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

2. 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

3. 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)

4. Step 1: Define the patient’s problem

5. 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)

6. 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

7. Step 2: Specify the treatment objective

8. 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

9. Step 3: Select the intervention

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

11. 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

12. 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

13. 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

14. 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)

15. 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

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

17. 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

18. Step 4: Start the treatment

19. 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

20. Step 5: Give information to the patient

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. Step 6: Monitor (or stop?) treatment

28. 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