阻力訓練 Resistance exercise training (RET)

阻力訓練可以增加肌肉量.
*High total energy expenditure leads to increased longevity (JAMA 2006;296:171) *Resistant exercise can increase muscle mass. (J Gerontol: Med Sci 2006; 61A: 78. J Appl Physiol 2001;90:2341)

Trunk Flexion extension.
Hip abduction/adduction

另, 老人的預防失能可以參考韓德生醫師的PPT
https://www.tma.tw/TakeCare2018/files/0819_4.pdf

靜態阻力訓練. 肌肉長度不改變 isometric exercise.

Resistance Tubing: The Answer to Weight Training Tools

還可以利用家中的環境作阻力訓練, 下面是露天拍賣的商品. 

https://goods.ruten.com.tw/item/show?30184833782490

也可以利用橡皮帶作訓練

或

老人的肌衰弱測試

.
.

.
.

運動處方 EIM 運動可治療的疾病

1. 關節炎 arthritis
Prevention: possibly through weight control
• Treatment: yes
• Effective modality: AET, RET, aquatic ex
– Low impact
– Adequate volume to achieve healthy weight

Cancer

• Prevention: yes 

• Treatment: yes, for QOL, wasting, lymph edema, psychological function, breast ca survival 

• Effective modality: AET, RET

COPD

• Prevention: no 

• Treatment: yes, for extrapulmonary benefit 

• Effective modality: AET, RET 

– RET is more tolerable in severe dis, complementary effects in combined modality 

– Ex with bronchodilator use 

– Use O2 during ex if needed

Cognitive impairment

• Prevention: yes 

• Treatment: yes 

• Effective modality: AET, RET 

– Mechanism unknown 

–Need supervision in dementia

Hypertension

• Prevention: yes 

• Treatment: yes 

• Effective modality: AET, RET 

– Large change in those reduce weight 

– Small reduction in both SBP & DBP

Osteoporosis

• Prevention: yes 

• Treatment: yes 

• Effective modality: AET, RET, balance training, high-impact ex 

– Weight bearing, high-impact, high-velocity (jump) 

– RET effect is local around contracted muscles 

– Balance training to prevent fall

Peripheral vascular disease 

• Prevention: yes

• Treatment: yes 

• Effective modality: AET, RET 

– Systemic vascular effect 

– Ex volume to the limits of pain tolerance to improve claudication 

– RET is less robust

Benefits of AET in older adult

• Aerobic ex capacity (A): sufficient AE intensity (>60% of pretraining VO2max), freq, and length (>3 d/wk for >16 wk) increase VO2max in healthy middle & old aged adults 

• CV effects (A): >3 mo of mod-intensity AE elicits CV adaptations in healthy middle & old aged adults, at rest & acute dynamic ex 

• Body composition (A/B): mod-intensity AET reduce body fat in obese middle & old aged adults, no effect on FFM 

• Metabolic effect (B): AET can enhance glycemic control, augment postprandial lipids clearance, and utilize fat during submax ex 

• Bone health (B): AET can counteract agerelated decline in BMD in post-menopausal ˖

• Muscle strength can be increased after RET(A)

• Muscle quality is increased after RET(B). similar between older and younger, male and female

• Muscle endurance can be improved by mod- or high-intensity RET, not low-intensity (C). 

• Body composition (B/C): FFM increased. FM decreased with mod- or high-intensity RET

• High-intensity RET improved BMD relative to sedentary control(B)

• Metabolic and endocrine effects (B/C): the evidence is mixed. 

Benefits of balance training in older adult 

• (C): Multimodal ex, including stength and balance ex, and Tai-chi 太極拳 have been shown to be effective in reducing the risk of non-injurious and sometimes injurious falls in populations who are at elevated risk of falling. 

Benefits of stretching and flexibility training in older adult

(D) there is some evidence that flexibility can be increased in the major joints by ROM ex; however, how much and what types of ROM ex are most effective have not been established. 

運動處方

FOTT-Pro

= frequency, intensity, time, type, proression. 

種類

- AET aerobic exercise training: jog, stair climb, brisk walk, bicycle, swim

- Resistance exercise training RET: weight lift, theraband, weight training. 

- Flexibility exercise: stretch

- balance impact exercise: sprinting, single-leg stance

特異性

有氧運動

- 中等強度 for 30-60 min on 5d/wk, 或vigorous-intensity 激烈強度 20-30 min on 3d/wk (1A). 

- 10 point scale (sitting 0, all-out 10)

~ mod: 5/6 , noticeable increase in HR and Breath. 

~ vig: 7/8 , large increase in HR and breath

- Routine light-intensiry ADL or mod-intensity activity < 10 min are not included. 

- Walking, stationary bike, aquatics (NWB no weight bearing). 

- define aerobic intensity by fitness, instead of absolute term (eg, MET). 

~~ 50-85% of O2 uptake reserve

~~5-8/10 of perceived effort 自覺運動強度

~~~ correlated but not linearly

~~A period of supervised exercise may help them learn the desired level of effort 

肌力訓練

Muscle-strengthening activity

• Maintain or increase muscular strength and endurance >2d/wk (IIaA) 

• At least 1 set of 8-10 ex using major m. on 2 or more nonconsecutive days per wk 

• 8-12rep, 1-3set, mod to high intensity 

• 10-point scale (no move:0, max effort:10) – Mod-int: 5/6, High-int: 7/8 – 40-50% 1RM -> 60-80% 1RM 

• Mode: progressive wt training, wt bearing calisthenics, stairs climbing, similar resistance ex

 

Greater amount of activity 

• Additional health benefits & physical fitness in higher levels of AE/RE(IA) 

– If no condition preclude higher amounts of PA 

      • Improve fitness 

      • Improve management of existing dz 

      • Reduce risk of premature chronic condition 

• Higher impact weight bearing activity for skeletal health (IIaB) 

• Higher PA for preventing weight gain (IIaB)

Flexibility activity

• 2 d/wk for >10 min/d to maintain flexibility necessary for regular PA and daily life (IIbB) 

• Major muscle and tendon with 30-60s for a static stretch 

• Stretch to the point of feeling tightness or slight discomfort; static, not ballistic 

• Perform on the day that AE or RE is performed 

• Specific health benefit is unclear 

   – Reduce risk of ex-related inj

Balance exercise

• Balance exercise to reduce risk of falls in community-dwelling older adults (IIaA) 

• Multi-component interventions prevent fall in community elderly 

• Ex, not activity (eg.dancing) is recommended, though PA itself could reduce falls 35-45% 

• 3 times/wk? Preferred types, frequency, and duration are unclear 

• No evidence for LTC and hospital setting

整合預防性及治療性活動

• 對許多疾病而言是相同的

• 骨質酥鬆為例, 預防性運動: 有氧,阻力, 平衡, 柔軟度,

  • 強調負重急高衝力活動, 例如跳躍 

   –Osteoporosis as example: preventive for aerobic, resistance, balance, flexibility. Emphasize wt bearing and high impact activity, like jumping

• At least avoid sedentary behavior, when chronic conditions preclude minimum recommended activity. – Activity limitation: assess the nature of the activity limitation, the capability and preferences of the person. Usually determine the target activity level and details of activity plan mostly in CR/PR centers, or ex classes.

老人照護的一般原則

- 不要給太辛, 太複雜活動, 最好是老人們以前熟悉有興趣的

- 從低強度開始, 隨時保持警覺性, 適時加以調整老人們活動內容及強度

- 提供老人安全舒適的活動空間, 例如照明, 地板防滑, 行進動線, 洗手間設備等. 

- 注意老人服用多種藥物的情況. 

 

野外與登山醫學---高海拔腦水腫 High Altitude Cerebral Edema 2019-12-17 by Jacob D. Jensen; Andrew L. Vincent.

High Altitude Cerebral Edema (HACE)
Jacob D. Jensen; Andrew L. Vincent.
Last Update: December 17, 2019.

Introduction 簡介

高海拔腦水腫 HACE 是高海拔疾病的嚴重潛在致死表現, 特徵是運動失調, 疲憊, 神智改變

HACE 被視為是 AMS 末期表現, 雖然 HACE 在高海拔疾病的發生率不高, 但可能在 24 小時內致死

(並非一定能活 24 小時, 而是 24 小時內若沒有適當診斷治療可能死亡)
(HACE沒有黃金時間, 一但診斷需立即處置)
High Altitude Cerebral Edema (HACE) is a severe and potentially fatal manifestation of high altitude illness and is often characterized by ataxia, fatigue, and altered mental status. HACE is often thought of as an extreme form/end-stage of Acute Mountain Sickness (AMS). Although HACE represents the least common form of altitude illness, it may progress rapidly to coma and death as a result of brain herniation within 24 hours, if not promptly diagnosed and treated.

Etiology 病因

HACE通常在上升到海拔 4000m 以上兩天後發生, 但也可能在較低海拔 2500m 快速發生. 

有一些患者會出現AMS症狀, 但並非全部. 也有些人會同時罹患 HAPE.

單獨發生HACE較罕見, 但即使沒有先出現 HAPE或 AMS, 也不能直接排除 HACE.
HACE generally occurs after 2 days above 4000m but can occur at lower elevations (2500m) and with faster onset. Some, but not all, individuals will suffer from symptoms of AMS such as headache, insomnia, anorexia, nausea prior to transitioning to HACE. Some may also have concomitant High Altitude Pulmonary Edema (HAPE). HACE in isolation is rare, but the absence of concomitant HAPE or symptoms of AMS prior to deterioration does not rule-out the presence of HACE. 

Epidemiology 

HACE在海拔 4000-5000 公尺的盛行率約 0.5-1%, HACE 會影響各年齡層與性別, 但年輕患者的機率較高 (年輕人較高的原因, 例如帶著症狀上升, 或爬升速率較快)

HACE危險因子包括

1. prior history of high altitude illness 先前曾經罹患高海拔疾病

2. lack of acclimatization 缺乏高度適應

3. heavy physical exertion 大量體力活動

4. rapid rate of ascent 快速上升

5. abrupt ascent from lower altitudes. 突然從低海拔爬升至高海拔

Incidence of HACE is 0.5-1% at altitudes of 4000-5000 m. HACE affects those of all ages and genders, though younger males may be at higher risk due to continuation of ascent despite symptoms of AMS and faster rate of ascent. Risk factors include prior history of high altitude illness, lack of acclimatization, heavy physical exertion, rapid rate of ascent, and abrupt ascent from lower altitudes.

Benzbromarone 促尿酸排泄 Gouless Euricon

促尿酸排泄藥物 (benzbromarone, sulfinpyrazone) 

對尿酸之製造無影響，而僅是增加其排除

會增加尿路結石及尿酸腎病變機率

因此不適用於下列病患：

(1) 製造過多引起的高尿酸血症

(2) 腎功能降低時，此類藥物會失去效用，尤其是 sulfinpyrazone 在肌酸酐廓清率 (creatinine clearance, CCr) <30 mL/min 時無效，宜避免使用

(3) 有尿酸成分尿路結石者為禁忌，因易增加尿路結石及尿酸腎病變危險。

促尿酸排泄藥物通常要從小劑量開始，且喝水要充足，以預防尿路尿酸結石的副作用。

Benzbromarone
初始劑量 50 mg qd. 需多喝水
Peak: 服藥之後 2-3 小時到達最大血中濃度
Duration: 半衰期 half life 12-13 小時
Max 100 mg qd. (但euricon原廠仿單說 150 mg qd)

警示, 六個月內應定期檢查肝功能.
1. 猛爆性肝炎, 服藥六個月內可能發生
2. 肝功能異常需停藥. 

禁忌
1. 腎結石病患, 嚴重腎功能不良
2. 懷孕或可能懷孕的婦女
3. 肝功能異常.

注意事項:
1. 急性痛風發作不要吃
2. 服藥初期有誘發痛風的可能
3. 尿液在酸性環境容易產生尿酸結石, 應增加喝水

Bell's palsy and Ramsay hunt syndrome 顏面神經麻痺 耳朵皰疹

下面這篇是黃醫師找到的, 來不及翻譯. 另外貼這裡 

Antiviral treatment for Bell's palsy (idiopathic facial paralysis).

Abstract

BACKGROUND:

Corticosteroids are widely used in the treatment of idiopathic facial paralysis (Bell's palsy), but the effectiveness of additional treatment with an antiviral agent is uncertain. This review was first published in 2001 and most recently updated in 2015. Since a significant benefit of corticosteroids for the early management of Bell's palsy has been demonstrated, the main focus of this update, as in the previous version, was to determine the effect of adding antivirals to corticosteroid treatment. We undertook this update to integrate additional evidence and to better assess the robustness of findings, taking risk of bias fully into account.

AUTHORS' CONCLUSIONS:

The combination of antivirals and corticosteroids may have little or no effect on rates of incomplete recovery in comparison to corticosteroids alone in Bell's palsy of various degrees of severity, or in people with severe Bell's palsy, but the results were very imprecise. Corticosteroids alone were probably more effective than antivirals alone and antivirals plus corticosteroids were more effective than placebo or no treatment. There was no clear benefit from antivirals alone over placebo.The combination of antivirals and corticosteroids probably reduced the late sequelae of Bell's palsy compared with corticosteroids alone. Studies also showed fewer episodes of long-term sequelae in corticosteroid-treated participants than antiviral-treated participants.We found no clear difference in adverse events from the use of antivirals compared with either placebo or corticosteroids, but the evidence is too uncertain for us to draw conclusions.An adequately powered RCT in people with Bell's palsy that compares different antiviral agents may be indicated.下面這篇是黃醫師找到的, 來不及翻譯. 另外貼這裡 

Antiviral treatment for Bell's palsy (idiopathic facial paralysis).

Abstract

BACKGROUND:

Corticosteroids are widely used in the treatment of idiopathic facial paralysis (Bell's palsy), but the effectiveness of additional treatment with an antiviral agent is uncertain. This review was first published in 2001 and most recently updated in 2015. Since a significant benefit of corticosteroids for the early management of Bell's palsy has been demonstrated, the main focus of this update, as in the previous version, was to determine the effect of adding antivirals to corticosteroid treatment. We undertook this update to integrate additional evidence and to better assess the robustness of findings, taking risk of bias fully into account.

AUTHORS' CONCLUSIONS:

The combination of antivirals and corticosteroids may have little or no effect on rates of incomplete recovery in comparison to corticosteroids alone in Bell's palsy of various degrees of severity, or in people with severe Bell's palsy, but the results were very imprecise. Corticosteroids alone were probably more effective than antivirals alone and antivirals plus corticosteroids were more effective than placebo or no treatment. There was no clear benefit from antivirals alone over placebo.The combination of antivirals and corticosteroids probably reduced the late sequelae of Bell's palsy compared with corticosteroids alone. Studies also showed fewer episodes of long-term sequelae in corticosteroid-treated participants than antiviral-treated participants.We found no clear difference in adverse events from the use of antivirals compared with either placebo or corticosteroids, but the evidence is too uncertain for us to draw conclusions.An adequately powered RCT in people with Bell's palsy that compares different antiviral agents may be indicated.

藥物不良反應 副作用 Statins

2014年 CLINICAL REVIEW  有一篇文章
Statin Adverse Effects: Sorting out the Evidence; Clinician Reviews. 2014 November;24(11):41-43,46-50

哪一種statin 比較安全呢?

WHICH DRUG? POTENTIAL DIFFERENCES IN STATINS

肝毒性機率並不高
HEPATIC EFFECTS ARE RARE

Historically, statins have been linked to potential hepatotoxicity, with case reports of serum transaminase elevation, cholestasis, hepatitis, and acute liver failure. It is now recognized that hepatic AEs are rare and that statins are not associated with a risk for acute or chronic liver failure.1,11 In patients with coronary heart disease, the incidence of hepatotoxicity with statin use is reported to be less than 1.5% over the course of five years and appears to be dosedependent.1 In 2012, the FDA revised the labeling for most statins, relaxing its earlier recommendations formonitoring of liver function, clarifying the risk for myopathy, and providing additional information about drug interactions.13 Checking transaminase levels before initiating therapy is recommended by both the ACC/AHA and the FDA.1,13 Routine monitoring is not necessary, the ACC/AHA guideline states, because RCTs have found little evidence of ALT/AST elevation.1 But here, too, evidence varies. An older meta-analysis (13 trials and nearly 50,000 participants) concluded that as a class, statins have no greater risk for transaminase elevations than placebo.22 But the 135-RCT meta-analysis4 found otherwise: Statins did increase the risk for transaminase elevation (odds ratio [OR], 1.51) compared with placebo, with differences associated with particular drugs and higher doses associated with more clinically significant elevations.4 It is important to note, however, that there was signifcant heterogeneity among the studies and no consistent definition of clinical significance. The bottom line: Statins have been shown in multiple prospective studies to be safe for patients with chronic liver disease.2

Statins 會造成DM 嗎? 機率並不高, 各種STATINS之間差異也不大. 有一篇分析 11 萬名病患的統合分析發現, 沒有統計上意義.
STATIN USE AND DIABETES: IS THERE A LINK?
Recent studies have found an increased risk for newonset type 2 diabetes in statin users, with a greater risk associated with higher-potency statins, including rosuvastatin and atorvastatin.4,24 Although the exact mechanism is not known, statins may modify insulin signaling in peripheral tissues or directly impair insulin secretion. The ACC/AHA guideline reports an excess rate of diabetes of one per 1,000 patient-years for moderateintensity therapy and three per 1,000 patient-years for high-intensity therapy.1 The 2013 meta-analysis found that the elevated risk for diabetes was relatively small (OR, 1.09).4 No difference among various statins was found. In another meta-analysis—this one encompassing 17 RCTs and more than 110,000 patients—no statistically significant difference in the incidence of new-onset diabetes was seen based on either the specific statin being taken or the intensity of therapy (high vs moderate)

一篇收集 24 萬人的統合分析發現

1. 所有statins, 因為副作用停藥的比例 5.7%

2. Atovastatin 和 Rosuvsatatin 停藥機率最高

3. Atovastatin 和 Fluvastatin 發生肝指數上升機率最高 (OR 各為 2.6 及 5.2 )

4. 患者對於 Pravastatin 和 Simvastatin 耐受性最佳, 這兩個是最安全的, 因副作用停藥機率最低

5. Simvastatin 如果服用超過一天40mg, 會顯著增加 CK 及 GPT(ALT) 上升機率 (OR 4.1 及 2.8), 罹患橫紋肌溶解機率也會上升

A meta-analysis with more than 240,000 participants evaluated patients taking seven different statins (atorvastatin, fluvastatin, lovastatin, pravastatin, pitavastatin, rosuvastatin, and simvastatin), looking at AEs of the drugs both collectively and individually.4 As noted earlier, the overall discontinuation rate due to AEs for all statins was 5.7%. Discontinuation rates for each agent were not reported.4

The researchers did report, however, that atorvastatin and rosuvastatin had the highest discontinuation rates; atorvastatin and fluvastatin had the highest incidence of transaminase elevations (OR, 2.6 and 5.2, respectively); and pravastatin and simvastatin appeared to be the best-tolerated and safest statins, with the lowest discontinuation rates. However, higher doses of simvastatin (> 40 mg/d) significantly increased the risk for CK and transaminase elevations (OR, 4.1 and 2.8, respectively),4 as well as the risk for rhabdomyolysis when taken at the highest dose.15,16

藥物不良反應 Statins pitavastatin

rate of adverse reactions/side effects
不良反應/副作用的機率
注意, 應該扣去安慰劑的比例
安慰劑造成肢體疼痛的機率比pitavastatin 2mg, 4mg 還高
對於pitavastatin 4 mg 而言, 背痛和肢體疼痛機率比安慰劑低, 便秘機率大於安慰劑, 肌肉痠痛機率高於安慰劑.

警示

WARNINGS & PRECAUTIONS
Myopathy and Rhabdomyolysis: Risk factors include age 65 and greater, renal impairment, inadequately treated hypothyroidism, concomitant use of certain drugs, and higher doses of ZYPITAMAG. ZYPITAMAG is contraindicated in patients taking cyclosporine and not recommended in patients taking gemfibrozil. The following drugs when used concomitantly with ZYPITAMAG may also increase the risk of myopathy and rhabdomyolysis: lipid-modifying dosages of niacin (>1 g/day), fibrates, and colchicine. Discontinue ZYPITAMAG if markedly elevated CK levels occur or myopathy is diagnosed or suspected. Temporarily discontinue ZYPITAMAG in patients experiencing an acute or serious condition at high risk of developing renal failure secondary to rhabdomyolysis; e.g., sepsis; shock; severe hypovolemia; major surgery; trauma; severe metabolic, endocrine, or electrolyte disorders; or uncontrolled epilepsy. Inform patients of the risk of myopathy and rhabdomyolysis when starting or increasing the ZYPITAMAG dosage. Instruct patients to promptly report any unexplained muscle pain, tenderness or weakness particularly if accompanied by malaise or fever.
Immune-Mediated Necrotizing Myopathy (IMNM): There have been rare reports of IMNM, an autoimmune myopathy, associated with statin use. IMNM is characterized by: proximal muscle weakness and elevated serum creatine kinase, which persist despite discontinuation of statin treatment; muscle biopsy showing necrotizing myopathy without significant inflammation; and improvement with immunosuppressive agents.
Hepatic Dysfunction: Increases in serum transaminases can occur. Rare postmarketing reports of fatal and non-fatal hepatic failure have occurred. Consider liver enzyme testing before initiating therapy and as clinically indicated thereafter. If serious hepatic injury with clinical symptoms and/or hyperbilirubinemia or jaundice occurs, promptly discontinue ZYPITAMAG.
Increases in HbA1c and Fasting Serum Glucose Levels: Increases of each have been reported with statins, including ZYPITAMAG. Optimize lifestyle measures, including regular exercise, maintaining a healthy body weight, and making healthy food choices.

ADVERSE REACTIONS: The most frequent adverse reactions (rate ≥ 2%) are myalgia, back pain, diarrhea, constipation and pain in extremity. This is not a complete list of all reported adverse events.

血糖異常應該多久再次檢測

無症狀成人的糖尿病篩檢建議 page 25

曾檢查為葡萄糖失耐、空腹血糖偏高、 或 HbA1C ≥5.7% 者，建議每年篩檢

其他情況, 通常是三年篩檢一次

甲狀腺亢進~停藥條件及停藥後的追蹤

甲狀腺功能異常-台大醫院衛教文章
甲狀腺機能異常與藥物治療
何時可考慮讓甲狀腺亢進病患停用藥物?

甲狀腺亢進停藥條件
治療一年之後(通常建議12-18個月)
.... 抗甲狀腺藥物治療時間通常是 1-2 年. 有研究說, 使用半年就停藥的復發機率較高
甲狀腺濃度正常.
沒有臨床症狀,
促甲狀腺分泌抗體 TSI 已經無法測得

抽血檢驗
停藥後至少追蹤甲狀腺功能3年 (第一年隔3~6個月，以後每隔6~12個月追蹤一次)

- 停藥第一年, 三個月抽血一次
- 停藥第二第三年, 6 個月抽血一次

如果 TSH 濃度上升, 應考慮再治療一年.

停用甲亢藥物之後, 應追蹤甲狀腺素三年

甲亢症復發通常是在停藥第一年內
第一年, 每三個月抽血一次
之後6個月抽血一次

甲亢症在停藥數年後仍可能發生
再發之後, 建議使用放射性碘, 或者手術治療, 也可以再次服用抗甲狀腺藥物

糖尿病合併慢性腎病/腎衰竭/腎功能不良/透析患者的藥物選擇

DPP4i

Onglyza (Saxagliptin) F.C Tab. 5mg CCR<30 2.5mg QD 但洗腎患者不建議使用
Trajenta (Linagliptin)不用調整劑量
Galvus (vildagliptin)eGFR < 50 劑量 50mg qd. 

Januvia 100 mg (sitagliptin) eGFR 45-60 不用調整劑量. 

Diabetes treatment in patients with renal disease: Is the landscape clear enough?

PRESCRIBING GUIDANCE IN PATIENTS WITH RENAL IMPAIRMENT TREND-UK: the diabetes nursing pioneers WWW.TREND-UK.ORG INFO@TREND-UK.ORG  @_TRENDUK TRAINING, RESEARCH AND EDUCATION FOR NURSES IN DIABETES Kindly provided through a PCDS and TREND-UK collaboration - July 2017

2016-09-30 藥學雜誌電子報

CKD stage 4-5 eGFR <30
第四及第五期慢性腎病, 不需調整劑量的抗糖尿病藥物
Pioglitazone 腎衰竭要小心使用 
Trajenta (Linagliptin)不用調整劑量


另一篇說 Gliclazide 和  clipizide 在腎衰竭是可以用的.
Gliclazide
Gliclazide is metabolized by the liver to inactive metabolites that are eliminated in the urine. Thus, gliclazide causes less hypoglycemia than other sulfonylureas. In CKD sage 1, 2, 3 (eGFR > 30 mL/min) gliclazide can be used. There are no data in patients with severe CKD but according to its metabolism the use (in reduced dose) of gliclazide is also permitted in these subjects[19].
Glipizide
Glipizide also does not need dose adjustment in severe and moderate renal disease and can be used safely. (The only caution remains the risk of hypoglycemia).

Pioglitazone: Glitis 30 mg. Actos 15 mg. TZD. 水腫.體液滯留 Cr>4 不用調整劑量

但洗腎患者不建議使用 TZD



Onglyza (Saxagliptin) F.C Tab. 5mg CCR<30 2.5mg QD 但洗腎患者不建議使用 
Trajenta (Linagliptin) 不用調整劑量 
Galvus (vildagliptin) eGFR < 50 劑量 50mg qd. 

CANAGLU 100MG Canagliflozin eGFR < 45 需停用 (Canaglu®可拿糖膜衣錠)

FORXIGA 10MG dapagliflozin eGFR< 45 需停用

 

JARDIANCE 25MG  empagliflozin eGFR<45 需停用

  

Pentoxiphylline 慢性腎病改善蛋白尿

Pentoxifylline 商品名 Ceretal, Pentop, Trental  循血敏 400mg

劑量 400mg TID. 腎功能不良需減量

eGFR 10-50 400mg BID

eGFR < 10 400mg QD

肝功能不良 400mg BID

Pentoxiphylline 應該服用多長時間療程仍不明. 

療效

1. 可改善蛋白尿

2. 是否能延緩 eGFR 衰退仍不明

methyl-xanthine 類衍生物

藉由非選擇性抑制 phosphodiesterase 而產生抗發炎與免疫調節等功能

可促進周邊血管灌流，常用於治療周邊血管或腦血管疾病

動物實驗

減少腎絲球 macrophage 產生

減少發炎前驅 cytokines， TNF-α, intercellular adhesion molecular 1 (ICAM-1)等物質的表現

藥物不良反應

 一般症狀包括噁心、嘔吐、腹瀉、頭痛、頭暈

藥物過量可能的症狀(需降低劑量). 

皮膚潮紅

心跳加快

胸悶

低血壓

禁忌

兒童、 視網膜出血、急性心肌梗塞、懷孕婦女

pentoxifylline 、 methylxanthines 、咖啡因、茶鹼等過敏者，不可使用。

膀胱過動症候群~頻尿、急尿、夜尿 Oxbu Betmiga

膀胱過動症, 不是單一疾病, 而是不同疾病總稱

症狀: 頻尿、急尿、夜尿

第一線治療: 行為治療

第二線治療: 藥物治療

第三線治療: 侵入性手術

第一線治療: 行為治療

排尿日誌，記錄三天, 瞭解病人的喝水量,排尿情形以及急尿感或漏尿的頻率。

每小時喝的水量，排尿時間及排尿量

急尿感或漏尿的情形

治療初步要讓病人了解排尿生理學，減少因為患者對於膀胱漲尿感覺太過敏感，導致習慣性排尿，再者要限制水分的過度攝取，避免容易刺激尿路上皮的食物或飲料，利用膀胱訓練來降低頻尿,急尿的感覺。

第二線治療: 藥物治療

藥物治療以抗膽鹼藥物為主，作用機轉~拮抗膀胱的乙醯膽鹼受體，減少膀胱逼尿 肌收縮。

禁忌: 隅角閉鎖性青光眼、胃排空延遲（gastric retention）、重症肌無力、尿液滯留

抗膽鹼藥物包含 darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine

1. 各類藥物特性不同
2. 各類藥物療效差異不大

3. 緩釋劑可減少副作用(口乾)

第二種藥物 mirabegron (Betmiga貝坦利持續性藥效錠25毫克)

選擇性 β3 乙型交感受體促進劑

作用機轉: 活化膀胱逼尿肌β3受體，進而抑制逼尿肌收縮，增加膀胱儲尿容積，

改善尿失禁症狀方面與抗膽鹼類藥物具相似療效，但價格較高。

mirabegron 劑量 25-50mg QD， 藥物半衰期長，一天一次即可

mirabegron 禁忌

血壓控制不良患者 (超過 180/110 mmHg)

藥物治療效果 (抗膽鹼/ mirabegron)

需服用 2-4 周才會達到明顯效果

若抗膽鹼藥物治療效果不佳, 可加上 mirabegron 

副作用太大, 調整劑量或更換另一種抗膽鹼藥物

副作用~口乾、便秘以及認知功能下降

1.機率與安慰劑相似

2.機率低於抗膽鹼藥物

其他副作用: 高血壓、鼻咽發炎（nasopharyngitis） 頭痛, 泌尿道感染

止痛藥與抽菸~何者發生慢性腎病機率高?

2015台灣慢性腎臟病臨床診療指引_國家衛生研究院
下載區

UKPDS 資料: 2006 年發表, 追蹤 5,102 名腎功能正常無白蛋白尿之 DM 成年人 15 年

1. 糖尿病

2003 年美國馬里蘭州研究, 追蹤20年

DM男性相較於沒有DM的男性, CKD 風險比 Hazard Ratio 5.0

DM女性相較於沒有DM的女性, CKD 風險比 Hazard Ratio 10.7

UKPDS 資料

DM 控制不良是未來發生 CKD 的危險因子：

糖化血色素每上升 1%，則未來發生微量白蛋白尿（microalbuminuria）的 HR 為 1.08（95% CI 為 1.03–1.12）；發生巨量白蛋白尿（macroalbuminuria）的 HR 為 1.10 （95% CI 為 1.02–1.18）。

DM 合併視網膜病變未來發生微蛋白尿的 HR 為 1.25 （95% CI 為 1.05–1.49），發生 GFR ﹤ 60 ml/min/1.73m2 的 HR 為 1.255（95% CI 為 1.020–1.544）

2. 高血壓
UKPDS 資料發現高血壓是未來發生 CKD 的危險因子, 收縮壓每上升 10 mmHg
** 未來發生微量白蛋白尿的 HR 為 1.15（95% CI 為 1.11–1.20）
** 未來發生巨量白蛋白尿 的 HR 為 1.15（95% CI 為 1.07–1.24），
** 未來發生 GFR<60 ml/min/1.73m2 的 HR 為 1.107（95% CI 為 1.06–1.16），
** 未來肌酸酐倍增的 HR 則為 1.39（95% CI 為 1.23–1.57）。

3. 心臟血管疾病
UKPDS 資料發現心血管疾病是未來發生 CKD 的危險因子

未來發生微白蛋白尿的 HR 為 1.46（95% CI 為 1.23–1.73）

發生巨量白蛋白尿的 HR 為 1.58（95% CI 為 1.16–2.15）

2007 年追蹤 13,826 名成年人的世代研究發現，有中風、心絞痛、間歇性跛行、 短暫性中風、接受開心手術或心導管術等心血管疾病成年人，未來發生 CKD 或腎功 能惡化較速的風險均較高﹔

追蹤九年後，發生腎功能下降有 520 人（3.8%），而發生 CKD 有 314 人（2.3%）

預測因子包括病前的心血管疾病勝算比（Odds Ratio, OR）=1.70；95% CI 為 1.36-2.13。

4. 家族病史

因高血壓（OR=1.5；95% CI 為 1.1-2.1）、糖尿病（OR=1.9；95% CI 為 1.4-2.6），與腎絲球腎炎（OR=2.1；95% CI 為 1.5-3.0）所引起的 ESRD，其家族成員中會有較高的風險有ESRD。

5. 高血脂
TG高, CKD風險上升
HDL高, CKD風險下降
LDL 與CKD 無關

6. 服用草藥
累積61∼100克以上的木通， 發生 ESRD 的 OR 為 1.47（95% CI 為 1.01-2.14）
累積200 克木通發生 ESRD 的 OR 為 5.82（95% CI 為 3.89-8.7）

與未服用防己的病人比較
累積 61 ∼ 100 克以上的防己，發生 ESRD 的 OR 為 1.60（95% CI 為 1.20-2.14）；
累積 200 克防己 發生 ESRD 的 OR 為 1.94（95% CI 為 1.29-2.92）
目前除了特定中草藥（如馬 兜鈴酸屬）之外，並無直接證據證實此相關性是否有因果關係

(雖有相關, 未必是因果關係)

7.急性腎損傷病史
心導管術後急性腎損傷, 未來需透析及死亡率 HR 1.91

外科手術, 術前腎功能正常, 術後發生急性腎損傷, 未來 ESRD 的 HR 22.69
術前有 CKD，術後發生 AKI , 未來發生 ESRD 的 HR 為 181.89

無 CKD、但發生 AKI 完全恢復者，未來發生 ESRD 的 HR 為 4.50（95% CI 為 2.43–8.35）

8. 老年人
( 八 ) 老年人
2003 年美國健康營養調查資料收錄 15,625 名非機構的 20 歲以上成年人CKD 盛行率為 11%,
腎絲球過濾率 eGFR < 60 ml/min/1.73m2 比率
** 20-39 歲族群 0.9%
** 40-59 歲佔 1.2%
** >70 歲族群佔 16%

UKPDS 資料發現年齡是未來發生 CKD 的危險因子, 年齡每增加五年
未來發生巨量白蛋白尿 HR 為 1.02（95%CI 為 0.94–1.12）
發生 GFR ﹤ 60 ml/ min/1.73m2 的 HR 為 2.15 (95% CI 為 1.98–2.34）
發生微量白蛋白尿風險則為不顯著升高，HR 為 1.01（95% CI 為 0.97–1.06）

9. 肥胖, 過重, 代謝症候群, 特徵~中央型肥胖、胰島素抗性、高三酸甘油脂血症
代謝症候群會增加 CKD機率

10. 長期吃止痛藥, 發生CKD風險增加 2.2 倍

11. 抽菸發生CKD風險, 男性增加 2.4 倍, 女性增加 2.9 倍
UKPDS 資料發現吸菸是未來發生 CKD 的危險因子

曾吸菸的成年人較未曾吸菸者相比，

發生微蛋白尿 HR 為 1.20（95% CI 為 1.01–1.42）

發生 GFR < 60 ml/ min/1.73m2 的 HR 為 1.25（95% CI 為 1.03–1.52）

12. 生活型態

中度活動量, 發生糖尿病腎病變/高血壓腎病變的 RR 3.7

低度活動量, 發生糖尿病腎病變/高血壓腎病變的 RR 10.1

13. 高尿酸血症或痛風

2013 年嘉義長庚醫院收錄 993 名無 CKD、無微蛋白尿病人發現，追蹤四年後， 新發生微蛋白尿的危險因子包括高尿酸血症

尿酸值每升高 1 mg/dL，則發生微蛋白 尿 OR 為 1.42（95% CI 為 1.27-1.59）

高血脂與慢性腎病 hyperlipidemia and CKD

2015台灣慢性腎臟病臨床診療指引

TG高, CKD風險上升
HDL高, CKD風險下降
LDL 與CKD 無關

高血脂 2000 年美國一項世代研究收錄 12,728 名腎功能相對良好的個案（男性血清肌酸 酐﹤ 2 mg/dL、女性﹤ 1.8 mg/dL），追蹤至血清肌酸酐上升 0.4 mg/dL 為觀察終點

2.9 年後發現，191 人達到試驗目標（5.1/ 千人年）

血中 TG 最高四分位病人相對最低四分位病人，發生 CKD 相對危險性（Rate Ratio, RR）為 1.65（95% CI 為 1.1-2.5）
HDL-C 最高的四分位受試者相較於最低的四分位者，未來發生 CKD 的 RR 是 0.47（95% CI 為 0.3-0.8）

LDL-C，並未與未來發生 CKD 相關

類固醇藥膏一次門診可以開幾條?

類固醇藥膏一次門診可以開幾條? 沒查到更詳細的描述
問皮膚科同學(同學的老公也是皮膚科), 她說她也不知道.
.
根據健保署108年藥品給付規定
13.3.2.含 calcipotriol 及類固醇之外用複方製劑（如 Daivobet）（94/5/1、99/12/1）
1.限確經診斷為尋常性牛皮癬（psoriasis）之病例使用，使用量以每星期不高於30gm 為原則，若因病情需要使用量需超過每星期30gm 者，應於病歷詳細紀錄理由。
2.同一部位之療程不得超過4週。

安眠藥物 Zaleplon zolpidem zopiclone eszopiclone 劑量 每天不要超過一顆

神經系統藥物 1.2.精神治療劑 Psychotherapeutic drugs
每天不要超過一顆. 需使用一顆以上. 可轉介精神科/神經科門診評估
連續使用不要超過六個月, 考慮會診精神科/神經內科
不建議併用兩種以上安眠藥.
第一次開安眠藥限七天

1.2.3. Zaleplon、zolpidem、zopiclone 及 eszopiclone（98/1/1、98/5/1、 98/10/1、102/11/1）

1.使用安眠藥物，病歷應詳載病人發生睡眠障礙的情形，並作適當的評估 和診斷，探討可能的原因，並提供衛教建立良好睡眠習慣。(98/5/1)

2.非精神科醫師、神經科專科醫師若需開立本類藥品，每日不宜超過一顆， 連續治療期間不宜超過 6 個月。若因病情需長期使用，病歷應載明原因， 必要時轉精神科、神經科專科醫師評估其繼續使用的適當性。(98/5/1、 98/10/1) 

3.精神科、神經科專科醫師應針對必須連續使用本藥的個案，提出合理的 診斷，並在病歷上詳細記錄。(98/5/1、98/10/1) 

4.依一般使用指引不建議各種安眠藥併用，應依睡眠障礙型態處方安眠 藥，若需不同半衰期之藥物併用應有明確之睡眠障礙型態描述紀錄，且應在合理劑量範圍內。(98/5/1)

5.對於首次就診尚未建立穩定醫病關係之病患，限處方 7 日內安眠藥管制

6. zaleplon 成分藥品用於治療難以入睡之失眠病人，僅適用於嚴重，病人 功能障礙或遭受極度壓力之失眠症患者，用於 65 歲以上病患時，起始劑 量為每日 5mg (98/1/1、98/10/1) 

7.成人病患使用 eszopiclone 成分藥品之起始劑量為睡前 1mg，最高劑量為 睡前 3mg，65 歲以上病患之最高劑量為 2mg。(102/11/1）

Pregabalin Lyrica (利瑞卡膠囊 75 毫克)健保給付條件 帶狀疱疹神經痛

看起來是帶狀皰疹神經痛比較容易合乎條件. 其他有專科限制. 還要做檢驗. 

1.1.7.Pregabalin（101/2/1、102/2/1、105/1/1、106/3/1、109/5/1）   Lyrica (利瑞卡膠囊 75 毫克)

1.使用於帶狀疱疹皮膚病灶後神經痛，並符合下列條件： 

(1)經使用其他止痛劑或非類固醇抗發炎劑（NSAIDs）藥品治療後仍無法 控制疼痛或有嚴重副作用者。(97/12/1、98/4/1) 

(2)每日最大劑量為 600mg。 

2.使用於纖維肌痛(fibromyalgia) 

(1)需符合 American College of Rheumatology (ACR)及臨床試驗實證纖維肌痛診斷標準： Ⅰ.WPI(wide spread pain index)≧7、Symptom severity (SS)≧5 且 pain rating scale≧6 分或 WPI 3-6、SS scale≧9 且 pain rating scale≧6 分。 Ⅱ.症狀持續超過三個月。 Ⅲ.應排除其他疾病因素，並於病歷詳載。 

(2)限風濕免疫科、神經內科、復健科、疼痛專科及精神科醫師使用，不 得併用同適應症之它類藥品。

(106/3/1)

 (3)如使用 3 個月後 pain rating scale 未減少 2 分以上應予停藥。 

(4)病歷每 3 個月應記載一次評估結果，每日最大劑量為 450mg。 

3.使用於糖尿病併發周邊神經病變並具有臨床神經疼痛 (neuropathic pain)，且符合以下條件(105/1/1): 

(1)經神經科專科醫師診斷或經神經傳導(NCV) 檢查證實之多發性神經病 變(polyneuropathy)。 (2)Pain rating scale≧4 分。

(3)不得併用同類適應症之藥品。 

(4)使用後應每 3個月評估一次，並於病歷中記載評估結果，倘 Pain rating scale 較前一次評估之數值未改善或未持續改善，應予停止使用。 

(5)每日最大劑量為 300 mg。 

4.使用於脊髓損傷所引起的神經性疼痛

(不包括 Lyrica、Tirica、 Phudialin、Suculin、Bergalin、Pregabalin "C.C.P.C."、 PMS-Pregabalin、Probalin 等藥品)，且符合以下條件(109/5/1): 

(1)經使用其他止痛劑或非類固醇抗發炎劑治療後無法控制疼痛(pain rating scale≧4)或有嚴重副作用。 

(2)每日最大劑量為 600mg。 

(3)不得併用同類適應症之藥品。 

(4)每 3 個月評估一次並於病例中記載評估結果，倘 pain rating scale 較前次評估數值未改善或未持續改善，應予停止使用。

門診開止痛藥膏一次可以開幾條?

止痛藥膏可以開幾條? => 以4周 40gm 為限. 所以是看容量, 不是看幾條. . 第一節 神經系統藥物(109.04.22更新) 1.1.1.非類固醇抗發炎劑外用製劑：(88/9/1、92/2/1、94/9/1、109/2/1) 1.外用非類固醇抗發炎軟膏，不得同時併用口服或其他外用非類固醇發炎 製劑，每 4 週至多以處方 40gm 為限(94/9/1、109/2/1)。 https://www.nhi.gov.tw/Content_List.aspx?n=E70D4F1BD029DC37&topn=3FC7D09599D25979

NSAID 健保給付條件 nabumetone celecoxib meloxicam etodolac nimesulide

106年12月01日  修訂含celecoxib 成分藥品給付規定

第1節 神經系統藥物 Drugs acting on the nervous system
1.1. 疼痛解除劑
1.1.5.非類固醇抗發炎劑（NSAIDs）藥品，屬下列成分之口服製劑：celecoxib、nabumetone、meloxicam、etodolac、nimesulide (90/7/1、97/9/1)、etoricoxib (96/1/1、99/10/1)、含naproxen及esomeprazole複方製劑(101/10/1) (106/12/1)
1.本類製劑之使用需符合下列條件之一者(99/10/1)：
(1)年齡大於等於六十歲之骨關節炎病患。(celecoxib可用於年齡大於等於五十歲之骨關節炎病患) (106/12/1)
(2)類風濕性關節炎、僵直性脊髓炎、乾癬性關節炎等慢性病發炎性關節病變，需長期使用非類固醇抗發炎劑者。
(3)合併有急性嚴重創傷、急性中風及急性心血管事件者 (97/2/1)。
(4)同時併有腎上腺類固醇之患者。
(5)曾有消化性潰瘍、上消化道出血或胃穿孔病史者。
(6)同時併有抗擬血劑者。
(7)肝硬化患者。
2.使用本類製劑之病患不得預防性併用乙型組織胺受體阻斷劑、氫離子幫浦阻斷劑及其他消化性潰瘍用藥，亦不得合併使用前列腺素劑（如misoprostol）
3.Nimesulide限用於急性疼痛緩解，其連續處方不得超過15日(97/9/1)。
4.含naproxen及esomeprazole複方製劑不得作為急性疼痛的初始治療。(101/10/1)
96年12月21日  全民健康保險藥品給付規定 修正規定
第1章 神經系統藥物 Drugs acting on the nervous system

1.1.疼痛解除劑 Drugs used for pain relief (自九十七年二月一日起生效)

非類固醇抗發炎劑（NSAIDs） 藥品（如 celecoxib、nabumetone、 meloxicam、etodolac、nimesulide） (90/7/1) etoricoxib(96/01/1) 

nabumetone 是介於一般 NSAID 與 COX2 的止痛藥.