DRUG THERAPY

PROBLEM Analysis
Dr. WIDYATI, MClin Pharm, Apt
Farmasis Klinik RSAL dr Ramelan
 PERSONAL DETAILS
• Sarjana Farmasi 1989 (UNPAD)
• Apoteker 1991 (UI)
• Hospital Pharmacy tour di 12 RS Australia(1995)
• MClin Pharm 1999(University of Queensland-Ausy)
• Dr: 2013 (Universitas Gajah Mada)
• Practising clinical pharmacy in hospital (Internal
Medicine, Critical Care)
• Teach clinical pharmacy in UGM, Ubaya
• Org: Angg Dewan Pakar IAI, Ketua Bidang
FarklinHISFARSI , Ketua Sub Kolegium Farklin
• Married, two children
• International Award: FIP International Travel Award
(2003), ILAE Travel Award (2013)
2
 DRUG THERAPY PROBLEM
• Undesirable event experienced by the
patient which involves, or is suspected to
involve, drug therapy, and that interferes
with achieving the desired goals of
therapy.
 Background Assessment
• Is each medication:
– Indicated?
– Effective?
– Safe?
– One the patient will be compliant with?
DTP Identificatiom
 Kasus
• Tn PO 49th, 62kg, 172cm, MRS dengan keluhan mual
muntah sejak 3 hari lalu. Mengaku memiliki riwayat DM
5 tahunan dan obat dari rumah adalah Levemir 14u
malam hari. Saat ini Hasil lab: GDA 462mg/dl, Cr
2,4mg/dl, BUN 34 mg/dl, WBC 12.300/mm3, Na
129meq/l; K 2,8 meq/l. Sedangkan hasil pemeriksaan
TTV oleh perawat adalah sbb: TD 168/94 mmHg,
Temperatur 37,8oC, Nadi 78x/menit. Pasien didiagnosa
sebagai HHS dengan leukositosis dan elektrolit
imbalance. Terapi yang diberikan saat ini Novorapid 3
unit/jam iv, KCl 50meq,.
 DTP ≠ Medication Error

• Medication Errors: the 5 rights

– Correct drug, dose, route, frequency &
duration – Focuses on prescribing &
dispensing accuracy
 DTP Categories

1. Drug therapy is unnecessary

2. Drug therapy needs to be added
3. Drug not effective/producing desired
response
4. Dosage too low to produce desired response
5. Drug is causing an adverse reaction
6. Dosage is too high resulting in toxicity
7. Patient not able/willing to take drug therapy
 1. Drug Unnecessary
• No valid indication
• Multiple drugs when single drug would work
• Non-drug therapy would be better(life-style)
• Treating an adverse effect of another drug
(including OTC’s or Herbals)
• Drug, tobacco or alcohol use is causing the
problem
 2. Drug Needs to be Added

• Medical condition requiring treatment

• Preventative drug therapy due to risk of
disease
• – Aspirin for heart attach &/or stroke
• – Calcium for osteoporosis
• • Medical condition requires addition for
synergy, additive or protective effects
 3. Drug Not Effective

• Not the most effective drug

• Medical condition is refractory
• – Treating high triglycerides without controlling
blood glucoses first
• Wrong dosage form
– Immediate release morphine for chronic pain
• • Drug not effective
– Antibiotic resistance
 4. Dose is Too Low

• Dose too low

• Interval too in frequent
– Once daily regular human insulin?!
• Drug interaction is reducing blood levels
– Rifampin and oral contraceptives
• Duration of therapy too short
 5.Adverse Drug Reaction

• Causes ADR (not dose related)

• Safer drug product available
• Drug interaction (not dose related)
• Drug regimen changed too quickly
• Allergic reaction
• Contraindicated(e.g.pregnancy)
 6. Dose Too High

• Dose too high

• Dosing frequency too short
• Duration of therapy too long
• Drug interactions resulting in toxic
levels
•Dose given or increased too quickly
 7. Non-Compliance

• Patient
– Doesn’t understand instructions
– Prefers not to (why?)
– Forgets
– Can’t afford
– Cannot swallow or self-administer
– Can’t obtain / find product
 Kasus
• Tn H 52th, ditransfer ke Chest Pain Unit
(CPU) karena mengalami atrial fibrilasi.
Dilaporkan nadi berkisar 150-161x/menit.
Pasien baru satu hari kembali dari operasi
Sinus. Obat yang diberikan saat itu adalah
Aldiza SR, Ramuan: Dexametason-
Mucilin-interhistin, Iliadin tetes hidung,
domperidon , lansoprazole. Terapi saat ini
Cordarone inj. Satu hari di CPU pasien
ditransfer kembali ke ruang perawatan dan
mendapat digoksin tab 1x0,250 ug.
 Prioritizing

• What needs to be fixed immediately?

– Contraindications or potential harm
– Problems addressing a chief complaint

• What problems can be fixed directly

– By you / the practitioner working with
patient & family

• What problems will require consultation /

help
 Dokumentasi
• Dituliskan dalam A (S-O-A-P) di Rekam
Medik
• Saat ini belum ada format khusus namun
perlu menghindari kalimat justifikasi (tepat,
error, inadequate)
 Etiquette for Communicating With
Prescribers
• It is important to carefully word recommendations that
are sent to prescribers. Many prescribers recognize
the value that pharmacists bring to the patient care
team.
• pharmacists may encounter resistance from
prescribers and should strive to carefully word all
recommendations so that prescribers do not feel that
their judgments are coming under attack or that the
pharmacist’s documentation leaves them exposed
legally

Saturday, September 20
23, 2017
 DOKUMENTASI
Documentation by pharmacists should meet established
criteria for:
legibility,
clarity,
lack of judgmental language,
completeness,
appropriate use of a standard format (e.g., SOAP
[subjective, objective, assessment,

Saturday, September 21
23, 2017
 Kasus Hari 1
• Tn MS 61 th, 162cm, 60kg, ditransfer dari ICCU dengan
terpasang nasal cannule setelah dirawat 4 hari dengan
Diagnosa saat MRS AMI STEMI. Pasien mengeluh masih
lemah kadang-kadang sesak, mual. Hasil Lab hari ke-4
dijumpai GDA 298mg/dl, CK-MB (N), Troponin (N), SGOT 212
U/l, SGPT 59 U/l, Na 132 meq/l, K 2,9 meq/l, Cr 1,9 mg/dl;
BUN 15 mg/dl, WBC 12.000/mm3, Hb 10,7g/dl.

• Riwayat DM disangkal. Sedangkan observasi perawat

dilaporkan TD 110/60 mmHg, nadi 64x/menit, Temp 37,2oC,
RR 18-24x/menit. Terapi yang diberikan adalah KCl infus 2x
20meq, Lisinopril 1x10mg, Bisoprolol 1x5mg, Nitrokaf 3x1tab,
Thromboaspilet 1x1tab
 SOAP Hari 1
S
0
A
P
MONITORING:
 Kasus 1 Hari ke-2

• Pasien mengeluh sesak masih ada, mual

hilang, sakit kepala, tidak bisa tidur karena
terganggu pasien sebelah. Hasil TTV perawat:
Temp 37oC, TD 160/90mmHg, Nadi 66x/menit,
RR 18-24x/menit
• Dokter menambahkan terapi: amlodipin
1x10mg, Novorapid 3x4u s.c

Saturday, September 24
23, 2017
 SOAP Hari ke-2

S,O
A
P
Saturday, September 25
23, 2017