Seleski obat PPDGS 1

7/30/2019 Seleski obat PPDGS 1

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Rational Medicine Use

Medicine Selection

Rustamaji

Centre for Clinical Pharmacology and Medicine PolicyGadjah Mada University

2011


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Objective

After attending this lecture, students are expected to be

able to:

1. Explain the steps in therapeutic process

2. Explain drug selection based on safety, efficacy, suitabilityand cost


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Six steps oftherapeutic decision process

Step 1: Define the patients problem

Step 2: Specify the treatment objectiveStep 3: Select the intervention

Step 4: Start the treatment

Step 5: Give information to the patientStep 6: Monitor (or stop?) treatment

(WHO, 1994)


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Step 1:

Define the patients problem


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Patient presents with a complaint or a problem.

To treat patient, physician should make a right

diagnosis Right diagnosis based on the complaint as describe

by patient, a detailed history, physical examination,laboratory tests, X-ray and other investigation

Patient complaints are mostly linked to symptoms(is not diagnosis)


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Sore throat complaint (1)

Man, 54 years, complaint severe sore throat.No general symptoms, no fever, slightredness of throat, no their finding

Man 43 years, compliant sore throat, slight

redness on the throat, no fever, no otherfinding. Medical record mentions that hesuffers from chronic diarrhea.


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Sore throat complaint (2)

Pt 1. His complaint probably results from aminor viral infection

Pt 2. Physician should refers to medicalrecord. Pt received loperamide to treatchronic diarrhea. This drug may producereduced salivation and dry mouth as adverse

event. Pt suffer AIDS ?


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Disease or disorder (diagnosis)

Sign of underlying disease

Psychological or social problems, anxiety

Side effect of drugs Refill request (polypharmacy)

Non-adherence to treatment

Request for preventive treatment Combination

Physician formulation may different with patient perceives


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Step 2:

Specify the treatment objective


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Specify the therapeutic objective

Woman 19 years, student. Complaint of asore throat. Slight redness of the throat, noother findings. After some hesitation she tellyou that she is three month overdue. Onexamination, she is three months pregnant

Sore throat by viral infection?

Problems on pregnancy?

Patient need a drugs?


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Specify the therapeutic objective

Therapeutic objective sometimesstraightforward, sometimes less clear.

Therapeutic objective can

Make physician concentrate on the realproblem

Prevent a lot of unnecessary drug useAvoid unnecessary prophylactic drugs

Discuss your therapeutic problems with patient


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Step 3:

Select the intervention


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Select the intervention

Make the inventory of possible treatments

Information or advice

Treatment without drugs Treatment with a drug

Referral

Combination


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Selection of the medicines

Medicines should effective, safe, suitable topatient and cheaper

Effective: please check to the referencestandard to looking for the EBM

Safety : check the side effects and frequencyof side effects

Suitability : check the contraindication of thedrug

Cost: check the total cost not only the price


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Efficacy of drug

Data Pharmacodinamic

Data pharmacokinetic (ADME)

Compare the dosage and formulation onabsorption, distribution, metabolism,excretion

Efficacy should be supported by good clinicaltrial with control


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Safety

Side effects

Toxic effects (depend on dug concentration)

If possible list he incidence of side effect

Unpredictable side effect (allergic reaction)may be caused by drugs


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Suitability

Contraindication of drug related by patientcondition (renal failure, hepatic disorder,

history of allergic reaction, other disease,other drugs (possibility of interaction))

Change of patient physiology (pregnancy andlactation, extreme age)


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Suitability

Are the active substance and dosage formsuitable for this patient?

Is the standard dosage suitable for thispatient?

Is the standard duration of treatment suitablefor this patient?

Pharmacokinetic data


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Cost

Check the cheaper drug

Discuss with the patient about the drug price


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DRY COUGH


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Six steps on dry cough

Problem : Dry cough

Objective: reduce the symptoms

Intervention:

Non Drug treatment? Drugs/medicines

opioid cough suppressant

Sedative antihistamine

Start the Tx:

Information and advice: Mucous membrane will not heal due to the cough

Avoid the further irritation (smoking, traffic exhaust fume

Refer if:

Monitoring and evaluation:


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Selection of medicines

Patient suffer dry cough that can be veryinconvenient

Suppressing for a few day may have abeneficial effect

Many cough preparation available in themarket


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Select the medicines of Dry cough

Opioid cough depressant

Codein, noscapine, dextromethorfan

Morphine, methadone

Effective to suppress the cough reflex

Allows the mucous membrane to regenerate

Side effects are constipation, dizziness andsedation, depress respiratory center


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Select the medicines of Dry cough

Sedative antihistamine

diphenhydramine

The efficacy is disputed

Side effects are drowsiness


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Step 4:

Start the treatment


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Start the treatment

Write a prescription Codein 30mg 3 x daily

Prescription is an instruction from a prescriber to adispenser

Information on prescription Name and address of the prescriber with

telephone number

Date of prescription

Name and strength of the drug Dosage form and total amount

Information for the package insert

Signature or initial

Patient identity


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Step 5:

Give information to the patient


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Give informationInstruction and warning

Effect of the drugs

Why the drug is needed

Which symptoms will disappear, and which not

When the effect is expected to start

What will happened if the drug is taken

incorrectly or not at all


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Side effects

Which side effect may occur How to recognize them

How long the will continue

What action to take


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Instruction

How the drug should be taken When it should be taken

How long the treatment should continue

How the drug should be stored What to do with left-over drugs


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Warnings

When the drug should not be taken What is the maximum dose

Why the full treatment course should betaken


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Future consultation

When to come back (or not)

In what circumstances to come earlier

What information the doctor will needed at

the next appointment

f


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Everything clear ?

Ask the patient whether everythingunderstood

Ask the patient to repeated the mostimportant information

Ask whether the patient has any morequestion


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Step 6:

Monitor (or stop?) treatment


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Monitor and stop the treatment

Was the treatment effective ?

Yes and disease cured

Stop the treatment Yes but not yet completed

Any serious effect?

No : Treatment can be continued

Yes : reconsider dosage or drug choice

No : check your all steps


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Drug Selection ofangina pectoris


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Case : Angina pectoris

Problems:

Angina pectoris is a symptom

Divided to classic and variant anginapectoris; stable and unstable


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Objective of treatment

Preventive? Treatment?

Pathophysiology:Angina pectoris is caused by imbalance of

oxygen demand and oxygen supply oncardiac muscle


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Objective treatment

As soon as possible to reduce the oxygendemand by:

Decreasing prelaod Reducing he contractility

Reducing the heat rate, and

Reducing the afterload


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Medicines selection

Preload Contractility Frequency Afterload

Nitrates ++ - - ++

Beta-blocker + ++ ++ ++

Ca-channel blocker + ++ ++ ++

Site of action


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Medicines selection

Efficacy Safety Suitability Cost

Nitrates + ++ +

Beta-blocker + - -

Ca-channel blocker + - -

GNT Tab/spay + ++ +

Isosorbide dinitrate tab + ++

Isosorbide mononitrate + ++

(tab)

Conclusion : GNT, sublingual tab 1mg, 1 tab as needed, second tab if pain persists,

duration of use based on results (closed monitor).

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Seleski obat PPDGS 1