2 December 1951

Bukit Tinggi
PhD in Clinical Pharmacology
FUSA-Fliner! "eical Centre
Au!tralia# 19$$
Pro%e!!or
&ea o% De'artment
Pharmacology ( Thera'eutic
School o% "eicine# USU
)ln* Triharma 22
+am'u! USU# "ean
S'F+# Clinical Pharmacologi!t
PB-,D, ( F+ U,# 1995
"D# F+ USU# 19-$
.mail/ a0nanlelo1yahoo*com
Aznan Lelo
Dep. Farmakologi & Terapeutik,
Fakultas Kedokteran
Universitas Sumatera
Utara
- 2ktober 2311# +24+.5 ,PS# )akarta
Rajin-rajin belajar ya nak,
supaya pintar dan jadi
dokter!
+ata orang

Mereka semua ter-lahir 'intar dan

baik,

Namun selanjutnya jadi booh dan

6ahat.

Lalu dimana kesempatan itu?

Baaya ! "an#erous
"o$to
"o$to
r
r
drug
therap
y
patien
t
Doctor
shoppin
g
Risk
factors
etc
RDA
Surgery
etc
OTC
er!al
med.
etc
%A&R'()*%K
%A&R'()*%K
+iatro ! dokter, +iatro ! dokter,
Sakit ke'ala
Sakit gigi
Bi!ulan
4yeri hai
5ematik
7out
Pon!tan
8oltaren
Femina9
,rga'an
Celebre9
4o:algin
Dangerou!
Dangerou!
Doctor ;
Doctor ;
4yeri bahu
4yeri 'inggang
4yeri lutut
4yeri tumit
yang 'enting hilangkan 4<.5,-nya
uru!an )A4TU47# belakangan
Ta'i=# !aya muah !e!ak
an !ering kencing malam
a
i
n
!
Sakit
gigi
A!am
me%enamat
Pegal
Pegal
>inu
>inu
4yeri
4yeri
bi!ul
bi!ul
4yeri
4yeri
hai
hai
4yeri
aa
etc#
etc#
etc#etc
etc#etc
etc
etc
Sakit ;
Sakit ;
Sakit
Sakit
in-'artu
in-'artu
A!am
me%enamat
A!am
me%enamat
A!am
me%enamat
A!am
me%enamat
A!am
me%enamat
A!am
me%enamat
A!am
me%enamat
Sakit ke'ala
7atal
Se!ak
"enceret
Tak bi!a
tiur
CT"
Salbutamol
,moium
Dia0e'am
Tramaol
Cam'uran yang Cam'uran yang
mematikan mematikan
Sakit ke'ala
Sakit gigi
Bi!ulan
5ematik
7out
Pon!tan
8oltaren
,rga'an
Con%orti
4o:algin
Suah keluargaku
mati
Uangku 'ula yang
habi!
5'
5'
5'
5'
5'
Dangerous person

Wishing to eliminate a
president of another
country

om!ing all areas of

the country

"illing the people in

that country

#pending 23 " US?

ut then offering only

233#333 US? to $hom
could !ring the head of
the president

Wishing to eliminate a
sign or symptom of a
disease

%i&ing an e'pensi&e
drug ( polypharmacy

)ncreasing *D+s (
iatrogenic disease

#pending a lot of
money

ut it cloud !e then
o&ercome !y the
cheapest drug
Dangerou! octor!
octor! are
the thir leaing
cau!e o% eath in the US#
cau!ing 253#333 eath!
e:ery year
http,--$$$.mercola.com-.///-jul-0/-doctors1death.htm
Doctor! :er!u! 7un! in the U*S#1999
#ome #tartling #tatistics
http,--$$$.concealcarry.org-DangerousDoctors.htm
Parameter Doctor!
7un
2@ner!
4umber o% 'er!on -33#333 $3#333#333
Acciental
eath!Ayear
123#333 1#533
Acciental eath! 'er
2doctor3 or 2gun o$ner3
3*1-1 3*33331$$
octor! are appro'imately
9#333 time! more angerou! than gun o@ner!
the number o% 'eo'le @ho ie
a! a re!ult o%/

"eical mi!take! kill almo!t 133#333

Accient!Aa:er!e e%%ect! B9C#333D#

4neumonia and influen5a 267,///3,

Dia!etes 270,///3,

#uicide 208,///3, or

"idney disease 2.9,///3 - and

certainly far more than in automo!ile

accidents, as the result of homicide or other
crimes, *)D#, etc.
http,--ash.org-dangerous-doctors.html
Eho i! the angerou! octor;

Does not kno$ that he or she kno$s nothing

:
Looks like kno$ing e&erything, !ut kno$s a fe$
only
:
Does not kno$ ho$ to manage the patient
properly, rational prescription 2i.e, polypharmacy3

Does not cure the disease !ut create the ne$

illness 2iatrogenic disease3
:
Does not treat the patients !ut referring them to
be buried, 2i.e., careless in the safety of medicine3
:
*l$ays $orse the patient;s emotion ( pocket

<nethical professional !eha&ior, not fit to

$ork as a doctor, etc
ho@ to %in them be%ore they kill youF
&o@ oe! !omeone become
a angerou! octor;

drug companies greatly influence doctors;

prescri!ing ha!its

family doctors are more likely to rely on

information supplied !y drug manufacturers
rather than on information from independent
sources

*!out =/ percent of %4s regarded drug

representati&es as an efficient $ay to o!tain
ne$ drug information

information may !e misleading, !iased or

inaccurate
Family Practice )anuary 23/C1-$#233G
Someone @ho /

al@ay! 're!cribe Hangerou! rugI

an agent @ith :ariou! a:er!e e%%ect!

oe! not care to/

the conition o% 'atient treate

the inication o% rug 're!cribe

the !a%ety o% rug amini!tere

the kinetic! o% rug amini!tere

the co!t o% rug amini!tere

the rug interaction

the correct an clear rug 're!cri'tion

Eho i! the angerou! octor;
A:er!e rug reaction !ur:eillance in 'eiatric
an ault 'atient! in an emergency room
Muno5 et al. Med >lin 2arc3 888203,?.-6,8??6
Drug! Chilren Ault!
4SA,D 13*JK 2$*2K
C8 rug! ; 15*9K
Antimicrobial! J9*5K 1J*5K
7,T rug! ; 11*1K
5e!'iratory rug! 19*9K ;
8accine! 9*2K ;
al@ay! 're!cribe Hangerou! rugI
4SA,D AD5-relate ho!'itali0ation!
Coo'er )E* #outh Med @ ?.293,A69-?/,8???
o not care ==========*
to the conition o% 'atient treate

Age Bchilren# elerly# nur!ing @omenD

Concomitance i!ea!e!

Poly'harmacy

"any octor! in:ol:e

Chilren are not ault! in !mall !i0e

.lerly al@ay! ha:e 'harmacological

'roblem!

Pre!cribing Ca!cae i! the common

cau!e o% 'oly'harmacy in elerly
Critical a''roache!
in !electing meicine!
Thera'eutic
e%%ect
A:er!e reaction
Minimal Ma'imal
Ma'imal <e! ;
Minimal ; 4o
44&
S"A>>.ST
75.AT.ST
BL 133D
44T
75.AT.ST
S"A>>.ST
B2-JD
Bhere are t$o reasons to $ithdra$ from the treatment either

no e%%icacy 244T &ery high3 or

!eriou! a:er!e reaction! 244& &ery lo$3.

W
i
t
h
d
r
a
$
a
l

2
C
3
55K
2GK
d
i
s
c
o
n
t
i
n
u
a
t
i
o
n

r
a
t
e

2
C
3
19 K
9 K
2*G K
3*- K
&enti tera'i
karena
tiak
mera!akan
e%ek tera'i
&enti tera'i
karena
mera!akan
e%ek !am'ing
number needed to treat +**&, -or at least ./0
pain relie- over 1-2 ours in patients 3it
moderate to severe pain, all oral analgesics
e"cept morphine, pethidine and ketorolac
4SA,D D
adju&ant analgesic
D $eak opioid
2codeine3
'aracetamol
or 4SA,D D
adju&ant analgesic
#trong opioid
D 4SA,D D
adju&ant analgesic
Princi'le! o% Analge!ic Pre!cribing
E&2 Analge!ic >aer
/ 8 . 0 A 9 7 = 6 ? 8/
Pain tolerance Pain thre!hol
mild
mild
moderate
moderate
se&ere
se&ere
B5A,4
Pharmacologic Agent!
A%%ect Pain Di%%erently
De!cening "oulation
Central Sen!iti0ation
P4S
Anticon:ul!ant!
2'ioi!
TricyclicAS45, Antie're!!ant!
C4S
S'inal
Cor
Peri'heral
Sen!iti0ation
Dor!al
&orn
,nhibition o%
A!cening
Pain Path@ay!
4SA,D!
Antiarrhythmic
>ocal Ane!thetic!
To'ical Analge!ic!
Anticon:ul!ant!
Tricyclic Antie're!!ant!
2'ioi!
2'ioi!
Al'ha-2 Delta agoni!t!
Anticon:ul!ant!
2'ioi!
4"DA-5ece'tor Antagoni!t!
TricyclicAS45, Antie're!!ant!
4ild vs Severe 5ain
"il Se:ere
Drug Lo$ dose Eigh dose
4otent agent
A$ute vs 6roni$ 5ain
Acute Chronic
Drug +apid onset Long duration
Duration o%
'ain
#hort, self limiting,
$ell-characteri5ed
4ersists after healing,
0 months
Com'onent Nocicepti&e Nocicepti&e
Neuropathic
.torico9ib# a long hal%-li%e B22 hour!D/
o!age an e%%icacy
5ain
indi$ations
"ose
+m#,
*ote
6roni$ pain
OA 7/ 8 2/
Curtis S#, et.al.
$%%&
A$ute pain
'outy arthritis 9:/ (a"imum )
days
Dysmenorrhea 9:/ (a"imum )
days
Dental #ain 9:/ -
:1/
(almstrom
*,et.al. $%%+
A$ute 5ain ; Severe 5ain
?
?
?
?
Slo@ly Chronic
&o@ to change the on!et o%
action o% the long hal%-li%e 4SA,D
&ime
6
o
n
$
e
n
t
r
a
t
i
o
n
)<e$tive $on$entration
Acute
N#*)D long half life
long uration
!ut slo$ onset
increa!e
the o!e F
By increa!ing the o!e ;;;/
on!et become! earlier
but a:er!e e%%ect! enhance
R
a
t
i
o
n
a
l

=



S
a
v
e

=



)
t

i
$

=



"
a
n
#
e
r
o
u
s

!
o not care ==========*
to the !a%ety o% rug amini!tere
The !a%ety o% rug amini!tere e'en on/

Ty'e o% rug

Pharmacoynamic

Eigher dose, greater effect !ut more to'ic

Pharmacokinetic

Bhe shortest half-life, the safest drug

Clinical conition

#e&ere condition, high risk for ad&erse effects

Duration o% amini!tration
o not care ==========*
to the !a%ety o% rug amini!tere
The only AD5 o%
The only AD5 o%
4SA,D i! 7, e:ent
4SA,D i! 7, e:ent
;
;
.:olution in arthriti! management/ %ocu! on C2M-2 inhibitor!
>arlos Faldes, 4harmD, >4#. >linical #cience Manager. 4harmacia >o.
*pril 8A, .//.
&e 9/ leadin# $auses o- deat
as a per$enta#e o- all deats
in te United States, 9>>/ and 9>>2
#ource, >D>, National >enter for Eealth #tatistics
199C 1993
?@' Statisti$al %n-ormation System +?@'S%S,
*umbers and rates +per-9//A///, o-
re#istered deats
United States o- Ameri$a - :///
4o Cau!e 4 5ate
8 C8S ?A8.9.A CC$*5
. Malignancy 990./?8 0?0.A
0 +espiratory disease 867.0A7 80..9
A 7a!trointe!tinal i!ea!e 6A./89 5$*$
9 *ccidents =0.=69 99.8
7 Dia!etes Mellitus 7?.0/8 A?..
= )nfectious ( 4arasitic disease 7?.//= A../
6 #kin ( #u!cutaneous tissue disease 0.=90 ..7
? Drug, medicaments causing ad&erse
effects in therapeutic use
../9? ..8
G Ulcer o% !tomach an uoenum A.9/A G*2
Adapted from Antman ,(, et al. Circulation. $%%-.//&0/12+3
/1+$.
4leeding 5lcer
Complications
Degree of Selecti6ity
4lood #ressure
7ncrease
Discontinuation
Throm!osis,
(yocardial 7nfarction
,
t
o
r
i
c
o
"
i
!
C
e
l
e
c
o
"
i
!
D
i
c
l
o
f
e
n
a
c
R
o
f
e
c
o
"
i
!
8
a
p
r
o
"
e
n
7
!
u
p
r
o
f
e
n
Discontinuation
6ardiovas$ular Risk (astrointestinal Risk
CO93$ CO93/
&e %mpli$ations o- *SA%"
Sele$tivity
Celeco9ib :! .torico9ib
C8 ( 5enal Sa%ety Pro%ile Bloo 're!!ure change
Hhang @ et al. @*M* .//7I.?7,878?-0.I #ch$art5 @) et al. J Clin Pharmacol .//=IA=,89.8-08
*SA%" (%
&oBi$ity
#enerally
varies
3it al--
li-e o-
te
a#ent
4SA,D Diclo%enac 4a'ro9en Piro9icam
Do!e BmgAD 133 -53 23
&al%-li%e BhrD 1*5 1J 53
.A hr fecal !lood
loss 2mL3
3*5G NA- 3*21 2*-C NA- 2*22 1*1C NA- 3*C2
enry, et al. 4(:.2/$0/&12,$%%%. Scharf, et al. Aust 8 ; : (ed
$)<+=0+21,/>>)
Sortest al--li-e
L
o
3
e
s
t

(
%

r
i
s
k
5i!k Factor! o%
Ulcer Com'lication! %rom 4SA,D!
Relative risk
4umber o% 5i!k Factor! (
,ncience o% Ulcer Com'lication!
Silverstein F)A Ann Intern Med 9>>.C9:7D:19->
**@ 9:.
**@ ./
**@ 9:
**@ .
i
n
$
i
d
e
n
$
e

o
-

u
l
$
e
r

+
0
,
'totoBi$
Bron$ospam
6@F
@epatotoBi$ U(%B
Bleedin#
*eprotoBi$
&o$olyti$ Aller#y
6olor blindness
Adverse )<e$ts o- *SA%"s
4e$anism o- ! 4e$anism o-
terapeuti$ e<e$ts adverse e<e$ts
U(%B
4yeri
engkul
lak!an!ia
A,4S
!t
anta!ia
iare iare
4yeri 4yeri
ulu hati ulu hati
tera'i ikutan Simtom baru
tera'i
+eaaan a@al
+a!kae 'ere!e'an i klinik 'ribai
kon!ti'a!i
Eipertensi
remato-
logis
*)N#
gastro-
entero-
logis
misoprostol
serangan
%J<B
4#M*
diare . . . . .
hidro
kloro-
tia5ida
,AT527.4,+
,AT527.4,+
Biatro O okterD Biatro O okterD
Anti-
hy'erten!ion
antaci
PA,4
iuretic
mi!o'ro!tol
%lui
retention
increa!e
BP
heart
burn
PUB
4SA,D
4rescri!ing >ascade 4rescri!ing >ascade
5' 5'
PA,4
5' 5'
%lui
retention
increa!e
BP
heart
burn
PUB
4SA,DO5'
,atrogenic Co!t
A>P&.,".5
D,S.AS.
CA4C.5
D,C>2A",S2 -5 mg BD
4,".SU>,D. 233 mg BD
4,".SU>,D. 133 mg BD
52F.C2M,B 25 mg 2D
".>2M,CA" 15 mg 2D
".>2M,CA" -*5 mg 2D
,BUP52F.4 $33 mg TDS
D,C>2F.4AC 53 mg TDS
C.>.C2M,B 233 mg 2D
C.>.C2M,B J33 mg 2D
52F.C2M,B 12*5 mg 2D
D,C>2 53 mg TDS N
>an!o'ra0ol 15 mg 2D
>JM4*+*B)FK >J#B# for .6 D*L# BEK+*4L
2in M, spent !y the %eneral Medical #er&ices on N#*)D in 8???3
o not care =========**
to the co!t o% rug amini!tere
Pain in ri!ky 'o'ulation
PAT,.4T 752UP P5.D,CTAB>.
P52B>."S
a!ies ( )nfants >ommunicationI drug handling
Klderly >oe'isting illnessI drug
handling
+espiratory
disease
+espiratory depressionI
N#*)Ds ( asthma
+enal Nailure Drug handlingI N#*)Ds
4regnant $omen Karly closure of ductus
arteriosus
"ru# a$$umulation
2 " / ? / " 2
,fek terapeutik ? ,fek samping o!at
Choose the shortest half-life
o not care ==========*
to the kinetic! o% rug amini!tere
o not care ==========*
to the correct an clear rug
're!cri'tion
citalopram 2Cele9aO3. a selecti&e serotonin 29-EB3 reuptake inhi!itor
CELEXAQ %or CELEBREXQ;
A Ca!e o% "eication Sam'le .rror
Moyer , #hrading W, urkhart ""
)nt @ Med Bo'icol 02.3,=,.///
%lle#ible and3ritin#
imagine ha&ing to read this P
Ca'to'ril 25mg
RC3
Tab i B,D
o not care ==========*
to the rug interaction
4SA,D N antihy'erten!i:e agent

Morgan ( *nderson. @ >lin Eypertens 9283,90-=,.//0

inomethacin $orsened the antihypertensi&e effect of enala'ril

hagat ". Kast *fr Med @ =628/3,9/=-?,.//8

iclo%enac# ibu'ro%en or !ulinac did not neutralise the

antihypertensi&e effect of li!ino'ril

%ra&es ( Eunder @ >lin Eypertens .273,0?7-6,.///

$orsening of hypertension !y >JQ-. )nhi!itors

"urata et al. @pn >irc @ 7028.3,8//.-0,8???

!ynco'e caused !y N#*)D lo9o'ro%en and *>K-inhi!itor

imia'ril

Eay et al. @ Kmerg Med ..2A3,0A?-9.,.//.

%atal hy'erkalemia related to com!ined therapy $ith a >JQ-.

inhi!itor ro%eco9ib, *>K inhi!itor enala'ril
<sed 4L*>KJ
N#*)D is the only analgesic
long- half-life analgesic for an acute pain
Eigh dose analgesic is the sa&est
Don;t care to,
: 4atient condition
: 4harmacokinetic
: Drug interaction
: >ost
Be a smart
do$tor
and te ri#t
one too
*,4A8''AA8 78DO8,S7A 58T5*
D587A