Therapeutics of Clinical Drugs 臨床藥物治療學 50% 25% 5 ( ) midodrine 4 midodrine 5 mg mg/ dose 17.5 mg 4 表一肝硬化合併腹水之治療選擇 (sodium restriction) spironol

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1 Midodrine 摘要建佑醫院藥劑科藥師許永佳張瓊月 (AASLD) midodrine midodrine refractory ascites diuretic-resistant ascites 壹前言 81% 1 58% 50% 2 ( nitric oxide glucagon endothelin) - - (renin-angiotensin-aldosterone system, RAAS) 3 (shifting dullness flank dullness) (ultrasound) (CT scan) (MRI) (paracentesis) 2013 ( ) 4 (2 g/ day) spironolactone furosemide 100 mg: 40 mg ( 400 mg: 160 mg) non-steroidal anti-inflammatory drugs (NSAIDs) angiotensin converting enzyme inhibitors (ACEIs) angiotensin receptor blocker (ARBs) -blockers 10% (diuretic-resistant ascites) (refractory ascites) 30 4 Dec 藥學雜誌臨床藥物治療學Midodrine 治療肝硬化合併腹水之案例

2 Therapeutics of Clinical Drugs 臨床藥物治療學 50% 25% 5 ( ) midodrine 4 midodrine 5 mg mg/ dose 17.5 mg 4 表一肝硬化合併腹水之治療選擇 (sodium restriction) spironolactone furosemide (NSAIDs) -blockers ACEIs ARBs midodrine - (TIPS) 貳案例報告 ( ) (ovoid shape) (pitting edema 4+) /min 19 /min 86/64 mmhg BUN 17 mg/ dl Cr 1.6 mg/dl GOT 51 U/L GPT 20 U/ L Na 125 meq/l K 3.2 meq/l Uric acid 9.7 mg/dl ( ) 7 20 spironolactone 25 mg/tab 3# QID + furosemide 20 mg/amp 1 amp Q8H + hydrochlorothiazide 50 mg/tab 1# BID 7 22 spironolactone 25 mg/tab 4# QID furosemide 20 mg/amp 2 amp Q8H 7 23 midodrine 2.5 mg/tab 2# TID # QID 3# QID (I/O ) -441 ml ~ -732 ml ml ~ ml ( ) (4+ 3+) 114 cm 103 cm 68 kg 57 kg ( ) 7 29 表二病人用藥紀錄 OPD UD / 5/14~6/03 7/20 7/21 7/22 7/23 7/24 7/25 7/26 7/27 7/28 7/29 A.M.Z 1# TID v Sennoside 12 mg/tab 2# HS v Roumin 5 mg/tab 1# TID v Dormicum 7.5 mg/tab 1# HS v Narcaricin 50 mg/cap 1# QD v 92 THE JOURNAL OF TAIWAN PHARMACY Vol.30 No.4 Dec

3 Midodrine OPD UD / 5/14~6/03 7/20 7/21 7/22 7/23 7/24 7/25 7/26 7/27 7/28 7/29 Spironolactone 25 mg/tab 2# QID v 3# QID 4# QID Gain-Vita (B-Complex) 1# BID v 1# TID Hydrochlorothiazide 50 mg/tab 1# BID v Furosemide 40 mg/tab 1# TID v Tamedin 200 mg/tab 1# QID Atinol 100 mg/tab 1/2# QD Furosemide 20 mg/amp 1 amp Q8H 2 amp Q8H Midodrine 2.5 mg/tab 2# TID 2# QID 3# QID 表三檢驗數據 7/20 7/26 WBC /μl RBC /μl Hb g/dl Ht % MCV fl MCH pg MCHC g/dl Platelet /μl BUN mg/dl Creatinine mg/dl Uric acid mg/dl GOP (AST) 3-38 U/L GPT (ALT) 3-37 U/L Albumin g/dl T-Bil mg/dl D-Bil mg/dl ALP U/L Cholesterol mg/dl TG mg/dl Na meq/l K meq/l Ammonia 9-47 μg/dl 表四病人用藥後臨床評估 7/20 7/21 7/22 7/23 7/24 7/25 7/26 7/27 7/28 7/29 I/O (ml) loss (kg) (cm) (mmhg) Dec

4 臨床藥Therapeutics of Clinical Drugs 物治療學圖一住院期間尿液排出量 (I/O 值 ) 變化參討論 AASLD spironolactone furosemide (3.2 meq/l) furosemide furosemide / (125 meq/l) 120 meq/l (spironolactone mg/day furosemide mg/day) furosemide furosemide furosemide 6 midodrine Singh V 7 20 ( ) midodrine midodrine (p < 0.05) midodrine (p = 0.013) midodrine midodrine (p < 0.046) 8 ( ) midodrine 7/23 midodrine 肆結論 AASLD 94 THE JOURNAL OF TAIWAN PHARMACY Vol.30 No.4 Dec

5 Midodrine (peritoneovenous shunt) - (transjugular intrahepatic portosystemic shunt; TIPS) (liver transplantation) midodrine 臨床藥物治療住院期間血壓值變化學圖二 Using Midodrine in A Patient with Cirrhosis and Ascites Yung-Chia Hsu, Chiung-Yueh Chang Department of Pharmacy, Chien-Yu Hospitol Abstract According to the guidelines of American Association for the Study of Liver Diseases (AASLD), patient with cirrhosis and ascites should abstain from alcohol, restrict sodium intake, and adopt combinational diuretics as first-line therapy. Second-line medications or surgical treatment are only considered for patients who develop resistance to diuretics or refractory ascites. Our case report concerns a patient with liver cirrhosis and severe ascites. Triple combination of diuretics was prescribed at the beginning of hospitalization. The patient showed poor response to these diuretics. Despite subsequent dose elevation of diuretics, no significant improvement was seen on patient s daily urination. After adding a second-line medication midodrine to the patient, his daily urination was markedly increased. Significant improvements on clinical manifestations, such as lower limbs edema, waistline and body weight, were also observed. 藥學雜誌 Dec

6 臨床藥物治療學 Therapeutics of Clinical Drugs 參考資料 Runyon BA, Montano AA, Akriviadis EA, et al: The serum-ascites albumin gradient is superior to the exudatetransudate concept in the differential diagnosis of ascites. Ann Intern Med. 1992;117(3):215. Gines P, Quintero E, Arroyo V, et al: Compensated cirrhosis: natural history and prognostic factors. Hepatology 1987;7: Martin PY, Gines P, Schrier RW: Nitric oxide as a mediator of hemodynamic abnormalities and sodium and water retention in cirrhosis. N Engl J Med 1998; 339: Runyon BA, AASLD. Introduction to the revised American Association for the Study of Liver Diseases Practice Guideline management of adult patients with ascites due to cirrhosis Hepatology. 2013;57(4):1651. THE JOURNAL OF TAIWAN PHARMACY Vol.30 No.4 Dec Bories P, Garcia Compean D, Michel H, et al: The treatment of refractory ascites by the LeVeen shunt. A multi-centre controlled trial (57 patients). J Hepatol. 1986;3(2):212. Spahr L, Villeneuve JP, Tran HK, et al: Furosemide induced natriuresis as a test to identify cirrhotic patients with refractory ascites. Hepatology 2001;33: Singh V, Dhungana SP, Singh B, et al: Midodrine in patients with cirrhosis and refractory or recurrent ascites: a randomized pilot study. J Hepatol 2012;56: Singh V, Singh A, Singh B, et al: Midodrine and Clonidine in Patients With Cirrhosis and Refractory or Recurrent Ascites: A Randomized Pilot Study. Am J Gastroenterol 2013; 108: Runyon BA, Such J: Ascites in adults with cirrhosis: Initial therapy. UpToDate online. Available at uptodate.com.(cited: 25/06/2013)

middle cerebral artery infarct) 16:43 rt-pa 5 mg 1 41 mg (muscle power, MP) (right middle cerebral artery infarct) diltiazem 15 mg TID PO 10

middle cerebral artery infarct) 16:43 rt-pa 5 mg 1 41 mg (muscle power, MP) (right middle cerebral artery infarct) diltiazem 15 mg TID PO 10 臨床藥物治療學缺血性腦中風的治療之案例報告中國醫藥大學藥學系江尚德台大醫院雲林分院藥劑部藥師張有邑莊謹如廖玲巧摘要 (recombinant tissue plasminogen activator, rt-pa) rt-pa rt-pa 壹前言 (7.3 %) (29.0 %) (11.5%) 1 67.9 % 2 (recombinant tissue plasminogen activator,