SIMULTANEOUS ANALYTICAL METHOD DEVELOPMENT OF 6-MERCAPTO¬PURINE AND 6-METHYLMERCAPTOPURINE IN PLASMA BY HIGH PERFOR¬MANCE LIQUID CHROMATOGRAPHY-PHOTODIODE ARRAY

Objective: 6-Mercaptopurin is antineoplastic drug that is included in antimetabolite group and is used in acute lymphoblastic leukemia medication. 6-Mercaptopurin is inactive pro-drug that will be metabolized into metabolites. One of its metabolites is 6-methylmercaptopurine. This study is aimed to optimize the analytical conditions and perform validation for the analysis of 6-mercaptopurine and 6-methylmercaptopurine in plasma. Method: Separation was performed using Waters 2996 HPLC, C18 SunfireTM column (5μm, 250 x 4.6 mm) with the mobile phase containing water-methanol-acetonitrile with gradient elution, and detected at 303 nm. 5-Fluorouracil was used as internal standard. Plasma extraction was done by liquid-liquid extraction using dichloromethane. Result: The method was linear at concentration range of 2.0 – 200.0 ng/mL with r > 0.9991 for 6-mercaptopurine and 20 – 2000 ng/mL with r > 0.9993 for 6-methylmercaptopurine. Accuracy and precision within-run and between-run fulfill the acceptance criteria with % RE and relative standard deviation (% RSD) ≤ 20% (LLOQ) and ≤ 15% (QC samples). 6-Mercaptopurine and 6-methylmercaptopurine was stable in plasma at least for 21 days when stored at -20ºC. Conclusion: The bio-analytical method was sensitive, selective and all the parameters fulfilled the acceptance criteria of the EMA Bio-analytical Method Validation Guideline, 2011

SIMULTANEOUS ANALYTICAL METHOD DEVELOPMENT OF 6-MERCAPTOPURINE AND 6-METHYLMERCAPTOPURINE IN DRIED BLOOD SPOT USING ULTRA PERFORMANCE LIQUID CHROMATOGRAPHY TANDEM MASS SPECTROMETRY

Objective: 6-mercaptopurine (6-MP) is a chemotherapeutic agent in the antimetabolite class. It has to go through the metabolic pathway to form6-methyl MP (6-MMP). This study aimed to obtain an optimum and validated method for the analysis of 6-MP and 6-MMP in dried blood spot (DBS)samples simultaneously and to evaluate the potential for future drug concentration monitoring in DBS samples.Methods: The quality control and calibration curves were made by spotting 40 μL blood on DBS paper and dried for 3 hrs. DBS papers were cut with adiameter of 8 mm and extracted with acetonitrile-methanol (1:3) containing internal standard 5-fluorouracil (5-FU). Separation was performed withwaters acquity ultra performance liquid chromatography BEH C18 column of 1.7 μm (2.1×100 mm) with a mobile phase consisting of 0.1% formicacid in water 0.1% formic acid in acetonitrile with gradient elution and a flow rate of 0.2 mL/minute. Mass detection was performed using WatersXevo TQD with positive electrospray ionization (ESI) for 6-MP and 6-MMP and negative ESI for 5-FU in the multiple reaction monitoring mode.Results: The detection rates of 6-MP, 6-MMP, and 5-FU were 153.09>119.09, 167.17>126.03, and 129.09>42.05, respectively. This method was linearwith the range at 26-1000 ng/mL for 6-MP and 13-500 ng/mL for 6-MMP with consecutive r≥0.998 and ≥0.999, respectively. The % relative errorvalue and % relative standard deviation for accuracy and precision of intraday and interday were not more than 15% and not more than 20% at thelower limit of quantification concentration, respectively.Conclusions: This method fulfilled the requirements of selectivity, linearity, carry over, and matrix effects referring to the European Medicines Agencyguidelines

Perbandingan Efikasi Beberapa Kombinasi Antiretroviral Pada Pasien Hiv/aids Ditinjau Dari Kenaikan Jumlah Cd4 Rata-rata (Analisis Data Rekam Medis Di Rsk Dharmais Jakarta Tahun 2005 – 2006)

Dharmais Cancer Hospital is one of 237 hospital appointed by the government of Indonesia to give treatment, support and ARV therapy for HIV/AIDS patients. Ev-ery year, there is a significant increasing number of HIV/AIDS patients in DharmaisCancer Hospital, therefore successfully of therapy is needed to be carried out regularly for the optimum result to the patients. One of methods to evaluating therapy is by reviewing efficacy of ARV combinations toward escalation of immunity respond (es-calation of CD4). The ARV combinations give a good efficacy if increasing CD4 > 50 cell/mm3. The objective of this study was to know the efficacy of four ARV combina-tion (each type consists of two Nucleosides Reverse Transcriptase Inhibitor and one Non-Nucleosides Reverse Transcriptase Inhibitor) base on increasing CD4 mean HIV/AIDS patients after 6 – 12 months treatment in Dharmais Cancer Hospital from 2005 – 2006, and to compare the efficacy of four ARV combinations. The four ARVcombinations are combination I (Lamivudin + Zidovudin + Efavirenz), combina-tions II (Lamivudin + Zidovudin + Nevirapin), combination III (Lamivudin + Stavudin + Efavirenz), and combination IV (Lamivudin + Stavudin + Nevirapin).This study was analytical, cross-sectional design. Samples for this study were taken by total sampling using all data of HIV/AIDS patients in Dharmais Cancer Hospital from the year 2005 – 2006. The inclusion criteria were patients of fifteen years of age or more, baseline count CD4  < 200 cell/mm3, received ARV treatment for 6 – 12 months, received treatment of either one of the four ARV combination, and had dataof CD4 from laboratory result before and after the treatment. Data were taken from patients’ medical record and analyzed with ANOVA-test. The result of this study from 151 patients showed that all the four combinations gave good efficacy based on the increasing CD4 mean. There was a significant difference increasing CD4 mean to HIV/AIDS patients between those received ARV combination II and those received ARV combination III (p value = 0,032). And there was not a significant difference for the other combinations. This study was from the four ARV combinations gave two the best efficacy are combination II and combination III

ANALYSIS OF 6-MERCAPTOPURINE AND 6-METHYLMERCAPTOPURINE IN DRIED BLOOD SPOTS USING LIQUID CHROMATOGRAPHY-TANDEM MASS SPECTROMETRY AND ITS APPLICATION IN CHILDHOOD ACUTE LYMPHOBLASTIC LEUKEMIA PATIENTS

Objective: To analyze and validate 6-mercaptopurine (6-MP) and 6-methylmercaptopurine (6-MMP) in dried blood spots (DBS) using liquid chromatography-tandem mass spectrometry (LC/MS-MS). Methods: Bio-sampling dried blood spot with DBS-CAMAG® paper diameter of 8 mm and extracted with acetonitrile-methanol (1:3) containing internal standard 5-fluorouracil (5-FU). Separation was performed with C18 column Acquity® 1.7 μm (2.1 mm × 100 mm), with a mobile phase mixture of 0.1% formic acid in water 0.1% formic acid in acetonitrile with gradient elution and flow rate 0.2 ml/min. Mass detection was Waters Xevo TQD with positive electrospray ionization (ESI) for 6-MP, 6-MMP and negative ESI for 5-FU in multiple reaction monitoring modes. The ions of 6-MP was detected at m/z 153.09->119.09, 6-MMP at m/z 167.17->126.03, and 5-FU at m/z 129.15->42.05. Results: This method fulfill the requirements of selectivity, linearity, lower limit of quantification, accuracy, precision, carry-over, matrix effects, and stability which refers to the european medicines agency (EMEA) guidelines. The linearity of 0.99 was 26-1000 ng/mL for 6-MP and 6-MMP, respectively. The validated method was applied to two childhood ALL maintenance phase. Retrieved 6-MP levels of 10.37 pmol/8×108 erythrocytes, respectively. The levels of 6-MMP gained 16.59 pmol/8×108 erythrocytes, respectively. Conclusion: The developed LC/MS-MS method is valid to analysis 6-MP and 6-MMP in DBS simultaneous in vitro according to EMEA guidelines. The method was successfully applied to authentic capillary blood samples from two childhood patients with ALL in the maintenance phase. Keywords: 6-mercaptopurine, 6-methylmercaptopurine, Dried blood spots, Acute lymphoblastic leukemia

PERBANDINGAN EFIKASI BEBERAPA KOMBINASI ANTIRETROVIRAL PADA PASIEN HIV/AIDS DITINJAU DARI KENAIKAN JUMLAH CD4 RATA-RATA (ANALISIS DATA REKAM MEDIS DI RSK DHARMAIS JAKARTA TAHUN 2005 – 2006)

Dharmais Cancer Hospital is one of 237 hospital appointed by the government of Indonesia to give treatment, support and ARV therapy for HIV/AIDS patients. Ev-ery year, there is a significant increasing number of HIV/AIDS patients in DharmaisCancer Hospital, therefore successfully of therapy is needed to be carried out regularly for the optimum result to the patients. One of methods to evaluating therapy is by reviewing efficacy of ARV combinations toward escalation of immunity respond (es-calation of CD4). The ARV combinations give a good efficacy if increasing CD4 > 50 cell/mm3. The objective of this study was to know the efficacy of four ARV combina-tion (each type consists of two Nucleosides Reverse Transcriptase Inhibitor and one Non-Nucleosides Reverse Transcriptase Inhibitor) base on increasing CD4 mean HIV/AIDS patients after 6 – 12 months treatment in Dharmais Cancer Hospital from 2005 – 2006, and to compare the efficacy of four ARV combinations. The four ARVcombinations are combination I (Lamivudin + Zidovudin + Efavirenz), combina-tions II (Lamivudin + Zidovudin + Nevirapin), combination III (Lamivudin + Stavudin + Efavirenz), and combination IV (Lamivudin + Stavudin + Nevirapin).This study was analytical, cross-sectional design. Samples for this study were taken by total sampling using all data of HIV/AIDS patients in Dharmais Cancer Hospital from the year 2005 – 2006. The inclusion criteria were patients of fifteen years of age or more, baseline count CD4  < 200 cell/mm3, received ARV treatment for 6 – 12 months, received treatment of either one of the four ARV combination, and had dataof CD4 from laboratory result before and after the treatment. Data were taken from patients’ medical record and analyzed with ANOVA-test. The result of this study from 151 patients showed that all the four combinations gave good efficacy based on the increasing CD4 mean. There was a significant difference increasing CD4 mean to HIV/AIDS patients between those received ARV combination II and those received ARV combination III (p value = 0,032). And there was not a significant difference for the other combinations. This study was from the four ARV combinations gave two the best efficacy are combination II and combination III.Key words : Dharmais Cancer Hospital, HIV/AIDS patients, ARV combinations, efficacy ARV combination, increasing CD4

ANALYSIS OF 4-HYDROXYCYCLOPHOSPHAMIDE IN CANCER PATIENTS PLASMA FOR THERAPEUTIC DRUG MONITORING OF CYCLOPHOSPHAMIDE

Objective: To quantify 4-hydroxycyclophosphamide in cancer patients' plasma for therapeutic drug monitoring of cyclophosphamide.Methods: The blood was collected at 0.5 and 1 h after administration of chemotherapy. Prior to analysis, 4-OHCP in plasma was derivatized with semicarbazide HCl, then was extracted using 4 ml ethyl acetate and finally was determined by Ultra High-Performance Liquid Chromatography–tandem mass spectrometry. Chromatographic separation was conducted using waters acquity BEH C18 column (1.7 μm; 50 mm x 2.1 mm). The mobile phase consisted of formic acid 0.1% and methanol (50: 50, v/v), column temperature 30 °C and flow rate of 0.3 ml/min. Mass detection was performed on waters xevo TQD equipped with an electrospray ionization (ESI) source at positive ion mode in the multiple reaction monitoring (MRM). Cyclophosphamide was detected at m/z 260.968>139.978, 4-hydroxycyclophosphamide-semicarbazide at m/z 338.011>224.97, and hexamethylphosphoramide as internal standard at m/z 180.17>92.08.Results: The method was linear in the range of 5–1000 ng/ml for cyclophosphamide and also for 4-hydroxycyclophosphamide. The results showed that the level of 4-OHCP in 39 cancer patients was in the range of 5.02 ng/ml to 832.44 ng/ml.Conclusion: 4-hydroxycyclophosphamide was detected on 39 patient samples with the lowest level of 5.40ng/ml and the highest level was 832.44 ng/ml. This can be a parameter that the regiment of cyclophosphamide was effective

SIMULTANEOUS QUANTIFICATION OF TAMOXIFEN AND 4-HYDROXY-N-DESMETHYLTAMOXIFEN LEVELS IN HUMAN PLASMA BY LIQUID CHROMATOGRAPHY-TANDEM MASS SPECTROMETRY: DEVELOPMENT AND APPLICATION IN BREAST CANCER PATIENTS

Objective: This study was aimed to develop a highly sensitive and selective liquid chromatography-tandem mass spectrometry (LC-MS/MS) methodfor the simultaneous quantification of tamoxifen, endoxifen, and clomiphene (internal standard) levels in human plasma.Methods: Plasma samples from 40 patients with breast cancer were prepared through liquid–liquid extraction in ethyl acetate, and chromatographicseparation was performed on an Acquity UPLC BEH C18 column (1.7 μm, 2.1 mm×100 mm). The sample was eluted within 6.50 min at a flow rate of0.200 ml/min under a gradient of 0.2% formic acid and acetonitrile. The analytes were then quantified through triple quadrupole MS with electrosprayionization in the positive ion mode and multiple reaction monitoring.Results: The method was successfully used to quantify the plasma levels of tamoxifen and endoxifen, yielding respective measurement rangesof 42.19–249.23 ng/ml and 1.52–26.62 ng/ml. Overall, this detection method was sensitive, with lower limits of quantitation of 0.625 ng/ml fortamoxifen and 0.125 ng/ml for endoxifen. In addition, this method was precise and accurate, with a between-run variation range of 5.19–12.38% and%diff range of −10.82%–+13.10%.Conclusion: This method demonstrated that approximately 80% of patients had plasma levels of endoxifen exceeding the expected clinical threshold(5.9 ng/ml). This rapid and simple method could be used to monitor tamoxifen metabolism and adjust doses as needed to achieve maximumeffectiveness

EVALUASI TOKSISITAS HEMATOLOGI AKIBAT PENGGUNAAN 6-MERKAPTOPURIN DALAM FASE PEMELIHARAAN PADA PASIEN PEDIATRI KANKER LEUKIMIA LIMFOBLASTIK AKUT DI RS KANKER DHARMAIS JAKARTA

Merkaptopurin merupakan obat kemoterapi yang digunakan pada fase konsolidasi dan pemeliharaan pada pasien pediatri kanker leukimia limfoblastik akut (LLA). Merkaptopurin diduga memiliki hubungan erat dengan terjadinya toksisitas pada hematologi. Penelitian ini bertujuan untuk mengetahui karatekristik pasien, angka kejadian, derajat keparahan dan penatalaksanaan toksisitas serta faktor risiko yang mempengaruhi  terjadinya  toksisitas  hematologi  penggunaan  6-MP  dalam  fase pemeliharaan pada pasien pediatri kanker LLA di RS Kanker Dharmais Jakarta. Penelitian  ini  dilakukan  dengan  desain  observasional  cross  sectional  dengan mengambil  data  pasien  secara  retrokspetif  dan  prospektif, dengan  subyek penelitian adalah pasien  kanker LLA anak yang berobat di RS Kanker Dharmais Jakarta  dari  tahun 2013 sampai dengan  periode  Maret-April  2014  yang  sedang dalam  fase  pemeliharaan.  Subyek  yang  memenuhi  kriteria  inklusi  adalah 23 pasien.  Pengumpulan  data dilakukan  dengan  melihat  rekam medik  untuk mendapatkan  data  identitas  pasien  dan  data  hematologi.  Hasil  penelitian menunjukkan bahwa  pasien  laki-laki  lebih  banyak  daripada  pasien  perempuan, dengan  usia  paling  banyak  berusia <  10  tahun,  dan  berstatus  gizi  normal  serta paling banyak  dengan  klasifikasi  LLA resiko  tinggi.  Angka  kejadian  toksisitas hematologi anemia paling banyak terjadi sebesar 95,66%. Derajat keparahan pada toksisitas  hematologi  paling  banyak terjadi  pada derajat  1.  Berdasarkan  faktorfaktor yang mempengaruhi terjadinya toksisitas diperoleh bahwa klasifikasi LLA berpengaruh  terhadap terjadinya  leukopenia  [RR=0,289;  interval  kepercayaan 95%:  0,079-1,051].  Penatalaksanaan toksisitas  dilakukan  jika  pasien mengalami anemia dan trombositopenia

Evaluation of Antibiotic Use Among Sepsis Patients in an Intensive Care Unit: A cross-sectional study at a referral hospital in Indonesia

Objectives: This study aimed to evaluate the appropriateness of antibiotic use and factors associated with outcomes among sepsis patients in an ntensive care unit (ICU). Methods: This cross-sectional study was carried out from February to May 2017 and included all adult patients with sepsis or septic shock admitted to the ICU of Dharmais Cancer Hospital, Jakarta, Indonesia. Data were collected from the patients’ medical records. Results: A total of 60 patients with sepsis or septic shock were admitted to the ICU during the study period. The most common source of infection was hospital-acquired pneumonia (61.7%) and the majority had two or more comorbidities (93.3%). There were 115 antibiotic regimens prescribed. Overall, 33.3% of patients were prescribed inappropriate types of antibiotics and 51.7% were given an inappropriate dosage. The mortality rate was 68.3%. There was a statistically significant association between patient outcome and inappropriate doses of antibiotics (P = 0.034), although not inappropriate types of antibiotics (P = 0.050). A multivariate analysis indicated that the main factors influencing patient outcome were septic shock and the presence of at least two comorbidities (P <0.050 each). Conclusion: Inappropriate doses of antibiotics, a diagnosis of septic shock and the presence of at least two comorbidities were found to significantly increase the mortality rate of sepsis patients admitted to an ICU in Indonesia. Keywords: Drug Prescription, trends; Antibiotics; Sepsis; Septic Shock; Intensive Care Units; Indonesia

EVALUASI PENGGUNAAN ANTIBIOTIKA PADA PASIEN PEDIATRI LEUKIMIA LIMFOBLASTIK AKUT DENGAN FEBRILE NEUTROPENIA SELAMA PEMBERIAN KEMOTERAPIDI RUMAH SAKIT KANKER DHARMAIS JAKARTA

Pemilihan  terapi  antibiotika  harus  berdasarkan  hasil  kultur,  pola  resistensi  serta guideline  yang  ada  karena  mikroorganisme  dan  sensitivitasnya  terhadap antibiotika  senantiasa  berubah.  Penelitian  ini  bertujuan  untuk mengevaluasi penggunaan  antibiotika  pada  pasien  pediatri  dengan  leukimia  limfoblastik  akut yang  mengalami  febrile  neutropenia  selama  pemberian  kemoterapi  kanker  di RSKD  Jakarta.  Penelitian  ini  merupakan  penelitian  non-eksperimental  dengan pengambilan data secara retrospektif dan prospektif di periode bulan  Maret -April 2014.  Data  diambil  dari  rekam  medik  pasien  kemudian  dianalisis  dengan dekskriptif.  Subyek  yang  memenuhi  kriteria  inklusi  adalah  pasien  pediatri  ≤  18 tahun  yang  mengalami  febrile  neutropenia  yang  mendapat kemoterapidan Absolute Neutrophile Count(ANC) &lt;  1500 sel/mm3 Suhu oral ≥ 38,3 °C atau 2-3x terukurnya  suhu  ≥  38°C  selama  lebih  dari  1  jam.  Pengumpulan  data  dilakukan dengan  melakukan  pencatatan  pada   form  pengambilan  data  yang  diambil  dari mediacal record.  Pada penelitian ini terdapat 25 episode pasien pediatri dengan febrile neutropenia  yang sesuai dengan kriteria inklusi. Tingkat keparahan  febrile neutropenia  yang  terjadi  sebanyak  (72  %)  severe,  (24  %)  moderate  dan  (4  %) mild. Penggunaan antibiotik paling banyak cefotaxime (56 %), ceftazidime (28 %) dan berdasarkan hasil kultur (28 %). Keberhasilan terapi antibiotik empirik yang digunakan  (88   %)  dan  kegagalan  terapi  sebesar  (12  %).  Pemilihan  terapi antibiotika  pada  pasien  pediatri  leukimia  limfoblastik  akut  yang  mengalami febrile  neutropenia  sudah  sesuai  dengan  guideline  dan  pola  kuman  di  RSKD Jakarta.Kata Kunci : febrile neutropenia, antibiotika, keberhasilan terap