METODE ANALISIS FARM

FINDING Wanita 28 tahun Pasangannya baru didiagnosa HIV/AIDS, kemungkinan TB Hamil 30 minggu

ASSESSMENTPasien suspect HIV : Ibu Janin

RECOMENDATION

TABEL ASSESSMENT

PMS/OMEDICATIONDRPANALYSISRef

Ibu hamil Suspect HIV Hamil 30 minggu Pasangannya baru didiagnosa HIV/AIDSPositive ARTZidovudineLamivudineNevirapine(Factor Risk B)rifampicin+zidovudinerifampicin meningkatkan metabolisme zidovudine sehingga akan menurunkan kadar zat aktif dari zidovudine. (Significant - Monitor Closely.)Mengganti NRTI (Zidovudine) dengan PI Atau

Meningkatkan dosis zidovudine dari 300mg jadi 450mg

Riwayat TBCIsoniazidRifampicinPyrazinamideEthambuthol

Keterangan : Penggunaan ART dengan obat antiTB tidak diperlukan pengaturan jeda konsumsi obat karena interaksi farmakokinetik yang terjadi disini ada dalam fase metabolisme. Solusi yang ditawarkan :1. Mengganti NRTI dari Zidovudin menjadi Stavudin karena metabolismenya tidak dipengaruhi Rifampicin.2. Mengganti gol. NRTI (Zidovudine) dengan gol. PI3. Meningkatkan dosis zidovudin 300mg450mg untuk memperoleh konsentrasi normal selama 1 bulan cek efektivitasnya, bila telah tercapai 1 bulan maka kembalikan dosis jadi 300mg.Catatan : Sifat inducer enzim dari rifampicin bila penggunaannya telah 1 bulan, tidak akan lagi berpengaruh. Pemilihan obat antiTB yang dianjurkan pada penderita baru adalah 2HRZE/4H3R3 yakni pemberian selama 2 bulan kombinasi INH, Rifampicin, Pirazinamide, dan ethambutol setiap hari (tahap intensif) dan dilanjutkan 4 bulan selanjutnya minum obat INH dan rifampisin 3 kali dalam semiggu (tahap lanjutan) Dosis yang diberikan pun sesuai dosis normal orang dewasa meskipun pasien dalam keadaan hamil.

TABEL ANALISIS OBAT

MEDICINEINDIKASIMEKANISMEInteraksiESOKIREF

Zidovudine300 mgLamivudine150 mgNevirapine200 mg

Diminum 2x1 tablet dengan atau tanpa makan

Pregnancy Risk Factor B

antiretroviral agents untuk terapi HIV-1LamivudineNRTI, fosforilasi berikutnya, menghambat reverse transcriptase HIV dengan pemutusan rantai DNA virus; sitosin analogfatigue,headache, nausea, vomiting, stomach pain, diarrhoea, fever, rash (red, raised or itchy), increase incertain liver enzymes, joint pain, muscle pain and other muscle disorders, dizziness, cough, nasalsymptoms, tiredness, difficulty sleeping, hair loss, anaemia (low red blood cell count) and neutropenia(low white blood cell count).Terlampir (NVP_3TC_AZT_GenericCombination halaman 2)WHO guideline of HIV pregnancy, Medscape, Dipiro, DIH,

ZidovudineNRTI, mengganggu polimerase virus HIV RNA-dependent DNA (menghambat replikasi virus); analog timidin

NevirapineNNRTI, mengikat reverse transcriptase, dan dengan demikian menghalangi aksi polimerase RNA dan DNA-DNA-dependent termasuk HIV-1 replikasi

IsoniazidRifampisinPyrazinamideEthambuthol

Dosis : peroral55 kg: 6 tabletsIn a single daily dose

Risk Factor CTuberculosis

RifampisinInhibits bacterial RNA synthesis by binding to the beta subunit of DNA-dependent RNA polymerase, blocking RNA transcriptioncardiorespiratory events (eg, chest pain, hemoptysis, palpitation, chest tightness, and pneumothorax) was higher with the combination product (7%) that that reported with individual agents (2%).Hepatitis

IsoniazidUnknown, but may include the inhibition of mycolic acid synthesis resulting in disruption of the bacterial cell wall

Pyrazinamidebacteriostatic or -cidal for Mycobacterium

EthambutolSuppresses mycobacteria multiplication by interfering with RNA synthesis

MONITORINGCek lab : Tes fungsi hati : SGPT/SGOT karena ESO ARV (nevirapine) & antiTB penting pada 18 minggu pertama.*Dalam beberapa kasus, kerusakan hati telah berkembang meskipun penghentian pengobatan.

PREGNANCYTreatment recommendations have been made to address the specific requirements for HIV-infected pregnant women and the prevention of vertical transmission.62 Therapy is warranted particularly in light of the dramatic reduction in transmission seen with zidovudine monotherapy (ACTG protocol 076). ACTG protocol 076 randomized 477 HIV-infected pregnant women (14 to 34 weeks gestation) to either zidovudine or placebo. The zidovudine regimen consisted of antepartum zidovudine (100 mg five times daily) plus a continuous infusion of zidovudine during labor (2 mg/kg intravenously over 1 hour followed by 1 mg/kg per hour), and zidovudine for the newborn (2 mg/ kg orally every 6 hours for 6 weeks). The HIV transmission rate was 25.5% among those who received placebo but was 8.3% when the mothers and their babies received zidovudine. This difference corresponds to a two-thirds reduction in the risk of maternal-to-infant HIV transmission. Adverse reactions associated with zidovudine therapy in the study were minimal: Hemoglobin concentrations were significantly lower at birth in infants whose mothers received zidovudine, but this difference disappeared by 12 weeks of age; there was no difference in minor or major structural abnormalities in the two groups.63C L I N I C A L CONTROVERSYUnfortunately, little is known about the use of other antiretrovirals in pregnant women and the effect these drugs may have on the developing fetus. PI use among 89 pregnant women appeared generally safe to both mother and baby in a retrospective multicenter survey.66 In general, pregnant women should be treated similarly as nonpregnant adults; if possible, zidovudine should be used for both mother and infant.62An abbreviated course of zidovudine (i.e., given during labor or in the first 48 hours of life) also can reduce transmission substantially and may be easier for the patient to take.64 Alternatively, single-dose nevirapine given to the mother during labor and to the baby within 3 days of birth also can reduce transmission of HIV.65

Reference : Dipiro