Ilmu Resep 1

Ilmu Resep 1
Muvita Rina Wati, MSc., Apt.

Departemen Farmasetika
Fakultas Farmasi UGM
[email protected]/
081.392.101.777
Locally Rooted, Globally Respected www.ugm.ac.id
Biodata
Muvita Rina Wati, MSc., Apt.
Gunung Kidul, 7 Mei 1986

Pharmacist, Manager of Rumah Sehat dan
Apotek UGM
Bachelor Degree: Faculty of Pharmacy UGM
2004 – 2009
Master Degree: Magister of Clinical Pharmacy
2012 – 2015
[email protected]
[email protected]
081.392.101.777
Locally Rooted, Globally Respected www.ugm.ac.id 2

Pokok Bahasan
1. Drug – drug interaction

2. Drug – food/ nutrient interaction
3. Drug – herb interaction

DRUG – DRUG INTERACTION

Interactions between drugs (drug–drug
interactions) may be beneficial or harmful.
Harmful drug–drug interactions are important

as they cause 10–20% of the adverse drug
reactions requiring hospitalization and
They can be avoided.

Drug – Drug Interaction
Patient harm from drug interactions can be

reduced by:
1. Using a personal formulary – using few drugs and
knowing them well
2. Recognizing drugs that are major perpetrators of
interactions
3. Recognizing narrow therapeutic index drugs as
vulnerable to interactions
4. Applying clinical pharmacology principles

Mechanism of drug – drug interactions:
1. Behavioural occur when one drug alters the patient’s

behavior to modify compliance with another drug.
Ex.: depressed patient taking an antidepressant may
become more compliant with medication as
symptoms improve.
2. Pharmaceutical drug–drug interactions occur when
the formulation of one drug is altered by another
before it is administered. For example, precipitation
of sodium thiophentone and vencuronium within an
intravenous giving set.
3. Pharmacokinetic
4. Pharmacodynamic

Examples of drug classes containing several
narrow therapeutic index (object) drugs
Drug class Example
Antiarrhythmics amiodarone
Anticoagulants warfarin
Antiepileptics phenytoin
Antineoplastics sunitinib
Aminoglycoside antibiotics gentamicin
Immunosuppressants tacrolimus
The therapeutic index is often easier to recognize than define, as the

vulnerability of the patient affects the dose–response relationship. A clinical
question which is useful to identify a narrow therapeutic index drug is: would
doubling or halving the dose of this drug have a major effect on this patient?

Important perpetrators of cytochrome P450
drug–drug interactions
Enzymes Inhibitors* Inducers

ciprofloxacin, fluvoxamine,
CYP1A2 phenytoin, rifampicin
ethinyloestradiol, interferon alfa-2b
CYP2C9 fluconazole carbamazepine, rifampicin
fluconazole, fluvoxamine, ticlopidine,
lopinavir/ritonavir,
CYP2C19 fluoxetine, clarithromycin, voriconazole,
rifampicin, St John’s wort
moclobemide

Cont’
Enzymes Inhibitors* Inducers
bupropion, fluoxetine, paroxetine, perhexiline,
CYP2D6 cinacalcet, doxepin, duloxetine, flecainide, moclobemide,
quinine, terbinafine
macrolides e.g. erythromycin, clarithromycin
azole antifungals e.g. voriconazole, itraconazole,
ketoconazole, fluconazole, posaconazole
carbamazepine,
protease inhibitors e.g. indinavir, ritonavir, modafinil, phenytoin,
CYP3A saquinavir, atazanavir, fosamprenavir phenobarbitone,
non-dihydropyridine calcium channel blockers e.g. rifabutin, rifampicin,
diltiazem, verapamil St John’s wort
grapefruit juice, aprepitant, cimetidine, ciprofloxacin,
cyclosporin, fluvoxamine, imatinib
* bold font indicates very strong inhibitors

five ‘rules’ to manage potential drug–drug
interactions in clinical practice
1. Any interactions between existing drugs in a given patient
have already occurred. Hence they are part of differential
diagnosis.
2. Knowledge of the pharmacological effects of drugs and of
patient physiology together allows recognition of potential
pharmacodynamic drug– drug interactions.
3. Drugs with a narrow therapeutic index are particularly
susceptible to pharmacokinetic drug–drug interactions.
4. A small number of drugs are important ‘perpetrators’ of
pharmacokinetic drug–drug interactions.
5. Starting or stopping a drug is a prescribing decision that
may cause a drug interaction.

Clinical Resources
1. Stockley’s Drug Interactions

2. Micromedex
3. Lexy comp
4. Drug’s Interaction Facts
5. Lactmed - toxnet
Drug interaction checker?

Medscape?
Drugs.com?

DRUG – FOOD/ NUTRIENT
INTERACTIONS

Read the journal for complete information

DRUG – HERB INTERACTIONS

Mechanism
The overlapping substrate specificity in the

biotransformational pathways of the physiologic
systems is seen as the major reason for
drug–drug, food–drug, and HDI.
(Marchetti et al., 2007)

The ability of different chemical moieties to
interact with receptor sites and alter
physiological environment can explain
pharmacodynamic drug interactions while
pharmacokinetic interactions arise from altered
absorption, interference in distribution pattern
as well as changes and competition in the
metabolic and excretory pathways

The major underlying mechanism of pharmacokinetic
HDI, like drug–drug interaction, is either the induction or
inhibition of intestinal and hepatic metabolic enzymes
particularly the CYP enzyme family. Additionally, similar
effect on drug transporters and efflux proteins
particularly the p-glycoproteins in the intestines is
responsible in most other cases (Meijerman et al., 2006;
Nowack, 2008; Farkas et al., 2010).
The pre-systemic activity of CYP and efflux proteins often
influence oral bioavailability, thus the modulating activity
of co-administered herbal products has been shown to
result in pronounced reduction or increase in the blood
levels of the affected drugs (Brown et al., 2008).

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Muvita Rina Wati, MSc., Apt.

Muvita Rina Wati, MSc., Apt.

Gunung Kidul, 7 Mei 1986

Locally Rooted, Globally Respected www.ugm.ac.id 2

1. Drug – drug interaction

Locally Rooted, Globally Respected www.ugm.ac.id 3

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Harmful drug–drug interactions are important

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Patient harm from drug interactions can be

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1. Behavioural occur when one drug alters the patient’s

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The therapeutic index is often easier to recognize than define, as the

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Enzymes Inhibitors* Inducers

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* bold font indicates very strong inhibitors

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1. Stockley’s Drug Interactions

Drug interaction checker?

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The overlapping substrate specificity in the

(Marchetti et al., 2007)

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