Pharmacotherapy Update

in
Endocrine System
dr. R. Setiadji, M.Sc

Standar Kompetensi Dokter Indoesia

The related drugs

Oral hypoglycaemic Insulin

Hypolipidemic
Antiobesity
Antithyroid
Corticosteroid

Gejala dan Tanda

Data Penunjang
Diagnosis
Terapi
Non Obat

Memilih obat P
Tetapkan diagnosis
Tetapkan tujuan pengobatan
Susun kelompok obat manjur
Susun obat manjur
Pilih obat manjur berdasar tujuan

Choose effective drug follow

EVIDENCE BASED MEDICINE*
Indication/Mechanism
Side effect
Availability/Posology

RCT
Cohort/CaseC
Time series
Testimony

Level I: Evidence obtained from at least one properly designed

randomized controlled trial
Level II-1: Evidence obtained from well-designed controlled trials
without randomization
Level II-2: Evidence obtained from well-designed cohort or case-control
analytic studies, preferably from more than one center or research
group.
Level II-3: Evidence obtained from multiple time series with or without
the intervention. Dramatic results in uncontrolled trials might also
be regarded as this type of evidence.
Level III: Opinions of respected authorities, based on clinical
experience, descriptive studies, or reports of expert committees.

US Preventive Services Task

Gunakan WHO Guideline

DM tipe II

Menurunkan BB *
Meningkatkan BB
Bila ada riwayat penyakit jantung
Yang menghambat absorpsi glukosa dari usus
Yang memacu sekresi insulin
Yang menghambat glukagon

Pharmacotherapy of Dyslipidemia

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Obat Dislipidemi

Kelompok obat yang efektif

Statin efek samping
Niacin efek samping
Gemfibrozil efek samping
Probucol efek samping
Bile acid sequestrant efek samping

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Drug Therapy
HMG CoA Reductase Inhibitors (Statins)
Reduce LDL-C 1855% & TG 730%
Raise HDL-C 515%
Major side effects
Myopathy
Increased liver enzymes
Contraindications
Absolute: liver disease
Relative: use with certain drugs
evidence

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HMG CoA Reductase

Inhibitors (Statins)
Statin

Dose Range

Lovastatin
Pravastatin
Simvastatin
Fluvastatin
Atorvastatin
Cerivastatin

2080 mg
2040 mg
2080 mg
2080 mg
1080 mg
0.40.8 mg

15

HMG CoA Reductase

Inhibitors (Statins) (continued)
Demonstrated Therapeutic Benefits

Reduce major coronary events

Reduce CHD mortality
Reduce coronary procedures (PTCA/CABG)
Reduce stroke
Reduce total mortality

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Kontroversi
Simvastatin dan amiodarone
..\..\..\..\..\Videos\Serious Muscle Injury w Simv
astatin Amiodarone Combination.mpg
Statin dan kanker
..\..\..\..\ found to INCREASE the risk of dying.mpg

17

Drug Therapy
Bile Acid Sequestrants
Major actions
Reduce LDL-C 1530%
Raise HDL-C 35%
May increase TG
Side effects
GI distress/constipation
Decreased absorption of other drugs
Contraindications
Dysbetalipoproteinemia
Raised TG (especially >400 mg/dL)

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Bile Acid Sequestrants

Drug Dose Range
Cholestyramine
416 g
Colestipol
520 g
Colesevelam
2.63.8 g

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Bile Acid Sequestrants (continued)

Demonstrated Therapeutic Benefits
Reduce major coronary events
Reduce CHD mortality

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Drug Therapy
Nicotinic Acid
Major actions
Lowers LDL-C 525%
Lowers TG 2050%
Raises HDL-C 1535%
Side effects: flushing, hyperglycemia,
hyperuricemia, upper GI distress, hepatotoxicity
Contraindications: liver disease, severe gout,
peptic ulcer

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Nicotinic Acid
Drug FormDose Range
Immediate release
(crystalline)
Extended release
Sustained release

1.53 g
12 g
12 g

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Nicotinic Acid (continued)

Demonstrated Therapeutic Benefits
Reduces major coronary events
Possible reduction in total mortality

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Drug Therapy
Fibric Acids
Major actions
Lower LDL-C 520% (with normal TG)
May raise LDL-C (with high TG)
Lower TG 2050%
Raise HDL-C 1020%
Side effects: dyspepsia, gallstones, myopathy
Contraindications: Severe renal or hepatic
disease

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Fibric Acids
Drug

Dose

Gemfibrozil
Fenofibrate
Clofibrate

600 mg BID
200 mg QD
1000 mg BID

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Fibric Acids (continued)

Demonstrated Therapeutic Benefits
Reduce progression of coronary lesions
Reduce major coronary events

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List of antiobesity drug

Orlistat
Sibutramine
Rimonabant
Metformin
Exenatide
Pramlintide

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Combined Therapy
Combined intervention of a caloriedeficit diet, increased physical activity,
and behavioral treatment is most
successful for weight loss and
maintenance.
Evidence Category A.
Nondrug interventions should be
attempted for at least 6 months before
considering
treatment.

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Pharmacotherapy
Drugs approved for long-term use by the FDA may be
used as part of a comprehensive weight loss program
including diet and physical activity. Evidence Category B.
For patients with a BMI of 30 or above with no
concomitant risk factors or diseases
For patients with a BMI of 27 or above for those with
concomitant risk factors or diseases (hypertension,
dyslipidemia, CHD, type 2 diabetes, sleep apnea)

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Pharmacotherapy (continued)
Drugs should never be used alone.
Drugs should be used in combination
with diet, exercise, and behavior
modification.

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Weight Loss Drugs

Drug
Dose
Sibutramine 5, 10, 15 mg
(Meridia)

Action
Adverse Effects
Norepinephrine,
Increase in heart

10 mg po qd

dopamine, and

to start, may be
increased to 15 mg

rate and blood

serotonin reuptake

pressure

inhibitor.

or decreased to 5 mg.
Orlistat
120 mg
(Xenical) 120 mg po tid
before meals.

Inhibits pancreatic
lipase, decreases
fat absorption.
and anal leakage.

Decrease in absorption
of fat-soluble
vitamins; soft stools

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Orlistat
Reduces intestinal fat absorption by inhibiting
pancreatic lipase
Sering b.a.b
Steatorrhea
Diet lemak dikurangi, gejala berkurang

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Sibutramine

Appetite suppresant
Increase blood pressure
Dry mouth
Constipation
Headache
Insomnia

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Rimonabant
Cannabinoid receptor antogonist, decreasing
appetite centrally
Increasing thermogenesis peripherally, increasing
energy expenditure
Reverse the metabolic effect of obesity, such as
insulin resistance and hyperlipidemia.
Weight loss has not to be greater than other drug

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Metformin
txt

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Exenatide
Byetta
Long acting analog of hormon GLP-1, which the
intestines response to the presence of food
Delays gastric emptying and promotes a feeling of
satiety
Subcutaneous twice daily

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Pramlintide
Symlin
Synthetic analog of hormone amylin
Secreted by pancreas in response to eating
Delays gastric emptying and promotes a feeling of
satiety
Being tested as antiobesity

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