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

Productive cough

Pengobatan batuk produktif :

GG

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

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
Dyspnea
Short of breathness

Icteric

Increase of total
bilirubin

Gangguan hepar

Pruritus
ALT 650,
AST 498

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 Rntgen 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 rntgen 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

GG untuk mengatasi batuk produktif

TB paru resisten pengobatan TB kategori 1

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)

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

Gangguan hepar karena efek samping obat TB

ASSESMENT
DRP

Ada

Solusi

Ada indikasi tidak ada obat

Ada obat tdk ada indikasi

Codein (narkotik)
Pemilihan obat tdk tepat

Batuk berdahak diberi GG

Utk px dyspnea & SOB, gang hati
tidak tepat

Overdose

Underdose

Muncul ESO

Codein menimbulkan depresi

pernapasan

Tidak dianjurkan

Interaksi obat

Pasien gagal menerima obat

Monitoring Keberhasilan Terapi

obat

P. Monitoring

Rentang Normal

Inj SNMC 80
mg/hari selama ALT AST, bilirubin
2 minggu

ALT = 11-41 u/L

HP Pro

Bilirubin total = 0,2-1,3

mg/dL

GG

AST = 10-41 U/L

Frekuensi batuk , RR RR = 20-24

End Point

Frekuensi Mon

Perbaikan fungsi hati.

Nilai tes lab hati
menjadi normal

Sebulan sekali

Batuk berkurang, tidak Sehari sekali

Dyspnea &SOB

Mual muntah
Omeprazole

Tidak mual muntah

Sehari sekali

Stress ulcer

MONITORING ESO
obat

P. Monitoring

Rentang Normal

Frekuensi Monitoring

Inj SNMC 80 mg/hari

selama 2 minggu

GG

Mual, mengantuk

Sehari sekali

Omeprazole

Diare, sakit kepala,

konstipasi, dll

Sehari sekali

HP Pro

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 menyempitRusak
Agregasi TrombusMenyumbatO2
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 IGD
1) Pasang infus intravena: dekstrosa 5% atau NaCl 0,9%.
2) Pantau tanda vital: setiap 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 jantung
Cont Penatalaksanaan di IGD
5). Medika mentosa :
Oksigen nasal
Mengatasi rasa nyeri: Morfin 2,5 mg (2-4 mg) iv, atau Petidin 25-50 mg iv, atau Tramadol 2550 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 heparin
8) Mengatasi rasa takut dan cemas: diazepam 3 x 2-5 mg oral
9) Obat pelunak tinja: laktulosa (laksadin) 2 x 15 ml.
10) Terapi tambahan: Penyekat beta, atau Penghambat ACE atau antagonis kalsium
PATIENT ASSESMENT

S
: chest pain during high activity, headache, dyspnea
O
: BW 95kg, heigh 165 cm, Lab chol 450 mg/dL, TG 250 mg/dL, LDL 100 mg/dL, TD
130/80
A
: AMI with acute STEMI
P
: 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 -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)

JURNAL Beta

Ventricular Ejection Fraction and Clinical Endpoints after Myocardial Infarction

Background: -Blockers have been found to reduce mortality and morbidity in postmyocardial
infarction patients. However, it is not fully understood whether all -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.
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 0.561.23, 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
Cont 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