Professional Documents
Culture Documents
Iwan Darmansjah
Pusat Uji KLinik Obat, FKUI
Dutch Foundation Seminar: Boerhaavse Kursus, FKUI 22-23 Apr.2002
www.guidelines.gov/
Class II:
www.guidelines.gov/
www.guidelines.gov/
by Elliot Israel, M.D., Taruna R., Banerjee, M.P.H., Garrett M. Fitzmaurice, Sc.D., Tania V. Kotlov,
M.S., Karen LaHive, M.D., and Meryl S. LeBoff, M.D.;
The New England Journal of Medicine, September 27, 2001.
Background
Here is the important background information that the authors give us:
-consensus reports recommend increased use of inhaled corticosteroids
(also referred to as glucocorticoids) for patients with asthma,
-it is known that oral corticosteroids accelerate bone loss, and that
fractures occur in 30 to 50% of patients on oral corticoids,
CHRONICITY INDEX is
a measure of chronic toxicity:
LD50
Endrin :
7
=
LD50
(90 hari)
= CI = 7
1
120
Deksametason :
= 1714
0.07
EBM in terms of
Benefit-Risk Ratio
The seriousness of the problem to be treated
The efficacy of the drug you intend to use
The seriousness and frequency of possible
adverse effects
The efficacy of other drugs which might be
used instead
The safety of other drugs which might be
used instead.
Primary literature
How much is
incorrect?
Correction
of errors
Much of it is correct
(adapted)
6. Nosocomial pneumonia
7. Acute bacterial exacerbations of chronic bronchitis
8. Secondary bacterial infections of acute bronchitis
9. Acute otitis media
10. Acute sinusitis
11. Streptococcal pharyngitis
(More indications may follow in response to industrys marketing
application of claims)
Atypical pneumonia
Viral peumonia
Acute bacterial pneumonia
Aspiration pneumonia
Ventilator-associated pneumonia
Pneumonia in an immuno-compromised
and/or neutropenic host.
Geriatric patients: ..
Agent
0.1-1.0 g/mL
> 2 g/mL
Amoxicillin ..
+++
+++
Doxycycline
+++
+/-
+++
+/-
Clindamycin
+++
++
TMP-SMZ .
++
Cefuroxime
+++
Cefotaxime
+++
+++
+++
+++
+++
Imipenem
+++
+++
Vancomycin ..
+++
+++
+++
++ : > 75%
+ : > 50%
- : < 40%
Bagaimana dg penisilin G
untuk CAP tanpa penyulit?
Intravenous crystalline Pen G, 3 - 5 juta Unit,
setiap 3 jam menghasilkan Cmax rata-rata
+ 20 45 g/ml*, yaitu 10 22 kali > MIC
S. pneumoniae yg resisten, tapi tidak disebut
dalam informasi tabel tadi.
Rasio Cmax / MIC yang besar merupakan faktor
daya bunuh kuman (conc.dependant) yg
ampuh.
CAP tanpa penyulit juga dianjurkan diobati di
rumah untuk menghindari nosocomial infection.
*(Kucers & Bennett, 4 ed. 1987, pg 23)
th
- Dilantin 400 mg
1.57
- Luminal 200 mg
30.19
- Carbzepine 200 mg 1.97
/10-20/
/15-40/
/4-10/
FDA
Masalah
Industri
terbesar ialah
Dokter
bahwa
Spesialis
evidence
Farmasis
dapat diartikan
Herbalis
berbeda-beda
Naturo-
menurut
patis
Awam
dsb.
setiap orang
atau profesi.
Control
group
Active
group
RRR
Absolute RR
(PC - PA)/PC
PC - PA
NNT
1/(PC - PA)
0.20
16 778
0.12
0.40
0.08
13
0.40
0.006
167
16 898
0. 015
15 165
0.009
15 238
(BMJ 1995;310:452-4)
Pravastatin
15.9%
12.3%
RR (relative risk)
0.76 (0.68-0.85)
Absolute risk
reduction
3.6%
Relative reduction
24%
Clopidogrel in addition to aspirin in unstable angina (source of Figure: Chris Cates , from
internet) original article: NEJM 2001;345(7):494-502)
EBM menjembatani
Ilmu Kedokteran dan Hukum ?
EBM mulai dibutuhkan juga oleh seorang
hakim menentukan apakah suatu
pengobatan tertentu sudah benar dalam
persidangan. Diperlukan ilmu (evidence)
di belakang pertimbangan suatu testimoni
seorang saksi ahli. (JAMA Vol. 283 No.21, June 2000)
Juga, EBM menentukan harga saham
pabrik obat, yang disebarkan mass media
ekonomi.
Glaxo
Westwod-Squibb
Asta Medica
Wyeth Ayerst
BMS
Abbott
Pharmacia-Upjohn
BMS
Merck
Wyeth-Ayerst
Merck
Astra Zeneca
Lilly
Solvay
Parke-Davis
2 companies
Aventis
Roche
Ketorolac
Lamivudine
Loratadine
Lovastatin
Metformin
Midazolam
Nabumetone
Omeprazole
Oxaprozin
Pemiroplast
Propofol
Ranitidine
Remifentanil
Ribavirin/Intron A
Sevoflurane
Sotalol
Stavudine
Tramadol
Allergan
Glaxo
Schering Corp.
Merck
BMS
Roche
SmithKline
Astra Zeneca
Glaxo
Santen
Zeneca
Glaxo
Abbott
Schering Corp.
Abbott
Berlex
BMS
Johnson
Conclusion
Proper drug use should be promoted nationally.
Education on drugs and EBM must take a
different approach (not education by coercive,
pharmaceutical marketing needs).
The cause of irrationalism is linked with a
perpetuating error in a larger (health) system.
Health and DrugUsePolicy must be established.
If the Health Department is failing, universities
and the profession should - morally - take
initiative.
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