Obat Pada Anak & Manula

7/23/2019 Obat Pada Anak & Manula

http://slidepdf.com/reader/full/obat-pada-anak-manula 1/89

Drug Therapy in InfantsDrug Therapy in Infants

PHARMACODYNAMICSPHARMACODYNAMICS

Factors Affecting Drug Effects on the Infant:Factors Affecting Drug Effects on the Infant:

I. Drug AbsorptionI. Drug Absorption

II. Drug DistributionII. Drug Distribution

III. Drug MetabolismIII. Drug MetabolismIV. Drug ExcretionIV. Drug Excretion




I. Drug AbsorptionI. Drug Absorption Absorption in infants and children follows the Absorption in infants and children follows the

same rules as in adults.same rules as in adults.

Factors affecting absorption are determined byFactors affecting absorption are determined bythe physiologic status of the infant or child andthe physiologic status of the infant or child and

are influenced by:are influenced by:

.! "lood flow at the site of administration..! "lood flow at the site of administration.

#.! $astrointestinal function.#.! $astrointestinal function.




Drug Absorption inDrug Absorption in

DrugDrug

Acetaminophen Acetaminophen

Ampicillin AmpicillinDia%epamDia%epam

DigoxinDigoxin

&enicillin $&enicillin $&henobarbital&henobarbital

&henytoin&henytoin

'ulfonamides'ulfonamides

the neonate compared to adults.the neonate compared to adults.

(ral Absorption(ral Absorption

DecreasedDecreased

IncreasedIncreased)ormal)ormal

)ormal)ormal

IncreasedIncreasedDecreasedDecreased

DecreasedDecreased

)ormal)ormal




.! "lood flow at the site of administration..! "lood flow at the site of administration.* &hysiological conditions that might affect blood flow are: cardio+ascular* &hysiological conditions that might affect blood flow are: cardio+ascular

shoc,- +asoconstriction sympathomimetic agents!- and heartshoc,- +asoconstriction sympathomimetic agents!- and heart

failure.failure.

* Diminished muscle mass in i/ch may reduce blood flow causing* Diminished muscle mass in i/ch may reduce blood flow causing

irregular and unpredicatble absorption. Drug will concentrate in theirregular and unpredicatble absorption. Drug will concentrate in themuscle and if perfusion suddenly increases- drug may reach toxicmuscle and if perfusion suddenly increases- drug may reach toxic

concentrations.concentrations.

e.g. cardiac glycosides- aminoglycoside antibiotics- and anticon+ulsants.e.g. cardiac glycosides- aminoglycoside antibiotics- and anticon+ulsants.





'ignificant changes occur in the neonate shortly after'ignificant changes occur in the neonate shortly after

birth.birth.

$astric acid secretion commences soon after birth$astric acid secretion commences soon after birth

and increases gradually o+er se+eral hours. Inand increases gradually o+er se+eral hours. In

preterm infants it appears slowly.preterm infants it appears slowly. Drugs affected byDrugs affected by

gastric p0 should not be administered orally.gastric p0 should not be administered orally.$astric emptying is prolonged in the first day of life.$astric emptying is prolonged in the first day of life.

1hus- drugs absorbed through $I may be more1hus- drugs absorbed through $I may be more

completely absorbed than anticipated.completely absorbed than anticipated.

&eristalsis in the neonate is slow.&eristalsis in the neonate is slow. If drugs areIf drugs are

absorbed in the small intestine- their effect may beabsorbed in the small intestine- their effect may be

delayed.delayed. Diarrhea causes decrease absorption inDiarrhea causes decrease absorption in

small intestine.small intestine.




II. Drug DistributionII. Drug Distribution As body composition changes with de+elopment so As body composition changes with de+elopment so

does the distribution +olume of drugs.does the distribution +olume of drugs.

In the neonate- 23*245 of body weight is water +sIn the neonate- 23*245 of body weight is water +s645 in preterm +s 43*735 in the adult.645 in preterm +s 43*735 in the adult.

Most neonates will experience diuresis in the firstMost neonates will experience diuresis in the first

#8*86hrs of life.#8*86hrs of life.

In neonate 835 of body weight is extracellularIn neonate 835 of body weight is extracellularwater +s #35 in the adult.water +s #35 in the adult.

In the neonate total body fat is 45 +s 5 inIn the neonate total body fat is 45 +s 5 in

preterm.preterm.




II. Drug DistributionII. Drug Distribution"inding to &lasma protein"inding to &lasma protein

&rotein binding of drugs is reduced in the&rotein binding of drugs is reduced in the

neonate.neonate. 1herefore- concentration of free drug1herefore- concentration of free drugin plasma is increased 9 increased effectin plasma is increased 9 increased effect oror

increase toxicity.increase toxicity.

Drugs e.g. sulfonamide antibiotics! thatDrugs e.g. sulfonamide antibiotics! that

displace bilirubin from albumin may causedisplace bilirubin from albumin may cause

,ernicterus.,ernicterus. ;on+ersely- bilirubin may also;on+ersely- bilirubin may also

displace protein*bound drugs e.g. phenytoin!.displace protein*bound drugs e.g. phenytoin!.



III. Drug MetabolismIII. Drug Metabolism

Metabolism of most drugs occurs in the li+er.Metabolism of most drugs occurs in the li+er.

1he metaboli%ing acti+ity of cytochrome &843*1he metaboli%ing acti+ity of cytochrome &843*dependent mixed*function oxidases is reduced independent mixed*function oxidases is reduced inneonates 43*235 of adult +alues!.neonates 43*235 of adult +alues!.

$lucoronide formation doesn<t occur until the =th$lucoronide formation doesn<t occur until the =th

*8rd years of life.*8rd years of life. 1hus- in the neonate- drugs1hus- in the neonate- drugsha+e slow clearance rates and prolonged half*ha+e slow clearance rates and prolonged half*li+es.li+es.

If the mother was ta,ing phenobarbital- neonatalIf the mother was ta,ing phenobarbital- neonatal

li+er en%ymes could ha+e been induced.li+er en%ymes could ha+e been induced. 1he1heability of the neonate to metaboli%e certain drugsability of the neonate to metaboli%e certain drugswould be greater than expected and the effectwould be greater than expected and the effectcould be less.could be less.



IV. Drug ExcretionIV. Drug Excretion

$lomerular filtration is much lower =3*835 of$lomerular filtration is much lower =3*835 ofadult! in neonates for the first few days of life.adult! in neonates for the first few days of life.

>ithin a wee, glomerular filtration and plasma>ithin a wee, glomerular filtration and plasmaflow increase by 435 and reach adult +aluesflow increase by 435 and reach adult +alueswithin 7*# months.within 7*# months. Drugs that depend on renalDrugs that depend on renalflow are eliminated +ery slowly in the first fewflow are eliminated +ery slowly in the first few

wee,s of life penicilins- aminoglycosidewee,s of life penicilins- aminoglycosideantibiotics- digoxin!antibiotics- digoxin!

Ampicillin Ampicillin

? 2 days old9 43*33 mg/@g/d - #d at # hr? 2 days old9 43*33 mg/@g/d - #d at # hrinter+als.inter+als.

2 days old 9 33*#33 mg/@g/d- =d at 6 hr 2 days old 9 33*#33 mg/@g/d- =d at 6 hrinter+als.inter+als.



D N t l A N t t A# lt t



Drug Neonatal Age Neonates t 1/

!hours"

A#ults t 1/

!hours"

Acetaminophn #.#4 3.B#.#Dia%epam #4B33 83B43

Digoxin 73B23 =3B73

&henobarbital 3B4 days #33 78B83

4B4 days 33

B=3 months 43

&henytoin 3B# days 63 #B6

=B8 days 68B43 days 7

'alicylate 8.4B 3B4

1heophylline )eonate =B#7 3B4

;hild =B8



Dosage Forms and ;ompliance:Dosage Forms and ;ompliance:

1o ease administration and compliance-1o ease administration and compliance-

drug manufacturers prepare drugsdrug manufacturers prepare drugsas:as:

a!a! Elixirs.Elixirs. Alcoholic solutions in which the Alcoholic solutions in which the

drug molecules are dissol+ed and e+enlydrug molecules are dissol+ed and e+enlydistributed.distributed.

b!b! 'uspensions.'uspensions. ;ontain undissol+ed;ontain undissol+ed

particles of drug which must beparticles of drug which must bedistributed throughout the +ehicle bydistributed throughout the +ehicle bysha,ing to pre+ent une+en drugsha,ing to pre+ent une+en drugdispensing.dispensing.



$eight

!%g" !l&" Age Surfa'eArea!("

Per'ent ofA#ultDose

) *+* Ne,&orn -+ 1

* 1)+ ) (onths -+) 1.

1- 1 year -+0 .

- 0+0 years -+. .

)- ** years 1 *-

- .. 1 years 1+) 2.

0- 11- 1 years 1+0 -

*- 1) A#ult 1+2 1-

2- 10 A#ult 1+2* 1-)



Age !Young3s rule"4

$eight !so(e,hat (ore pre'ise is Clar%3s rule"4

; ff; li b diffi lt t hi i



;ompliance may be difficult to achie+e in;ompliance may be difficult to achie+e in

pediatric medicine and may pro+e apediatric medicine and may pro+e a

challenge when ta,ing into account:challenge when ta,ing into account:

measuring errorsmeasuring errors

spillsspills

spittingspitting A calibrated medicine spoon should be A calibrated medicine spoon should be

recommended.recommended.

&arents should be told to repeat dosage or not after&arents should be told to repeat dosage or not after

spitting or whether to wa,e up the child e+ery 7spitting or whether to wa,e up the child e+ery 7

hr dose day or night. &ossible drug*drughr dose day or night. &ossible drug*drug

interactions with (D; medications should beinteractions with (D; medications should be

discussed.discussed.

Drug Effect on Comments



Drug Effect on

Infant

Comments

Ampicillin Minimal No significant adverse effects; possible

occurrence of diarrhea or allergicsensitization.

Aspirin Minimal Occasional doses probabl safe; high

doses ma produce significant

concentration in breast mil!" but infantdose is nevertheless lo#.

Caffeine Minimal Caffeine inta!e in moderation is safe;

concentration in breast mil! is about$% of that in maternal blood.

Chloral

hdrate

&ignificant Ma cause dro#siness if infant is fed at

pea! concentration in mil!.

Chloramphe

nicol

&ignificant Concentrations too lo# to cause gra

bab sndrome; possibilit of bonemarro# suppression does e'ist;

recommend not ta!ing chloramphenicol#hile breast(feeding.

)hiazide Minimal No adverse effects reported.

C*+ Minimal Appears insignificant.Codeine Minimal No adverse effects re orted.

Dia5epa( Signifi'ant May 'ause se#ation in &reast6fe# infants7 'lini'al



Dia5epa( Signifi'ant May 'ause se#ation in &reast6fe# infants7 'lini'al(onitoring re'o((en#e#+

Di'u(arol Mini(al No a#8erse si#e effe'ts reporte#+

Digo9in Mini(al Insignifi'ant :uantities enter &reast (il%+

;thanol Mo#erate <arge a(ounts 'onsu(e# &y (other 'an pro#u'eal'ohol effe'ts in infant+

Heroin Signifi'ant ;nters &reast (il% an# 'an prolong neonatal nar'oti'#epen#en'e+

Io#ine !ra#" Signifi'ant ;nters (il% in :uantities suffi'ient to 'ause thyroi#suppression in infant+

Isonia5i#!INH"

Mini(al Mil% 'on'entrations e:ual (aternal plas(a'on'entrations+ Possi&ility of pyri#o9ine #efi'ien'y#e8eloping in the infant+

=ana(y'in Mini(al No a#8erse effe'ts reporte#+

<ithiu( Signifi'ant >reast6fee#ing ,ith 'aution7 le8els 'an &e (easure# in(il%+

Metha#one Signifi'ant !See heroin+" ?n#er 'lose physi'ian super8ision@ &reast6fee#ing 'an &e 'ontinue#+ Signs of opioi#,ith#ra,al in the infant (ay o''ur if (other stopsta%ing (etha#one or stops &reast fee#ing a&ruptly+



Oral'ontra'epti8es

Mini(al May suppress la'tation in high #oses+

Peni'illin Mini(al ery lo, 'on'entrations in &reast (il%+

Pheno&ar&ital Mo#erate Hypnoti' #oses 'an 'ause se#ation in the infant+ Close(onitoring of infant+

Phenytoin Mo#erate A(ounts entering &reast (il% are not suffi'ient to 'ausea#8erse effe'ts in infant+

Pre#nisone Mo#erate <o, (aternal #oses !0 (g/#" pro&a&ly safe+ Doses t,o or(ore ti(es physiologi' a(ounts !B 10 (g/#" shoul#pro&a&ly &e a8oi#e#+

Propranolol Mini(al ery s(all a(ounts enter &reast (il%+

Propylthioura'il Signifi'ant May suppress thyroi# fun'tion in infant+

Spironola'tone Mini(al ery s(all a(ounts enter &reast (il%+

Tetra'y'line Mo#erate Possi&ility of per(anent staining of #e8eloping teeth inthe infant+ Shoul# &e a8oi#e# #uring la'tation+

Theophylline Mo#erate Can enter &reast (il% in (o#erate :uantities &ut not li%elyto pro#u'e signifi'ant effe'ts+

Thyro9ine Mini(al No a#8erse effe'ts in therapeuti' #oses+

Tol&uta(i#e Mini(al <o, 'on'entrations in &reast (il%+

$arfarin Mini(al ery s(all :uantities foun# in &reast (il%+




DrugsDrugs

;ontraindicated;ontraindicated

Amphetamine Amphetamine

"romocryptine"romocryptine

;ocaine;ocaine

;yclophosphamide;yclophosphamide

;yclosporine;yclosporineDoxorubicinDoxorubicin

during Cactation:during Cactation:

ErgotamineErgotamine

0eroin0eroin

CithiumCithium

MariuanaMariuana

MethotrexateMethotrexate

)icotine)icotine&henindione&henindione



("A1 &ADA MA)CA("A1 &ADA MA)CA

)oor >iayahadi)oor >iayahadi



Medications Most ;ommonly sedMedications Most ;ommonly sed

in the ;ommunityin the ;ommunity

Analgesics Analgesics

DiureticsDiuretics;ardio+ascular ;ardio+ascular

'edati+e*hypnotics'edati+e*hypnotics




in the )ursing 0omein the )ursing 0ome

Antipsychotics Antipsychotics


DiureticsDiuretics

Antihypertensi+es Antihypertensi+es


;ardio+ascular ;ardio+ascular

Antibiotics Antibiotics



ManulaManula esi,o tinggi mengalamiesi,o tinggi mengalami

efe, merugi,an dari obatefe, merugi,an dari obat

Fa,tor penderitaFa,tor penderita B Age*associated changes in Age*associated changes in pharmaco,ineticspharmaco,inetics

B Age*associated changes in Age*associated changes in pharmacodynamicspharmacodynamics

B ;omorbidity;omorbidity: drug*disease interactions: drug*disease interactions B &olypharmacy&olypharmacy: drug*drug interactions: drug*drug interactions

B @emampuan homeostasis ber,urang@emampuan homeostasis ber,urang

B Fungsi organ ber,urangFungsi organ ber,urang

Fa,tor sistem layanan medi,Fa,tor sistem layanan medi, B Fragmentation of care &oly*doctoring!Fragmentation of care &oly*doctoring!

B InadeGuate training in principles of geriatric practiceInadeGuate training in principles of geriatric practice



1herapeutic esponse

1oxic esponse

Therapeutic Window

Age



Increasing Age

“The Precipice”

&hysiologic

eser+es

A+ailable

&hysiologic

eser+es

Already In se



Masalah UtamaMasalah Utama

Pilihan obat atau dosis yang tidak tepatPilihan obat atau dosis yang tidak tepat

Concomitant diseaseConcomitant disease affect metabolismaffect metabolism

of or response to drugof or response to drug

PolypharmacyPolypharmacy drug - drug interactionsdrug - drug interactions

Patient behavioural factorsPatient behavioural factors



Perubahan PHARMACO!"#$!C%Perubahan PHARMACO!"#$!C%

AbsorptionAbsorption

active transferactive transfer

&ody composition&ody composition

lean body masslean body mass

body fatbody fat

plasma albuminplasma albumin

'iver metabolism'iver metabolismo(idation ) microsomal en*ymeso(idation ) microsomal en*ymes

Renal clearanceRenal clearance



PerubahanPerubahan

PHARMACO+,"AM!C%PHARMACO+,"AM!C%

&rain sensitivity&rain sensitivity &en*odia*epines and&en*odia*epines and

narcotic analgesics more effectivenarcotic analgesics more effective

Coagulation mechanism controlCoagulation mechanism control

Anticoagulants more potentAnticoagulants more potent

Adrenergic receptor sensitivityAdrenergic receptor sensitivity

&-blockers less effective&-blockers less effective



Penurunan fungsi homeostasisPenurunan fungsi homeostasis

&aroreceptor sensitivity&aroreceptor sensitivity

postural hypotensionpostural hypotension

$hermoregulation$hermoregulation

hypothermiahypothermia



COMMO" P!$A''% . /COMMO" P!$A''% . /

0agal mengobati kondisi yang seharusnya0agal mengobati kondisi yang seharusnyabisa diobati 1treatable conditions2bisa diobati 1treatable conditions2

$hrombolytic therapy$hrombolytic therapythe older the patient3 the greater the benefitthe older the patient3 the greater the benefit

the older the patient3 the less likely to bethe older the patient3 the less likely to be

thrombolysedthrombolysed

HypertensionHypertension45 - 657 decrease in risk of C8A if !%H treated45 - 657 decrease in risk of C8A if !%H treated



&'OO+ PR#%%UR# A"+ A0#&'OO+ PR#%%UR# A"+ A0#

-

-

-

*-

.-

1--

1-

1-

1*-

)- - 0- *- 2- .-



COMMO" P!$A''% 9 /COMMO" P!$A''% 9 /

Prescribing for symptom and not forPrescribing for symptom and not for

diagnosisdiagnosis

: A pill for every ill ;



PR#%CR!P$!O"% &, A0#PR#%CR!P$!O"% &, A0#1!tems per person per year21!tems per person per year2

* 0- 0 0. * ** 2- 2 2. . .* --

0

1-

10

-

0

)-

)0

-

* 0- 0 0. * ** 2- 2 2. . .* -



##C$!8# PR#%CR!&!"0 .##C$!8# PR#%CR!&!"0 .

Utamakan non-pharmalogical treatmentUtamakan non-pharmalogical treatment

modify dietmodify diet

stop smoking3 reduce alcoholstop smoking3 reduce alcohol

physical e(ercisephysical e(ercise

<alking aids3 household adaptations<alking aids3 household adaptations

social supportssocial supports



##C$!8# PR#%CR!&!"0 9##C$!8# PR#%CR!&!"0 9

$reat conditions in order of$reat conditions in order of prioritypriority

PertimbangkanPertimbangkan kegagalan fungsi organkegagalan fungsi organ

%tart lo<%tart lo< mulai dosis kecilmulai dosis kecil 3 naikkan3 naikkan

dengan hati-hatidengan hati-hati

0unakan0unakan formulariumformularium yang terbatasyang terbatas

MonitorMonitor compliance and responsecompliance and response

Revie<Revie< pemakaian obat secara regulerpemakaian obat secara reguler

!kut sertakan P#"+#R!$A!kut sertakan P#"+#R!$A



>ho 1a,es the Most MedicationsH>ho 1a,es the Most MedicationsH

>omen>omen

Indi+iduals withIndi+iduals with

multiple healthmultiple health

conditionsconditions

Frail elderlyFrail elderly

)ursing home)ursing home

residentsresidents




in the ;ommunityin the ;ommunity


DiureticsDiuretics;ardio+ascular ;ardio+ascular


hi hi



mur mempengaruhimur mempengaruhi

metabolisme obatHmetabolisme obatH

&ada manula:&ada manula:

B 'lower organ function'lower organ function

B 'lower blood circulation'lower blood circulation

B Increased body fatIncreased body fat

obat bertahan lama di dalam tubuhobat bertahan lama di dalam tubuh

resi,o ter,ena efe, samping obatresi,o ter,ena efe, samping obat

mening,atmening,at



Age*elated ;hanges: Age*elated ;hanges:

1otal body water menurun1otal body water menurun ,onsentrasi dalam,onsentrasi dalam

darah obat yang larut*air mening,atdarah obat yang larut*air mening,at

&erubahan berat badan&erubahan berat badan

mempengaruhi dosismempengaruhi dosisyang diperlu,an dan lama obat dalam tubuh:yang diperlu,an dan lama obat dalam tubuh:

B More body fatMore body fat prolonged half*lifeprolonged half*life

B Cess lean body massCess lean body mass increased drug concentrationincreased drug concentration

&erubahan sistem pencernaan&erubahan sistem pencernaan mempengaruhi ,ecepatan absorbsi obatmempengaruhi ,ecepatan absorbsi obat

onset obat lebih lamaonset obat lebih lama



Age*elated ;hanges: Age*elated ;hanges:

'lower circulation'lower circulation delay drugs gettingdelay drugs getting

to li+er and ,idneysto li+er and ,idneys

'low down of li+er and ,idneys'low down of li+er and ,idneys

affectsaffects

time it ta,es for medication to brea, downtime it ta,es for medication to brea, down

and lea+e bodyand lea+e body

Cess absorption from transdermal patchesCess absorption from transdermal patches

Drug receptorJ sites may be different inDrug receptorJ sites may be different in

older adultsolder adults

;



;hanges in &harmaco,inetics;hanges in &harmaco,inetics

&erubahan fisiologis dan fungsi organ pada&erubahan fisiologis dan fungsi organ pada

manulamanula perubahan Farma,o,ineti,perubahan Farma,o,ineti,

&harmaco,inetics is the time course of a drug&harmaco,inetics is the time course of a drug

and its metabolites through the bodyand its metabolites through the body B Absorption Absorption

B DistributionDistribution

B ;learance: elimination renal!- metabolism li+er!;learance: elimination renal!- metabolism li+er!

#338: ;usac,- Amer. K of $eriatric &harmacotherapy#338: ;usac,- Amer. K of $eriatric &harmacotherapy

Volume of Distribution Vd!Volume of Distribution Vd!



Volume of Distribution Vd!Volume of Distribution Vd!

&roporsi lema, mening,at dan +olume otot&roporsi lema, mening,at dan +olume otot

ber,urangber,urang merubah Vdmerubah VdVd obat larut lema, Vd obat larut lema, fat soluble drugfat soluble drug!!

mening,atmening,at wa,tu paro mening,at:wa,tu paro mening,at:

#ia5epa(@#ia5epa(@ thiopental@ tra5a#onethiopental@ tra5a#oneVd obat larut air Vd obat larut air water soluble drugwater soluble drug!!

menurunmenurun ,adar obat dalam plasma,adar obat dalam plasma

mening,at:mening,at: ethanol@ lithiu(@ethanol@ lithiu(@a(inogly'osi#es@ al'ohol@ #igo9ina(inogly'osi#es@ al'ohol@ #igo9in



&rotein "inding&rotein "inding

albumin ber,urangalbumin ber,urang chronic disease:chronic disease:

e.g.-malnutrition- li+er or ,idney conditions.e.g.-malnutrition- li+er or ,idney conditions.

obat dengan i,atan protein tinggiobat dengan i,atan protein tinggi ,adar,adar

obat bebas mening,at.obat bebas mening,at.

ceftriaxone-dia%epam- phenytoin-ceftriaxone-dia%epam- phenytoin-

warfarin.warfarin.



;li(inasi O&at (enurun;li(inasi O&at (enurun

Fungsi ginal menurunFungsi ginal menurun eliminasi oleh ginaleliminasi oleh ginalber,urang.ber,urang.

E+en in the absence of ,idney disease renal clearanceE+en in the absence of ,idney disease renal clearance

may be reduced =4*435.may be reduced =4*435. therapeutic effect dan resi,o to,sisitas mening,attherapeutic effect dan resi,o to,sisitas mening,at

perlu pengurangan dosis atau perubahan inter+alperlu pengurangan dosis atau perubahan inter+alpemberian obat.pemberian obat.



Metabolisme hepar ber,urangMetabolisme hepar ber,urang

•Phase I, terutama reaksi oksidatif menurun

•Phase II, terutama reaksi konjugasi relatif tidak berubah.

diazepam is metabolized via Phase I reactions in the liver,

at least initially.



Drugs with ;ytochrome &843 EffectsDrugs with ;ytochrome &843 Effectspartial!partial!

!nhibitors !nducers

Allopurinol Metronida*ole &arbiturates

Amiodorone =uinolones Carbama*epineA*ole antifungals Phenytoin

Cimetidine Rifampin

!"H $obacco

%%R!s

$acrine



0epatic Metabolism0epatic Metabolism

Decreased li+er si%e and hepatic blood flow.Decreased li+er si%e and hepatic blood flow.

egional blood flow to the li+er at age 74 is reduceegional blood flow to the li+er at age 74 is reduceby 83*845 compared to a #4 year old.by 83*845 compared to a #4 year old.

Metabolic clearance of drugs by the li+er may beMetabolic clearance of drugs by the li+er may bereduced.reduced.

Disease effects: li+er congestion from heart failureDisease effects: li+er congestion from heart failuredecreases warfarin metabolism and an increaseddecreases warfarin metabolism and an increasedpharmacologic response.pharmacologic response.

En+ironmental effects: smo,ing stimulatesEn+ironmental effects: smo,ing stimulatesmonoxygenase en%ymes and increases clearancemonoxygenase en%ymes and increases clearanceof theophylline.of theophylline.

;h i &h d i;h i &h d i



;hanges in &harmacodynamics;hanges in &harmacodynamics

(lder patients may ha+e more sedation and(lder patients may ha+e more sedation and

impaired function after a single dose ofimpaired function after a single dose of

ben%odia%epines than younger persons.ben%odia%epines than younger persons.

After single dose of nitra%epam older patients After single dose of nitra%epam older patientsmade more mista,es on psychomotor testingmade more mista,es on psychomotor testing

compared to placebo while younger patientscompared to placebo while younger patients

had no impairment .had no impairment .



'uboptimal Luality'uboptimal Luality

1ypology of Luality &roblems:1ypology of Luality &roblems:

B (+eruse &olypharmacy!(+eruse &olypharmacy!

B nderusenderuse

B Misuse Inappropriate &rescribing!Misuse Inappropriate &rescribing!

B ErrorsErrors



'uboptimal &rescribing'uboptimal &rescribing

&olypharmacy&olypharmacy

nderuse of Effecti+e Medicationsnderuse of Effecti+e Medications

Drug*Drug InteractionsDrug*Drug Interactions

Drug*Disease InteractionsDrug*Disease Interactions

InadeGuate MonitoringInadeGuate Monitoring

Inappropriate DosingInappropriate Dosing

Inappropriate DurationInappropriate Duration

Drugs to A+oidDrugs to A+oid



Drug*Drug InteractionsDrug*Drug Interactions

Penye&a& tersering ;SO pa#a (anulaPenye&a& tersering ;SO pa#a (anulau(lahnya sangat &anya%u(lahnya sangat &anya% Al(ostAl(ost'ountless'ountless peresepan ele%troni%peresepan ele%troni%

So(e 'o((on e9a(plesSo(e 'o((on e9a(ples B 'tatins and erythromycin and other antibiotics'tatins and erythromycin and other antibiotics

B 1;As and clonidine or type Anti*arrythmics1;As and clonidine or type Anti*arrythmics

B >arfarin and multiple drugs>arfarin and multiple drugs

B A;E inhibitors increase hypoglycemic effect of A;E inhibitors increase hypoglycemic effect ofsulfonylureassulfonylureas



Drug*disease InteractionsDrug*disease Interactions

&atient with &D ha+e increased ris, of drug&atient with &D ha+e increased ris, of druginduced confusioninduced confusion

)'AIA and ;(*#<s! s can exacerbate ;0F)'AIA and ;(*#<s! s can exacerbate ;0F

rinary retention in "&0 patients onrinary retention in "&0 patients ondecongestants or anticholinergicsdecongestants or anticholinergics

;onstipation worsened by calcium-;onstipation worsened by calcium-ahticholinergics- calcium channel bloc,ersahticholinergics- calcium channel bloc,ers

)euroleptics and Guinolones lower sei%ure)euroleptics and Guinolones lower sei%urethresholdsthresholds



&olypharmacy&olypharmacy

Polyphar(a'y pe(&erian &anya%Polyphar(a'y pe(&erian &anya%

o&at (ele&ihi in#i%asi penggunaano&at (ele&ihi in#i%asi penggunaan

0E (anula (en#apat o&at tanpa0E (anula (en#apat o&at tanpa

in#i%asi yang Felas+in#i%asi yang Felas+

00E (anula (en#apat o&at00E (anula (en#apat o&at tanpatanpa

in#i%asiin#i%asi@ )+2E (en#apat@ )+2E (en#apat o&at yango&at yang

ti#a% efe%tif ti#a% efe%tif @ 1*+.E (en#apat@ 1*+.E (en#apat o&ato&at#upli%asi#upli%asi#33: 0anlon- KA$'#33: 0anlon- KA$'



nderusenderuse

A(ong patients el#erly patients ,ithA(ong patients el#erly patients ,ith'ar#io8as'ular #isease an# #ia&etes@ only'ar#io8as'ular #isease an# #ia&etes@ only1+1E of patients ,ere pres'ri&e# statins+ In1+1E of patients ,ere pres'ri&e# statins+ Inpatients ** to 2 years ol#@ the a#Fuste#patients ** to 2 years ol#@ the a#Fuste#

pro&a&ilities of statin pres'ription ,ere )2+2E@pro&a&ilities of statin pres'ription ,ere )2+2E@*+2E@ an# )+E in the 'ategories of lo,@*+2E@ an# )+E in the 'ategories of lo,@inter(e#iate@ an# high &aseline ris%@inter(e#iate@ an# high &aseline ris%@respe'ti8ely+respe'ti8ely+

The li%elihoo# of statin pres'ription ,as *+EThe li%elihoo# of statin pres'ription ,as *+Elo,er !a#Fuste# o##s ratio@ -+7 0Elo,er !a#Fuste# o##s ratio@ -+7 0E'onfi#en'e inter8al@ -+)6-+0" for ea'h year of'onfi#en'e inter8al@ -+)6-+0" for ea'h year ofin'rease in age an# ea'h 1E in'rease inin'rease in age an# ea'h 1E in'rease in

pre#i'te# )6year (ortality ris%+pre#i'te# )6year (ortality ris%+#338: @o- KAMA#338: @o- KAMA



Inappropriate &rescribingInappropriate &rescribing

#3*#25 manula mendapat resep yang#3*#25 manula mendapat resep yang

tida, diperlu,an inappropriate!.tida, diperlu,an inappropriate!.

Inappropriate prescribing mening,at,anInappropriate prescribing mening,at,an

resi,o atuh- fra,tur femur- cogniti+eresi,o atuh- fra,tur femur- cogniti+e

impairment- diminished independence-impairment- diminished independence-

dan mortalitasdan mortalitas



inappropriate drug prescribing toinappropriate drug prescribing to

the elderlyHthe elderlyH

The Beers List The Beers List .

a list of medications identified by an expert

panel as being inappropriate for older persons

because of ineffectiveness or because they

pose a high risk for adverse drug events.

>eers MH Arch Intern Med 12

1h " Ci



1he "eers Cist1he "eers Cist

1he "eers Cist- berisi == obat dalam =1he "eers Cist- berisi == obat dalam =,ategori:,ategori:

3. Drugs ith some indications, but that are often

misused.

!. Drugs that are rarely appropriate.

". Drugs that should always be avoided .

Ghan et al+ JAMA --1

D A d D t A idD A d D t A id



Drugs And Dosages to A+oidDrugs And Dosages to A+oid

Meperi#ineMeperi#ine

Diphenhy#ra(ineDiphenhy#ra(ine

The (ost anti'holinergi' tri'y'li's4The (ost anti'holinergi' tri'y'li's4

a(itryptiline@ #o9epin@ i(ipra(inea(itryptiline@ #o9epin@ i(ipra(ine<ong a'ting &en5o#ia5epines su'h as<ong a'ting &en5o#ia5epines su'h as

#ia5epa(#ia5epa(

<ong a'ting NSAIDs su'h as piro9i'a(<ong a'ting NSAIDs su'h as piro9i'a(High #ose thia5i#es !B0(g"High #ose thia5i#es !B0(g"

Iron4 )0 (g on'e #aily is enoughIron4 )0 (g on'e #aily is enough

drugs that should always be drugs that should always be



drugs that should always be drugs that should always be

a+oided in the elderly:a+oided in the elderly:

"arbiturates"arbiturates

;hlorpropamide;hlorpropamide

Flura%epamFlura%epam

MeperidineMeperidine

MeprobamateMeprobamate

&enta%ocine&enta%ocine

"elladonna al,aloids"elladonna al,aloids

DicyclomineDicyclomine

0yoscyamine0yoscyamine

&ropantheline&ropantheline

1rimethoben%amide1rimethoben%amide

Ghan et al+ JAMA --1

1angga &eresepan1angga &eresepan



a gga e esepagg p

&rescribing ;ascade!&rescribing ;ascade!

#he prescribing cascade terjadi

bila satu obat diresepkan,

$enyebabkan timbulnya

efek samping obat % adverse

drug event &'D(),

$endorong peresepan obat

kedua untuk mengatasi (*+

sebelumnya

rug 1

rug 2

A E

Ro'hon PA et al@ BMJ 12

1he &rescribing ;ascade1he &rescribing ;ascade




$etoclopramide

(xtrapyramidal (ffects

evodopa -x

#here are numerous examples of the prescribing cascade in the

medical literature.

or example, it has been observed that patients prescribed

metoclopramide & a gastric motility agent) are more likely to be initiated

on treatments generally reserved for the management of idiopathic

Parkinson/s Disease &e.g. Drugs containing evodopa).

In this case, metoclopramide use

can lead to extrapyramidal

symptoms, hich may be

misdiagnosed as Parkinson/s

Disease.

A8orn et al@ JAMA 10

1h & ibi ; d1he &rescribing ;ascade



0*'ID -x

'ntihypertensive -x

1lood Pressure


'nother example relates to the fact that older persons ho have

been prescribed 0*'IDs appear to be at increased risk for beinginitiated on antihypertensive therapy.

In this case, 0*'ID useincreases blood pressure

leading to the need for blood

pressure loering therapy.

In both examples, the initiation of ne drug treatments in older persons

could have been avoided if there as recognition of the risks of certain

drug treatments &e.g. metoclopramide and 0*'IDs) in elderly patients.

ur,it5 H et al@ JAMA 1



1he &rescribing ;ascadeJ1he &rescribing ;ascadeJ

Penye&a& uta(a polyphar(a'y pa#aPenye&a& uta(a polyphar(a'y pa#a(anula(anula

So(e 'o((on e9a(plesSo(e 'o((on e9a(ples B )'AID *01)*antihypertensi+e therapy)'AID *01)*antihypertensi+e therapy B Metoclopromide *&ar,insonism *'inemetMetoclopromide *&ar,insonism *'inemet

B Dihydropyridine * edema *furosemideDihydropyridine * edema *furosemide

B )'AIA *0# bloc,er *delirium *haldol)'AIA *0# bloc,er *delirium *haldol

B 0;1N *gout*)'AIA *#nd antihypertensi+e0;1N *gout*)'AIA *#nd antihypertensi+e

B 'udafed *urinary retention *alpha bloc,er 'udafed *urinary retention *alpha bloc,er

B Antipsychotic *a,ithesia *more meds Antipsychotic *a,ithesia *more meds

)'AID Anti inflamasi non steroid!)'AID Anti inflamasi non steroid!



)'AID Anti*inflamasi non*steroid!)'AID Anti*inflamasi non*steroid!

Efe,tifitas &arasetamol 9 )'AIDs padaEfe,tifitas &arasetamol 9 )'AIDs padaosteoartritis ringanosteoartritis ringan

)'AIDs side effects)'AIDs side effects

B $I hemorrhage$I hemorrhage B Decline in $FDecline in $F

Decreased effecti+eness of diuretics- anti*Decreased effecti+eness of diuretics- anti*hypertensi+e agentshypertensi+e agents

Indication should ustify the increased toxicityIndication should ustify the increased toxicityof )'AIDsof )'AIDs

D d ; iti I i t



Drugs and ;ogniti+e ImpairmentDrugs and ;ogniti+e Impairment

Anti'holinergi' #rugs are 'o((onAnti'holinergi' #rugs are 'o((onoffen#ers !TCAs@ &ena#ryl an# otheroffen#ers !TCAs@ &ena#ryl an# other

antihista(ines@ (any others"antihista(ines@ (any others"Other offen#ers 'i(eti#ine@ steroi#s@Other offen#ers 'i(eti#ine@ steroi#s@NSAIAsNSAIAsMe#i'al <etter --- Drug Safety 1 Drugs an# Aging 1Me#i'al <etter --- Drug Safety 1 Drugs an# Aging 1

Drugs and FallsDrugs and Falls



Drugs and FallsDrugs and Falls

"iggest ris, drugs are long acting ben%odia%epines"iggest ris, drugs are long acting ben%odia%epinesand other sedati+e*hypnoticsand other sedati+e*hypnotics

"oth ''Is and 1;As associated with increased"oth ''Is and 1;As associated with increasedris, of fallingris, of falling

"eta bloc,ers )(1 associated with increased ris,"eta bloc,ers )(1 associated with increased ris,of falling in published literatureof falling in published literature

Mild increase in fall ris, from diuretics- type AMild increase in fall ris, from diuretics- type Aanti*arrythmics- and digoxinanti*arrythmics- and digoxin

Ceip%ig- KA$'Ceip%ig- KA$'



Drug*Food InteractionsDrug*Food Interactions

Interactions between drugs and foodInteractions between drugs and food B warfarin and Vitamin @ containing foodswarfarin and Vitamin @ containing foods

remember green tea- as well!remember green tea- as well!

B &henytoin O +itamin D metabolism&henytoin O +itamin D metabolism B Methotrexate and folate metabolismMethotrexate and folate metabolism

Drug impact on appetiteDrug impact on appetite

B Digoxin may cause anorexiaDigoxin may cause anorexia B A;E inhibitors may alter taste A;E inhibitors may alter taste



Anticipate 'ide Effect Anticipate 'ide Effect

Nar'oti'sNar'oti's B >egin la'tulose or sor&itol an# a sti(ulant la9ati8e>egin la'tulose or sor&itol an# a sti(ulant la9ati8e

B Cola'e is NOT suffi'ient in (ost instan'esCola'e is NOT suffi'ient in (ost instan'es

Steroi#sSteroi#s

B Thin% a&out osteoporosis pre8entionThin% a&out osteoporosis pre8ention B Re(e(&er steroi# in#u'e# #ia&etesRe(e(&er steroi# in#u'e# #ia&etes

<e8othyro9ine<e8othyro9ine B Cal'iu( interferes ,ith a&sorption of le8othyro9ineCal'iu( interferes ,ith a&sorption of le8othyro9ine

Drug DiscrepanciesDrug Discrepancies



Drug DiscrepanciesDrug Discrepancies

Difference between medical record andDifference between medical record and

medication bottles in 275 of casesmedication bottles in 275 of cases

B 45 of time medication not recorded45 of time medication not recorded

B #5 medication recorded that patient not#5 medication recorded that patient notta,ingta,ing

B #35 dosage discrepancy#35 dosage discrepancy

is, Factors: Age- number of medicationsis, Factors: Age- number of medications B "edell et al Arch Intern Med 73- #333"edell et al Arch Intern Med 73- #333



0igh is, 'ituations0igh is, 'ituations

Patient seeing (ultiple pro8i#ersPatient seeing (ultiple pro8i#ers

Patient on (ultiple #rugsPatient on (ultiple #rugs

Patient li8es alone an#/or hasPatient li8es alone an#/or has

'ogniti8e i(pair(ent'ogniti8e i(pair(ent

Dis'harge fro( hospital or anyDis'harge fro( hospital or any

'hange in 8enue'hange in 8enue

0ospitali%ation: A 0igh is, 1ime0ospitali%ation: A 0igh is, 1ime



0ospitali%ation: A 0igh is, 1ime0ospitali%ation: A 0igh is, 1ime

At hospitali5ation4At hospitali5ation4

-E of a#(ission (e#i'ations stoppe#-E of a#(ission (e#i'ations stoppe#

0E of #is'harge (e#i'ations ,ere starte#0E of #is'harge (e#i'ations ,ere starte#Serious pres'ri&ing pro&le(s in ESerious pres'ri&ing pro&le(s in E

Other pres'ri&ing pro&le(s in **EOther pres'ri&ing pro&le(s in **E

B >eers AS 1.@ <ipton Me#i'al Care 1>eers AS 1.@ <ipton Me#i'al Care 1



)onadherence)onadherence

<a'% of un#erstan#ing of ho, to ta%e<a'% of un#erstan#ing of ho, to ta%e B High ris% ti(es4 Hospital #is'harge@ ne, (e#sHigh ris% ti(es4 Hospital #is'harge@ ne, (e#s

a##e#@ 'o(ple9 regi(ensa##e#@ 'o(ple9 regi(ens

?na&le to ta%e?na&le to ta%eCons'ious nona#heren'eCons'ious nona#heren'e B Si#e effe'tsSi#e effe'ts

B <a'% of un#erstan#ing of &enefits of #rug<a'% of un#erstan#ing of &enefits of #rug B inan'ialinan'ial

Complementary TherapiesComplementary Therapies



Complementary TherapiesComplementary Therapies

Very commonly used in the elderlyVery commonly used in the elderly'ome common herbs and alternati+e therapies:'ome common herbs and alternati+e therapies:

B Anti*agingJ Anti*agingJ D0EA- growth hormoneD0EA- growth hormone

B DementiaDementia $ing,o biloba$ing,o biloba

B "&0"&0 'aw palmetto- &;*'&E''aw palmetto- &;*'&E'

B (A(A ;hondroiton sulfate-;hondroiton sulfate-

glucosamineglucosamine

B DepressionDepression 't. Kohn<s wort- 'AMe't. Kohn<s wort- 'AMe



Adulterants in &roducts Adulterants in &roducts

California Depart(ent of HealthCalifornia Depart(ent of HealthSer8i'es@ oo# an# Drug >ran'hSer8i'es@ oo# an# Drug >ran'h B s'reene# 0- Asian her&al pro#u'tss'reene# 0- Asian her&al pro#u'ts

B'olle'te# fro( her&al stores in California'olle'te# fro( her&al stores in California

B assaye# pro#u'ts using gas 'hro(atography@assaye# pro#u'ts using gas 'hro(atography@(ass spe'tro(etry@ an# ato(i'6a&sorption(ass spe'tro(etry@ an# ato(i'6a&sorptionte'hni:ueste'hni:ues

B =o@ N;M 1.7 ))7 .2=o@ N;M 1.7 ))7 .2

)E 'ontaine# unla&ele# (e#i'ations@)E 'ontaine# unla&ele# (e#i'ations@1E (er'ury@ 1E arseni'@ 1-E lea#1E (er'ury@ 1E arseni'@ 1-E lea#

0erbals and 'upplements:0erbals and 'upplements:



egulationegulation

Demonstration of safety is )(1 reGuired prior toDemonstration of safety is )(1 reGuired prior tomar,etingmar,eting

Manufacturing standards are not reGuiredManufacturing standards are not reGuired

;an ha+e;an ha+e healthhealth claims- but not claims aboutclaims- but not claims abouttreating- pre+enting- or curingtreating- pre+enting- or curing

For glucosamine/chondroitin- on third ofFor glucosamine/chondroitin- on third of

combinations did not contain listed ingredientcombinations did not contain listed ingredient

www.consumerlabs.com has some drugwww.consumerlabs.com has some drug

informationinformation

0erbals and 'upplements:&otential0erbals and 'upplements:&otential



pppp

interactions with x Drugsinteractions with x Drugs

SAMe (ay in'rease ho(o'ysteineSAMe (ay in'rease ho(o'ysteine

le8elsle8els

St+ ohnJs ,ort an# Oral 'ontra'epti8esSt+ ohnJs ,ort an# Oral 'ontra'epti8es

in%go (ay in'rease anti'oagulantin%go (ay in'rease anti'oagulant

effe'ts of ASA@ ,arfarin@ NSAIAs@effe'ts of ASA@ ,arfarin@ NSAIAs@

ti'lopi#ine@ an# (ay intera't ,ith MAOIsti'lopi#ine@ an# (ay intera't ,ith MAOIs

>otto( line4 Try to %no, ,hat your>otto( line4 Try to %no, ,hat your

patient is ta%ing@ an# as% in apatient is ta%ing@ an# as% in a

nonFu#g(ental ,aynonFu#g(ental ,ay

& i i M (b t& i i M (b t



&rinsip Manaemen (bat&rinsip Manaemen (bat

iwayat pema,aian obat yang leng,ap-iwayat pema,aian obat yang leng,ap-termasu, obat herba/tradisional/obat bebastermasu, obat herba/tradisional/obat bebas

0indari pemberian obat bila0indari pemberian obat bila,euntungan/benefit ,ecil - atau ada alternatif,euntungan/benefit ,ecil - atau ada alternatif

pengobatan non*farma,ologispengobatan non*farma,ologis&ertimbang,an harga&ertimbang,an harga

'tart low- go slow- but get thereP'tart low- go slow- but get thereP

"uat cara pemberian yang sederhana"uat cara pemberian yang sederhana1ulis cara pema,aian seelas mung,in1ulis cara pema,aian seelas mung,in

Minta penderita membawa seluruh obat yangMinta penderita membawa seluruh obat yangsedang diminum setiap ,ali peri,sasedang diminum setiap ,ali peri,sa



&rinciples continued!&rinciples continued!

&ertimbang,an pema,aian ,ota, obat harian&ertimbang,an pema,aian ,ota, obat harianatau medisetJatau medisetJ

0enti,an pema,aian obat yang tida, elas0enti,an pema,aian obat yang tida, elas

,euntungannya atau resi,o efe, sampingnya,euntungannya atau resi,o efe, sampingnya

lebih merugi,anlebih merugi,an

0ati*hati pema,aian obat baru newer drugs!0ati*hati pema,aian obat baru newer drugs!

0indari penggunaan obat 4 macam0indari penggunaan obat 4 macam

;onsider if the benefit of the 2th or 6th drug is;onsider if the benefit of the 2th or 6th drug issufficient to ustify the cost- increase insufficient to ustify the cost- increase in

complexity of regimen- and ris, of side effectscomplexity of regimen- and ris, of side effects

)ewer drugs)ewer drugs



gg

$hat is uni:ue a&out this 'o(poun#K$hat is uni:ue a&out this 'o(poun#K

$hat 'lini'al #ata is a8aila&leK$hat 'lini'al #ata is a8aila&leK

Ho, #oes it 'o(pare ,ith tra#itionalHo, #oes it 'o(pare ,ith tra#itional

therapyKtherapyK

Ho, e9pensi8e is itKHo, e9pensi8e is itK

$ith thir# party payers 'o8er this$ith thir# party payers 'o8er this

pro#u'tKpro#u'tK

Does the potential a#8antage of this ne,Does the potential a#8antage of this ne,

#rug Fustify the ris% of using a ne, #rugK#rug Fustify the ris% of using a ne, #rugK

1h M f 1 d1h M f 1 d



1he Message for 1oday1he Message for 1oday

'tart low'tart low

$o slow but get to therapeutic le+els!$o slow but get to therapeutic le+els!

'ometimes say no how about other non*drug'ometimes say no how about other non*drugtreatmentsH!treatmentsH!

Obat Pada Anak & Manula

Documents

Transcript of Obat Pada Anak & Manula