醫學新知 : 古育瑄 1 游惟勝 1 李仰光 2 康曉妍 2 前言 5~13% [2] 案例 cm 83kg 30.9 kg/m 2 178/93 mmhg 78 / B amlodipine 5 mg B 10 1 壢新醫院家庭醫學科住院醫師 2 壢新醫院家庭醫學科主治醫師 hype

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: 古育瑄 1 游惟勝 1 李仰光 2 康曉妍 2 前言 5~13% [2] 案例 38 164 cm 83kg 30.

Secondary hypertension, Hypokalemia, Plasma renin activity 3 X-ray (GOT)133 U/L (GPT) 86 U/L B (K) 2.

1 : 古育瑄 1 游惟勝 1 李仰光 2 康曉妍 2 前言 5~13% [2] 案例 cm 83kg 30.9 kg/m 2 178/93 mmhg 78 / B amlodipine 5 mg B 10 1 壢新醫院家庭醫學科住院醫師 2 壢新醫院家庭醫學科主治醫師 hyperaldosteronism, Secondary hypertension, Hypokalemia, Plasma renin activity 3 X-ray (GOT)133 U/L (GPT) 86 U/L B (K) 2.1 meq/l (CPK) 7000 U/ L (aldosterone) pg/ml ( pg/ml) (PRA) <0.13 ng/ml/hr( ng/mL/hr) (K) 3.1 meq/l 討論 114 家庭醫學與基層醫療第四期

2 50% 17% (aldosterone-producing adenomas, APAs) (bilateral idiopathic hyperaldosteronism, IHA) (familial hyperaldosteronism Type I, Type II, Type III) (unilateral adrenal hyperplasia) (aldosterone-producing adrenocortical carcinomas ) ( ectopic aldosterone-producing tumors) (Cushing syndrome) (renin-secreting tumors) 診斷 (case detection) (case confirmation) thiazide ( 150 mmhg 100 mmhg) ( [ ] 140 mmhg 90 mmhg 140/90 mmhg ) (adrenal incidentaloma) 40 (plasma aldosterone concentration, PAC) (plasma renin activity, PRA) ARR(aldosterone to renin ratio) 15 ng/dl(416 pmol/l) ARR 30 SI 830 ARR 30( SI 830) fludrocortisone captopril 1. (oral sodium loading 家庭醫學與基層醫療第四期 115

3 test) 5,000 mg mcg/24 hours(33 nmol/day) 2. (intravenous saline infusion test) 8 2L 4 5 ng/ dl(139 pmol/l) 10 ng/dl(277 pmol/l) 5~10 ng/dl 3. Fludrocortisone (Fludrocortisone suppression test) 4 2 gm 6 Fludrocortisone acetate 0.1 mg 6 ng/dl 4. Captopril captopril 25 ~ 50 mg 2 captopril 30% 亞型分類診斷 (adrenal vein sampling, AVS) (posture change test) 4 cm 35 1 cm 35 (nonfunctioning cortical adenoma) (adrenal vein) 2 (posture change test) 2~4 50% 116 家庭醫學與基層醫療第四期

4 圖 : 診斷原發性高醛固酮症及鑑別診斷醛固酮分泌腺瘤或雙側腎上腺增生流程 ( 整理自 uptodate 及 JCEM 資訊 ) 1. 高血壓合併低血鉀 2. 嚴重高血壓或阻抗性高血壓 3. 高血壓合併腎上腺偶見瘤 (adrenal incidentaloma) 4. 高血壓合併家族史有早發性高血壓或是家族中有 40 歲前中風案例 5. 高血壓合併睡眠呼吸中止症案例偵測 (case detection) 比值 >30 ng/dl per ng/ml/hour 合併血漿醛固酮濃度 >15 ng/dl 血漿醛固酮濃度 / 血漿腎素活性比值比值 <30 ng/dl per ng/ml/hour 可能為原發性高醛固酮症本態性高血壓案例偵測 (case detection) 1. 口服鈉鹽負載試驗尿醛固酮濃度 >12 mcg/24 hours 2. 靜脈生理食鹽水輸注試驗血漿醛固酮濃度 >10 ng/dl 3. Fludrocortisone 抑制試驗血漿醛固酮濃度 >6 ng/dl 4. Captopril 測試血漿醛固酮濃度下降 <30% 是原發性高醛固酮症否本態性高血壓電腦斷層腎上腺靜脈取樣姿勢變化檢查兩側腎上腺皆為異常單側 >4cm 的腎上腺腫瘤腎上腺靜脈醛固酮血漿醛固酮 >2 倍腎上腺靜脈皮質醇血漿皮質醇單側雙側臥姿睡眠, 隔天抽晨血後, 持續站姿 2~4 小時再抽第二次血第二次血漿醛固酮濃度高於第一次 50% 以上雙側腎上腺增生腎上腺癌或無功能皮質腺瘤單側腺瘤雙側腎上腺增生是否雙側腎上腺增生醛固酮分泌腺瘤家庭醫學與基層醫療第四期 117

5 治療 spironolactone 1~6 spironolactone 3.0 mmol/l (spironolactone) 12.5~25 mg 400 mg 4~6 4~8 spironolactone 25~50mg spironolactone amiloride triamterene eplerenone spironolactone 總結參考資料 1. John W Funder, Robert M Carey, Franco 118 家庭醫學與基層醫療第四期

Mantero, et al: The management of primary aldosteronism: case detection, diagnosis, and treatment: An endocrine society clinical practice guideline J Clin Endocrinol Metab 20

6 Mantero, et al: The management of primary aldosteronism: case detection, diagnosis, and treatment: An endocrine society clinical practice guideline J Clin Endocrinol Metab 2016; 101: Vongpatanasin W: Resistant hypertension: a review of diagnosis and management JAMA 2014; 311: Uptodate : approach to the patient with hypertension and hypokalemia approach-to-the-patient-with-hypertension-andhypokalemia?source=search_result&search=hyp eraldosteronism&selectedtitle=1~106 Accessed Mar 28, Lim V, Guo Q, Grant CS, Thompson GB, Richards ML, Farley DR: Accuracy of adrenal imaging and adrenal venous sampling in predicting surgical cure of primary aldosteronism J Clin Endocrinol Metab 2014; 99: Rossi GP, Auchus RJ, Brown M, Lenders JW, Naruse M, Plouin PF: An expert consensus statement on use of adrenal vein sampling for the subtyping of primary aldosteronism. Hypertension 2014; 63: Ahmed AH, Cowley D, Wolley M: Seated saline suppression testing for the diagnosis of primary aldosteronism: a preliminary study. J Clin Endocrinol Metab 2014; 99: 下期預告基層醫學第 32 卷第 5 期題目作者類別 statins 相關肌肉不良反應的診治和預防李燕鳴脂漏性皮膚炎的臨床表現診斷與治療張孟捷余文瑞何清幼蔡依妙柯澐蓁李慕凡社區醫學常見良性皮膚腫瘤劉威宏金霍歌家庭醫業淺談酒精使用疾患鄭琪霖張玉立謝偉倫家庭醫業家庭醫學與基層醫療第四期 119

Ferriman-Gallwey 資料來源 : 參考資料 ) testosterone 150 ng/dl (5.2 nmol/ L) free testosterone2 ng/dl (0.07 nmol/l) DHEA-S700 mcg/dl (13.6 µmol/l

Ferriman-Gallwey 資料來源 : 參考資料 ) testosterone 150 ng/dl (5.2 nmol/ L) free testosterone2 ng/dl (0.07 nmol/l) DHEA-S700 mcg/dl (13.6 µmol/l 家庭醫業前言及定義病態生理學 F e r r i m a n - G a l l w e y hirsutism scoring system 9 04 Ferriman-Gallwey score8 (hirsutism) hypertrichosis hypertrichosis hirsutism androgen t e s t o s t e r o n e d i h y d r o