Peran Apoteker dalam Kepatuhan Pasien Tuberkulosis

Dr. apt. Widyati, MClin Pharm,

OUTLINE
• Latar Belakang
• Peran Apoteker
• Adherence Vs Compliance
• Future Adherence Model
• Model Intervensi yang Sukses
• Improved Counselling
Adherence Vs Compliance
• adherence is an active choice of • passive behavior in which a
patients to follow through with patient is following a list of
the prescribed treatment while instructions from the doctor.
taking responsibility for their
own well-being
Adherence
• Adherence to tuberculosis (TB) drugs is one of the key aspects of global
TB control,
• Poor adherence to treatment can increase the risk of recurrence and of
developing drug-resistant tuberculosis, as shown in previous studies
(Munro SA, et al., 2007; Patel AR, et al. , 2017; Abolhassani R, et al., 2020)
• Treatment adherence is affected by multiple factors.
• These factors are divided into five different interacting dimensions:
including socio-economic, health care system, condition, therapy and
patient factors (WHO, 2003)
• TB cure was low with self‐administration across all studies (range 41%
to 67%) (Karumbi et al., 2015)
 Outcome TB Treatment (WHO, 2014)
• Medication adherence consists of three phases: initiation, implementation, and
persistence ( Vrijens, B. et al., 2016)
• Completed treatment was defined as a TB patient who completed treatment
without evidence of failure but with no record showing that sputum smear or
culture results were positive in the last month of treatment,
• Defaulted treatment was defined as an interruption of TB treatment for two or
more consecutive months.
• Adherence rate was identified by the proportion of anti-TB drug dose taken during
the treatment period.
• Cured treatment was defined as smear or culture negative in the last month of
treatment and on at least one previous occasion,
• Negative sputum conversion was defined as the conversion sputum to a negative
result.
• Poor treatment outcome is a combination of defaulted, failed treatment and death
outcome.
• Failed treatment was defined as a positive sputum smear or culture at the fifth
month after treatment initiation.
Intervensi yang Sukses (Pradipta Ivan et al., 2020)
Several interventions were found effective in improving medication
adherence and outcomes of active TB patients,
• DOT with daily home visits by community-trained members,
• SMS reminders combined with TB education,
• a reinforced counselling method
• a monthly voucher intervention.
In LTBI patients: DOT and a shorter regimen significantly improved
treatment completion.
Drug box reminder or its combination with text messaging reminders
significantly improved medication adherence rates among active TB
patients,
Fakta tentang DOT
• DOT’s effectiveness is varied compared to self-administered therapy
• DOT did not provide a solution to poor adherence in TB
treatment. (Karumbi et al., 2015)
• DOT by family members was not superior in improving treatment
adherence compared to self-administered therapy.
• Institutional DOT provided for latent TB infection effectively improved
treatment completion Pradipta IS, Houtsma D, van Boven JF, Alffenaar
JC, Hak E. Interventions to improve medication adherence in
tuberculosis patients: a systematic review of randomized controlled
studies. NPJ Prim Care Respir Med. 2020;30:21.
 Future Adherence Model

Video Observe Therapy

Health Belief Model (HBM)

Information and communication technology

digital technology
Measuring the Adherence
Pengukuran adherence can be categorized as direct :
• DOT,
• ingestible sensors,
• drug or metabolites measurements (TDM, urine test)
Indirect:
• patient self-report,
• pill counts, health information system, electronic pill bottles and SMS.
• Digital adherence technologies have been developed that offer large potential
to measure and improve medication adherence in TB patients. DAT which
include feature phone–based and smartphone-based technologies, digital
pillboxes and ingestible sensors—have the potential to facilitate more
patient-centric approaches for monitoring tuberculosis (TB) medication
adherence than existing directly observed therapy (DOT) models.
Rifampicin
Data Deskripsi
Absorbsi well absorbed, makanan akan sedikit mengurangi kadar puncak
Distribusi Sangat lipofilik
Penetrasi. Ke BBB Cukup dengan atau tanpa inflamasi
Ikatan protein 80%
Metabolisme Hepatik, melalui resirkulasi enterohepatik
Bioavailabilitas Sangat baik
Waktu paruh eliminasi Dewasa 2-3jam; bayi>4 bulan dan anak-anak: 1-4 jam;
Time to peak Dewasa 2 jam; bayi dan anak 6 bulan - <5tahun: 1 jam
Ekskresi Faeces 60-65%; urine<30% sebagai unchanged drug
Cmax 8mg/dl
Dosis Dewasa: 8-12mg/kgBB; bayi, anak, remaja:10-20mg/kgBB; max 600 mg/dosis
CKD maupun ESRD Tidak perlu penyesuaian dosis
INH
Data Deskripsi
Absorbsi Baik secara oral, i.m.; makanan menggangu kecepatan absorpsi
Distribusi Ke semua jaringan dan cairan termasuk SSF
Penetrasi ke BBB Baik
Ikatan protein 10-15%
Metabolisme Hepatik menjadi acetylisoniazid yang tergantung pada tipe acetilasi
Bioavailabilitas Baik
Waktu paruh eliminasi Prolong pada pasien disfungsi liver atau CKD berat; Fast Acetylator 30-100 menit;
Slow acetylator 2-5jam
Time to peak 1-2 jam
Ekskresi Urine 75-95% unchanged + metabolit
Cmax
Dosis 5mg/kg/hari (600mg); DOT 3x seminggu: 15mg/kg/dose (900mg)
CKD maupun ESRD Tidak ada panduan, namun waspada dan monitoring secara ketat
Improved Counselling
• Luangkan waktu
• Friendly manner, personal approach, raih simpati pasien
• Dampak kegagalan terapi
• Mengapa perlu patuh minum obat
• Hal-hal yang akan menggagalkan adherence
• Pola makan tinggi protein
• Interaksi dengan obat lain
• ADR: sampaikan yang pasti terjadi seperti perubahan warna urin
Dampak Kegagalan Terapi
• Kerusakan paru, jaringan ikat menggantikan jaringan paru yang
fungsinya (-)
• Sering sesak, mudah terkena pneumonia
• Menjadi Resisten TB, MDR TB: menularkan ke orang lain
• Infeksi menyebar ke organ lain: Ginjal, Usus, Kelenjar Getah Bening,
Tulang
Kesimpulan