Post on 04-Jun-2018
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Etika Kedokterandalam
FarmakoterapiAznan Lelo
Dep. Farmakologi & Terapeutik,Fakultas Kedokteran
Universitas Sumatera Utara7 Se tember 2008 IDI DKK Medan FK USU MER-C
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HUBUNGAN PENDERITA dan DOKTER
penderita Dokter
keluhan
keluhan
gejala
penyakit
gejala
OBAT
OBAT
OBAT
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Sakit kepala
Sakit gigi
Bisulan
Nyeri haid
Rematik
Gout
Ponstan
Voltaren
Feminax
IrgapanConfortid
Novalgin
Benar kah?Etis kah ?
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IATROGENIK
(iatro = dokter)
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Everyone has the r ightto a standard of living
adequate for the health of himself and of his
family, including food, clothing, housing andmedical careand necessary social services
(Art.25.1; Universal Declaration of Human Rights 1948)
Right to health facilities, goods and services
includes appropr iate treatmentof prevalentdiseases, preferably at community level; and
the provision of essent ial d rugs(Art 12.2.d; May 2000)
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Committee on Economic, Social and CulturalRights. General Comment nr.14 (May 2000)
Essential components of fulfillment of right to health
Availability includes essential drugs as defined by the WHO
Action Programme on Essential Drugs Accessibility
based on non-discrimination, physical accessibility,affordability and access to information
Acceptability respectful of medical ethics and culturally appropriate
and sensitive to gender and life-cycle
Quality scientifically and medically
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etika terapan (applied ethics)
matra normatif
tuntunan utk bertanggung-jawab
matra praksistuntutan rasionalitas tindakan
etika khusus (profesional)
peer review
otokritik tindakan sejawat = disiplin
kode etik
pemurnian dan penyesuaian
Kemurnian niat
Kesungguhan kerja
Kerendahan hati
Integritas ilmiah& sosial
etika kedokteran
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Metode Etika Terapan
Sikap awal
Informasi
Norma-norma moral
Logika berpikir
Primum no nocere
First do no harm
Evidence based
Pharmacologicalapproaches
Optimal therapeutic
effects
Avoid harm effects Rational
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Prinsip Etika Kedokterancontoh dalam penggunaan AINS pada nyeri
Prinsip Secara Farmakoterapeutik
BENEFICENCE :
mengutamakan
kepentingan pasien
Potent, onset
Diclofenac, mefenamic acid, ibuprofen
AUTONOMY :
menghormati hak pasien
dalam memutuskan
Mengingatkan pharmacoeconomic,
Preference
NON MALEFICENCE :
tidak memperburukkeadaan pasien
Tidak memperburuk hipertensi
Ibuprofen, diclofenac, ketoprofen
JUSTICE :
tidak mendiskriminasikan
pasien, apapun dasarnyaSelalu meresepkan obat generik
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Rational prescription (WHO,1995)
Patient receiveappropriate medicines
according to theirclinical needs
at an appropriatedosage,administration
& durationand in a way
that encouragesthe patient compliance
andat the lowest cost
to the community
Appropriate patient( Tepat Pasien )
Appropriate indication( Tepat Indikasi )
Appropriate drug( Tepat Obat )
Appropriate dosage,administration & duration
(Tepat dosis, cara & lama pemberian)
Appropriate information( Tepat Information )
Appropriate cost
( Tepat biaya )
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Kasus 1
Usia muda, hipertensi diastolik, takikardi,nyeri dada, muffle heart sound (+).
A. ACE-inhibitor captopril
B. Beta-1 selective blocker atenolol
C. Calcium antagonist nifedipin
D. Diuretic hydrochlorothiazide
E. Alfa-2 agonist clonidine
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non-malefficiency (tidak merugikan )
A. ACE-inhibitor
captopril
B. Beta-1 selective
blocker atenololC. Calcium antagonist
nifedipin
D. Diuretic
hydrochlorothiazideE. Alfa-2 agonist
clonidine
A. tetap takikardi
B. Bradikardi, nyeri
dada berkurangC. Reflex tachycardia,
nyeri bertambah
D. Hilang elektrolit,
renin meningkatE. Withdrawal
phenomenon
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HASIL ...... Golongan obat yang paling banyak
digunakan : antiinfeksicairan-ivfd
analgetika
0
20
40
6080
100
120
140
160
ANTIINFEKSI CAIRAN-IVFD ANALGETIKA
0
50
100
150
200
250
GENERIK PATEN
Penggunaan obat GENERIK hampir
sama banyak dengan obat PATEN
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nangis
anti-infeksi
demam
cemas
batuk
diare
etc,etc,etcetc
susahtidur
sesakanti-infeksianti-infeksianti-infeksianti-infeksianti-infeksianti-infeksianti-infeksi
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Sudah diminumatau belum?
Ini dia,tapi aku lupabagaimana cara
menggunakannya
Dimana obatku?
3 x 1 1 x 3Efek terapeutik Efek samping obat
Hindari pemakaian obat yang berbahaya . .. . . . . . . . . . . . . . pilihlah obat yang aman
. . dengan regimen obat yang sederhana
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The grandmother was syncope
due to hyperkalemia, bradycardia
Risk factors Case
Age Elderly (80 years)
Gender Woman
Concomitant disease
(CVS, kidney & liver)hypertension
Concomitantdrugs used
ACE-Inhibitorimidapril
NSAID loxoprofen prescribed byan orthopedic to treat a patient with lumbago
Kurata etal., (1999)
What next?
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Harus menulis RESEPdengan JELAS dan
RASIONAL, teristimewakombinasinya
R/ FeldenR/ Intidrol
R/ VoltarenR/ Lasix
R/ TanapressR/ Dextrometorphan
R/ Alludona
R/ Supraf lu
R/ Piroxicam
INTERAKASI OBAT
citalopram (Celexa). a selective serotonin (5-HT) reuptake inhibitor
CELEXA for CELEBREX?
A Case of Medication Sample ErrorBradley Moyer,MD; Walter Shrading,MD;
Keith K. Burkhart, MD, FACMTThe Pennsylvania State University, Hershey, PA
Int J Med Toxicol 2000; 3(2): 7
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Outcome Measuresfor arthritis management
CELECOXIB Less CV event QOL Cost >>
Agent IndicatorClinical
Outcome
Humanistic
Outcome
Economic
Outcome
NSAID pain
CV event
GI event
Renal failure
QOLCost/mmHg BP
Cost/stroke avoided
Cost/life year saved
IBUPROFEN Better GI event QOL COST
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Penilaian kritis dalam
menentukan obat pilihanBuktiEfek
Terapi
Bukti Efek Samping
Minimal MaksimalMaksimal Ya ?
Minimal ? Tidak
PERAN OBAT: Piluntuk setiap IL L ?BATAS KEMAMPUAN OBAT: What drugs may really do, and
what it can not do
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Nyeri bahu
Nyeri pinggang
Nyeri lutut
Nyeri tumit
yang penting hilang NYERI-nyaurusan JANTUNG, belakangan
Tapi, saya mudah sesakkencing malam
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Medicaljournals are
an extensionof themarketing armof drugcompanies
Richard SmithChief executive,United HealthEurope
Formerly editor BMJ
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An ideal oneis due to
wronginformation,so sad !
http://webster.commnet.edu/grammar/images/thinking.gif8/13/2019 Etika Kedokteran Dalam Farmakoterapi PRINT
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Gastricmucosal
protection
InflammationPain
Fever
COX-1 COX-2
anti-inflammatory
Hidden issues of NSAIDs
COOH
Arachidonic acid
PGI2inhibits
platelet
aggregation
vasodilation
TXA2stimulates
platelet
aggregation,
vasoconstriction
COX-2specific inhibitor
ischemicthrombosis
STROKE MCI
InflammationPain
FeverRenal functionBone formationReproduction
hidden
issuescauses GI damage
ProstaglandinesPGE2, PGI2, TXA2
ProstaglandinesPGE2, PGI2, TXA2
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Anti-hipertensi antasida
NYERI
diuretik misoprostol
Retensicairan
TDmeningkat
Nyeriulu hati
PUB
OAINS
Prescribing CascadeKaskade Peresepan
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Rp Rp
PAIN
Rp Rp
fluidretention
increaseBP
heartburn
PUB
NSAID=Rp
Iatrogenic Cost
ALZHEIMERDISEASECANCER
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Dangerous personWishing to eliminate a
president of anothercountry
Bombing all areas of
the country
Killing the people in
that country
Spending 20 M US$
But then offering only
200,000 US$to whomcould bring the head of
the president
Wishing to eliminate a
sign or symptom of adisease
Increasing ADRs &
iatrogenic disease
Spending a lot of
moneyBut it cloud be then
overcome by the
cheapest drug
Giving an expensive
drug & polypharmacy
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Etika Kedokteran dalamFarmakoterapi
Melibatkan berbagai pertimbangan
Human right Apakah obat akan memperbaiki kondisi
penderita?
Obat essensial
Pharmaco-economic
Iatrogenic cost Hati-hati informasi salah
Pharmaco-politic
Persepan salah
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Dangerous doctors
doctors are
the thirdleadingcause of death in the US,
causing 250,000deathsevery year
http://www.mercola.com/2000/jul/30/doctors_death.htm
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UK & US Market Withdrawal
Year
NSAID
CV
event
Hepato-
toxicityothers
Withdrawn Approval
1982 Benoxaprofen 82 deaths
1984 indomethacinSR
40deaths
1999 Indoprofen 217adversereactions
1998 1997 Bromfenac Acute liverfailure
2004 1999 Rofecoxib 139.000AMI/SCD/Stroke
1985 Nimesulide 6
2003 Lumiracoxib 2
? ? ? ? ? ?
Pharmaco-politics ?
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Complimentary Therapies
1. Special diets
2. Mega-dose vitamins
3. Hydrazine sulfate
4. Herbal therapies
5. Shark cartilage
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If you want others to be happy,practice compassion.
If you want to be happy,practice compassion.
- Dalai Lama