini diberikan untuk:

Penderita baru BTA negatif dan röntgen positif sakit ringan Penderita TB ekstra paru ringan

PENATALAKSANAAN TERAPI

TB Dengan gangguan hati kronik

2 RHES/6RH atau 2HES/10HE atau 9RE

Regimen pengobatan TB RESISTEN (WHO):

6Z-Km-Mfx-Eto-Trd/ 18 Z-Mfx-Eto-Trd Z = pirazinamid

Km(Am) = Kanamisin inj (Aminkasin inj) 1000 mg /vial

Mfx = Moxifloxacin

Eto = Ethionamide 125 mg

Trd = terizidone

PHARMACEUTICAL CARE

Mr. S, 50 yo, was admitted to the hospital eith productive cough, dyspnea, short of brethness, icteric and pruritus since 1 month ago. He was treated with cathegory 1 TB medicine, but there was no good response. The doctor asked the pharmacist about the most possible drug which could be resistant to this patient and about the best theraphy.

R/ inj SNMC

R/ HP Pro 1 x 1 tab

R/ GG 3 x 1 tab

R/ codein 1 x 1 tab

R/ omeprazole

PH : TB since 5 weeks ago DH : 1 cathegory of TB medicine

Lab ALT 650, AST 498, Increase of Total Bilirubin

PROBLEM

Problem medis Terapi

TB paru resisten pengobatan TB kategori 1• GG untuk mengatasi batuk produktif

Rekomendasi pengobatan TB selanjutnya yaitu second line :

• PAS 500 mg 1x sehari• Levofloxacin 250 mg 1 x sehari

• Etionamid 125 mg 1x sehari

• Amicacyin 1000 mg 1 x sehari

• (selama 6 bulan)

Gangguan hepar karena efek samping obat TB• Inj SNMC 2 ampul (@20 ml)/hari selama 2

minggu, dilanjutkan 80 mg 2x/minggu selama 24 minggu

• HP pro 1 x 1 tab

• Omeprazole 20 mg sekali sehari untuk mengatasi gejala mual muntah karena gangguan hati

ASSESMENT

DRP Ada Solusi

Ada indikasi tidak ada obat - -

Ada obat tdk ada indikasi - -

Pemilihan obat tdk tepatCodein (narkotik)

Utk px dyspnea & SOB, gang hati tidak tepat

Batuk berdahak diberi GG

Overdose - -

Underdose - -

Muncul ESO Codein menimbulkan depresi pernapasan

Tidak dianjurkan

Interaksi obat - -

Pasien gagal menerima obat - -

Monitoring Keberhasilan Terapi

obat P. Monitoring Rentang Normal End Point Frekuensi Monitoring

Inj SNMC 80 mg/hari selama 2 minggu

HP Pro

ALT AST, bilirubin

ALT = 11-41 u/L

AST = 10-41 U/L

Bilirubin total = 0,2-1,3 mg/dL

Perbaikan fungsi hati. Nilai tes lab hati menjadi normal

Sebulan sekali

GG Frekuensi batuk , RR

RR = 20-24 Batuk berkurang, tidak Dyspnea &SOB

Sehari sekali

OmeprazoleMual muntah

Stress ulcer- Tidak mual muntah Sehari sekali

MONITORING ESO

obat P. Monitoring Rentang Normal Frekuensi Monitoring

Inj SNMC 80 mg/hari selama 2 minggu

HP Pro

- - -

GG Mual, mengantuk - Sehari sekali

Omeprazole Diare, sakit kepala, konstipasi, dll

- Sehari sekali

Kasus 7

A 50 yo male patient admit to the Emergency Departement with chest pain, especially during high activity, headache and dyspnea. He was diagnosed with AMI with acute STEMI. BW 95 kg, height 165 cm

R/ Streptokinase inj, dose confirm pharmacist

R/ Aspirin 1x 80 mg

R/ isosorbid mononitrat 3x1tab

R/ carvedilol

Problem klinik

• Pasien didiagnosis menderita AMI dengan STEMI akut

FARMAKOTERAPI

• Tujuannya adalah:

1. Mengatasi kondisi gawat darurat

2. Membatasi luasnya infark

3. Mempertahankan fungsi jantung

4. Meningkatkan kualitas hidup pasien (quality of life)

5. Mencegah serangan AMI kedua

Unstable

Angina Non occlusive

thrombus

Non specific

ECG

Normal cardiac

Enzymes

NSTEMI

Occluding thrombus

sufficient to cause

tissue damage & mild

myocardial necrosis

ST depression +/-

T wave inversion on

ECG

Elevated cardiac

enzymes

STEMI

Complete thrombus

occlusion

ST elevations on

ECG or new LBBB

Elevated cardiac

enzymes

More severe

symptoms

PATOFISIOLOGI

Aterosklerosis →Pemb. Darah menyempit→Rusak

→Agregasi →Trombus→Menyumbat→O2 ↓

→AMI

ETIOLOGI

• Terlepasnya plak aterosklorosis dari arteri koroner dan menyumbat aliran darah ke miokardium

• Suplai oksigen ke miocard berkurang

• Curah jantung yang meningkat

• Kebutuhan oksigen miocard meningkat

RISK FACTORS

Uncontrollable

• Jenis kelamin• Hereditas

• Umur

Controllable• Tekanan darah tinggi• Kolesterol darah tinggi• Merokok• Aktivitas fisik• Obesitas• Diabetes• Stress

Penatalaksanaan di IGD1) Pasang infus intravena: dekstrosa 5% atau NaCl 0,9%.2) Pantau tanda vital: setiap ½ jam sampai stabil, kemudian tiap 4 jam atau sesuai dengan kebutuhan (frekuensi jantung)3) Aktifitas istirahat di tempat tidur dengan kursi commode di samping tempat tidur dan mobilisasi sesuai toleransi setelah 12 jam.4) Diet: puasa sampai bebas nyeri, kemudian diet cair. Selanjutnya diet jantungCon’t Penatalaksanaan di IGD5). Medika mentosa :• Oksigen nasal• Mengatasi rasa nyeri: Morfin 2,5 mg (2-4 mg) iv, atau Petidin 25-50 mg iv, atau Tramadol 25-50 mg iv. Nitrat sublingual/patch, intravena jika nyeri berulang dan berkepanjangan.6) Terapi reperfusi (trombolitik) streptokinase 7) Antitrombotik :• Aspirin (160-325 mg hisap atau telan) atau heparin8) Mengatasi rasa takut dan cemas: diazepam 3 x 2-5 mg oral9) Obat pelunak tinja: laktulosa (laksadin) 2 x 15 ml.10) Terapi tambahan: Penyekat beta, atau Penghambat ACE atau antagonis kalsiumPATIENT ASSESMENT

S : chest pain during high activity, headache, dyspneaO : BW 95kg, heigh 165 cm, Lab chol 450 mg/dL, TG 250 mg/dL, LDL 100 mg/dL, TD 130/80A : AMI with acute STEMIP : analgetic narkotika, trombolitica agent, vasodilator, resustasi cairan, O2

DRP

1 Ada indikasi tidak ada obat

Analgetik (Morfin injeksi), Antianxietas (Diazepam), Obat pelunak tinja (laktulosa)

2 Ada obat tidak ada indikasi -

3 Pemilihan obat yang tidak tepat

Isosorbid mononitrat diganti isosorbid dinintrat

4 Gagal memperoleh obat -

5 Dosis subterapetik Aspirin 1x80 mg diganti 160-325 mg

6 Overdosis -7 Reaksi efek samping obat -

8 Interaksi obat Carvedilol & Diazepam

EBM ISDN

• P: AMI with acute STEMI• I : Isosorbid mononitrat

• C: Isosorbid dinitrat

• O : oncet, effectiveness

• Jurnal: Comparison of the time to onset of action on myocardial ischaemia following intravenous administration of isosorbide dinitrate and 5-isosorbide mononitrate in Chinese patients.

• DOC: digunakan ISDN

Quick Management Guide in Emergency Medicine, 2010

JURNAL ISDN

EBM Beta Bloker

• P: acute myocard infaction• I : atenolol

• C: carvedilol

• O : vasodilatasi

• Jurnal: A Comparison of the Two β-Blockers Carvedilol and Atenolol on Left Ventricular Ejection Fraction and Clinical Endpoints after Myocardial Infarction

• DOC: atenolol (tidak ada perbedaan bermakna antara carvedilol dan atenolol namun pada carvedilol ada kejadian kardiovaskuler serius)

Ventricular Ejection Fraction and Clinical Endpoints after Myocardial Infarction

Background: β-Blockers have been found to reduce mortality and morbidity in postmyocardial infarction patients. However, it is not fully understood whether all β-blockers have similar favourable cardiovascular effects. The aim of this study was to compare the effects of carvedilol and atenolol on global and regional left ventricular ejection fraction (LVEF) and on predefined cardiovascular endpoints.

JURNAL Beta Bloker

Methods: In a single-centre, randomized, open, endpoint-blinded, parallel group study, 232 patients with acute myocardial infarction were randomized to treatment with carvedilol or atenolol. LVEF was measured by gated blood pool scintigraphy during the first week and after 12 months. The treatment was given orally within 24 h. The mean dose was 36.2 and 72.1 mg in the carvedilol and atenolol groups, respectively.

Results: No significant difference was found between the two study groups in the mean global and regional LVEF. There tended to be fewer first serious cardiovascular events in the carvedilol compared with the atenolol group (RR = 0.83, 95% CI 0.56–1.23, p = 0.39). Cold hands and feet were observed less frequently in the carvedilol group (20 vs. 33%, p = 0.025).

Conclusion: In patients following an acute myocardial infarction, no difference in either global or regional LVEF was observed between baseline and 12 months when treatment with carvedilol was compared with atenolol.

EBM Antihiperlipidemia

• P:• I :

• C:

• O :

• Jurnal:

• DOC:

JURNAL Antihiperlipidemia

Plan

Untuk SERANGAN:

R/NaCl 0,9% infus

R/Streptokinase inj 1,5 jt IU/1 jam

R/Aspirin 165 mg

R/Morfin 2,5 mg iv

R/ atenolol 50 mg/hari

Con’t Plan

Untuk PEMELIHARAAN:

R/ISDN 10 mg 2x1

R/Aspirin 80 mg

R/ laksadin 2 x 15 ml

R/ atenolol 50 mg/hari

R/simvastatin 20-50 mg/hari

Monitoring

Keberhasilan terapi, meliputi:

- Monitoring trombus pasien End point = kesadaran pasien pulih- EKG End point = gelombang ST (mendekati normal)

- Kadar kolesterol normal End point = 200 mg/dL

- Kadar TG normal End point = 150 mg/dL

- Penggunaan vasodilator End point = tekanan darah

Monitoring

Efek samping, meliputi:

- ES carvedilol: sakit kepala, bradikardi

Konseling

• Hentikan faktor resiko.• Minum obat secara teratur.

• Bila ada masalah dalam penggunaan obat hubungi apoteker anda