Catharina Triwikatmani

Presc iption

Mr Good Day, 25 y male, with productive cough for a week

Rales in hemithorax dextra, x ray: infiltrates, sputum: coccus gram +

Dx ? Tx ? Prescription ?

Ms Communi Cation, 72 y female with long standing hypertension

Treatment: nifedipin 3x10 mg Px: BP 170/100 mmHg, pulse 88 x/mnt reg,

cardiomegali, no basal rales. Px ? Tx ? Prescription ?

Mr Best Zer, 45 y male, dysuria & ↑ frequency for 5 days

Costovertebral angle flank pain – dextra Lab ? Dx ? Tx ? prescription

4A Influenza Asma bronkial Bronkitis akut Pneumonia,

bronkopneumonia Tuberkulosis paru tanpa

komplikasi3A Bronkiektasis Tuberkulosis dengan HIV Emfisema paru Abses paru

3B Acute Respiratory Distress

Syndrome (ARDS) SARS Flu burung Status asmatikus (asma

akut berat) Pneumonia aspirasi Efusi pleura masif Penyakit Paru Obstruksi

Kronik (PPOK) eksaserbasi akut

Edema paru

4A Hipertensi esensial3B Syok (septik, hipovolemik,

kardiogenik, neurogenik) Angina pektoris Infark miokard Gagal jantung akut Takikardi: supraventrikular,

ventrikular Fibrilasi ventrikular Atrial flutter Kor pulmonale akut Ensefalopati hipertensi

3A Gagal jantung kronik Fibrilasi atrial Ekstrasistol

supraventrikular, ventrikular Kor pulmonale kronik Hipertensi sekunder Tromboflebitis Limfangitis Limfedema (primer,

sekunder) Insufisiensi vena kronik

4A Kandidiasis mulut Ulkus mulut (aphtosa,

herpes) Gastritis Gastroenteritis (termasuk

kolera, giardiasis) Refluks gastroesofagus Demam tifoid Keracunan makanan Penyakit cacing tambang Strongiloidiasis Askariasis Skistosomiasis Taeniasis Hepatitis A Disentri basiler, disentri

amuba Hemorrhoid grade 1-2

3B Lesi korosif pada esofagus Perdarahan gastrointestinal Botulisme3A Esofagitis refluks Ulkus (gaster, duodenum) Malabsorbsi Hepatitis B Abses hepar amoeba Perlemakan hepar Divertikulosis/divertikulitis Kolitis Irritable Bowel Syndrome Proktitis

4A Infeksi saluran kemih Pielonefritis tanpa

komplikasi

3A Glomerulonefritis akut

(Anak) Glomerulonefritis kronik

4A Infeksi saluran kemih

bagian bawah Anemia defisiensi besi pada

kehamilan

3B Infeksi pada kehamilan:

TORCH, hepatitis B, malaria

4A Diabetes melitus tipe 1 Diabetes melitus tipe 2 Hipoglikemia ringan Malnutrisi energi-protein Defisiensi vitamin Defisiensi mineral Dislipidemia Hiperurisemia Obesitas

3B Ketoasidosis diabetikum Hiperglikemi hiperosmolar Hipoglikemia berat Tirotoksikosis Cushing’s disease Krisis adrenal Sindrom metabolik (3B?)3A Diabetes melitus tipe lain

(intoleransi glukosa akibat penyakit lain atau obat-obatan)

Hipoparatiroid Hipertiroid Goiter

4A Anemia defisiensi besi Limfadenitis Demam dengue, DHF Malaria Leptospirosis Reaksi anafilaktik Tetanus HIV AIDS tanpa komplikasi3B Bakteremia Dengue shock syndrome Sepsis Malaria serebral Rabies

3A Anemia hemolitik Anemia makrositik Limfadenopati Toksoplasmosis AIDS dengan komplikasi Lupus eritematosus

sistemik Polimialgia reumatik Demam reumatik (Anak) Artritis reumatoid Artritis, osteoartritis Osteoporosis Tenosinovitis supuratif

Prescription sheet

Prescribing doctor: Physician's name, degree and address (phone, license no.)

Date of prescription / treatment R/ Prescription drug(s): name of drug, form, number,

dosage Full name of patient (no nicknames) for whom

drug is prescribed, age, body weight

Rational approach to therapeutics Define the patient’s problem Specify the therapeutic objective Selecting therapeutic strategies

Non-pharmacological treatment Pharmacological treatment

Selecting the correct group of drugs Selecting the drug from the chosen group Verifying the suitability of the chosen pharmaceutical

treatment for each patient Prescription writing Giving information, instructions and warnings Monitoring treatment

Variation in dose response

Drug formulation Body weight and age Physiological and pharmacokinetic variables Drug distribution Drug metabolism and excretion Pharmacodynamic variables Disease variables Environmental variables

Geriatric Patients

They experience an increased incidence of adverse drug effects

There is an increased likelihood that the patient will respond atypically to a given drug Enhanced effect Diminished effect Unexpected adverse effect

~ Age-related pharmacokinetic & pharmacodynamic changes, be aware of nonpharmacologic problems

… Geriatric Patients

Age-related : physiologic changes in renal function physiologic changes in liver function changes in the CNS changes in protein binding changes in body composition

…Geriatric Patients

High incidence of adverse effects in the elderly

Drug-drug interactions Multiple chronic diseases require several

medications→ ddi & becomes difficult to manage Visit different providers for care & obtain meds at

different pharmacies Medications considered inappropriate : risk >

benefit

Adverse Drug Reaction

An adverse drug reaction: a drug response that is noxious or unintended and occurs at prophylactic, diagnostic, or therapeutic doses

Adverse Drug Reaction…

Major factors predisposing to adverse effects Extremes of age

Can present atypically in the elderly ex. symptoms from constipation confusion

Intercurrent illness Drug interactions

Direct association: age ~ medication use Strong relationship: number of medication ~ incidence of

adverse reactions Incompatibilities between drugs and intravenous fluids Adverse effects caused by traditional medicines The effect of food on drug absorption

Polypharmacy

The use of multiple medications: 3-5, >9 medications/day The administration of more medications than clinically

indicated Risk factors: increased

increased age increased number of physicians and pharmacies increased number of office/hospital visits decline in health status the influence of pharmaceutical industry advertising

Be aware that neither generic nor brand-name prescribing is a superior method

…Polypharmacy

Contributing factor: tx of an adverse effect of one drug w. another medication

Polypharmacy increases the risk of ADR drug interactions medication noncompliance decline in medical status Increase in health care costs

Can be prevented: communication & education

Polypharmacy in geriatric patient Obtain a geriatric drug history If an adverse effect occurs, don’t add a drug. Take

one away Discontinue all drugs deemed unnecessary or of

questionable therapeutic efficacy Identify the overtreated patient Employ nonpharmacologic treatments whenever

feasible

Adherence (compliance) with drug treatment

Patient reasons Disease reasons Doctor reasons The doctor-patient interaction Prescription reasons Pharmacist reasons The health care system

Recommendations

Review the prescription to make sure it is correct. Quiz the patient periodically to see if medication is being

taken correctly Observe the patient Reevaluate the regimen periodically

Spend time explaining the health problem and the reason for the drug.

Establish good rapport with the patient. Explore problems, for example difficulty with reading

the label or getting the prescription filled. Utilize nonchildproof containers if necessary

Recommendations…

Encourage patients to bring their medication to the clinic, so that tablet counts can be done to monitor compliance. Inspect the contents of the patient’s medication bottles

Encourage patients to learn the names of their medicines, and review their regimen with them. Write notes for them.

Keep treatment regimens simple. Consider combination agents when medically (and

financially) appropriate Attempt to treat specific conditions with monotherapy or

groups of disease with the same medication

Compliance

Don’t assume that every patient can remember a complicated medication regimen

Avoid qid and tid regimens if possible

Recommendations…

Communicate with other health care proffessionals, to develop a team approach and to collaborate on helping and advising the patient.

Involve the partner or another family member. Listen to the patient.

Be aware that the prescriber’s job does not end with the prescription

Thank you