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PI SFARMAKOTERA
IROSIS HEPATIK
Budi Suprapti
Departemen Farmasi Klinis
Fakultas Farmasi UniversitasAirlangga
Suraa!a
1
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EPIDEMIO"O#I
WHO 2011 : Indonesia - 45.000 kasus
Asia tenggara : Kematian 280.000/th
0! - kematian g"o#a"
$irosis He%atik &5! %asien ra'at ina% I()
4*&4! %asien ra'at ina% + %en,akit
"ier
tio"ogi-H 2!
H-H) + 15! 3$ease& 2008
)unia : He%atitis + 2 i",ar 240
He%atitis - 1*0 6uta
kematian 1&5 6uta/tahun
6uta H kronis
Indonesia: He%atitis - 2 6uta
He%atitis + 2 6uta
7iskesdas 200*:
(emeriksaan #iomedis + &4!
(O$I9I( HsAg
3Kemenkes 7I& 2012 2
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SIROSIS HEPATIK
3
. Chirose-warna orange-kuning orange hati / liver
. Kerusakan difuse irreversibel dari liver
dikarakterisasi oleh hilangnya architecture
liver normal secara lengkap
diganti oleh fibrosis yang ekstensif dengan
nodul-2 regenerasi parenchim
!ipiro" 2#11$
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!ipiro" 2#11%
9IOO;I $I7O$I$ H(A9IK
Konsumsi a"koho" kronik
He%atitis ira" kronis 3ti%e & & )
(en,akit meta#o"ik "ier:
(en,akit hemokromatosis
(en,akit Wi"son
)eona"koho"ik steatohe%atitis
3?att, "ier
,sti@ H& meti"do%a& amiodaron& metotreat&
tamoi?en& retino"& (9B& didanosin
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FU$#SI "I%ER & $ORMA"
&anong" 2#1#$'
-(nergi- interkonversi substrat
)etabolisme K*" prot." lipid- +intesis-sekresi prot.plasma"clotting factor
- +olubilisasi" transpor" storage ,
. +irkulasi empedu
. ipoprotein-transpor lipid
. itamin" glycogen
- rotektif 0 klirens. agositosis
. )etabolisme ammonia
. +intesis glutathion
. )etabolisme obat" hormon
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orotora" 2##3$
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orotora" 2##3$
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Features '( )lini*all! imp'rtant +epatitis viruses ,Dipir'-
Hepatocellular Ca No Yes Yes Yes No )chee" 2##$
Hepatitis A Hepatitis B Hepatitis C Hepatitis D Hepatitis E
Virus HAV HBV HCV HDV HEV
Genome ssRNA dsDNA ssRNA ssRNA ssRNA
Incubation 14-4 4!-1"! #-"4 4!-1"! 14-$!% da&s '
(ransmission )ecal-oral *arenteral *arenteral *arenteral )ecal-
oral
+e,ual +e,ual +e,ual%'
*erinatal *erinatal *erinatal
.ucous .ucous
membrane membrane
+erolo/ic mar0ers
Anti/ens HAVA/ HBsA/ HCVAA/
HDVA/ NA
HBcA/
HBeA/
Abtibodies Anti-HAV Anti-HBs Anti-HCV Anti-
HDV NA
Anti-HBc
Anti2HBe
Viral mar0ers HAVRNA HBV DNA HCVRNA HDVRNA NADNA pol&meraseHepatocellular Ca No Yes Yes Yes No )chee"
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A*tive
, *'ntinuing
)ellular
)chee" 2##$Deat+
Re*'ver!
, .it+ n'rmal
Appearing/
Regeneratedliver -
Hepat'
*ar*in'ma
)irr+'sis
)+r'ni*
Hepatitis
$e*r'sis -
Fulminant
Hepatitis
, massive
ne*r'sis -
+r'ni*
rsistentHepatitis
, )arrier state -
stati*
Hepatitis
A*ute
Hepatitis
)+'leSu*lini*al
Hepatitis
)
P
e
,
In(e*ti'n
Hepatitis %ruses
& HA%
& HB%
& H)%
& Delta
& HE%
Clincal syndromes associated with viral hepatitis &anong$
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RESPO$S IMMU$ SE"U"AR TERHADAP %IRUS HEPATITIS B
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9A>)A )A> ;CAA
HA:
H
sangat #erariasi& tidak
)emam
>,eri sendi. otot
ke"e"ahan
anoreksia
s%esi?ik
ua"& muntah kem#ung
;e6a"a kuning& gata"
AK se%erti teh
A %u@atH : D 0! asim%tomatik
Kemenkes" 2#12
12
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1'
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1
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14
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Tipe dis(ungsi liver
. Dis(ungsi +epat'sit&l'ulus0 Dis(ungsi sirkulasi ,HT p'rtal-
15
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orotora" 2##3$16
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2#
"I%ER FAI"URE & )OMP"I)ATIO$
7*%0 0 *C83-*ypo- 9lbuminemia
ortal*ypertension
Cholestasis
at 9bs.
9scites (:udativeenteropathy
arices itamin Kdeficiency ;rea
*yperaldo
+teronism
Clotting factors
*ypokalemia &< =leeding
9romatic 99
>enal 7*%0
roduction
(nteric 99
=reak down
*yper 9mmonemia alse 7eurotransmiters
9lkalosis *ypervent. (ncephalopathy
+ilbernagi" 2###$
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)chee" 2##$21
)anifestasi klinik sirosis
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Mani(etasi & data la'rat'rium
Hip'alumin
Pr't+r'min time 1
Tr'm'sit'peni
Alkali ('s(atase 1
Pening+katanAST/
A"T/ ##T
!ipiro" 2#11$
22
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anagemen tera%i
23
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PE$DEKATA$ TERAPI
Identi(ikasi&eliminasi pen!ea
sir'sis
Pr'(ilaksis 2 T3 vari*eal leedingAsites 4
T3
SBP
HE
M'nit'r
(armak'l'gi2para*entesis
+epat'renal s!ndr'me
!ipiro" 2#11$
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HT p'rtal&vari*eal leeding
50
60
70
*ega+ perdara+an 4 pr'(ilkasis
T3 a*ute vari*eal +em'rr+age
)ega+ releeding&pr'(ilaksis sekunder
NOTE ,arises ? '@ pasien sirosis 1 th
25@ pasien sirosis 3 tahun 9cute variceal bleeding terAadi pada 2' ? %#@ pasien
dengan tingkat kematian 3#@>ebleeding dalam 1# hari < , '#@
!ipiro" 2#11" 9CC
2#13$
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9d. 1)encegah perdarahan variceal
0!ipiro" 2#11" 9CC
2#13$
0 Me 8 p'rtal in(l'. 9 tekanan p'rtal
0 β
Adrenergik l'*ker4 8HR 6:; ,::&
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Ad060 T? A)UTE %ARI)EA" B"EEDI$#
0 Resusitasi *airan *ukup @ stailisasi +em'dinamika
*airan kristal'id/ FFP/ platelet/ PR)
0 Kendalikan leeding
O*tre'tide := m*g iv 'lus := m*g2am ,7&: +ari-
S'mat'statin 6:= m*g iv 'lus
6:=&:== m*g2+ari
,7&: +ari-
0 Antii'tika
0 Kuin'l'n
0 )e(tria3'n
0 PPI/ H6RA/ Su*ral(at
!ipiro" 2#11" 9CC 2#13$
Hindari peningkatan v'l0intravask0 erlei+an
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Ad07 )ega+ releeding&pr'(ilaksis sekunder
!ipiro" 2#11" 9CC
2#13$
0β Bl'*ker 4 l'ng a*ting
0 Pr'pan'l'l 7 3 6= mg
$ad'l'l 5 3 6= 4 >= mg
"akukan titrasi mingguan di*apai HR ::&
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*(9
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Hepati* en*+ep+al'pat! ,HE-
!ipiro" 2#11" 9CC 2#13$
Terapi pat'genesis
Batasi pr'tein intake 5&5/: g2kg +ari sumer naati 4stl+ HE teratasi
"aktul'sa & Me 8 amm'nia dara+
A.ali 7=& dd 5:&7= ml
angka panang
$e'misin 7&< g2+ari d'sis teragi 7&> 3
Antag'nis resept'r en'diaepin G Flumaenil
Supplemen Jin*
In(us Asam Amin' )aang Falseneur'transmiter