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TUBERKULOSIS
Ika Mustikaningtias, M.Sc., Apt.
Laboratorium Farmakologi dan Farmasi Klinik
Jur. Farmasi FKIK
Univ. Jenderal Soedirman
Tuberculosis??
WHO :
an airborne infectious disease that is preventable and curable
Ika Mustikaningtiass Lecture Notes
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Ika Mustikaningtiass Lecture Notes
TB is one of the worlds deadliest disease
One third of the worlds population is
infected with TB
In 2011, nearly 9 million people around the
world became sick with TB disease
TB is a leading killer of people who are HIV
infected
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Ika Mustikaningtiass Lecture Notes
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Factor that determine the probability of transmission of M. tuberculosis
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Unexplained weight loss
Loss of appetite
Night sweats
Fever
Fatigue
Coughing for 3 weeks
Hemoptysis Chest pain
Medical history
Physical examination
Test Mantoux (Tuberculin Skin Test = TST)
Chest Radiograpgh
Diagnostic Microbiology (sputum test)
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Alur
diagnosis
TB paru
Bagaimana caranya agar pasien
bisa mengeluarkan dahak?
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Tuberkulosis
TB paru TB ekstra paru
BTA + BTA -
Berat Ringan
Berat Ringan
Meningitis
Milier
Perikarditis
Peritonitis
Tulang belakang
Usus
Saluran kemih
Alat kelamin
Kelenjar limfe
Tulang (kec. Tlg
blkg)
Sendi
Kel. adrenal
Tipe Keterangan
Kasus baru Penderita blmpernah diobati OAT atau sudah pernah
menelan OAT <1 bulan (4 minggu)
Kambuh (relaps) Penderita TB sblmnya pernah mdp pengobatan TB & telah
dinyatakan sembuh (pengobatan lengkap), didx kembali dgn
BTA +
Default (stlh putus
berobat)
Penderita yg telah berobat & putus berobat 2 bulan/lebih dgn
BTA +
Gagal (failure) Penderita dgn pmx dahak tetap + atau kembali mjd + pada
bulan ke-5 atau lbh selama pengobatan
Pindahan (transfer in) Penderita yg dipindahkan dr UPK yg memiliki register TB lain
utk melanjutkan pengobatan
Kasus lain Semua kasus yg tdk memenuhi ketentuan di atas, trmsk
kasus kronik (penderita dgn BTA masih + stlh pgbtn ulangan)
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Tujuan terapi
Menyembuhkan penderita
Mencegah kematian
Mencegah kekambuhan
Menurunkan tingkat penularan
Sasaran terapi
Jumlah basil TB
Lokasi (ekstra sel, intra sel)
Strategi terapi
Basmi basil (hambat dan hilangkan)
Obat Anti TB (OAT)
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Kategori Pengobatan
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Paket Pengobatan
1. Menjamin efektivitas, mengurangi ESO
2. Menurunkan risiko resistensi obat ganda,
mengurangi kesalahan penulisan resep
3. Pemberian obat lebih sederhana,
meningkatkan kepatuhan terapi
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Paduan OAT di Indonesia
Kategori I
OAT KDT
Kombipak
Paduan OAT di Indonesia
Kategori II
OAT KDT
Kombipak
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Paduan OAT di Indonesia
Kategori III
2HRZ/4H3R3
Paduan OAT di Indonesia
OAT Sisipan
OAT KDT
Kombipak
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Paduan OAT di Indonesia
Pengobatan pada anak
OAT KDT
Kombipak
Pengobatan TB dengan kondisi khusus
Kondisi Informasi Penting
Hamil Streptomisin bersifat ototoksik permanen pada janin dan
dpt menembus plasenta.
Menyusui Pengobatan pencegahan dengan INH diberikan pada bayi
sesuai dengan berat badannya.
Pengguna kontrasepsi Rifampisin menurunkan efikasi kontrasepsi hormonal
Hepatitis akut S dan E maks. 3 bulan sampai hepatitis membaik,
dilanjutkan dengan R dan H selama 6 bulan
Hepatitis kronik Menghindari Z. Anjuran paduan OAT 2RHES/6RH atau
2HES/10HE
Gagal ginjal S dan E diekskresi melalui ginjal. Anjuran paduan OAT
2HRZ/4HR
Diabetes melitus R menurunkan efektivitas SU
E dapat memperberat retinopati diabetik
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Drug-resistant TB is caused by M. tuberculosis organisms
that are resistant to the drugs normally used to treat the
disease
Drug-resistant TB is transmitted in the same way as
drug-susceptible TB, and is no more infectious than
drug-susceptible TB
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MDR-TB
MDR-TB (Multidrug-resistant TB) is caused by organisms
resistant to the most effective anti-TB drugs, INH and
RFP. These drugs are considered 1
st
line drugs and are
used to treat most person with TB didease.
XDR-TB
XDR-TB (Extensively drug-resistant TB) is a relatively
rare type of DR-TB. XDR-TB is resistant to INH and RFP
plus any Fluoroquinolone, and at least one of three
injectable 2
nd
line drugs (amikacin, kanamycin, or
capreomycin).
Strategi Pengobatan MDR/XDR-TB
Pengobatan standar
Dasar regimen pengobatan adalah data dari populasi pasien
Tidak tersedia hasil uji resistensi individu
Pengobatan empiris
Dasar regimen pengobatan adalah data dari populasi pasien dan
riwayat pengobatan TB sebelumnya
Regimen empiris akan disesuaikan setelah hasil uji resistensi individu
Pengobatan individual
Dasar regimen pengobatan adalah riwayat pengobatan TB sebelumnya
dan hasil uji resistensi individu
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Langkah Menyusun Regimen Pengobatan
TB-MDR
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1. Regimen sedikitnya terdiri dari 4 obat atau lebih yang masih efektif
2. Jika memungkinkan, PZA, EMB, dan Fluoroquinolon diberikan 1x
sehari (lebih efektif)
3. Etionamid/protionamid, sikloserin, PAS diberikan dalamdosis
terbagi
4. Dosis obat berdasarkan BB
5. Injectable drugs digunakan minimal selama 6 bulan dan sekurang-
kurangnya 4 bulan setelah konversi kultur
6. Minimum lama pengobatan adalah 18 bulan setelah konversi
kultur
Hal-hal yang perlu diperhatikan pada
regimen TB-MDR
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Interaksi obat
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Peran dari ARV therapy
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Overlapping side effects
Side effect TB drug ARV
Skin rash PZA
RIF
INH
Nevirapine
Efavirenz
Abacavir
Nausea, vomiting PZA
RIF
INH
Zidovudine
Ritonavir
Amprenavir
Indinavir
Hepatitis PZA
RIF
INH
Nevirapine
Protease inhibitor
Leukopenia, anemia RIF Zidovudine
Treatment Interruption
Treatment interruption is common
Restart or continue therapy based on when interruption
occurred and duration of interuption
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Treatment Interruption
Algorithm for management of initial phase treatment
interruption
Treatment is
interrupted
Is it for <14
days?
Start over from
the beginning
Can the initial phase
treatment be
completed within 3
months?
Start over from
the beginning
Continue
treatment to
complete total
doses required
Yes No
No Yes
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Algorithm for management of continuation phase treatment
interruption
Determine the
total % of doses
completed
Is the % of doses
<80%
If sputum smear was
AFB + at baseline,
continue treatment to
completes planned total
number of doses
warranted
Is the duration of
interruption <3
months?
Start initial phase 4-
drug regimen from
the beginning
Continue
treatment
Yes No
No Yes
If sputum smear was
AFB - at baseline,
additional treatment
may not be necessary
Can treatment
be completed
within required
time frame for
regimen?
Start initial phase 4-
drug regimen from
the beginning
Complete
treatment
No Yes
Algorithm for management of continuation phase treatment
interruption
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1. INH, RIF, sebaiknya diminumsaat perut kosong
2. Bila pencernaan terganggu (mual, muntah) dapat diminum2 jam
sesudah makan
3. EMB dan PZA sebaiknya diminumsaat perut isi
4. Bila perlu minumantasida, beri antara beberapa jam
5. Bila lupa minumobat, minumsesegera mungkin, tetapi bila dekat
waktu dosis berikutnya, kembali ke jadwal semula jangan didobel
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Untuk menjamin keteraturan pengobatan
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Recommended Examinations for Baseline Monitoring
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Pemantauan Kemujuan Pengobatan Pada Anak
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Hasil Pengobatan TB
Efek Samping OAT
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Efek Samping Berat OAT
Monitoring ADR
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Monitoring ADR
Monitoring ADR
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Daftar Pustaka
WHO, 2011, WHO Report 2011 Global Tuberculosis Control
www.cdc.gov/tb
http://www.cdc.gov/TB/publications/guidelines/specpop.htm
http://www.cdc.gov/TB/publications/guidelines/MDR_TB.htm
www.cdc.gov/TB/publications/guidelines/default.htm
http://www.cdc.gov/tb/topic/globaltb/default.htm
http://www.cdc.gov/tb/statistics/default.htm
http://www.cdc.gov/TB/topic/basics/default.htm
http://www.niaid.nih.gov/sitecollectionimages/topics/tuberculosis/tb1.jpg
http://www.niaid.nih.gov/sitecollectionimages/topics/tuberculosis/simple2.jpg
Ika Mustikaningtiass Lecture Notes