PROSES TERAPI DAN PERMASALAHANNYA Rustamaji Faculty of Medicine Universitas Gadjah Mada 2017

Objective After attending this lecture, students are expected to be able to: Explain the steps in therapeutic process Explain drug selection based on safety, efficacy, suitability and cost

Six steps of therapeutic decision process Step 1: Define the patient’s problem Step 2: Specify the treatment objective Step 3: Select the intervention Step 4: Start the treatment Step 5: Give information to the patient Step 6: Monitor (or stop?) treatment (WHO, 1994)

Step 1: Define the patient’s problem

Define the patient’s problem Patient presents with a complaint or a problem. To treat patient, physician should make a right diagnosis Right diagnosis based on the complaint as describe by patient, a detailed history, physical examination, laboratory tests, X-ray and other investigation Patient complaints are mostly linked to symptoms (is not diagnosis)

Define the patient’s problem Disease or disorder (diagnosis) Sign of underlying disease Psychological or social problems, anxiety Side effect of drugs Refill request (polypharmacy) Non-adherence to treatment Request for preventive treatment Combination Physician formulation may different with patient perceives

Step 2: Specify the treatment objective

Specify the therapeutic objective Therapeutic objective sometimes “straightforward”, sometimes less clear. Therapeutic objective can Make physician concentrate on the real problem Prevent a lot of unnecessary drug use Avoid unnecessary prophylactic drugs Discuss your therapeutic problems with patient

Step 3: Select the intervention

Select the intervention Make the inventory of possible treatments Information or advice Treatment without drugs Treatment with a drug Referral Combination

Selection of the medicines Medicines should effective, safe, suitable to patient and cheaper Effective: please check to the reference standard to looking for the EBM or STGs Safety : check the side effects and frequency of side effects Suitability : check the contraindication of the drug Cost: check the total cost not only the price

Efficacy of drug Data Pharmacodinamic Data pharmacokinetic (ADME) Compare the dosage and formulation on absorption, distribution, metabolism, excretion Efficacy should be supported by good clinical trial with control

Safety Side effects Toxic effects (depend on dug concentration) If possible list he incidence of side effect Unpredictable side effect (allergic reaction) may be caused by drugs

Suitability Contraindication of drug related by patient condition (renal failure, hepatic disorder, history of allergic reaction, other disease, other drugs (possibility of interaction)) Change of patient physiology (pregnancy and lactation, extreme age)

Suitability Are the active substance and dosage form suitable for this patient? Is the standard dosage suitable for this patient? Is the standard duration of treatment suitable for this patient? Pharmacokinetic data

Cost Check the cheaper drug Discuss with the patient about the drug price

Selection of medicines Patient suffer dry cough that can be very inconvenient Suppressing for a few day may have a beneficial effect Many cough preparation available in the market

Step 4: Start the treatment

Start the treatment Write a prescription Codein 30mg 3 x daily Prescription is an instruction from a prescriber to a dispenser Information on prescription Name and address of the prescriber with telephone number Date of prescription Name and strength of the drug Dosage form and total amount Information for the package insert Signature or initial Patient identity

Step 5: Give information to the patient

Give information Instruction and warning Effect of the drugs Why the drug is needed Which symptoms will disappear, and which not When the effect is expected to start What will happened if the drug is taken incorrectly or not at all

Give information Instruction and warning Side effects Which side effect may occur How to recognize them How long the will continue What action to take

Give information Instruction and warning How the drug should be taken When it should be taken How long the treatment should continue How the drug should be stored What to do with left-over drugs

Give information Instruction and warning Warnings When the drug should not be taken What is the maximum dose Why the full treatment course should be taken

Give information Instruction and warning Future consultation When to come back (or not) In what circumstances to come earlier What information the doctor will needed at the next appointment

Give information Instruction and warning Everything clear ? Ask the patient whether everything understood Ask the patient to repeated the most important information Ask whether the patient has any more question

Step 6: Monitor (or stop?) treatment

Monitor and stop the treatment Was the treatment effective ? Yes and disease cured Stop the treatment Yes but not yet completed Any serious effect? No : Treatment can be continued Yes : reconsider dosage or drug choice No : check your all steps