臨 Therapeutics of Clinical Drugs 肆 糖 尿 病 神 經 病 變 的 3 一 血 糖 控 制 % (HbA1c) 1.3 m/sec mg/dl 8% % 5,6 二 足 部 護 理 伍 糖 尿 病 引 起 週 邊 神 經 痛 之

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1 糖 尿 病 之 神 經 病 變 與 疼 痛 臨 中 山 醫 大 附 設 醫 院 劑 科 師 吳 雀 維 林 政 仁 中 山 醫 大 護 理 系 兼 任 講 師 陳 鈺 如 摘 要 amitriptyline venlafaxine duloxetine pregabalin - diabetic neuropathy glycemic control foot care painful diabetic neuropathy 壹 前 言 1 貳 發 生 糖 尿 病 神 經 病 變 的 原 因 2 參 糖 尿 病 神 經 病 變 的 型 態 75% "" "" ( ) 302 Jun 雜 誌

2 臨 Therapeutics of Clinical Drugs 肆 糖 尿 病 神 經 病 變 的 3 一 血 糖 控 制 % (HbA1c) 1.3 m/sec mg/dl 8% % 5,6 二 足 部 護 理 伍 糖 尿 病 引 起 週 邊 神 經 痛 之 () (insulin neuritis) (diabetic neuropathic cachexia) (diabetic anorexia) 表 一 糖 尿 病 週 邊 神 經 痛 的 臨 特 性 ( 用 於 區 分 糖 尿 病 週 邊 神 經 痛 與 末 梢 血 管 性 疾 病 ( 間 歇 性 跛 行 )) 7 8 ( amitriptyline duloxetine venlafaxine) ( pregabalin sodium valproate) (capsaicin) (lidocaine) alpha-lipoic acid (~) 3 表 二 糖 尿 病 週 邊 神 經 痛 的 及 處 置 Amitriptyline 25 mg to 100 mg 54 THE JOURNAL OF TAIWAN PHARMACY Vol.30 No.2 Jun

3 Duloxetine 60 mg Venlafaxine 75 mg to 225 mg Pregabalin 100 mg to 200 mg Sodium valproate 500 mg to 2000 mg Capsaicin Lidocaine Alpha-lipoic acid 600 mg Isosorbide dinitrate 表 三 2011 美 國 神 經 會 (American Academy of Neurology; AAN) 建 議 疼 痛 性 糖 尿 8 病 神 經 病 變 的 及 處 置 Level A Level B 一 抗 憂 鬱 Pregabalin, mg/ Gabapentin, mg/ Sodium valproate, mg/ Venlafaxine, mg/ Duloxetine, mg/ Amitriptyline, mg/ Dextromethorphan, 400 mg / Morphine sulphate, 120 mg/ Tramadol, 210 mg/ Oxycodone, 37 mg/120 mg/ Capsaicin, 0.075% Isosorbide dinitrate -/ Oxcarbazepine Lamotrigine Lacosamide Clonidine Pentoxifylline Mexiletine Magnetic field treatment Low-intensity laser therapy Reiki therapy Amitriptyline duloxetine venlafaxine ( 一 ) 三 環 類 抗 憂 鬱 Amitriptyline mg 100 mg 3 Amitriptyline () duloxetine venlafaxine Amitriptyline Amitriptyline ( doxepin) ( 二 )Duloxetine Duloxetine (SNRI) 60 mg Duloxetine 臨 302 Jun 雜 誌

4 臨 Therapeutics of Clinical Drugs Duloxetine (102/8/1) 1. (neuropathic pain) (1) (NCV) (polyneuropathy) (2) Pain rating scale Pain rating scale 4.60 mg Duloxetine Duloxetine 3 ( 三 )Venlafaxine Venlafaxine (SNRI) 60 mg 150 mg 225 mg 5123% Venlafaxine 3 二 抗 驚 厥 Pregabalin Valproate Gabapentin ( 一 )Pregabalin Pregabalin gabapentin 2-delta GABA benzodiazepine Pregabalin 2- Ca 2+ (glutamate) P (substance P) (calcitonin gene-related peptide (CGRP)) 50 mg 150 mg(100 mg )600 mg Pregabalin (Clcr) > 60 (ml/min) 150 mg Clcr (ml/min)75 mg Clcr (ml/min) 25 mg Clcr < 15 (ml/min) 25 mg Pregabalin 24%-50%600 mg 41 50% 3 ( 二 )Gabapentin Gabapentin mg 900 mg ( 三 )Valproic acid mg27-30% 56 THE JOURNAL OF TAIWAN PHARMACY Vol.30 No.2 Jun

5 ( 四 ) 其 他 Carbamazepine Lamotrigine Topiramate 表 四 Pregabalin 與 Duloxetine 衛 生 署 適 應 症 Pregabalin Duloxetine Lyrica () Cymbalta () 三 辣 椒 素 (Capsaicin) 乳 霜 (0.075%)P ( ) 四 麻 醉 劑 Lidocaine (5%) 18 五 α- 硫 辛 酸 Alpha-lipoic acid (ALA) - ALA 600 mg ALA 600 mg (Amitriptyline Duloxetine Venlafaxine) (Pregabalin) 六 阿 片 類 七 複 合 八 非 固 醇 類 抗 炎 (Nonsteroidal antiinflammatory drugs, NSAIDs) NSAIDs 陸 結 論 和 建 議 amitriptyline venlafaxine (Grade 2B) duloxetine pregabalin (Grade 2A) amitriptyline ( ) (Grade 2C) - (Grade 2C) 3 臨 302 Jun 雜 誌

6 臨 Therapeutics of Clinical Drugs Treatment of Diabetic Neuropathy and Neuropathic Pain Chueh-Wei Wu 1, Yu-Ju Chen 2, Zheng-Ren Lin 1 Department of Pharmacy of Chung Shan Medical University Hospital 1 School of Nursing of Chung Shan Medical University 2 Abstract Peripheral neuropathy is the most common complication of diabetes. The most important treatment of diabetic neuropathy is optimal glucose control. Foot care is important to prevent ulceration, infection, and amputation. For patients with painful diabetic neuropathy, we suggest initial therapy using either amitriptyline or venlafaxine, duloxetine or pregabalin. If patients with single drug therapy ineffective, it is recommended that the composite treatment using two different classes of drugs. Replacement therapy, including capsaicin cream, lidocaine patch, -lipoic acid or transcutaneous electrical nerve stimulation. We suggest not using opioids for the treatment of painful diabetic neuropathy. 參 考 資 料 : 1. Feldman EL, Shefner JM, Dashe JF. Clinical manifestations and diagnosis of diabetic polyneuropathy. UpToDate Feldman EL, Shefner JM, Dashe JF. Pathogenesis and prevention of diabetic polyneuropathy. UpToDate Feldman EL, McCulloch DK, Shefner JM, Nathan DM, Dashe JF. Treatment of diabetic neuropathy. UpToDate Amthor KF, Dahl-Jorgensen K, Berg TJ, et al: The effect of 8 years of strict glycaemic control on peripheral nerve function in IDDM patients: the Oslo Study. Diabetologia 1994;37: The effect of intensive diabetes therapy on the development and progression of neuropathy. The Diabetes Control and Complications Trial Research Group. Ann Intern Med 1995;122: Reichard P, Berglund B, Britz A, Cars I, Nilsson BY, Rosenqvist U. Intensified conventional insulin treatment retards the microvascular complications of insulin-dependent diabetes mellitus (IDDM): the Stockholm Diabetes Intervention Study (SDIS) after 5 years. J Intern Med 1991;230: Attal N. Neuropathic Pain: Mechanisms, Therapeutic Approach, and Interpretation of Clinical Trials. Continuum Lifelong Learning Neurol 2012;18: Bril V, England J, Franklin GM, et al: Evidence-based guideline: Treatment of painful diabetic neuropathy: Report of the American Academy of Neurology, the American Association of Neuromuscular and Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation. Neurology 2011;76: Wong MC, Chung JW, Wong TK. Effects of treatments for symptoms of painful diabetic neuropathy: systematic review. BMJ 2007;335: Max MB, Lynch SA, Muir J, Shoaf SE, et al: Effects of desipramine, amitriptyline, and fluoxetine on pain in diabetic neuropathy. N Engl J Med. 1992;326(19): THE JOURNAL OF TAIWAN PHARMACY Vol.30 No.2 Jun