从老人用药门诊及长照处方看潜存的用药问题分析.ppt

从老人用药门诊及长照处方看潜存的用药问题 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 学名 含量 剂量 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种药（不只一位医师的处方） 8种用法，用药时间复杂 用药总次数：20次/日 用药总量：20颗药/日 健保给付：508元/日 On NG，有时由邻居协助灌食 不可磨粉的药品 商品名 学名 含量 剂型 1 Nexium Esomeprazole 40 mg 肠溶锭 （延迟释放） 2 Harnalidge Tamsulosin 0.2 mg 持续性释放胶囊 持续释放口溶锭 3 Tramadol 100 mg 持续性药效锭 4 Etodolac 400 mg 持续性药效锭 药品磨粉后 Nexium：esomeprazole Mg在酸性pH迅速降解 持续性药效剂型： 不良反应?，作用持续时间? 数据源：台大医院处方集、健保用药品项查询、卫生署许可证 用药注意事项 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 药品交互作用或不适当用药 Sertraline + tramadol ? risk of seizures & serotonin syndrome (HTN, hyperthermia, myoclonus, mental status changes) 高血压病人长期服用etodolac Na+ and water retention 同药理作用 2 α-blockers Hytrin? (terazosin) For HTN and BPH Harnalidge? (tamsulosin) For BPH 必要性？ 该个案为bladder Ca, on foley 常见处方问题 用药品项繁多 处方来自不同医师或医疗院所 用以判断剂量或禁忌的信息不足 使用鼻胃管或药品需磨粉，却开立、使用不可磨粉的药品 Dulcolax? tab (bisacodyl) 剂量过高或不足 用药期间过