Dangerous doctor in pain management.ppt

8/20/2019 Dangerous doctor in pain management.ppt

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2 December 1951Bukit Tinggi

PhD in Clinical PharmacologyFUSA-Flin er! "e ical CentreAu!tralia# 19$$

Pro%e!!or &ea o% De'artmentPharmacology ( Thera'euticSchool o% "e icine# USU

)ln* Tri harma 22+am'u! USU# "e an

S'F+# Clinical Pharmacologi!tPB-,D, ( F+ U,# 1995

"D# F+ USU# 19 $

.mail/ a0nanlelo yahoo*com


2/54

Aznan Lelo

Dep. Farmakologi & Terapeutik, Fakultas Kedokteran

Universitas SumateraUtara

ktober 2311 + 4+. ,PS )akarta


3/54


4/54

Rajin-rajin belajar ya nak,

supaya pintar dan jadi


5/54


6/54

+ata orang

• Mereka semua ter-lahir 'intar danbaik ,

• Namun selanjutnya jadi bo oh dan 6ahat .

• Lalu dimana kesempatan itu?


7/54

Ba aya "an#erous

"o$to"o$torr

drugtherapy

patient

Doctorshopping

Riskfactors etc

RDA

Surgery

etc

OTC

er!almed.

etc


8/54

%A&R'()*%K %A&R'()*%K +iatro dokter+iatro dokter


9/54

Sakit ke'ala

Sakit gigi

Bi!ulan

4yeri hai

ematik

7out

Pon!tan

8oltaren

Femina

,rga'anCelebre

4o:algin

Dangerou!Dangerou!

Doctor ;Doctor ;


10/54

4yeri bahu

4yeri 'inggang

4yeri lutut

4yeri tumit

yang 'enting hilangkan 4


11/54

Sakitgigi

A!amme%enamat

PegalPegal>inu>inu

4yeri4yeribi!ulbi!ul

4yeri4yerihaihai

4yeria a

etc#etc#etc#etcetc#etcetcetc

Sakit ;Sakit ; SakitSakitin-'artuin-'artuA!amme%enamatA!amme%enamatA!amme%enamatA!amme%enamatA!amme%enamatA!amme%enamatA!amme%enamat


12/54

Sakit ke'ala

7atal

Se!ak

"enceret

Tak bi!ati ur

CT"

Salbutamol

,mo ium

Dia0e'am

Trama ol

Cam'uran yangCam'uran yang

mematikanmematikan


13/54

Sakit ke'ala

Sakit gigi

Bi!ulan

ematik

7out

Pon!tan

8oltaren

,rga'anCon%orti

4o:algin

Su ah keluargakumati

Uangku 'ula yanghabi!

'

'

'

''


14/54

Dangerous personWishing to eliminate apresident of anothercountry

om!ing all areas of

the country"illing the people inthat country

#pending 23 " US?

ut then offering only233#333 US? to $homcould !ring the head of

the president

Wishing to eliminate asign or symptom of adisease%i&ing an e'pensi&edrug ( polypharmacy)ncreasing *D+s (iatrogenic disease#pending a lot of

moneyut it cloud !e theno&ercome !y thecheapest drug


15/54

Dangerou! octor!

octor! are

the thir lea ingcau!e o% eath in the US#

cau!ing 253#333 eath!e:ery year

http $$$.mercola.com /// jul 0/ doctors1death.htm


16/54

Doctor! :er!u! 7un! in the U*S#1999 #ome #tartling #tatistics

http $$$.concealcarry.org DangerousDoctors.htm

Parameter Doctor! 7un@ner!4umber o% 'er!on 33#333 $3#333#333

Acci entaleath! year 123#333 1#533

Acci ental eath! 'er2doctor3 or 2gun o$ner3 3*1 1 3*33331$$

octor! are appro'imately9#333 time! more angerou! than gun o@ner!


17/54

the number o% 'eo'le @ho ie

a! a re!ult o%/"e ical mi!take! kill almo!t 133#333Acci ent! a :er!e e%%ect! 9 #333 #4neumonia and influen5a 267,///3,Dia!etes 270,///3,#uicide 208,///3, or"idney disease 2 9,///3 - and

certainly far more than in automo!ileaccidents, as the result of homicide or othercrimes, *)D#, etc.

http ash.org dangerous-doctors.html


18/54

Eho i! the angerou! octor;• Does not kno$ that he or she kno$s nothing

: Looks like kno$ing e&erything, !ut kno$s a fe$only

: Does not kno$ ho$ to manage the patientproperly, rational prescription 2i.e, polypharmacy3

• Does not cure the disease !ut create the ne$illness 2iatrogenic disease3 : Does not treat the patients !ut referring them to

be buried , 2i.e., careless in the safety of medicine3

: *l$ays $orse the patient;s emotion ( pocket•


19/54

&o@ oe! !omeone becomea angerou! octor;

• drug companies greatly influence doctors;prescri!ing ha!its

• family doctors are more likely to rely on

information supplied !y drug manufacturersrather than on information from independentsources

• *!out =/ percent of %4s regarded drug

representati&es as an efficient $ay to o!tainne$ drug information

• information may !e misleading, !iased orinaccurate

Family Practice )anuary 23/ 1-$#233G


20/54

Someone @ho /al@ay! 're!cribe H angerou! rugI

an agent @ith :ariou! a :er!e e%%ect!

oe! not care to/ the con ition o% 'atient treate the in ication o% rug 're!cribe the !a%ety o% rug a mini!tere the kinetic! o% rug a mini!tere the co!t o% rug a mini!tere the rug interaction the correct an clear rug 're!cri'tion

Eho i! the angerou! octor;


21/54

A :er!e rug reaction !ur:eillance in 'e iatrican a ult 'atient! in an emergency room

Muno5 et al. Med >lin 2 arc3 888203 -6,8 6

Drug! Chil ren A ult!4SA,D 13*JK 2$*2K

C8 rug! ; 15*9KAntimicrobial! J9*5K 1J*5K

7,T rug! ; 11*1Ke!'iratory rug! 19*9K ;

8accine! 9*2K ;

al@ay! 're!cribe H angerou! rugI

4SA,D AD -relate ho!'itali0ation!

Coo'er )E* #outh Med @ 293 A69- /,8


22/54

o not care ==========*to the con ition o% 'atient treate

Age chil ren# el erly# nur!ing @omenConcomitance i!ea!e!

Poly'harmacy"any octor! in:ol:eChil ren are not a ult! in !mall !i0e

.l erly al@ay! ha:e 'harmacological'roblem!Pre!cribing Ca!ca e i! the commoncau!e o% 'oly'harmacy in el erly


23/54

Critical a''roache!in !electing me icine!

Thera'eutice%%ect

A :er!e reactionMinimal Ma'imal

Ma'imal >.ST2-J

Bhere are t$o reasons to $ithdra$ from the treatment eitherno e%%icacy 244T &ery high3 or

!eriou! a :er!e reaction! 244& &ery lo$3.


24/54

W i t h d r a $

a l 2

C 3

55K

2GK

d i s c o n

t i n u a t

i o n r a

t e 2 C 3

19 K

9 K

2*G K3* K

&enti tera'ikarenati ak

mera!akane%ek tera'i

&enti tera'i

karenamera!akane%ek !am'ing


25/54

number needed to treat +**& or at least ./0pain relie over 1-2 ours in patients 3itmoderate to severe pain, all oral analgesics

e"cept morphine, pethidine and ketorolac


26/54

4SA,D adju&ant analgesic

$eak opioid2codeine3

'aracetamolor 4SA,D

adju&ant analgesic

#trong opioid4SA,D

adju&ant analgesic

Princi'le! o% Analge!ic Pre!cribingE& Analge!ic >a er

/ 8 0 A 9 7 = 6 8/

Pain tolerancePain thre!hol

mildmild moderatemoderate se&erese&ere


27/54


28/54

B A,4

Pharmacologic Agent!A%%ect Pain Di%%erently

De!cen ing "o ulation

Central Sen!iti0ationP4S

Anticon:ul!ant!

'ioi !Tricyclic S4 , Anti e're!!ant!C4S

S'inal

Cor

Peri'heralSen!iti0ation

Dor!al&orn

,nhibition o% A!cen ingPain Path@ay!

4SA,D!Antiarrhythmic>ocal Ane!thetic!To'ical Analge!ic!Anticon:ul!ant!Tricyclic Anti e're!!ant!

'ioi !

'ioi !

Al'ha-2 Delta agoni!t!

Anticon:ul!ant!'ioi !4"DA- ece'tor Antagoni!t!Tricyclic S4 , Anti e're!!ant!


29/54

4ild vs Severe 5ain"il Se:ere

Drug Lo$ dose Eigh dose

4otent agent

A$ute vs 6 roni$ 5ain

Acute ChronicDrug +apid onset Long durationDuration o%

'ain#hort, self limiting,$ell-characteri5ed

4ersists after healing,0 months

Com'onent Nocicepti&e Nocicepti&eNeuropathic


30/54

.torico ib# a long hal%-li%e 22 hour! /o!age an e%%icacy

5ainindi$ations

"ose+m#

*ote

6 roni$ pain

OA 7/ 8 2/ Curtis S#, et.al.$%%

A$ute pain'outy arthritis 9:/ (a"imum )

days

Dysmenorrhea 9:/ (a"imum )A$ute 5ain ; Severe 5ain

?? ??


31/54

Slo@ly Chronic

&o@ to change the on!et o%action o% the long hal%-li%e 4SA,D

&ime

6 o n $ e n

t r a

t i o n

)


32/54

o not care ==========*to the !a%ety o% rug a mini!tereThe !a%ety o% rug a mini!tere e'en on/

Ty'e o% rugPharmaco ynamic

Eigher dose, greater effect !ut more to'icPharmacokinetic

Bhe shortest half-life, the safest drugClinical con ition

#e&ere condition, high risk for ad&erse effectsDuration o% a mini!tration


33/54

o not care ==========*

to the !a%ety o% rug a mini!tere

The only AD o%The only AD o%4SA,D i! 7, e:ent4SA,D i! 7, e:ent ;;

:olution in arthriti! management/ %ocu! on C M 2 inhibitor!


34/54

.:olution in arthriti! management/ %ocu! on C M-2 inhibitor!>arlos Faldes, 4harmD, >4#. >linical #cience Manager. 4harmacia >o.

*pril 8A, //


35/54

& e 9/ leadin# $auses o deatas a per$enta#e o all deat s

in t e United States, 9>>/ and 9>>2

#ource >D>, National >enter for Eealth #tatistics

1991993

?@' S i i$ l % i S ?@'S%S


36/54

?@' Statisti$al %n ormation System +?@'S%S*umbers and rates +per-9// /// o

re#istered deat sUnited States o Ameri$a - :///

4o Cau!e 4 ate8 C8S A8.9 A $*5

Malignancy 990./ 8 0 0.A

0 +espiratory disease 867.0A7 80 .9

A 7a!trointe!tinal i!ea!e 6A./89 5$*$9 *ccidents =0.=69 99.8

7 Dia!etes Mellitus 7 .0/8 A .

= )nfectious ( 4arasitic disease 7 .//= A ./

6 #kin ( #u!cutaneous tissue disease 0.=90 .7

Drug, medicaments causing ad&erseeffects in therapeutic use

./9 .8

G Ulcer o% !tomach an uo enum A.9/A G*2


37/54

Adapted from Antman (, et al. Circulation . $%%- // 0/12+3

4leeding 5lcerComplications

Degree of Selecti6ity

4lood #ressure7ncrease

Discontinuation

Throm!osis,(yocardial 7nfarction

, t o r i c o

" i !

C e l e

c o " i !

D i c l o

f e n a

c

R o f e

c o " i !

8 a p r

o " e n

7 ! u p

r o f e n

Discontinuation

6ardiovas$ular Risk (astrointestinal Risk

CO93$ CO93/

& e %mpli$ations o *SA%"Sele$tivity


38/54

Celeco ib :! .torico ibC8 ( enal Sa%ety Pro%ile Bloo 're!!ure change

Hhang @ et al. @*M* //7I 7 878 -0 I #ch$art5 @) et al. J Clin Pharmacol //=IA= 89 8-08

% (%


39/54

*SA%" (%&o i$ity

#enerallyvaries3it al -

li e ot ea#ent4SA,D Diclo%enac 4a'ro en Piro icam

Do!e mg 133 53 23

&al%-li%e hr 1*5 1J 53

A hr fecal !loodloss 2mL3 3*5G N - 3*21 2* N - 2*22 1*1 N - 3* 2

enry, et al. 4(:.2/$0/ 12,$%%% Scharf, et al. Aust 8 ; : (ed

S ortest al -li e

Lo3est(%risk

http://bmj.bmjjournals.com/content/vol312/issue7046/images/large/704601.jpeg


40/54

i!k Factor! o% Ulcer Com'lication! %rom 4SA,D!

Relative risk


41/54

4umber o% i!k Factor! (,nci ence o% Ulcer Com'lication!

Silverstein F) Ann Intern Med 9>>.C9:7D:19->

**@ 9:.**@ ./

**@ 9:

**@ .

i n $ i

d e n $ e o - u

l $ e r

+ 0 ,


42/54

'toto i$

Bron$ ospam 6@F

@epatoto i$ U(%B

Bleedin# *ep roto i$

&o$olyti$Aller#y

6olor blindness

Adverse )


43/54

4yeriengkul

lak!an!ia

A,4S

!t

anta!i a

iareiare

4yeri4yeriulu hatiulu hati

tera'i ikutanSimtom barutera'i+ea aan a@al

+a!ka e 'ere!e'an i klinik 'riba i

kon!ti'a!i

http://images.google.com/imgres?imgurl=www.sla.purdue.edu/academic/fll/JapanProj/FLClipart/Medical/stomachache.gif&imgrefurl=http://www.sla.purdue.edu/academic/fll/JapanProj/FLClipart/Medical.html&h=1097&w=1256&prev=/images%3Fq%3Dstomachache%26svnum%3D10%26hl%3Den%26lr%3D%26ie%3DUTF-8%26oe%3DUTF-8http://images.google.com/imgres?imgurl=health.indiamart.com/gifs2/constipation.jpg&imgrefurl=http://health.indiamart.com/ayurveda/common-problems/constipation.html&h=225&w=180&prev=/images%3Fq%3Dconstipation%26svnum%3D10%26hl%3Den%26lr%3D%26ie%3DUTF-8%26oe%3DUTF-8


44/54

Eipertensi

remato-logis

*)N#

gastro-entero-

logis

misoprostol

serangan%J


45/54

Anti-hy'erten!ion antaci

PA,4

iuretic mi!o'ro!tol

%luiretention

increa!eBP

heartburnPUB

4SA,D

4rescri!ing >ascade4rescri!ing >ascade


46/54

' '

PA,4

' '

%luiretention

increa!eBP

heartburnPUB

4SA,DO '

atrogenic Co!t

A> &.,".D,S.AS.CA4C.

**


47/54

D,C> ",S 5 mg BD

4,".SU>,D. 233 mg BD

4,".SU>,D. 133 mg BD

F.C M,B 25 mg D

".> M,CA" 15 mg D".> M,CA" *5 mg D

,BUP F.4 $33 mg TDS

D,C> F.4AC 53 mg TDS

C.>.C M,B 233 mg DC.>.C M,B J33 mg D

F.C M,B 12*5 mg D

D,C> 53 mg TDS N>an!o'ra0ol 15 mg D

>JM4*+*B)FK >J#B# for 6 D* # BEK+*42in , spent !y the %eneral Medical #er&ices on N#*)D in 8 3

o not care =========**to the co!t o% rug a mini!tere


48/54

Pain in ri!ky 'o'ulation

PAT,.4T 7 UP P .D,CTAB>.P B>."S

a!ies ( )nfants >ommunicationI drug handling

Klderly >oe'isting illnessI drughandling

+espiratorydisease

+espiratory depressionIN#*)Ds ( asthma

+enal ailure Drug handlingI N#*)Ds4regnant $omen Karly closure of ductus

arteriosus


49/54

"ru# a$$umulation2 " / ? / " 2

fek terapeutik ? fek samping o!atChoose the shortest half-life

o not care ==========*to the kinetic! o% rug a mini!tere


50/54

o not care ==========*to the correct an clear rug're!cri'tion

citalopram 2 Cele a O3. a selecti&e serotonin 29-EB3 reuptake inhi!itor

CELEXA Q %orCELEBREX Q;A Ca!e o% "e ication Sam'le .rror

Moyer , #hrading W, urkhart "")nt @ Med Bo'icol 02 3 =, ///


51/54

%lle#ible and3ritin#imagine ha&ing to read this P

Ca'to'ril 25mgR 3

Tab i B,D


52/54

o not care ==========*to the rug interaction 4SA,D N antihy'erten!i:e agent

Morgan ( *nderson. @ >lin Eypertens 9283 90-=, //0in omethacin $orsened the antihypertensi&e effect of enala'ril

hagat ". Kast *fr Med @ =628/3 9/=- , //8

iclo%enac# ibu'ro%en or !ulin ac did not neutralise theantihypertensi&e effect of li!ino'ril %ra&es ( Eunder @ >lin Eypertens 273 0 7-6, ///

$orsening of hypertension !y >JQ- )nhi!itors

"urata et al. @pn >irc @ 7028 3 8// -0,8!ynco'e caused !y N#*)D lo o'ro%en and *>K-inhi!itorimi a'ril

Eay et al. @ Kmerg Med 2A3 0A -9 , //%atal hy'erkalemia related to com!ined therapy $ith a >JQ-inhi!itor ro%eco ib , *>K inhi!itor enala'ril


53/54

• K J• N#*)D is the only analgesic• long- half-life analgesic for an acute pain• Eigh dose analgesic is the sa&est• Don;t care to

: 4atient condition

: 4harmacokinetic : Drug interaction : >ost


54/54

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Dangerous doctor in pain management.ppt