LABORATORY ACTIVITY PHARMACY

Topic :

Prescribing Individual Drugs of Solid dosage form

Learning Objective :At the end of the activity student should be able to write prescription of individual drugs of solid dosage form

Case 2 Name : Andi, 10 months old Symptom : body temperature 38,50 C, productive cough, dyspnoe Diagnose : mild bacterial acute bronchopneumonia

Would you write a good use prescription for this patient

Medicament treatment : Antibiotic, antipyretic, expectorant antitusive, anti allergy

1.Indivudal drugs : Antibiotic : Amoxicillin antipyretic : Acetaminophen expectorant : Glyceril guaiacolat antitusive : dextromethorphan HBr anti allergic agent : Chlorpheniramin maleat = CTM

• Pasien Dina 4 tahun, batuk, demam , akan diberi obat Codein HCl, Glyceryl Guaiacolat, lama pengobatan 4 hari, frekuensi pemberian sehari 2 kali 1 bungkus.

Dr Arifin Jln Cilas No 28 Bandung SIP : 345/8.244.

Bandung,………..

R/ Codein HCL 5 mg. Acetaminophen 125 mg.

Glyceril guaiacolas. 25 mg Sch.lact. q.s m.f.pulv. dtd no.X S.t.d.d.1 -----’’-------

Name : DinaAge : 4 years Address : Jl Pasirkaliki 190

Case 1 :Name : Mrs. Wanti 30 weeks pregnant Symptom : body temperatur 39 0 C, headache, myalgia, productive cough.Diagnose : acute bacterial bronchitisMedicament treatment :Antibiotic, analgesic/antipyretic, antihistamine, expectorant Would you write a good use prescription for this patient

Case 2 : Name : Boyke, 4 years oldSymptom : Body temperature 38,5 0 C, mild dyspnoe caused by obstructive rhinitis, mild productive coughDiagnose : Allergic rhinitis and pharyngeal infection Medicament treatment : Antibiotic, antipyretic, antihistamine, decongestant Would you write a good use prescription for this patient

Cases for discussion :

Antibiotic : Amoxycillin, Erithromycine Analgetic/antipyretic : Acetaminophen , Acetosal, Mefenamic acid Antihistamine : Chlorpheniramin maleate = CTMExpectorant : Glyceril guaiacolate

Doses :Amoxycillin : 500 mg three times daily 5 daysAcetaminophen : 500 mg three times dailyCTM : 4 mg three times daily 3 daysGlyceril guaiacolate : 100 mg three times daily

Topic to be discussed : 1. P- drug (refers to lecturing material of P-drug and drugs that penetrate into placental barrier, producing milk and contra-indication) 2. Route of administration 3. Calculation of regimen dose 4. Dosage form that appropriate for individual patient 5. Management of medication ( time,frequency and duration) 6. Writing prescription order 7. Adverse drug interaction

Dose : is a quantity of drug that given within a certain period time The measure of dose : a. Unity of weight : µg, mg., gr b. Volume : µl, ml c. International unit : IU (Vit. A, Vit.D ) d. percent (%)

refers to lecturing material of individual drug

The proper RODA drug therapy Rate , drug absorbed and DOA RODA Oral preparation is preferred

Official books that provide usual dose is : - Farmakope Indonesia I, II, III Other general sources : - Manufacturer catalogs - Dosage information inserts on their product - ISO, IIMS - Pediatric dosage Handbook Terminology of dose :

Usual dose, regimen dose, therapeutic dose, maximum dose, toxic dose, lethal dose.

Dose may be stated as : - Single dose - Daily dose (divided the frequency of taking medication )

FACTOR INFLUENCING DOSE :1. Age ; infant, children, adult, elderly2. Body weight, sex, rash, surface area 3. Route of administration4. Disease : renal and hepatic impairment5. Obesities

THERAPEUTIC DOSE ; initial dose adjustment dose maintenance dose

REGIMEN DOSE :proper drug is selected designing a therapeutic dosage regimen

Properly designed dosage regimen to achieve an optimum conc. of drug at receptor site to produce an optimal therapeutic response with minimal adverse effect

Individualization of dose is unnecessary for drugs that have a large margin of safety (such as ibuprofen, cimetidin, naproxen and others) and its necessary for drugs with narrow therapeutic window such as digoxin, amino glycosides, amtiarrhytmics and antiasmathics such as theopylline.

.

• The initial dosage regimen is calculated based on body weight after consideration of pharmacokinetic of drugs , and known patient’s pathophysiology such as renal /and hepatic disease and patient drug’s history

• Makes decision based on empirical clinical data, personal experience and observations

• In many cases the physicians takes USUAL DOSE that recommended by literature

The patient monitored for therapeutic response by :

physical examination , serum drug level

After evaluation make readjustment of dosage regimen

Calculation of regimen dose : - Adult patient usual dose from literature - Infant, baby and children : - Infant and baby dose table - calculate using an appropriate equation

Formula for calculating baby and children dose :A. Young’s ( for 2 years and older children ) : n ( age = year) child dose = X adult’s dose (approx.) n ( age= year) + 12

B. Clark’s ( for 2 years and older children ) :

weight (lb) Child dose = X adult dose (approx.) 150

Clark’s :

weight (kg) Child dose = X adult dose (Approx.) 68 (kg)

C. Fried’s ( for infant up to 2 years old ) : age (month) Child dose = X adult dose (Approx.) 150

D.Dilling ( for infant up to 2 years old ) :

n (year) Child dose = X adult dose (Approx.) 20

Dosage form must be acceptable to the patientFactors influence choosing of dosage form :1. Age : - infant, baby : drop, divided powder - children : syrup, divided powder - adult : tablet, capsule, caplet, divided powder, syrup2. Site of action : - local : - topical : lotion, bulk powder, ointment, cream etc - mouth : lozenges, gargle - systemic : - enteral : tablet, capsule, inhaler - par enteral

Classified into : - Solid - Semi solid - Liquid

4. Condition of patient : - unconscious ; injection, suppositories - nausea - difficult to swallow ; syrup - hyper emesis - post operative of GIT ; injection

3. Onset of action : - immediate : injection, suppositoria, sublingual tablet,nasal preparation - sustained release

Drugs administered to patient Optimum effect

direction for patient = signature

taking of medication should be managed

For ex.: S.t.t.d Caps.I 1.h.a.c ( One Capsule three times a day one hour before meal)

1. INTERVAL OF MEDICATION Standard : * Hourly* every …….. hours (for ex. every three-hours)* ……… times a day

2. TIME OF MEDICATIONStandard :* in the morning, in the midday, in the night* before, after, or during meals; before sleeping* during episode, during attack, after attack

3. TECHNIQUES OF MEDICATION

CLASSIFICATION :

STANDARD ADMINISTRATION TIMES

DAILYOnce : 10.00 (morning)/22.00 (night)

Twice : 10.00 , 14.00Three times : 10.00 , 14.00, 18.00Four times : 10.00, 14.00, 18.00, 22.00

EVERY12-hourly : 10.00, 22.008-hourly : 06.00, 14.00, 22.006-hourly : 06.00, 12.00, 18.00, 24.004-hourly : 06.00, 10.00, 14.00, 18.00. 22.00, 02.00

TIMING OF MEDICATIONIn the morning : In the night : * Steroid * Contraceptive pills * Diureticum * Laxative Bisacodyl tablet * Antihypertension * Suppositoria

* Vaginal tablets * Hypnotics * Cimetidine

* AnticholesterolaemiDuring daily activitiesDuring meal =With meal : - promptly after meal

- During Meal

Empty Stomach : 1 hour before meal (without meal) 2 hours after meal

During episode* angina drugs* Drugs for migraine-cephalgy* Anti asthmatic drugs

Table Drugs with absorption reduced, delayed, increase or not affected by thePresence of food

Reduced Delayed Increased Not affectedAmoxicillin Acetaminophen Griseofulvin ChlorpropamideAmpicillin Amoxicillin Hydralazine GlibenclamideFurosemide Aspirin Hydrochorthiazide Prednisone Levodopa Digoxin Phenytoin Theophyline Tetracycline

Drugs that absorption reduced by food taken on empty stomach : 1 h. a.c. and 2 h.p.c.

Duration therapy : Symptomatic therapy : three days, < or > than three days Causative therapy : eliminate the cause of the case antimicrobial agent eradicate all infecting organism oral administration : 5 – 7 days or < if given high dose

The component part of a prescription :• Prescriber’s information • Date ( include place = city ; Bandung, August, 20th

2005)• Superscription = R/ symbol = recipe = you take• Inscription = medication prescribed• Subscription = direction to pharmacist• Signa = direction for patient • Refill information • Prescriber signature • Patient information ; name, age, address

PHYSICIAN’S PRESCRIPTION

In IndonesiaName :Specialist :Address :License of Practice

Bandung,………2005

R/

Ampicillin.500mg caps No.XXIV

S.4. d. d. caps I a.c.

Name :Age :Address :

Superscription

Inscription

Prescriber information

Signatura

Patient information

Subscription

Date

Dr. ChristineSIP No. : Jln. Pasirkaliki No. 196 Bandung

Bandung,……2005 Bandung,……2005

R/ Parasetamol 500 mg R/ Parasetamol tab. No. X M.f. Pulv. d.t.d No. X S. t.d.d. tab. I S.t.d.d. pulv. I …….”…… …….”…….

Pro : Ny. Nina Pro : Ny.Nina Umur : Umur :Alamat : Alamat :

Dr. ChristineSIP No. :

Jln. Pasirkaliki No. 196 Bandung

1. Precompounded ( formula officinales ) A drug(s) in dosage form supplied by the Pharmaceutical company in its official or proprietary name 2. Compounded ( Formula magistrales / Extemporanous ) The physician selects and write the drugs, doses, and dosage form desired. The name of drugs can be written as generic name (nonproprietary) or proprietary name.

Precompounded : Compounded :

R/ Panadol tab. No. IX R/ Acetaminophen 500 mg S.t.d.d tab.I M.f. pulv d.t.d No. IX S.t.d.d. pulv I ……..”……. ………”…….. prescriber’s signature

R/ Erytrin Cap. 500 mg No. XV R/ Erytrin Cap. 500 mg No. XV S.t d.d. Cap. I S.t.d. Cap.I 1.h.a.c. ……..”…….. …….”………

R/ Antacid Tab. No. X R/ Antacid Tab. No. X S. t.d.d. tab.I S.t.d.d tab. I 2 h.p.c. …….”…….. …….”…….

After writing the prescription order, make avoiding the possibility of occurrence adverse drug interaction.

For ex. :

Proper steps in prescribing medicament :1. Choose Individual drug ( refers to lecturing material)2. Choose route of administration3 Choose dosage form4. Calculate regimen dose 5. Manage frequency, time and duration of medication6 Writing prescription order7. Be aware of possible adverse drug interaction Example Case 1 Name : Mrs FarmawatiSymptoms : Body temperatur 38,50 C, headache, pharyngeal painDiagnose : Acute bacterial tonsilopaharingitisPatient allergy to AmpicillinMedicament treatment : Antibiotic, antipyreticWould you write a prescription order according to above information

How to write a prescription

Empirical antibiotic for infection of upper respiratory tract. are Ampicillin, Amoxicillin and Erythromycin Antipyretic ; Acetaminophen, Mefenamic acid , Acetosal

Prescribing :1. Individual drug : antibiotic : Erythromycin antipyretic/analgesic : Mefenamic acid 2. Route of administration : Oral3. Dosage form : solid dosage form for oral administration : tablet, caplet, capsule 4. Dose : Adult woman, take the dose from Official book ( Farrmakope Indonesia) Oral single dose Erythromycin : 250 – 500 mg mild infection 250 mg, moderate 500 mg Single dose Mefenamic acid : 250 – 500 mg

Mefenamic acid : Frequency : recommended 500 mg first and followed with 250 mg or 500 mg three times a day Available dosage form are : Capsule 250 mg and Capsule 500 mg Duration of therapy : 3 days, given 3 X 3 = 9 Capsules

Writing prescription : A. Precompounded B. Compounded

5. Management of administration : Erythromycin : Frequency of administration is given every 6 hours ( four times a day ) Available oral solid dosage form are : Capsule 250 mg, Caplet 500 mg Duration of therapy : 5 days, so given 5 X 4 = 20 caplets

A. Compounded : R/ Erythromycin 500 mg or R/ Erythromycin 500 mg M.f.. Pulv. d.t.d. No XV M.f. pulv. d.t.d No. XV da in

cap. S.t.d.d. pulv I 1.h.a.c. S.t.d.d. Cap. I 1.h.a.c. …….”………. …….”……….

R/ Mefenamic acid 500 mg or R/ Mefenamic acid 500 mg M.f. pulv. d..t.d. No IX M.f. pulv d.t.d. No IX da in Cap. S.t.t.d. pulv I S.t.t.d. Cap.I …….”………. …….”……….

B Precompounded : R/ Erytrin Cap. 500 mg No. XV S.t d.d. Cap. I 1 h.a.c. …….”………

R/ Ponstan Cap. 500 mg No. IX S.t.d.d. Cap. I …….”………

Case 2 Name : Andi, 10 months old Symptom : body temperature 38,50 C, productive cough, dyspnoe Diagnose : mild bacterial acute bronchopneumonia

Would you write a good use prescription for this patient

Medicament treatment : Antibiotic, antipyretic, expectorant antitusive, anti allergy

1.Indivudal drugs : Antibiotic : Amoxicillin antipyretic : Acetaminophen expectorant : Glyceril guaiacolat antitusive : dextromethorphan HBr anti allergic agent : Chlorpheniramin maleat = CTM

2. Route of administration : oral3. Dosage form : divided powder, drop.4. Calculation of doses : Amoxicillin : oral ; 25 – 75 mg/kg body weight daily divided into three doses ( Farmakope Ind. ) See body weight on body weight table : 10 months = 8 kg

Single dose = 8 X 50 mg = 133 mg 3 Acetaminophen : Single dose - for 6 – 12 months is 50 mg ( F.I ) single adult dose 500 mg - Fried’s : 10 X 500 mg = 35 mg 150 Glyceril guaiacolate : single adult dose 100 mg – 200 mg Single dose : 10 X (100 – 200) mg = ( 6 - 12 ) mg 150

Dextromethrphan HBr 1 mg/Kg BW divided to three doses Single dose : 8 X 1 mg = 3 mg 3

Chlorpheniramin maleat 0,35 mg/Kg BW divided 4 dosesSingle dose = 0,35 X 8 = 0,7 mg 4

5. Management of Administration Amoxycillin Frequency : three times a day Duration of therapy : 5 days given 3 x 5= 15doses

Frequency of :Acetaminophen,Glyceril guaiacolate,Dextromethrphan HBr, Chlorpheniramin maleat are three times a dayDuration of therapy : 3 days given 3 x 3= 9 doses

Writing prescription

R/ Amoxycillin 133 mg m.f , pulv d.t.d. No XV S. t .d.d. pulv I. -----”------ R/ Acetaminophen 50 mg Glyseril guaiacolas 6 mg Dextrometorphan Hbr 3 mg Chlorpeniramin maleas 0.7 mg m.f . pulv d.t.d. No IX S. t .d.d. pulv I -----”------

Case 1 :Name : Mrs. Wanti 30 weeks pregnant Symptom : body temperatur 39 0 C, headache, myalgia, productive cough.Diagnose : acute bacterial bronchitisMedicament treatment :Antibiotic, analgesic/antipyretic, antihistamine, expectorant Would you write a good use prescription for this patient

Case 2 : Name : Boyke, 4 years oldSymptom : Body temperature 38,5 0 C, mild dyspnoe caused by obstructive rhinitis, mild productive coughDiagnose : Allergic rhinitis and pharyngeal infection Medicament treatment : Antibiotic, antipyretic, antihistamine, decongestant Would you write a good use prescription for this patient

Cases for discussion :

Antibiotic : Amoxycillin, Erithromycine Analgetic/antipyretic : Acetaminophen , Acetosal, Mefenamic acid Antihistamine : Chlorpheniramin maleate = CTMExpectorant : Glyceril guaiacolate

Doses :Amoxycillin : 500 mg three times daily 5 daysAcetaminophen : 500 mg three times dailyCTM : 4 mg three times daily 3 daysGlyceril guaiacolate : 100 mg three times daily