PENGGUNAAN

OBAT RASIONAL
apt. Annisa Primadiamanti, S. Farm., M.Sc
■ Proses pelayanan pasien adalah suatu metode yang sistematik dan komprehensif dan
digunakan untuk mengidentifikasi, menyelesaikan, dan mencegah problema problema
dalam terapi obat.
■ Suatu problema terapi obat adalah suatu aspek terapi obat pada pasien yang
mengganggu hasil terapi pasien yang positif dan yang diinginkan.
■ Problema terapi obat = Drug Related Problems (DRPs)
 Proses Pelayanan Pasien
- Terapi non-
Keluhan pasien Diagnosis (oleh dokter) Pemberian terapi farmakologi
- Terapi farmakologi

Peresepan

Outcome :
- Efek yang dikehendaki
Penggunaan obat - Dispensing
MESO (efek farmakologi)
- ADR oleh pasien - Konseling
Asesmen terhadap Kebutuhan Pasien
akan Obat
■ Langkah pertama  mengumpulkan, menyusun dan mengintegrasikan informasi
tentang pasien, obat dan penyakit pasien.
■ Pasien merupakan sumber informasi primer.
■ Informasi dapat diperoleh dari pasien, anggota keluarga pasien dan rekam medik.
Tipe-tipe Informasi yang Relevan

■ Informasi tentang pasien;

– Demografi dan latar belakang (umur, jenis kelamin, bobot, tinggi badan)
– Riwayat sosial (lifestyle, pekerjaan, kebutuhan spesifik lainnya)
– Riwayat keluarga
– Informasi asuransi
■ Informasi tentang penyakit;
– Riwayat penyakit lalu, penyakit sekarang dan diagnosis
■ Informasi tentang obat
– Alergi obat
– Efektivitas dan efek samping obat-obat yang digunakan
– Obat-obat dengan dan tanpa resep yang pernah digunakan
Drug Related Problem (DRPs) atau
Problema Terapi Obat
■ Kerasionalan pemberian obat pada pasien sebenarnya dapat dicapai dengan memenuhi
segala kebutuhan pasien akan obat tersebut.
■ Bila kebutuhan pasien akan obat itu tidak terpenuhi, maka problema terapi obat akan
muncul.
 Pemantauan Terapi Obat
• Pemantauan Terapi Obat (PTO) merupakan suatu proses yang
mencakup kegiatan untuk memastikan terapi Obat yang aman,
efektif dan rasional bagi pasien.
• Kegiatan tersebut mencakup: pengkajian pilihan obat, dosis, cara
pemberian obat, respons terapi, reaksi obat yang tidak dikehendaki
(ROTD), dan rekomendasi perubahan atau alternatif terapi.
• Tujuan PTO adalah meningkatkan efektivitas terapi dan
meminimalkan risiko Reaksi Obat yang Tidak Dikehendaki
(ROTD).
• Pemantauan terapi obat harus dilakukan secara berkesinambungan
dan dievaluasi secara teratur pada periode tertentu agar
keberhasilan ataupun kegagalan terapi dapat diketahui.
 Kegiatan dalam PTO
• Pengkajian pemilihan Obat, dosis, cara
pemberian Obat, respons terapi, Reaksi
Obat yang Tidak Dikehendaki (ROTD);
• Pemberian rekomendasi penyelesaian
masalah terkait Obat; dan
• Pemantauan efektivitas dan efek samping
terapi Obat.
TATA LAKSANA/TAHAPAN
PTO
• Seleksi Pasien
• Pengumpulan Data Pasien
• Identifikasi Masalah Terkait Obat
(DRPs)
• Rekomendasi Terapi
• Rencana Pemantauan
• Tindak Lanjut
 DEFINISI DRPs
• Drug Related Problems atau Masalah Terkait Obat adalah
peristiwa atau keadaan yang melibatkan terapi obat yang
benar-benar atau berpotensi mengganggu hasil kesehatan yang
diinginkan (PCNE, 2017).
• Pharmaceutical Care Europe (PCNE)
Network mengklasifikasikan DRPs, klasifikasi terakhir
yaitu PCNE Classification for Drug-Related Problems
dengan
V9.00
 PCNE Classification for Drug-Related Problems V9.00 - Page 3

The basic classification

Code Primary domains

V9.0
Problems P1 Treatment effectiveness
(also potential) There is a (potential) problem with the (lack of) effect
of the pharmacotherapy
P2 Treatment safety
Patient suffers, or could suffer, from an adverse drug
P3
event
Other
Causes C1 Drug selection
(including possible causes The cause of the DRP can be related to the selection of the
for potential problems) drug
C2 Drug form
The cause of the DRP is related to the selection of the drug
form
C3 Dose selection
The cause of the DRP can be related to the selection of the
dosage schedule
C4 Treatment duration
The cause of the DRP is related to the duration of treatment
C5 Dispensing
The cause of the DRP can be related to the logistics of the
prescribing and dispensing process
C6 Drug use process
The cause of the DRP is related to the way the patient gets
the drug administered by a health professional or carer, in
spite of proper instructions (on the label)
C7 Patient related
The cause of the DRP can be related to the patient and his
behaviour (intentional or non-intentional)
C8 Patient transfer related
The cause of the DRP can be related to the transfer of
patients between primary, secondary and tertiary care, or
transfer within one care institution.
C9 Other
Planned Interventions I0 No intervention
I1 At prescriber level
I2 At patient level
I3 At drug level
I4 Other
Intervention Acceptance A1 Intervention accepted
A2 Intervention not accepted
A3 Other
Status of the D R P O0 Problem status unknown
O1 Problem solved
O2 Problem partially solved
O3 Problem not solved
 PCNE Classification for Drug-Related Problems V9.00 - Page 4

The Problems

Primary Domain Code Problem

V9.0
1.Treatment effectiveness P1.1 No effect of drug treatment
There is a (potential) problem Effect of drug treatment not optimal
with the (lack of) effect of P1.2 Untreated symptoms or indication
the pharmacotherapy
P1.3
2. Treatment safety P2.1 Adverse drug event (possibly) occurring
Patient suffers, or could
suffer, from an adverse drug
event.
N.B. If there is no specific
cause, skip Causes coding.
3. Other P3.1 Problem with cost-effectiveness of the treatment
P3.2 Unnecessary drug-treatment
P3.3 Unclear problem/complaint. Further clarification
necessary (please use as escape only)
 Potential Problem

 Manifest Problem
 PC NE Classification for Drug-Related Problems V9.00 - Page 5

The Causes (including possible causes for potential problems)

[N.B. One problem can have more causes]
Primary Domain Code Cause
V9.0
1. Drug selection C1.1 Inappropriate drug according to guidelines/formulary
The cause of the (potential) C1.2 Inappropriate drug (within guidelines but otherwise
DRP is related to the selection contra- indicated)
of the drug (by patient or
health professional)
C1.3 No indication for drug
C1.4 Inappropriate combination of drugs, or drugs and herbal

Prescribing & drug selection

medications, or drugs and dietary supplements
C1.5 Inappropriate duplication of therapeutic group or active
ingredient
C1.6 No or incomplete drug treatment in spite of existing
indication
C1.7 Too many drugs prescribed for indication
2. Drug form C2.1 Inappropriate drug form (for this patient)
The cause of the DRP is
related to the selection of the
drug form
3. Dose selection C3.1 Drug dose too low
The cause of the DRP is C3.2 Drug dose too high
related to the selection of the Dosage regimen not frequent enough
C3.3
dose or dosage
C3.4 Dosage regimen too frequent
C3.5 Dose timing instructions wrong, unclear or missing
4. Treatment duration C4.1 Duration of treatment too short
The cause of the DRP is C4.2 Duration of treatment too long
related to the duration of
treatment
5. Dispensing C5.1 Prescribed drug not available
The cause of the DRP is C5.2 Necessary information not provided
related to the logistics of the
Disp
prescribing and dispensing C5.3 Wrong drug, strength or dosage
process C5.4 advised (OTC)
Wrong drug or strength dispensed
6. Drug use process C6.1 Inappropriate timing of administration or dosing
The cause of the DRP is C6.2 intervals Drug under-administered
related to the way the patient C6.3
gets the drug administered by
Drug over-administered
C6.4 Drug not administered at all
a health professional or other
C6.5
carer, despite proper dosage Wrong drug administered
instructions (on label/list)
C6.6
Drug administered via
wrong route
7. Patient related C7.1 Patient uses/takes less drug than prescribed or does not
The cause of the DRP is take the drug at all
Use

related to the patient and his
behaviour (intentional or
non- intentional)
C7.2 Patient uses/takes more drug than
C7.3 prescribed Patient abuses drug (unregulated
C7.4 overuse) Patient uses unnecessary drug
C7.5 Patient takes food that interacts
C7.6 Patient stores drug inappropriately
C7.7 Inappropriate timing or dosing intervals
C7.8 Patient administers/uses the drug in a wrong way
C7.9 Patient unable to use drug/form as directed
C7.10 Patient unable to understand instructions properly
 PCNE Classification for Drug-Related Problems V9.00 - Page 6
8. Patient transfer
related
The cause of the DRP can be
related to the transfer of
Seamles
patients between primary,
secondary and tertiary care, or
transfer within one care
institution.
9. Other
N.B. One problem can lead to more interventions
Primary Domain Code Intervention
No intervention
1. At prescriber level
2. At patient level
3. At drug level
4. Other intervention or
activity
C8.1 No medication reconciliation at patient transfer.
C8.2 No updated medication list available.
Discharge/transfer information about medication
C8.3 incomplete or missing
Insufficient clinical information about the
C8.4 patient.
Patient has not received necessary medication at discharge
C8.5 from hospital or clinic.
C9.1 No or inappropriate outcome monitoring (incl. TDM)
C9.2 Other cause; specify
C9.3 No obvious cause
The Planned Interventions
V9.0
I0.1 No Intervention
I1.1 Prescriber informed only
I1.2 Prescriber asked for information
I1.3 Intervention proposed to prescriber
I1.4 Intervention discussed with prescriber
I2.1 Patient (drug) counselling
I2.2 Written information provided (only)
I2.3 Patient referred to prescriber
I2.4 Spoken to family member/caregiver
I3.1 Drug changed to …
I3.2 Dosage changed to …
I3.3 Formulation changed to …
I3.4 Instructions for use changed to …
I3.5 Drug paused or stopped
I3.6 Drug started
I4.1 Other intervention (specify)
I4.2 Side effect reported to authorities
 PCNE Classification for Drug-Related Problems V9.00 - Page 7

Acceptance of the Intervention proposals

N.B. One status of acceptance per intervention proposal

Primary domain Cod Implementation

e
9.0
1. Intervention accepted A1. Intervention accepted and fully implemented
(by prescriber or patient) 1 Intervention accepted, partially implemented
A1. Intervention accepted but not implemented
2 Intervention accepted, implementation unknown
A1.
3
A1.
4
2. Intervention not A2. Intervention not accepted: not feasible
accepted 1 Intervention not accepted: no agreement
(by prescriber or A2. Intervention not accepted: other reason (specify)
patient) 2 Intervention not accepted: unknown reason
A2.
3
A2.
4
3. Other (no information on A3. Intervention proposed, acceptance unknown
Primary Domain
acceptance) 1
Cod Intervention
Outcome not proposed
of intervention
A3.
e
2V9.0
0. Not known O0.1 Problem status unknown
1. Solved O1.1 Problem totally solved
2. Partially solved O2.1 Status
Problemofpartially
the DRP solved
3. Not solved O3. Problem not solved, lack of cooperation of patient
N.B. This domain depicts the outcome
1 of the intervention.
Problem not solved,One
lackproblem (or the combination
of cooperation of
of interventions) can only lead O3.
to one level of solving
prescriber the problem
2 Problem not solved, intervention not effective
 KLASIFIKASI LAIN DRPs
• Masalah terkait obat menurut Hepler dan Strand dapat
dikategorikan sebagai berikut:
1. Untreated indications
2. Improper drug selection
3. Subtherapeutic dosage
4. Failure to receive drugs
5. Over dosage
6. Adverse Drug Reactions (ADRs) = ROTD (Reaksi
Obat Tidak Dikehendaki)
7. Drug interactions
8. Drug use without indication.
TUGAS
■ Failure to receive drugs erat kaitannya dengan komplians (kepatuhan) tidak terpenuhi.
■ Penyebabnya antara lain :
– Produk obat tidak tersedia
– Tidak mampu menebus obat
– Tidak dapat menelan obat/ memakai obat
– Tidak mengerti aturan pemakaian
– Pasien memilih tidak memakai obat
■ Penyebab ADRs :
– Obat tidak aman untuk pasien
– Reaksi alergi
– Pemakaian tidak benar
– Kenaikan dan penurunan dosis yang terlalu cepat
– Efek tidak dikehendaki
Problema Terapi Obat Aktual vs Potensial

■ Problema terapi obat aktual : problema yang telah terjadi dan problema itu harus
diupayakan untuk dibenahi.
■ Problema terapi obat potensial : problema yang sangat mungkin dapat terjadi dan pasien
yang mendapat terapi itu mempunyai resiko untuk memperoleh problema terkait bila
intervensi tidak dilakukan.
– Contoh : pasien diketahui pernah mendapat reaksi hipersensitivitas terhadap
amoksisilin. Kemudian pasien itu mendapat amoksisilin dengan resep dokter.
– Apakah pasien tersebut menghadapi problema terapi obat aktual atau potensial ?
Contoh problema terapi obat lainnya

■ Pemakaian bersama ciprofloxacin dan sukralfat

– Jumlah ciprofloxacin yang diabsorbsi dari saluran cerna jauh berkurang sehingga
kegagalan terapi, dapat terjadi. Pertanyaannya , kenapa absorbsi Ciprofloxacin
bisa berkurang ?
■ Interaksi antara digoksin dan verapamil
– Verapamil dapat meningkatkan kadar digoksin dalam darah sebesar 44%, hal ini
karena verapamil menurunkan sekresi digoksin melewati saluran empedu.
Assesment

Silakan berikan contoh-contoh DRPs (aktual atau potensial) beserta alasannya !