MODULE FOR

STUDENTS
RATIONAL DRUG USE
NEURO-PSYCHO-PHARMACOLOGY

FACULTY OF MEDICINE
BRAWIJAYA UNIVERSITY
MALANG
 SKILL LAB of PHARMACOTHERAPY

RATIONAL DRUG USE

Forewords

Choosing a therapeutic agent, drug or non drug, is an academic and experienced based
process. These processes should not be based on the choices of other practitioners, or
even seniors. Drug choice and prescription making requires the understanding of
pathophysiology, disease pathogenesis, basic pharmacology (e.g. drug pharmacodynamic
and pharmacokinetic) and the cultural and social background of the patient. The response
towards a drug is very personal -different between one patient and the next, thus, drug
choices to a patient is also personal. In community treatments, the individual responses of
a drug are often not considered.

A physician's right in the choice of drug is based on a rational drug use concept. However,
the patient also has the right to choose the therapy or drug. Therefore, sufficient doctor-
patient communication is required before the prescription is written and the therapy is
initiated (e.g. information concerning drug effect, side effects, usage instruction, do's and
don'ts during the usage of the drug, and other contextual things). A treatment is not
considered to be finished before monitoring and evaluation of the drug results is
conducted.

To obtain the ability to choose drug abiding to rational drug use based pharmacotherapy
requires repeated practice and to not do the same mistakes in next practices/modules. A
beginning to end practice is an unseparated unity. The real application to the patient would
be done by you during the hospital training and internship program.

Best of Luck

Head of Pharmacology Laboratory

FKUB
 INTRODUCTION

The application of Competence Based Curriculum (CBC) has an effect on the learning
process and methods. This also applies to the learning of pharmacotherapy - it is no
longer based on only pharmacology, it also has the basis of other competence needed to
be achieved and integrated with other basic medical science and clinical knowledge.

Problem arises in CBC application, particularly in pharmacotherapy, when teaching the

students only beginning their medical training: they have insufficient knowledge in medical
basic science and don't completely understand clinical science. Therefore,
pharmacotherapy skill lab training with the basis of rational drug use is given through
simple phases and processes, increasing in difficulty and complexity (in both the drug
selection and the case given).

First Phase

Introduction to the concept of "rational drug use" uses an approach describing P-treatment
and P-drugs by comparing Efficacy, Safety, Suitability and Cost for the patient with
different pathophysiology, social-economy and culture condition. This phase is ended with
prescription writing practice in different conditions, such as, a variety of age, disease
patterns and socio-economy-culture conditions. The first phase is followed with an
independent practice/ structural task of making a pocket book for each student, consisting
of P-drugs, the forms available, and the usual dosage and a few notes considered to be
critical and urgent.

Second Phase

The student is guided in a drug selection practice; prescription writing based on rational
drug use against few diseases often encountered during daily private practices in
Indonesia.

The Third/Final Phase

This concept is applied during assistantship (Co As) in every clinic and also consists of
independent training during the internship. It is hoped that this 'habit' of knowledge
application would be carried on until the student is a physician working under the
professional standard (based on ethics, disciplined/ competent, and service standards
consistent with the local means, infrastructure and human resources).

Reading Materials:

1. Therapeutic Process

2. Pharmacotherapy Module

3. Drug Forms and Prescription Writing

4. Guide to Good Prescribing, WHO

I. Learning Goals
In the end of this training, the student is expected to be able to:

1. To apply Rational Drug Use concept using a P-treatment and P-drugs approach.
2. To plan a P-drug considering many different conditions of the patient
3. To write a prescription lege artis.
4. To apply rational drug use concept in new simulation cases.
5. Have the competence to apply the therapy according to general practitioner
competence based on competence standards.

Phases:

• Goal 1 to 4 can be obtained during the training in the skill lab.

• Goal 5 can be reached when the student is in the clinical assistantship phase (Co
As).

II. Rational Drug Use Concept with P Treatment Approach

II.1 Explanation of Rational Drug Use Concept and P Treatment

STEP 1: Define the patient's problem

STEP 2: Specify the therapeutic objective
STEP 3: Verify the suitability of your P-drug
STEP 4: Write a prescription
STEP 5: Give information, instructions and warnings
STEP 6: Monitor (and stop?) the treatment
II.2 P Drug Training by Comparing Efficacy, Safety, Suitability and Cost

HOW TO SELECT P-DRUG

i Define the diagnosis (pathophysiology)

ii Specify the therapeutic objective

iii Make an inventory of effective groups

iv Choose a group according to criteria

Efficacy Safety Suitability Cost

Group 1

Group 2

Group 3

v Choose a P-drug

Efficacy Safety Suitability Cost

Drug 1

Drug 2

Drug 3

Conclusion: Active substance, dosage form:

Standard dosage schedule:

Standard duration:
II.3 Prescription Making

A complete prescription should include:

1. The doctors name

2. Practice permit/assignment letter number
3. Address and phone number of the practice
4. The time the practice opens and close
5. The time and date of the prescription
6. The name and dosage of the drug (the knowledge of the form of the drug and the
usual dosage is required)
7. The form of the drug asked
8. Drug Usage Instruction
9. Signature
10. Name, Age, Weight of the Patient
11. Address of Patient (Hospital: Registry Number)

Dr. Fatiroh

Jl. Saturnus 3, Malang

Telp. 0341 582110

SIP. 446.DU/012/35.73.306/2007

Example of Prescription:
Malang, 3 Oktober 2009
1. A prescription for a patient with angina pectoris case

R/ Glyceryl trinitrat 1 mg tab No X

S 2 dd I sublingual

----,,---- ft

Pro : Tn. Amin

Umur : 60 th.

Alamat : Jl. Planet no 10, Malang

2. Patient required staying in the hospital

Dr. Ida

Jl. Saturnus 3, Malang

Dr. St. Nurin
Telp. 0341 582110
Jl. Baru no 80
SIP. 446.DU/012/35.73.306/2007
Malang. Telp. 573440

SIP : 446.DU/012/35.73.306/2007
Malang, 3 Oktober 2009

Malang, 15-10-2007
R/ Aminophyllin amp No II

S imm
R/ Amoksisilin syrup fl No.I
----,,---- id
S 3 dd cth II

---,,--- stn
Pro : Tn. Amin

Umur : 35 th.

Alamat : Jl. Planet no 10, Malang

Pro : An. Uci

Umur : 5 th

Alamat : Jl. Guntur no 49, Malang

3. Amoxicillin syrup for a child, 5 years old, weight of 20 kg

Explanation:

Amoxicillin dosage for children 30-50 mg/KgBW (body weight)

Syrup: 1 spoon (5 ml) contains 125 mg

 SKILL LAB of PHARMACOTHERAPY

RATIONAL DRUG USE

1. General Guide for Pharmacotherapy based on Rational Drug Use - consisting of the
basics of drug selection, prescription making, communication with patients and
complementary additions, such as therapy process resume, pharmacotherapy
modules, drug forms and prescription making and Guide to Good Prescribing.

2. Before the skill lab begins, the students should:

a) Understand the Rational Drug Use concept.
b) Understand the classification of the drug for therapy according to the
pathophysiology of the disease.
c) ASSIGNMENT 1: Make notes in the form of a pocket book containing the
ANALGESIC-ANTIINFLAMMATORY DRUGS, including important notes about
drug mechanism, specific pharmacokinetic, important side effects,
formulations of the medicine (written at home before skill lab activity).
d) Understand prescription structure.

An example of the pocket book/notes of drugs:

Class Generic and Pharmaco- Pharmaco- Presentation and Cost

Brand Name kinetic Dosage
 dynamic

Analgesic Paracetamol: Mechanism: ..? Important ADME Tab 500 mg

panadol, pamol,
biogesic Indication: Syr 125 mg / 5ml
Muscle pain
3x 500 mg/hari
Contraindica-
tion

Side Effect

Mechanism

Indication
Mefenamic acid:
ponstan, mefinal Contraindica-
Analgesic-anti tion Tab 500 mg
inflammation
Syr 125 mg / 5ml
Side effects
...........

...........

etc
Gel?

ASSIGNMENT 2:

P-Drug Assignment:

• Each class is divided into groups.

Each group (20-25 students) formulates P-drug for analgesic-antiinflammatory drugs.

• Each group divides itself into 5 subgroups (with a maximum of 4-5 people per
subgroup).
Each subgroup chooses one P-drug case (the P drug is taken from the pocket book).

P-Treatment Assignment:

• Each group works on one P-treatment case (make a P-treatment based on efficacy,
safety, suitability, and cost).
This assignment is done at home BEFORE skill lab activity (read the materials already
provided).

3. During the Skill Lab:

• A short summary of Rational Drug Use
• P-Drug practice and prescription writing practice: for normal adults, using various
drug forms.
• P-treatment practice
4. Structured Assignment after Skill Lab:
a) Complete the pocket book of drug form and shapes.
b) Complete P drugs for analgesic-antiinflammatory drugs.

EXAMPLE

Mr. Bejo, 50 y.o., complains of knee pain. His job is a peddler. He also complains of
stomach aches after drinking coffee. Make a P Treatment with 6 steps therapeutic
process.

1. Problem:
• Knee pain
• Dyspepsia syndrome, gastric acid increase
2. Therapeutic Goal:
• To reduce knee pain
• Neutralize gastric acid
• Reduce gastric acid secretion
• Reduce nausea
3. Therapeutic Intervention
• Advice:
Do not eat spice, acidic, and fatty food.

Do not be late for a meal and do not drink coffee

Avoid stress

• Non Drug: -
• P-Drug:
Anti-inflammation drugs that do not influence the stomach.

There are 2 types of anti-inflammatory drugs: Non selective COX inhibitor and
COX-2 selective inhibitor. COX-2 selective inhibitors do not affect the stomach:
Celecoxib (but the price is high).

4. Regiment Dosage and Prescription Making

Dr. Santi

Practice: Jl. Nangka no 102

Telp. 021 723 4444

SIP. 446.DU/012/35.73.306/2007

Surabaya, 21 Oktober 2007

R/ Celecoxib No X

S 2 dd tab I p.c

-------,,------ st

-------------------------------------------------------------------

Pro : Pak Bejo

 Age : 50 th

Address : Jl. Tanjung Pura 16

Surabaya

5. Information, Instructions and Warning→Communicate the Prescription in

Step 4
Sir, I made a prescription for you. There are 3 kinds of medicines. The first is an
antacid which would neutralize your gastric acid, take it 3 times a day after a regular
meal. The second one is a famotidine, which would suppress acid release, take it twice
a day, and the third one is a metochlopramide that is anti-nausea, take it 3 times a day.
After taking the medication, you might have diarrhea or constipation. And so on about
the side effects of the drug.

6. Monitoring and Evaluation

If there are any symptoms that you feel too disturbing, please return here...etc

MODULE TASK :

RATIONAL DRUG USE

PHARMACOTHERAPY:

NERVOUS SYSTEM, PSYCHIATRY, EYES, and EARS, THROAT, NOSE

(ENT) SYSTEM

P-DRUG CASE

NEUROLOGIC CASE
1. Adi, 10 years old (25 kg), suffered from tonic clonic generalized seizures 3
to 5 times per week.

2. Joko, 65 years old, suffered from resting tremor, rigidity, slowness of

movement, masked facies, and postural instability. The cognition is
impaired and functionally disabled.

OPHTHALMOLOGIC CASE
3. Yuni, 55 years old, suffered from burning, itching, and redness of the eyes.
She feels that there is a speck of dirt in her eyes.
4. Andi, 25 years old. Her eyes are hyperemia and itchy after he got
something in his eyes. There are lacrimation and scant mucopurulent
discharge. There is no eye lid edema.

ENT SYSTEM CASE

5. Dina, 9 years old (26 kg), suffered from fever and pain when swallowing.
Her pharynx is hyperemia.

6. Bakti, 29 years old, suffered from clear rhinorrhea, paroxysms of sneezing,

nasal congestion, postnasal drip, and pruritic nose, after exposure of dust.
He is working now, so he asks non-sedative medication.

PSYCHIATRIC CASE

7. A schizophrenic patient developed bradykinesia, rigidity, and tremor during

treatment with haloperidol.

8. Maria, 17 years old, screams uncontrolled after being scolded by her

parents because she got bad marks in her examinations.

P-TREATMENT CASE

Make a P-Treatment with 6 steps therapeutic process.

NEUROLOGIC CASE

Case 1

Anna, 30 years old, suffered from headache with a pressing/tightening

(nonpulsating) quality, mild to moderate intensity, bilateral location, and no
aggravation with physical activity. The headache occurs 15 days a month, each
lasting more than 1 hour. She could not sleep well since her husband passed
away 2 months ago. From physical examination, the temporal and neck
muscles are contracted.

Case 2

Andi, 8 years old (24 kg) is having learning difficulties at school. He has brief
lapses of awareness with eyelid fluttering that occur every 5-10 minutes. EEG
studies reveal brief 3-Hz spike and wave discharges appearing synchronously
in all leads. His mother asks medication in syrup form.

OPHTHALMOLOGIC CASE

Case 3

Sintia, 25 years old, suffered from pain and photophobia in her left eye. She
often wears contact lenses. From physical examination, there are decrease of
visus, lacrimation, blefarospasm, conjunctival injection, and cloudy infiltrate in
left cornea.

Case 4

Joni, 7 years old (22 kg). His eyes are hyperemia and itchy after playing football
in daylight. From physical examination, there are conjunctival injection and
“ropy” discharge.

ENT SYSTEM CASE

 Case 5

Yani, 12 years old (35 kg), suffered from purulent secrete that come out from
her left ear since 2 months ago. There is no pain, but there is decrease of
hearing. From physical examination, the tympani membrane is perforated and
there is purulent secrete.

Case 6

Zaki, 8 years old (24 kg), suffered from common cold since 5 days before.
There are purulent rhinorrhea and frequent cough with purulent sputum. From
physical examination, the temperature is 38°C. His mother asks medication in
syrup form.

PSYCHIATRIC CASE

Case 7

Ahmad, 40 years old (55 kg), who A schizophrenic patient developed

bradykinesia, rigidity, and tremor during treatment with haloperidol.

Case 8

Maria, 17 years old, screams uncontrolled after being scolded by her

parents because she got bad marks in her examinations.

PHARMACOTHERAPY SKILLS
Name :
NIM :
Group :
Date :

No. Activity Score

0 1 2
1. Greet the patient and allow him to sit comfortably
2. Introduce yourself to the patient
3. Re-confirm the patients identity: name, age, address, job, family status
4. Determine the problem/ diagnosis of the patient
5. Determine the therapeutic goal
6. Determine the P-Treatment (Advice, non-drug)
Determine the drug choice (P-drug) considering:
- Efficacy
- Safety
- Suitability
- Cost
7. Identify the chosen drug:
 - Drug name
- Drug formulation
- Dosage
- Treatment time
8. Write a full prescription

- Name and Address Administration method

- Date Amount
- Generic drug name Instructions
- Drug formulation Signature
- Dosage Name and address of the patient
9. Give information, instructions, and warnings consisting of:
- The effect of the drug (effect, when the effect would appear and how long)
- Side effects (effects and what to do)
- Instruction (How to take the medicine, dosage, interval, how long, and what to notice)
- Warning (maximum dosage, interaction, unwanted effects, drug termination)
Determine when to return to monitor and evaluate the treatment.
10.
Notes: the communication given in number 9 and 10 must be :
- Clear and understandable
- Systematic
- Give the patient (or family members) to express themselves or ask questions
- Make sure the patient (or family) understands the instruction given. Ask the patient (or
family) to repeat the instructions.
Total

Grading starts from 4 – 10 (number of questions 7)

Malang,
Information: 0 = did not do
Tutor,
1 = did but incorrect

2 = done perfectly

Total score

Final Score = -------------------------- x 100 =

10

Notes: Students PASS if the final score is ≥ 90

For pharmacotherapy lab skills based on Rational Drug Use, the forms filled are no 6, 7, 8, 9, 10.