長期藥事照用藥安全 Drug Safety 護長期臥床病人合併多重疾病之藥物使用評估 臺北市立聯合醫院藥劑部藥師趙瑩 葉馨智 方秀麗 樓亞洲 陳立奇 摘要 67 98 7 warfarin 98 8 99 4 warfarin atrial fibrillation stroke diabetes 壹 前言 (Atrial fibrillation, AF) aspirin warfarin 貳 案例介紹一 基本資料 67 151.4 cm 57.7 kg BMI 25 kg/m 2 97/10/14 1250 kcal 二 過去病史 insulin 97/10/13~98/6/31 98/6/10~99/1/13 97/11/26~98/3/20 ( ) 132 THE JOURNAL OF TAIWAN PHARMACY Vol.28 No.2 Jun. 30 2012
期藥事照護三 家族史 表一疾病問題與用藥 98/ 2 98/3 98/4 98/5 98/6 98/7 98/8 98/9 98/10 98/11 98/12 99/1 99/2 99/3 99/4 99/5 Pantoloc (pantoprazole 40 mg) po 1 tab qd ac v v Kascoal (dimethicone 40 mg) po 1 tab tid v v v v v Tsurupinate (piperilatet HCl /Neusilin149 mg) po 1 tab tid v Topaal (alginic acid/al (OH) 3 /MgCO 3 300 mg) po 1 tab tid v v v Emetrol (domperidone 10 mg) po 1 tab tid v v v Nogout (benzbromarone 100 mg) po 1 tab qd v v v v v v v v DC Fluitran (trichlormethiazide 2 mg) po 1 tab qd v v v v v v v v v v v v v v v v Warfarin (warfarin 5 mg) po 0.5 tab qd v v v v v 7/6 DC po 0.5 tab qod 7/ 15 v v v v v v v Perilax (pentoxifylline 400 mg) po 1 tab bid v v v v v 7/8 DC Lipanthyl (fenofibrate 160 mg) po 1 tab qn 6/10 on v v v v v v v DC Warfarin Vitamin K1 (Vitamin K 10 mg) im 1amp stat 7/8 stat 四 檢驗報告 Novomix (insulin aspart30%, insulin aspart protamine70%) SC 24U/16U v v v v v v v v v v v v v v SC 18U/12U v v ~ () 表二 INR 值 / 98/4/14 98/5/13 98/7/6 98/7/8 98/7/15 98/8/21 98/9/18 98/10/15 INR 3 1.71 1.7 7.7 8.11 1 2.9 1.52 1.52 / 99/1/12 99/1/18 99/2/11 99/4/27 INR 3 3.9 3.95 0.95 1.37 參 案例問題評估與建議追蹤 一 Warfarin 引起出血事件評估 ( 一 ) 病人出血事件經過及處置 1. 98/7/5 98/7/6 INR 7.7 warfarin 98/7/8 INR 8.11 ( ) vitamin K pentoxifylline 2. Warfarin (International Normalized Ratio, INR) INR>5 1,2 INR 5-9 warfarin INR vitamin K 0.5-1 mg INR 8 28 2 Jun. 30 2012 藥學雜誌第 111 冊 133 長
長期藥事照用藥安全 Drug Safety 護3. (1) - warfarin fenofibrate INR warfarin (prothrombin time, PT) INR 3 (2) - pentoxifylline ( 二 ) 出血事件後 warfarin 使用討論 1. warfarin 1 warfarin ( ) 10-20% Af INR 2.0-3.0 1.5-2.5 2,4 INR 3.0 INR 2,4 2. 98/7/15 warfarin 2.5 mg qd 2.5 mg qod 98/7/15 INR 1.0 98 8-12 INR 8/21 (coffee ground) 99 1 INR 3 INR warfarin 99 3 99/3/28 3 INR warfarin 1 2 二 高血脂用藥評估 ( 一 ) 病人血脂控制情形 9 8 / 5 / 2 7 (TG, triglyceride) 308 mg/dl (TC, total cholesterol) 226 mg/dl HDL-C 34 mg/dl LDL-C = (TC) (HDL-C) (TG 5) 130.4 mg/dl ( ) 98/6/10 fenofibrate 160 mg 98/10/22 TG 183 mg/dl TC 195 mg/dl 表三一般檢驗項目與檢驗值 / 98/3/10 98/5/27 98/7/14 98/8/29 98/10/22 99/1/18 99/5/5 BUN 6-21 mg/dl 18.4 21.3 29.2 21 3.1 22.1 SCr 0.5-1.3 mg/dl 0.6 0.6 0.7 0.6 0.8 0.7 0.8 AST 11-47 IU/L 23 14 15 16 15 ALT 7-53 IU/L 28 15 3 10 TG 150 mg/dl 308 227 183 98 TC 200 mg/dl 226 226 195 167 HDL 50 mg/dl 34 46 LDL 70 mg/dl 130.4 Uric acid 4.8-8.7 mg/dl 10.1 3.1 2.4 1.4 134 THE JOURNAL OF TAIWAN PHARMACY Vol.28 No.2 Jun. 30 2012
期藥事照護( 二 ) 討論 98/10/22 TG TC 200 (Ame r i c a n mg/dl Diabetes Association, ADA) TG 150 mg/dl LDL-C <100 99/1/13 fenofibrate warfarin mg/dl fenofibrate < 70 mg/dl HDL-C 40 99/2 mg/dl 50 mg/dl 5 98/9 99 BMI ( ) ( 三 ) 追蹤及建議 99/5 TG TC LDL-C HDL-C 表四飲食熱量控制與 BMI 值 / 98/1 98/2 98/8 98/9 99/1 99/6 kcal/day 1250 1250 1250 1000 1000 1000 BMI 18.5~24 kg/m 2 27 28 23.9 23.8 23 23.5 三 高尿酸用藥評估 ( 一 ) 病人尿酸控制 10 98/5/27 10.1 mg/ 98 5 dl 98/6/10 99/1/13 benzbromarone ( ) 2 98/10/22 2.4 mg/dl 99/5 1.4 mg/dl 四 血糖控制情形討論 ( 二 ) 討論 建議及追蹤 ( 一 ) 病人血糖控制 7.0 mg/ HbA1c 97-98 dl 7 7.5% 180-7 6 6 190 mg/dl ( ) ( 二 ) 討論 建議及追蹤 insulin 28 2 Jun. 30 2012
長期藥事照用藥安全 Drug Safety 護 99/4-6 6.3% 2 7.0% 6.5% 7 表五血糖值 / 98/5 98/8 98/10 98/11 99/2 99/4 99/6 Glucose AC 70-130 mg/dl 83 194 89 192 63 HbA1c 7.0% 7.4 7.6 7.4 6.3 表六血壓值 / 98/7 98/8 98/9 98/10 98/11 98/12 99/1 99/2 99/3-5 130/80 mmhg 124/66 129/70 122/71 120/73 119/75 127/71 116/75 122/65 128/76 肆 結論 warfarin 8 4 伍 致謝 參考資料 : 1. MICROMEDEX(R) Healthcare Series:Warfarin http://newmdx.csis.com.tw/hcs/librarian 2010/06/23 2. Fuster V, Rydén LE, Cannom DS., et al: ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation-Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): Developed in Collaboration With the European Heart Rhythm Association and the Heart Rhythm Society. Circulation 2006;114;700-752. 3. http://dif.fda. gov.tw/ 2010/06/23 4. [ ] ; 2007 184p 5. American Diabetes Association: Standards of medical care in diabetes-2010. Diabetes Care. 2010; 33(Suppl. 1): S11-6. 6. Joseph T. DiPiro, Robert L. Talbert, Gary C. Yee, et al. Pharmacotherapy: A Pathophysiologic Approach, 7th. Ed. New York: McGraw-Hill 2008: 1539-50. 7. Dluhy RG, McMahon GT. Intensive glycemic control in the ACCORD and ADVANCE trials. N Engl J Med 2008; 358(24): 2630-3. 136 THE JOURNAL OF TAIWAN PHARMACY Vol.28 No.2 Jun. 30 2012
期藥事照護Drug Evaluation of Patient with Abstract Long-Term Bed-Ridden and Multiple Diseases Ying Zhao, Shing-Chih Yeh, Show-Li Fang, Yea-Jou Lou, Lih-Chi Chen Department of Pharmacy, Taipei City Hospital A 67-year-old female has lived in a nursing home since October 2008. Her past history included stroke, type II diabetes, congestive heart failure, atrial fibrillation (AF), pulmonary embolism, hypertensive heart disease, hyperuricemia, hyperlipidemia, and functional gastrointestinal disorder. She was taking eight drugs for these diseases. Warfarin was one of her medications and was prescribed for preventing the recurrence of stroke due to Af. An adverse event of warfarin intoxication occurred in July, 2009. We were tasked with evaluating her medication. Problems with drug-drug interaction and unnecessarily prescribed drugs were found. After our intervention, the total numbers of drugs in her prescription reduced from eight to four in a year. This may prevent the occurrence of drug-drug interaction and the waste of unnecessary medication. 28 2 Jun. 30 2012 藥學雜誌第 111 冊 137 長