1
Praktikum Farmakologi A. Kasus Kasus Geriatri
Nama
: TN. DK
TTL
: 12 Februari 1966
TB/BB
: 160 cm/60kg
MRS
: 23 Ari! 2016 uku!: 19:10 "#B
R$D
: %AD & 1 bu!a' (a'g !a!u )i S$.*$
Ri+a(a, -b -ba,
: a airi'%$ Ni Ni,ra, Si Sima,a,i' Bi Bi-r-!-!
$aie' MRS )e'ga' ke!ua' !ema e4ak & 5 ari (a'g !a!u. Maka' mi'um me'uru'. Mua! mu',a e,ia maka'. Demam. BAK BAB ,erakir '-rma!. $aie' 4uga me'ge!u e)iki, eak. $ii ka'a' kiri mu!ai be'gkak ,a)i agi. Ke)ua kaki u)em muka uca, !ema. Diag'-a Diag'-a
: b. A'emia A'emia D('eu D('eu e/c %AD
Ke!ua' aie' $emerikaa' 7iik: GCS: E4V5M6
Keluhan
Tanggal 23/4
24/4
Lemas
+++
-
ual muntah
+
-
!emam
+
-
"esak
+++
u#em kaki
+++
$%eri saat &AK
25/4
Pagi-malam hari +++ +++
+++
+
+
26/4
2
&atuk
+
+
'ematuria
+
+
8ai!
Ta'gga! 23/4
24/4
25/4
Suu
30%
3650%
350%
8R
90/m',
3/m',
61/m',
RR
;0/m',
;0/m',
19/m',
TD
9;/50 mm8g
6/;< mm8g
9/63 mm8g
Sa2
9=
9=
96=
Da,a Lab $aie': Ni!ai N-rma!
23/4
8b
12>16 g/)!
13 g/)!
8c,
35>; =
;23=
Leuk-i,
;<00>11000 e e!/mm 3
5.900 e!/mm 3
Tr-mb-i,
1<0000>;<0000 e!/mm 3
161.000 e!/mm 3
?reum
10><0 mg/)!
132 mg/)!
Krea,i'i'
@13 mg/)!
19 mg/)!
DS
1;0 mg/)L
123 mg/)L
ST
@3 232 ?/L
232 ?/L
S$T
@;1 232 ?/L
16 ?/L
%KMB
@2< 232 ?/L
3< ?/L
%KNA%
@165 232 ?/L
10<0 ?/L
Na
13< 1<3 mC/L
125;
K
3.< <.1 mC/L
;3
24/4
25/4
3
8bA
>
Pemeriksaan (enun)ang* Tanggal 25/4* kesan #ari hasil ontgen* Kar#iomegali #engan e#ema (aru
$e'g-ba,a' yang di dapatkan: Nama ba,
D-i
23/4
24/4
25/4
26/4
RL
10 ,m
;0 ,m
12 cc/4am
')a'e,r-' $a',-raE-! i'4. Ke,-,eri!
mg/;m!
21 am ;0 mg 21 ia! 32 ,ab # (ri (ri'g 'gee
D-bu,ami'
um ;cc/4am
TriEe)-' MR Bi-r-!-! %!-i)-gre! a!ia'be Ke,-r-!ac i'4.
21 ,ab < mg 11/2 ,ab 5< mg 11 ,ab < mg 11 ,ab 30
mg/m!
Gbi!a '(eriH
%-)ir-', cum e 21 ca ?r-ge,i D-ami'e
100 mg 31 ,ab 1<cc/4am
)i!a )i!a'4 '4u, u, 63 cc/4am
4
&. !asar Te Teori a. Pato ato,is ,isiolo iologi gi Pato,isiologi ongesti0e 'eart Failure !e,inisi 'F
aga! 4a',u'g k-'ge,i7 a)a!a kea)aa' a,-7ii-!-gi berua ke!ai'a' 7u'gi 4a',u'g ei'gga 4a',u'g ,i)ak mamu mem-ma )ara u',uk meme'ui kebu,ua' me,ab-!ime 4ari'ga' a,au kemamua''(a a'(a a)a ka!au )ier,ai e'i'ggia' -!ume )ia,-!ik ecara ab'-rma!. $e'amaa' gaga! 4a',u'g k-'ge,i7 (a'g eri'g )igu'aka' ka!au ,er4a)i gaga! 4a',u'g ii kiri )a' ii ka'a' GSu)-(- 201;H. 1tiologi 'F
aga! 4a',u'g k-'ge,i7 )aa, )iebabka' -!e : 1H Ke!a Ke!ai' i'a' a' -,-, -,-, 4a', 4a',u' u'gg aga! 4a',u'g eri'g ,er4a)i a)a e')eri,a ke!ai'a' -,-, 4a',u'g )iebabka' me'u me'uru ru'' ''(a (a k-', k-',ra rak, k,i! i!i, i,a a 4a', 4a',u' u'g. g. K-') K-')i iii (a'g (a'g me') me')a aari ari e'( e'(eb ebab ab ke!ai'a' 7u'gi -,-, me'caku a,eri-k!er-i k-r-'er ier,e'i ar,eria! )a' e'(aki, )ege'era,i7 a,au i'7!amai. 2H A,erA,er-k k!er !er- -i i k-rk-r-'e 'err. Me'gakiba,ka' )i7u'gi mi-kar)ium kare'a ,erga'ggu'(a a!ira' )ara ke -,-, 4a',u'g. Ter4a)i i-kia )a' ai)-i Gakiba, e'umuka' aam !ak,a,H. #'7ark mi-kar)ium Gkema,ia' e! 4a',u'gH biaa'(a me')au!ui ,er4a)i'(a gaga! 4a',u'g. $era)a'ga' )a' e'(aki, mi-kar)ium )ege'era,i7 berubu'ga' )e'ga' gaga! 4a',u'g kare'a k-')ii (a'g ecara !a'gu'g meruak erabu, 4a',u'g me'(ebabka' k-',rak,i!i,a me'uru'. me'uru'. 3H 8ie 8ier, r,e' e'i i i, i,em emik ik a,au a,au u!m u!m-' -'a! a! Me'i'g Me'i'gka, ka,ka' ka' beba' beba' ker4a ker4a 4a',u' 4a',u'gg )a' a)a a)a gi!ira' gi!ira''(a '(a me'gak me'gakiba, iba,ka' ka' ier,r-7i erabu, -,-, 4a',u'g. ;H $era)a' $era)a'ga' ga' )a' )a' e'(a e'(aki, ki, mi-ka mi-kar)i r)ium um )ege' )ege'era, era,ie ie Ber Berub ubu' u'ga ga'' )e'g )e'ga' a' gaga gaga!! 4a',u 4a',u'g 'g kare kare'a 'a k-') k-')i iii i'i i'i ecar ecaraa !a'g !a'gu u'g 'g meruak erabu, 4a',u'g me'(ebabka' k-',rak,i!i,a me'uru'.
5
emi!u emi!u'er 'erH H ke,i)a ke,i)akma kmamu mua' a' 4a',u' 4a',u'gg u',uk u',uk me'gi me'giii )ara )ara G,am-' G,am-'a)e a)e erikar)ium erikar)i,i7 k-',rik,i7 a,au ,e'-i AH AH e'i'gka,a' me')a)ak a7,er!-a). 6H Fak, Fak,--r i i,em ,emik Ter)aa er)aa,, e4um! e4um!a a bear bear 7ak,-r 7ak,-r (a'g (a'g berer berera' a' )a!am )a!am erkem erkemba' ba'ga' ga' )a' bera,'(a gaga! 4a',u'g. Me'i'gka,'(a !a4u me,ab-!ime Gmia!: )emamH i-kia )a' a'emia )ier!uka' e'i'gka,a' cura 4a',u'g u',uk meme'ui kebu,ua' -kige' i,emik. 8i-kia )a' a'emia 4uga )aa, me'uru'ka' u! u!ai ai -ki -kige ge'' ke 4a', 4a',u' u'g. g. Ai) Ai)- -i i re reir ira, a,-r -rik ik a,au a,au me,a me,abb-!i !ikk )a' )a' ab'-rma!i,a ab'-rma!i,a e!ek,r-'ik e!ek,r-'ik )aa, me'uru'ka me'uru'ka'' k-',rak,i!i k-',rak,i!i,a ,a 4a',u'g 4a',u'g GSu)-(- GSu)-(- 201;H. Pato,isiologi 'F
aga! 4a',u'g buka'!a ua,u kea)aa' k!i'i (a'g a'(a me!iba,ka' a,u i,em ,ubu me!ai'ka' ua,u i')r-ma k!i'ik akiba, ke!ai'a' 4a',u'g ei'gga 4a',u'g ,i)ak mamu mem-ma meme'ui kebu,ua' me,ab-!ime ,ubu. aga! 4a',u'g )i,a')ai )e'ga' a,u re-' em-)i'amik gi'4a! (ara7 )a' -rm-'a! (a'g '(a,a er,a ua,u kea)aa' a,-!-gik berua e'uru'a' 7u'gi 4a',u'g. Sa!a a,u re-' em-)i'amik (a'g ,i)ak '-rma! a)a!a e'i'gka,a' ,eka'a' e'giia' G filling filling pressureH )ari 4a',u'g a,au re!-a). Re-' ,era)a 4a',u'g me'imbu!ka' beberaa meka'ime k-me'ai (a'g ber,u4ua' u',uk me'i'gka,ka' -!ume )ara )ara -!ume -!ume rua'g 4a',u'g 4a',u'g ,aa'a' ,aa'a' embu!u embu!u )ara eri7er )a' ier,r-i ier,r-i -,-, 4a',u'g. K-')ii i'i 4uga me'(ebabka' ak,iai )ari meka'ime k-me'ai ,ubu (a'g aku, berua e'imbu'a' air )a' garam -!e gi'4a! )a' ak,iai (,em ara7 a)re'ergic GSu)-(- 201;H. $e',i'g )ibe)aka' a',ara kemamua' 4a',u'g u',uk mem-ma (pump function)
)e'ga' k-',rak,i!ia -,-, 4a',u'g G myocardial function H. $a)a beberaa
kea)aa' )i,emuka' beba' ber!ebia' ei'gga ,imbu! gaga! 4a',u'g ebagai -ma ,a'a ,er)aa, )erei a)a -,-, 4a',u'g i',ri'ik. Seba!ik'(a )aa, u!a ,er4a)i )erei -,-, 4a',u'g i',ri'ik ,e,ai ecara k!i'i ,i)ak ,amak ,a')a>,a')a gaga! 4a',u'g kare'a beba' 4a',u'g (a'g ri'ga'. $a)a a+a! gaga! 4a',u'g akiba, % (a'g re')a )i )a!am ,ubu ,er4a)i e'i'gka,a' ak,ii,a ara7 ima,i )a' i,em re'i' a'gi-,e'i' a!)-,er-' er,a e!eaa' argi'i' a-rei' (a'g keemua'(a meruaka' meka'ime k-me'ai u',uk memer,aa'ka' ,eka'a' )ara (a'g a)ekua,. $e'uru'a' k-',rak,i!i,a e',rike! aka' )iiku,i e'uru'a' cura 4a',u'g
6
(a'g e!a'4u,'(a ,er4a)i e'uru'a' ,eka'a' )ara )a' e'uru'a' -!ume )ara ar,eri (a'g e7ek,i7 GSu)-(- 201;H. 8a!
i'i
aka'
mera'ga'g
mekanisme
kompensasi
neurohumoral .
a-k-',riki )a' re,e'i air u',uk eme',ara +ak,u aka' me'i'gka,ka' ,eka'a' )ara e)a'gka' e'i'gka,a' re!-a) aka' me'i'gka,ka' k-',rak,i!i,a 4a',u'g me!a!ui ukum S,ar!i'g. Aabi!a kea)aa' i'i ,i)ak egera ,era,ai e'i'ggia' a7,er!-a) e'i'ggia' re!-a) )a' ier,r-7i )i!a,ai 4a',u'g aka' !ebi me'amba beba' 4a',u'g ei'gga ,er4a)i gaga! 4a',u'g (a'g ,i)ak ,erk-me'ai. Di!a,ai e',rike! me'(ebabka' )i7u'gi i,-!ik Ge'uru'a' 7raki e4ekiH )a' re,e'i caira' me'i'gka,ka' -!ume e',rike! G)i!a,aiH. *a',u'g (a'g ber)i!a,ai ,i)ak e7iie' ecara meka'i Gukum La!aceH. *ika ere)iaa' e'ergi ,erba,a Gmia! a)a
e'(aki,
k-r-'erH
e!a'4u,'(a
bia
me'(ebabka'
ga'ggua'
k-',rak,i!i,aGSu)-(- 201;H. Se!ai' i,u kekakua' e',rike! aka' me'(ebabka' ,er4a)i'(a )i7u'gi e',rike!. $a)a gaga! 4a',u'g k-'ge,i7 ,er4a)i ,ag'ai a!ira' )ara emb-!iai i,emik )ari ,r-mbu mura! )a' )iri,mia e',rike! re7rak,er. Diami'g i,u kea)aa' e'(aki, 4a',u'g k-r-'er ebagai a!a a,u e,i-!-gi %8F aka' me'uru'ka' a!ira' )ara ke mi-kar) (a'g aka' me'(ebabka' ikemik mi-kar) )e'ga' k-m!ikai ga'ggua' irama )a' i,em k-')uki ke!i,rika' 4a',u'g GSu)-(- 201;H. Beberaa )a,a me'(ebu,ka' bra)iari,mia )a' e'uru'a' ak,ii,a !i,rik me'u'4uka' e'i'gka,a' ree',ae kema,ia' 4a',u'g me')a)ak kare'a 7rekue'i ,akikar)i e',rike! )a' 7ibri!ai e',rike! me'uru'. "8 me'(ebu,ka' kema,ia' 4a',u'g me')a)ak bia ,er4a)i akiba, e'uru'a' 7u'gi meka'i 4a',u'g eer,i e'uru'a' ak,ii,a !i,rik a,auu' kea)aa' eer,i emb-!i i,emik Gemb-!i u!m- 4a',u'gH )a' kea)aa' (a'g ,e!a )iebu,ka' )ia,a GSu)-(- 201;H. Meka'ime (a'g me')aari gaga! 4a',u'g me!iu,i ga'ggua' kemamua' k-',rak,i!i,a 4a',u'g (a'g me'(ebabka' cura 4a',u'g !ebi re')a )ari cura 4a',u'g '-rma!. K-'e cura 4a',u'g a!i'g baik )i4e!aka' )e'ga' eramaa' %I 8R J S )ima'a cura 4a',u'g a)a!a 7u'gi 7rekue'i 4a',u'g J -!ume eku'cu GSu)-(- 201;H. %ura 4a',u'g (a'g berkura'g me'gakiba,ka' i,em ara7 ima,i aka' memercea, 7rekue'i 4a',u'g u',uk memer,aa'ka' cura 4a',u'g bi!a
7
meka'ime k-me'ai u',uk memer,aa'ka' er7ui 4ari'ga' (a'g mema)ai maka -!ume eku'cu 4a',u'g!a (a'g aru me'(euaika' )iri u',uk memer,aa'ka' cura 4a',u'g. Tai a)a gaga! 4a',u'g )e'ga' maa!a u,ama keruaka' )a' kekakua' erabu, -,-, 4a',u'g -!ume eku'cu berkura'g )a' cura 4a',u'g '-rma! mai )aa, )ier,aa'ka' GSu)-(- 201;H. -!ume eku'cu , 4um!a )ara (a'g )i-ma a)a e,ia k-',raki ,erga',u'g a)a ,iga 7ak,-r (ai,u: 1H $re!-a): e,ara )e'ga' ii )ia,-!ik akir (ai,u 4um!a )ara (a'g me'gii 4a',u'g berba')i'g !a'gu'g )e'ga' ,eka'a' (a'g )i,imbu!ka' -!e a'4a'g'(a rega'ga' erabu, 4a',u'g. 2H K-',rak,i!i,a: me'gacu a)a erubaa' kekua,a' k-',raki (a'g ,er4a)i a)a ,i'gka, e! )a' berubu'ga' )e'ga' erubaa' a'4a'g erabu, 4a',u'g )a' ka)ar ka!ium. 3H A7,er!-a): me'gacu a)a bear'(a e',rike! (a'g aru )i ai!ka' u',uk mem-ma )ara me!a+a' erbe)aa' ,eka'a' (a'g )i ,imbu!ka' -!e ,eka'a' ar,eri-!e GSu)-(- 201;H.
$*K (a'g bera,
Tr-mb-emb-!i
Ber)amak a)a a!ira' )ara3 a)a m(-car)
Ari,mia )a' ga'ggua' ak,i2i,a.
(a'g be!um i'7ark Gangguan Kontraklitas
8ier,r-7i )i!a,ai
K!aan pada C"#
Di.7u'g.i )ia.,-!ik )a'
)i7u'gi i,-!ik Baga' 1. $a,-7ii-!-gi %8F GSu)-(- 201;H. ani,estasi Klinis 'F
$
Ma'i7e,ai k!i'i gaga! 4a',u'g berariai ,erga',u'g )ari umur aie' bera,'(a gaga! 4a',u'g e,i-!-gi e'(aki, 4a',u'g rua'g>rua'g 4a',u'g (a'g ,er!iba, aaka ke)ua e',rike! me'ga!ami kegaga!a' er,a )era4a, ga'ggua' e'ami!a' 4a',u'g. $a)a e')eri,a gaga! 4a',u'g k-'ge,i7 amir e!a!u )i,emuka' : 1) 2)
e4a!a aru berua dyspnea, orthopnea )a' paroxysmal nocturnal dyspnea. e4a!a i,emik berua !ema cea, !e!a -!iguri '-k,uri mua! mu',a
ai,e ea,-mega!i )a' e)ema eri7er. 3) e4a!a uu'a' ara7 ua, berua i'-m'ia aki, kea!a mimi buruk amai )e!irium GSu)-(- 201;H. Kom(likasi 'F
Tr-mb-emb-!i a)a!a riik- ,er4a)i'(a bekua' e'a G,r-mb-i e'a )a!am a,au deep venous thrombosis )a' emb-!i aru a,au $H )a' emb-!i i,emik ,i'ggi ,eru,ama a)a %8F bera,. Bia )i,uru'ka' )e'ga' emberia' +ar7ari' GSu)-(- 201;H. K-m!ikai 7ibri!ai a,rium eri'g ,er4a)i a)a %8F (a'g bia me'(ebabka' erburuka' )rama,i. 8a! ,erebu, i')ikai ema',aua' )e'(u, 4a',u'g G)e'ga' )ig-i' a,au b!-cker )a' emberia' +ar7ari'H GSu)-(- 201;H. Kegaga!a' -ma r-grei7 bia ,er4a)i kare'a e'ggu'aa' )iure,ik )e'ga' )-i )i,i'ggika' GSu)-(- 201;H. Ari,mia e',rike! eri'g )i4umai bia me'(ebabka' i'k- a,au sudden cardiac death
G2<><0= kema,ia' %8FH. $a)a aie' (a'g berai! )ireui,ai
ami-)ar-' b!-cker )a' ebri!a,-r (a'g )i,a'am mu'gki' ,uru, memu'(ai era'a' GSu)-(- 201;H. 2 Pato,isiologi 1#ema Pulmo
)ema aru ,er4a)i 4ika ,er)aa, eri')aa' caira' )ari )ara ke rua'g i',er,i,ia! a,au ke a!e-!i (a'g me!ebii 4um!a e'gemba!ia' caira' ke)a!am embu!u )ara )a' a!ira' caira' ke (,em embu!u !im7e. Da!am kea)aa' '-rma! ,er4a)i er,ukara' caira' k-!-i) )a' -!u,e )ari embu!u )ara ke rua'g i',er,i,ia!. $a)a kai!er aru eer,i a)a kai!er i,emik 7i!,rai )i,e',uka' -!e ,eka'a' 7i!,rai e7ek,i7 (ai,u erbe)aa' a',ara gra)ie', ,eka'a' i)r-,a,ik )a' -'k-,ik. $e'i'gka,a' ,eka'a' 7i!,rai e7ek,i7 a)a embu!u )ara aru me'imbu!ka' be')u'ga' aru 7i!,rai caira' !ama ke )a!am rua'g i',er,iia!
%
me'(ebabka' e)ema aru i',er,iia! )a' ergeraka' caira' !ama ke )a!am a!e-!u me'imbu!ka' e)ema aru a!e-!u. $e'i'gka,a' ,eka'a' i)r-,a,ik a)a kai!er aru ,er4a)i 4ika ker4a em-maa' e',rike! kiri ,i)ak a)ekua,. $e'(ebab'(a a)a!a e'uru'a' kekua,a' mi-kar)ium a,au kea)aa' (a'g me'u',u, e'i'gka,a' ker4a mi-kar)ium ,e'-i ka,u mi,ra! a,au regurgi,ai. Akiba,'(a e'i'gka,a' ,eka'a' a,rium kiri aka' )ia',arka' ke be!aka'g embu!u )ara aru. S(,em !im7a,ik )ieriaka' u',uk me'erima !aru,a' k-!-i) )a' caira' baik )ari embu!u )ara. Akiba, ,eka'a' (a'g !ebi 'ega,i )i )era i',er,i,ia! eribr-'kia! )a' eriaku!ar )a' )e'ga' e'i'gka,a' kemamua' )ari i',er,i,ium '-'a!e-!ar i'i caira' !ebi eri'g me'i'gka, 4um!a'(a )i ,ema, i'i ke,ika kemamua' mem-ma )ari a!ura' !im7a,ik ,erebu, ber!ebia'. Bi!a kaai,a )ari a!ura' !im7e ,er!amaui )a!am a! 4um!a aira' maka aka' ,er4a)i e)ema. a'ggua' )rai'ae !im7a,ik memermu)a embe',uka' e)ema aru. Biaa'(a ke!ebia' caira' 7i!,rai aka' )ibua'g me!a!ui (,em !im7a,ik. Namu' kemamua' (,em !im7a,ik aru re!a,ie re')a baka' )a!am kea)aa' (a'g 7ii-!-gi. Dierkiraka' a)a aie' )e'ga' bera, 50 kg )a!am kea)aa' i,iraa, kaai,a (,em !im7e kira>kira 20 m!/4am. $a)a erc-baa' )i)aa,ka' kaai,a (,em !im7e bia me'caai 200 m!/4am a)a -ra'g )e+aa )e'ga' ukura' ra,a> ra,a. *ika ,er4a)i e'i'gka,a' ,eka'a' a,rium kiri (a'g kr-'ik (,em !im7e aka' me'ga!ami ier,r-7i )a' memu'(ai kemamua' u',uk me',ra'-r,aika' 7i!,ra,e kai!er )a!am 4um!a (a'g !ebi bear ei'gga )aa, me'cega ,er4a)i'(a e)ema. Sei'gga ebagai k-'ekue'i ,er4a)i e)ema i',er,iia! a!ura' 'a7a (a'g keci! )a' embu!u )ara ka' ,erk-mrei. *ika gaga! 4a',u'g ka'a' ,er4a)i beramaa' )e'ga' gaga! 4a',u'g kiri ,eka'a' e'a i,emik aka' me'i'gka, begi,u u!a ,eka'a' a)a ,ema, )rai'ae embu!u !im7a,ik ke )a!am e'a )i u)u, e'a ei'gga me'gamba, )rai'ae !im7a,ik. Teka'a' -'k-,ik )i kai!er berkura'g a)a i-r-,ei'emia ei'gga me')uku'g ,er4a)i'(a e)ema aru. 8i-r-,ei'emia biaa'(a ,er4a)i akiba, ieri)rai c-',-'(a a)a u!ai caira' (a'g ba'(ak a,au ,i)ak euai a)a aie' )e'ga' e'uru'a' ekkrei gi'4a! Gmia!'(a akiba, gaga4 gi'4a!H. $e'uru'a' embe',uka' r-,ei' !ama )i a,i a,au kei!a'ga' r-,ei' !ama c-',-'(a me!a!ui gi'4a! (ai,u i')r-m 'e7r-,ik 4uga me'uru'ka' k-'e',rai r-,ei' !ama.
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$e'i'gka,a' ermeabi!i,a kai!er )aa, me'imbu!ka' e)ema aru. $e'i'gka,a' ermeabi!i,a )i')i'g kai!er ,era)a r-,ei' aka' me'uru'ka' gra)ie', ,eka'a' -'k-,ik ei'gga me'i'gka,ka' ,eka'a' 7i!,rai e7ek,i7. $ermeabi!i,a kai!er mia!'(a )aa, )i,i'gka,ka' )e'ga' i'a!ai ga k-r-i7 a,au i'irai 2 mur'i (a'g !ama. 7ek )ari be')u'ga' aru a)a!a e'uru'a' er7ui aru ei'gga me'gamba, e'gambi!a' 2 makima!. $e!ebara' embu!u )ara (a'g ,erbe')u'g me'cega erbeara' a!e-!u )a' me'uru'ka' k-m!ia' aru. Se!ai' i,u br-'ku me'(emi, kare'a e!ebara' embu!u )ara )a' rei,e'i er'aaa' (a'g me'i'gka,. $a)a u)ema aru i',er,iia! rua'g i',er,iia! )i a',ara kai!er )a' a!e-!u me'i'gka,. Akiba,'(a ,er4a)i ga'ggua' )i7ui (a'g ,eru,ama me'gga'ggu e'gambi!a' -kige'. *ika akiba, ak,ii,a 7iik kebu,ua' -kige' me'4a)i me'i'gka, k-'e,rai -kige' )i )a!am )ara aka' ,uru'. Teka'a' (a'g ,eru me'i'gka, )a' keruaka' )i')i'g a!e-!u me'(ebabka' 7i!,rai ke )a!am rua'g a!e-!u. A!e-!u (a'g ,erii caira' ,i)ak !agi ,eriba, )a!am r-e er'aaa' Ger,ukara' gaH )a' i',aa' ar,eri-e'-a 7u'gi-'a! Gar,eri u!m-'a!i ke e'a u!m-'a!iH ,er4a)i beramaa' )e'ga' e'uru'a' 2 )i )a!am )ara ar,eri i,emik Gia'-i e',ra!H. %aira' memauki 4a!a' 'aa ei'gga me'i'gka,ka' rei,e'i 4a!a' 'aa. $e'i'gka,a' 7i!,rai caira' ke )a!am r-'gga !eura Ge7ui !euraH 4uga me'gamba, er'aaa'. Secara a,-7ii-!-gi e)ema aru ka)i-ge'ik )i,a')ai )e'ga' ,ra'u)ai caira' )e'ga' ka')u'ga' -,ei' (a'g re')a ke aru akiba,'(a ,er4a)i'(a e'i'gka,a' ,eka'a' a,rium kiri )a' ebagia' kai!er aru. Tra'u)ai i'i ,er4a)i ,a'a erubaa' a)a ermeabi!i,a a,au i',egri,a )ari membra'e a!e-!i>kai!er )a' ai! akir (a'g ,er4a)i a)a!a e'uru'a' kemamua' )i7ui i-kemia )a' eak 'a7a. )ema aru meruaka' e'imbu'a' caira' er-a a,au er-a'gui'-a (a'g ber!ebia' )a!am rua'g i',er,i,ia! aru )a' a!e-!u aru. *ika e)ema ,imbu! aku, )a' !ua eri'g )iuu! -!e kema,ia' )a!am +ak,u i'gka,. )ema aru )aa, ,er4a)i kare'a e'i'gka,a' ,eka'a' i)r-,a,ika )a!am kai!er aru e'uru'a' ,eka'a' -m-,ic k-!-i) eer,i a)a 'e7ri,i a,au keruaka' )i')i'g kai!er. Di')i'g kai!er (a'g ruak )aa, )iebabka' -!e i'a!ai ga>ga (a'g berbaa(a era)a'ga' eer,i a)a 'eum-'ia a,au kare'a ga'ggua' !-ca! r-e -kige'ai.
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$e'(ebab ,ereri'g e)ema aru a)a!a kegaga!a' e',rike! kiri akiba, e'(aki, 4a',u'g ar,eri-k!er-,ik a,au ,e'-i mi,ra!i G-b,ruki ka,u mi,ra!H. *ika ,er4a)i gaga! 4a',u'g kiri )a' 4a',u'g ka'a' ,eru mem-maka' )ara maka ,eka'a' kai!er aru aka' me'i'gka, amai ,er4a)i e)ema aru G$rice 2006H $embe',uka' e)ema aru )aa, ,er4a)i )a!am )ua ,a)ium: )ema i',er,i,ia! (a'g )i,a')ai e!ebara' rua'g eriaku!er )a' rua'g eribr-'kia! er,a e'i'gka,a' a!ira' ge,a be'i'g )a' )ema a!e-!ar ,er4a)i e+ak,u caira' bergerak mauk ke )a!am a!e-!i. $!ama )ara me'ga!ir !ebi cea, ke )a!am a!e-!i )aria)a kemamua' emberia' -!e ba,uk a,au ge,a be'i'g aru. $!ama i'i aka' me'gga'ggu )i7ui 2 ei'gga i-kia 4ari'ga' (a'g )iakiba,ka''(a me'amba kece')eru'ga' ,er4a)i'(a e)ema. A7ikia )aa, ,er4a)i bi!a ,i)ak egera )iambi! ,i')aka' u',uk me'i!a'gka' e)ema aru. $e'g-ba,a' )arura, a)a e)ema aru aku, berua ,i')aka'>,i')aka' u',uk me'gura'gi ,eka'a' i)r-,a,ik aru a',ara !ai' )e'ga' me'ema,ka' aie' )a!am -ii F-+!er )e'ga' kaki me'gga',u'g ,-r'ike, (a'g beri')a>i')a a,au 7!eb-,-mi Gembua'ga' )ara eba'(ak kira>kira 0< LH. ,i')aka' !ai' a)a!a )e'ga' emberia' )iure,ic 2 )a' )igi,a!i u',uk memerbaiki k-',rak,i!i,a mi-kar)ium G$rice 2006H. *ika ,er4a)i k-'ge,i aru ai7 kr-'ik mu'gki' aka' ,imbu! erubaa' ,ruc,ura! aru Gmia!'(a 7ibr-i aruH. $erubaa'>erubaa' i'i memu'gki'ka' aru ber7u'gi )a!am kea)aa' ,er4a)i e'i'gka,a' ,eka'a' i)r-,a,ik u',uk eme',ara 'amu' ,a'a e)ema aru. Aka' ,e,ai keeimba'ga' i'i ,i)ak a,i )a' aie' mu'gki' me'ga!ami era'ga' )i'eu a)a +ak,u ma!am ari akiba, e'i'gka,a' ,eka'a' i)r-,a,ik aru (a'g ,imbu! kare'a -ii ,ubu -riE-',a! G$rice 2006H. ambara' Ra)i-!-gi aga! *a',u'g Kiri $a)a 7-,- ,-rak gaga! 4a',u'g ,er!ia, erubaa' c-raka' aku!er aru Di,e'i e'a )i -bu ueri-r be',uk'(a me'(eruai uru7 )e'ga' caba'g !uru me')a,ar ke !a,era! Ba,a i!u u!m,er!ia, kabur Me'u'4ukka' a)a'(a e)ema u!m-'um kea)aa' a+a! Ter)aa, ,a')a>,a')a e)ema u!m-'um me!iu,i e)ema aru i',er,i,ia! )a' a!e-!ar. )ema i',er,i,ia!: e)ema i'i me'u'4ukka' e,a! !i'e (a'g )ike'a! ebagai. Ker!e( !i'e a)a ; 4e'i (ai,u: Ker!e( A: gari a'4a'g )i !-bu ueri-r aru beraa! )ari )aera i!u me'u4u ke a,a )a' eri7er Ker!e( B: gari>gari e')ek )e'ga' ara -riE-',a! ,egak !uru a)a )i')i'g !eura )a' !e,ak'(a )i !-bu i'7eri-r a!i'g mu)a ,er!ia, kare'a !e,ak'(a ,ea, )ia,a i'u c-,-re'icu ari i'i a)a!a
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(a'g a!i'g mu)a )i,emuka' )i gaga! 4a',u'g Ker!e( %: gari>gari e')ek bercaba'g a)a )i !-bu i'7eri-r. $er!u e'ga!ama' u',uk me!ia,'(a kare'a amir ama )e'ga' embu!u )ara. Ker!e( D: gari>gari e')ek -riE-',a! !e,ak'(a re,r-,re'a! a'(a ,amak a)a 7-,- !a,era! GMa!ueka 200H. )ema a!e-!ar: ,er4a)i e'gura'ga' !ue'i aru (a'g )i7u mu!ai )ari i!u amai ke eri7er bagia' a,a )a' ba+a. ambara' i'i )i'amaka' bu,,er7!( aeara'ce/ bu,,er7!( a,,er' a,au ba, +i'g a,,er'. Ba,a ke)ua i!u me'4a)i kabur GMa!ueka 200H. ambara' Ra)i-!-gi aga! *a',u'g Ka'a'. Beberaa ,a')a ka gaga! 4a',u'g ka'a' a)a!a:e'a caa ueri-r me!ebar ,er!ia, ebagai e!ebara' )i urai!er ka'a' amai ke a,a e'a aE(g- membear amai me'caai !ebi )ari 2 mm 7ui !eura biaa'(a ,er)aa, )i ii ka'a' a,au ,er4a)i bi!a,era! #',er!-bar e77ui-' a,au 7iura! e77ui-'. Seri'g ,er4a)i a)a 7iure mi'-r be',uk'(a -a! a,au e!i. Se,e!a gaga! 4a',u'g )aa, )ia,ai maka e7ui ,erebu, me'gi!a'g ei'gga )i'amaka' a'ii'g !u'g ,um-r ebab be',uk'(a miri ,um-r aru. Ka)a'g>ka)a'g )ier,ai )e'ga' e7ui ericar)ia! GMa!ueka 200H. $e'a,a!aka'aa' gaga! 4a',u'g a)a ri'i'(a )aa, )i!akuka' a!>a! beriku, i'i: Me'i'gka,ka' -kige'ai )e'ga' emberia' 2 )a' me'uru'ka' emakaia' -kige' )e'ga' emba,aa' ak,ii,a Memerbaiki k-',rak,i!i,a -,-, 4a',u'g Me'uru'ka' beba' 4a',u'g )e'ga' )ie, re')a garam )iure,ic )a' a-)i!a,-r GSu)-(- 2009H. 3 Pato,isiologi Aut enal !isease
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$a,-7ii-!-gi e'(aki, gi'4a! kr-'ik a)a a+a!'(a ,erga',u'g a)a e'(aki, (a'g me')aari'(a ,ai )a!am erkemba'ga' e!a'4u,'(a r-e (a'g ,er4a)i kura'g !ebi ama. $e'gura'ga' maa gi'4a! me'(ebabka' ier,r-7i ia 'e7r-' ecara ,ruk,ura! )a' 7u'gi-'a! ebagai ua(a k-me'ai. 8ier,r-7i Ok-me'a,-riP i'i akiba, ier7i!,rai a)a,i7 (a'g )iera',arai -!e e'ambaa' ,eka'a' kai!er )a' a!ira' g!-meru!u. $r-e a)a,ai i'i ber!a'gu'g i'gka, akir'(a )iiku,i -!e r-e ma!a)a,ai berua k!er-i 'e7r-' (a'g mai ,eria. $r-e i'i akir'(a )iiku,i )e'ga' e'uru'a' 7u'gi 'e7r-' (a'g r-grei7 +a!auu' e'(aki, )aar'(a u)a ,i)ak ak,i7 !agi. A)a'(a e'i'gka,a' ak,ii,a aki re'i'>a'gi-,e'i'a!)-,er-' i',rare'a! iku, memberika' k-',ribui ,era)a ,er4a)i'(a ier7i!,rai k!er-i )a' r-gei7i,a ,erebu,. Ak,ii,a 4a'gka a'4a'g
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aki re'i'>a'gi-,e'i'a!)-,er-' ebagia' )iera',arai -!e growth factor eer,i transforming growth factor
Q. Beberaa a! (a'g 4uga )ia'gga berera' ,era)a ,er4a)i'(a
r-grei7i,a e'(aki, gi'4a! kr-'ik a)a!a a!bumi'uria ier,e'i ierg!ikemia )i!ii)emia. Ter)aa, ariabi!i,a i',eri')ii)ua! u',uk ,er4a)i'(a k!er-i )a' 7ibr-i g!-meru!u mauu' ,ubu!-i',er,i,ia!. $a)a ,a)ium (a'g a!i'g )i'i e'(aki, gi'4a! kr-'ik ,er4a)i kei!a'ga' )a(a ca)a'g gi'4a! G renal reserveH a)a kea)aa' ma'a baa! LF mai '-rma! a,au ma!a me'i'gka,. Kemu)ia' ecara er!aa' ,ai a,i aka' ,er4a)i e'uru'a' 7u'gi 'e7r-' (a'g r-grei7 (a'g )i,a')ai )e'ga' e'i'gka,a' ka)ar urea )a' krea,i'i' erum. Samai a)a LF ebear 60= aie' mai be!um meraaka' ke!ua' Gaim,-ma,ikH ,ai u)a ,er4a)i e'i'gka,a' ka)ar urea )a' krea,i'i' erum. Samai a)a LF ebear 30= mu!ai ,er4a)i ke!ua' a)a aie' eer,i '-k,uria ba)a' !ema mua! 'a7u maka' kura'g )a' e'uru'a' bera, ba)a'. Samai a)a LF )i ba+a 30= aie' memer!ia,ka' ge4a!a )a' ,a')a uremia (a'g '(a,a eer,i a'emia e'i'gka,a' ,eka'a' )ara ga'ggua' me,ab-!ime 7-7-r )a' ka!ium ruri,u mua! mu',a )a' !ai' ebagai'(a. $aie' 4uga mu)a ,erke'a i'7eki eer,i i'7eki a!ura' kemi i'7eki a!ura' 'aa mauu' i'7eki a!ura' cer'a. *uga aka' ,er4a)i ga'ggua' keeimba'ga' air eer,i i- a,au ier-!emia ga'ggua' keeimba'ga' e!ek,r-!i, a',ara !ai' 'a,rium )a' ka!ium. $a)a LF )iba+a 1<= aka' ,er4a)i ge4a!a )a' k-m!ikai (a'g !ebi eriu )a' aie' u)a memer!uka' ,erai e'gga',i gi'4a! G renal replacement therapyH a',ara !ai' )ia!ii a,au ,ra'!a',ai gi'4a!. $a)a kea)aa' i'i aie' )ika,aka' amai a)a ,a)ium gaga! gi'4a!. . Gui#eline Thera(% Gui#eline ongesti0e 'eart Failure
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2 Gui#eline 1#ema Pulmo
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3 Gui#eline Aut enal !isease
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1$
. Farmakologi
L a ekanisme ker)a
Keu'ggu!a' ,ere',i'g )ari !aru,a' Ri'ger Lak,a, a)a!a k-m-ii e!ek,r-!i, )a' k-'e',rai'(a (a'g a'ga, erua )e'ga' (a'g )ika')u'g caira' ek,rae!u!er. Na,rium meruaka' ka,i-' u,ama )ari !ama )ara )a' me'e',uka' ,eka'a' -m-,ik. K!-ri)a meruaka' a'i-' u,ama )i !ama )ara. Ka!ium meruaka' ka,i-' ,ere',i'g )i i',rae!u!er )a' ber7u'gi u',uk k-')uki ara7 )a' -,-,. !ek,r-!i,>e!ek,r-!i, i'i )ibu,uka' u',uk me'gga',ika' kei!a'ga' caira' a)a )ei)rai )a' (-k i--!emik ,ermauk (-k er)araa'.
1%
!osis
K-m-ii Gmm-!/100m!H : Na I 130>1;0 K I ;>< %a I 2>3 %! I 109>110 Baa I 2>30 mC/!. Da' kemaa' : <00 )a' 1000 m!. Aturan (emakaian oat *
#'4eki #',ra e'a 3 )-i euai )e'ga' k-')ii e')eri,a4ika k-')ii aie' caira' ,abi! )i bere',ika' )a' -berai agar ,i)ak ,er4a)i e7ek ami'g me,ab-!ic. Lama e'g-ba,a' u',uk ,erai !ek,r-!i,>e!ek,r-!i, i'i )ibu,uka' u',uk me'gga',ika' kei!a'ga' caira' a)a )ei)rai )a' (-k i--!emik ,ermauk (-k er)araa'. # n#ikasi
Me'gemba!ika' keeimba'ga' e!ek,r-!i, a)a kea)aa' )ei)rai )a' (-k i--!emik. Ri'ger !ak,a, me'4a)i kura'g )iukai kare'a me'(ebabka' ierk!-remia )a' ai)-i me,ab-!ik kare'a aka' me'(ebabka' e'umuka' aam !ak,a, (a'g ,i'ggi akiba, me,ab-!ime a'aer-b e Kontrain#ikasi , 1,ek sam(ing
$a'a i'7eki )a ,ema, e'(u',ika' ,r-mb-i e'a a,au 7!ebi,i (a'g me!ua )ari ,ema, e'(u',ika' ek,raaai. g 'uungan umur #an oat *
Kare'a -ba, i'i )iberika' me!a!ui i',rae'a GRLH ,e,e )emi ,e,e )e'ga' i'7ui-' e,. ?',uk uia )e+aamaka aie' aka' )iberika' -ba, i'i )e'ga' )-i 1; ,e,e/me'i, )e'ga' !ama emberia' a)a!a amai aie' ,i)ak !ema kemba!i u',uk ke,abi!a' caira'. h 'uungan oat #engan #ata klinis #an La *
PN-, 7-r ue i' ,e ,rea,me', -7 !ac,ic aci)-iP. 8a,i>a,i emberia' a)a e')eri,a e)ema eri7er u!m-'er ear, 7ai!ure a,au imaire) re'a! 7u'c,i-' )a' re>ek!amia er,a e)ema 4ari'ga' a)a e'ggu'aa' -!ume (a'g bear biaa'(a aru>aru.
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i 'uungan (engoatan #engan ria%at (en%akit #an (engoatan *
Ke!ai'a' a)a gi'4a! )a' ga'ggua' a,i a)a ere)ara' )ara )a' e'ga,ura' caira' aka' a'ga, membera,ka' -rga'>-rga' (a'g me'ga!ami ga'ggua' ,eru,ama gi'4a! me'ga!ami
ga'ggua' 4ika emberia' RL
me'(ebabka' 7i!,rai reab-ri gi'4a! ,erga'ggu )i)a!am ,ubu ,erga'ggu u',uk r-e ker4a i',ra )a' ek,rae! )a' a)a ga'ggua' gi'4a! )aa, meme'garui aie' )e'ga' ier'a,remi. ) nteraksi oat ke oatmakanan #an )amu*
?',uk me'cega i'k-ma,ibi!i,a e',i'g )iikirka' bagaima'a -ba, bia beri',eraki )i )a!am a,au )i !uar ,ubu. *ika a')a aru me'camur ua,u -ba, e!a!u iku,i e,u'4uk abrik eer,i -!ume )a' 4e'i -ba, (a'g ,ea, ma'a !aru,a' (a'g bia )i,ambaka' ke emberia' Oigg( backP )a' !aru,a' Obi!aP aa (a'g aru )igu'aka' )i a',ara emberia' ua,u r-)uk )a' r-)uk !ai' u',uk me'gi')ari ke4a)ia'>ke4a)ia' eer,i e'ge')aa' )i )a!am e!a'g i'7u Gebagai c-',- 4a'ga' er'a memberika' 7e'i,-i' ke )a!am i'7u 4aga (a'g me'ga')u'g )ek,r-a a,au 4a'ga' camur am-,erici' B )e'ga' '-rma! a!i'eH. 8a!>a! !ai' (a'g er!u )ier,imba'gka' a)a!a a)a'(a e!ek,r-!i, Gmia!. ka!ium k!-ri)aH (a'g )icamur ke i'7u k-',i'(u mia! a)a i,em igg(back. *ika i'gi' me'camur -ba, )a!am ui, u',uk emberia' b-!u a,ika' -ba,>-ba, i'i k-ma,ibe! )i )a!am ui,. "aa)a )e'ga' -ba, (a'g )ike'a! memi!iki ri+a(a, i'k-ma,ibi!i,a bi!a berk-',ak )e'ga' -ba, !ai'. %-',->c-',- 7ur-emi)e GLaiH e'(,-i' GDi!a',i'H eari' mi)aE-!am Gere)H )a' )iaEeam Ga!iumH bi!a )igu'aka' )a!am camura' #. 2 7n#ansetron in). a
!eskri(si
')a'e,r-' 8%! berbe',uk erbuk ber+ar'a u,i a,au amir u,i (a'g !aru, )a!am air )a' N-rma! Sa!i'e. Bera, M-!eku!'(a 36<6. Nama kimia'(a : G&H 23>Dii)r->9>me,i!>3>G2>me,i!imi)aE-!>1>i!Hme,i!carbaE-!> ;G180>-' m-'-i)r-k!-ri)a )ii)ra,
Frmakokinetik #an ,armako#inamik
21
Se,e!a emberia' er -ra! ')a'e,r-' (a'g )iberika' )e'ga' )-i mg aka' )iera )e'ga' cea, )a' k-'e',rai makimum G30 'g / m!H )a!am !ama )icaai )a!am +ak,u 1< 4am. K-'e',rai (a'g ama )aa, )icaai )a!am 10 me'i, )e'ga' emberia' ')a'e,r-' ; mg i.. Bi-aa!ibi!i,a -ra! ab-!u, ')a'e,r-' eki,ar 60=. K-')ii i,emik (a'g e,ara 4uga )aa, )icaai me!a!ui emberia' ecara i.m a,au i.. "ak,u aru'(a eki,ar 3 4am. -!ume )i,ribui )a!am kea)aa' ,a,i eki,ar 1;0 L. ')a'e,r-' (a'g berika,a' )e'ga' r-,ei' !ama eki,ar 50 56=. ')a'e,r-' )ime,ab-!ime a'ag, baik )i i,em irku!ai ei'gga a'(a kura'g )ari < = a4a (a'g ,er)e,eki )i uri'e. Meka'ime ker4a -ba, i'i ebe'ar'(a be!um )ike,aui )e'ga' a,i. Mekiu' )emikia' (a'g aa, i'i u)a )ike,aui a)a!a ba+a ')a'e,r-' beker4a ebagai a',ag-'i e!ek,i7 )a' beri7a, k-me,i,i7 a)a ree,-r <8T3 )e'ga' cara me'gamba, ak,iai a7ere'>a7ere' aga! ei'gga me'eka' ,er4a)i'(a re7!ek mu',a. $emberia' i,-,a,ika Gkem-,eraiH )a' ra)iai )aa, me'(ebabka' e!eaa' <8T )a!am uu a!u (a'g meruaka' a+a! ,er4a)i'(a re7!ek mu',a kare'a ,er4a)i ak,iai a7ere'>a7ere' aga! me!a!ui ree,-r < 8T3. Ak,iai a7ere'>a7ere' aga! 4uga )aa, me'(ebabka' e!eaa' <8T a)a )aera -,rema -,ak (a'g ,er)aa, )i )aar e',rike! ;. 8a! i'i mera'ga'g ,er4a)i'(a e7ek mu',a me!a!ui meka'ime e',ra!. *a)i e7ek -')a'e',r-' )a!am e'ge!-!aa' mua! mu',a (a'g )iebabka' i,-,a,ika Gkem-,eraiH )a' ra)i-,erai beker4a ebagai a',ag-'i ree,-r <8T3 a)a 'eur-'>'eur-' (a'g ,er)aa, a)a i,em (ara7 ua, )a' i,em (ara7 ,ei.
n#ikasi
1H Me'cega )a' me'g-ba,i mua!>mu',a aku, aca be)a G$NH 2H Me'cega )a' me'g-ba,i mua!>mu',a aca kem-,erai a)a e')eri,a ka'ker 3H Me'caga )a' me'g-ba,i mua!>mu',a aca ra)i-,erai a)a e')eri,a ka'ker
# Kontrain#ikasi
$aie' iere'i,i7 ,era)a ')a'e,r-'
e
nteraksi oat
Kare'a ')a'e,r-' )ime,ab-!ime -!e e'Eim me,ab-!ik i,-kr-m $>;<0
era'ga'ga' )a' e'gamba,a' ,era)a e'Eim i'i )aa, me'guba k!ire' )a' +ak,u aru'(a. $a)a e')eri,a (a'g e)a'g me')aa, e'g-ba,a'
22
)e'ga' -ba,>-ba, (a'g ecara kua, mera'ga'g e'Eim me,ab-!ime %$3A; Geer,i Fe'i,-i' KarbamaEei' )a' Ri7amii'H k!ire' ')a'e,r-' aka' me'i'gka, ecara ig'i7ika' ei'gga k-'e',rai )a!am )ara aka' me'uru'. ,
Peringatan #an Perhatian
')a'e,r-' ebaik'(a ,i)ak )igu'aka' a)a +a'i,a ami! kuu'(a a)a ,rime,er # kecua!i 4ika ,er)aa, reik- (a'g !ebi bera, a)a ba(i akiba,
e'uru'a' bera, ba)a' ibu. ')a'e,r-' )iekrei a)a air uu ibu ei'gga )ia'4urka' u',uk ,i)ak )iberika' a)a ibu me'(uui. g
1,ek sam(ing
')a'e,r-' a)a umum'(a )aa, )i,-!era'i )e'ga' baik. K-',iai meruaka' e7ek ami'g (a'g a!i'g eri'g )i,emuka' G11=H. Ka)a'g )aa, )i4umai aki, kea!a +a4a ke meraa' G7!ui'gH raa a'a a,au a'ga, )i kea!a
)a'
eiga,rium
(a'g
beri7a,
eme',ara.
$e'i'gka,a'
ami'-,ra'7erae ,a'a )ier,ai ge4a!a>ge4a!a Ka)a'g 4uga )aa, )i4umai e'i'gka,a' erum ,ra'ami'ae G<=H )a' ruam ku!i, G1=H e)ai )a' )iare kare'a me'i'gka,'(a +ak,u ,ra'7er )i uu bear. $er'a )i!a-rka' ,er4a)i'(a reaki iere'i,i7 amai ke4a)ia' a'a7i!aki )a' ga'ggua' iua! eme',ara Ga')a'ga' kaburH. *uga er'a )i!a-rka' ,er4a)i'(a geraka'>geraka' ,a'a a)ar e,e!a emberia' ')a'e,r-' ecara cea, ,e,ai kau i'i a'ga, 4ara'g )a' ,a'a )ier,ai ge4a!a>ge4a!a ia h 'osis !osis
$e'cegaa' $N
mg
$e'g-ba,a' $N ; mg Kem-,erai a'ga, A+a! : mg eme,-ge'ik
ara Pemerian
.-. 1 4am ebe!um a'e,ei )iiku,i mg ,ia 4am )a!am 16 4am i.. er!aa' aa, i')uki a'e,ei i.. er!aa' eaa, ebe!um
Diiku,i : 1 mg/4am e!ama kem-,erai 2; 4am a,au
i'7u
2 mg A,au
i.. )e'ga' 4arak +ak,u 2 ; 4am
A+a! : 32 mg Diiku,i 2 mg
i'7u e!ama 1< me'i, eaa, ebe!um ke-m,erai .-. e!ama < ari
23
Kem-,erai
kura'g A+a! : mg
eme,-ge'ik
i..
er!aa'
eaa,
ebe!em
A,au mg
kem-,erai
Di!a'4u,ka' : 2 mg
.-. 1 2 4am ebe!um kem-,erai
Kem-,erai a)a a'ak ; A+a! : < mg /mU
.-. amai < ari #'7u e!ama 1< me'i, eaa,
,au'
Di!a'4u,ka' : 2 ; mg
ebe!um kem-,erai
Ra)i-,erai
A+a! : mg
.-. e!ama < ari .-. 1 2 4am ebe!um ra)i-,erai
?ia La'4u,
Di!a'4u,ka' : mg .-. amai 12 4am Daa, )i,-!erir )e'ga' baik a)a uia 6< ,au'. Ti)aka
)ier!uka'
e'(euaia' )-i a'(a er!u 7rekue'i
)ier,imba'gka' )a'
cara
emberia''(a $aie' )e'ga' ga'ggua' Ti)ak )ier!uka' 7u'gi gi'4a!
e'(euaia' )-i aria' 7rekue'i
)a'
cara
emberia' $aie' )e'ga' ga'ggua' T-,a! )-i aria' ,i)ak 7u'gi ear
b-!e !ebi )ari mg
3 Panto(ra8o in). a ekanisme Ker)a
$e'gamba, -ma r-,-' meruaka' e'gamba, ekrei aam !ambu'g !ebi kua, )ari A82. ba, i'i beker4a )i r-e ,erakir r-)uki aam !ambu'g !ebi )i,a! )ari AM$. Saa, i'i (a'g )igu'aka' )i k!i'ik a)a!a -meraE-! e-meraE-! !a'-raE-! raberaE-! )a' a',-raE-!. $erbe)aa' )ari ke!ima e)iaa' ,erebu, a)a!a a)a ub,i,ui )i ci'ci' iri)i' )a'/a,au be'Ei)imaE-!. Farmakokinetik #an Farma#inamika
$e'gamba, -ma r-,-' ebaik'(a )iberika' )a!am e)iaa' a!u, e',eric u',uk me'cega )egra)ai Ea, ak,i7 ,erebu, )a!am uaa'a aam.
24
Se)iaa' i'i ,i)ak me'ga!ami ak,iai )i !ambu'g ei'gga bi-ai!abi!i,a'(a !ebi baik. Tab!e, (a'g eca )i !ambu'g me'ga!ami ak,iai !a!u ,erika, a)a berbagai gugu u!7i)ri! muku )a' maka'a'. Bi-ai!ibi!i,a'(a aka' me'uru' amai <0= kare'a e'garu maka'a'. !e ebab i,u ebaik'(a )iberika' 30 me'i, ebe!um maka'. ba, i'i memu'(ai maa!a bi-aai!ibi!i,a 7-rmu!ai berbe)a memer!ia,ka' ree',ai 4um!a ab-ri (a'g berariai !ua. Bi-aai!ibi!i,a ,ab!e, (a'g buka' a!u, e',eric me'gika, )a!am <>5 ari i'i )aa, )i4e!aka' berkura'g'(a r-)uki aam !ambu'g e,e!a -ba, beker4a. ba, i'i )ime,ab-!ime )i a,i -!e i,-kr-m $;<0 G%$H ,eru,ama %$2%19 )a' %$3A;. $e'gamba, -ma r-,-' a)a!a ua,u r-)ug (a'g membu,uka' uaa'a aam u',uk ak,iai'(a. Se,e!a )iab-ri )a' mauk ke irku!ai i,emik -ba, i'i aka' ber)i7ui ke e! arie,a! !ambu'g ,erkumu! )i ka'a!iku!i ekre,-ar )a' me'ga!ami ak,iai )ii,u me'4a)i be',uk u!7-'ami)e ,e,raik!ik. Be',uk ak,i7 i'i berika,a' )e'ga' gugu u!7i)ri! e'Eim 8 K AT$ae Ge'Eim i'i )ike'a! ebagai -ma r-,-'H )a' bera)a )i membra' aika! e! arie,a!. #ka,a' i'i me'(ebabka' ,er4a)i'(a e'gamba,a' e'Eim ,erbu,. $r-)uki aam !ambu'g ,ere',i 0= amai 90= e,e!a e'gamba,a' -ma r-,-' ,erebu,. $e'gamba,a' ber!a'gu'g !ama a',ara 2;>; 4am )a' )aa, me'uru'ka' ekrei aam !ambu'g baa! akiba, ,imu!ai !ea )ari 4e'i era'ga'g'(a i,ami'e ae,i!k-!i' a,au ga,ri'. 8amba,a' i'i i7a,'(a ireeribe! r-)uki aam baru )aa, kemaba!i ,er4a)i e,e!a 3>; ari e'g-ba,a' )ibere',ika'. nteraksi oat
$r-,-' $um #'ibi,-r G$$#H )aa, meme'garui e!imi'ai beberaa -ba, (a'g memu'(ai 4a!ur me,ab-!ime (a'g ama )e'ga''(a a',ara !ai' +ar7ari' Ge-meraE-! !a'-raE-! -meraE-! )a' raberaE-!H )iaEeam Ge-meraE-! -meraE-!H )a' ik!--ri' G-meraE-! )a' reberaE-!H Di a',ara $$# a'(a -meraE-! (a'g )aa, me'gamba, ak,ii,a e'Eim %$2%19 Gei'gga me'uru'ka' k!ire' )iu!7iram 7e'i,-i' )a' beberaa -ba, !ai' (a'g )ime,ab-!ime -!e e'Eim ,erebu,H er,a me'gi')uki
25
%$1A2 Gei'gga me'i'gka,ka' k!ire' imirami' beberaa -ba, a',iik-,ik ,akri' )a' ,e-7i!i'H. # !osis
$a',-raE-! ,ere)ia ebagai ,ab!e, 20 mg )a' ;0 mg.
D-i u',uk )e+aa )e'ga' ,ukak Du-)e'a! Mi'um ;0 mg eari eka!i )-i )i,i'gka,ka' e,ia 12 mi'ggu )e'ga' ;0 mg ecara ber,aa amai makimum 120 mg er ari u',uk 2 mi'ggu. Da,a ,e!a me'gu'gkaka' ba+a m-'-,erai )e'ga' )-i aria' ;0 mg ,e!a )ikai,ka' )e'ga' e'(embua' emur'a ,ukak )u-)e'a! amai 5= )a' 9;= aie' e,e!a ;> mi'ggu ber,uru,>,uru,.
D-i u',uk )e+aa )e'ga' Tukak Lambu'g Mi'um ;0 mg eari eka!i. Da,a ,e!a me'gu'gkaka' ba+a m-'-,erai )e'ga' )-i aria' ;0 mg ,e!a )ikai,ka' )e'ga' e'(embua' emur'a ,ukak !ambu'g amai 5= )a' 9;= aie' e,e!a ;> mi'ggu ber,uru,>,uru,.
$e')araa' S,re ?!cer $r-(!ai )a!am e'a'ga'a' era+a,a' kri,i: 0 mg )ua ka!i eari ebagai i'7u b-!u amai eki,ar 1< me'i, u',uk )-i aria' makima! 2;0 mg ,erbagi )a!am ,iga )-i (a'g ama.
$e')araa' $e,ic ?!cer $r-(!ai e,e!a em-,ai )a!am e'a'ga'a' era+a,a' kri,i: 0 mg # b-!u )iiku,i )e'ga' i'7u berke!a'4u,a' mg/4am e!ama 3 ari e,e!a ,erai )aa, )i!a'4u,ka' )e'ga' -ra! $$#
e n#ikasi
#')ikai e'gamba, -ma r-,-' ama A82 (ai,u a)a e'(aki, e,ic. Tera)a i')r-m V-!!i'ger>!!i-' -ba, i'i )aa, me'eka' r-)uki
26
aam !ambu'g !ebi baik )ari A82 a)a )-i (a'g e7ek ami'g'(a ,i)ak ,er!a!u me'gga'ggu. , 1,ek sam(ing
7ek ami'g (a'g a!i'g umum ,er4a)i a)a!a mua! '(eri eru, k-',iai )iare )a' 7!a,u!e'ce. Di!a-rka' 4uga ,er4a)i mi-a,i ubaku, a,ra!gia aki, kea!a )a' ruam ku!i, 4
Ketosteril a
K-m-ii Aam Ke,- ee'ia!. #')ikai #'u7iie'i gi'4a! kr-'i a)a re,e'i ,erk-me'ai a,au ,er)ek-me'ai. $era,ia' e4a!a>ge4a!a aam uremia me'i'gka, emberia' A!G8H3 aru )ikura'gi. 8i-7-7a,emia. #',eraki ba, Te,raik!i' meme'garui ab-ri Ka!ium.
#
D-i 1. #'u7iie'i gi'4a! kr-'i : 3 ka!i eari ;> ,ab!e, . 2. Re,e'i ,erk-me'ai : 3 ka!i eari ;>6 ,ab!e, )e'ga' 'u,rii re')a r-,ei' ,i'ggi ka!-ri. 3. Re,e'i ,er)ek-me'ai : 3 ka!i eari ;> ,ab!e, )e'ga' 'u,rii re')a r-,ei' ,i'ggi ka!-ri.
5
Tri8e#on a ekanisme Ker)a
Trime,aEi)i'e
memer!amba,
-ki)ai
aam
!emak
)e'ga'
me'gamba, e!ek,i7 )ari ra',ai a'4a'g 3>ke,-a,e,i!>%-A ,i-!ae (a'g me'(ebabka' e'i'gka,a' -ki)ai g!uk-a )a' k-'4ugai reabi!i,ai a',ara g!ik-!ii )a' )ekarb-ki!ai -ki)a,i7 me'(ebabka' er!i')u'ga' ,era)a ikemia mi-kar). GSe,ia+a,i 2012H
27
Trime,aEi)i'e me'gura'gi 4um!a ai)-i i',rae!u!ar )a' erubaa' a!ira' i-' ,ra'membra' (a'g ,imbu! e!ama ikemia me'uru'ka' ,i'gka, migrai )a' i'7i!,rai 'eu,r-7i! -!('uc!ear )i )aera ikemik )a' reer7ui 4ari'ga' 4a',u'g ei'gga me'gura'gi ukura' keruaka' mi-kar). GSe,ia+a,i 2012H Farmakokinetik #an Farma#inamika
$u'cak k-'e',rai !ama ,er4a)i < 4am e,e!a emberia' -ra! ,ab!e,. Ke,ika eri-)e 2;>4am )ie!a4ari ka)ar !ama ,e,a ama a,au !ebi bear )ari 5<= )ari k-'e',rai makimum e!ama 11 4am.Trime,aEi)i'e Diekkreika' ,eru,ama me!a!ui gi'4a!.GSe,ia+a,i 2012H !osis
D-i (a'g )ia'4urka' a)a!a ;0>60 mg / ari )a!am )-i ,erbagi. GSe,ia+a,i 2012H # n#ikasi
Tambaa' u',uk ,erai a',i a'gi'a )a' ,erai 4a'gka a'4a'g u',uk a'gi'a ec,-ri.GSe,ia+a,i 2012H e Kontrain#ikasi
8i')ari emakaia' ,rime,aEi)i'e a)a ibu ami! mauu' ibu (a'g e)a'g me'(uui.GSe,ia+a,i 2012H , 1,ek sam(ing
a'ggua' e'cer'aa' Gmua! )a' mu',aH. GSe,ia+a,i 2012H 6
!outamin a $ama Kimia
D-bu,ami'e ()r-c!-ri)e Farmakokinetik #an Farma#inamika
'e, -7 ac,i-' G+ak,u -'e,H : # : 1>10 me'i,$eak e77ec, Ge7ek u'cakH: 10>20 me'i,Me,ab-!ime : )i 4ari'ga' )a' ear me'4a)i be',uk me,ab-!i, (a'g ,i)ak ak,i7 TW e!imi'ai Ga!7>!i7e e!imi'a,i-'H : 2 me'i, kkrei : uri' Gebagai me,ab-!i,H nteraksi oat
2$
Me'i'gka,ka' e7ek/,-kii,a : a'a,e,ik umum Gc-',-: a!-,a' a,au ik!-r-a'H )a' )-i !aEim )-bu,ami' me'(ebabka' ari,mia e',riku!ar a)a e+a'. Bre,(!ium )aa, mem-,e'iai e7ek )-bu,ami'. Be,a b!-cker G'-'e!ec,ieH )aa, me'i'gka,ka' e7ek ier,e'ii')ari e'ggu'aa' ecara beramaa'. K-kai' )aa, me'(ebabka' ari,mia eba,. ua'e,i)i' i'ibi,-r MA me,i!)-a reeri' )a' a',i)erea' ,riik!ik )aa, me'i'gka,ka' re-' re-r a)a ima,-mime,ik.Me'uru'ka' e7ek : b!-ker be,a a)re'ergik )aa, me'uru'ka' e7ek )-bu,ami' )a' me'i'gka,ka' riiki-,e'i (a'g bera,. # !osis
A+a! : 100 200 mcg/m', # #'7u : 2< 10 mcg/kgBB/m',. Daa, )i,i'gka,ka' i'gga ;0 mcg/kgBB/m', )ieuaika' )e'ga' re-''(a. e n#ikasi
S(-k kar)i-ge'ik: i')ikai u,ama emberia' )-bu,ami' a)a!a (-k kar)i-ge'ik akiba, i'7ark mi-kar) a,au a)a gaga! 4a',u'g kr-'i. D-i mu!ai 2< Xg/KgBb/m', kemu)ia' )i,i,rai amai ,er4a)i erbaika' TD. Se,e!a em-)i'amik ,abi! ecea, mu'gki' -ba, i'i )i,aeri'g -77 kare'a emberia'
)-bu,ami'
berari>ari
)aa,
me'(ebabka'
mi-kar) exhausted ei'gga u!i, me'ge',ika' -ba,. Bra)ikar)ia (a'g ,i)ak re-' )e'ga' emberia' a,r-i' G#H a,au aie' bra)ikar)ia (a'g membu,uka' +ak,u (a'g !ama u',uk memer-!e ba',ua' -ba,>-ba, !ai' a,au i',ere'i Gemaa'ga' acemaker ,em-rerH. Dri )-bu,ami' )-i re')a e7ek,i7 u',uk me'i'gka,ka' !a4u 4a',u'g. , Kontrain#ikasi
8iere'i,i7 ,era)a )-bu,ami'e a,au u!7i, Gbeberaa e)iaa' me'ga')u'g -)ium me,abiu!7a,H a,au beberaa k-m-'e' )a!am 7-rmu!ai i)i-a,ic (er,r-ic uba-r,ic ,e'-i G#8SSH g 1,ek sam(ing
Takikar)ia )a' me'i'gka,'(a ,eka'a' )ara i,-!ik me'u'4ukka' ,er4a)i -er)-i 7!ebi,i 4ara'g ,er4a)i e7ek ,r-mb-i,-e'ia
2%
h 'uungan (engoatan #engan #ata klinik #an #ata laoratorium *
ba, i'i kemu'gki'a' )iberika' kare'a me!ia, )ari )a,a ,eka'a' )ara aie' (a'g re')a (ai,u 9;/50mm8g i 'uungan (engoatan #engan ria%at (en%akit (asien #an ria%at (engoatan
$a)a ri+a(a, e'(aki, )i)aa,ka' ,er)iag'-i %AD kura'g !ebi 1 bu!a' (a'g !a!u -ba, i'i )imaku)ka' u',uk me'ga,ai (-k kar)i-ge'ik (a'g ,er4a)i akiba, a(a 4a',u'g (a'g mu'gki' u)a ,er4a)i 9
&iso(rolol a ekanisme Ker)a
Me'uru'ka' kebu,ua' -kige' -,-, 4a',u'g )e'ga' cara me'uru'ka' 7rekue'i )e'(u, 4a',u'g,eka'a' )ara )a' k-',rak,i!i,a.Su!ai -kige' me'i'gka, kare'a e'uru'a' 7rekue'i )e'(u, 4a',u'g ei'gga er7ui k-r-'er membaik aa, )ia,-!. !osis
10>20 mg 1 Seari Aturan (emakaian oat
1. 8a,i>a,i bi!a )iberika' a)a e')eri,a ke!ai'a' gi'4a! )a' a,i. 2. ba,>-ba, g-!-'ga' be,a b!-ker ebaik'(a ,i)ak )iberika' a)a e')eri,a ke!ai'a' 4a',u'g. 3. $a)a e')eri,a br-'k-a,ik ebaik'(a ,i)ak )iberika' -ba,>-ba,a' g-!-'ga' be,a b!-ker kare'a i7a, ek,ii,a be,a>1 (a'g re!a,i7 ,e,ai bi-r-!-! )aa, )igu'aka' ecara a,i>a,i a)a e')eri,a br-'k-a,ik (a'g ,i)ak me'u'4ukka' re-' a,au ,i)ak ,-!era' ,era)a e'g-ba,a' a',iier,e'i !ai'. ;. Be,a b!-ker )aa, me'u,ui beberaa be',uk i-g!ikemia kuu'(a ,akikar)ia. !e kare'a i,u e')eri,a i-g!ikemia a,au )iabe,e (a'g
3&
me')aa, i'u!i' a,au -ba,>-ba,a' i-g!ikemik aru a,i>a,i. Begi,u 4uga )e'ga' e'ggu'aa' bi-r-!-! 7umara,. # Lama (engoatan untuk tera(i
Lama e'ggu'aa' -ba, (a'g )igu'aka' u',uk e'g-ba,a' ier,e'i maka )-i be,a>b!-cker aru )i,i,rai me'uru, ,eka'a' )ara (a'g i'gi' )icaai. Seme',ara 4ika be,a>b!-cker )igu'aka' )a!am 4a'gka a'4a'g eer,i a)a gaga! 4a',u'g kr-'ik a,au aca> i'7ark mi-kar) )-i aru )i,i,rai euai )e'ga' )-i (a'g )igu'aka' )a!am u4i k!i'i. $e'ge',ia' ,erai be,a> b!-cker e,e!a e'g-ba,a' kr-'ik )aa, me'imbu!ka' beberaa ge4a!a eer,i ier,e'i ari,mia )a' ekaerbai a'gi'a. e n#ikasi
Bi-r-!-! )ii')ikaika' u',uk e'g-ba,a' ier,e'i bia 4uga )igu'aka' ebagai
m-'-,erai a,au k-mbi'ai )e'ga' a',iier,e'i
g-!-'ga' !ai'. , 1,ek sam(ing
1. $a)a i,em ara7 ua,: aki, kea!a er,ig- a'ie,a k-'e',rai berkura'g. 2. A)a kar)i-aku!ar: bra)ikar)ia a!i,ai aki, )a)a c-!) e,remi,ie i-,e'i )a' gaga! 4a',u'g. 3. $a)a ga,r-i',e,i'a!: '(eri eru, ga,ri,i mua! mu',a )iare k-',iai. ;. $a)a ku!i,: ku!i, kemeraa'iri,ai ku!i, 4era+a, ga,a!>ga,a! )erma,i,i ek7-!ia,i7 <. $a)a er'a7aa': ama br-'k-ame ba,uk i'ui,i g 'uungan umur #engan oat
?',uk aie' !a'ia 4ika )e'ga' bi-r-!-! aie' e'(aki, ,erke')a!i aru )i era,ika' )-i )a' embere',ia' -ba,. h 'uungan oat #engan #ata klinis #an la *
Bi-r-!-! )igu'aka' a'(a e,i'gka, ge4a!a k!i'i )ari ier,e'i ri'ga' )a' e)a'g a4a i 'uungan (engoatan #engan ria%at (en%akit #an (engoatan
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Bi-r-!-! aka' me'amba e7ek ami'g (a'g )iakiba,ka' aie' (a'g memi!iki ga'ggua' i,emik ,eru,ama r-,ei' !ama (a'g ,i)ak ,abi!. ) nteraksi 7at #engan 7atmakanan #an )amu * nteraksi eta-loker #engan anti hi(ertensi.
Be,a>b!-cker )e'ga' )iure,ika. Diure,ika eri'g )igu'aka' u',uk ,erai ier,e'i. Tai ka!au )iure,ika a4a maka ai! ,erai'(a ,erba,a. ?',uk me'caai ai! (a'g !ebi baik maka ebaik'(a )ik-mbi'aika' )e'ga' a',i ier,e'i !ai'. $erc-baa' )i k!i'ik me'u'4ukka' ba+a k-mbi'ai be,a> b!-cker )e'ga'! )iure,ika )ier-!e ker4a a',i ier,e'i (a'g !ebi baik. Da!am a! i'i ,i)ak ,er4a)i -,ura! i-,e'i )a' ,ac(car)i (a'g )iebabka' -!e )iure,ika G,iaEi)eH. Da' 4uga e'i'ggia' !ama re'i' akiba, emberia' )iure,ika aka' )ikura'gi -!e be,a>b!-cker. Be,a>b!-cker )e'ga' a-)i!a,-r. K-mbi'ai
-ba, i'i aka'
me'gai!ka' e77ek ,erai (a'g !ebi baik. Ter'(a,a e77ek ami'g'(a aka' berkura'g. $emberia' ()ra!aEi'e (a'g me'imbu!ka' re7!e ,ac(car)i aka' berkura'g bi!a emberia''(a )ik-mbi'aika' )e'ga' be,a>b!-cker. Be,a>b!-cker )e'ga' me,(!)-a. $e'ggu'aa' k-mbi'ai )ari me,(!)-a )a' be,a>b!-cker ,er'(a,a !ebi ama' )iba')i'gka' )e'ga' emakaia''(a ecara ,u'gga!. 77ek ami'g )ari me,(!)-a berua -,ura! i-,e'i aka' i!a'g bi!a )iberika' berama> ama )e'ga' be,a>b!-cker. Be,a>b!-cker )e'ga' gua'e,i)i'e )a' be,a)i'e. $e'garu k-mbi'ai i'i amir ama )e'ga' k-r'bi'ai be,a>b!-cker )e'ga' me,(!)-a. 77ek ami'g )ari gua'e,i)i'e )a' be,a)i'e aka' berkura'g ,eru,ama -,ura! i-,e'i (a'g )iebabka' gua'e,i)i'e )a' be,a)i'e. nteraksi &eta-loker #engan anti-arrh%thmia.
Be,a>b!-cker )e'ga' )igi,a!i. $e'g-ba,a' arr(,mia )e'ga' )igi,a!i )aa, me'imbu!ka' ar-(ma! ,ac(car)ia. Maka emberia' be,a>b!-cker berama>ama )e'ga' )igi,a!i )aa, me'g-',r-! ,ac(car)i )e'ga' baik.
32
Be,a>b!-cker )e'ga' Cui'i)i'e. Yui'i)i'e (a'g )igu'aka' a)a arr(,mia 4a',u'g )aa, r'e'imbu!ka' e',ricu!ar 7ibri!!a,i-'. Bi!a )iberika' berama>ar'a )e'ga' be,a>b!-cker maka e77ek ami'g i'i berkura'g.Be,a> b!-cker )e'ga' r-cai'ami)e. $emberia' r-cai'ami)e ebagai a',i> arr(,mia )aa, me'imbu!ka' e'uru'a' ,eka'a' )ara (a'g a'ga, cea, ,eru,ama bi!a )iberika' ecara i',rae'a. $emberia' berama>ama )e'ga' be,a>b!-cker aka' me'(ebabka' e77ek (a'g berbaa(a kare'a beker4a i'ergi,ik. nteraksi
eta-loker
#engan
anti-#e(ressan
#an
antl-(sikotik
tranguikner.
$emberia' a',i>)erea' mia!'(a )eria, ,ric(c!ic )a' )eria, e'-,iaEi'e )aa, me'imbu!ka' )(r(,mia. Maka emberia' be,a>b!-cker aka' me'gi')arka' e77ek )(r(,mia akiba, emberia' a',i>)erea' ,erebu, nteraksi eta-loker #engan al,a a#renergik stimulan.
$a)a erc-baa' me'u'4ukka' ba+a emberia' be,a>b!-cker berama> Sama )e'ga' '-rei'eri'e aka' me'(ebabka' a-k-',riki. Akiba, (a'g a'ga,Z merugika' ia!a ga'ggre'. 8a! i'i ,imbu! kare'a '-rei'eri'e e77ek'(a )-mi'a' ,era)a ree,-r a!7a nteraksi eta-loker #engan neuromuskular-loker.
Be,a>b!-cker (a'g )ik-mbi'aika' )e'ga' 'eur-muku!ar>b!-cker mia!'(a : ucci'(c-!i'e Decame,-'ium )>Tub-curari'e a!!ami'e aka' me'imbu!ka' ker4a i'ergi,ik nteraksi eta-loker #engan oat hi(oglikemik.
abu'ga' ke)ua -ba, i'i me'gai!ka' e77ek i'ergi,ik. 8a! i'i ,er4a)i kare'a be,a>b!-cker meme'garui ker4a g!ik-ge'-!i,ik )ari g!ukag-' )a' 4uga mera'ga'g e!eaa' i'u!i'. nteraksi eta-loker #engan anti-in,lammasi.
33
Be,a>b!-cker me'gamba, e77ek a',i>i'7!ammai )ari -ba,>-ba, Na,rium a!ii!a, Ami'-iri' Fe'i!bu,aE-' 8i)r-k-r,i-'. 8a! i'i )iebabka' kare'a k-me,ii !a'gu'g a',ara ke)ua -ba, i'i a)a ree,-r (a'g ama. nteraksi eta-loker #engan anti-angina.
abu'ga' ke)ua -ba, i'i me'gai!ka' i'ergime. Be,a>b!-cker me'gura'gi ker4a 4a',u'g )e'ga' me'gura'gi ear, ra,e. Demikia' u!a Ni,ra, berbua, a! (a'g Sama )e'ga' me'gura'gi e'-u re,ur' )a' -!ume er,a ,eka'a' )a!am e',rike!! kiri. nteraksi eta-loker #engan atro(in.
abu'ga' ke)ua -ba, i'i )aa, memerbaiki i'u ,ac(car)ia (a'g ,er4a)ii kare'a er'beria' )-i bear a,r-i' a)a e'g-ba,a' keracu'a' i'ek,ii)a -rga'-7-7a,. Seba!ik'(a ke4a)ia' bra)ikar)i akiba, ke!ebia' )-i be,a>b!-cker )aa, )ia,aii )e'ga' emberia' a,r-i' nteraksi eta-loker #engan temakau.
$a)a mereka (a'g ba'(ak mer-k-k emakaia' be,a>b!-cker aka' memer!uka' )-i (a'g iebi bear. ebab ,embakau beker4a a',ag-'i,ik )e'ga' be,a>b!-cker.$a)a e')eri,a e'(aki,>e'(aki, (a'g ,erebu, )iba+a i'i ebaik'(a )-i be,a>b!-cker )ikura'gi (ai,u a)a e')eri,a Reima,-i) ar,ri,i %-!i,i u!cer-a S,a(!-c-cca! 'eum-'ia )a' %r-'[ )ieae Bi-r-!-! ebaik'(a ,i)ak )ik-mbi'aika' berama -ba,>-ba,a' g-!-'ga' be,a b!-ker. Bi-r-!-! ebaik'(a )igu'aka' ecara a,i>a,i bi!a )iberika' beramaa' )e'ga' -ba,>-ba, e'eka' -,-, 4a',u'g a,au e'gamba, k-')uki A eer,i ka!ium a',ag-'i kuu'(a 7e'i!a!ki!ami' Geraami!H )a' g-!-'ga' be'E-,iaEei' G)i!,iaEemH a,au -ba,>-ba,a' a',iari,mik eer,i )i-irami). $e'ggu'aa' berama ri7amii' )aa, me'i'gka,ka' beria' me,ab-!i, bi-r-!-!. : lo(i#ogrel ;PG a Kom(osisi*
%!-i)-gre!
34
&entuk "e#iaan*
Tab!e, a!u, e!au, 5< mg Farmakologi*
Se!ek,i7 me'gamba, ika,a' denosine !i"#hosphate GAD$H a)a ree,-r AD$ )i !a,e!e, ei'gga me'gamba, ak,iai k-m!ek g!ik-r-,ei' $##b/###a (a'g )ime)iai -!e AD$ )a' me'(ebabka' e'gamba,a' ,era)a agregai !a,e!e,. Ab-ri cea, a)a emberia' er -ra! )a' e'(eraa''(a ,i)ak )ie'garui -!e maka'a'. # n#ikasi*
?',uk me'uru'ka' a,er-,r-mb-i (a'g me'(er,ai : Sera'ga' i'7ark mi-kar) era'ga' ,r-ke a,au e'(aki, embu!u )ara eri7er. $on"%& segment elevation acute coronary syndr -me )e'ga' emakaia' berama ae,-a!. e !osis*
1. Sera'ga' i'7ark mi-kar) era'ga' ,r-ke a,au e'(aki, embu!u )ara eri7er: De+aa )a' uia !a'4u, : )-i (a'g )irek-me')aika' a)a!a 5< mg a,u ka!i eari 2. $aie' )e'ga' non"%& segment elevation acute coronary syndrome : A'gi'a ,i)ak ,abi! a,au i'7ark mi-kar) non"'"wave )-i a+a! : 300 mg eka!i emberia' )a' )i!a'4u,ka' )e'ga' 5< mg a,u ka!i eari )e'ga' ae,-a! G5< mg 32< mg a,u ka!i eariH 3. D-i ae,-a! (a'g !ebi ,i'ggi berkai,a' )e'ga' me'i'gka,'(a reik- ,er4a)i'(a er)araa' maka )irek-me')aika' )-i Ae,-a! ebaik'(a ,i)ak me!ebii 100 mg. , Kontrain#ikasi*
$aie' (a'g iere'i,i7 ,era)a k-m-'e' (a'g ,erka')u'g )i )a!am %$. $aie' (a'g me'ga!ami er)araa' a,-!-gi eer,i u!ku e,ikum a,au er)araa' i',rakra'ia!. g Peringatan #an Perhatian*
$e'ggu'aa' %$ 4ara'g me'(ebabka' ,imbu!'(a &hrombotic &hrombocytopenic #urpura GTT$H (a'g ,er4a)i a)a a+a! emakaia'.
35
%$
)aa,
memera'4a'g
+ak,u
er)araa'
ei'gga
e'ggu'aa''(a aru a,i>a,i. $aie' )e'ga' ga'ggua' ga,r-i',e,i'a! aru a,i>a,i e'ggu'aa''(a kare'a )aa, me'(ebabka' er)araa'. $e'ggu'aa' %$ a)a aie' )e'ga' ga'ggua' 7u'gi a,i bera, )e'ga' )ia,ei er)araa' e'ggu'aa''(a aru a,i>a,i begi,u u!a )e'ga' aie' )e'ga' ga'ggua' 7u'gi gi'4a! bera, kare'a e'ga!ama' e'ggu'aa' %$ mai ,erba,a a)a aie' ,erebu,. $e'ggu'aa' a)a ibu ami! )a' me'(uui: $emberia' %$ a)a ibu ami! mauk )a!am ka,eg-ri B e'e!i,ia' mai baru )i!akuka' a)a bi'a,a'g erc-baa' 4a)i be!um a)a buk,i kua, )a' ,erk-',r-! )e'ga' baik a)a ke!-m-k i'i. Kare'a %$ )aa, )iekkreika' me!a!ui air uu emberia' a)a ibu me'(uui ,i)ak )ia'4urka'. 7ek,ii,a )a' keama'a' %$ a)a a'ak>a'ak be!um )ike,aui. h 1,ek "am(ing*
Secara umum )aa, ,er4a)i k-',iai )iare u!ku e,ikum u!ku ga,er )a' )u-)e'um mu',a er)araa' ga,ri,i. < =alisane ;&en8o#ia8e(in
Be'E-)iaEei' )aa, )ig-!-'gka' ke )a!am 3 ke!-m-k 1.
Long ating.
ba,>-ba, i'i )ir-mbak )e'ga' 4a!a' )eme,iai )a' i)r-ki!ai
me'4a)i me,ab-!i, ak,i7 Gei'gga memera'4a'g +ak,u ker4aH (a'g kemu)ia' )ir-mbak kemba!i me'4a)i -kaEeam (a'g )ik-'4ugai me'4a)i g!uk-r-i)a,ak ak,i7. Me,ab-!i, ak,i7 )eme,i! biaa'(a beri7a, a'i-!i,a. Sei'gga biaa'(a Ea, !-'g ac,i'g !ebi ba'(ak )igu'aka' ebagai -ba, ,i)ur +a!auu' e7ek i')uk'(a (a'g a!i'g me'-'4-! a)a!a e)a,ie>i'-,ik. %-',-'(a )iaEeam 7!uraEeam GSe,ia+a,i 2012H 2. "hort ating. ba,>-ba, i'i )ime,ab-!ime ,a' ame'gai!ka' Ea, ak,i7. Sei'gga +ak,u ker4a'(a ,i)ak )iera'4a'g. ba,>-ba, i'i 4ara'g me'gai!ka' e7ek ia kare'a ,i)ak ,erakumu!ai a)a e'ggu'aa' beru!a'g. 3.
%-',-'(a !-raEeam e,aE-!am GSe,ia+a,i 2012H >ltra short ating
Lama ker4a'(a a'ga, kura'g )ari -r, ac,i'g. 8a'(a kura'g )ari << 4am. 7ek ab,i'e'ia !ebi bear ,er4a)i a)a -ba,>-ba, a'4e'ii'i. Se!ai' ia me,ab-!i, ak,i7 me'e',uka' u',uk era'4a'ga' +ak,u ker4a a7i'i,a ,era)a
36
ree,-r 4uga a'ga, me'e',uka' !ama'(a e7ek (a'g ,er4a)i aa, e'ggu'aa'. Semaki' kua, Ea, berika,a' a)a ree,-r'(a emaki' !ama 4uga +ak,u ker4a'(a. %-,-'(a mi)aE-!am ,riaE-!am GSe,ia+a,i 2012H Se!ai' iame,ab-!i, ak,i7 me'e',uka' u',uk era'4a'ga' +ak,u ker4a a7i'i,a ,era)a ree,-r 4uga a'ga, me'e',uka' !ama'(a e7ek (a'g ,er4a)i aa, e'ggu'aa'. Semaki' kua, Ea, berika,a' a)a ree,-r'(a emaki' !ama +ak,u ker4a'(a GSe,ia+a,i 2012H a ekanisme Ker)a
Meka'ime ker4a )iaEeam ber,i')ak )e'ga' me'i'gka,ka' aki ABA Gamma" minobutyric cid H (a'g meruaka' 'eur-,ra'mi,,er i'ibii u,ama )a!am i,em ara7 ua,. Be'E-)iaEei' berika,a' )e'ga' ree,-r ,er,e',u a)a k-m!ek ree,-r ABA )a' )emikia' mem7ai!i,ai e'gika,a' ABA ke i,u ree,-r ei7ik. #ka,a' )e'ga' ree,-r i'i me'(ebabka' e'i'gka,a' 7rekue'i embukaa' a!ura' k!-ri)a me'(ebab ier-!ariai membra'e (a'g me'gamba, eki,ai e!u!er $e'i'gka,a' 'eur-,ra'mii ABA me'(ebabka' e7ek e)ai re!akai -,-, !urik a'i-!(i )a' a',ik-'u!a'. S,imu!ai ree,-r ABA i,em ara7 ,ei )aa, me'(ebabka' e'uru'a' ke 4a',u'g )a' a-)i!a,ai.$erubaa' i'i memi!iki -,e'i u',uk me'guba er7ui 4ari'ga' GSe,ia+a,i 2012H Farmakokinetik #an Farma#inamika
1. Ab-rbi. Aabi!a )igu'aka' u',uk me'g-ba,i kecemaa' a,au ga'ggua' ,i)ur e)a,ie>i'-,ik biaa'(a )iberika' ecara -ra!. Kecea,a' ab-rbi -ra! )iaEeam !ebi cea, )iba')i'g be'E-)iaEei'e a)a umum'(a. Ber)aarka' !ama ker4a )iaEeam ,ermauk g-!-'ga' be'E-)iaEei'e )e'ga' cara ker4a +ak,u aru !ebi !ama )ari 2; 4am. DiaEeam )iab-rbi )e'ga' baik )i a!ura' cer'a. Secara -ra! -'e,'(a 30 me'i, )e'ga' +ak,u u'cak 1>2 4am )a')urai 2>3 4am. Secara i',rae'a -'e,'(a !>< me'i, +ak,u u'cak'(a 1< me'i, )a' )urai 1<>60 me'i,. $a)a emberia' i',ramucu!ar -'e,'(a 1< me'i, +ak,u u'cak'(a 30>90 me'i, )e'ga' )urai (a'g ama 30>90 me'i,. $!ama k-'e',rai )ari )iaEeam a)a!a 002>101 micr-gram/m!. $a)a emberia' -ra! a,au er rec,a! k-'e',rai !ama ra,a>ra,a 56= )a' 1= Bi-aai!ibi!i,a !ebi re')a a)a emberia' u-i,-ria GSe,ia+a,i 2012H
37
2. Di,ribui. Tra'-r e)a,ie>i'-,ika )i )a!am )ara meruaka' r-e )i'ami )ima'a m-!eku!>m-!eku! -ba, mauk )a' ke!uar 4ari'ga' a)a kecea,a' (a'g berga',u'g a)a a!ira' )ara erbe)aa' k-'e',rai )a' ermeabi!i,a. Ke!aru,a' )a!am !ii) memega'g era'a' e',i'g )a!am me'e',uka' e)a,ie>i'-,ika ,er,e',u. Kecea,a' ,ra'7-rmai me,ab-!i )a' e!imi'ai )iaEeam a'ga, !amba,. DiaEeam )a' ebagia' bear e)a,ie>i'-,ika !ai''(a berika,a' kua, )e'ga' r-,ei' !ama. Kekua,a' ika,a''(a berubu'ga' era, )e'ga' i7a, !i-7i!ik'(a a)a )iaEeam a)a!a 99= Ka)ar'(a a)a caira' erebr-i'a! kira>kira ama )e'ga' ka)ar -ba, beba )i )a!am !ama. DiaEeam aka' me'ga!ami akumu!ai a)a e'ggu'aa' )-i beru!a'gGSe,ia+a,i 2012H 3. Me,ab-!ime. ba, g-!-'ga' be'E-)iaEei'e )ime,ab-!ime ecara ek,e'i7 -!e ke!-m-k e'Eim i,-kr-m $;<0 )i a,i ,eru,ama %$3A; )a' %$2%19 Beberaa be'E-)iaEei'e eer,i -kaEeam )ik-'4ugai !a'gu'g )a' ,i)ak )ime,ab-!ime -!e e'Eim ,erebu,. Tra'7-rmai me,ab-!i me'4a)i me,ab-!i, (a'g !ebi mu)a !aru, )i )a!am air )ier!uka' u',uk k!ire' -ba, )a!am ,ubu. DiaEeam me'ga!ami -ki)ai mikr--ma! Greaki7ae #H me,ab-!i, e!a'4u,'(a )ik-'4ugai Greaki7ae ##H -!e g!ucur-'-(! ,ra'7erae membe',uk g!uc-r-'i)e (a'g )iekkrei uri'e GSe,ia+a,i 2012H. ;. krei. DiaEeam )iekkrei me!a!ui uri'e baik )a!am be',uk beba mauu'
,erk-'4ugai. DiaEeam )i
ekrei)a!am uri'e
ebagai
g!uc-r-'i)ea -i)iEe) me,ab-!i,. "ak,ue !imi'ai !ama aka' mema'4a'g a)a 'e-'a,u geria,rik )a' aie' )e'ga' ga'ggua' !ier. $a)a ebagia' bear kau erubaa' 7u'gi gi'4a! ,i)ak memi!iki e7ek (a'g kua, ,era)a e!imi'ai -ba, i')uk GSe,ia+a,i 2012H. Farmako#inamika*
8amir emua e7ek be'E-)iaEei'e meruaka' ai!
ker4a g-!-'ga' i'i a)a SS$ )e'ga' e7ek u,ama: e)ai ('-i e'gura'ga' ,era)a ra'ga'ga' em-i/ a'ie,a re!akai -,-, )a' a',i k-'u!i. 8a'(a )ua e7ek a4a (a'g meruaka' ker4a g-!-'ga' i'i a)a 4ari'ga' eri7er a-)i!a,ai k-r-'er e,e!a emberia' )-i ,erai ecara # )a' b!-cka)e 'eur-mucu!ar (a'g a'(a ,er4a)i a)a emberia' )-i ,i'ggi. Targe, )ari ker4a be'E-)iaEei'e a)a!a ree,-r ABA. Ree,-r i'i ,er)iri )ari ubu'i, \ )a' ] )ima'a berk-mbi'ai )e'ga' !ima a,au !ebi )ari
3$
membra'e -,i'a,ik. Be'E-)iaEei'e me'i'gka,ka' e7ek ABA )e'ga' berika,a' ke ,ema, (a'g ei7ik )a' a7i'i,a ,i'ggi. Ree,-r i-'-,r-ik i'i ua,u r-,ei' e,er-!ig-me,rik ,ra'membra' (a'g ber7u'gi ebagai ka'a! i-' k!-ri)a (a'g )iak,iai -!e 'eur-,ra'mi,,er ABA i'ibi,-rik GSe,ia+a,i 2012H. nteraksi 7at
$e'i'gka,a' e7ek e)ai )a' )erei 'a7a )a' )erei kar)i-aku!ar )aa, ,er4a)i a)a e'ggu'aa' )iaEeam berama -ba, !ai' (a'g me')erei SS$ ,ermauk a!k--! a',i )erea' e)a,ie a',ii,ami' a',iik-,ik ge'era! a'a,ei -ba, i'-,ik>e)a,i7 !ai''(a )a' a'a!geik -ia,. 7ek ami'g 4uga )aa, mu'cu! )e'ga' e'ggu'aa' -ba, (a'g )aa, me'gga'ggu me,ab-!im )iaEeam. A'a!geik )a' )iaEeam )aa, me'(ebabka' ,er4a)i )erei 'a7a %ir-7!-aci' me'uru'ka' k!ere' )iaEeam )a' mema'4a'gka' , e)a'gka' ri7amii' me'uru'ka' ,
)ari )iaEeam )a' i-'iaEi)
me'i'gka,ka' +ak,u , )iaEeam a)a )-i ,u'gga!. #ka,a' !ama )iaEeam )a' )eme,(!)iaEeam me'uru' )a' k-'e',rai beba me'i'gka, )a' egera me'giku,i eari' ke )i )a!am a!ira' )ara A',i)erea' )aa, me'gga'ggu me,ab-!ime
-ba,>-ba,
g-!-'ga'
be'E-)iaEei'e.
ba,
g-!-'ga'
be'E-)iaEei'e ,i)ak b-!e )i berika' berama -ba, a',i ira! ,eru,ama 8#> r-,eae i'ibi,-r. $r-a'-!-! )a' me,-r-!-! me'gamba, me,ab-!im )iaEeam. Dig-i' me'gga'ggu e7ek 7arma-ki'e,ik )iaEeam. ba, !ai' (a'g beri',eraki )e'ga' )iaEeam )iu!7iram ga,r-i',e,i'a! )rug ge'era! a',ei. ra! k-',raei. Muc!e re!aka' ,embakau )a' a',i' GSe,ia+a,i 2012H. # !osis
$a)a e'ggu'aa' u',uk a',i a'ie,a re!akai -,-, mukuek!e,a! )e+aa : 2>10 mg ,erbagi 2>; ka!i ari geria,ri : 2< mg )a!am 2 ka!i ari
3%
a'ak : 012>0 mg/KgBB/ ari ,erbagi )a!am beberaa )-i ,ia 6> 4am # )a' #M :)e+aa : 2>10 mg )iu!a'g 3>; 4am a'ak : 00;>03 mg/kg/ )-i ,ia 2>; 4am makimum: 0< mg/kg
)a!am 4am ?',uk $rea'a,eia #: )e+aa geria,ric : <>1< mg )a!am <>10 me'i, Sebe!um )imu!ai A'ak : 02>02 mg/kg makimum 10 mg e4a!a +i,)ra+a! )e+aa geria,ric : 10 mg 3>; ka!i e!ama 2; 4am er,ama !a!u
)i,uru'ka' <>10 mg 3> ; ka!i ari 4ika er!u # #M :)e+aa geria,ri : mu!a'(a 10 mg )iiku,i <>10 mg ,ia 3>; 4am S,a,u i!e,iku #: )e+aa geria,ri : <>10 mg ,ia 10>1< me'i, i'gga 30 mg/ 4am a'ak < ,au'^ : 00<>03 mg/kg/)-i,ia 1<>30 me'i, makimum 10
mg/)-i a'ak _< ,au' : 00<>03 mg/kg/)-i ,ia 1<>30 me'i, makimum < mg )-i
e n#ikasi
Secara umum e'ggu'aa' ,erai be'E-)iaEei'e berga',u'g kea)a +ak,u aru'(a. )a' ,i)ak e!a!u euai )e'ga' i')ikai (a'g )iaarka'. 7ek ,eraeu,ik )iaEeam )igu'ka' u',uk me'gai!ka' e7ek a'i-!(,ic me'i'gka,ka' amba'g ke4a'g me'gai!ka' re!akai mucu!-ke!e,a!. DiaEeam )igu'aka' u',uk e'g-ba,a' 4a'gka a'4a'g a)a a'ie,a. DiaEeam 4uga )igu'aka' u',uk ,erai ame mucu!-ke!e,a! eer,i ,rai' )a' a,ii,a )ari ga'ggua' )ege'era,ie. DiaEeam meruaka' -ba, i!ia' )a!am me'ga,ai ke4a'g ei!ei ,ie gra')ma ,a,u ei!e,iku berma'7aa, u',uk )igu'aka' )a!am e'a'ga'a' aku, )ari ge4a!a u,u -ba, a!c--! GSe,ia+a,i 2012H. , Kontrain#ikasi
Ti)ak b-!e )igu'aka' a)a aie' )e'ga' a'g!ec!-ure g!auc-ma k-ma )erei SS$ )rei 'a7a aki, bera, '(eri (a'g ,i)ak ,erk-',r-! aku, u!m-'ar( i'u7iie'i m(a,e'ia grai a,au !ee a'ue. $er!u )iera,ika' a)a e'ggu'aa' ,era)a geria,ri a,au aie' (a'g )a!am kea)aa' !ema kare'a ce')eru'g !ebi mu)a ,erke'a e7ek ami'g. $e'ggu'aa' -ba, i'i 4uga er!u era,ia' kuu a)a aie' )e'ga' ke!emaa' -,-, ga'ggua'
4&
gi'4a! )a' ga'ggua' ear (a'g biaa'(a membu,uka' a)a'(a e'uru'a' )-i. 7ek e)ai (a'g mu'cu! a)a a,au a+a! e'ggu'aa' er!u )iera,ika' ei'gga aie' ,i)ak berke')ara. e')iri me'g-raika' mei'. $a)a e'ggu'aa' e)ai )a!am er!u era,ia' a)a 7u'gi kar)i-reirai ba, )iaEeam 4uga er!u )iera,ika' a)a e'ggu'aa''(a a)a aie' ga'ggua' )aera -,ak !a a,u'(a ar,eri-k!er-i. $aie' )e'ga' ri+a(a, keca')ua' a!c--! )a' -ba,> -ba,a' aru )i era,ika'. ba, i'i ,i)ak bia )iberika' a)a ibu ami! )a' me'(uui berubu'ga' )e'ga' -ba, i'i )aa, me'embu barrier !ae',a. $a)a ibu me'(uui )aa, )iberika' )e'ga' )-i re')a aabi!a ,eraka )a' ,i)ak )aa, )ii')ari e'ggu'aa''(a GSe,ia+a,i 2012H. g 1,ek sam(ing
7ek ami'g (a'g eri'g )aa, mu'cu! a)a e'ggu'aa' )iaEeam a)a!a e)ai ke!emaa' -,-, )a' a,aia. 7ek ami'g (a'g 4ara'g ,imbu! er,ig- aki, kea!a bi'gu'g )erei )iar,ria erubaa' !ibi)- ,rem-r ga'ggua' iua! re,'i uri' a,au i'k-',i'e'ia uri' erubaa' a!ia )a' am'eia GSe,ia+a,i 2012H. h 'uungan oat #engan #ata klinik #an #ata la
Ti)ak a)a ubu'ga''(a i 'uungan oat #engan ria%at (en%akit #an ria%at (engoatan
Ti)ak a)a ubu'ga' ei7ik a'(a a4a -ba, i'i )igu'aka' u',uk me'eka' ua ,i)ur a)a aie' bi!a a)a i'-m'ia. ? Ketorola in). a $ama generi
Ke,-r-!ac $ama #agangn%a
D-!ac Ke,-ai' Ke,-r-!ac B Dea La',iai' Rem-ai' Rem-ai' R-!ac Sce,,- T-ra)-! T-rami'e T-raic T-rai' Tr-!ac Je-!ac
41
Farmakokinetik #an Farma#inamika
Ke,-r-!ac ,r-me,ami'e )iera )e'ga' cea, )a' !e'gka e,e!a emberia' i',ramuku!ar )e'ga' k-'e',rai u'cak ra,a>ra,a )a!am !ama ebear 22 mcg/m! e,e!a <0 me'i, emberia' )-i ,u'gga! 30 mg. "ak,u aru ,ermi'a! !ama <3 4am a)a )e+aa mu)a )a' 5 4am a)a -ra'g !a'4u, uia Guia ra,a>ra,a 52 ,au'H. Lebi )ari 99= Ke,-r-!ac ,erika, a)a k-'e',rai (a'g beragam. Farmak-ki'e,ik Ke,-r-!ac a)a ma'uia e,e!a emberia' ecara i',ramuku!ar )-i ,u'gga! a,au mu!,ie! a)a!a !i'ear. Ka)ar ,ea)( ,a,e !ama )icaai e,e!a )iberika' )-i ,ia 6 4am )a!am eari. $a)a )-i 4a'gka a'4a'g ,i)ak )i4umai erubaa' beria'. Se,e!a emberia' )-i ,u'gga! i',rae'a -!ume )i,ribui'(a ra,a>ra,a 02< L/kg. Ke,-r-!ac )a' me,ab-!i,'(a Gk-'4uga, )a' me,ab-!i, ara>i)r-kiH )i,emuka' )a!am uri' Gra,a>ra,a 91;=H )a' ia'(a Gra,a>ra,a 61=H )iekkrei )a!am 7ee. $emberia' Ke,-r-!ac ecara are',era! ,i)ak me'guba em-)i'amik aie'. Ke,-r-!ac ,r-me,ami'e meruaka' ua,u a'a!geik '-'>'ark-,ik. ba, i'i meruaka' -ba, a',i>i'7!amai '-',er-i) (a'g me'u'4ukka' ak,ii,a a',iire,ik (a'g !ema )a' a',i>i'7!amai. Ke,-r-!ac ,r-me,ami'e me'gamba, i',ei r-,ag!a')i' )a' )aa, )ia'gga ebagai a'a!geik (a'g beker4a eri7er kare'a ,i)ak memu'(ai e7ek ,era)a ree,-r -ia,. # !osis
Ke,-r-!ac amu! )i,u4uka' u',uk emberia' i'4eki i',ramuku!ar a,au b-!u i',rae'a. D-i u',uk b-!u i',rae'a aru )iberika' e!ama mi'ima! 1< )e,ik. Ke,-r-!ac amu! ,i)ak b-!e )iberika' ecara ei)ura! a,au i'a!. Mu!ai ,imbu!'(a e7ek a'a!geia e,e!a emberia' # mauu' #M erua kira> kira 30 me'i, )e'ga' makimum a'a!geia ,ercaai )a!am 1 i'gga 2 4am. Durai me)ia' a'a!geia umum'(a ; amai 6 4am. D-i ebaik'(a )ieuaika' )e'ga' kearaa' '(eri )a' re-' aie'. Lama'(a ,erai : $emberia' )-i aria' mu!,ie! (a'g ,eru>me'eru ecara i',ramuku!ar )a' i',rae'a ,i)ak b-!e !ebi )ari 2 ari kare'a e7ek ami'g )aa, me'i'gka, a)a e'ggu'aa' 4a'gka a'4a'g. !easa
Amu! : D-i a+a! Ke,-r-!ac (a'g )ia'4urka' a)a!a 10 mg )iiku,i )e'ga'
42
1030 mg ,ia ; amai 6 4am bi!a )ier!uka'. 8aru )iberika' )-i e7ek,i7 ,ere')a. D-i aria' ,-,a! ,i)ak b-!e !ebi )ari 90 mg u',uk -ra'g )e+aa )a' 60 mg u',uk -ra'g !a'4u, uia aie' ga'ggua' gi'4a! )a' aie' (a'g bera, ba)a''(a kura'g )ari <0 kg. Lama'(a ,erai ,i)ak b-!e !ebi )ari 2 ari. $a)a e!uru -u!ai gu'aka' )-i e7ek,i7 ,ere')a )a' ei'gka, mu'gki'. ?',uk aie' (a'g )iberi Ke,-r-!ac amu! )-i aria' ,-,a! k-mbi'ai ,i)ak b-!e !ebi )ari 90 mg G60 mg u',uk aie' !a'4u, uia ga'ggua' gi'4a! )a' aie' (a'g bera, ba)a''(a kura'g )ari <0 kgH. nstruksi #osis khusus
$aie' !a'4u, uia Amu! : ?',uk aie' (a'g uia'(a !ebi )ari 6< ,au' )ia'4urka' memakai kiara' )-i ,ere')a: ,-,a! )-i aria' 60 mg ,i)ak b-!e )i!amaui G!ia, $era,ia'H. Anak-anak : Keama'a' )a' e7ek,ii,a'(a a)a a'ak>a'ak be!um )i,e,aka'. !e kare'a i,u Ke,-r-!ac ,i)ak b-!e )iberika' a)a a'ak )i ba+a 16 ,au'. a'ggua' gi'4a! : Kare'a Ke,-r-!ac ,r-me,ami'e )a' me,ab-!i,'(a ,eru,ama )iekkrei )i gi'4a! Ke,-r-!ac )ik-',rai')ikaika' a)a ga'ggua' gi'4a! e)a'g amai bera, Gkrea,i'i' erum 160 mm-!/!H aie' )e'ga' ga'ggua' gi'4a! ri'ga' )aa, me'erima )-i (a'g !ebi re')a G,i)ak !ebi )ari 60 mg/ari # a,au #MH )a' aru )ia',au ke,a,. A'a!geik -i-i) Gmi. M-r7i' $e,i)i'eH )aa, )igu'aka' beramaa' )a' mu'gki' )ier!uka' u',uk me')aa,ka' e7ek a'a!geik -,ima! a)a eri-)e aca be)a a+a! bi!ama'a '(eri ber,amba bera,. Ke,-r-!ac ,r-me,ami'e ,i)ak me'gga'ggu ika,a' -i-i) )a' ,i)ak me'ce,uka' )erei 'aa a,au e)ai (a'g berkai,a' )e'ga' -i-i). *ika )igu'aka' berama )e'ga' Ke,-r-!ac amu! )-i aria' -i-i) biaa'(a kura'g )ari (a'g )ibu,uka' ecara '-rma!. Namu' e7ek ami'g -i-i) mai aru )ier,imba'gka' ,eru,ama a)a kau be)a )a!am eari. e n#ikasi
Ke,-r-!ac )ii')ikaika' u',uk e'a,a!aka'aa' 4a'gka e')ek ,era)a '(eri aku, e)a'g amai bera, e,e!a r-e)ur be)a. Durai ,-,a! Ke,-r-!ac ,i)ak b-!e !ebi )ari !ima ari. Ke,-r-!ac ecara are',era! )ia'4urka' )iberika' egera e,e!a -erai. 8aru )iga',i ke a'a!geik a!,er'a,i7 eegera mu'gki' aa!ka' ,erai Ke,-r-!ac ,i)ak me!ebii < ari. Ke,-r-!ac ,i)ak )ia'4urka' u',uk )igu'aka' ebagai -ba, rabe)a -b,e,ri
43
a,au u',uk a'a!geia -b,e,ri kare'a be!um )ia)aka' e'e!i,ia' (a'g a)ekua, me'ge'ai a! i'i )a' kare'a )ike,aui memu'(ai e7ek me'gamba, bi-i',ei r-,ag!a')i' a,au k-',raki raim )a' irku!ai 7e,u. , Kontrain#ikasi
1. $aie' (a'g ebe!um'(a er'a me'ga!ami a!ergi )e'ga' -ba, i'i kare'a a)a kemu'gki'a' e'i,ii,a i!a'g. 2. $aie' (a'g me'u'4ukka' ma'i7e,ai a!ergi eriu akiba, emberia' Ae,-a! a,au -ba, a',i>i'7!amai '-',er-i) !ai'. 3. $aie' (a'g me')eri,a u!ku e,ikum ak,i7. ;. $e'(aki, erebr-aku!ar (a'g )icurigai mauu' (a'g u)a a,i. <. Dia,ei em-ragik ,ermauk ga'ggua' k-agu!ai. 6. Si')r-m -!i 'aa! !e'gka a,au aria! a'gi-e)ema a,au br-'k-ame. 5. Terai beramaa' )e'ga' ASA )a' NSA#D !ai'. . 8i--!emia akiba, )ei)rai a,au ebab !ai'. 9. a'ggua' gi'4a! )era4a, e)a'g amai bera, Gkrea,i'i' erum 160 mm-!/LH. 10. Ri+a(a, ama. 11. $aie' aca -erai )e'ga' riik- ,i'ggi ,er4a)i er)araa' a,au em-,ai i'k-m!i, aie' )e'ga' a',ik-agu!a' ,ermauk 8eari' )-i re')a G2.<00<.000 u'i, e,ia 12 4amH. 12. Terai beramaa' )e'ga' e',(7i!!i'e $r-be'eci) a,au garam !i,ium. 13. Se!ama keami!a' era!i'a' me!airka' a,au !ak,ai. 1;. A'ak @ 16 ,au'. 1<. $aie' (a'g memu'(ai ri+a(a, i')r-m S,ee'>*-'-' a,au ruam eiku!-bu!-a. 16. $emberia' 'eurakia! Gei)ura! a,au i',ra,eka!H.
44
15. $emberia' r-7i!aki ebe!um be)a ma(-r a,au i',ra>-era,i7 4ika em-,ai be'ar>be'ar )ibu,uka' kare'a ,i'ggi'(a riik- er)araa'. g 1,ek sam(ing
Sa!ura'
cer'a
:
)iare
)ieia
'(eri
ga,r-i',e,i'a!
'auea.
Suu'a' Sara7 $ua, : aki, kea!a ui'g me'ga',uk berkeri'ga,. o#i(ront um( e@( a Kan#ungan
Tia kau! me'ga')u'g: K-)ei' a'i)ra, 30 Fe'i!,-!-kami' 10 Gke)ua'(a )a!am be',uk rei'a, ,erika, )e'ga' i-'>eca'gerH
mg mg
S#R?$ Tia < m! me'ga')u'g: K-)ei' a'i)ra, 1111 Mg Fe'i!,-!-kami' 365 Mg Gke)ua'(a )a!am be',uk rei'a, ,erika, )e'ga' i-'>eca'gerH Farmakokinetik #an Farma#inamika
%-)ir-', me'ga')u'g )ua Ea, ak,i7 )e'ga' ,ema, ker4a (a'g berbe)a. K-)ei' aka' me'gura'gi ba,uk )e'ga' e'eka'a' e',ra! a)a ua, ba,uk. Fe'i!,-!-kami' meruaka' a',ii,ami' (a'g memu'(ai e7ek a)a a!ergi. Va, ak,i7 %-)ir-', ,erika, )e'ga' i-'>eca'ger (a'g memu'gki'ka' e!eaa' !amba, )a' eragam )a!am a!ura' e'cer'aa'. ?',uk me'caai e7ek a',i,ui7 (a'g !ama )e'ga' )-i 2 ka!i eari. nteraksi oat
$emberia' %-)ir-', berama )e'ga' -ba, e',ra! )erea' Gmia!: ik-7armaka barbi,ura, beberaa macam a'a!geik )a' a',ia!ergi/ a',ii,ami' H aka' me'imbu!ka' -,e'iai e)ai )a' me')erei er'a7aa'. K-mbi'ai %-)ir-', )e'ga' a!k--! aka' me'gura'gi kemamua' ik-m-,-r Gkemamua' berk-'e',rai )a' memecaka' maa!a (a'g k-m!ekH !ebi kua, )iba')i'gka' mai'g>mai'g k-m-'e' -!e kare'a i,u k-mbi'ai i'i ,i)ak )ierb-!eka'.
45
# !osis
KA$S?L Me'uru,
e,u'4uk
)-k,er.
A'ak>a'ak )ia,a 1; ,au' )a' )e+aa 2 ka!i eari 1 kau! a)a agi )a' -re ari. S#R?$ Kecua!i )iebu,ka' !ai' )a!am ree -!e )-k,er )imi'um 2 ka!i eari a)a agi )a' -re ari: A'ak>a'ak : 2 > ; ,au' : W e')-k ` < m! G 2< m!H ; > 6 ,au' : 1 e')-k ` < m! G <0 m! H 6 > 1; ,au' : 2 e')-k ` < m! G100 m!H Dia,a 1; ,au' )a' )e+aa : 3 e')-k ` < m! G 1<0 m! H Sebaik'(a )iberika' berama maka'a' : Ka: Te!a' u,u 4a'ga' )iku'(a/)ia'curka'. e n#ikasi
$e'g-ba,a' im,-ma,ik ba,uk keri'g e!ama br-'ki,i 7!u ra)a'g a!ura' er'aaa' kare'a a!ergi a,au i'7eki. , Kontrain#ikasi
1. 2. 3. ;. <. 6. 5. . 9.
$aie' (a'g (ere'i,ie ak,i7 ,era)a %-)ir-', #'u7iie'i er'a7aa' Sera'ga' aama aku, K-ma ier,r-7i r-,a, )e'ga' embe',uka' uri' rei)u g!auk-ma u)u, emi, ga'ggua' # ami! !ak,ai %-)ir-', ,i)ak )iberika' a)a a'ak kura'g )ari 2 ,au' kare'a )aa, me'i'gka,ka' reik- ,er4a)i'(a )erei er'a7aa'.
g 1,ek sam(ing
1. Mua! mu',a ua bua'g air bear aki, kea!a (a'g beri7a, ri'ga' agak me'ga',uk kea)aa' eki,ai a)a ba(i Ga)a kau -er)-iH me'gi')uki g!auk-ma u)u, ,er,u,u erubaa' 4um!a )ara Ga'ga, 4ara'gH )a' ga'ggua' bua'g air keci!. 2. *ara'g : ga,a!>ga,a! reaki ku!i, Gkemeraa'H eak 'a7a mu!u, keri'g ga'ggua' ,i)ur a,au ,i'i,u G,e!i'ga ber)e'gi'g ,a'a ra'ga'g )ari !uarH. 3. Sa'ga, 4ara'g : reaki iere'i,i7 bera,. ;. Kau>kau i')ii)ua! : bera, ba)a' me'i'gka,.
46
2 >rogeti@ a Farmakokinetik #an ,armako#inamika
$e'aE-(ri)i'e 8%! be!um )ike,aui. $e'aE-(ri)i'e 8%! cea, )iekkreika' -!e gi'4a! eba'(ak 66= )ari )-i -ra! (a'g )iekkreika' ,i)ak beruba )a!am uri'. ekanisme ker)a
$e'aE-(ri)i'e 8%! )iekkreika' )a!am uri' )i ma'a ia memberika' ebua e7ek a'a!geik ,-ika! a)a muk-a )ari a!ura' kemi. Ti')aka' i'i memba',u u',uk me'gi!a'gka' raa aki, ,erbakar urge'i )a' 7rekue'i. Meka'ime (a'g ,ea, be!um )ike,aui. nterakssi
$e'ggu'aa' )e'ga' a',ibi-,ic !ebi bagu 'amu' ,i)ak b-!e )i gu'aka' !ebi )ari 2 ari. # !osis
?',uk )e+aa 200 mg 3 /ari. ?',uk a'ak 6>12 ,au' 100 mg 3 /ari. e Aturan Pemakaian
?',uk )e+aa 200 mg 3 /ari. ?',uk a'ak 6>12 ,au' 100 mg 3 /ari. Se,e!a maka'. $e'ggu'aa' -ba, i'i ,i)ak b-!e !ebi )ari 2 ari. , n#ikasi
?',uk me'gura'gi ge4a!a aki, eri a,au raa ,erbakar urge'i 7rekue'i )a' kea)aa' ,i)ak e'ak !ai' kare'a i'7eki muk-a a!ura' kemi bagia' ba+a. g Kontrain#ikasi
a'ggua' 7u'gi gi'4a! ea,i,i h 1,ek sam(ing
47
Saki, kea!a er,ig- mua! ea,-,-kik gaga! gi'4a! ruam ku!i,. Me,em-g!-bi'emia )a' a'emia em-!i,ik. i 'uungan umur #an oat
$e'ggu'aa' -ba, i'i u)a ,ea, euai umur. ) 'uungan oat #engan #ata klinis #an la
$e'ggu'aa' -ba, i'i u)a ,ea, kare'a ,er)aa, )a,a k!i'i aki, a)a aa, BAK. Namu' er!u )iera,ika' a)a aie' i'i kare'a -ba, i'i k-',ra i')ikai )e'ga' e'(aki, gaga! gi'4a!. Kare'a aka' me'i'gka,ka' ka)ar erum )a' me'4a)i ,-kik. 3 !o(amine a ekanisme Ker)a
$rekur-r N i'i memu'(ai ker4a !a'gu'g a)a ree,-r )-ami'ergik )a' a)re'ergik )a' 4uga me!eaka' N e')-ge'. $a)a ka)ar re')a )-ami' beker4a a)a ree,-r )-ami'ergik D 1 embu!u )ara ,eru,ama )i gi'4a! mee',erium )a' embu!u )ara k-r-'er. S,imu!ai ree,-r D1 me'(ebabka' a-)i!a,ai me!a!ui ak,iai a)e'i!ik!ae. D-ami' )-i re')a aka' me'i'gka,ka' a!ira' )ara gi'4a! !a4u 7i!,rai g!-meru!u )a' ekkrei Na . $a)a )-i (a'g e)iki, !ebi ,i'ggi )-ami' me'i'gka,ka' k-',rak,i!i,a mi-kar) me!a!ui ak,iai a)re'-e,-r 1. GSe,ia+a,i 2012H D-ami' 4uga me!eaka' N e')-ge' (a'g me'amba e7ek'(a a)a 4a',u'g. $a)a )-i re')a amai e)a'g rei,e'i eri7er ,-,a! ,i)ak beruba. 8a! i'i kare'a )-ami' me'gura'gi rei,e'i ar,eria! )i gi'4a! )a' mee',erium )e'ga' a'(a e)iki, e'i'gka,a' )i ,ema, ,ema, !ai'.)e'ga' )emikia' )-ami' me'i'gka,ka' ,eka'a' i,-!ik )a' ,eka'a' i,-!ik )a' ,eka'a' 'a)i ,a')a me'guba ,eka'a' )ia,-!ik G a,au e)iki, me'i'gka, H. Akiba,'(a )-ami' ,eru,ama bergu'a u',uk kea)aa' cura 4a',u'g re')a )ier,ai )e'ga' ga'ggua' 7u'gi gi'4a! mia!'(a (-k kar)i-ge'ik )a' gaga! 4a',u'g (a'g bera,. GSe,ia+a,i 2012H $a)a ka)ar (a'g ,i'ggi )-ami' me'(ebabka' a-k-',riki akiba, ak,iai ree,-r \1 embu!u )ara. Kare'a i,u bi!a )-ami' )i gu'aka' u',uk (-k (a'g me'ga'cam 4i+a ,eka'a' )ara )a' 7u'gi gi'4a! aru
4$
)im-'i,-r. Ree,-r )-ami' 4uga ,er)aa, )a!am -,ak ,e,ai )-ami' (a'g )i berika' # ,i)ak me'imbu!ka' e7ek e',ra! kare'a -ba, i'i ukar me!e+a,i a+ar )ara>-,ak.GSe,ia+a,i 2012H Farmakokinetik #an Farma#inamika
D-ami' ,i)ak e7ek,i7 a)a emberia' -ra!)a' ,i)ak )iab-rbi )e'ga' baik )a!am emberia' ubku,a'. D-ami' )i me,ab-!ime )i a,i gi'4a! )a' caira' !ama )e'ga' ba',ua' e'Eim monoamine oxidase )a' cathechol"" methyl transferase.
Se!ai' i,u )-ami' aka' )i ekrei -!e gi'4a!.GSe,ia+a,i
2012H !osis
1. D-i re')a
: 1
a!ira' )ara a)a gi'4a!.GSe,ia+a,i 2012H 2. D-i e)a'g : <>1<0mcg/kg/mi' # )aa, me'i'gka,ka' ,eka'a' )ara )a' a-k-',riki. GSe,ia+a,i 2012H # n#ikasi
K-me'ai ,era)a ke,i)akeimba'ga' em-)i'amik a)a aie' )e'ga' (-k (a'g berubu'ga' )e'ga' i'7ark mi-kar) gaga! 4a',u'g )a' )ek-me'ai kr-'ik.GSe,ia+a,i 2012H e Kontrain#ikasi
D-ami' aru )ii')arka' a)a aie' (a'g e)a'g )i-ba,i )e'ga' e'gamba, MA )a' (a'g memi!iki iere'i,ii,a ,era)a i'u!i'. GSe,ia+a,i 2012H , 1,ek sam(ing
D-i be!ebi )aa, me'imbu!ka' e7ek a)re'ergik (a'g ber!ebia'. Se!ama i'7ue )-ami'e )aa, ,er4a)i mua! mu',a ,akikar)ia ari,mia '(eri )a)a '(eri kea!a ier,e'i )a' e'i'gka,a' ,eka'a' )ia,-!ik.GSe,ia+a,i 2012H . Penatalaksanaan Kasus #an Pemahasan
4%
. 2. 3. 4.
"u)ekti, 7)ekti, Assesment (lan
Tanggal
"u)ekti,
7)ekti,
Lemas ual muntah !emam "esak ia%at A!
23/4
24/4
Assesment
T&* 6? m &&* 6? kg T* 234 >#em kaki #an (i(i Puat TT= ia%at 7at T! <4/9? mm'G 4?@/mnt airi'%$Ni,ra, T 3:? Sima,a,i'Bi- ' #em (i(i #an tungkai La* ' 13 g/)! 't ;23= Leukosit 5.900 e!/mm3 Tromosit 161.000e!/mm3 G!" 123 mg/)L >reum 132 mg/)! reatinin 19 mg/)! "G7T 232 ?/L !GPT 16 ?/L K& 3< ?/L K$A 10<0 ?/L $a 125; K 43 'sAg ;-
ongesti0e
"esak $%eri saat &AK &atuk
ongesti0e
'ematuria >#em kaki TT= T! 6:/45 mm'G 4?@/mnt T 369? ' :3@/mnt "a72 <:
'eart Failure ;'F
Plan !o(amine !outamin lo(i#ogrel L 7n#ansetron Panto(ra8ol in). PP 1KG Trigliseri# Kolesterol total L!L '!L
'eart Failure ;'F
!o(amine !outamin lo(i#ogrel L 7n#ansetron Panto(ra8ol in).
Aut enal !isease
Panto(ra8ol Ketorola in).
5&
;A! $%eri saat &AK &atuk
25/4
>#em kaki 'ematuria TT= T! :
ongesti0e 'eart Failure ;'F
!o(amine !outamin lo(i#ogrel L 7n#ansetron Panto(ra8ol in).
Aut enal
Panto(ra8ol Ketorola in).
!isease ;A!
PP* ek
1#ema
Alumin
Pulmo
26/4
Nama ba,
T. #')ikai
RL
')a'e,r-'
T. Pasien
T. oat
T. !osis
J G10,mH
J G; mg 21 amu!H
$a',-raE-! i'4.
Ke,-,eri!
J
J
J
J
Bas(a#a e,ek sam(ing
8ier'a,remia ek,raaai Lema. $e'i'gka,a' e'Eim a,i )em eri7er mu',a !e!a
Kar)i-i-a, D-bu,ami'
-b,ruk,i7 ,e'-i uba-r,a
51
TriEe)-' MR
J
J
J
J
Bi-r-!-!
J
J
J
J
Bra)ikar)i i-,e'i $er)araa' # ,rack
%!-i)-gre!
er)araa' i',racra'ia! ga'ggua' a,i bera,
a!ia'be
J
J
J
J D(eia '(eri # ,rack
Ke,-r-!ac i'4.
mua!
aki,
kea!a )iare e)ema %-)ir-', cum e J
J
J
J
?r-ge,i
J
J
J
J
Takikar)ia!i D-ami'e
,ai mu',a
5. Pemahasan
Terai '-' 7armak-!-gi )e'ga' meruba ga(a i)u 1. Terai '-' 7armak-!-gi )e'ga' merubaa' ga(a i)u Terai '-' 7armak-!-gi (a'g er,ama a)a!a meruba ga(a i)u e,ia ma'uia memu'(ai ga(a i)u (a'g berbe)a>be)a ebagia' bear )ari mereka ,i)ak memera,ika' ga(a i)u ea, ei'gga me'(ebabka' mereka mu)a ,erera'g e'(aki, eer,i a!'(a e')eri,a e'(aki, gaga! 4a',u'g k-'ge,i7 e')eri,a e'(aki, ,erebu, aka' a'ga, memer!uka' eka!i ga(a i)u ea, eer,i ,i)ak mer-k-k mabuk>mabuka' me'g-'umi maka'a' ber!emak ,i'ggi maka'a' bermi'(ak )a' mai ba'(ak !agi )e'ga' begi,u e')eri,a e'(aki,
mua!
52
gaga! 4a',u'g k-'ge,i7 aka' emaki' membaik )a' ,i)ak me'imbu!ka' ge4a!a kambu (a'g membaa(aka'. 2. Terai '-' 7armak-!-gi )e'ga' k-'umi maka'a' (a'g )ia'4urka' Maka'a' (a'g a'ga, )ia'4urka' bagi e')eri,a e'(aki, gaga! 4a',u'g k-'ge,i7 a)a!a maka'a' (a'g memu'(ai re')a !emak eer,i (a'g ,er)aa, a)a a(ur bua )a' bi4i>bi4ia'. Sa(ur (a'g baik u',uk e')eri,a e'(aki, gaga! 4a',u'g a)a!a a(ur (a'g ba'(ak me'ga')u'g be,akar-,e' ,eru,ama a)a br-k-!i )a' ba(am e)a'gka' u',uk bua e')eri,a )aa, me'gk-'umi bua re')a !emak eer,i a!uka, 'a'a ema'gka 4ambu bi4i )a' mai ba'(ak !agi !a!u u',uk bi4i>bi4ia' e')eri,a )aa, me'g-'umi bi4i>bi4ia' (a'g ka(a aka' r-,ei' eer,i ke)e!ai )a' kaca'g i4au. 3. Terai '-' 7armak-!-gi )e'ga' me'gura'gi k-'umi gu!a u!a )aa, me'4a)i emicu ,imbu!'(a -bei,a a,au kegemuka' e!ai' i,u gu!a 4uga )aa, me'imbu!ka' e'(aki, )iabe,e. Ke)ua e'(aki, ,erebu, )aa, memerburuk kea)aa' e')eri,a gaga! 4a',u'g ke'ge,i7 kare'a ,eka'a' )ara me'4a)i a'ga, bear ei'gga a!ira' 4a',u'g a)a embu!u e'a aka' emaki' ,erga'ggu. De'ga' me'gura'ggi k-'umi gu!a maka ge4a!a (a'g mu'gki' aka' kambu )ari e'(aki, gaga! 4a',u'g k-'ge,i7 i'i )aa, )imi'ima!iir )e'ga' mu)a. A,au 4ika ,i)ak bia me'gura'gi k-'umi gu!a maka ga',i gu!a me'4a)i gu!a re')a !emak. #,u!a e)iki, u!aa' me'ge'ai ,erai '-' 7armak-!-gi e'(aki, gaga! 4a',u'g k-'ge,i7. De'ga' me!akuka' ,erai '-' 7armak-!-gi ,erebu, maka ge4a!a kambu )ari e'(aki, mema,ika' i'i aka' ,era,ai )e'ga' baik )a' me'gura'gi reikkema,ia' me')a)ak bagi e')eri,a 'amu' ,erai '-' 7armak-!-gi aru )i,eraka' ecara ru,i' -!e e')eri,a a! ,erebu, ber,u4ua' agar ,erai '-' 7armak-!-gi i'i )aa, beker4a ecara -,ima!. ;.
Die, $emba,aa' aua' Na%! )a' caira' er,a )ie, !ai' euai e'(aki, )aar
<. Ak,ii,a Fiik
53
Ak,ii,a 7iik (a'g )aa, )i!akuka' u'ruk aie' gaga! 4a',u'g ,abi! (ai,u )e'ga' -!a raga ,era,ur eer,i ber4a!a' a,au beree)a 6. #,iraa, ?',uk aie' )e'ga' gaga! 4a',u'g aku, )a' ,i)ak ,abi! )ia'4urka' u',uk i,iraa, !ebi ba'(ak. 5.
8a,i>a,i ,era)a -ba,>-ba,a'
Sebaik'(a aie' gaga! 4a',u'g ,i)ak me'gk-'umi -ba, ,a'a ree )-k,er kare'a berbaa(a u',uk keea,a' c-',-'(a NSA#D %-ib k-r,ik-,er-i) )a' !ai'>!ai'. Terai '-' 7armak-!-gi Acu, ki)'e( )ieae 1. Me'gi')arka' maka'a' beruri' ,i'ggi a!a a,u e'(ebab gaga! gi'4a! kr-'ik a)a!a e'(a+a uri' a,au eri'g ki,a ke'a! ebagai e'(a+a aam ura,. Maka'a' beruri' ,i'ggi a',ara !ai' eer,i maka'a' ea7--) 4u'k7--) maka'a' ai' )a' 4er-a'. Maka'a' beruri' ,i'ggi aka' me(ebabka' e'guma!a' uri' a)a gi'4a! ei'gga g!-meru!u ,i)ak aka' mamu me'(ari'g k-,-ra' a,auu' racu' )a!am )ara. )e'ga' me'gura'gi maka'a' beruri' ,i'ggi ,erebu, maka )ara aka' beri )ari k-,-ra' a,auu' racu' ei'gga membe',u ker4a g!-meru!u (a'g u)a ,i)ak makima! !agi. 2. K-'umi ba'(ak air mi'era! Air u,i a,au air mi'era! a'ga, bergu'a u',uk me!aru,ka' k-,-ra' (a'g ,er)aa, a)a gi'4a! ei'gga 7u'gi gi'4a! )aa, ber4a!a' )e'ga' mu)a )a!am me!akuka' e'(ari'ga' a! i'i ,er4a)i ke,ika ki,a ba'(ak mi'um air u,i maka caira' racu' (a'g ,er)aa, )a!am )ara aka' beri7a, e'cer ei'gga g!-meru!u mamu mem7i!,rai racu' ,erebu, )e'ga' baik !ai' a!'(a bi!a ki,a 4ara'g mi'um air u,i maka ka')u'ga' racu' (a'g ,er)aa, a)a )ara aka' beri7a, eka, ei'gga g!-meru!u aka' u!i, u',uk mem7i!,ra, Ea, racu' ,erebu,. )e'ga' me'gk-'umi air u,i ecara ru,i' mi'ima! ge!a eari maka racu' (a'g ,er)aa, a)a )ara aka' mamu )iari'g a,au 7i!,rai -!e g!-meru!u )e'ga' baik. 3. Ru,i' ber-!araga
54
Ka')u'ga' racu' )a!am )ara e!ai' )ike!uarka' !e+a, gi'4a! racu' ,erebu, 4uga )ike!uarka' !e+a, keri'ga, 4a)i aka' a'ga, e',i'g aabi!a e')eri,a e'(aki, gaga! gi'4a! kr-'ik u',uk ecara ru,i' me'ge!uarka' keri'ga, mereka a!a a,u cara ,ermu)a )a!am me'ge!uarka' keri'ga, a)a!a )e'ga' ber-!araga. !araga ,i)ak er!u me'ga'gka, beba' ber!ebi aka' ,e,ai cuku me!akuka' (-ga a,auu' 4-ggi'g e,ia agi ari e!ama 30 me'i, maka keri'ga, aka' ke!uar )e'ga' e')iri'(a ambi! memba+a racu' ei'gga a! i'i )aa, memba',u g!-meru!u )a!am me'(ari'g Ea, berbaa(a eer,i racu'.
!. Kesim(ulan )rdasarkan *asil diskusi ka!i+ untuk p!,rian o,at kpada pasin trs,ut dak ssuai dngan apa yang ada di,uku+ ada ,,rapa o,at yang dak ka!i ,rikan karna dirasa dak prlu digunakan pada pasin trs,ut- )rikut adala* o,at apa sa.a yang di,rikan :
Ta'gga! 23/;
2;/;
2
26/;
ba, / / / / / / / / / / / / / / / / / / / / /
D-i RL ')a'e,r-' $a',-raE-! i'4 D-bu,ami' # D-ami'e RL $a',-raE-!e i'4 D-bu,ami' # D-ami'e %!-i)-gre! Ke,-r-!ac RL $a',-raE-!e i'4 D-bu,ami' # D-ami'e %!-i)-gre! Ke,-r-!ac RL $a',-raE-! i'4 D-bu,ami' # D-ami'e
/ / / / / / / / / / / / / / / / / / / / /
10 ,m ; mg 21 amu! ;0 mg 21 ; cc/4am 1<cc/4am 10 ,m ;0 mg 21 ; cc/4am 1< cc/4am 5< mg 11,ab 30mg/m! 10,m ;0 mg 21 12cc/ 4am 63 cc/4am 5< mg 11 ,ab 30mg/m! 10 ,m ;0 mg 21 12cc/4am 63 cc/4am
55
/
%!-i)-gre!
/
5
Da7,ar $u,aka 8i)a(a, A. AEiE A!imu! )a' Mari7a,u!. 2011. $rak,ik Kebu,ua' Daar Ma'uia. Suraba(a.8ea!, B--k. Ka,Eu'g.2012.Farmak-!-gi Daar )a' K!i'ik.)ii 10.*akar,a.% Se,ia+a,i Ari'i )a' Na7ria!)i. 2012. Farmak-!-gi )a' Terai )ii <. FK?# *akar,a Nu7)+i. 2010. Terai aga! *a',u'g. *akar,a. Su)-(- Aru ". 202;. Buku A4ar #!mu $e'(aki, Da!am )ii
