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1 bipolar disorder manic-depressive- illness mood disorder neurotransmittersnorepinephrine NEserotonin 5-HT dopamineda synapse acetylcholine Ach gamma-aminobutyric acidgaba ; American Psychiatric Association DSM- American Psychiatric Association bipolar 3 bipolar cyclothymic disorder bipolar disorder not otherwise specified NOS 21 DSM- (Major depressive- episode) (Manic episode) (Hypomanic episode) (Mixed episode) 15-35% antidepressants electroconvulsive therapy, ECT

2 lithium lithium lithium weight gain tremor excessive urination confusion seizure compliance valproatevpa carbamazepine CBZ ValproateVPA FDA divalproex sodiumdepakote 1995 FDA lithium valproate VPA Divalproex sodium carbamazepinecbz valproate mood stabilizers lithium lithium FDA VPA mixed rapid cycle VPA VPA lithium lithium hypothyroidism lithium lithium VPA CarbamazepineCBZ

3 epilepsy trigeminal neuralgia CBZ severe mania rapid antipsychotics cycle mixed 2-4 lithium CBZ CBZ lamotriginegabapentin topiramate CBZ leukopenia atypical antipsychotics clozapineolanzapine hypomanic risperidone clozapine Olanzapine FDA lithium FDA Risperidone mixed episodes rapid cyclers Benzodiazepines refractory insomnia anxiety continuous cyclers benzodiazepine benzodiazepine lithium valproate carbamazepine benzodiazepine

4 Type depressive bipolar disorder manic mixed Type depressive bipolar disorder hypomanic Cyclothymic subsyndromal disorder depressive hypomanic Bipolar disorder not otherwise specified Depression Mania empty mood euphoric sad anxious guilt worthlessness helplessness restlessness irritability 1. Fankhasuer M, Benefield Jr WH. Bipolar Disorder, in Dipiro JT, Talbert FL, Yee GC et al (eds): Pharmacotherapy: A Pathophysiolgic Approach, 4th ed., Appleton and Lange, 1999:

5 Weissman MM, Leaf PJ, Tischler GL, Blazer DG, Karno M, Bruce ML, Forio EP: Affective disorders in five United States communities. Psychol Med 1988; 18: Weller BW, Weller RA: Mood disorders, in Child and Adolescent Psychiatry: A Comprehensive Textbook. Edited by Lewis M. Baltimore, Williams & Wilkins, Gershon ES, Berrettini W, Numberger J, Goldin LR: Genetics of affective illness, in Psychopharmacology: The Third Generation of Progress. Edited by Meltzer HL. New York, Raven Press, Mood disorders. In: Diagnostic and Statical Mannual of Mental Disorders, 4th ed (DSM- ). Washington, DC, American Psychiatric Press, 1994: Practice Guideline for the Treatment of Patients with Bipolar Disorder. American Psychiatric Association Practice Guidelines. Am J Psychiatry 1994; 151(suppl): l Gemer RH, Stanton A. Algorithm for patient management of acute manic states: Lithium, valproate, or carbamazepine. J Clin Psychopharmacol 1992; 12:57S-63S. 8. Goodwin FK, Jamison KR (eds). Psychotherapy, in Manic-Depressive Illness. New York, Oxford University Press. 1990: Goodwin FK, Jamison KR (eds). Maintenance medical treatment, in Manic-Depressive Illness. New York, Oxford University Press. 1990: Suppes T, Webb A, Paul B, Carmody T, Kraemer H, Rush AJ. Clinical outcome in a randomized 1-year trial of clozapine versus treatment as usual for patients with treatment-resistant illness and a history of mania. American Journal of Psychiatry, 1999; 156(8): Goodwin FK, Jamison KR. The manic-depressive spectrum. In: Goodwin FK, Jamison KR (eds). Manic-Depressive Illness. New York. Oxford University Press, 1990: Chou JC. Recent advances in treatment of acute mania. J Clin Psychopharmacol 1991; 11:3-21.

6 Labetalol Carvedilol 25mg 9,000/ul Cephapirin 194/83 Labetalol ( beta-blockers ) Atenolol Carvedilol Atenolol Carvedilol 50mg 130 (4 26 )MRA ( descending aorta ) Type B Labetalol Candesartan 8mg 3 Nifedipine 10mg ( ) 39.8 o C 13.1 x /ul Nifedipin 10mg 20mg 12 Atenolol 100mg o C ( false lumen ) ( intima ) C ( C-reactive protein ) 25.5mg/dl Cephapirin 1g q6h cocaine Labetalol Labetalol ( Marfan syndrome )

7 DeBakey ( ascending aorta ) Type I TypeII Type III Stanford Type IType II Type A Type III Type B( ) 194/83 Nitroprusside labetalol Type A Type Angiotensin-converting enzyme inhibitors B ( Calcium channel blockers ) Labetalol ( Carvedilol 50mg qd ) ( descending aorta ) Type B ( Candesartan 8mg qd ) ( Nifedipine 20mg q12h ) Nitroprusside Labetalol Nitroprusside ( shearing force or dp/dt ) ( ascending aorta ) ( aortic arch ) Propranolol EsmololPropranolol mcg/kgesmolol

8 Nitroprusside Nitroprusside cyanmethemoglobin ( cyanide ) 130/80 thiocyanate Nitroprusside 2 ( 2 mcg/kg/min ) thiocyanate Nitroprusside ( IV tube ) Labetalol ( combined α, β blockers ) 20 Nitroprusside 2 Labetalol Labetalol

9 Drug names 4/ / Labetalol 1.25mg/ml taper dc ml/hr ml/hr MgO 250mg tid dc Candesartan 8mg qd Nifedipine 10mg tid mg q12h Atenolol 100mg qd dc Cephapirin 1g q6h dc Carvedilol 25mg qd # qd Bisacodyl 10mg hs # 1 # ---- tid tid Simethicone 80mg tid Lactulose 15ml tid ---- dc Estazolam 2mg hs # BP /70 /49 /59 /59 /80 /98 /80 /80 /74 /50 BT ( o C ) Micromedex 2002, volume htm 3. e/vln4/introduction.htm 4.Applied Therapeutics 7th edition 5.Harrison s : Principles of Internal Medicine 15th edition ( )

11 CYP3A 1.Greenblatt DJ. Patki KC. von Moltke LL. Shader Drug interactions with grapefruit juice: an update. J Clin Psychopharmacol 2001;21(4): Bailey DG, Spence JD, Edgar B, et al. Ethanol enhances the hemodynamic effects of felodipine. Clin Invest Med 1989;12: Bailey DG, Dresser GK, Kreeft JH, et al. Grapefruit-felodipine interaction: effect of unprocessed fruit and probable active ingredients. Clin Pharmacol Ther 2000;68: Lown KS, Bailey DG, Fontana RJ, et al. Grapefruit juice increases felodipine oral availability in humans by decreasing intestinal CYP3A protein expression. J Clin Invest 1997; 99:

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16 KanamycinPolymyxin Tetracycline Penicillamine (FluphenazineHaloperidol) Digoxin Warfarin P-450(cytochrome P-450) Theophylline BarbituratesPhenytoinBenzodiazepine P-450 Felodipine Amlodipine CyclosporineLovastatin Griseofulvin Penicillin

17 AmitryptylineAmphetamineMeperidine Tyramine ( ) Quinidine Tyramine Acetazolamide SalicylatePhenobarbital Tyramine DextroamphetamineMethylcellulose Methyldopa Cyproheptadine ChlorpromazineInsulinGlucocorticoids ( ) Anticholinergics Neomycin Antacids adsorption to drug kaolin/pectin Charcoal Pargyline Isocarboxazid Tranylcypromine Carbamazepine, Diazepam Dicumerol,, Erythromycin Griseofulvin, Hydralazine, Hydrochlorothiazide, Labetalol Metaprolol Nitrofurantoin, Phenytoin, Propoxyphene,

18 Propranolol Spironolactone, Acetaminophen Ampicillin Amoxicillin Aspirin Atenolol, Captopril Cephalosporins Chlorpromazine, Cimetadine Digoxin,, Erythromycin stearate ; Glipizide, Isoniazid, Levodopa Lincomycin, Methyldopa Metronidazole Nafcillin, Penicillamine Penicillin G, Penicillin VK Piroxicam Propantheline Quinidine Sulfonamides ; Tetracylines, Chlordiazepoxide - Diazepam - Lorazepam - - Clorazepate - - Meprobamate - Pentobarbital -

19 Chlorpromazine Chloral hydrate - - Tolbutamide - Phenytoin - Warfarin - Antipyrine - Chlormethiazole - Acetaminophen - Vitamin B 12 K + supplements Colchicine ph Vit. B 12, Vit. B 12 Vitamin B 6 Oral contraceptives Vit. B 6 Hydralazine Penicillamine Vitamin C Salicylates Vit. C Tetracyclines Vitamin A, D, E, K Mineral oil Vitamin A, D, K Cholestyramine Vit. A, D, K Vitamin A Neomycin Ethanol Vit. A Tetracycline Vitamin D Cathartics (irritants) Vit. D Glutethimide Vit. D Vitamin E Dicumarol Digoxin Vitamin K Anticonvulsants Dicumerol Hypoprothrombin 1.Thomas JA. Drug-nutrient interaction. Nutrition Reviews 1995; Kirk JK. Significant drug-nutrient interactions. American Family Physician 1995; Nowlin DB, Blanche W. Refining a food-drug interaction program. American Journal of Health-System Pharmacy 1998;

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<4D6963726F736F667420506F776572506F696E74202D20C1BFB871A4A4A6E8C3C4A8D6A5CEAA60B74EA8C6B6B52E707074205BACDBAE65BCD2A6A15D> 藥師公會全國聯合會中藥執業推廣計畫藥師在中藥用藥安全之重要現代保健之中醫藥趨勢環境變遷與健保制度涵蓋中醫藥服務台灣民眾 66% 經常性使用中藥中醫藥占我國健保門診使用率之 15% 於整體專業醫療所扮演之角色日重臺大