OBAT

TUBERCULOSIS
KLASIFIKASI
Berdasarkan kelompok pasien
Berdasarkan letak anatomis
Berdasarkan riwayat pengobatan
Berdasarkan hasil pemeriksaan uji kepekaan obat
Berdasarkan status HIV
 TUJUAN TERAPI
Menyembuhkan, mempertahankan kualitas hidup dan
produktivitas pasien
Mencegah kematian akibat TB aktif atau efek lanjutan
Mencegah kekambuhan TB
Mengurangi penularan TB kepada orang lain
Mencegah perkembangan dan penularan resisten obat
 PRINSIP TERAPI
Pemberian bentuk paduan OAT tepat mengandung min. 4 macam
untuk mencegah resistensi
Diberikan dalam dosis yang tepat
Ditelan secara teratur dan diawasi langsung oleh PMO sampai
selesai masa pengobatan
Pengobatan diberikan dalam jangka waktu yang cukup terbagi
dalam tahap awal dan tahap lanjutan untuk mencegah kekambuhan
 FASE INTENSIF
Diberikan setiap hari
Menurunkan jumlah kuman dalam tubuh

A PA N Menimalisir pengaruh sebagian kecil kuman

yang mungkin sudah resisten sejak sebelum

TA H I
diobati

P
Pasien baru --> 2 bulan

TE RA FASE LANJUTAN
Membunuh sisa kuman yang masih ada
dalam tubuh, kuman persisten --> sembuh
dan cegah kekambuhan
Durasi 4 bulan
Obat diberikan setiap hari
DOSIS REKOMENDASI OAT LINI PERTAMA
UNTUK DEWASA
TB KASUS BARU
 STANDARISASI KATEGORI PENGOBATAN

Kategori 1 ... Kasus baru dahak BTA +

Kasus baru dahak BTA - dg kelainan
parenkim paru luas
Kasus baru pd TB di luar PARU yg berat
Kategori 2 … Kambuh ; Gagal terapi
Putus berobat
Kategori 3 … Kasus baru dahak (- ) dg kelainan parenkim
paru yg tidak luas
Kasus TB di luar yg tidak berat
Kategori 4 … Kasus kronik
Regimen Terapi Standard WHO
DEFINISI
HASIL
PENGOBATAN
PENDEKATAN BERDASARKAN GEJALA UNTUK
MENGOBATI EFEK SAMPING DARI OAT
PENDEKATAN BERDASARKAN GEJALA UNTUK
MENGOBATI EFEK SAMPING DARI OAT
ISONIAZID

Drug Interaction
Phenytoin

01.
Monitoring
Routine monitoring is not necessary
For patients with pre-existing liver disease or who
develop abnormal liver function test should be measured
monthly and when symptoms occur

Prevention

02. Vitamin B6 may prevent peripheral

neuropathy and CNS effects
isoniazid
RIFAMPISIN (R)
Derivat rifamycin (rifabutin, rifapentine)
Bakterisid
FD= hambatan DNA dependent RNA polymerase
RIF binds to the β-subunit of the RNAP --> physically blocking the elongation of the growing RNA chain after 2 - 3
nucleotides have been added --> RIF-mediated transcriptional interference which ultimately leads to cell death
FK : absorbsiterbaiksaatperutkosong, mengalamienterohepatic cycle, ekskresilwtfaeces, amanutkpasiendisfungsiginjal,
sbg inducer enzmetab, penetrasibaiklwtsemuamembrantms BBB, amanutkbumil
Ox paling aktif dlmtxlepra
Adverse effects:
Cutaneous reactions
Gastrointestinal reactions
Flu-like syndrome
Hepatotoxicity (paling kecil)
Severe immunologic reactions
Orange discoloration of bodily fluids
Patients should be informed in advance of urine and contact lens discoloration
RIFAMPISIN (R)
ETHAMBUTOL
Bakteriostatik
Ethambutol exhibits bacteriostatic action by specifically targeting multiplying bacilli, which is achieved by affecting the
arabinogalactan biosynthesis in the cell wall
FD: hamb arabinosyl transferase- hamb sintesis arabinogalaktan (komponen dind sel)
ETHAMBUTOL
Adverse effect:
Visual toxicity - Optic neuritis (impaired perception of the red and green
colors). Deficiency in zinc and copper - cause destruction of myelin and glial
cell proliferation in rat optic nerves. Zinc and copper supplements have also
been proposed as a treatment to reduce ethambutol neurotoxicity
Cutaneous reactions
Monitoring
Baseline and monthly tests of visual acuity and color vision
Educate patient about self monitoring their vision and reporting any visual
changes to their physician immediately
PYRAZINAMIDE (P)
Weakly bactericidal – pd kuman yg aktif
FD= PZA difusi msk ke dlm sel, dikonversi mjd pyrazinoic acid (POA). POA
menurunkan pH-hamb sintesis fatty acid, hamb pertumb MTB, kerusakan
membran
PYRAZINAMIDE (P)
Adverse effects:
Hepatotoxicity
GI symptoms
Non-gouty polyarthralgia
Hyperuricemia
Acute gouty arthritis
Rash
Monitoring
Serum uric acid measurements are not routinely recommended
Liver function tests should be performed when the drug is used in patients with
underlying liver disease
Second-Line Anti-TB Medications
Cycloserine
Psychosis, seizures
Ethionamide and PAS
GI upset
Fluoroquinolones
Tendon rupture
Aminoglycosides
Deafness
Renal failure
MONITORING / EVALUASI SELAMA PENGOBATAN

klinis
radiologis
bakteriologik
efek samping
keteraturan minum obat
 EVALUASI
BAKTERIOLOGIS
KAPAN MONITOR BTA SPUTUM ?
MENGATASI EFEK SAMPING BERAT
PENGOBATAN TB
PADA KEADAAN
KHUSUS
TB MILIER
Rawat inap
Paduan obat 2 RHZE/4RH
Pada keadaan sakit berat, pengobatan dapat
2RHZE/7RH
Pemberian kortikosteroid diberikan pada keadaan:
Tanda / gejala menigitis
Sesak napas
Tanda/gejalatoksik
Demamtinggi

Prednison 30-40 mg/hari.

Dosis diturunkan 5-10 mg/hari setiap 5-7 hari,
Lama pemberian 4-6 minggu
EFUSI PLEURA
Paduan obat 2RHZE/4RH atau RHZ/4RH
Evakuasi cairan
Dosis steroid prednison 30-40 mg/hari. Dosis
diturunkan 5-10 mg/hari setiap 5-7 hari, lama pemberian
3-4 minggu
TB PARU DG DM
Paduan OAT : 2 RHZ (E-S)/4 RH dg regulasi gula yang
optimal
Bila kadar gula tidak terkontrolàfaselanjutan 7 bulan : 2
RHZ(E-S)/ 7 RH
Hati-hati dg etambutol: ES di mata
Penggunaan rifampisin dapat menurunkan efektivitas
OAD (sulfonil urea), sehingga dosis perlu dinaikkan
TB PARU DG HIV/AIDS
Paduan (ATS) : RHZE/RH6-9 bulan setelah konversi
dahak
WHO :
Paduan & lama pengobatan = TB paru tanpa HIV/AIDS
TB PARU DG KEHAMILAN DAN MENYUSUI

Tidak ada indikasi pengguguran kehamilan pd penderita

TB dg kehamilan
OAT tetap diberikan kecuali steptomisin
Pend TB menyusui :
OAT & ASI tetap dapat diberikan.
Walau dapat tembus ke dalam ASI àkonsentrasi kecil &
tidak toksik pd bayi
TB PARU DG KELAINAN LIVER

Pemeriksaanfaal hati sebelum pengobatan

Pyrazinamid tidak boleh diberikan
Paduan OAT (WHO) :
2 SHRE / 6 RH atau 2 SHE / 10 HE
Pada hepatitis akut atau klinik ikterik :
tunda OAT sampai sembuh.
Bila diperlukan : beri E dan S maksimal 3 bulan sampai
hepatitisnya sembuh & dilanjutkan 6 RH
Sebaiknyadirujuk
THANK YOU
VERY MUCH!
 OBAT
ANTI
MALARIA
By. dr. TARA MANDIRICHA, M.Si
INDIKASI PENGGUNAAN
Profilaksis
Untuk mencegah serangan klinis
Suppressive prophylaxis
blood schizontocides
Causal prophylaxis
Tissue schizontocides – untuk mencegah parasit
menetap di hepar
INDIKASI PENGGUNAAN
Kuratif
Terapi supresi serangan akut dg blood schizontocides®tdk
terbentuk skizon baru ®tdk terjadi lisis eritrosit®tdk
muncul gx klinis.
Terapi radikal dg kombinasi blood schizontocides dan
tissue schizontocides
Mencegah transmisi
Eradikasi infeksi pada nyamuk dg gametocytocides atau
sporontocides.
Mencegah Relapse
Tissue schizontocid : Primaquine
 Terapi
P falciparum and P malariae P vivax and P ovale
•Invasi ke hepar hanya 1 siklus, infeksi sel Merupakan dormant parasites di
hati berhenti spontan < 4 mgg, hepar --> bisa terjadi relapse.
multiplikasi terbatas pada fase eritrositik
•Dibutuhkan obat untuk eradikasi
saja terapi ditujukan untuk mengeliminasi
parasit hepatis dan parasit eritrositik
parasit fase eritrositik
Tissue schizontocides
PRIMAQUINE
01
Primaquine is a synthetic 8-aminoquinoline.
Primaquine eradicates liver stages of P vivax and P ovale and should be used in conjunction with a
blood schizonticide
Primaquine forms quinoline-quinone metabolites, which are electron-transferring redox compounds
that act as cellular oxidants.

PROGUANIL (CHLORGUANIDE)
02 Ascribed to cycloguanil, a cyclic triazine metabolite (structurally related to pyrimethamine)
and selective inhibitor of the bifunctional plasmodial dihydrofolate reductase–thymidylate
synthetase that is crucial for parasite de novo purine and pyrimidine synthesis

PYRIMETHAMINE
03 Pyrimethamine selectively inhibits the plasmodial form of dihydrofolate
reductase, reducing the production of folic acid required for nucleic acid
synthesis in the malarial parasite
PYRIMETHAMINE
 AQ, Amodiaquine; ART, Artemisinin; ATQ, Atovaquone; AZT, Azithromycin; CQ, Chloroquine; CLD, Clindamycin; CyTb, cytochrome b
complex; dhfr, dihydrofolate reductase; dhps, dihydropteroate synthase; DOX, Doxycycline; ER, endoplasmic reticulum; K13, Kelch 13; LMF,
Lumefantrine; MFQ, Mefloquine; PPQ, Piperaquine; PRG, Proguanil; PYR, Pyrimethamine; QN, Quinine; SDX, Sulphadoxine
Blood-schizonticides
CHLOROQUINE
Chloroquine is a 4-aminoquinoline derivative.

01 Chloroquine accumulates in the food vacuole of plasmodia and prevents polymerization of the
hemoglobin breakdown product heme into hemozoin
Chloroquine is highly effective against the erythrocytic forms of P. vivax in most settings, P. ovale, P.
malariae, P. knowlesi, and chloroquine-sensitive strains of P. falciparum

MEFLOQUINE
02 Mefloquine is a highly effective blood schizonticide
Mefloquine should be reserved for the prevention and treatment of malaria caused by known
or suspected drug-resistant P. falciparum and P. vivax; it is no longer considered first-line
treatment of malaria

QUININE
03 Quinine acts against asexual erythrocytic forms and has no significant effect on hepatic
forms of malarial parasites.
This drug is more toxic and less effective than chloroquine
GAMETOCIDES
Membunuh bentuk seksual dari parasit dan mencegah transmisi ke nyamuk

P. vivax & ovale :

01 Chloroquine, & Quinine

02 P. falciparum: Primaquine

HYPNOZOITOCIDES
Membunuh dormant hypnozoites dari P. vivax & P. ovale di hepar

Primaquine 01
ARTEMISININ
Artemisinin and its three major semisynthetic
derivatives in clinical use, dihydroartemisinin,
artemether, and artesunate, are potent and fast-
acting antimalarials
They are optimized for the treatment of severe P.
falciparum malaria and are also effective against
the asexual erythrocytic stages of P. vivax
For uncomplicated malaria, the standard
treatment approach employs orally administered
artemisinin-based combination therapies (ACTs),
in which the rapid-acting and rapidly eliminated
artemisinin component is paired with a slower-
acting and slower-eliminated partner drug with a
distinct antiparasitic mechanism of action
 ANTI FOLATE
Drugs
BLOOD SCHIZONTICIDES

Pharmacokinetics
The antifolate group includes pyrimethamine,
proguanil, sulfadoxine, and dapsone.
All these drugs are absorbed orally and are
excreted in the urine, partly in unchanged
form. Proguanil has a shorter half-life (12–16 h)
than other drugs in this subclass
(half-life >100 h)
MOA
Sulfonamides act as antimetabolites of p-aminobenzoic
acid (PABA) and block folic acid synthesis in certain
protozoans by inhibiting dihydropteroate synthase.
Proguanil (chloroguanide) is bioactivated to
cycloguanil.
Pyrimethamine and cycloguanil are selective inhibitors
of protozoan dihydrofolate reductases

Presentation by Morgan Maxwell

OTHER ANTIMALARIAL DRUGS
DOXYCYCLINE
01 Tetracycline is chemoprophylactic (taken daily) for travelers to geographical
areas with multidrug-resistant P falciparum. It is sometimes used in
combination with quinine in active falciparum infections

AMODIAQUINE

02
Low cost and, in some geographical areas, effectiveness against chloroquine-resistant
strains of P falciparum
Used in fixed combination with artesunate. Hematologic toxicity, including
agranulocytosis and aplastic anemia, has been associated with the use of amodiaquine

ATOVAQUONE
03
Quinine derivative, a component of Malarone (with proguanil), appears to disrupt
mitochondrial electron transport in protozoa
Malarone is effective for both chemoprophylaxis (taken daily) and treatment of
falciparum malaria
ANTIBIOTICS
DRUGS USED IN THE TREATMENT OF MALARIA