從老人用药门诊及长照处方看潜存的用药问题.pptVIP

從老人用藥門診及長照處方看潛存的用藥問題 吳如琇 藥師 Drug-Related Problems A Drug-related problem is an event or circumstance involving drug therapy that actually or potentially interferes with desired health outcomes. PCNE Classification scheme for Drug-Related Problems V5.01, 2006 PCNE: Pharmaceutical Care Network Europe Foundation Drug-Related Problems Suboptimal Prescribing Overuse or polypharmacy Inappropriate use Underuse Prescribing or dispensing errors Drug use process Inappropriate administration Lack of monitoring Adverse drug events A case of polypharmacy 75 y/o, male Homebound, bedridden 重度失能 On NG, on foley CVA, HTN Bladder Ca, metastatic 商品名 學名 含量 劑量 1 Mekei Megestrol 160 mg 1# QD 2 Bonfos clodronate 400 mg 1# BID 3 Nexium Esomeprazole 40 mg 1# QDAC 4 Harnalidge Tamsulosin 0.2 mg 1# HS 5 Hytrin Terazosin 2 mg 1# HS 6 Tramadol 100 mg 1# Q12H 7 Sertraline 50 mg 1# HS 8 Flutamide 250 mg 1# TID 9 Etodolac 400 mg 1# Q5PM 10 MgO 250 mg 1# QID 11 Ambroxol 30 mg 1# TID QID TID Q12H QD BID QD AC Q5PM HS 每天服用11種藥（不只一位醫師的處方） 8種用法，用藥時間複雜 用藥總次數：20次/日 用藥總量：20顆藥/日 健保給付：508元/日 On NG，有時由鄰居協助灌食 不可磨粉的藥品 商品名 學名 含量 劑型 1 Nexium Esomeprazole 40 mg 腸溶錠 （延遲釋放） 2 Harnalidge Tamsulosin 0.2 mg 持續性釋放膠囊 持續釋放口溶錠 3 Tramadol 100 mg 持續性藥效錠 4 Etodolac 400 mg 持續性藥效錠 藥品磨粉後 Nexium：esomeprazole Mg在酸性pH迅速降解 持續性藥效劑型： 不良反應?，作用持續時間? 資料來源：台大醫院處方集、健保用藥品項查詢、衛生署許可證 用藥注意事項 Bonefos? (clodronate sodium) Oral absorption ? by food, esp. those containing Ca2+ or other polyvalent cation Maintain adequate hydration throughout treatment Adjust dose according to renal function Monitor serum and urinary calcium, serum phosphate, and SCr 藥品交互作用或不適當用藥 Sertraline + tramadol ? risk of seizures serotonin syndrome (HTN, hyperthermia, myoclonus, mental status changes) 高血壓病人長期服用etodolac Na+ and water retention 同藥理作用 2 α-blockers Hytrin? (terazosin) For HTN and BPH Harnalidge? (tamsulosin) For BPH 必要性？ 該個案為bladder Ca, on foley 常見處方問題 用藥品項繁多 處方來自不同醫師或醫療院所 用以判斷劑量或禁忌的資訊不足 使用鼻胃管或藥品需磨粉，卻開立、使用不可磨粉的藥品 Dulcolax? tab (bisacodyl) 劑量過高或不足