Etika Kedokteran dalam Farmakoterapi

Aznan Lelo
Dep. Farmakologi & Terapeutik,

Fakultas Kedokteran Universitas Sumatera Utara

7 September 2008, IDI, DKK Medan, FK USU MER-C

HUBUNGAN PENDERITA dan DOKTER

OBAT

keluhan keluhan

penyakit penderita
gejala gejala

Dokter

OBAT

OBAT

Sakit kepala
Sakit gigi

Benar kah? Etis kah ?

Novalgin
Ponstan

Bisulan
Nyeri haid

Rematik
Gout Irgapan

Voltaren
Feminax

Confortid

IATROGENIK
(iatro = dokter)

 Everyone has the right to a standard of living adequate for the health of himself and of his family, including food, clothing, housing and medical care and necessary social services
(Art.25.1; Universal Declaration of Human Rights 1948)

Right to health facilities, goods and services includes appropriate treatment of prevalent diseases, preferably at community level; and the provision of essential drugs
(Art 12.2.d; May 2000)

Committee on Economic, Social and Cultural Rights. General Comment nr.14 (May 2000)
Essential components of fulfillment of right to health Availability
includes essential drugs as defined by the WHO Action Programme on Essential Drugs based on non-discrimination, physical accessibility, affordability and access to information respectful of medical ethics and culturally appropriate and sensitive to gender and life-cycle

Accessibility

Acceptability
Quality

scientifically and medically

etika kedokteran
etika terapan (applied ethics) matra normatif Kemurnian niat tuntunan utk bertanggung-jawab matra praksis tuntutan rasionalitas tindakan Kesungguhan kerja

etika khusus (profesional)

peer review otokritik tindakan sejawat = disiplin kode etik pemurnian dan penyesuaian

Kerendahan hati Integritas ilmiah & sosial

Metode Etika Terapan

Sikap awal Informasi Norma-norma moral Logika berpikir Primum no nocere First do no harm Evidence based Pharmacological approaches Optimal therapeutic effects Avoid harm effects Rational

Prinsip Etika Kedokteran

contoh dalam penggunaan AINS pada nyeri
Prinsip
BENEFICENCE : mengutamakan kepentingan pasien AUTONOMY : menghormati hak pasien dalam memutuskan NON MALEFICENCE : tidak memperburuk keadaan pasien JUSTICE : tidak mendiskriminasikan pasien, apapun dasarnya

Secara Farmakoterapeutik
Potent, onset Diclofenac, mefenamic acid, ibuprofen Mengingatkan pharmacoeconomic, Preference Tidak memperburuk hipertensi Ibuprofen, diclofenac, ketoprofen

Selalu meresepkan obat generik

Rational prescription (WHO,1995)

Patient receive appropriate medicines according to their clinical needs at an appropriate dosage, administration & duration and in a way that encourages the patient compliance and at the lowest cost to the community Appropriate patient ( Tepat Pasien ) Appropriate indication ( Tepat Indikasi ) Appropriate drug ( Tepat Obat ) Appropriate dosage, administration & duration
(Tepat dosis, cara & lama pemberian)

Appropriate information ( Tepat Information )

Appropriate cost ( Tepat biaya )

Kasus 1
Usia muda, hipertensi diastolik, takikardi, nyeri dada, muffle heart sound (+). A. ACE-inhibitor captopril B. Beta-1 selective blocker atenolol C. Calcium antagonist nifedipin D. Diuretic hydrochlorothiazide E. Alfa-2 agonist clonidine

non-malefficiency (tidak merugikan )

A. ACE-inhibitor captopril B. Beta-1 selective blocker atenolol C. Calcium antagonist nifedipin D. Diuretic hydrochlorothiazide E. Alfa-2 agonist clonidine A. tetap takikardi

B. Bradikardi, nyeri dada berkurang C. Reflex tachycardia, nyeri bertambah D. Hilang elektrolit, renin meningkat E. Withdrawal phenomenon

HASIL ...... Golongan obat yang paling banyak digunakan : antiinfeksi cairan-ivfd analgetika Penggunaan obat GENERIK hampir sama banyak dengan obat PATEN
160 140 120 100 80 60 40 20 0
ANTIINFEKSI CAIRAN-IVFD ANALGETIKA

250 200 150 100 50 0 GENERIK PATEN

etc, etc,etc etc susah tidur

demam batuk

antiinfeksi
diare

sesak

cemas

nangis

Ini dia,tapi aku lupa bagaimana cara menggunakannya

Dimana obatku ?

Sudah diminum atau belum?

3x11x3 Efek terapeutik Efek samping obat

Hindari pemakaian obat yang berbahaya . . . . . . . . . . . . . . . . pilihlah obat yang aman . . dengan regimen obat yang sederhana

Kurata etal., (1999) NSAID loxoprofen prescribed by an orthopedic to treat a patient with lumbago

Risk factors
Age
Gender Concomitant disease
(CVS, kidney & liver)

Case
Elderly (80 years)
Woman hypertension ACE-Inhibitor imidapril

Concomitant drugs used What next?

The grandmother was syncope due to hyperkalemia, bradycardia

Harus menulis RESEP dengan JELAS dan RASIONAL, teristimewa kombinasinya

INTERAKASI OBAT

R/ Felden R/ Intidrol R/ Voltaren R/ Lasix

CELEXA for CELEBREX? A Case of Medication Sample Error

Bradley Moyer,MD; Walter Shrading,MD; Keith K. Burkhart, MD, FACMT The Pennsylvania State University, Hershey, PA Int J Med Toxicol 2000; 3(2): 7

R/ Tanapress R/ Dextrometorphan R/ Alludona R/ Supraflu R/ Piroxicam

citalopram (Celexa). a selective serotonin (5-HT) reuptake inhibitor

Outcome Measures for arthritis management

Agent
Indicator Clinical Outcome
CV event GI event Renal failure

Humanistic Outcome QOL

Economic Outcome
Cost/ mmHg BP Cost/stroke avoided Cost/life year saved

NSAID

pain

CELECOXIB

Less

CV event

QOL

Cost >>

IBUPROFEN

Better

GI event

QOL

COST <<

Penilaian kritis dalam menentukan obat pilihan

Bukti Efek Terapi Bukti Efek Samping

Minimal Maksimal Ya ? ? Tidak

Maksimal Minimal

PERAN OBAT: Pil untuk setiap ILL ? BATAS KEMAMPUAN OBAT: What drugs may really do, and what it can not do

Tapi, saya mudah sesak kencing malam

Nyeri bahu Nyeri pinggang Nyeri lutut Nyeri tumit

yang penting hilang NYERI-nya urusan JANTUNG, belakangan

Medical journals are an extension of the marketing arm of drug companies

Richard Smith Chief executive, United Health Europe Formerly editor BMJ

An ideal one is due to wrong information, so sad !

Hidden issues of NSAIDs

COOH

COX-1
Prostaglandines PGE2, PGI2, TXA2

Arachidonic acid

COX-2
Prostaglandines PGE2, PGI2, TXA2

Gastric mucosal protection

TXA2 PGI2 stimulates inhibits platelet platelet aggregation, aggregation vasoconstriction vasodilation

COX-2 specific inhibitor

thrombosis
causes GI damage STROKE

hidden issues
MCI

ischemic

Inflammation Inflammation Pain Pain Fever Fever Renal function Boneantiformation Reproduction inflammatory

NYERI
OAINS
TD meningkat

Retensi cairan

PUB

Nyeri ulu hati

diuretik

Anti-

hipertensi

misoprostol

antasida

Kaskade Prescribing Peresepan Cascade

PAIN
CANCER
ALZHEIMER DISEASE

NSAID=Rp

fluid retention

increase BP

PUB

heart burn

Rp

Rp

Rp

Rp

Iatrogenic Cost

Dangerous person
Wishing to eliminate a president of another country Bombing all areas of the country Killing the people in that country Spending 20 M US$ Wishing to eliminate a sign or symptom of a disease Giving an expensive drug & polypharmacy Increasing ADRs & iatrogenic disease Spending a lot of money But it cloud be then overcome by the cheapest drug

But then offering only 200,000 US$ to whom could bring the head of the president

Etika Kedokteran dalam Farmakoterapi

Melibatkan berbagai pertimbangan Human right
Apakah obat akan memperbaiki kondisi penderita?

Obat essensial Pharmaco-economic

Iatrogenic cost

Hati-hati informasi salah

Pharmaco-politic

Persepan salah

Dangerous doctors
doctors are the third leading cause of death in the US, causing 250,000 deaths every year
http://www.mercola.com/2000/jul/30/doctors_death.htm

UK & US Market Withdrawal

Year
Withdrawn Approval

NSAID
Benoxaprofen
indomethacin SR Indoprofen

CV event

Hepatotoxicity

others

1982 1984
1999

82 deaths
40 deaths 217 adverse
reactions
Acute liver failure

1998 1997 Bromfenac 2004 1999 Rofecoxib

1985 2003 Nimesulide
Lumiracoxib 139.000
AMI/SCD/Stroke

??????
6 2

Pharmaco-politics ?

Complimentary Therapies
1. 2. 3. 4. 5. Special diets Mega-dose vitamins Hydrazine sulfate Herbal therapies Shark cartilage

If you want others to be happy, practice compassion. If you want to be happy, practice compassion.
- Dalai Lama