MESA SUKMADANI RUSDI, M.SC.

, APT
farmasi universitas dharma andalas
 Anonim, 2009, Informatorium Obat Nasional Indonesia (IONI), Dep. Kesehatan RI,
Jakarta
 Dipiro, J.T., Talbert, R.L., Yee G.C., Matzke G.R., Wells A.G., Posey L.M. 2011,
Pharmacotherapy : A Pathophysiologic Approach, 8thEd, Appleton & Lange, Stamford
 Goodman & Gilman’s, 1991, The Pharmacological basic of therapeutic, Mc Graw- Hill
 Herfindal, ET., Gourley, DR., 2000, Textbook of Therapeutics, Drug and Disease
 Management, 7th Ed., Lippincot & Williams, Philadelphia
 Koda-Kimble, M.A., Young, L.Y., Alldredge, B.K., Corelli,R.L., Guglielmo, B. J.,
Kradjan, W.A., Williams, B.R., 2009, Applied Therapeutics: The Clinical Use Of Drugs,
9 thEd, Lippincott Williams & Wilkins,
 McPhee S.J. Hammer G.D., 2010, Pathophysiology of Disease : An Introduction to
 Clinical Medicine, 6rd Ed, The McGraw-Hill Companies Inc, New York
 O’Grady F, Lambert HP, Finch, RG, Greenwood D, 1997, Antibiotic and
Chemotherapy : Anti-infective agents and their use in therapy, 7 th, Churchill
Livingstone
 Scwinghammer TL., 2002, Pharmacotherapy Casebook : A Patient Focused Approach,
5th Ed., McGraw-Hill, Pennsylvania 7
 ISO, MIMS, DOI terbaru, jurnal-jurnal terkait
 Geriatri ; orang dengan umur lebih dai 65 tahun
 Umur yang sudah tua; mempengaruhi farmakodinamik dan
farmakokinetik obat
 Tujuan farmakoterapi pada orang tua adalah meningkatkan dan
menjaga kesehatannya
 Karena banyak menggunakan obat (polifarmasi);; banyak terjadi
masalah terkait obat;; drug related problems/ DRP
 Farmasis dapat memerankan peran utama dengan pengoptimalan
terapi obat dan penghindaran DRP
 Memiliki 5 – 10 diagnosis ex hipertensi, jantung coroner,
osteoarthritis, osteoporosis, dm tipe 2 pikun, Alzheimer,
depresi, insomnia, dll
 Penggunaan obat meningkat ;; polifarmasi
 Interaksi obat yang potensial
 Efek samping obat yang potensial
 Farmakodinamik dan farmakokinetik pada geriatric ;; mengalami
perubahan seiring dengan waktu.
 Farmakokinetik/ADME pada orang tua berpengaruh terhadap
umur; yang paling penting secara klinis adalah pengeluaran
obat pada eliminasi di ginjal
 Absorbsi ; melambatnya gerakan peristaltic dan waktu
pengosongan lambung ;; memperlambat absorbsi di GI,
terutama pada obat lepas lambat ;; lambat waktu absobsi
mengakibatkan lamanya waktu untuk obat menimbulkan efek;;
tapi tidak mengubah jumlah obat yang diabsorbsi
 • Geriatri minum lebih banyak obat. 87 persen pasien dengan umur 75 th, mengkonsumsi obat; 34
% mengkonsumsi 3 – 4 obat.
• Obat yang paling banyak di konsumsi adalah diuretic 34%, analgetik 27%,
• Eliminasi obat menjadi kurang efisien seiring bertambahnya umur
• Mekanisme homeostatis menjadi kurang efektif dengan bertambahnya umur, jadi tubuh kurang
bias melakukan kompensasi terhadap efek samping
• SSP menjadi lebih sensitive terhadap obat sedative

 Pharmacokinetic changes in the elderly include:  There is reduced hepatic clearance of long
half-life benzodiazepines.
 Absorption of iron, calcium and thiamine is
reduced.  Declining renal function is the most important
cause of
 There is an increased volume of distribution of
fat-soluble drugs (e.g. diazepam).  drug accumulation.
 There is a decreased volume of distribution of
polar drugs (e.g. digoxin).
 Distribusi; perubahan fisiologi yang paling mendasar pada geriatric
adalah perubahan lemak, air dan protein plasma.
 Massa otot pada geriatric menurun 12 – 19 persen;; obat di dalam darah
utamanya didistribusikan ke massa otot sehingga terjadi peningkatan
konsenterasi plasma ;; risiko overdosis
 Massa otot berkurang, massa lemak bertambah;; wanita 33 – 45 persen,
pria 18 – 36 persen
 Obat larut lemak ex.diazepam, amiodaron, verapamil mengalami
peningkatan volume distribusi (Vd);;peningkatan konsenterasi jaringan
obat dan memperpanjang durasi aksi ;; meningkatkan t ½ ;;
 Total air dalam tubuh berkurang 10 – 15 persen;; menurunkan Vd obat
larut air ;; meningkatkan konsenterasi plasma obat.;; efek toksik bisa
terjadi jika dehidrasi dan pengurangan cairan ekstraseluler pada
penggunaan diuretik
 Metbolisme; metabolism obat dipengaruhi oleh umur, penyakit akut
dan kronis, dan interaksi obat
 Hati merupakan tempat metabolism utama tubuh yang menurun
sesuai umur, sehingga menurunkan metabolism berbagai obat
 Liver mass is reduced by 20% to 30% with advancing age, and hepatic
blood flow is decreased by as much as 40%. These changes can
drastically reduce the amount of drug delivered to the liver per unit of
time, reduce metabolism, and increase the half-life. Metabolic
clearance of some drugs is decreased by 20% to 40% (eg,
amiodarone, amitriptyline, warfarin, and verapamil), but it is
unchanged for drugs with a low hepatic extraction.
 Ekskresi; the clinically most important pharmacokinetic
change in the elderly is the decrease in renal drug
elimination. As people age, renal blood flow, renal mass,
glomerular filtration rate, filtration fraction, and tubular
secretion decrease. After age 40, there is a decrease in the
number of functional glomeruli, and renal blood flow
declines by approximately 1% yearly.
 Clinically significant effects of decreased renal clearance
include prolonged drug half-life, increased serum drug
level, and increased potential for adverse drug reactions
(ADRs).
 Renal excretion: the GFR falls with age
 At 80 years the GFR is 60 -70 ml/min
 Tubular function also falls with age
 Drug excreted mainly in the urine are required reductions in dosage: digoxin,
gentamicin & other aminoglycosides, lithium, and procainamide.
 Reduction of renal excretion is also shown for furosemide
 Some drugs are avoided for old people: tetracyclines accumulate when renal
function is poor causing nausea and vomiting, which in turn causes dehydration, and
may cause further deterioration of renal function
 Tetracyclines also have antianabolic action: worsens uraemia and promote muscle
wasting.

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PHARMACODYNAMIC FACTORS
 Altered sensitivity to drugs
 Receptor sensitivity: some people are more sensitive to the effect of digoxin,
probably because of increased sensitivity of their Na/K-ATPase. Combined
with the increased susceptibility to K loss due to diuretics and their reduced
renal function, make them more liable to digitalis toxicity.
 β-adrenoceptor sensitivity reduced: terbutalin (agonist)
 Pharmacodynamic changes in the elderly include:
 increasedsensitivity to central nervous system (CNS) effects (e.g.
benzodiazepines, cimetidine);
 increased incidence of postural hypotension (e.g. phenothiazines, beta-
blockers, tricyclic antidepressants, diuretics);
 reduced clotting factor synthesis, reduced warfarin for anticoagulation;
 increased toxicity from NSAIDs;
 increased incidence of allergic reactions to drugs.
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 Altered physiological response: anti hipertension nifedipine
 Increased sensitivity to warfarin
 Increased responsiveness of the brain to centrally active
drugs: hypnotics, sedatives, tranquillizers, antidepressants,
and neuroleptic drugs

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 KREATININ SERUM DAN CLEARANCE
 Pada umumnya, produksi creatinine sama dengan eksresi creatinine.
 Padapasien yang dengan penurunan flitrasi glomerulus, serum kreatinin
mengalami akumulasi sebanding dengan derajad kerusakan GFR.
 Serum kreatinin juga digunakan untuk mengukur klirens kreatinin
 Klirens kreatinin didefinisikan sebagai voulume bersih plasma dari kreatinin dibagi
unit waktu.
 Dapat dihitung dengan membagi kecepatan ekskresi kreatinin dibagi dengan
konsentrasi kreatinin (ml/min)
 Dapat juga dihitung dengan membandingkan serum kreatinin dan klirens kreatinin
dalam 24 jam
 Incomplete compliance is extremely common in elderly people.
 This is commonly due to a failure of memory or to not understanding how
the drug should be taken. In addition, many patients store previously
prescribed drugs in the medicine cupboard which they take from time to
time.
 It is therefore essential that the drug regimen is kept as simple as
possible and explained carefully. There is scope for improved methods of
packaging to reduce over- or under-dosage. Multiple drug regimens are
confusing and increase the risk of adverse interactions
 Common-sense rules for prescribing do not apply only to the elderly, but are especially
important in this vulnerable group
 Take a full drug history (see Chapter 1), which should include any adverse reactions and use
of over-the-counter drugs.
 Know the pharmacological action of the drug employed.
 Use the lowest effective dose.
 Use the fewest possible number of drugs the patient needs.
 Consider the potential for drug interactions and co-morbidity on drug response.
 Drugs should seldom be used to treat symptoms without first discovering the cause of the
symptoms (i.e. first diagnosis, then treatment).
 Drugs should not be withheld because of old age, but it should be remembered that there is
no cure for old age either.
 A drug should not be continued if it is no longer necessary.
 Do not use a drug if the symptoms it causes are worse than those it is intended to relieve.
 It is seldom sensible to treat the side effects of one drug by prescribing another.