Tri Widyawati

Siti Syarifah
Dep. Farmakologi & Terapeutik,
Fakultas Kedokteran
Universitas Sumatera Utara
 Polifarmasi
Kaskade peresepan
 Prescription Drug Use: Harms
• Medications have the potential for harm as well as
benefit and adverse drug events (ADE) are common.
• An ADE is an injury from a medication.
• Annually 35% of community-dwelling elders
experienced an ADE, 29% required health care
services.
• Adverse drug events responsible for 5-28% of acute
hospitalizations among geriatric patients.
• In nursing home residents, 51% of ADEs were found
to be preventable.
 Visiting Findings
Percentage
 Polypharmacy
Causes and Consequences

• Contributing factors • Consequences

– Age
– Multiple medical conditions – Adverse drug events
– Multiple symptoms – Noncompliance
– Copious prescribing – Increased cost
– Multiple providers
– Multiple pharmacies used
– Self treating
– Drug regimen changes
– Prescribing cascade
 Interaksi obat yang menakutkan
1. banyaknya obat baru yang informasi
tentang interaksinya dengan obat lain
masih terbatas
2. semakin banyak obat yang dapat diperoleh
tanpa resep dokter
3. meningkatnya usia harapan hidup
manusia menyebabkan meningkatnya
kelompok masyarakat yang membutuhkan
perlakuan dengan polifarmasi.
4. Harga obat melambung yang diikuti dengan
iatrogenic cost
 Lethal Combination of Tramadol and
Multiple Drugs Affecting Serotonin
Ripple MG. et al. Am J For Med Path. 21(4):370-4,2000

• The threshold for seizures is lowered by

tramadol. In addition, the risk for seizure is
enhanced by the concomitant use of tramadol
with selective serotonin reuptake inhibitors or
neuroleptics.
• The cause of death in this individual was
seizure activity complicating therapy for back
pain and depression
 Potential Drug Interactions
Number of Number of
Interactions
Drugs Interactions
1 0
2 A+B 1
3 A+B A+C 3
B+C
A+B A+C
4 A+D B+C 6
B+D C+D
Potential Drug Interactions
 Kaskade Peresepan
PRESCRIBING CASCADE
obat 1 Adverse drug effect
misinterpreted as
Drug 1 new medical condition
efek samping obat
diinterprestasikan sebagai
suatu kondisi klinis baru

obat 2
Drug 2 Adverse drug effect
efek samping obat
Rochon PA, Gurwitz JH. BMJ. 315:1096-9,1997.
Kaskade pengobatan di masyarakat
Kaskade peresepan di klinik pribadi
Keadaan awal terapi Simtom baru terapi ikutan

Nyeri
dengkul
OAINS
Nyeri
ulu hati
antasida

konstipasi

laksansia
diare
dst
 remato-
logis
serangan OAINS
GOUT
PSMBA
hidro gastro-
Hipertensi kloro- entero-
tiazida logis
misoprostol

diare . . . . . IATROGENIK
(iatro = dokter)
 Examples of prescribing cascade
Initial Adverse Subsequent
treatment effect treatment
Non-steroidal Rise in blood Antihypertensive
anti-inflammatory pressure treatment
drugs

Thiazide Hyperuricaemia Treatment for

diuretics gout
Metoclopramide Parkinsonian Treatment with
treatment symptoms levodopa
Odds rasio pada
pengobatan awal dengan:
 antihipertensi 2,5

2
sebagai terapi 1,5

lanjutan setelah 1

pemberian OAINS 0,5

0
none low medium high

 obat anti-gout 3
2,5

sebagai terapi 2
1,5
lanjutan setelah 1

pemberian tiazid 0,5

0
none < 25 mg 25-50 mg > 50 mg

 anti-Parkinson 6
5

sebagai terapi lanjutan 4

3

setelah pemberian 2
1
metoklopramide 0
none < 10 mg 10-20 mg > 20 mg
 NYERI

OAINS

TD
Retensi Nyeri
meningkat GGN GI TRACT
cairan ulu hati

Anti-
diuretik hipertensi misoprostol antasida

Kaskade
Prescribing
Peresepan
Cascade
 Lingkaran setan …

Lansia efek samping  

Bermacam-
Poly-
Poli- tanda/
macam simptom baru ?
problem klinis pharmacy
farmasi

terapi
lanjutan
 PAIN
ALZHEIMER
CANCER DISEASE

NSAID=Rp

fluid increase heart

PSMBA
retention BP burn

Rp Rp Rp Rp
Iatrogenic Cost
 Upaya meminimalisasi kaskade
peresepan di rumah sakit

 menegakkan diagnosa kerja dengan

cermat
 melakukan pendekatan non-farmakologi
 menggunakan pengobatan sederhana
yang efektif dengan dosis paling rendah
 kurangi dosis yang diberikan
 mencoba obat pilihan lain
 pertimbangkan dengan seksama
penambahan obat baru yang benar-benar
dibutuhkan dan aman
Pharmaco-economics
 Treatment cost for pneumonia
Long-term study, CCP-DPS GMU, December 1997 – March 2002

Average standard pneumonia treatment cost (Rp) Exchange rate to US$1 (Rp)
15000 16000

12000
12000

9000
8000
6000

4000
3000

0 0

Private pharmacy Private hospital Public hospital

Healthcenter Drug store Consumer Price Index
 Pharmaceutical spending, as % of total health
spending, is greatest in developing countries
Greece
Germany Developed countries
Italy
France (7 - 20%)
Spain
Denmark
UK
United States
Netherlands
Norway

Bulgaria Transitional countries

Czech Rep.
Hungary
(15 - 30%)
Croatia
Poland
Estonia
Slovenia
Lithuania

Mali
Egypt
China
Indonesia
Thailand
Tunisia Developing countries
Jordan
(24 - 66 %)
Argentina
South Africa

0 10 20 30 40 50 60 70
 Pharmacoeconomics
• Adding drugs to the formulary involves careful
consideration of:
– Efficacy
– Safety
– Quality
– Cost
• Cost factors are becoming more important
• Science of pharmacoeconomics is emerging
– Pharmacoeconomics
– Cost (total resources consumed in producing a good or
service)
– Price (the amount of money required to purchase an item)
 Adding drugs to the formulary
clinic available Introduced
GI ulcer H2-antagonist PPI
Arthritis NSAID COXIB,
anti-TNF agents
Mental TCA SSRIs, Atypical
health Anti-Psychotics
Women’s - (osteoporosis) biphosphonate
health
AIDS - Protease
Inhibitors/cocktail
 Medical Outcomes
ECHO Model

Economic Clinical Humanistic

 Expense  Cure  Physical

 Savings  Comfort  Emotional
 Cost  Survival  Social
Avoidance
 Relationship between Outcomes,
Pharmacoeconomics and Pharmaceutical Care

pharmaco- outcomes
economics research

pharmaceutical
care
 Definition
• Economic outcomes measure that focuses on
the evaluation of pharmaceutical products and
pharmaceutical services

Clinical
Economic

Humanistic
 cost-minimisation

cost-benefit Pharmacoeonomics cost-effectiveness

cost-utility
 Commonly Prescribed Drugs

• Anti-inflammatory agents
• Analgesic agents
• Antimicrobial agents
(antibiotics, antifungal, antiviral)
• Corticosteroids
• Antianxiety/sedative agents
**Adjuvant analgesic agents**
 Outcome Measures

Clinical Humanistic
Disease Indicator Economic Outcome
Outcome Outcome
Renal failure
Cost/ mmHg BP
Stroke
Hypertension BP
MI
QOL Cost/stroke avoided
Cost/life year saved
Death
Angina
Cost/MI avoided
Hyperlipidemia LDL levels MI QOL
Cost/point  in LDL
Death
Retinopathy Cost/change in A1C
A1C Nephropathy
Diabetes QOL Cost/kidney transplant
BG levels Death avoided
Exacerbation
FEV, Cost/symptom free
Asthma event QOL
day
peak flow
Death
 Outcome Measures
for pain management
Clinical Humanistic Economic
Agent Indicator
Outcome Outcome Outcome
CV event Cost/ mmHg BP
NSAID pain GI event QOL Cost/stroke avoided
Renal failure Cost/life year saved

CELECOXIB Less CV event QOL Cost >>

IBUPROFEN Better GI event QOL Cost <<

Types of Pharmacoeconomic Analysis

Methodology Cost measurement Outcome unit

unit
Cost Dollars Various- but
minimization equivalent in
comparative groups
Cost benefit Dollars Dollars

Cost Dollars Natural units (life

effectiveness years, mg/dl blood
sugar, LDL
cholesterol)
Cost utility Dollars Quality adjusted life
years
 Pharmacoeconomics
say NO say YES

--- + Now what ?

New
Medications
$$
_
+++ do it!

Effectiveness
Medical License

“ My name is Bond,
James Bond OO7,
I have License to kill”

“ Medical profession
has a better License,
to save and
also to kill”