Etika Kedokteran Dalam Farmakoterapi PRINT

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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.gif
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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