Frequent

Asking & Question

Budi Raharjo
Penerapan Pilot Project Pelayanan Informasi Obat Rumah Sakit Kelas C, RSUD Kota Yogyakarta, 26-28 Mei 2008
 Asking from Doctor - 1

 Tn. K 73 thn MRS dg KU lemah, mual,

muntah min 5 x sehari, 5 hari tidak mau
makan, kencing nyeri, kesadaran turun.
Dx dokter Azotemia (Uremia)+Anemia.
RPD: DM+HT+Retinopati+LVH+CRF,
TB= 150 cm BB= 40 kg. Di RS diduga
Sepsis, masuk ICU butuh Antibiotika hsl
kultur pseudomonas, sensitif gentamisin
 Dokter minta hitung dosis genta CRF
Tanggal 26 Mar’08 3 Apr’08 10 Apr’08
BUN (10-24 mg/dl) 32,0 45,6 45,9
Kreatinin (0,5-1,5 mg/dl) 2,32 2,59 2,57
 Serum Creatinine
(Male 0,6-1,2 mg/dL; Female 0,2-0,4 mg/dL)
 By product of muscle metabolism
 Rate of formation proportional to muscle
mass
 Freely filtered by glomerolus (little
secretion or reabsorption by tubule)
 Indicator of renal function, but…..
 Factor affecting serum creatinine:
 Diet, time of day, age, sex, exercise, drugs
 Caution in unstable renal function or acute
renal disease
 Creatinine Clearance
 Measurement of creatinine clearance give
an estimate of GFR (Glomerular Filtration
Rate)
 Creatinine clearance varies with age, sex,
and size
 Measurement:
 Urinecollection
 Cockroft and Gault Equation
Creatinine Clearance
 Normal reference = 120 ml/min
 Renal disorder if: 60 < CrCl < 120 ml/min 
symptomless
 Renal insuficiency:
 Mild  20 – 50 ml/min
 Moderate  10 – 20 ml/min
 Severe  < 10 ml/min
 ESRD  < 5 ml/min
(End State of Renal Disease)
 Urine Collection
 Accurate collection of over 24 hour periode
(note problems with patient compliance)
 Plasma sample midway through 24 hour
periode
U x V
Clcr = -------------
S
U = Urine Creatinine concentration (mg/dL)
V = Urine flow rate (ml/min)
S = Serum Creatinine concentration (mg/dL)
 Cockroft & Gault Equation
F x (140 – age) x IBW
CrCl = ml/min
Serum Cr (mg/dL) x 72
F = 1,23 (males) F = 1,04 (females)
IBW (Ideal Body Weight)
Males
 TB > 152,5 cm IBW = 50 + [(TB - 152,4) x 0,89]
 TB < 152,5 cm IBW = 50 - [(152,4 - TB) x 0,89]

Females
 TB > 152,4 cm IBW = 45,5 + [(TB - 152,4) x 0,89]
 TB < 152,4 cm IBW = 45,5 - [(152,4 - TB) x 0,89]
Limitation of
Cockroft & Gault Equation
Cannot be used if
 Age < 15 years old or age > 90 years old
 Renal function is changing rapidly
 Pregnancy (GFR  + 20 %)
 Serum creatinine > 3 x normal range
 Amputated limb
 Tn. K 73 th, TB= 150 cm BB= 40 kg
 IBW = 50 - [(152,4 - TB) x 0,89]

= 50 - [(152,4-150) x 0,89]
= 50 - [(152,4-150) x 0,89]
= 50 - 2,14 = 47,86 kg > BB = 40 kg
1,23 x (140 – 73) x 40
CrCl = ml/min
2,32 x 72
3.296,4
CrCl = = 19,73 ml/min
167,04
 Dosage Adjustment
DRrf = DRn x [(1 - Feu) + (Feu x RF)]
Patient creatinine clearance (ml/mnt)
RF =
Ideal creatinine clearance (120ml/mnt)
• DRrf = Dosing Rate in renal failure
• DRn = Dosing Rate in normal state
• RF = the extent of Renal Failure
• Feu = Fraction of drugs normally excreting unchage
in the urine
 Dosage Adjustment
Patient creatinine clearance (ml/mnt)
RF =
Ideal creatinine clearance (120ml/mnt)
19,73 ml/mnt
RF = = 0,17
120 ml/mnt
DRrf = 160 x [(1 - 1) + (1 x 0,17)]
= 160 x 0,17 = 27,2 mg/hari
 2 x 13,6 mg injeksi i.v.
Feu Gentamisin = 1
 Asking from Doctor - 2

 Tn D, 82 th, 50 kg TB 163 cm, MRS dgn

DM Hipoglikemi, di RS GDA fluktuatif.
Dokter bingung krn kadar kalium turun
terus meski sdh dikoreksi injeksi KCl i.v.
 Tidak minum obat DM, Riwayat Batuk
dan Sesak nafas. Foto Thorax tampak
infiltrat paru. Terapi : Aminofilin drip,
terbutalin oral. Di RS kesadaran turun
 Reff.: Drugs induce hypokalaemia 
Aminofilin, agonis beta-2 (terbutalin)
 Asking from Doctor - 3

 Ibu Tatik 22 tahun sedang hamil 2 bulan,

akan menjalani operasi insisi bisul di
lengan kanannya. Dokter bedah konsul
kpd Farmasis karena dia membutuhkan
antibiotika profilaksis bedah & analgetika
untuk pasien ini.
 Apa rekomendasi anda sebagai farmasis
utk kasus ini?
 Drug Safety & Selection
Drug Class During Pregnancy During Lactation
Analgesic Acetaminophen Acetaminophen
Anticoagulant Heparin, LMWH Heparin, Warfarin
Anticonvulsant Phenobarbital Carbamazepin/Etho-
suximide/Valproic
Antidiabetic Insulin Insulin,Tolbutamide
Antihypertensi Methyldopa ACEI/Ca-antagonist
Anti-infection Penicillin/Cephalo- Penicillin/Cephalo-
sporin sporin
LMWH: low molecular weight heparin; ACEI: Angiotensin Converting Enzyme
Inhibitor
 Drug Safety & Selection
Drug Class During Pregnancy During Lactation
Corticosteroids Prednisone Prednisolone
Decongestan Oxymetholazide Oxymetholazide
drop/spray drop/spray
GI protection MgOH, AlOH,Ca- Sucralfate,famotidin
carbonat,ranitidin,
sucralfate

Laxative/Stool Psyllium/docusate Psyllium/docusate

Softener
MgOH= Magnesium Hydroxida; AlOH= Aluminium Hydroxida
 Question from Patient

 Ibu EK 38 th, guru SD, keluhan sesak,

lemas, berdebar-debar. DX dokter CHF,
mendapat resep:
R/ Digoxin VII
S 1 dd ½
R/ Diazepam 2mg XV
S 3 dd 1
 Sedang menyusui anaknya yg berumur 3
bulan bagaimana rekomendasi anda ?
 Pendekatan utk Minimalisasi Expos bayi
1. Tidak Minum Obat;
Obat Obat sakit kepala, obat flu, dpt
dihindari dg kerjasama ibu,
2. Tunda Pemberian Obat; Obat jika ibu ada rencana utk sapih
ASI, maka obat/operasi elektif dapat ditunda
3. Pilih obat yg sedikit diekskresikan dlm ASI;
ASI utk klas
terapi yg sama, pilih yg paling sedikit melewati ASI.
4. Pilih alternatif rute pemberian lainnya;
lainnya utk kurangi
konst.obat dlm darah ibu maka digunakan sediaan lokal
5. Minum obat sebelum bayi tidur lama; lama berguna utk obat
long acting yg diminum sekali sehari
 Pendekatan utk Minimalisasi Expos bayi
6. Tidak menyusui bayi pd saat konstr. obat dlm ASI
maksimal;
maksimal scr umum konstr.obat dlm ASI capai maks.: 1-
3 jam setelah dosis oral sang ibu, menyusui tepat
sebelum minum obat hanya u/ obat dg t½ pendek.
7. Berhenti menyusui;
menyusui bila demi kesehatan ibu & utk obat
yg sangat toksis (khemoterapi kanker).
8. Tidak menyusui bayi utk sementara waktu;
waktu bila digunakan obat
jangka pendek stlh prosedur operasi. ASI dipompa (tapi dibuang)
slm terapi tetap dilakukan utk jaga aliran ASI. ASI dpt diberikan
stlh 1-2 x t½ eliminasi obat (50-75% tereliminasi). Utk obat yg
sangat toksis, ASI diberikan stlh 4-5 kali t½ (94-97% obat telah
tereliminasi