Peran Apoteker dalam Edukasi

Pasien dengan Gangguan

Gastrointestinal

apt. Yovita Diane Titiesari, M.Sc.

Dibawakan dalam Webinar Apoteker Peduli AMR
dan Piogama, 12 Juni 2021
Learning Objectives
• Memahami dan mampu melaksanakan edukasi
kefarmasian kepada pasien dengan gangguan
gastrointestinal
• Memahami dan mampu menerapkan poin-poin
penting dalam edukasi pasien dengan gangguan
gastrointestinal
Outline

Obat gangguan Poin penting dalam edukasi

obat (OTC dan prescribed)
Apoteker dan gastrointestinal pada kasus:
edukasi kepada yang sering - Tukak lambung
- Konstipasi
pasien dijumpai pada - Diare
praktik klinis - Emesis
 Apoteker dan Edukasi Kepada Pasien

• Standar pelayanan kefarmasian:

• Permenkes No. 72 Tahun 2016
tentang Standar Pelayanan Pengelolaan obat,
Kefarmasian di Rumah Sakit alkes, BMHP
• Permenkes No. 73 Tahun 2016
tentang Standar Pelayanan
Kefarmasian di Apotek
• Permenkes No. 74 Tahun 2016 Pelayanan farmasi
tentang Standar Pelayanan
Kefarmasian di Puskesmas
klinis
sebagaimana diubah dengan
Permenkes No. 26 Tahun 2020
 Pelayanan Farmasi Klinik

• Meningkatkan
Pelayanan •
outcome terapi
Meminimalkan risiko
Langsung terjadinya ESO

Oleh Apoteker
kepada pasien

Permenkes No. 72 Tahun 2016 tentang Standar Pelayanan Kefarmasian di Rumah Sakit
 Pelayanan Farmasi Klinik
Rumah Sakit
• Pengkajian dan pelayanan resep
• Penelusuran riwayat penggunaan
obat
• Rekonsiliasi obat
• Pelayanan Informasi Obat
• Konseling
• Visite
• Pemantauan terapi obat
• Monitoring Efek Samping Obat
• Evaluasi penggunaan obat
• Dispensing sediaan steril
• Pemantauan kadar obat dalam
darah
Apotek Puskesmas
• Pengkajian resep • Pengkajian resep,
• penyerahan obat, dan
Dispensing
• Pelayanan Informasi Obat pemberian informasi obat
• Konseling • Pelayanan Informasi Obat
• Pelayanan kefarmasian di • Konseling
rumah (home pharmacy • Ronde/visite pasien (khusus
care) Puskesmas rawat inap)
• Pemantauan terapi obat • Pemantauan dan pelaporan
• Monitoring Efek Samping efek samping obat
• Pemantauan terapi obat
Obat
• Evaluasi penggunaan obat
 Pharmacist and GI Tract

Pharmacists are in an ideal position to support patients

in achieving good GI health - from top to bottom.

Non-prescriptions treatments and triage

Prescribed medicines - ensuring to the best extent
treatment success with fewest side effects

Federation Internationale Pharmacetique, Module CE. FIP ARTICLE Pharmacists : On the front lines of GI Care.
Commonly Used GI Drugs

Drugs for acid-related disorders

OTC/Self

Laxatives medication

Prescribed
Drugs for diarrhea medication

Antiemetics
Acid supressing medications
• Antacids
• Histamine H2 receptor antagonists (H2RAs)
• Proton pump inhibitors (PPIs)

Mucosal defense enhancer

• Sucralfate
• Rebamipide
• Prostaglandins analogue

Goodman&Gilman’s The Pharmacological Basis of Therapeutics 13th Edition

Drugs Strength and form OTC DOWA Prescribed
Antacids Various v x v
Histamine-H2 receptor antagonists (H2RAs)
Ranitidine IV, 50 mg x x v
PO, tab 150 mg x v v
PO, syr 75 mg/5mL x x v
Famotidine PO, tab 20 mg and 40 mg x v v
Cimetidine PO, tab 200 mg x x v
Drugs Strength and form OTC DOWA Prescribed
Proton pump inhibitors
Omeprazole IV, 40 mg x x v
PO, 20 mg x v v
Pantoprazole IV, 40 mg x x x
PO, 20 mg and 40 mg x x v
Lansoprazole IV, 30 mg x x v
PO, 30 mg x x v
Esomeprazole IV, 40 mg x x v
PO, 20 mg and 40 mg x x v
Rabeprazole PO, 10 mg and 20 mg x x v
 Case study: GERD
More than 60 million
adult Americans have Rule out any alarming
heartburn at least once Asking questions related symptoms advice
a month and 60% to GERD attribution patient to seek medical
choose an over-the attention ASAP
counter medication

Advice on lifestyle
Active listening!
modifications

Sheen CL, Colin-Jones DG. Review article: Over-the-counter drugs and the gastrointestinal tract. Aliment Pharmacol Ther. 2001;15(9):1263-1270.
MacFarlane B. Management of gastroesophageal reflux disease in adults: a pharmacist perspective. Integr Pharm Res Pract . 2018;Volume 7:41-52
Case study: GERD
Question about Remarks
Age GERD in pts >65 y.o. maybe an alarming conditions
Symptoms - Burning sensation
- Beginning in the midpoint of the abdomen and rising toward
the throat
- Rising of food into throat/mouth
- Happened after large meal, or fatty meal, or after bending
Duration of symptoms Days / weeks / months / years
Frequency of symptoms Daily, <3 times per week, >3 times per week
History of any other health E.g. gastric ulcer
condition
Any medications consumption E.g. NSAID
Already take any meds? Yes/no
MacFarlane B. Management of gastroesophageal reflux disease in adults: a pharmacist
perspective. Integr Pharm Res Pract. 2018;Volume 7:41-52
Case study: GERD
• If pts having any alarming symptoms  refer to physician
• E.g.:
 Darkened bowel motions
 Vomiting blood
 Crushing chest pain
 Frequent vomiting
 Weight loss
 Difficulty swallowing
 Severe abdominal pain
OTC meds for GERD: for a duration of 14 days  refer to physician if symptoms
persist
MacFarlane B. Management of gastroesophageal reflux disease in adults: a pharmacist perspective. Integr
Pharm Res Pract. 2018;Volume 7:41-52
Pharmacist education for self medication for GERD
Choice of agents

Medication class Benefits Considerations

Antacids • Fast relief of mild, intermittent heartburn • Insufficient for moderate and
• Faster onset than H2RAs frequent heartburn
• Safety  decades of use • Frequent dosing
• Inexpensive • Drug interactions
H2RAs • More effective than antacids • Slower onset of action vs
(INA: ranitidine 150 • Longer duration of action antacids
mg tab, DOWA) • Faster onset of symptoms relief than PPIs • Less effective vs PPIs
PPIs • Mainstay of acute management and • Full effect takes several days
(INA: omeprazole 20 maintenance treatment for reflux disorder of dosing
mg caps, DOWA max • Most potent medications for gastric acid • Possible drug interactions
7 caps) suppression
Simonson W. Implications of over-The-counter proton pump inhibitors for patient counseling by pharmacists. Am J Ther. 2013;
20(6):676-684.
Dosing guidance and possible drug interactions

Antacids
• Suspension preparation is preferred vs tablet or powder  probably
greater effect of acid suppression
• Time to take: after food or at bedtime
- Antacid on empty stomach: neutralizing effect around 30 minutes
- Antacid with food: neutralizing effect around 2 – 3 hours 
elevated gastric pH
• Possible drug-drug interactions: gefitinib, mefenamic acid,
mycophenolate, phenytoin, pazopanib, etc.
Goodman&Gilman’s The Pharmacological Basis of Therapeutics 13th
Edition
Dosing guidance and possible drug interactions

H2RAs
• Take 30 to 60 minutes before food
• Possible drug-drug interactions:
- Ranitidine: erlotinib, gefitinib, pazopanib, tacrolimus, etc.
- Famotidine: QT prolongation
- Cimetidine: phenytoin

Sheen CL, Colin-Jones DG. Review article: Over-the-counter drugs and the gastrointestinal tract. Aliment Pharmacol Ther. 2001;15(9):1263-1270
Simonson W. Implications of over-The-counter proton pump inhibitors for patient counseling by pharmacists. Am J Ther. 2013;20(6):676-684
 Dosing guidance and possible drug interactions
Proton pump inhibitors ONCE DAILY DOSING for PPI
• Enteric coated formulation to prevent
degradation by gastric acid  do not Omeprazole • morning
crush or opened and • evening dose might be beneficial
• Esomeprazole  some brand rabeprazole for pts with nocturnal reflux
formulation is meant to be dispersed
in water Esomeprazole
• any time of the day,
• Generally PPI is administered 30-60
depends on symptoms
minutes BEFORE food  food is
affecting PPI absorption
Pantoprazole • morning
• Possible drug interaction:
clopidogrel (pantoprazole and
lansoprazole seems to least
Lansoprazole
• morning dose might
interacted)
Wiesner A, Zwolińska-Wcisło M, Paśko P. Effect of food and dosing regimen on safety and
efficacy of proton pump inhibitors therapy—a literature review. Int J Environ Res Public Health .
enhance bioavailability
2021;18(7).
Dosing guidance and possible drug interactions

Sucralfate
• Better to consume at empty stomach (1 hr AC or 2 hr PC)
• Shake well before use
• Use measuring spoon or glass
Lifestyle modification

Avoiding
Avoiding
lying Elevating
triggers
Weight Smoking down 2-3 head
(food,
loss cessation hours when
beverage
after sleeping
s)
meals

MacFarlane B. Management of gastroesophageal reflux disease in adults: a pharmacist

perspective. Integr Pharm Res Pract. 2018;Volume 7:41-52
Simonson W. Implications of over-The-counter proton pump inhibitors for patient counseling by
pharmacists. Am J Ther. 2013;20(6):676-684.
Agents of choice
Medication class Examples OTC Onset of action Remarks
Bulk-forming Psyllium v 24 hours
laxatives
Stimulant • Bisacodyl v Tab: 6 – 10 hours Sometimes cause cramps
laxatives • Senna Supp: 15 – 60
minutes
Osmotic laxatives • Lactulose v Lactulose: 12 – 72 Patient needs to drink
• Polyethyleneglyc hours sufficient water
ol (PEG)
• Glycerine
Stool softener Sodium docusate v 12-72 hours Efficacy is questionable?
Krinsky, D. 2020. OTC Today: Constipation. www.pharmacist.com
Jin J. Over-the-counter Laxatives. JAMA. 2014;312(11):1167
Points of counselling

OTC Proper Special

laxatives are 3F: administratio population:
Should not
for short n of geriatric,
Fiber – Fluid be used for
period of suppositorie pregnant
– Fitness weight loss
time (FDA: 7 s and women,
days) enemas children

Krinsky, D. 2020. OTC Today: Constipation. www.pharmacist.com

Jin J. Over-the-counter Laxatives. JAMA. 2014;312(11):1167
Choice of agents
Agents OTC Remarks
Loperamide X • Max dose: 16 mg daily
• Max duration: 48 hours
• Possible drug interaction: QT prolongation
• Not to be used in diarrhea caused by: Salmonella, Clostridium difficile,
Shigella, acute dysentery  increasing colitis severity

Attapulgite V • Absorbent: 2 hours apart from other drug / nutrition

• 2 tablets after defecation, Max dose: 12 tablet/day

www.accessdata.fda.gov
www.mims.com/indonesia/
Product information New Diatabs® dan Enterostop®
Pharmacist education
Antiemetic Example OTC Counselling points
class
Dopamine Domperidone x Taken on empty stomach  food is delaying absorption
antagonist
Metoclopramide DOWA
Antihistamines Dimenhydrinate v Drowsiness side effects
Serotonin 5- Ondansetron x • 30 – 60 minutes prior to chemo or radiotherapy
HT3 • Possible QT prolongation effect  drug-drug
antagonists interaction

StatPearls, MIMS, Micromedex Drug Ref.

Take Home Messages
GI problems are quite common
Pharmacist has prominent roles on ensuring safety and
efficacy of GI medications  by giving sufficient education
to patients
Both for self-medication (OTC) or prescribed medications
For OTC: giving advice on choosing the right treatment
and to refer to physician when there are alarming
symptoms
For prescribed meds: ensuring safety, right time and way
to consume meds, possible drug interaction, addressing
other DRPs
References
1. Permenkes No. 72 Tahun 2016 tentang Standar Pelayanan Kefarmasian di Rumah Sakit
2. Goodman&Gilman’s The Pharmacological Basis of Therapeutics 13th Edition
3. MacFarlane B. Management of gastroesophageal reflux disease in adults: a pharmacist&rsquo;s perspective.
Integr Pharm Res Pract. 2018;Volume 7:41-52. doi:10.2147/iprp.s142932
4. Sheen CL, Colin-Jones DG. Review article: Over-the-counter drugs and the gastrointestinal tract. Aliment
Pharmacol Ther. 2001;15(9):1263-1270. doi:10.1046/j.1365-2036.2001.01042.x
5. Simonson W. Implications of over-The-counter proton pump inhibitors for patient counseling by pharmacists.
Am J Ther. 2013;20(6):676-684. doi:10.1097/MJT.0b013e318217a5d1
6. Federation IP, Module CE. FIP ARTICLE Pharmacists : On the front lines of GI Care.
7. Wiesner A, Zwolińska-Wcisło M, Paśko P. Effect of food and dosing regimen on safety and efficacy of proton
pump inhibitors therapy—a literature review. Int J Environ Res Public Health. 2021;18(7). doi:10.3390/
ijerph18073527
8. Jin J. Over-the-counter Laxatives. JAMA. 2014;312(11):1167. doi:10.1001/jama.2014.2078
9. Krinsky, D. 2020. OTC Today: Constipation. www.pharmacist.com
10.MIMS Online
11.StatPearls – NCBI