長貳案例報告 cm 49 kg BMI 22.3 kg/m ~2 ( ) 99 2 ( ) (1400 kcal/day) ml 99/3/8 50 ml 8~10 表一各科別處方物 Requip 0.25 mg FC ta

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1 長公共衛生學暨管理 Hygiene Pharmacy and Pharmacy Administration 理之家老人長三軍總醫院臨床學部師金秦瑩葉爵榮陳智德台北市立聯合醫院劑部師陳立奇摘要 85 amantadine alendronate elderly long-term care 壹前言 ( ) ( ) (benztropine trihexyphenidyl) ( ) 1 54 THE JOURNAL OF TAIWAN PHARMACY Vol.28 No.1 Mar

2 長貳案例報告 cm 49 kg BMI 22.3 kg/m ~2 ( ) 99 2 ( ) (1400 kcal/day) ml 99/3/8 50 ml 8~10 表一各科別處方物 Requip 0.25 mg FC tab ropinirole 1# tid PO Biperin 2 mg tab biperiden 1# qd PO Nootropil 1.2 g FC tab piracetam 1# bid PO PK-Merz 100 mg FC tab amantadine 1# tid PO 1# qd Co-diovan 80 mg/12.5 mg FC tab valsartan/ hydrochlorothiazide 0.5# qd PO Orfarin 5 mg tab warfarin 0.25# qd PO Propranolol 10 mg tab propranolol 1# qd PO Rosis 40 mg tab furosemide 0.5# qod PO Through 2 mg tab sennoside 2# qn PO Through 2 mg tab sennoside 1# qn PO DC Ferrum Hausmann chewable tab ferric-hydroxidepolymaltose complex Calbo 950 mg tab calcium citrate 1# qd PO Fosamax plus 70 mg tab alendronate cholecalciferol 1# bid PO DC 1# qw PO DC Rosis 40 mg tab furosemide 0.5# qod PO Rosis 40 mg tab furosemide 0.5# bid PO ( ) Mydocalm 150 mg tab tolperisone 1# qd PO Mobicam 15 mg tab meloxicam 0.5# qd PO Celebrex 200 mg cap celecoxib 1# qd PO DC Wellpin tab simethicone, Al (OH)3- Mg, carbonate Supergel simethicone, Al (OH)3- Mg, carbonate 1# qd PO 1# qd PO DC 28 1 Mar 學雜誌第 110 冊 55

3 長公共衛生學暨管理 Hygiene Pharmacy and Pharmacy Administration 表二檢驗報告 ( 超過參考值上限, 低於參考值下限 ) ( 一 ) 生化檢驗值 99 1/8 1/23 1/24 1/25 1/26 1/28 1/29 1/31 2/23 8/23 8/24 Glucose (Fasting) mg/dl 82 Glucose (Urgent) mg/dl 134 Total Cholesterol < 200 mg/dl Triglyceride < 200 mg/dl BUN 6-20 mg/dl Creatinine mg/dl Uric Acid mg/dl Total Calcium mg/dl AST < 32 U/L ALT < 31 U/L Total Protein (Blood) g/dl Albumin g/dl A/G Ratio Sodium mmol/l Potassium mmol/l Free Calcium mg/dl 3.7 Magnesium mg/dl WBC (10^3/UL) RBC (10^6/UL) Hb g/dl PT patient sec PT control sec INR APTT Aptt patient sec. 31 APTT control sec LDH U/L 397 CK U/L 195 CKMB < R -GT 5-36 U/L THE JOURNAL OF TAIWAN PHARMACY Vol.28 No.1 Mar

4 長參案例討論與建議及追蹤 ( 一 ) 老人經常性便秘改善與緩瀉劑選擇 6~40% calcium citrate (Calbo) ( ) bisacodyl (Dulcolax) 2 sennoside (Through) (Rhein anthrone) (1) (2) (3) ( ) 15~20 g sennoside (60 / ) 3 (Bifidobacteria microflora) 99/8/27 ( 二 ) 帕金森氏症 ( p a r k i n s o n ' s disease) 治療與腎功能不良之品劑量調整 3 (Dopaminergic agents) ropinirole pergolide bromocriptine pramipexole levodopa (Anticholinergics) benztropine trihexyphenidyl COMT entacapone tolcapone MAO selegiline 2009 Beers criteria entacapone ropinirole carbidopa levodopa 4 piracetam nootropic ADP ATP 5 6 (cholinergic transmission) Piracetam warfarin ropinirole (Requip) amantadine 200 / 400 / 100 / ( ClCr ml/min) (ClCr ml/min) (ClCr < 15 ml/min) /8/24 Cr 1.4 mg/dl Cockcroft Gault ClCr 21.7 ml/min amantadine (Pkmerz) Mar 學雜誌第 110 冊 57

5 長公共衛生學暨管理 Hygiene Pharmacy and Pharmacy Administration amantadine 100 / ( 三 ) 重覆用 (meloxicam celecoxib) (Wellpin Supergel) Meloxicam celecoxib 50 celecoxib ClCr < 30 ml/min 8 warfarin celecoxib 3 99/2/4 (Occult Blood) 3 99/6/30 Celebrex Supergel ( 四 ) 治療或預防骨質疏鬆用合適性 (ClCr < 35 ml/min 2, ,11 D calcitonin (Miacalcic 200 IU nasal spray) 43 alendronate sodium, cholecalciferol (Fosamax plus) calcitonin 肆結論伍致謝參考資料 : 1. Joseph TD, Robert LT, Drug-Induced Constipation: Pharmacotherapy: A Pathophysiologic Approach, 7th ed: (5): UpToDate Inc : Drug treatment of Parkinson disease 2011: UpToDate online. 4. Developing Explicit Positive Beers Criteria for Preferred Central Nervous System Medications in Older Adults 2009: Branconnier RJ. The efficacy of the cerebral metabolic enhancers in the treatment of senile dementia. Psychopharmacol Bull 1983; 19(2): Nicholson CD. Nootropics and metabolically active compounds in Alzheimer's disease. Biochem. Soc. Trans 1989; 17(1): Micromedex Healthcare Series: amantadine Lexicomp Online. Celecoxib. servlet/crlonline Micromedex Healthcare Series: alendronate sodium Rebecca W,Vicky B. Handbook of Drug Administration via Enteral Feeding Tubes 2007: THE JOURNAL OF TAIWAN PHARMACY Vol.28 No.1 Mar

6 11. Tanner SB, Taylory HM. Feeding Tube Administration of Bisphosphonates for Treating Osteoporosis in Institu- tionalized Patients with Developmental Disabilities Bone 2004; 34(1): Long Term Pharmaceutical Care of Nursing Home Chin-Ying Chin1, Jue-Zong Yeh1, Jye-Daa Chen1, Lih-Chi Chen2 Department of Pharmacy Practice, Tri-Service General Hospital1 Department of Pharmacy, Taipei City Hospital2 Abstract The elderly have large differences in physiology responses, so this often influences the processes of absorption, distribution, metabolism, and elimination in pharmacokinetics. In addition, those elders with complex symptoms have to take multiple drug therapy for the long term. Therefore, the problems of inappropriate drug usage can be reduced by pharmacists being involved in the doctor-patient communication. This case is about pharmacists' intervention in drug usage for an 85-year-old female long-term care patient with many serious diseases such as cardiovascular disease and Parkinson's combined with dementia. Before the pharmacists' intervention, the patient used 20 medications in total. Consequently, the pharmacists suggested the appropriate treatment according to the dosage of the drug and the repetition and selection of the drug efficacy. The result after the pharmacists' intervention was that the dosage of amantadine was decreased and alendronate was deleted according to the patient's renal function and four inappropriate drugs (iron, laxatives, analgesics, and antacids) were terminated. 第 28 卷第 1 Mar 學雜誌第110冊 59 長理之家老人長

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長 貳 案 例 報 告 cm 49 kg BMI 22.3 kg/m ~2 ( ) 99 2 ( ) (1400 kcal/day) ml 99/3/8 50 ml 8~10 表 一 各 科 別 處 方 物 Requip 0.25 mg FC ta

長貳案例報告 cm 49 kg BMI 22.3 kg/m ~2 ( ) 99 2 ( ) (1400 kcal/day) ml 99/3/8 50 ml 8~10 表一各科別處方物 Requip 0.25 mg FC ta