dangerous doctor in pain management

8/11/2019 Dangerous Doctor in Pain Management

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2 December 1951Bukit Tinggi

PhD in Clinical PharmacologyFUSA-Fliner! "eical CentreAu!tralia# 19$$

Pro%e!!or &ea o% De'artmentPharmacology ( Thera'euticSchool o% "eicine# USU

)ln* Triharma 22+am'u! USU# "ean

S'F+# Clinical Pharmacologi!tPB-,D, ( F+ U,# 1995

"D# F+ USU# 19$

.mail/ a0nanleloyahoo*com



Aznan Lelo

Dep. Farmakologi & Terapeutik, Fakultas KedokteranUniversitas Sumatera

Utara

ktober 2311 +4+. ,PS )akarta



Rajin-rajin belajar ya nak,

supaya pintar dan jadi



+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

rr

drugtherap

y

patient

Doctorshoppin

gRisk

factorsetc

RDA

Surgery

etc

OTC

er!almed.

etc



%A&R'()*%K %A&R'()*%K

+iatro dokter+iatro dokter



Sakit ke'ala

Sakit gigi

Bi!ulan

4yeri hai

ematik

7out

Pon!tan

8oltaren

Femina

,rga'anCelebre

4o:algin

Dangerou!Dangerou!

Doctor ;Doctor ;



4yeri bahu

4yeri 'inggang

4yeri lutut

4yeri tumit

yang 'enting hilangkan 4<.,-nya

uru!an )A4TU47# belakangan

Ta'i=# !aya muah !e!ak

an !ering kencing malam

a i n !



Sakitgigi

A!amme%enamat

PegalPegal

>inu>inu

4yeri4yeribi!ulbi!ul

4yeri4yerihaihai

4yeriaa

etc#etc#etc#etcetc#etcetcetc

Sakit ;Sakit ; SakitSakitin-'artuin-'artuA!amme%enamatA!amme%enamatA!amme%enamatA!amme%enamatA!amme%enamatA!amme%enamatA!amme%enamat



Sakit ke'ala

7atal

Se!ak

"enceret

Tak bi!atiur

CT"

Salbutamol

,moium

Dia0e'am

Tramaol

Cam'uran yangCam'uran yang

mematikanmematikan



Sakit ke'ala

Sakit gigi

Bi!ulan

ematik

7out

Pon!tan

8oltaren

,rga'an

Con%orti

4o:algin

Suah keluargakumati

Uangku 'ula yang

habi!

'

'

'

''



Dangerous personWishing to eliminate a

president of another

countryom!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

moneyut it cloud !e then

o&ercome !y the

cheapest drug



Dangerou! octor!

octor! are

the thir leaingcau!e o% eath in the US#

cau!ing 253#333 eath!e:ery year

http$$$.mercola.com///jul0/doctors1death.htm



Doctor! :er!u! 7un! in the U*S#1999 #ome #tartling #tatistics

http$$$.concealcarry.orgDangerousDoctors.htm

Parameter Doctor! 7un@ner!

4umber o% 'er!on 33#333 $3#333#333

Accientaleath!year

123#333 1#533

Acciental eath! 'er2doctor3 or 2gun o$ner3

3*11 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!a:er!e e%%ect! 9#333# 4neumonia and influen5a 267,///3,

Dia!etes 270,///3,

#uicide 208,///3, or

"idney disease 29,///3 - and

certainly far more than in automo!ileaccidents, as the result of homicide or othercrimes, *)D#, etc.

httpash.orgdangerous-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 patientproperly, 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 you



&o@ oe! !omeone becomea angerou! octor;

• drug companies greatly influence doctors;prescri!ing ha!its

• family doctors are more likely to rely on

information supplied !y drug manufacturersrather than on information from independentsources

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

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

• information may !e misleading, !iased orinaccurate

Family Practice )anuary 23/1-$#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 'eiatrican ault 'atient! in an emergency room

Muno5 et al. Med >lin 2arc3 888203-6,86

Drug! Chilren Ault!

4SA,D 13*JK 2$*2K

C8 rug! ; 15*9K

Antimicrobial! J9*5K 1J*5K

7,T rug! ; 11*1Ke!'iratory rug! 19*9K ;

8accine! 9*2K ;

al@ay! 're!cribe Hangerou! rugI

4SA,D AD-relate ho!'itali0ation!

Coo'er )E* #outh Med @ 293A69-/,8



o not care ==========*to the conition o% 'atient treate

Age chilren# elerly# nur!ing @omen

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 commoncau!e o% 'oly'harmacy in elerly



Critical a''roache!in !electing meicine!

Thera'eutice%%ect

A:er!e reaction

Minimal Ma'imal

Ma'imal <e! ;

Minimal ; 4o

44&

S"A>>.ST

7.AT.ST

L 133

44T

7.AT.ST

S"A>>.ST2-J

Bhere are t$o reasons to $ithdra$ from the treatment eitherno 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 K3* K

&enti tera'ikarena

tiakmera!akane%ek tera'i

&enti tera'i

karenamera!akan

e%ek !am'ing



number needed to treat +**& or at least ./0pain relie over 1-2 ours in patients 3itmoderate to severe pain, all oral analgesics

e"cept morphine, pethidine and ketorolac



4SA,D adju&ant analgesic

$eak opioid2codeine3

'aracetamolor 4SA,D

adju&ant analgesic

#trong opioid 4SA,D

adju&ant analgesic

Princi'le! o% Analge!ic Pre!cribingE& Analge!ic >aer

/ 8 0 A 9 7 = 6 8/

Pain tolerancePain thre!hol

mildmild moderatemoderate se&erese&ere



BA,4

Pharmacologic Agent!A%%ect Pain Di%%erently

De!cening "oulation

Central Sen!iti0ationP4S

Anticon:ul!ant!

'ioi!TricyclicS4, Antie're!!ant!

C4SS'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!

'ioi!

'ioi!

Al'ha-2 Delta agoni!t!

Anticon:ul!ant!'ioi!

4"DA-ece'tor Antagoni!t!

TricyclicS4, Antie're!!ant!



4ild vs Severe 5ain

"il Se:ere

Drug Lo$ dose Eigh dose

4otent agent

A$ute vs 6roni$ 5ain

Acute ChronicDrug +apid onset Long duration

Duration o%'ain

#hort, self limiting,$ell-characteri5ed

4ersists after healing,0 months

Com'onent Nocicepti&e Nocicepti&eNeuropathic



.toricoib# a long hal%-li%e 22 hour!/o!age an e%%icacy

5ainindi$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 )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!ethe o!e

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 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 AD o%The only AD o%

4SA,D i! 7, e:ent4SA,D i! 7, e:ent ;;

.:olution in arthriti! management/ %ocu! on CM-2 inhibitor!



.:olution in arthriti! management/ %ocu! on CM-2 inhibitor!>arlos Faldes, 4harmD, >4#. >linical #cience Manager. 4harmacia >o.

*pril 8A, //



&e 9/ leadin# $auses o deatas a per$enta#e o all deats

in te United States, 9>>/ and 9>>2

#ource >D>, National >enter for Eealth #tatistics

1991993

?@' Statisti$al %normation System +?@'S%S



?@' Statisti$al %normation System +?@'S%S*umbers and rates +per-9///// o

re#istered deatsUnited States o Ameri$a - :///

4o Cau!e 4 ate8 C8S A8.9A $*5

Malignancy 990./8 00.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&erseeffects 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

4leeding 5lcerComplications

Degree of Selecti6ity

4lood #ressure7ncrease

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



Celecoib :! .toricoib

C8 ( enal Sa%ety Pro%ile Bloo 're!!ure change

Hhang @ et al. @*M* //7I7878-0I #ch$art5 @) et al. J Clin Pharmacol //=IA=898-08

*SA%" (%



*SA%" (%&oi$ity

#enerallyvaries3it al-

lie ote

a#ent

4SA,D Diclo%enac 4a'roen PiroicamDo!e mg 133 53 23

&al%-li%e hr 1*5 1J 53

A hr fecal !loodloss 2mL3 3*5G N- 3*21 2* N- 2*22 1*1 N- 3*2

enry, et al. 4(:.2/$0/12,$%%% Scharf, et al. Aust 8 ; : (ed

Sortest al-lie

Lo3

est(%risk

http://bmj.bmjjournals.com/content/vol312/issue7046/images/large/704601.jpeg



i!k Factor! o% Ulcer Com'lication! %rom 4SA,D!

Relative risk



4umber o% i!k Factor! (,ncience o% Ulcer Com'lication!

Silverstein F) Ann Intern Med 9>>.C9:7D:19->

**@ 9:.

**@ ./

**@ 9:

**@ .

i n $ i d e n $ e o - u l $ e r + 0 ,



'totoi$

Bron$ospam 6@F

@epatotoi$ U(%B

Bleedin# *eprotoi$

&o$olyti$Aller#y

6olor blindness

Adverse )<e$ts o *SA%"s

4e$anism o 4e$anism o

terapeuti$ e<e$ts adverse e<e$t

U(%B



4yeriengkul

lak!an!ia

A,4S

!t

anta!ia

iareiare

4yeri4yeriulu hatiulu hati

tera'i ikutanSimtom barutera'i+eaaan a@al

+a!kae 'ere!e'an i klinik 'ribai

kon!ti'a!i

http://images.google.com/imgres?imgurl=www.sla.purdue.edu/academic/fll/JapanProj/FLClipart/Medical/stomachache.gif&imgrefurl=http://www.sla.purdue.edu/academic/fll/JapanProj/FLClipart/Medical.html&h=1097&w=1256&prev=/images%3Fq%3Dstomachache%26svnum%3D10%26hl%3Den%26lr%3D%26ie%3DUTF-8%26oe%3DUTF-8

http://images.google.com/imgres?imgurl=health.indiamart.com/gifs2/constipation.jpg&imgrefurl=http://health.indiamart.com/ayurveda/common-problems/constipation.html&h=225&w=180&prev=/images%3Fq%3Dconstipation%26svnum%3D10%26hl%3Den%26lr%3D%26ie%3DUTF-8%26oe%3DUTF-8



Eipertensi

remato-

logis

*)N#

gastro-

entero-logis

misoprostol

serangan

%J<B

4#M*

diare . . . . .

hidrokloro-

tia5ida

,AT7.4,+,AT7.4,+iatro O okteriatro O okter



Anti-hy'erten!ion antaci

PA,4

iuretic mi!o'ro!tol

%luiretention

increa!eBP

heartburn

PUB

4SA,D

4rescri!ing >ascade4rescri!ing >ascade



' '

PA,4

' '

%luiretention

increa!eBP

heartburn

PUB

4SA,DO'

,atrogenic Co!t

A>&.,".D,S.AS.CA4C.

t



D,C>",S 5 mg BD

4,".SU>,D. 233 mg BD

4,".SU>,D. 133 mg BD

F.CM,B 25 mg D

".>M,CA" 15 mg D".>M,CA" *5 mg D

,BUPF.4 $33 mg TDS

D,C>F.4AC 53 mg TDS

C.>.CM,B 233 mg DC.>.CM,B J33 mg D

F.CM,B 12*5 mg D

D,C> 53 mg TDS N

>an!o'ra0ol 15 mg D

>JM4*+*B)FK >J#B# for 6 D*# BEK+*4

2in , spent !y the %eneral Medical #er&ices on N#*)D in 83

o not care =========**to the co!t o% rug amini!tere



Pain in ri!ky 'o'ulation

PAT,.4T 7UP P.D,CTAB>.PB>."S

a!ies ( )nfants >ommunicationI drug handling

Klderly >oe'isting illnessI drughandling

+espiratorydisease

+espiratory depressionIN#*)Ds ( asthma

+enal ailure Drug handlingI N#*)Ds

4regnant $omen Karly closure of ductusarteriosus



"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 2CeleaO3. a selecti&e serotonin 29-EB3 reuptake inhi!itor

CELEXA Q %or CELEBREX Q;A Ca!e o% "eication Sam'le .rror

Moyer , #hrading W, urkhart ""

)nt @ Med Bo'icol 023=,///

%ll ibl d i i



%lle#ible and3ritin#imagine ha&ing to read this P

Ca'to'ril 25mg

R3

Tab i B,D

t



o not care ==========*to the rug interaction

4SA,D N antihy'erten!i:e agent Morgan ( *nderson. @ >lin Eypertens 928390-=,//0

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

hagat ". Kast *fr Med @ =628/39/=-,//8

iclo%enac# ibu'ro%en or !ulinac did not neutralise theantihypertensi&e effect of li!ino'ril

%ra&es ( Eunder @ >lin Eypertens 27307-6,/// $orsening of hypertension !y >JQ- )nhi!itors

"urata et al. @pn >irc @ 702838//-0,8 !ynco'e caused !y N#*)D loo'ro%en and *>K-inhi!itor

imia'ril

Eay et al. @ Kmerg Med 2A30A-9,// %atal hy'erkalemia related to com!ined therapy $ith a >JQ-

inhi!itor ro%ecoib, *>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 smartdo$tor

and te ri#tone too

dangerous doctor in pain management

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