Evaluation Of Treatment From Seizures.docx.pdf

EVALUATION OF TREATMENT FROM SEIZURES, TOXOPLASMOSIS CEREBRAL, ORAL CANDIDIASIS, HEMIPARESE DEXTRA, SUSPECTED PULMONARY TUBERCULOSIS, PULMONARY PNEUMONIA, HYPOKALEMIA, AND HYPONATREMIA, PATIENTS ON HIV / AIDS IN FLOOR GENERAL MAINTENANCE IV ARMY HOSPITAL EDUCATION GATOT SOEBROTO CENTRAL JAKARTA Muh. Arrivad Iriansyah Pharmacist Professional Education Program, Pharmacy Faculty, 17 Agustus 1945 University Of Jakarta Email : ​[email protected] ABSTRACT HIV infection is defined as an individual with HIV infection according to clinical phase (including Phase 4 is known as AIDS) were confirmed by laboratory criteria of each country. Ny.Y patients age 44 years. On 24 April 2014 came to the Gatot Subroto Army Hospital. Patients present with seizures only on the right side of the body, the right hand often stiff, tingling, nausea, vomiting accompanied by fever. Patients with AIDS are phase IV. In 2011 the patient had a seizure and get treatment, the patient stopped consuming medicines after feeling recovered. Disconnect antiretroviral drugs for 7 months. Patients diagnosed by a doctor suffering from seizures, Hemiperase The right, and cerebral toxoplasmosis. In the course of treatment of patients experiencing nosocomial infections and re-diagnosed as Suspect Pulmonary Tuberculosis, Pneumonia Pulmonary patients also experienced, and occurs Hypokalemia and hyponatremia, based on the doctor's examination and laboratory values ​were obtained. 18 patients given the drug type Ceftriaxone, Omeprazole, Dexamethasone, Pirimethamine, Clindamicyn, Neurobion 5000, Metronidazole, Kotrimoksazole, Curcuma, Candistatin drip, Coditam, Mycamine, Rantin, KSR, Methycol, Fluconazole, Albumin and Paracetamol. Of the Drug Related Problem (DRP) is required additional medication with antibiotics right combination, therapy received by the patient is not a first-line therapy in the standard treatment of Cerebral toxoplasmosis and Oral candidiasis in AIDS patients in which immunoglobulin G antibodies CD4 + count <100uL³, use of metronidazole and dexamethasone, metronidazole and sulfametaksazol, sulfametakzasol and fluconazole, as well as fluconazole and trimethoprim simultaneously can cause significant interactions. Key Word: HIV/AIDS, RSPAD Gatot Soebroto.

Introduction HIV infection is defined as an individual with HIV infection according to clinical phase (including Phase 4 is known as AIDS) were confirmed by laboratory criteria of each country​(7)​. HIV infection occurs through three main ways: sexual, parenteral, and perinatal. Sex, either anal or vaginal, is the most common mode. The possibility of transmission through anal intercourse 0.1 to 3% and 0.1-0.2% contact / contact vaginal sex. In general, the risk increases with the severity of sexual partners. Individuals who are at high risk in heterosexual relationships is a person with ulcerative sexually transmitted diseases, many sexual partners, sexual partners of parenteral drug users​(7)​. The use of contaminated needles by injecting other drug users is a major cause of transmission is parenteral and final end of the quarter the number of reported AIDS cases in the United States. Health workers have a small risk of contracting HIV as a result of his work, most of the transmission from needles​(7)​. Perinatal or vertical transmission of infection, the major cause (> 90% 0 in children with HIV infection. Risk of mother-child transmission of approximately 25% occurred in the case of not breastfeeding or ARV therapy. Providing breast milk (breast milk) can also transmit HIV​(6)​. Clinical manifestations of primary infection varies, but patients often experience symptoms or mononucleosis-like illness such as fever, pharyngitis, and adenopathy. (glands especially lymph gland disorder). Symptoms may disappear after a year of two weeks​(7)​. The possibility of the development of AIDS associated with RNA virus loads, in a study, developing speed in the 5 years was 8%, 26%, 49%, and 62% for a copy of the virus / mL or <4530, <4531 becomes 13020, 13021, 36270 and be > 36 270 copies of virus​(7)​. AIDS indicator includes some but not all of the clinical phase 4 as pneumocystis pneumonia, oesophageal candidiasis, cryptococcal meningitis, cerebral toxoplasmosis, unexplained washting or malnutrition. Defined according to the WHO Integrated Management of Childhood Illness Guidelines: Oral thrush is a small plaque on the soft white-beige normal mucosa / red that can be cleaned (pseudomembranous), or red spots on the tongue, palate or edges are generally soft and

sore mouth. Severe pneumonia cough or difficulty breathing in children with chest interested, or common dangerous sign. Latheragi or unconscious, can not drink milk or suck, vomiting or a history of seizures during the last illness. Severe sepsis: Fever or low body temperature in infants with signs of severity such as rapid breathing or chest interested, the crown stands, lethargi, sweating movement, do not drink or breastfeed, convulsions, and stiff neck​(7)​. Methodology The survey was conducted on a 44-year-old female patient in the general care floor IV Gatot Subroto Army Hospital, based on the length of time the treatment, expected retrieval time for 36 (thirty six) days to obtain profiles that may represent a therapeutic treatment that the patient executed. Evaluation studies conducted on the use of patient medication include drug name, dose and route of administration. It is also rational (proper dosage, proper indications, the right patient, the right way of life) of treatment of patients with a look at whether there is interaction or the potential side effects that occur from the use of drugs based on the literature. Percentage of Clinical Ny.Y patients age 44 years. On 24 April 2014 came to the Gatot Subroto Army Hospital. Patients present with seizures on the right side of the body, the right hand often stiff, tingling, nausea, vomiting accompanied by fever. The patient is known HIV / AIDS phase 4 In 2011 the patient had a seizure and get treatment, the patient stopped consuming medicines after feeling recovered. ARV drug withdrawal 7 months. Patients diagnosed by a doctor suffering from seizures, Hemiperase The right, and cerebral toxoplasmosis. Suspect Pulmonary Tuberculosis, Pneumonia Lung, hypokalemia, and hyponatremia Evaluation Clinic Patient Getting Omeprazole therapy to cope with peptic ulcers and duodenal ulcers, associated with NSAIDs, gastric lesions and dudenum, H. pylori eradication regimens in peptic ulcer and reflux esophagitis​(1)​. Ceftriaxon for treatment of bacterial infections of gram-positive and gram-negative​(1)​. Dexamethason to relieve the symptoms of the disease, improve the appetite, provide a healthy feeling and can improve the prognosis of serious diseases​(1)​. Pyrimethanime as antiparasitik for the therapeutic treatment of toxoplasmosis​(2)​. Clindamisin for therapeutic treatment of staphylococcal infections, and infections of the mouth caused by

Candida albicans​(1)​. Neurobion 5000 as an adjunctive therapy for vitamin deficiency​(1)​. Metronidazole

in the treatment of protozoal infections and anaerobic infections​(1)​.

Co-trimoxazole is a combination of trimethoprim and sulfa metaksazol with a ratio of 1: 5 for the therapeutic treatment of toxoplasmosis​(3)​. Candistatin for therapeutic treatment of fungal infections of oral and perioral​(1)(3)​. Fluconazole 1x1 (iv) for the treatment of Candida albicans infections​(1)(3)​. Paracetamol as an antipyretic to treat pain and reduce fever​(1)(3)​. Mycamine cup (in RL 100 ml) for the acute treatment of candidiasis​(5)​. Methycol 3x1 tablet (po) as additional vitamins for liver dysfunction​(5)​. Curcuma for the treatment of liver dysfunction​(5)​. Potassium 1x1 tablet (po) for the therapeutic treatment of potassium deficiency​(1)(5)​. Albumin (iv) for the emergency treatment of shock, and conditions membuthkan returns blood to the segerah formula​(5)​. Coditam 1x1 tablet (po) equivalent to 30 mg of Codeine to relieve severe pain​(5)​. Rantin for omeprazole replacement therapies​(5)​. Results and Discussion Based on the results of laboratory tests on the first day of acquired immunological abnormal results. The number of CD4 count 4 cell / uL (410-1590 cells / uL), Anti-HIV (Rapid I) Reactive (non-reactive) and HBsAg (Rapid) non-reactive (non-reactive). Based on the results of laboratory tests of hematology on April 28, 2014, obtained results under normal abnormal amount of hemoglobin is 11.2 g / dL (12-16 g / dL), hematocrit 34% (37-47%) and erythrocytes 4.1 million / uL (4.3 to 60 million / mL). Value of clinical chemistry laboratory results above normal AST is 73 U / L (<35 U / L), alanine aminotransferase 105 U / L (<40 U / L), globulin 3.6 g / dL (2.5-3.5 g / dL). Cl 108 mmol / L (95-105 mmol / L). \ Based on the results of laboratory tests of hematology on 6th May 2014, obtained results are abnormal. That is the normal hematocrit below 35% (37-47%), erythrocyte sedimentation rate Advanced (LED) which is as high as 61 mm / h (0-20 mm / h). In the clinical chemistry laboratory tests abnormal results obtained above normal AST value is 153 U / L (<35 U / L), and alanine aminotransferase 105 U / L (<40 U / L), leukocytes 11,700 uL (4800-10800 mL), Value Businofil below normal differential count is 0% (1-3%), Trunk 1% (2-6%), segment 86% (50-70%), lymphocytes 9% (20-40%), MCV 79fL (80 to 96 fL).

Based on clinical chemistry laboratory results On May 14, 2014, obtained results are abnormal. Na below normal value is 130 mmol / L (135-147 mmol / L), potassium 5.8 mmol / L (3.5-5 mmol / L), total bilirubin 16.7 mg / mL (<1.5 mg / mL), Fospatase Alkaline (ALP) 1486 U / L (42-98 U / L), AST 280 U / L (<35 U / L), AST 431 U / L (<40 U / L), Ɣ- GT 1778 U / L (5-36 U / L), albumin 3.3 g / dL (3.5-5.0 g / dL). Based on the results of laboratory tests of hematology at the date of May 27, 2014, the results were abnormal. Normal hemoglobin values ​below 4.5 g / dL (12-16 g / dL), hematocrit 12% (37-47%), erythrocytes 1.5 million / mL (4.3 to 60 million / mL), leukocytes 28,000 uL (4800-10800 mL), counts MCHC 37 g / dL (32-36 g / dL). Clinical chemistry laboratory results obtained results under normal, abnormal sodium is 127 mmol / L (135-147 mmol / L). Based on the results of laboratory tests of hematology at the date of May 28, 2014, the results were abnormal. Normal hemoglobin values ​below 8.0 g / dL (12-16 g / dL), hematocrit 23% (37-47%), erythrocytes 2.8 million / mL (4.3 to 60 million / mL), leukocytes 23 280 uL (4800-10800 mL), Platelets 18,200 uL (150000-400000 mL), Value Businofil below normal counts were 0% (1-3%), segment 76% (50-70%), monocytes 1% (2-8 %), MCV 80 fL (80-96 fL), RDW 17.10% (from 11.5 to 14.5%). Clinical chemistry laboratory results obtained abnormal results. Total bilirubin value of 27.37 mg / mL (<1.5 mg / mL), Fospatase Alkaline (ALP) 785 U / L (42-98 U / L), AST 162 U / L (<35 U / L), ALT 133 U / L (<40 U / L), total protein 4.3 g / dL (6 to 8.5 g / dL) Albumin 2.4 g / dL (3.5-5.0 g / dL) , globulin 1.9 g / dL (2.5-3.5 g / dL). Based on the results of laboratory tests for the microbiological examination of sputum smear-type material on the 9th, 12th, 13th, and May 14 obtained negative results. Patients treated with omeprazole 2x40 mg (iv) to treat nausea and vomiting was given for 19 days (April 24-May 14). Ceftriaxon 2x2 grams (iv) for the treatment of bacterial infections of gram-positive and gram-negative given for 19 days (April 24-May 14) then treatment is given again on May 27, during treatment (27 to 30 May). Dexamethason (iv). 100 mg 2 ampoules. (first time) then 4x5 mg (iv) a day to relieve the symptoms of the disease, improve the appetite, provide a healthy feeling and can improve the prognosis of serious illness​(1) was given for 19 days (April 24-May 14) and then the dose was lowered to 2x5 mg (po) (on 8-14 May) until the end of therapy dismissed. Pyrimethanime 8 tabs. 25 mg (first time) is given in the emergency

department before entering the treatment room, then 3x25 mg (po) daily as antiparasitik for therapeutic treatment of toxoplasmosis, treatment was given for 36 days (April 24-May 30). Clindamisin 4x600 mg (po) for the therapeutic treatment of staphylococcal infections, and infections of the mouth caused by Candida albicans is given for 20 days (April 25-May 14). Neurobion 5000 1x1 as an adjunctive therapy for vitamin deficiency is given for 16 days (April 29-May 14). 3x500 mg metronidazole (iv) as a therapy protozoal infections and anaerobic infections for 12 days (2 to 14 May). Curcuma 3x1 (po) as a therapeutic treatment of impaired liver function is given during treatment (7 to 30 May). Cotrimoxazole 1x960 mg tablets (po) a combination of trimethoprim and sulfa metaksazol with a ratio of 1: 5 for toxoplasmosis treatment therapy is given during treatment (7 to 30 May). Candistatin drop 4x1 (po) for the therapeutic treatment of oral and perioral fungal infections, given for treatment (7 to 30 May). Rantin 2x1 (iv) in lieu of the use of Omeprazole to reduce nausea and vomiting, was given for 8 days (May 15 to 23). Fluconazole 1x1 (iv) additional therapy for the treatment of Candida albicans infection (19 to 30 May). On May 25-26 patients receiving treatment with 4x500 mg paracetamol for fever then replaced with 3x1 Sistenol (po) is given when (if) the patient's fever (May 28). Mycamine cup (in RL 100 ml) for the acute treatment of candidiasis was given for 6 days (May 15 to 21). Methycol 3x1 tablet (po) as additional vitamins to impaired liver function, given during treatment (15-30 May). Potassium Tablets (po) for the therapeutic treatment of potassium deficiency. At Ny therapies. Y, is found the DRP (Drug Related Problem) that required additional medication with antibiotics right combination​(3)​, treatment received by the patient is not a first-line therapy to standard treatment of Cerebral toxoplasmosis in which immunoglobulin G antibodies CD4 + count <100 μL³ and oral candidiasis in AIDS patients (3) ​ ​and drug interactions (5)​

. Concomitant use of metronidazole and dexamethasone. Metronidazole will increase the

effects of dexamethasone and affect CYP3A4 enzyme metabolism in liver / intestine. Significant interactions required close monitoring​(4)​. The use of metronidazole and sulfamethoxazole Mechanism:

decreased

metabolism.

Significant

interaction​(4)​.

Concomitant

use

of

sulfamethoxazole and fluconazole, increase QTc interval (QT interval is a measure of the time between the beginning of the Q wave and the end of the T wave in the heart of the electrical cycle. QT interval represents electrical depolarization and repolarization of the ventricles. Prolonged QT interval is a potential marker for ventricular tachyarrhythmias such as torsades de pointes and risk factors for sudden death)​(8)​. Interaction potential as a dangerous, use with caution and close monitoring is required​(4)​. Concomitant use of fluconazole and trimethoprim increase QTc interval, as a potential dangerous interaction, use with caution and close monitoring is required​(4)​. Conclusion Of the DRP is required additional medication with antibiotics right combination, therapy received by the patient is not first-line therapy in the standard treatment of toxoplasmosis and oral candidiasis in AIDS patients in which immunoglobulin G antibodies CD4 + count <100uL³, and drug interactions, namely between metronidazole and dexamethasone, metronidazole and sulfametaksazol, sulfametakzasol and fluconazole, as well as fluconazole and trimethoprim​(4)​. Suggestion 1. It is recommended to do a test toxo, because the use of the therapy requires regular monitoring of laboratory results. 2. Need additional treatment with appropriate antibiotics. Standard first-line treatment for the treatment of toxoplasmosis in which immunoglobulin G antibodies CD4 + count <100uL³ namely Trimethoprim and sulfamethoxazole 1 tablet orally (cotrimoxazole) with 2 power (active substance) 480 mg once daily​(3)(6)​. Therapy for acute infection in adult AIDS patients is pyrimethamine 200 mg orally once a day then 50-75 mg / day in combination with sulfadiazine 1-1.5 g orally 4 times a day and leucovorin 10-20 mg orally once daily for 4-6 weeks​(3)​. The first choice for the treatment of oral candidiasis in AIDS patients is Fluconazole 100 mg orally for 7-14 days (AI) or 500,000 units of oral nystatin swish (~ 5 mL) 4 times daily for 7-14 days (BII)​ (3)​. 3. It should be monitoring the results of routine CD4+ immunoserologi laboratorium​(1)​.

4. Need setting the time interval between the administration of metronidazole and dexamethasone, metronidazole and sulfametaksazol, sulfametakzasol and fluconazole, pyrimethamine and sulfametaksazol and fluconazole and trimethoprim​(4)​. Bibliography

1. Badan Pengawas Obat dan Makanan Republik Indonesia. 2008, ​Informatorium Obat Nasional Indonesia 2008​. KOPERPOM, dan CV Sagung Seto: Jakarta. 2. Chandra, G. 2013. ​Toxoplasma gondii :​ ​Aspek Biologi, Epidemiologi, Diagnosis, dan Penatalaksanaannya​. Aventis Pharma: Indonesia. 3. Dipiro, J.T., R.L Talbert, G.C. Yee, B.G. Wells, and L. M. Posey. 2005, ​Pharmacotherapy : A Pathophysiologic Approach, 7th Edition.​ Mc. Graw-Hill Companiec Inc Wahington, D.C.: United State Of America. Section 16: Infection Diseases. Page: 2065-2084. 4. http://www.medscape.com 5. Kasim, F. 2008. ​ISO:​ ​Informasi Spesialite Obat Indonesia, Volume 4.​ Penerbit ISFI: Jakarta. 6. Schwinghammer, T. L., Koehler., J. M. 2009, ​Pharmacotherapy Casebook : A Patient Focused Approach, 7th Edition.​ Mc. Graw-Hill Companiec Inc Wahington, D.C.: United State Of America. 7. Sukandar, E. Y., Andrajati, R., Sigit, J. I., Adnyana, I. K., Setiadi, A. P., and Kusnandar. 2011. ​ISO Farmakoterapi Volume 2.​ Penerbit Ikatan Apoteker Indonesia: Jakarta. 8. Wikipedia Indonesia​ ​http://en.wikipedia.org/wiki/QT_interval