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 99 5 10 ( ) ( ) (benztropine trihexyphenidyl) ( ) 1 54 THE JOURNAL OF TAIWAN PHARMACY Vol.28 No.1 Mar. 31 2012
長 貳 案 例 報 告 85 148 cm 49 kg BMI 22.3 kg/m 2 20 96 1~2 ( ) 99 2 ( ) (1400 kcal/day) 2000-3000 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 99 5 6 7 8 9 10 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. 31 2012 學 雜 誌 第 110 冊 55
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) 74-109 mg/dl 82 Glucose (Urgent) 74-109 mg/dl 134 Total Cholesterol < 200 mg/dl 73 108 Triglyceride < 200 mg/dl 49 51 BUN 6-20 mg/dl 90 89 57 39 30 31 35 40 53 Creatinine 0.5-0.9 mg/dl 2.8 2.4 1.5 1.2 1 1.1 1 0.9 1.4 Uric Acid 2.4-5.7 mg/dl 7.4 5.5 Total Calcium 8.6-10.2 mg/dl 6.7 8.2 AST < 32 U/L 72 36 152 38 ALT < 31 U/L 32 129 30 Total Protein (Blood) 6.6-8.7 g/dl 4.6 6.6 Albumin 3.97-4.94 g/dl 1.9 2.6 2.8 A/G Ratio 1.2-2.4 0.7 Sodium 136-145 mmol/l 150 151 136 153 152 144 137 130 139 Potassium 3.5-5.1 mmol/l 4.3 3.7 2.9 3.2 3.1 3 3.5 3.9 3.3 Free Calcium 4.50-5.30 mg/dl 3.7 Magnesium 1.7-2.55 mg/dl 1.7 1.8 WBC 4.50-11.00 (10^3/UL) 8.72 7.3 5.1 6.3 7.7 6.2 RBC 3.90-5.50 (10^6/UL) 4.23 3.65 3.36 3.05 3.07 2.66 Hb 12.0-16.0 g/dl 13.2 11.9 10.9 9.9 10 8.7 PT patient 10.0-14.0 sec. 23.7 12.9 13.7 12.5 PT control 11.0-14.0 sec. 11.4 11.3 11.4 10.4 INR 3.6 1.2 1.4 1.2 APTT Aptt patient 23.9-35.5 sec. 31 APTT control 20.0-40.0 sec. 28.7 LDH 135-225 U/L 397 CK 26-192 U/L 195 CKMB < 25 21 R -GT 5-36 U/L 13 56 THE JOURNAL OF TAIWAN PHARMACY Vol.28 No.1 Mar. 31 2012
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 30-50 ml/min) 200 100 (ClCr 15-29 ml/min) 200 100 (ClCr < 15 ml/min) 200 7 99/8/24 Cr 1.4 mg/dl Cockcroft Gault ClCr 21.7 ml/min amantadine (Pkmerz) 300 28 1 Mar. 31 2012 學 雜 誌 第 110 冊 57
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 2,9 10 50 30 10,11 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: 624. 2. 2008 51(5):29-32. 3. 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 2009:601-610. 5. Branconnier RJ. The efficacy of the cerebral metabolic enhancers in the treatment of senile dementia. Psychopharmacol Bull 1983; 19(2):212-9. 6. Nicholson CD. Nootropics and metabolically active compounds in Alzheimer's disease. Biochem. Soc. Trans 1989; 17(1):83-5. 7. Micromedex Healthcare Series: amantadine. http://newmdx.csis.com.tw. 2011 8. Lexicomp Online. Celecoxib. http://online.lexi.com/crlsql/ servlet/crlonline. 2011. 9. Micromedex Healthcare Series: alendronate sodium. http://newmdx.csis.com.tw. 2011 10. Rebecca W,Vicky B. Handbook of Drug Administration via Enteral Feeding Tubes 2007:72-73. 58 THE JOURNAL OF TAIWAN PHARMACY Vol.28 No.1 Mar. 31 2012
11. Tanner SB, Taylory HM. Feeding Tube Administration of Bisphosphonates for Treating Osteoporosis in Institu- tionalized Patients with Developmental Disabilities Bone 2004; 34(1): 97-98. 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. 31 2012 學雜誌 第110冊 59 長 理之家老人長