Kasus: Fitoterapi pada gangguan saluran pencernaan.

Seorang pasien Ny.WP (53 thn) datang ke klinik saintifikasi jamu untuk berkonsultasi tentang
obat bahan alam yang bisa digunakan untuk menurunkan tekanan darah pasien. Hasil assesment:
pasien mengkonsumsi spironolactone (100 mg)2 dd 1 dan ibuprofen (400 mg)3 dd 1, untuk
artritis pada pinggul, lutut, dan tangan. Pasien mengkonsumsi licorice untuk menurunkan
progresivitas penyakit peptic ulcer akibat pemakaian aspirin (sebelum ibuprofen). Pasien juga
mengkonsumsi Aloe vera karena sering mengalami konstipasi.
Hasil pemeriksaan :
6 bulan yang lalu : Tekanan darah pasien adalah 116/78 mmhg dan kadar kalium 4,5 mEq/L
(dosis spironolactone 50 mg 2dd1).
2 minggu yang lalu : Tekanan darah pasien adalah 140/90 mmHg; Kadar kalium 3,5 mEq/L.
Dokter meningkatkan dosis spironolakton menjadi 100 mg 2dd1 (sebelumnya 50 mg, 2dd1),
pasien diberi resep suplemen kalium dan diminta untuk kontrol kembali dalam 2 minggu.
Pasien berkonsultasi kepada anda mengenai obat bahan alam yang secara alami dapat
menurunkan tekanan darah dan meningkatkan kadar kalium. Dari hasil assesment diketahui
pasien tidak menginformasikan kepada dokter mengenai penggunaan licorice dan Aloe vera
karena tidak ditanya.

Pertanyaan:
1. Jelaskan mengapa pasien mengalami penurunan kadar kalium serum?
Glycyrrhetic acid, the active metabolite in licorice, inhibits the enzyme11--
hydroxysteroid dehydrogenase enzyme type 2 with a resultant cortisol-
inducedmineralocorticoid effect and the tendency towards the elevation of sodium and
reduction ofpotassium levels. This aldosterone-like action is the fundamental basis for
understanding itshealth benefits and the wide spectrum of adverse effects.

Licorice root (Glycyrrhiza spp) can cause sodium and fluidretention and potassium loss.
This effect only occurs withextended use at high doses and can be minimised by a
highpotassium diet. An adult dose equivalent to 3 g/day shouldnot cause this problem
(kimble, 2013)

Typical adult dosage ranges are:

l 3 to 12 g/day of dried root and stolon or by decoction orinfusion
l 2 to 6 mL/day of a 1:1 liquid extract
1.5 to 4.5 mL/day of a 1:1 high glycyrrhizin liquid extractor its equivalent in tablet or
capsule form
 1.2 to 4.8 mL/day of deglycyrrhizinised licorice extract BPor its equivalent as a dry
extract.

The Commission E indicates that, when licorice is used asa flavouring component, a
maximum daily dosage of less than100 mg glycyrrhizin is acceptable.

Higher doses of licorice should not be consumed long term.The Commission E advises
that licorice should not be takenfor longer than 6 to 8 weeks without professional
supervision.(This relatively short time restriction is probablyrelated to the high dose of
licorice recommended by theCommission E: 5 to 15 g of root, equivalent to 200 to 600
mgof glycyrrhizin. For dosages at the lower end of the range recommendedabove,
licorice can be administered for a longertime period without risk of side effects.)

Since higher doses can cause an aldosterone-like side effect,licorice must be taken within
the recommended therapeuticrange. Careful assessment of the patients blood pressure
andother medications is required before prescribing licorice. Ahigh potassium and low
sodium intake will minimise the riskof this adverse reaction. Use of high doses of licorice
shouldnot be recommended in conjunction with digoxin and potassium-
losing drugs such as laxatives and thiazide diuretics.

Licorice (Glycyrrhetic acid) yang mengandung senyawa yang bekerja mirip aldosterone
dapat menyebabkan hipokalemi ketika digunakan berlebihan dengan menghambat enzim
11-beta hidroksisteroid dehidrogenase

ALOE who monograph vol 1 dapat menyebabkan hipokalemi jika pemakaian

jangka panjang. Dan juga dapat menginduksi hipokalemi jika digunakan bersamaan
dengan obat-obatan diuretik thiazide, adrenocorticosteroids dan licorize. Long-term
laxative abuse may lead to electrolyte disturbances (hypokalaemia, hypocalcaemia),
metabolic acidosis, malabsorption, weight loss, albuminuria, and haematuria. Weakness
and orthostatic hypotension may be exacerbated in elderly patients when stimulant
laxatives are repeatedly used

IBUPROFEN merupakan golongan NAID yang dapat meningkatkan resiko efek

samping di GI seperti pendarahan, ulceration, dan perforasi usus/intestinal. ES :
konstipasi 1-3%, epigastric pain 3-9%, retensi cairan 1-3%, vomit 1-3%.

2. Apakah obat bahan alam yang digunakan oleh Ny.WP untuk mengatasi peptic ulcer dan
konstipasi sudah tepat ? Jelaskan alasannya berdasarkan hasil analisa saudara terhadap
kondisi fisik Ny.WP!
Tidak, karena licorice menunjukkan efek samping yaitu HT dan hipokalemi. Jadi
sebaiknya diberikan golongan lain. Dan aloe dapat berinteraksi dengan licorize sehingga
meneybabkan pasien hipokalemia. Pemakaian aloe 1-2 minggu tidak boleh lebih. Jika
pemakaian dalam jangka panjang dapat menyebabkan ketidakseimbangan elektolit.
LICORIZE
Contraindications
Radix Glycyrrhizae is contraindicated in patients with hypertension, cholestaticdisorders
or cirrhosis of the liver, hypokalaemia, or chronic renal insufficiency,and during
pregnancy

Warnings
Prolonged use of large doses (>50g/day) of the drug for extended periods (>6weeks) may
increase water accumulation, causing swelling of the hands andfeet. Sodium excretion is
reduced and potassium excretion is increased. Bloodpressure may rise.

Drug interactions
Because it increases potassium loss, Radix Glycyrrhizae should not be administeredfor
prolonged use with thiazide and loop diuretics or cardiac glycosides. Because it reduces
sodium and water excretion, the effectiveness of drugsused in the treatment of
hypertension may be reduced. Radix Glycyrrhizaeshould not be administered in
conjunction with spironolactone or amiloride

ALOE
Contraindications
As with other stimulant laxatives, products containing Aloe should not be usedin patients
with intestinal obstruction or stenosis, atony, severe dehydrationwith electrolyte
depletion, or chronic constipation. Aloe should not beadministered to patients with
inflammatory intestinal diseases, such as appendicitis,Crohn disease, ulcerative colitis,
irritable bowel syndrome, ordiverticulitis, or to children under 10 years of age. Aloe
should not be usedduring pregnancy or lactation except under medical supervision after
evaluatingbenefits and risks. Aloe is also contraindicated in patients with cramps,
colic,haemorrhoids, nephritis, or any undiagnosed abdominal symptoms such aspain,
nausea, or vomiting.
Warnings
Aloe-containing products should be used only if no effect can be obtainedthrough a
change of diet or use of bulk-forming products. Stimulant laxativeproducts should not be
used when abdominal pain, nausea, or vomiting arepresent. Rectal bleeding or failure to
have a bowel movement within 24 hoursAloeafter use of a laxative may indicate a serious
condition. Chronic use may causedependence and need for increased dosages,
disturbances of water and electrolytebalance (e.g. hypokalaemia), and an atonic colon
 with impaired function.The use of stimulant laxatives for more than 2 weeks requires
medicalsupervision.Chronic abuse with diarrhoea and consequent fluid and electrolyte
losses(mainly hypokalaemia) may cause albuminuria and haematuria, and may resultin
cardiac and neuromuscular dysfunction, the latter particularly in the case ofconcomitant
use of cardiac glycosides (digoxin), diuretics, corticosteroids, orliquorice root (see
Precautions below).

Precautions
General
Laxatives containing anthraquinone glycosides should not be used continuouslyfor longer
than 12 weeks, owing to the danger of electrolyte imbalance.
Drug interactions
Decreased intestinal transit time may reduce absorption of orally
administereddrugs.Existing hypokalaemia resulting from long-term laxative abuse can
potentiatethe effects of cardiotonic glycosides (digitalis, strophanthus) and
antiarrhythmicdrugs such as quinidine. The induction of hypokalaemia bydrugs such as
thiazide diuretics, adrenocorticosteroids, and liquorice root may
be enhanced, and electrolyte imbalance may be aggravated.

3. Jika obat bahan alam yang digunakan Ny.WP kurang tepat, berikan rekomendasi obat
bahan alam untuk mengatasi peptic ulcer dan konstipasi pada Ny.WP ? (beserta senyawa
aktif, dosis, bentuk sediaan dan lama pemakaian)

Foeniculum (fennel) improve gastrointestinal motility

Indikasi Carminative, spasmolytic, galactagogue, oestrogenic,

antimicrobial,expectorant.
 PreparationsFruit as a decoction, syrup (including honey), liquidextract, essential oil
and tablets or capsules for internal use.Decoction, extract or essential oil for topical
use.As with all essential oil-containing herbs, use of the freshplant or carefully dried herb
is advised. Keep covered if infusingthe herb to retain the essential oil

Dosage
l 900 to 1800 mg/day of the dried fruit or as an infusion
3 to 6 mL/day of 1:2 liquid extract, 7 to14 mL/day of 1:5tincture or equivalent in tablet or
capsule forml 5 to 20 drops/day of the essential oil.
Duration of useThe Commission E advised that fennel preparations shouldnot be taken
for more than several weeks without medicaladvice.14 Despite this unexplained caution,
fennel is safe foruse in the long term, although prolonged intake should beavoided in
children due to potential oestrogenic side effects.
Gentiana trophic effect on the gastric mucous membrane

Golden seal restorative to mucous membranes

Indikasi : Hydrastis canadensis: stomachic, reputed oxytocic,

antihaemorrhagic,anticatarrhal, trophorestorative for mucousmembranes, antimicrobial,
bitter, anti-inflammatory, depurative,vulnerary, choleretic

PreparationsDried or fresh stem bark or root bark (Berberis) or rhizome and rootlets
(Hydrastis) for decoction, liquid extract, tincture tablets and capsules for internal or
external use.

Dosis Hydrastis canadensis: 0.7 to 2 g/day of the dried rhizome/ root or 2 to 5 mL/day
of the 1:3 tincture; 3.5 to 8.0 mL/day of the 1:5 tincture. Equivalent herb doses can also
be taken in tablet or capsule form.long term within the recommended dosage.

Kandungan : Contains not less than 2.0% hydrastine and not less than 2.5%
berberinedetermined by high-performance liquid chromatography (3).

Major chemical constituentsThe major constituents are isoquinoline alkaloids (2.5

6.0%), principallyhydrastine (1.55.0%), followed by berberine (0.54.5%), canadine
(tetrahydroberberine,0.51.0%), and lesser quantities of related alkaloids
includingcanadaline, corypalmine, hydrastidine and jatrorrhizine. The structures of
hydrastine, berberine and canadine (a mixture of-canadine (R-isomer) and -canadine
(S-isomer))
 Linseed (bulk laksatif)
Indikasi konstipasi
Lama pemakaianBulk laxatives need to be taken whole as powdered
material,most conveniently in capsule form, with food.Long-term therapy with
extra supplementation of solublefibre is not always advisable and both soluble
and insolublefibre intake should be reviewed where absorption of
mineralnutrients is a critical issue.

4. Rekomendasi apa yang perlu saudara sampaikan kepada dokter yang merawat Ny.WP
terkait terapi yang saat ini diterima oleh Ny.WP ?
- Ibuprofen dihentikan atau dapat diganti dengan obat lain selain golongan NSAID
karena dapat menginduksi peptic ulcer

- Diassesment lebih dalam mengenai terapi yang digunakan termasuk fitoterapi yang
digunakan karena dimungkinkan terjadinya interaksi antara obat yang diresepkan
dengan obat fiterapi yang digunakan dengan pasien
- Diturunkan dosis spironolakton mjd 50 mg 2 dd 1 di monitoring selama 6 minggu

5. Berikan rekomendasi terapi nonfarmakologi untuk Ny.WP !

 - Menghindari stres

- Menghindari obat-obatan yang memicu PUD seperti NSAID

- Menghindari makanan berserat dan berlemak

- Menjaga pola makan

ALOEwho monograph vol 1 dapat menyebabkan hipokalemi jika pemakaian jangka

panjang. Dan juga dapat menginduksi hipokalemi jika digunakan bersamaan dengan obat-obatan
diuretik thiazide, adrenocorticosteroids dan licorize. Long-term laxative abuse may lead to
electrolyte disturbances(hypokalaemia, hypocalcaemia), metabolic acidosis, malabsorption,
weight loss, albuminuria, and haematuria. Weakness and orthostatic hypotension may be
exacerbated in elderly patients when stimulant laxatives are repeatedly used

Short-term treatment of occasional constipation

Aloe contains as its major and active principles hydroxyanthrone derivatives, mainly of the aloe-
emodin-anthrone 10-C-glucoside type. The major constituent is known as barbaloin (aloin) (15
40%). It also contains hydroxyaloin (about 3%). Barbaloin (_aloin) is in fact a mixture of aloin A
(10S) [1] and B (10R). A. ferox also contains aloinoside A [3] and B [4]. Aloin A and B
interconvert through the anthranol form as do aloinoside A and B

Aloes mechanism of action is twofold. It stimulates colonic motility, augmenting propulsion and
accelerating colonic transit, which reduces fluid absorption from the faecal mass. It also
increases paracellular permeability across the colonic mucosa probably owing to an inhibition of
Na_, K_-adenosine triphosphatase or to an inhibition of chloride channels, which results in an
increase in the water content in the large intestine