farmakoterapi gangguan saraf psik aj

8/8/2019 Farmakoterapi Gangguan Saraf Psik Aj

1/19

FarmakologiFarmakologi ObatObatGangguanGangguan SarafSaraf

M.M. BakhriansyahBakhriansyah, H., dr.,, H., dr., M.KesM.Kes,,M.Med.EdM.Med.Ed

BagianBagian FarmakologiFarmakologi FK UNLAMFK UNLAMBanjarbaruBanjarbaru


2/19

StatusStatus EpilepticusEpilepticus

SE :SE :

Continues seizuresContinues seizuresoccuringoccuring 30 minutes30 minutes((epilepsiepilepsi foundation)foundation)

More than 30 minutesMore than 30 minutes

of continues seizuresof continues seizuresactivity or 2 or moreactivity or 2 or moresequential seizuressequential seizures

without full recovery ofwithout full recovery ofconsciousness betweenconsciousness betweenseizures (Dodson,seizures (Dodson,1993)1993)..
http://../My%20Videos/epilepsy%20.flvhttp://../My%20Videos/epilepsy%20.flvhttp://../My%20Videos/epilepsy%20.flvhttp://../My%20Videos/epilepsy%20.flvhttp://../My%20Videos/epilepsy%20.flvhttp://../My%20Videos/epilepsy%20.flvhttp://../My%20Videos/epilepsy%20.flvhttp://../My%20Videos/epilepsy%20.flvhttp://../My%20Videos/epilepsy%20.flvhttp://../My%20Videos/epilepsy%20.flvhttp://../My%20Videos/epilepsy%20.flvhttp://../My%20Videos/epilepsy%20.flvhttp://../My%20Videos/epilepsy%20.flvhttp://../My%20Videos/epilepsy%20.flvhttp://../My%20Videos/epilepsy%20.flvhttp://../My%20Videos/epilepsy%20.flvhttp://../My%20Videos/epilepsy%20.flvhttp://../My%20Videos/epilepsy%20.flvhttp://../My%20Videos/epilepsy%20.flvhttp://../My%20Videos/epilepsy%20.flvhttp://../My%20Videos/epilepsy%20.flvhttp://../My%20Videos/epilepsy%20.flvhttp://../My%20Videos/epilepsy%20.flvhttp://../My%20Videos/epilepsy%20.flvhttp://../My%20Videos/epilepsy%20.flvhttp://../My%20Videos/epilepsy%20.flvhttp://../My%20Videos/epilepsy%20.flvhttp://../My%20Videos/epilepsy%20.flvhttp://../My%20Videos/epilepsy%20.flvhttp://../My%20Videos/epilepsy%20.flvhttp://../My%20Videos/epilepsy%20.flvhttp://../My%20Videos/epilepsy%20.flvhttp://../My%20Videos/epilepsy%20.flvhttp://../My%20Videos/epilepsy%20.flvhttp://../My%20Videos/epilepsy%20.flvhttp://../My%20Videos/epilepsy%20.flvhttp://../My%20Videos/epilepsy%20.flvhttp://../My%20Videos/epilepsy%20.flvhttp://../My%20Videos/epilepsy%20.flv


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Systemic and primary brain changesSystemic and primary brain changes related torelated to

morbidity and mortality ratesmorbidity and mortality rates Decreasing GABA inhibition.Decreasing GABA inhibition.

Increasing blood pressure (early stage)Increasing blood pressure (early stage) decreasingdecreasing

Acidosis (+)Acidosis (+) Pulmonary edemaPulmonary edema

HyperthermiaHyperthermia

MildMild leukocytosisleukocytosis

GABAergicGABAergic mechanism failsmechanism fails


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Goal of therapy: to treat the epilepsy and toGoal of therapy: to treat the epilepsy and to

minimaliseminimalise the side effectsthe side effects

Principal therapy:Principal therapy:

MonotherapyMonotherapy is better thanis better than polypharmacypolypharmacy Dosage is increased until the therapeutic effect orDosage is increased until the therapeutic effect or

toxicity effect are met.toxicity effect are met.

PolypharmacyPolypharmacy is introduced whenis introduced when monotherapymonotherapydoes not workdoes not work

Avoiding the sudden withdrawalAvoiding the sudden withdrawal


5/19

Treatment flowchart for statusTreatment flowchart for status

epilepticusepilepticus


6/19

MedicationsMedications

BarbituratBenzodiazepin

Asam valproatGabapentin

Lamotrigin

FenitoinKarbamazepin

Asam valproatEtosuksimid

FenitoinKarbamazepin

GABA

Glutamate

Ca

Na

STATUS EPILEPTICUS


7/19

Parsial Petit mal Grand malAtonik,

Mioklonik

First line Karbamazepin

Fenitoin

Asam valproat

Etosuksimid

Asam valproat

Karbamazepin

Fenitoin

Fenobarbital

Asam valproat

Alternative Gabapentin*

Lamotrigin

Primidon

Fenobarbital

Klonazepam Primidon

Asam valproat

Lamotrigin

Klonazepam

Felbamat


8/19

Parkinson diseaseParkinson disease

A progressiveA progressive

neurodegenerativeneurodegenerativedisorder associateddisorder associatedwith loss ofwith loss ofdopaminergicdopaminergicnigrostriatalnigrostriatal neurons.neurons.

Distinctive features:Distinctive features: Resting tremor, rigidity,Resting tremor, rigidity,

bradikinetiabradikinetia, and, andpostural instabilitypostural instability
http://../My%20Videos/parkinsonism%20.flvhttp://../My%20Videos/parkinsonism%20.flvhttp://../My%20Videos/parkinsonism%20.flvhttp://../My%20Videos/parkinsonism%20.flvhttp://../My%20Videos/parkinsonism%20.flvhttp://../My%20Videos/parkinsonism%20.flvhttp://../My%20Videos/parkinsonism%20.flvhttp://../My%20Videos/parkinsonism%20.flvhttp://../My%20Videos/parkinsonism%20.flvhttp://../My%20Videos/parkinsonism%20.flvhttp://../My%20Videos/parkinsonism%20.flvhttp://../My%20Videos/parkinsonism%20.flvhttp://../My%20Videos/parkinsonism%20.flvhttp://../My%20Videos/parkinsonism%20.flvhttp://../My%20Videos/parkinsonism%20.flvhttp://../My%20Videos/parkinsonism%20.flvhttp://../My%20Videos/parkinsonism%20.flvhttp://../My%20Videos/parkinsonism%20.flvhttp://../My%20Videos/parkinsonism%20.flvhttp://../My%20Videos/parkinsonism%20.flvhttp://../My%20Videos/parkinsonism%20.flvhttp://../My%20Videos/parkinsonism%20.flvhttp://../My%20Videos/parkinsonism%20.flvhttp://../My%20Videos/parkinsonism%20.flvhttp://../My%20Videos/parkinsonism%20.flvhttp://../My%20Videos/parkinsonism%20.flvhttp://../My%20Videos/parkinsonism%20.flvhttp://../My%20Videos/parkinsonism%20.flvhttp://../My%20Videos/parkinsonism%20.flvhttp://../My%20Videos/parkinsonism%20.flvhttp://../My%20Videos/parkinsonism%20.flv


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Principle therapyPrinciple therapy

Increasing the synthesisIncreasing the synthesisand release of dopamineand release of dopamine(L(L--dopa+karbidopadopa+karbidopa,,

amantadinamantadin)) InhibitingInhibiting dopamindopamin

metabolismmetabolism

((selegilin/deprenilselegilin/deprenil

))

Activating dopamineActivating dopaminereceptor (receptor (bromocriptinebromocriptine,,pergolidepergolide))

BlockingBlocking muscarinicmuscarinic//cholinergic receptorcholinergic receptor((trihexiphenidiletrihexiphenidile,,

benzathropinebenzathropine,,diphenhidraminediphenhidramine))

To facilitate action of dopaminergic To suppress action of cholinergic


10/19

Anti cholinergicAmantadine

L-dopa+karbidopa

Dopamine agonists drugsMAO B inhibitors

Protocol of therapyProtocol of therapy


11/19

LL--dovadova ((levodopalevodopa))

Dopamine precursorDopamine precursor

inactive forminactive form

Activated byActivated by

decarboxilasedecarboxilase enzyme;enzyme; BrainBrain

Lever & kidneysLever & kidneys cancan

not pass through BBBnot pass through BBB bioavailabilitybioavailability countered bycountered bykarbidopa/benserazidekarbidopa/benserazide..

On/off phenomenonOn/off phenomenon(+) after 3(+) after 3--5 years5 yearsapplicationapplication mechanism ???mechanism ???Desensitization ofDesensitization ofdopamine receptordopamine receptor

Not a first line therapyNot a first line therapy


12/19

Headache/Headache/CephalgiaCephalgia

MigraineMigraine

Tension headacheTension headache Cluster headacheCluster headache


13/19

MigraineMigraine

Mechanism:Mechanism: GeneticGenetic

VascularVascular NeuralNeural

Neurotransmitter serotoninNeurotransmitter serotonin

Neurotransmitter dopamineNeurotransmitter dopamine Activation ofActivation ofsymphaticsymphatic

nervous systemnervous system

NSAIDsNSAIDs + caffeine+ caffeine((asetaminophenasetaminophen, acetic, acetic

salicilicsalicilic acid, etc)acid, etc) Serotonin receptorSerotonin receptor

agonists (ergotamine,agonists (ergotamine,

dihidroergotaminedihidroergotamine,,sumatriptanesumatriptane,,naratriptanenaratriptane,, rizatriptanerizatriptane,,zolmatriptanezolmatriptane))

Dopamine antagonistDopamine antagonist((metochlopramidemetochlopramide, CPZ,, CPZ,proCPZproCPZ))


14/19

Protocol of therapyProtocol of therapy

Serotonin receptor agonists (SC/IM/IV), orDopamine receptor antagonist (IM/IV)

Serotonin receptor agonists (oral/nasal/SC), or

Dopamine receptor antagonist (oral)

NSAIDs, orSerotonin receptor agonist (oral)

Severe migraine

Moderate migraine

Mild migraine


15/19

NSAIDsNSAIDs

SE:SE: dispepsiadispepsia

Stimulator of serotonin (5Stimulator of serotonin (5--HTHT11) receptors:) receptors:

1.1. ergotamine,ergotamine, dihidroergotaminedihidroergotamine

Non selective 5Non selective 5--HTHT11 receptor agonistreceptor agonist

Contra indication: CHD, pregnancy, peripheralContra indication: CHD, pregnancy, peripheralblood vessel constriction, level and kidneyblood vessel constriction, level and kidney

disorders.disorders.


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Dopamine antagonistsDopamine antagonists

Adjuvant therapyAdjuvant therapy

Increasing gut motilityIncreasing gut motilityAlso could treat: Nausea &Also could treat: Nausea &

vomitvomit

PreventionPrevention

3 times per month3 times per month

Beta blockers (Beta blockers (propanololpropanolol,,timololtimolol))

Anti convulsive agentsAnti convulsive agents((valproicvalproic acid)acid)

MAO inhibitorsMAO inhibitors((phenelzinephenelzine,,isokarbosazideisokarbosazide))

SerotonergicSerotonergic agentsagents((metisergidemetisergide,,siproheptadinesiproheptadine))

Ca antagonist (Ca antagonist (verapamilverapamil))


17/19

TensionTension headacheheadache

Usually bilateralUsually bilateral

Usually following anxiety or depressionUsually following anxiety or depressionTherapy:Therapy:

NSAIDsNSAIDs ++ coffeinecoffeine Muscle relaxant agentsMuscle relaxant agents

Prevention:Prevention: amitriptilineamitriptiline a.na.n


18/19

Cluster headacheCluster headache

PeriorbitalPeriorbital painpain

(temporal bone pain)(temporal bone pain) Some signs andSome signs and

symptoms related tosymptoms related to

eyeseyesMechanism: ??? MayMechanism: ??? May

bebe serotonergicserotonergic

transmission disordertransmission disorder

Therapy:Therapy:

PrednisonPrednison

LithiumLithium

MetisergidMetisergid

ErgotamineErgotamine NaNa valproicvalproic

VerapamilVerapamil


19/19

farmakoterapi gangguan saraf psik aj

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