實證探討雙極性憂鬱症臨床治療藥物之選擇

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1 Clot-dissolving drugs Given within three hours of the start of symptoms Used in carefully selected patients Blood-thinning drugs (anticoagulants) Heparin given by vein Oral medication ( warfarin ) given if long-term treatment with blood-thinner is expected Antiplatelet drugs Aspirin 藥物治療 Clopidogrel (Plavix), dipyridamole (Persantine), and ticlopidine (Ticlid)

2 Medication Antiplatelet agents : Aspirin Clopidogrel Ticlopidin Dipyridamole Anticoagulant agents : Heparin Warfarin

3 Antiplatelet therapy for secondary prevention of stroke Aspirin, clopidogrel, and the combination of aspirin plus extended-release dipyridamole (ER-DP) (Aggrenox) are all acceptable options for preventing recurrent noncardioembolic ischemic stroke. For patients with a history of noncardioembolic stroke or transient ischemic attack (TIA) of atherothrombotic, lacunar (small vessel occlusive type), or cryptogenic type, we recommend treatment with an antiplatelet agent. We suggest initial antiplatelet therapy using either clopidogrel (75 mg daily) as monotherapy, or the combination of aspirin plus ER-DP (25 mg/200 mg twice a day), rather than aspirin. The choice between clopidogrel and aspirin plus ER-DP is dependent mainly on patient tolerance and contraindications. UPTODATE ONLINE 18.1

4 Antiplatelet therapy for secondary prevention of stroke Although the optimal dose of aspirin is uncertain, there is no compelling evidence that any specific dose is more effective than another, and fewer gastrointestinal side effects and bleeding occur with lower doses ( 325 mg a day). We recommend a dose of 50 to 100 mg daily when using aspirin for the secondary prevention of ischemic stroke For patients having carotid endarterectomy, we recommend aspirin (81 to 325 mg daily) started before surgery and continued indefinitely in the absence of a contraindication. UPTODATE ONLINE 18.1

5 Antiplatelet therapy for secondary prevention of stroke Aggrenox contains aspirin and should not be used in patients who cannot tolerate aspirin. Clopidogrel (75 mg/day) is an obvious alternative for patients who cannot tolerate aspirin. Ticlopidine should be reserved for patients intolerant of aspirin and clopidogrel. For most patients with a noncardioembolic stroke or TIA, we recommend NOT using aspirin and clopidogrel in combination for long-term stroke prevention, given the lack of greater efficacy compared with clopidogrel alone and the substantially increased risk of bleeding complications. UPTODATE ONLINE 18.1

6 Medication conclusion Dipyridamole + Aspirin > Aspirin or Dipyridamole treatment effective for prevent stroke Aspirin > Ticlopidine Clopidogrel > Aspirin

7 抗血小板藥物學名作用機轉劑量副作用 Aspirin COX-I mg/day Dipyridamole PDE-I mg bid-tid 胃腸不適潰瘍紅疹耳鳴眩暈頭痛低血壓心跳加速顏面潮紅 Clopidogrel ADP-I 75 mg qd 胃腸不適皮膚症狀 Ticlopidine ADP-I mg/day Max. 500 mg/day 胃腸不適紅疹耳鳴血尿白血球減少血小板減少 Tirofiban GP IIb/IIIa R- antagonist 出血血小板減少噁心發熱頭痛

8 FDA labeled indications Warfarin-Anticoagulant Atrial fibrillation - Thromboembolic disorder Atrial fibrillation - Thromboembolic disorder; Prophylaxis Myocardial reinfarction; Prophylaxis Prosthetic cardiac valve component embolism Prosthetic cardiac valve component embolism; Prophylaxis Pulmonary embolism Pulmonary embolism; Prophylaxis Thrombotic disorder, Post myocardial infarction; Prophylaxis Venous embolism Venous embolism; Prophylaxis Venous thromboembolism Venous thromboembolism; Prophylaxis 69

9 ACC/AHA/ESC 2006 Guidelines for the management of patients with AF 1.Age>=75 y/o,women 使用 Warfarin 2.Age>=65 y/o with heart failure or DM or CAD 3.LVEF<35% and hypertension 4.RHD with MS 5.Prosthetic heart valves 6.Prior thromboembolism or CVA or TIA 7.Persistent atrial thrombus on TEE(IIa indication) 8.CHADS2 score >=3 70

10 71

11 ACC/AHA/ESC 2006 Guidelines for the management of patients with AF 1.Age>=75 y/o, men 2.CHADS2 score 1 or 2 考慮使用 Aspirin or Warfarin 至少要用 Aspirin 的情況 1.Age y/o 2.Age<60 with heart disease 考慮使用 Aspirin 或皆不使用 1.Age<60 without heart disease (lone AF) 72

12 應告知醫師 Antiplatelet agents 衛教有貧血出血問題或其他血液的問題潰瘍氣喘嚴重肝臟疾病的病史若您正服用含 aspirin 之藥品其他止痛藥品抗凝血劑 ( 如 Warfarin) 大蒜人參銀杏或維他命 E 如果您將要進行手術 ( 包含牙科手術 ), 要記得告訴醫師或牙醫師您正在使用血小板抑制劑醫師會告訴您在進行手術前是否需停止服用血小板抑制劑請告訴醫師您是否有飲酒習慣 ; 服用此類藥物期間請勿飲酒

13 Antiplatelet agents 衛教若是有以下症狀發生嚴重的情形或是持續時, 請告知您的醫師 : 胃不舒服嘔吐胃痛若您有下列任一症狀, 請立即就醫 : 出血現象 ( 如嘔吐出血或類似咖啡渣的棕色物質血便或黑便血尿紅色或暗棕色尿突然出現瘀傷牙齦出血經血過多從未發生過的頭痛腹痛或背痛 ) 或發熱發冷虛弱喉嚨痛皮疹及搔癢胸悶胃腸不適糞便顏色變淡皮膚或眼睛變黃等

14 Antiplatelet therapy for secondary prevention of stroke We recommend oral anticoagulation for patients with atrial fibrillation and a recent stroke or TIA. We recommend aspirin for patients with atrial fibrillation and cardioembolic stroke who have contraindications to anticoagulant therapy. UPTODATE ONLINE 18.1

15 How to control the BP in acute stroke?

16 Blood Pressure Management in Patients With Stroke Candidates for fibrinolysis Blood Pressure Pretreatment SBP >185 or DBP >110 mm Hg Posttreatment DBP >140 mm Hg SBP >230 mm Hg or DBP mm Hg SBP mm Hg or DBP mm Hg Treatment Labetalol mg IVP 1-2 doses or Enalapril 1.25 mg IVP Sodium nitroprusside (0.5 mcg/kg/min) Labetalol mg IVP and consider labetalol infusion at 1-2 mg/min or nicardipine 5 mg/h IV infusion and titrate Labetalol 10 mg IVP, may repeat and double every 10 min up to maximum dose of 150 mg

17 Blood Pressure Treatment Noncandidates for fibrinolysis DBP >140 mm Hg SBP >220 or DBP mm Hg or MAP >130 mm Hg SBP< 220 mm Hg or DBP mm Hg or MAP <130 mm H Sodium nitroprusside 0.5 mcg/kg/min; may reduce approximately 10-20% Labetalol mg IVP over 1-2 min; may repeat and double every 10 min up to maximum dose of 150 mg or nicardipine 5 mg/h IV infusion and titrate Antihypertensive therapy indicated only if AMI, aortic dissection, severe CHF, or hypertensive encephalopathy present *Adopted from Advanced Cardiac Life Support (ACLS) guidelines and 2003 American Stroke Association Scientific Statement Abbreviations: SBP - systolic blood pressure; DBP - diastolic blood pressure; IVP - intravenous push; MAP - mean arterial pressure

Ischemic stroke Tolerating arterial hypertension under special conditions The presence of a high-grade stenosis or occlusion of the extra- or intracranial large arteries Patients with longstanding

18 Ischemic stroke Tolerating arterial hypertension under special conditions The presence of a high-grade stenosis or occlusion of the extra- or intracranial large arteries Patients with longstanding severe arterial hypertension with and advanced white matter disease of the brain Elevated BP should also be tolerated in eclampsia to avoid placental hypoperfusion Acta Neurologica Scandinavica.2003 April;107(4):

19 台灣腦中風防治指引 2008 急性缺血性腦中風時, 血壓之增高, 可提高腦血流量, 改變腦組織之缺血狀態美國中風學會建議急性缺血性腦中風期間, 收縮血壓在 220mmHg 以上或舒張血壓在 mmHg 時, 應使血壓慢慢下降 10-15% 若舒張血壓超過 140mmHg 時, 可使用靜脈點滴 Sodium nitroprusside, 並監控血壓, 慢慢下降 10-15%(27)(Class I, Level of Evidence C) 若使用抗凝血劑或血栓溶解劑 tissue plasminogen activator(t-pa) 治療時, 血壓應控制在 180/105mmHg 範圍內, 血壓在此範圍內, 不會造成腦部二度傷害 (28,29)(Class I, Level of Evidence B) 美國中風學會 (American Stroke Association) 對於血栓溶解劑 (t-pa) 治療前後之血壓控制, 建議使用 Labetaolol 或 Nicardipine 或 Nitroprusside 等藥物來控制血壓, 並密集監測血壓

急性出血性腦中風時美國中風學會建議 : 台灣腦中風防治指引 2008 若收縮血壓在 200mmHg 以上或平均動脈血壓在 150mmHg 以上時, 應持續靜脈滴注降血壓藥物並每 5 分鐘監測血壓若收縮血壓在 180mmHg 以上或平均動脈血壓在 130mmHg 以上, 臨床上懷疑或有腦壓升高之證據時, 應監測顱內壓,

20 急性出血性腦中風時美國中風學會建議 : 台灣腦中風防治指引 2008 若收縮血壓在 200mmHg 以上或平均動脈血壓在 150mmHg 以上時, 應持續靜脈滴注降血壓藥物並每 5 分鐘監測血壓若收縮血壓在 180mmHg 以上或平均動脈血壓在 130mmHg 以上, 臨床上懷疑或有腦壓升高之證據時, 應監測顱內壓, 並同時使用間歇性或持續性靜脈滴注降血壓藥物, 維持大腦灌注壓在 60-80mmHg 以上若收縮血壓在 180mmHg 以上或平均動脈血壓在 130mmHg 以上, 臨床上並沒有腦壓升高之證據時, 應考慮使用間歇性或持續性靜脈滴注降血壓藥物來溫和地控制血壓 ( 平均動脈血壓在 110mmHg 或目標血壓在 160/90mmHg 左右 ), 同時每 15 分鐘檢查病人

21 台灣腦中風防治指引 2008 高血壓是中風多重危險因子中最重要的, 而且是可以治療的, 控制高血壓, 可有效預防初次或再次中風若以預防中風為主要目的時, 選擇降高血壓藥物, 應先考慮 Diuretic, 另外, 添加 ACEI 可達加成效果若因為副作用之緣故, 無法使用 Diuretic 或 ACEI 時, 可考慮使用 CCB 或 ARB 急性中風時, 降低血壓是很危險的, 避免過度降低血壓, 使用 tpa 時, 必頇把血壓控制在 180/105mmHg 左右, 避免造成腦組織二度損傷長期高血壓之治療, 血壓應控制在 140/90mmHg 之下, 有糖尿病危險因子之病人, 應更為嚴格, 血壓宜控制在 130/80mmHg; 控制高血壓時, 應注意病人之耐受度, 特別是頸動脈狹窄嚴重之病患

22 藥物治療 Other drugs are used to: Control blood pressure ( labetalol, the firstline drug, or sodium nitroprusside) Reduce chance of additional clot formation (aspirin or similar medications) Reduce brain swelling Correct irregular heart rhythm (eg, atrial fibrillation)

23 手術治療中風或 TIA 以後, 可能需要進行手術, 以預防其復發手術技術 : 頸動脈內膜剝離術 Carotid endarterectomy 外科醫師將脂肪沉積物從頸動脈上剝除 ( 頸動脈是頸內通往腦部的主要動脈 ) 頸動脈氣球擴張術和支架術 Carotid angioplasty and stenting 這是一種侵入性比頸動脈內膜剝離術低的手術外科醫師擴張頸動脈, 然後將一個網架插入動脈, 以保持動脈開放顱外 / 顱內搭橋術 Extracranial/intracranial bypass 外科醫師繞過堵塞的動脈, 利用健康的頭皮動脈重建血供路線開顱術 Craniotomy 出血性中風時, 外科醫師採用開顱術緩解腫脹引起的腦內壓力積聚

24 Rehabilitation Physical therapy Occupational therapy Speech therapy Stroke

25 Prevention To help reduce your chance of getting a stroke, take the following steps: Exercise regularly. Eat more fruits and vegetables and limit dietary salt and fat. Stop smoking. Drink alcohol only in moderation (1-2 drinks per day). Maintain a healthy weight. Frequently check blood pressure and follow doctor recommendations for keeping it in a safe range. Take a low dose of aspirin (75 milligrams per day) if your doctor says it is safe. Keep chronic medical conditions under control (such as high cholesterol and diabetes). Seek medical care if you have symptoms of a stroke, even if symptoms stop. Stop the use of recreational drugs (cocaine, heroin, marijuana, amphetamines). S T R O K E

26 憂鬱症

27 憂鬱症會有哪些症狀? 身體方面 : 失眠或睡太多, 食慾低落 ( 不想吃 ) 或暴食 ( 吃太多 ), 脾氣暴躁或不想動, 身體沒力氣, 表情泠漠, 疲倦, 甚至完全不動, 性慾降低心理方面 : 注意力不集中, 無價值, 無助無望感, 漠不關心, 覺得自已是別人的負擔, 以淚洗面思考減慢, 迷惑常想到死亡, 失去自我控制能力, 出現自殺的行為嚴重的會出現幻聽和妄想

28 憂鬱症診斷標準? 要達到憂鬱症的診斷, 至少要有持續 2 週時間, 有下列 5 種症狀以上持續出現憂鬱心情或無望感對幾乎所有的活動都沒有興趣食慾, 體重增加或降低失眠或多眠生理性的激動, 無法靜坐, 或動作緩慢喪失精力或疲倦罪惡感 ( 誇大對某些事件的責任 ) 或無價值感 ( 對自已的負面評價 ) 無法集中注意力, 不尋常地猶豫不決想到死亡或是自殺

29 憂鬱 - 身體症狀心情不好的心理疾病, 情緒低落容易哭泣確實是憂鬱症的一個重要症狀憂鬱症的診斷定義, 憂鬱症至少可能還包含有睡眠的改變 ( 幾乎每天失眠或嗜睡 ) 食慾的改變 ( 明顯食慾變差或增加 ) 幾乎每天覺得疲累等身體症狀

30 憂鬱 - 身體症狀臨床上, 常見的憂鬱身體症狀還包括 : 胸悶心悸腸胃不適肌肉緊繃或酸痛骨頭關節酸痛頭痛背痛胸痛頭暈等症狀不是每位憂鬱症患者都有上述的身體症狀, 有些患者可能只有少數症狀, 但有部份身體症狀很多的憂鬱症患者會以為自己身體生病了, 而多次求診內科醫師或做身體檢查, 但卻找不到有明顯的內科疾病可以完全解釋身體不舒服的狀況憂鬱有一種全身是病的感覺但又找不到明顯的病因有部份憂鬱患者會將心情的憂鬱歸因於身體的諸多不適, 相反的, 有些醫療人員或家屬可能會將患者的身體不適歸因於心理作用而否定患者的不舒服, 以致患者覺得無法獲得體諒, 因而情緒更糟

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既設建築物汙水處理設施生化需氧量三 O 化學需氧量一 OO 流量大於二五 O 立方公尺 / 日懸浮固體三 O 大腸桿菌群二 OO OOO 生化需氧量五 O 既設建築物指中華民國九化學需台灣基層透析協會本會宗旨 : 關懷透析病患, 提升透析品質, 維護透析診所與病患的權益, 最新消息 : 協助政府制定相關醫療政策及推行健康保險制度 105 年 6 月 1 日, 腎臟醫學會林元灝秘書長和基層透析協會顏大翔秘書長至劉建國立

實證探討 雙極性憂鬱症臨床治療藥物之選擇

實證探討雙極性憂鬱症臨床治療藥物之選擇