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romboplastin parsial adalah fosfolipid yang berfungsi sebagai penggantiplatelet

factor 3 (PF3), dapat berasal dari manusia, tumbuhan dan hewan, dengan aktivator
seperti kaolin, ellagic acid, micronized silica atau celite. Reagen komersil yang
dipakai misalnya CK Prest 2 yang berasal dari jaringan otak kelinci dengan kaolin
sebagai aktivator. Reagen Patrhrombin SL menggunakan fosfolipid dari tumbuhan
dengan aktivator micronized silica.
Masa tromboplastin parsial teraktivasi (activated partial thromboplastin time, APTT)
adalah uji laboratorium untuk menilai aktifitas faktor koagulasi jalur intrinsik dan jalur
bersama, yaitu faktor XII (faktor Hagemen), pre-kalikrein, kininogen, faktor XI
(plasma tromboplastin antecendent, PTA), faktor IX (factor Christmas), faktor VIII
(antihemophilic factor, AHF), faktor X (faktor Stuart), faktor V (proakselerin), faktor II
(protrombin) dan faktor I(fibrinogen). Tes ini untuk monitoring terapi heparin atau
adanya circulating anticoagulant. APTT memanjang karena defisiensi faktor
koagulasi instrinsik dan bersama jika kadarnya <> 7 detik dari nilai normal, maka
hasil pemeriksaan itu dianggap abnormal.
APTT memanjang dijumpai pada :
1. Defisiensi bawaan
o Jika PPT normal kemungkinan kekurangan :

Faktor VIII

Faktor IX

Faktor XI

Faktor XII

o Jika faktor-faktor koagulasi tersebut normal, kemungkinan kekurangan


HMW kininogen (Fitzgerald factor)
o Defisiensi vitamin K, defisiensi protrombin, hipofibrinogenemia.
2. Defisiensi didapat dan kondisi abnormal seperti :

o Penyakit hati (sirosis hati)


o Leukemia (mielositik, monositik)
o Penyakit von Willebrand (hemophilia vaskular)
o Malaria
o Koagulopati konsumtif, seperti pada disseminated intravascular
coagulation (DIC)
o Circulating anticoagulant (antiprothrombinase atau circulating
anticoagulant terhadap suatu faktor koagulasi)
o Selama terapi antikoagulan oral atau heparin

Penetapan
Pemeriksaan APTT dapat dilakukan dengan cara manual (visual) atau dengan alat
otomatis (koagulometer), yang menggunakan metode foto-optik dan elektromekanik. Teknik manual memiliki bias individu yang sangat besar sehingga tidak
dianjurkan lagi. Tetapi pada keadaan dimana kadar fibrinogen sangat rendah dan
tidak dapat dideteksi dengan alat otomatis, metode ini masih dapat digunakan.
Metode otomatis dapat memeriksa sampel dalam jumlah besar dengan cepat dan
teliti.
Prinsip dari uji APTT adalah menginkubasikan plasma sitrat yang mengandung
semua faktor koagulasi intrinsik kecuali kalsium dan trombosit dengan tromboplastin
parsial (fosfolipid) dengan bahan pengaktif (mis. kaolin, ellagic acid, mikronized
silica atau celite koloidal). Setelah ditambah kalsium maka akan terjadi bekuan fibrin.
Waktu koagulasi dicatat sebagai APTT.
Bahan pemeriksaan yang digunakan adalah darah vena dengan antikoagulan
trisodium sitrat 3.2% (0.109M) dengan perbandingan 9:1. Gunakan tabung plastik
atau gelas yang dilapisi silikon. Sampel dipusingkan selama 15 menit dengan

kecepatan 2.500 g. Plasma dipisahkan dalam tabung plastik tahan 4 jam pada suhu
205oC. Jika dalam terapi heparin, plasma masih stabil dalam 2 jam pada suhu
205oC kalau sampling dengan antikoagulan citrate dan 4 jam pada suhu 205oC
kalau sampling dengan tabung CTAD.

Nilai Rujukan
Nilai normal uji APTT adalah 20 35 detik, namun hasil ini bisa bervariasi untuk tiap
laboratorium tergantung pada peralatan dan reagen yang digunakan.

Faktor yang dapat mempengaruhi temuan laboratorium :

Pembekuan sampel darah,

Sampel darah hemolisis atau berbusa akibat dikocok-kocok,

Pengambilan sampel darah pada intravena-lines (mis. pada infus heparin).

ALTEPLASE
Indikasi:
Terapi trombolitik pada infark miokard akut, embolisme paru dan stroke
iskemik akut.
Peringatan:
lihat keterangan di atas; untuk stroke akut monitor perdarahan
intrakranial, tekanan darah (antihipertensi dianjurkan jika sistolik di atas
180 mmHg atau diastolik di atas 105 mmHg); gangguan fungsi ginjal.
Interaksi:
lihat lampiran 1.
Kontraindikasi:

lihat keterangan di atas, pada stroke akut, kejang yang menyertai stroke,
stroke berat, riwayat stroke pada pasien diabetes, stroke 3 bulan
sebelumnya, hipoglikemi, hiperglikemi.
Efek Samping:
lihat keterangan di atas, risiko perdarahan otak meningkat pada stroke
akut.
Dosis:

Infark miokard, rejimen dipercepat (dimulai dalam 6 jam). Awal,


injeksi intravena 15 mg, diikuti dengan infus 35 mg selama 60 menit
(total 100 mg selama 90 menit); pada pasien dengan berat badan
kurang dari 65 kg, dosis diturunkan.

Infark miokard, terapi awal diberikan dalam 6-12 jam: Awal, injeksi
intravena 10 mg, diikuti dengan infus intravena 50 mg selama 60
menit. Kemudian 4 kali infus intravena 10 mg selama 30 menit (total
100 mg selama 3 jam; maksimal 1,5 mg/kg bb pada pasien dengan
berat badan kurang dari 65 kg).

Embolisme paru, injeksi intravena 10 mg selama 1-2 menit, diikuti


dengan infus intravena 90 mg selama 2 jam; maksimal 1,5 mg/kg bb
pada pasien dengan berat badan kurang dari 65 kg.

Stroke akut, (terapi harus dimulai dalah 3 jam), meliputi intravena


900 mcg/kg bb (maksimal 90 mg) selama 60 menit; 10% dosis
diberikan melalui injeksi intravena; Lansia. Tidak dianjurkan untuk usia
diatas 80 tahun.

List Nama Dagang


Actilyse

Flecainide is used for:


Treating and preventing various types of irregular heartbeat that lead to
life-threatening heart rhythm disturbances.
Flecainide is an antiarrhythmic. It works by stabilizing the heart rhythm
when the heart is beating too fast or in an irregular rhythm.

Do NOT use flecainide if:

you are allergic to any ingredient in flecainide


you have severe heart problems (eg, certain types of heart blocks
or shock) or a history of severe heart problems
you are taking an HIV protease inhibitor (eg, ritonavir)

Contact your doctor or health care provider right away if any of these
apply to you.

SLIDESHOW

Atrial Fibrillation - Stroke Prevention Guidelines & Treatment Options

Before using flecainide:


Some medical conditions may interact with flecainide. Tell your doctor or
pharmacist if you have any medical conditions, especially if any of the
following apply to you:

if you are pregnant, planning to become pregnant, or are breastfeeding

if you are taking any prescription or nonprescription medicine,


herbal preparation, or dietary supplement

if you have allergies to medicines, foods, or other substances

if you have heart problems (eg, congestive heart failure, heart


attack, sick sinus syndrome) or a history of heart problems

if you have severe kidney or liver problems

if you have abnormal potassium blood levels

Some MEDICINES MAY INTERACT with flecainide. Tell your health care
provider if you are taking any other medicines, especially any of the
following:

Calcium channel blockers (eg, nifedipine, verapamil), cimetidine,


HIV protease inhibitors (eg, ritonavir), or serotonin norepinephrine
reuptake inhibitors (eg, duloxetine) because they may increase the risk

of flecainide's side effects, including heart problems, blood problems,


or seizures, may be increased

Antiarrhythmics (eg, amiodarone, quinidine, disopyramide),


arsenic, beta-blockers (eg, propranolol, sotalol), droperidol, pimozide,
serotonin receptor antagonists (eg, dolasetron), or ziprasidone
because the risk of side effects, such as irregular heartbeat or other
heart problems, may be increased

Digoxin because the risk of its side effects may be increased by


flecainide

This may not be a complete list of all interactions that may occur. Ask
your health care provider if flecainide may interact with other medicines
that you take. Check with your health care provider before you start,
stop, or change the dose of any medicine.

How to use flecainide:


Use flecainide as directed by your doctor. Check the label on the
medicine for exact dosing instructions.

Take flecainide by mouth with or without food.

The initial dose of flecainide will be given by a qualified health care


provider in a medical setting.

If you miss a dose of flecainide, take it as soon as possible. If it is


almost time for your next dose, skip the missed dose and go back to
your regular dosing schedule. Do not take 2 doses at once.

Ask your health care provider any questions you may have about how to
use flecainide.

Important safety information:

Flecainide may cause dizziness, blurred vision, or


lightheadedness. These effects may be worse if you take it with
alcohol or certain medicines. Use flecainide with caution. Do not drive
or perform other possibly unsafe tasks until you know how you react to
it.

Tell your doctor or dentist that you take flecainide before you
receive any medical or dental care, emergency care, or surgery.

Do not suddenly stop taking flecainide without checking with your


doctor.

LAB TESTS may be performed to monitor your progress or to


check for side effects. Be sure to keep all doctor and lab
appointments.

Flecainide should not be used in CHILDREN; safety and


effectiveness in children have not been confirmed.

PREGNANCY and BREAST-FEEDING: If you become pregnant,


contact your doctor. You will need to discuss the benefits and risks of
using flecainide while you are pregnant. Flecainide is found in breast
milk. If you are or will be breast-feeding while you are using flecainide,
check with your doctor. Discuss the risks to your baby.

Possible side effects of flecainide:


All medicines may cause side effects, but many people have no, or
minor, side effects. Check with your doctor if any of these most
COMMON side effects persist or become bothersome:
Blurred vision; constipation; difficulty focusing; dizziness; faintness;
headache; nausea; seeing spots; stomach discomfort; tiredness;
unsteadiness; weakness.
Seek medical attention right away if any of these SEVERE side effects
occur:
Severe allergic reactions (rash; hives; itching; difficulty breathing;
tightness in the chest; swelling of the mouth, face, lips, or tongue); chest
pain; difficulty breathing; fainting; fast heartbeat; heart attack; lifethreatening irregular heartbeat; lightheadedness; pounding in the chest;
seizures; tremor; yellowing of the skin or eyes.
This is not a complete list of all side effects that may occur. If you have
questions about side effects, contact your health care provider. Call your
doctor for medical advice about side effects. To report side effects to the

appropriate agency, please read the Guide to Reporting Problems to


FDA.

If OVERDOSE is suspected:
Contact 1-800-222-1222 (the American Association of Poison Control
Centers), your local poison control center, or emergency room
immediately. Symptoms may include fainting; nausea; seizures; slow
heartbeat; vomiting.
Proper storage of flecainide:
Store flecainide at room temperature, between 59 and 86 degrees F (15
and 30 degrees C). Store away from heat, moisture, and light. Do not
store in the bathroom. Keep flecainide out of the reach of children and
away from pets.

General information:

If you have any questions about flecainide, please talk with your
doctor, pharmacist, or other health care provider.

Flecainide is to be used only by the patient for whom it is


prescribed. Do not share it with other people.

If your symptoms do not improve or if they become worse, check


with your doctor.

Check with your pharmacist about how to dispose of unused


medicine.

This information should not be used to decide whether or not to take


flecainide or any other medicine. Only your health care provider has the
knowledge and training to decide which medicines are right for you. This
information does not endorse any medicine as safe, effective, or
approved for treating any patient or health condition. This is only a brief
summary of general information about flecainide. It does NOT include all
information about the possible uses, directions, warnings, precautions,
interactions, adverse effects, or risks that may apply to flecainide. This
information is not specific medical advice and does not replace
information you receive from your health care provider. You must talk

with your healthcare provider for complete information about the risks
and benefits of using flecainide.

DVT Prophylaxis (Orthopedic Surgery)


Indicated for prophylaxis of deep vein thrombosis (DVT), which may lead to pulmonary
embolism (PE) in patients undergoing knee or hip replacement surgery
Knee replacement: 10 mg PO qDay for 12 days; may take with or without food
Hip replacement: 10 mg PO qDay for 35 days; may take with or without food
Administer initial dose at least 6-10 hr after surgery once hemostasis has been established

Nonvalvular Atrial Fibrillation


Indicated to reduce the risk of stroke and systemic embolism in patients with nonvalvular
atrial fibrillation
20 mg/day PO with the evening meal

DVT or PE Treatment
Indicated for treatment of DVT and PE
15 mg PO q12hr for 21 days with food, THEN 20 mg PO qDay for 6 months
Reduce risk for recurrent DVT or PE

Indicated to reduce the risk of recurrence of DVT and PE following initial 6 months
treatment for DVT and/or PE

20 mg PO qDay following initial 6 months of treatment for DVT and/or PE


Dosage Modifications
Renal impairment (risk reduction of recurrent DVT/PE)

Moderate (CrCl 30 to <50 mL/min): Observe closely and promptly evaluate any signs
or symptoms of blood loss in patients with moderate renal impairment
Severe (CrCl <30 mL/min): Avoid use, due to expected increase in rivaroxaban
exposure and pharmacodynamic effects
If acute renal failure develops while on rivaroxaban, discontinue treatment
Renal impairment (nonvalvular AF)

CrCl >50 mL/min: 20 mg/day PO with the evening meal


CrCl 15-50 mL/min: 15 mg/day PO with the evening meal

CrCl <15 mL/min: Avoid use


If acute renal failure develops while on rivaroxaban, discontinue treatment
Renal impairment (postoperative thromboprophylaxis)

CrCl >50 mL/min: Dose adjustment not necessary


CrCl 30-50 mL/min: Use with caution; dose adjustment not necessary
CrCl <30 mL/min: Avoid use
Hepatic impairment

Moderate impairment: Not studied


Avoid use in patients with moderate-to-severe impairment (Child-Pugh B) or severe
(Child-Pugh C) hepatic impairment or with any hepatic disease associated with
coagulopathy
Dosing Considerations
Discontinuation for surgery or other procedures

Stop rivaroxaban at least 24 hours before procedure


Restart rivaroxaban after surgery/procedure as soon as adequate hemostasis is
established
If unable to take oral medication following surgical intervention, consider
administering a parenteral drug
Switching to rivaroxaban

From warfarin to rivaroxaban: Discontinue warfarin and start rivaroxaban as soon as


INR is below 3.0
From anticoagulant other than warfarin to rivaroxaban: Start rivaroxaban 0 to 2 hours
prior to next scheduled evening administration of the drug and omit administration of the
other anticoagulant
From unfractionated heparin continuous infusion to rivaroxaban: Stop infusion and
start rivaroxaban at the same time
Switching from rivaroxaban

From rivaroxaban to warfarin: No clinical trial data are available; INR measurements
made during coadministration with warfarin may not be useful for determining the
appropriate dose of warfarin; one approach is to discontinue rivaroxaban and begin both a
parenteral anticoagulant and warfarin at the time the next dose of rivaroxaban would have
been taken

From rivaroxaban and transitional to rapid-onset anticoagulant: Discontinue


rivaroxaban and five first dose of other anticoagulant at the time the next rivaroxaban dose
would have been taken
Administration
10 mg tablets: May take with or without food
15 mg and 20 mg tablets: Take with food

Patients unable to swallow whole tablets

10 mg, 15 mg, or 20 mg tablets may be crushed and mixed with applesauce


immediately prior to use
After administration of a crushed 15 mg or 20 mg tablet, the dose should be
immediately followed with food
Stable in applesauce for up to 4 hr
Feeding tube administration

10 mg, 15 mg, or 20 mg tablets may be crushed and suspended in 50 mL of water


and administered via NG or gastric feeding tube
Absorption dependent on site of drug release in the gastrointestinal tract (gastric vs
small intestine); avoid administrating distal to the stomach which can result in reduced
absorption and thereby, reduced drug exposure
When administering as a crushed tablet via a feeding tube, confirm gastric placement
of the tube
After administration of a crushed 15 mg or 20 mg tablet, the dose should be
immediately followed by enteral feeding
Stable in water for up to 4 hr
Missed dose

If a dose is not taken at the scheduled time, take as soon as possible on the same
day and continue on the following day with the once-daily regimen as recommended
If taking 15 mg q12hr: Take immediately to ensure intake of 30 mg/day; in this
instance, two 15 mg tablets may be taken at once; continue with regular 15 mg q12hr on
the following day
If taking 10, 15, or 20 mg qDay: Take the missed dose immediately