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NAUSEA & VOMITING

FARMASI KOMUNITAS I

Disampaikan oleh:
Lisa Aditama
DEFINISI
MUAL & MUNTAH
(NAUSEA & VOMITING)
Mual (Nausea) adalah rasa tidak nyaman pada
GI, tanpa sensasi nyeri yang dapat
menyebabkan seseorang berpotensi muntah.
Muntah (Vomiting) adalah respon yang bersifat
otonom dan terorganisir, yang akhirnya
menimbulkan dorongan kuat pengeluaran isi
lambung melalui mulut.
Muntah secara natural bertujuan untuk
melindungi seseorang dari substansi berbahaya
yang tertelan.
Namun perlu diperhatikan jika mual dan muntah
Vomiting
Nausea
menjadi kronis,
Autonomic
perlu diwaspadai
Retching adanya respon
Contraction
& forced
Contraction
patologis dari beberapa kondisi penyakit.
Symptoms expel of GI
ETIOLOGI

Gastrointestinal disorder

Chemical mechanism &


infectious cause

Central Nervous System

Vestibular

Unexplained
ETIOLOGI (LANJUTAN...)
ETIOLOGI (LANJUTAN...)
ETIOLOGI (LANJUTAN...)
PATOFISIOLOGI

Pain,
Anxiety)
PATOFISIOLOGI
FASE MUNTAH

Nausea

Retching

Vomiting
VOMITING REFLEX
VOMITING PATHWAY
VOMITING PATHWAY
OBAT ANTI MUAL & MUNTAH
OBAT ANTI MUAL & MUNTAH
(PREMEDIKASI KEMOTERAPI)
1ST LINE ANTIEMETIC

Metoclopramide as Prokinetic Antiemetic : by acting as an


agonist at a specific
subtype of serotonin receptor (5-HT4), it simultaneously
increases tone in the lower esophageal sphincter and increases
gastric motility, both of which
promote gastric emptying. These actions make it an attractive
antiemetic in patients with a history of gastroesophageal
reflux.
1ST LINE ANTIEMETIC (LANJUTAN...)
DOPAMINE ANTAGONISTS SIDE EFFECTS
Unfortunately, D2 antagonist ability to also block dopamine transmission
within the basal ganglia may result in so-called extrapyramidal
syndromes (EPSs) that include akathisia, parkinsonian symptoms, and
tardive dyskinesia.
Of these syndromes, akathisia is most common and presents as a
subjective feeling of restlessness leading to a compelling need to move.
Patients feel that they must get up and walk or continuously move about.
This behavior may be mistaken for agitation, and their distinction is critical
to avoid an inclination to further sedate the patient. Although
extrapyramidal symptoms are bizarre and generally frighten the patient
and practitioner alike, they are never fatal. Like Parkinsons disease, this
syndrome reflects not only a defect in dopaminergic transmission, but also
a relative excess of cholinergic activity within the basal ganglia. For this
reason, the more specific anticholinergic actions of diphenhydramine
are useful for countering acute episodes
Many antiemetic and psychotropic drugs that have dopaminergic and
cholinergic blocking activity have been implicated in producing a
prolonged Q-T interval, an electrocardiographic change that may trigger
1ST LINE ANTIEMETIC (LANJUTAN...)
2ND LINE ANTIEMETIC
DEXAMETHASONE AS ANTIEMETIC

Glucocorticoids such as dexamethasone are well-


established antiemetics for chemotherapy-induced as well
as postoperative nausea and vomiting.
How they produce this effect is unknown, but it is
speculated that they may suppress production of
inflammatory autacoids that may somehow potentiate
known vomiting pathways within the vomiting center.
A similar mechanism has been proposed to explain the
beneficial effects of nonsteroidal anti-inflammatory drugs
in nausea and vomiting induced by systemic irradiation.
Glucocorticoids have a slow onset of action, and their
benefit is limited to prophylactic regimens.
2ND LINE ANTIEMETIC (LANJUTAN...)
2ND LINE ANTIEMETIC
OTHER MEDICATIONS
OTHER MEDICATIONS (LANJUTAN...)
HAL YG PERLU DIPERHATIKAN
ASSESSMENT
PENGOBATAN ALTERNATIF
HAL-HAL YANG HARUS DIPERHATIKAN
HAL-HAL YANG HARUS DIPERHATIKAN...

1. Age Infant, child, adult, elderly?


Usia belia dan lansia paling berisiko mengalami dehidrasi
yang disebabkan muntah.
Muntah pada bayi < 1 thn saat minum susu dapat
disebabkan gangguan makan, infeksi, atau penyumbatan spt
pyloric stenosis (jarang)
Bedakan muntah dg regurgitasi
Regurgitasi biasanya terjadi pada bayi. Bila orang dewasa
yang mengalaminya dapat disebabkan penyakit pd esofagus
shg sulit menelan rujuk ke dokter
PYLORIC STENOSIS
HAL-HAL YANG HARUS DIPERHATIKAN...

2. Pregnancy
Biasanya terjadi pada bulan awal kehamilan
Terjadi di pagi hari.
Umumnya lebih sering pada kehamilan pertama
3. Duration
Pada dewasa, jika > 2 hari
Pada anak <2 tahun
Muntah kronis
Rujuk
Rujuk ke
ke
(kemungkinan peptic ulcer atau gastric carcinoma) dokter
dokter !!!
!!!
HAL-HAL YANG HARUS DIPERHATIKAN...

4.Associated symptoms
Infeksi?
Infeksi akut (gastroenteritis) sering menyebabkan muntah, yang terkadang juga disertai
diare.
Gastroenteritis pada anak2 sering disebabkan rotavirus
highly infectious sehingga biasanya mengenai >1 anak dalam sekeluarga.
Biasanya juga dapat disertai cold symptoms.
FIR: Makanan yang dimakan selama 2 hari sebelumnya.

DARAH?
Muntah + darah indikasi: penyakit serius rujuk ke dokter
Kemungkinan dapat disebabkan pendarahan dari peptic ulcer atau gastric carcinoma.
Terkadang trauma dari muntah dapat menyebabkan keluar sedikit darah.
HAL-HAL YANG HARUS DIPERHATIKAN...

4. Associated symptoms (lanjt..)


Bau?
Muntah yang berbau tinja (faecal smell) obstruksi GI Rujuk ke
dokter.

Mual dan muntah dapat disertai migrain.


Perhatikan apa ada RPD spt dizziness atau vertigo krn merupakan
petunjuk adanya penyt. telinga bagian dalam (cth: labyrinthitis atau
menieres disease).

Alcohol intake ?
Minum alcohol >> muntah (sering di pagi hari)
Hati2 dalam bertanya !
HAL-HAL YANG HARUS DIPERHATIKAN...

5. Medication
ES obat
cth: Aspirin & NSAIDs, Doxycycline, estrogen, steroid,
narcotic analgesic
Gejala toksisitas Digoxin ati2 pada lansia konseling??
Hati2 px yg muntah, yang menggunakan Digoxin atau
diuretik. Kenapa??
6. Previous history
Px dengan RPD mual/muntah kronis rujuk ke dokter
METOCLOPRAMIDE INFORMATION
Metoclopramide is a gastrointestinal stimulant that is commonly
used for gastroesophageal reflux related to reduced gastric tone
in both adults and children.
It also has been found to stimulate prolactin release by blocking
dopamine from inhibiting the production of prolactin, and so has
been used off-label to increase milk production. Clinical studies
have shown that metoclopramide can increase milk production
an average of 66 to 100 percent, and it has been used to help
increase milk production in North America for more than two
decades.
The effects of metoclopramide have been found to be dose-
related; the right amount is necessary for a good result.
Metoclopramide is transferred into human milk in an amount
that is substantially less (1-5 percent) than the dose which is
commonly prescribed to treat gastrointestinal distress in an
infant.
METOCLOPRAMIDE
SIDE EFFECT

One concern with metoclopramide is its ability to penetrate the blood-


brain barrier, which can result in central nervous system side-effects such
as depression and involuntary body movements (dystonia), especially with
longer term use.
Such side-effects are considered uncommon for non-breastfeeding uses,
but informal reports from lactation specialists and physicians suggest that
postpartum women may be more vulnerable, and one study recently
theorized that women in general may be more susceptible to such
negative effects.
Another case report raised concerns for combining metoclopramide with
the new generation SSRI (Selective Serotonin Reuptake Inhibitors) anti-
depressants.
Women who have a personal or family history of depression should avoid
using metoclopramide. The American Academy of Pediatrics considers it a
drug whose effect on nursing infants is unknown but may be of concern,
and pharmacology expert Tom Hale has rated it L2 (safer).(Hale uses a
five-point lactation rating system: L1- Safest; L2- Safer; L3)
MOTION SICKNESS
Motion sickness disebabkan konflik dari
pesan2 yang diterima di otak dari mata,GI
tract, dan vestibular system di telinga.
Gejala meliputi: mual muntah, pucat dan
keringat dingin.

nowledgement to : Anita Purnamayanti & Amelia Lorensia


MOTION SICKNESS

Epidemiology
Motion sickness is more common in women than
men.
It is uncommon in children under 2 years and
most common in children between 2 and 12,
reaching a peak at 12 years. Incidence reduces
thereafter and
After 21 declines significantly with age.
Women are more susceptible during menstruation
and pregnancy.
MOTION SICKNESS
Signs and symptoms
Muscarinic effects, including:
nausea
vomiting
increased salivation
general malaise
pallor
sweating
yawning
hyperventilation.
Gastric motility is also reduced and digestion
impaired.
MOTION SICKNESS
HAL2 YANG HARUS DIPERHATIKAN...
HAL2 YANG HARUS DIPERHATIKAN...
1. Age - Infant, child, adult
Umumnya terjadi pada anak kecil.
Bayi dan anak2 usia <2 tahun jarang
mengalaminya.
Makin bertambah usia makin kemungkinan
mengalaminya.
Perhatikan batas usia minimal dari OTC.

2. Previous history
pastikan anggota keluarga yg mana yg pernah
menderita mabuk perjalanan & siapa pasien yg
akan diobati saat ini
HAL2 YANG HARUS DIPERHATIKAN...

3. Mode of travel: car, bus, air, ferry, etc.


4. Length of journey
Perhatikan tipe dan lama perjalanan
5. Medication
Perhatikan obat yang sedang diminum.
Perhatikan obat untuk terapi motion sickness yang pernah
diminum dan bagaimana keefektifannya.
DIFFERENTIAL DIAGNOSIS

Nausea and vomiting occur in a wide range


of conditions, but the symptoms of motion
sickness are usually very clearly associated
with travel. Patients will nearly always ask
for advice on prevention rather than
treatment of current symptoms.
TERAPI MOTION SICKNESS

Terapi yang diberikan oleh farmasis bersifat


untuk pencegahan
Terapi bersifat antikolinergik:

Antikolinergik Cth : hyoscine

Antihistamin Cth : cinnarizine & promethazine

Tx. Alternatif ??
TERAPI MOTION SICKNESS

Sedating antihistamines and hyoscine are licensed for use


without prescription for prophylaxis and treatment of
motion sickness. They appear to be of more or less
equivalent efficacy.
They are effective for prevention, but use for treatment is
often unsuccessful as vomiting and gastric stasis prevent
or substantially reduce their absorption.
TERAPI MOTION SICKNESS
Cth : Hyoscine hydrobromide Antikolinergi
Dapat diberikan pada usia >3 tahun k
D.o.a. pendek (1-3 jam) shg cocok unt perjalanan
jarak pendek. Diminum 20 mnt sblm mulai perjalanan
ES : blurred vision, dry mouth, constipation & urinary
retention
KI: BPH & glaukoma
Hati2 terjadinya IO, karena px menggunakan obat lain
yang punya ef antikolinergik, spt:
tricyclic antidepressants (e.g. amitriptyline)
butyrophenones (e.g. haloperidol)
Phenothiazines (e.g. chlorpromazine)
Terapi Motion Sickness

Antihistamin
Cth : cinnarizine, meclozine & promethazine
ES : drowsiness (terutama: promethazine)
Meclozine & promethazine theoclate punya doa panjang untuk
perjalanan panjang. Diminum 1x/hari.
Cinnarizine & promethazine theoclate KI: usia >5 tahun
Meclozine dapat diberikan untuk usia >2 tahun
KI pada wanita hamil.
Terapi Motion Sickness
Terapi Motion Sickness

Tx
Alternatif....
Ginger (Sari Jahe)
Mekanisme tdk diketahui.
MORNING SICKNESS
DAFTAR PUSTAKA
1. Blenkinsopp, A., Paxton, P., Blenkinsopp, J. (2007) Symptoms in The
Pharmacy A Guide to the Management of Common Illness. 6th ed, Oxford :
Blackwell Publishing Ltd.
2. Nathan, A. (2008). Managing Symptoms in The Pharmacy, UK:
Pharmaceutical Press.
3. DiPiro, J., Talbert, R., Yee, G., Matzke, G., Wells, B., Michael, L. (2005)
Pharmacotherapy: A Pathophysiologic Approach. 6th ed, US: The McGraw-
Hill Companies.
4. Daniel E. Becker, DDS. Nausea, Vomiting, and Hiccups: A Review of
Mechanisms and Treatment. 2010
5. Case Management Guidelines: Nausea and Vomiting. Department of Health
and Human Services. Palliative Care. 2010.
6. Scorza Keith, et.al. Evaluation of Nausea and Vomiting. AFP. 2007.