MODULE FOR STUDENTS

RATIONAL DRUG USE NEURO-PSYCHO-PHARMACOLOGY

FACULTY OF MEDICINE BRAWIJAYA UNIVERSITY MALANG

SKILL LAB of PHARMACOTHERAPY RATIONAL DRUG USE

Forewords

Choosing a therapeutic agent, drug or non drug, is an academic and experienced based process. These processes should not be based on the choices of other practitioners, or even seniors. Drug choice and prescription making requires the understanding of pathophysiology, disease pathogenesis, basic pharmacology (e.g. drug pharmacodynamic and pharmacokinetic) and the cultural and social background of the patient. The response towards a drug is very personal -different between one patient and the next, thus, drug choices to a patient is also personal. In community treatments, the individual responses of a drug are often not considered.

A physician's right in the choice of drug is based on a rational drug use concept. However, the patient also has the right to choose the therapy or drug. Therefore, sufficient doctorpatient communication is required before the prescription is written and the therapy is initiated (e.g. information concerning drug effect, side effects, usage instruction, do's and don'ts during the usage of the drug, and other contextual things). A treatment is not considered to be finished before monitoring and evaluation of the drug results is conducted.

To obtain the ability to choose drug abiding to rational drug use based pharmacotherapy requires repeated practice and to not do the same mistakes in next practices/modules. A beginning to end practice is an unseparated unity. The real application to the patient would be done by you during the hospital training and internship program.

Best of Luck

Head of Pharmacology Laboratory FKUB

INTRODUCTION

The application of Competence Based Curriculum (CBC) has an effect on the learning process and methods. This also applies to the learning of pharmacotherapy - it is no longer based on only pharmacology, it also has the basis of other competence needed to be achieved and integrated with other basic medical science and clinical knowledge.

Problem arises in CBC application, particularly in pharmacotherapy, when teaching the students only beginning their medical training: they have insufficient knowledge in medical basic science and don't completely understand clinical science. Therefore, pharmacotherapy skill lab training with the basis of rational drug use is given through simple phases and processes, increasing in difficulty and complexity (in both the drug selection and the case given).

First Phase Introduction to the concept of "rational drug use" uses an approach describing P-treatment and P-drugs by comparing Efficacy, Safety, Suitability and Cost for the patient with different pathophysiology, social-economy and culture condition. This phase is ended with prescription writing practice in different conditions, such as, a variety of age, disease patterns and socio-economy-culture conditions. The first phase is followed with an independent practice/ structural task of making a pocket book for each student, consisting of P-drugs, the forms available, and the usual dosage and a few notes considered to be critical and urgent.

Second Phase The student is guided in a drug selection practice; prescription writing based on rational drug use against few diseases often encountered during daily private practices in Indonesia.

The Third/Final Phase This concept is applied during assistantship (Co As) in every clinic and also consists of independent training during the internship. It is hoped that this 'habit' of knowledge application would be carried on until the student is a physician working under the professional standard (based on ethics, disciplined/ competent, and service standards consistent with the local means, infrastructure and human resources). Reading Materials: 1. Therapeutic Process 2. Pharmacotherapy Module 3. Drug Forms and Prescription Writing 4. Guide to Good Prescribing, WHO

I.

Learning Goals In the end of this training, the student is expected to be able to: 1. 2. 3. 4. 5. To apply Rational Drug Use concept using a P-treatment and P-drugs approach. To plan a P-drug considering many different conditions of the patient To write a prescription lege artis. To apply rational drug use concept in new simulation cases. Have the competence to apply the therapy according to general practitioner competence based on competence standards.

Phases: Goal 1 to 4 can be obtained during the training in the skill lab. Goal 5 can be reached when the student is in the clinical assistantship phase (Co As). II. Rational Drug Use Concept with P Treatment Approach

II.1 Explanation of Rational Drug Use Concept and P Treatment STEP 1: Define the patient's problem STEP 2: Specify the therapeutic objective STEP 3: Verify the suitability of your P-drug STEP 4: Write a prescription STEP 5: Give information, instructions and warnings STEP 6: Monitor (and stop?) the treatment

II.2 P Drug Training by Comparing Efficacy, Safety, Suitability and Cost HOW TO SELECT P-DRUG
i ii iii iv Define the diagnosis (pathophysiology) Specify the therapeutic objective Make an inventory of effective groups Choose a group according to criteria Efficacy Group 1 Group 2 Group 3 v Choose a P-drug Efficacy Drug 1 Drug 2 Drug 3 Safety Suitability Cost Safety Suitability Cost

Conclusion:

Active substance, dosage form: Standard dosage schedule: Standard duration:

II.3 Prescription Making A complete prescription should include: 1. 2. 3. 4. 5. 6. The doctors name Practice permit/assignment letter number Address and phone number of the practice The time the practice opens and close The time and date of the prescription The name and dosage of the drug (the knowledge of the form of the drug and the usual dosage is required) 7. The form of the drug asked 8. Drug Usage Instruction 9. Signature 10. Name, Age, Weight of the Patient 11. Address of Patient (Hospital: Registry Number)

Example of Prescription: 1. A prescription for a patient with angina pectoris case Dr. Fatiroh Jl. Saturnus 3, Malang Telp. 0341 582110 SIP. 446.DU/012/35.73.306/2007

Malang, 3 Oktober 2009

R/ Glyceryl trinitrat 1 mg tab S 2 dd I sublingual ----,,---ft

No X

Dr. Ida Jl. Saturnus 3, Malang Telp. 0341 582110 SIP. 446.DU/012/35.73.306/2007 Pro : Tn. Amin 2009 Umur : 60 th. Malang, 3 Oktober

Alamat : Jl. Planet no 10, Malang R/ Aminophyllin amp S imm ----,,---id No II

Pro : Tn. Amin Umur : 35 th. Alamat : Jl. Planet no 10, Malang

2. Patient required staying in the hospital Dr. St. Nurin Jl. Baru no 80 Malang. Telp. 573440 SIP : 446.DU/012/35.73.306/2007

Malang, 15-10-2007

R/

Amoksisilin syrup fl No.I S 3 dd cth II ---,,--stn

Pro Umur

: An. Uci : 5 th

Alamat : Jl. Guntur no 49, Malang

3. Amoxicillin syrup for a child, 5 years old, weight of 20 kg Explanation: Amoxicillin dosage for children 30-50 mg/KgBW (body weight) Syrup: 1 spoon (5 ml) contains 125 mg

SKILL LAB of PHARMACOTHERAPY RATIONAL DRUG USE

1. General Guide for Pharmacotherapy based on Rational Drug Use - consisting of the basics of drug selection, prescription making, communication with patients and complementary additions, such as therapy process resume, pharmacotherapy modules, drug forms and prescription making and Guide to Good Prescribing. 2. Before the skill lab begins, the students should: a) Understand the Rational Drug Use concept. b) Understand the classification of the drug for therapy according to the pathophysiology of the disease. c) ASSIGNMENT 1: Make notes in the form of a pocket book containing the ANALGESIC-ANTIINFLAMMATORY DRUGS, including important notes about drug mechanism, specific pharmacokinetic, important side effects, formulations of the medicine (written at home before skill lab activity). d) Understand prescription structure.
An example of the pocket book/notes of drugs: Class Analgesic Generic and Brand Name Paracetamol: panadol, pamol, biogesic Pharmacodynamic Mechanism: ..? Indication: Muscle pain Contraindication Side Effect Mechanism Indication Analgesic-anti inflammation Mefenamic acid: ponstan, mefinal Contraindication Side effects Tab 500 mg Syr 125 mg / 5ml Pharmacokinetic Important ADME Presentation and Dosage Tab 500 mg Syr 125 mg / 5ml 3x 500 mg/hari Cost

........... ........... etc

Gel?

ASSIGNMENT 2: P-Drug Assignment: Each class is divided into groups. Each group (20-25 students) formulates P-drug for analgesic-antiinflammatory drugs. Each group divides itself into 5 subgroups (with a maximum of 4-5 people per subgroup). Each subgroup chooses one P-drug case (the P drug is taken from the pocket book).

P-Treatment Assignment: Each group works on one P-treatment case (make a P-treatment based on efficacy, safety, suitability, and cost). This assignment is done at home BEFORE skill lab activity (read the materials already provided). 3. During the Skill Lab: A short summary of Rational Drug Use P-Drug practice and prescription writing practice: for normal adults, using various drug forms. P-treatment practice 4. Structured Assignment after Skill Lab: a) Complete the pocket book of drug form and shapes. b) Complete P drugs for analgesic-antiinflammatory drugs. EXAMPLE Mr. Bejo, 50 y.o., complains of knee pain. His job is a peddler. He also complains of stomach aches after drinking coffee. Make a P Treatment with 6 steps therapeutic process. 1. Problem: Knee pain Dyspepsia syndrome, gastric acid increase 2. Therapeutic Goal: To reduce knee pain Neutralize gastric acid Reduce gastric acid secretion Reduce nausea 3. Therapeutic Intervention Advice: Do not eat spice, acidic, and fatty food. Do not be late for a meal and do not drink coffee Avoid stress Non Drug: P-Drug: Anti-inflammation drugs that do not influence the stomach. There are 2 types of anti-inflammatory drugs: Non selective COX inhibitor and COX-2 selective inhibitor. COX-2 selective inhibitors do not affect the stomach: Celecoxib (but the price is high). 4. Regiment Dosage and Prescription Making

Dr. Santi Practice: Jl. Nangka no 102 Telp. 021 723 4444 SIP. 446.DU/012/35.73.306/2007

Surabaya, 21 Oktober 2007

R/ Celecoxib S 2 dd tab I p.c -------,,------ st

No X

------------------------------------------------------------------Pro Age Address : Pak Bejo : 50 th : Jl. Tanjung Pura 16 Surabaya

5. Information, Instructions and WarningCommunicate the Prescription in Step 4 Sir, I made a prescription for you. There are 3 kinds of medicines. The first is an antacid which would neutralize your gastric acid, take it 3 times a day after a regular meal. The second one is a famotidine, which would suppress acid release, take it twice a day, and the third one is a metochlopramide that is anti-nausea, take it 3 times a day. After taking the medication, you might have diarrhea or constipation. And so on about the side effects of the drug. 6. Monitoring and Evaluation If there are any symptoms that you feel too disturbing, please return here...etc

MODULE TASK : RATIONAL DRUG USE PHARMACOTHERAPY: NERVOUS SYSTEM, PSYCHIATRY SYSTEM P-DRUG CASE NEUROLOGIC CASE 1. Adi, 10 years old (25 kg), suffered from tonic clonic generalized seizures 3 to 5 times per week. 2. Joko, 65 years old, suffered from resting tremor, rigidity, slowness of movement, masked facies, and postural instability. The cognition is impaired and functionally disabled.

PSYCHIATRIC CASE 3. A schizophrenic patient developed bradykinesia, rigidity, and tremor during treatment with haloperidol. 4. Maria, 17 years old, screams uncontrolled after being scolded by her parents because she got bad marks in her examinations. P-TREATMENT CASE Make a P-Treatment with 6 steps therapeutic process. NEUROLOGIC CASE Case 1 Anna, 30 years old, suffered from headache with a pressing/tightening (nonpulsating) quality, mild to moderate intensity, bilateral location, and no aggravation with physical activity. The headache occurs 15 days a month, each lasting more than 1 hour. She could not sleep well since her husband passed away 2 months ago. From physical examination, the temporal and neck muscles are contracted. Case 2 Andi, 8 years old (24 kg) is having learning difficulties at school. He has brief lapses of awareness with eyelid fluttering that occur every 5-10 minutes. EEG studies reveal brief 3-Hz spike and wave discharges appearing synchronously in all leads. His mother asks medication in syrup form. PSYCHIATRIC CASE Case 3 Ahmad, 40 years old (55 kg), who A schizophrenic patient developed bradykinesia, rigidity, and tremor during treatment with haloperidol. Case 4 Maria, 17 years old, screams uncontrolled after being scolded by her parents because she got bad marks in her examinations.

KETRAMPILAN FARMAKOTERAPI
Nama NIM Kelompok Tanggal : : : :

No 1. 2. 3. 4. 5.

Jenis kegiatan
0

Skor 1

6.

7.

Menyapa pasien dan mempersilahkannya duduk dengan pengaturan yang nyaman Memperkenalkan diri kepada pasien Menanyakan kembali identitas pasien: nama, usia, tempat tinggal, pekerjaan, status keluarga Menetapkan problem / diagnosa pasien Menentukan tujuan terapi Menentukan P-treatment (Advis, non drug) Menentukan pemilihan obat (P-drug) dengan mempertimbangkan ; - Efficacy - Safety - Suitability - Cost Mengidentifikasi obat yang dipilih meliputi : - Nama obat - Bentuk obat - Dosis - Lama pengobatan Menulis resep lengkap - Nama & alamat - Tanggal - Nama generik obat - Bentuk obat - Dosis - Cara pemberian - Jumlah - Instruksi - Signature - Nama & alamat pasien Memberikan informasi, instruksi dan perhatian yang meliputi : - Efek obat (efeknya apa, kapan efek muncul, berapa lama efeknya) - Efek samping (berupa apa, apa yang akan dilakukan) - Instruksi (cara minum/penggunaan obat, dosis, interval, berapa lama, apa yang harus diperhatikan) - Perhatian (dosis maksimum, interaksi, efek yang tidak dikehendaki, penghentian obat) Menyampaikan kapan kontrol untuk monitoring & evaluasi pengobatan
Catatan : Komunikasi yang disampaikan untuk no 9 dan 10 harus : -Jelas dan dapat dimengerti - Struktur pembicaraan runtut - Beri kesempatan pasien (atau keluarga yang mengantar) untuk mengekspresikan dirinya atau memberikan pertanyaan ke dokter -Pastikan pasien (keluarganya) mengerti instruksi yang diberikan. Pasien (keluarganya) diminta untuk mengulangi instruksi

8.

9.

10.

Jumlah skor LULUS / MENGULANG

Penilaian dimulai dari no urut 4 10 (jumlah soal 7) Keterangan : 0 = tidak dikerjakan 1 = dikerjakan tetapi kurang sesuai/benar

2 = dikerjakan dengan benar

Catatan:

Mahasiswa/peserta dinyatakan LULUS apabila : - Jumlah skor akhir mencapai kisaran 8 14 - Untuk cek list no.8 (menulis resep lengkap), tiap mahasiswa harus mencapai nilai skor = 2 (dikerjakan dengan benar) Tutor,

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