NILAI LAB. Hemoglobin : M < 13 g/dL dan F < 12 g/dL Hemoglobin Jumlah Hb per unit volume whole blood Hematokrit Volume hct per unit volume whole TERAPI FARMAKOLOGI blood RBC Jumlah hct unit volume whole blood Iron Deficiency Anemia (IDA) MCV Mean Corpuscular Volume Lab Serum iron dan ferritin << Rata-rata volume RBC (Hct/RBC count) TIBC >> MCH Mean Corpuscular Hemoglobin Tx Ferrous sulfate 100-200 mg Persentase colume Hb dalam RBC (Hb/RBC count) (200 mg FS = 65 mg besi elemental) Serum iron Kons. besi yg berikatan dg transferin Penyerapan terbaik sebelum makan TIBC Total Iron-Binding Capacity Profilaksis = 1-2dd 1tab An indirect measurement of the iron- (anak > 6 tahun 0,5-1 tab <6 tahun 0,25-0,5 tab) binding capacity of serum transferrin Terapi = 3dd 1 tab Transferrin (Serum iron/TIBC) x 100 Monitor 100-200 mg / ml (0,1-0,2 g/dl) per hari saturation Serum Ferritin Jumlah besi yg disimpan dalam liver, atau 2 g/dl dalam 3-4 minggu spleen dan bone marrow cells Hb & Hct per minggu (Best indicator of iron deficiency) ES Mual dan tinja berwarna berubah Erythropoietin Healthy individuals require 10 to 30 level milliunits/mL of EPO to maintain Anemia Megaloblastik normal Hb and Hct concentrations Lab Vit B12 (<150 pg/ml) / folate deficiency MCV tinggi (100-140 fL) dan normal Hct << Tx Vit B12 dan asam folat Folic Acid Deficiency Tx Asam folat 1-5 mg/hari Anemia Chronic Disease Lab MCV rendah Serum ferritin normal atau tinggi TIBC rendah Tx Besi oral maupun PI tidak efektif Rekombinan: Epoietin alfa 50-100 IU/kgBB 3x /mgg Darbepoietin alfa Monitor Hb tiap 2 minggu (target 11-12g/dl) Iron,TIBC, transferrin saturation, ferritin level
KLASIFIKASI ANEMIA Makrolitik defisiensi vit B12 dan asam folat Mikrositik defisiensi besi dan sickle cell anemia Normositik blood loss, hemolisis, bone marrow failure, dan anemia chronic disease
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DIABETES MELITUS NILAI LAB. 6,5-7,5% monotherapy Hiperglikemia 7,6-9% dual therapy HbA1C ≥ 6,5% > 9% insulin or triple therapy GDP ≥ 126 mg/dl (no caloric intake for at least 8 h) GD2PP ≥ 200 mg/dl GDA ≥ 200 mg/dl Insulin Secretagogues Hipoglikemia SULFONILUREA GDA < 70 mg/dl moA Merangsang sekresi insulin di kelenjar pankreas Korelasi HbA1C dan GDP Efek glikemik Fasting & prandial ES Hipoglikemik, peningkatan BB, mual, diare, leukopenia, trombosi- topenia, agranulositosis, anemia aplastik IO Sulfonamida, alkohol, salisilat dosis besar, fenilbutazon, steroid, oksifenbutazon, probenezida, kloramfenikol, MAO Inhibitor. KI Px geriatri, wanita hamil, gangguan fungsi hari atau ginjal, ketoasidosis Contoh Glibenklamide Dosis awal 2,5-5 mg; >10 mg dalam 2 dosis terbagi (max 20 mg/hari) Efek hipoglikemik poten Glipizide ALGORITMA TERAPI Dosis awal 2,5-5 mg; >15 mg dalam 2 dosis terbagi (max 40 mg/hari) Durasi lebih lama drpd gliben Glikazide Dosis awal 30 mg/hari; 60,90,120 mg/hari Efek hipoglikemik sedang Bs u/ px ggg hati & ginjal Glimepiride Dosis awal 1-2 mg/hari, 4 mg/hari (max 8 mg/hari) Onset pendek Durasi lama E hipoglikemik lbh < drpd gliben BS u/ px ggg ginjal atau geriatri Glikuidon Dosis awal 15 mg/hari; 45-60 mg/hari dalam dosis terbagi (max 180 mg/hari) Bs u/ px ggg hati & ginjal NON-SULFONILUREA (GLINID) moA Merangsang sekresi insulin di kelenjar pankreas Efek glikemik Prandial
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ES Hipoglikemik (lbh < drpd sulfonil), Efek glikemik Fasting & prandial peningkatan BB ES Mual, muntah, nyeri pd area injeksi IO Sda IO Acarbose, captopril KI Sda KI Ggl ginjal Contoh Repaglinide Contoh Exenatide Nateglinide 2 mg/minggu BIGUANIDA Liraglutide moA Menurunkan produksi glukosa hati dg menurunkan glikoneolisis & glukoneogenesis Efek glikemik ES Mual, muntah, diare, asidosis laktat (minim), BB turun IO Sda TIPE INSULIN KI Ggg hepar, ginjal (SCr < 1,5 mg/dl), Rapid acting Onset in 15 minutes peny. Jantung, wanita hamil, Duration 4-5 hours keadaan gawat darurat Ex: Lispro, Humalog Contoh Metformin Use before meals Dosis awal 500 mg bid/tid; atau 850 Short/regular Onset in 30-45 minutes mg bid bersama makan acting Duration 5-6 hours THIAZOLIDINEDIONES Ex: Humulin R moA Meningkatkan sensitivitas insulin & Use before meals << glikoneogenesis *<< TG & LDL, >> HDL Intermediate Onset in 2-4 hours Efek glikemik Fasting & prandial acting Duration 10-16 hours (NPH) & ES Peningkatan BB, edema, >> risk ggg 12-18 hours (Lente) jantung, osteoporosis, ca. bladder Ex: NPH, Lente, Glargine IO Loop diuretic Use in the morning or before KI Px ggl jantung dg edema & hepar bedtime Contoh Rosiglitazone Long acting Onset in 6-10 hours 2,4,8 mg (1-2/day) effect up to Duration 20 hours or more 24 h Ex: Ultralente Pioglitazone Use in the morning or before 15,30,45 mg (once daily) effect bedtime 24 h α-GLUCONIDASE INHIBITOR moA Menghambat enzime α-glukonidase INTENSIVE INSULIN REGIMEN pd dinding usus halus Step 1 : Determine total daily dose Efek glikemik Prandial 0,5 units x body weight (kg) 72kg Px: 36 U ES GI adverse effect Step 2 : Determine basal requirements IO Sda 40% of total daily dose KI Ketoasidosis MDI: basal insulin subcutaneously at bedtime Contoh Acarbose NPH: 14U/day Dosis awal 50 mg; 150-600 mg/hari Step 3 : Determine meal requirements pada suapan pertama 60% of total daily dose Miglitol Remaining of 35% before breakfast, 25,50,100 mg (1-3 times/day) 30% before lunch, 35% before dinner effect up to 3 h MDI:meal insulin subcutaneously before each meal Lispro: 8U subcutaneously before breakfast DPP-4 INHIBITOR Lispro: 6U subcutaneously before lunch moA Lispro: 8U subcutaneously before dinner Efek glikemik Prandial ES Risk pankreatitis, mahal IO Sda SPLIT-MIXED INSULIN REGIMEN KI Ggl jantung, ginjal, hati Step 1 : Determine total daily dose Contoh Sitagliptin 0,5 units x body weight (kg) 72kg Px : 36U 25,50,100 (once daily) effect 24 h Step 2 : Determine each dose Saxagliptin 2/3 of total daily dose before breakfast, 2,5-5 mg/hari 1/3 before dinner GLP-1 AGONIST 24 IU before breakfast moA 12 IU before dinner Ega Kurniasari, S.Farm., Apt. - Page 3 of 4 Step 3 : Determine components of each dose 2/3 of each dose as basal insulin, 1/3 as meal insulin NPH 16U + 8U regular insulin sc before breakfast NPH 8U + 4U regular insulin sc before dinner
