FARMAKOTERAPI DASAR

FARMAKOTERAPI RASIONAL

DISUSUN OLEH :
DEASY NUR CHAIRIN HANIFA, M.CLIN.PHARM., APT.

UNIVERSITAS MUHAMMADIYAH KALIMANTAN TIMUR

2020
Niatkan
kuliah
sebagai
ibadah
 Personality

Tipe pembelajar
WHO AM I ???
????
Teacher Centred Learning Student Centred Learning
(TCL) (SCL)

vs
SUKSES
????
 Penilaian
Skor akhir =
• 10 % kehadiran
• 15 % Tugas Mandiri (kuis) dan keaktifan
• 10 % Tugas Terstruktur
• 30 % UTS
• 35 % UAS
 COURSE OUTLINE
PENDAHULUAN 1. FARMAKOTERAPI RASIONAL
SALURAN 2. PEPTIC ULCER DISEASE (PUD)
PENCERNAAN 3. GERD
PENGLIHATAN 4. GLAUCOMA, KONJUNCTIVITY, KATARAK,
RABUN, DLL
SALURAN 5. ASMA
PERNAPASAN 6. COPD
7. TBC
8. PNEUMONIA
ENDOKRIN + 9. OSTEOARTRITIS
RHEUMATOLOGI 10. RHEUMATOID ARTRITIS
11. GOAT
12. OSTEPOROSIS
13. DIABETES MELLITUS
14. THYROID
Mari kita mulai.....
 • the study of pharmaca or biologi-
cally active chemical, on intact
animal organism.
• Not restricted to therapeutic agent or
Pharmacology drug, also applies to all active agent
such as fungicides, insecticides etc.

• the study of the use of drugs in the

prevention and treatment of disease.
• drug useful in therapy because they
Drug study Pharmacotherapy
have only minimal effect on man but
can destroy or eliminate pathologic
cells or organism.

• the study of drugs on both healthy

volunteers and special patients.
Clinical • take place when a new drug have
Pharmacology potential pharmacological profile and
no toxicity.
 Radiotherapy

Nonpharmacology Surgery

Alternative therapy
Therapy
approach
• 1600 chemical agents
• 40.000 formulations
• 100.000 OTC
Pharmacology
Drug therapy

Pharmacotherapy Imunotherapy

Genetherapy
 Process of rational drug therapy

Patient Presentation Process of Rational Result of Intervention

Therapeutics

Presenting 2. Understanding Functional Outcome

1. Making Dx
symptoms • relief of symptoms
pathophysiology
Clinical Clinical
Patient Patient
features outcomes
expectations satisfactions
of illness • efficacy
3. Reviewing menu
• toxicity
of Rx options Costs
• morbidity
Potential • mortality • direct
consequences • indirect
4. Selecting
optimal drug/
dose for patient

6. Making alliance
with patient, 5. Choosing
following endpoints
endpoints to follow
 Rational therapeutics
Obat yang diresepkan dengan cara yang
memaksimalkan efek klinis (memaksimalkan
efikasi dan meminimalkan toksisitas), status
fungsional, dan kepuasan pasien secara
keseluruhan, dengan biaya total yang harus
dikeluarkan serendah mungkin.

Terapi rasional berusaha untuk menyesuaikan

rencana terapi secara individual agar sesuai dengan
kebutuhan pasien dan berdasarkan prinsip-prinsip
ilmiah kedokteran dan farmakologi.
 WHO conference of experts Nairobi 1985

The rational use of drugs requires that patients receive

medications appropriate to their clinical needs, in
doses that meet their own individual requirements for
an adequate period of time, and at the lowest cost to
them and their community.
1. correct drug
2. appropriate indication
3. appropriate drug considering efficacy, safety,
suitability for the patient, and cost
4. appropriate dosage, administration, duration
5. no contraindications
6. correct dispensing, including appropriate
information for patients
7. patient adherence to treatment
Terjemahan

Penggunaan obat secara rasional mengharuskan pasien

menerima obat yang sesuai dengan kebutuhan klinis mereka,
dalam dosis yang memenuhi kebutuhan individu mereka untuk
periode waktu yang memadai, dan dengan biaya terendah bagi
mereka dan komunitas mereka.

1. obat yang benar

2. indikasi yang sesuai
3. obat yang tepat mempertimbangkan kemanjuran, keamanan, kesesuaian untuk
pasien, dan biaya
4. dosis yang tepat, pemberian, durasi
5. tidak ada kontraindikasi
6. pengeluaran yang benar, termasuk informasi yang sesuai untuk pasien
7. kepatuhan pasien terhadap pengobatan
 Penggunaan Obat Rasional

Diagnosis Tindak lanjut

Indikasi TEPAT Kondisi pasien

jenis obat Informasi

Dosis, cara & lama pemberian

 Faktor yang Mempengaruhi
Farmakoterapi
Intrinsic
Information Prior
Knowledge
Scientific
Habits
Information

Influence Social &

of Drug Cultural
Industry Factors
Societal
Workload & Prescribing Economic &
Staffing Legal Factors

Workplace Infrastructure Authority &

Relationships Supervision
With Peers
Workgroup
Tantangan peresepan
Current
best knowledge
Tekanan
pasien
Tekanan
ekonomi

Waktu
terbatas
Prescribing

Individual
preference
Ketidak-
tahuan
Tekanan
industri farmasi
Problems in Irrational
Therapy
 % drugs that are prescribed
unnecessarily
estimated by a comparison of expected versus actual prescription

Chalker HPP 1996, Hogerzeil et al Lancet 1989, Isah et al 2000

80
70
60
50
40
30
20
10
0
Nepal Yemen Nigeria

% antibiotics % injections % drugs % cost

WHO, Dept. Essential Drugs and Medicines Policy

 5-55% of PHC patients receive
injections - 90% may be medically
unnecessary
AFRICA

Ghana

Cameroon

Nigeria

Sudan

Tanzania

Zimbabwe

ASIA

Yemen

Indonesia

Nepal

L.AMER. & CAR.

ä 15 billion injections per year globally
Ecuador
ä half are with unsterilized needle/syringe
Guatemala

El Salvador ä 2.3-4.7 million infections of hepatitis B/C

Jamaica

Eastern Caribean
and up to 160,000 infections of HIV per
year associated with injections
0% 10% 20% 30% 40% 50% 60%
% of primary care patients receiving injections
Source: Quick et al, 1997, Managing Drug Supply
 30 to 60 % of PHC patients receive
antibiotics - perhaps twice what is
clinically needed
AFRICA
Sudan
Sw aziland
Cam eroon
Ghana
Tanzania
Zim babw e
ASIA
Indonesia
Nepal
Bangladesh
L.AMER. & CAR.
Eastern Caribean
El Salvador
Jam aica
Guatem ala

0% 10% 20% 30% 40% 50% 60% 70%

% of PHC patients receiving antibiotics

Source: Quick et al, 1997, Managing Drug Supply
 Problems with Irrational Pharmacotherapy

The pharmacotherapy process

 Problems with Irrational
Diagnosis Pharmacotherapy :

1. Penyakit kompleks atau banyaknya masalah kesehatan:

Example: A patient has many symptoms, but is embarrassed to talk
about the main one, so the situation does not get addressed
2. Kurangnya keterampilan yang sesuai dalam menentukan diagnosis
yang tepat dan mempengaruhi resep yang diberikan:
Example: Prescriber does not do a physical exam and prescribes
drugs based solely on oral information provided by the patient
3. Resep terlalu banyak bekerja:
Example: health facility has only one prescriber, and an average of 300
patients per day to consult
4. Kurangnya peralatan diagnostik dasar dan tes
Example 1: No microscope or reagents to examine blood & urine
Example 2: No x-ray machine to test a patient suspected of having
tuberculosis
 Prescribing
1. Menggunakan obat-obatan mahal
Example 1: The antibiotic cefalexin is more expensive than
cotrimoxazole in treating simple infections
Example 2: Ampicillin injection is prescribed when the patient could
take ampicillin tablets, which are cheaper, easy to take, and
involve lower risk of side effects
2. Memilih obat yang salah untuk penyakit pasien
Example: An antidiarrhoeal drug is prescribed when the patient is
dehydrated with simple diarrhoea and only ORS is needed
3. Menggunakan beberapa obat yang memiliki efek yang sama
(Polifarmasi)
Example: Sulfadoxine/pyrimethamine and paracetamol are prescribed
when the patient has fever, but not malaria
4. Pemberian Resep obat pada penyakit yang dapat sembuh sendiri
dan pasien akan menjadi lebih baik tanpa mengkonsumsi
obat apa pun
Example: Ampicillin is prescribed when the patient has a simple cold,
without sore throat, cough or fever
 Dispensing
1. Salah dalam menafsiran resep
Example: Ampicillin is prescribed, but amoxicillin is dispensed.

2. Salah dalam mengeluarkan jumlah obat

(kuantitas)
Example: Artemether/Lumefantrine is prescribed to be taken four tablets
two times daily for three days (should be a total of 24
tablets), but the patient only receives 16 tablets, which is
sufficient for only 2 days
3. Pelabelan salah atau tidak memadai
Example: Sulphadoxine/pyrimethamine (white tablet) is dispensed, but
the name of the drug is not written on the container label,
meaning that the drug will be unidentifiable once the patient
leaves the pharmacy
4. Informasi yang disampaikan salah / tidak
cukup:
Example: paracetamol 250mg is prescribed for a
child, but only paracetamol 500mg is
available in the pharmacy. The higher
dosage pill is given to the child’s mother
without telling her to divide the tablet
before giving it to the child

5. Praktik yang tidak bersih

Example: 20 tablets of paracetamol 500mg were
being counted, when some tablets fell to
the floor. These were picked up and
dispensed to be given to the patient
anyway
 Packaging
1. Kualitas bahan pengemasan yang buruk
Example: packaging material must protect the drug
against the sun and humidity in order to ensure
the integrity and quality of the dosage form
required by the patient

2. Ukuran wadah yang tidak memadai saat

mengemas ulang produk
Example: the size of the packaging material must conform
to the quantity of medication dispensed. In the
case of oral drugs, too large a container could
cause break-up of the items packed within
3. Tidak cukup jelas label dan informasi obat
After the patient leaves the health centre and arrives home,
it is very easy to forget instructions given by the prescriber
and dispenser.

At the very minimum, the following information must

be written on the container label:
• Name of patient
• Date drug was dispensed
• Name of the drug
• Strength of the drug
• Quantity dispensed
• Instructions on how to take the drug during the day
(example: 1 tablet 4 times daily)
• Instructions on how long to take the drug
• Comments, instructions or warnings specific to the
drug (example, take with milk, may cause
drowsiness)
 Kepatuhan yang buruk
Kepatuhan adalah tingkat di mana pasien
melakukan instruksi dokter tentang cara
mengonsumsi obat dan perawatan yang sesuai
dengan yang diresepkan.

Banyak studi tentang kepatuhan rawat jalan yang

dilakukan di negara-negara berkembang
menunjukkan bahwa hanya sekitar 50% pasien
mengikuti instruksi yang diberikan oleh dokter
 Kepatuhan yang Buruk
Penyebabnya:
1. Pelabelan yang tidak benar
Neither the name of the patient, nor the name
of the drug is on the container labels when
dispensed. If two or more drugs are dispensed
together, the patient does not know which
drug he/she is taking
2. Instruksi yang tidak memadai
The instructions on dosage frequency must be
written on the drug label, or the patient could
forget how to take it when he/she arrives
home and becomes involved in other activities
3. Perawatan / instruksi yang tidak
mempertimbangkan aspek sosial
ekonomi dan budaya pasien
Example: In cases where the patient does not
know how to read, proper instructions
would include graphic symbols of how to
take the drug.

For a treatment of three days, for example, you could

number the days 1 to 3, and then below each day, make a
mark for each time the drug must be taken that day
• Kurang pengetahuan
• Dipengaruhi oleh orang lain
• Sikap negatif
• Pengalaman sendiri
• Persepsi sendiri
• Regimen yang sulit / rumit
• Umur ekstrem dan kebutuhan akan bantuan
SO....
WHAT’S AFFECTS PATIENT
COMPLIANCE ??
 Consequences in
Irrational Therapy
 Kesehatan Masyarakat dan Konsekuensi Ekonomi
• Kemungkinan efek mematikan dan merugikan,
mis. karena penyalahgunaan antibiotik atau penggunaan obat yang
tidak tepat dalam pengobatan sendiri
• Efikasi terbatas,
mis. dalam kasus dosis antibiotik, tuberkulosis, atau obat kusta
yang kurang terapeutik
• Resistensi antibiotik,
karena terlalu sering menggunakan antibiotik serta
penggunaannya dalam dosis terapi yang kurang
• Ketergantungan obat,
mis. karena penggunaan harian antinyeri dan obat penenang
• Risiko infeksi
karena penggunaan suntikan yang tidak tepat: abses, polio,
hepatitis dan HIV / AIDS
 Adverse drug events
Review by White et al, Pharmacoeconomics, 1999, 15(5):445-458

• 4-6th leading cause of death in the USA

• Estimated costs from drug-related morbidity &
mortality 30 million-130 billion US$ in the USA
• 4-6% of hospitalisations in the USA & Australia
• commonest, costliest events include bleeding,
cardiac arrhythmia, confusion, diarrhoea, fever,
hypotension, itching, vomiting, rash, renal failure

WHO, Dept. Essential Drugs and Medicines Policy

 Overuse and misuse of antimicrobials
contributes to antimicrobial resistance

• Malaria
– choroquine resistance in 81/92 countries
• Tuberculosis
– 2 - 40 % primary multi-drug resistance
• Gonorrhoea
– 5 - 98 % penicillin resistance in N. gonorrhoeae
• Pneumonia and bacterial meningitis
– 12 - 55 % penicillin resistance in S. pneumoniae
• Diarrhoea: shigellosis
– 10-90+ % amp, 5-95% TMP/SMZ resistance
Source: DAP, EMC, GTB, CHD (1997)
WHO, Dept. Essential Drugs and Medicines Policy
 Konsekuensi Ekonomi

Penggunaan obat yang tidak tepat atau terapi irasional juga

berdampak pada anggaran kesehatan rumah tangga dan
nasional,

Contoh:
- penggunaan produk bermerek mahal, sementara obat generik
yang lebih murah tersedia,
- Peresepan kombinasi,
- resep multi-obat
Improve Rational Therapy
 1. Educational

Prescribers
2. Managerial
Intervention
Type
3. Financial Consumers

4. Regulatory