從老人用藥門(mén)診及長(zhǎng)照處方看潛存的用藥問(wèn)題(課堂PPT)

1、從老人用藥門(mén)診及長(zhǎng)照處方看潛存的用藥問(wèn)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

2、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 fol

3、ey CVA, HTN Bladder Ca, metastatic,每天服用11種藥（不只一位醫(yī)師的處方） 8種用法，用藥時(shí)間複雜 用藥總次數(shù)：20次/日 用藥總量：20顆藥/日 健保給付：508元/日 On NG，有時(shí)由鄰居協(xié)助灌食,不可磨粉的藥品,藥品磨粉後 Nexium：esomeprazole Mg在酸性pH迅速降解 持續(xù)性藥效劑型： 不良反應(yīng)，作用持續(xù)時(shí)間 資料來(lái)源：臺(tái)大醫(yī)院處方集、健保用藥品項(xiàng)查詢、衛(wèi)生署許可證,用藥注意事項(xiàng),Bonefos (clodronate sodium) Oral absorption by food, esp. those containing Ca2

4、+ 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(dāng)用藥,Sertraline + tramadol risk of seizures & serotonin syndrome (HTN, hyperthermia, myoclonus, mental status chan

5、ges) 高血壓病人長(zhǎng)期服用etodolac Na+ and water retention,同藥理作用,2 -blockers Hytrin (terazosin) For HTN and BPH Harnalidge (tamsulosin) For BPH 必要性？ 該個(gè)案為bladder Ca, on foley,常見(jiàn)處方問(wèn)題,用藥品項(xiàng)繁多 處方來(lái)自不同醫(yī)師或醫(yī)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(kāi)立、使用不可磨粉的藥品 Dulcolax tab (bisacodyl) 劑量過(guò)高或不足 用藥期間過(guò)長(zhǎng) 以藥品治療藥品不良反應(yīng),常見(jiàn)處方問(wèn)題,長(zhǎng)期服用癥狀治療的藥

6、品 Antihistamine 止咳、化痰藥品 消化系統(tǒng)用藥 止痛藥 頭暈的藥 Diphenidol, Sibelium (flunarizine) 促進(jìn)循環(huán)的藥 Euclidan (nicametate), Trental (pentoxifylline),常見(jiàn)處方問(wèn)題,併用同藥理作用之藥品 Benzodiazepine -blocker 數(shù)種CNS depressants Benzodiazepine, hypnotic, antihistamine, TCA,常見(jiàn)處方問(wèn)題,藥品交互作用 Fibrate + statin 藥品禁忌或特別注意事項(xiàng) BPH的病人用anticholinergic

7、或有anticholinergic side effects的藥品 Imipramine, 1st generation antihistamine 高血壓病人長(zhǎng)期服用NSAIDs,處方評(píng)估之後,對(duì)處方問(wèn)題提出建議 原開(kāi)方醫(yī)師的接受度 病人或家屬的接受度 機(jī)構(gòu)的接受度 何時(shí)更改處方 當(dāng)處方來(lái)自不同醫(yī)師 該對(duì)哪位醫(yī)師提出建議,服藥時(shí)間,82歲的阿嬤說(shuō)她每天下午5點(diǎn)多都會(huì)發(fā)生低血糖現(xiàn)象，測(cè)得的血糖值在70 mg/dL以下 服藥時(shí)間 Metformin：早餐後 Glyburide：下午3點(diǎn)，沒(méi)吃任何食物,與用藥相關(guān)的問(wèn)題,不了解用藥時(shí)間、方法或注意事項(xiàng) Hypoglycemic agent, diuretics, adsorbent Inhaler 藥品儲(chǔ)存的問(wèn)題 地點(diǎn)、空間、溫度 發(fā)生不良反應(yīng)不知尋求醫(yī)療協(xié)助 Aspirin or NSAID related bleeding disorder 保健食品,如何讓藥品發(fā)揮最大的