SWAMEDIKASI

— Elisabeth Kasih —
 Pasien ke apotek

Mengeluhkan Meminta Membawa

gejala obat resep
Mengeluhkan Gejala

• Lakukan penggalian mendalam ttg gejala

yg dikeluhkan
• Gunakan medical mnemonics
• Putuskan apakah gejala tsb merupakan
gejala penyakit ringan/ kronis
• Jika penyakit ringan  swamedikasi
• Jika ada warning symptoms/ penyakit
kronis  rujuk ke dokter
Pengumpulan Data

Data penyakit Data terapi Lifestyle

• Riwayat penyakit • Riwayat terapi • Faktor sosial–
• Penyakit yg sdg • Pengobatan yg sdg ekonomi
diderita digunakan saat ini • Gaya hidup
• Pemeriksaan fisik • Penggunaan • Kebiasaan
& lab supplemen/ obat
• Kondisi sakit herbal
 Medical Mnemonics
WWHAM ASMETHOD SITDOWNSIR ENCORE
W : Who is the Px? A : Age/ appearance? S : Site/ location? E : Explore
W : What are the S : Self/ someone I : Intensity/ N: No medication
symptoms? else? severity? C : Care
H : How long have M : Medication? T : Type/ nature? O: Observe
the symptoms E : Extra medicines? D : Duration? R : Refer
been present?
T : Time persisting? O: Onset? E : Explain
A : Action taken?
H : History? W: With (other
M : Medication symptoms)?
O : Other symptoms?
being taken?
D : Danger symptoms? N: aNnoyed/
aggravated by?
S : Spread/ radiation?
I : Incidence/
frequency pattern?
R : Relieved by?
Assessment

• Minor illness

• Major problems
K
• Ada alarm/ warning symptoms
• Harus dirujuk ke dokter
Self Medication Area

Pain

Gastrointestinal problems

Common cold & cough

 Warning Symptoms/ When to
Refer
♦ Cough lasting 2 weeks/ more & not improving
♦ Sputum (yellow, green, rusty/ blood-stained)
♦ Chest pain
♦ Shortness of breath
♦ Wheezing
♦ Whooping cough/ croup
♦ Recurrent nocturnal cough
♦ Suspected adverse drug reaction
♦ Failed medication ♦ Failure to respond to antacids
♦ Pain radiating to arms
♦ Difficulty in swallowing
♦ Regurgitation
♦ Long duration
♦ Increasing severity
♦ Children
 Medication Used for Dypepsia
Drug
Medicines Children Side Effects Exercise Care Pregnancy
Interactions
Antacids
Sodium > 12 years None None Heart disease Can be used
Tetracyclines,
Calcium Constipation None Can be used
quinolones
Magnesium Heart disease None
Not
Aluminium None
recommended
Alginate > 6 years None None Heart disease None
Diarrhea,
Not
H2-blocker > 16 years constipation, None None
recommended
headache
Diarrhea, Agents
Severely ill,
Short-term constipation, metabolized Not
PPI gastric
use nausea, in the liver, recommended
malignancy
vomiting, etc. etc.
 Perbandingan Efektivitas

Obat Onset Durasi Aturan Pakai

Antasida < 5 menit 20-30 menit 1 jam setelah makan

30 menit s/d 1 jam sblm

H2-blocker 30-45 menit 4-10 jam
makan

H2-blocker +
< 5 menit 8-10 jam
antasida

PPI 2-3 jam 12-24 jam 30 menit sebelum makan

Warning Symptoms/ When to
Refer

♦ Diarrhea greater than:

1 day’s duration  in children < 1 year
2 day’s duration  in children < 3 year & elderly
3 day’s duration  in older children & adults
♦ Association with severe vomiting & fever
♦ Recent travel abroad
♦ Suspected drug-induced reaction to prescribed medicine
♦ History of change in bowel habit
♦ Presence of blood/ mucus in the stools
♦ Pregnancy
 Warning Symptoms/ When to
Refer

♦ Headache associated with injury/ trauma

♦ Severe headache of > 4-h duration
♦ Suspected adverse drug reaction
♦ Headache in children < 12 years
♦ Severe occipital headache (across the back of the head)
♦ Headache that is worse in the morning & then improves
♦ Associated drowsiness, unsteadiness, visual disturbances
of vomiting
♦ Neck stiffness
♦ Frequent migraines requiring prophylactic treatment
♦ Frequent & persistent headaches
 Patient with complaint of
headache
Assess patient & the pain.
Obtain medical & medication
history. Ask about attempted
treatments
Exclusions for self- Yes
treatment (see box)
No
Analgesic used for headache Yes
> 3 days per week?
No
Diagnosed migraine/ Yes
symptoms typical of sinus
or tension-type headache?
Yes
Recommend appropriate
non pharmacologic &
pharmacologic therapy
Exclusions for Self-Treatment
♦ Severe head pain
♦ Headaches that persist for 10
days with/ without treatment
♦ Last trimester of pregnancy
♦ < 8 years of age
♦ High fever/ signs of serious
Medical referral infection
♦ History of liver disease/
consumption of ≥ 3 alcoholic
Decrease analgesic drinks per day
use over a few days, ♦ Headache associated with
medical referral if underlying pathology (2nd
headache persists
headache)
♦ Symptoms consistent with
migraine but no formal
Medical referral diagnosis of migraine headache
Prinsip Terapi Analgesik

• Ketahui frekuensi, durasi, kejadian &

etiologi nyeri
• Jika disertai dg nyeri tulang  NSAID
digunakan secara rutin
• Upayakan penggunaan obat hingga dosis
max sebelum beralih ke langkah
selanjutnya (kec nyeri benar-benar tdk
terkendali)
• Jika nyeri terjadi rutin  berikan obat
pd jam-jam terjadi nyeri
Referensi

• Daftar Obat Wajib Apotek, Daftar Obat Bebas & Bebas

Terbatas
• Textbook:
• Blenkinsopp A, Paxton P, Blenkinsopp J. Symptoms in the
Pharmacy: A Guide to the Management of Common Illnes, 6th
Ed. 2009. Wiley-Blackwell.
• DiPiro JT, et al. Pharmacotherapy: A Pathophysiologic
Approach. 2014
• Guideline:
• Antman EM, Bennett JS, Daugherty A, et al. Use of Non
Steroidal Anti-inflammatory Drugs: An Update for Clincians.
Circulation, 2007; 115: 1634-1642.
• Related clinical guidelines
• Journal:
• Wedemeyer RS, Blume H. Pharmacokinetic Drug Interaction
Profiles of Proton Pump Inhibitors. Drug Saf (2014) 37: 201-211
Meminta Obat

• Show & tell

• Lakukan penggalian tentang:
• Asal info yg diperoleh pasien ttg obat tsb
• Jika sdh pernah menggunakan obat tsb 
tanyakan efektivitas obat thd keluhan
pasien
• Jika terkait gejala  lakukan penggalian
lebih lanjut utk gejala tsb (gunakan medical
mnemonics)
Membawa Resep

• Pasien datang utk menebus R/ dr dokter

• Menggali data  3 prime questions:
• Apa yg dokter katakan ttg obat Anda?
• Bagaimana kata dokter ttg cara
pemakaiannya?
• Apa harapan dokter ttg terapi obat Anda?
• Lanjutkan assessment data lengkap
pasien yg relevan utk penilaian terapi
obat
Pertimbangan

Status
Obat Pencegahan
Kesehatan
• Ketepatan • Faktor resiko • Tindakan
• Efektivitas pasien pencegahan
• Keamanan • Pengetahuan yg perlu
pasien dilakukan
• Kepatuhan Px
(compliance)
Drug Therapy Problems (DRPs)

• Semua kejadian yg tidak diharapkan yg

dialami oleh pasien (yg diduga/ melibatkan
terapi obat) & mengganggu pencapaian
tujuan terapi
Drug Therapy Problems (DRPs)
Unnecessary drug therapy
Need for additional drug therapy
Ineffective drug
Dosage too low/ high
Adverse drug reactions
Drug interactions
Non compliance
Main Types of ADR

Type Definition
The patient over-reacts to the drug  the desired effect is much
Type A
more than reasonable expected

The patient has an idiosyncratic reaction (sometimes termed bizarre

Type B effects)  these tend to be totally unpredictable & not related to
the dose of drug given

The patient shows a deteriorating drug response  when a drug is

Type C given for a long time for a chronic disorder (such as arthritis), the
desired effect gradually wears off

Type D The ADR only occurs in the patient after long term drug use

Type E These occur after drug treatment has been discontinued

 Main Types of ADR

Type of Type A Type B Type C Type D Type E

ADR (Excessive) (Idiosyncratic) (Chronic) (Delayed) (Subsequent)
Drug
Headache
Diarrhea Bacterial High Mg Dependency on
Anti-ulcer drugs (PPI) Fatigue
Abdominal pain infection serum level further dosage
B12 deficiency
Raised
Abdominal pain Insomnia Hepatitis
Anti-retrovirals cholesterol
Diarrhea Headache Anemia Liver failure
(protease inhibitor) Ingrown nails
Flatulence Mood swings Skin rash
Gynecomastia
Headache Hyperkalemia Persistent cough
Anti-hypertensive agents
Hypotension Dizziness Renal Congenital
(ACE-inhibitor)
Fatigue impairment abnormalities
Anti-asthma drugs Deterioration of
Tachycardia Effects on the heart
(Bronchodilators) lung function
Eye damage Peptic ulcer
Anti-inflammatories Osteoporosis
Hypertension Depression Hypogonadism Osteoporosis
(Corticosteroids) Skin damage
Anxiety Hypothyroid
Interaksi Obat

• Perubahan efek suatu obat karena adanya

pengaruh obat lain, obat herbal/
supplemen, ataupun makanan
• Interaksi obat dapat terjadi pd fase:
• Absorpsi
• Distribusi
• Metabolisme
• Ekskresi
Absorpsi
Metabolisme
Ekskresi
Penentuan DRPs

• Berdasarkan evidence based medicine

• Penentuan obat yg paling efektif utk suatu
kondisi tertentu
• Melihat angka kejadian/ insiden DRPs utk suatu
golongan obat tertentu
• Farmakologi & farmakodinamik
• Melihat respon tubuh thdp obat
• Farmakokinetika
• Melihat profil obat di dalam tubuh
Penentuan Goal of Therapy

Goal of Therapy Kondisi Medis

Menyembuhkan penyakit Diare

Mengurangi gejala Rhinitis alergi, common cold

Diabetes mellitus, hipertensi (pada

Memperlambat perjalanan penyakit
umumnya penyakit-penyakit kronis)
Osteoporosis, penyakit jantung
Mencegah timbulnya penyakit
coroner

Normalisasi data laboratorium Anemia, hypokalemia, hipoalbumin

Penentuan Goal of Therapy

Parameter (Tujuan Jangka Waktu

Farmakoterapi)

Waktu yg dibutuhkan utk

Perbaikan gejala klinis mencapai tujuan

Perbaikan pd data lab/ Waktu yg dibutuhkan utk

pemeriksaan fisik mengukur perbaikan