糖尿病合併慢性腎病何時考慮作腎臟切片

若病人有以下症狀，建議施行腎臟切片，以排除其他造成腎病變之原因：

( 一 ) 未合併糖尿病視網膜病變；

( 二 ) 腎絲球過濾率快速下降； 

( 三 ) 快速增加之蛋白尿或合併腎病症候群；

( 四 ) 頑固型高血壓； 

( 五 ) 多重尿液檢驗異常，如合併小便之紅血球 / 白血球或其柱狀體；

( 六 ) 合併系統性疾病之全身表現

( 七 ) 腎絲球過濾率在使用 ACEi/ARB 後三個月內下降 >30%

糖尿病腎病變惡化危險因子

年齡

糖尿病病史

性別

腎絲球過濾率

血清肌酸酐

尿液白蛋白 - 肌酸酐比值

收縮血壓

糖化血色素

慢性B型肝炎的治療方式及藥物

慢性B型肝炎的治療方式及藥物
chronic hepatitis 

treatment
治療目標:
● 肝發炎指數AST(GOT)、ALT(GPT)恢復正常，避免肝臟持續處於發炎狀態，以免走向肝纖維化、肝硬化、肝癌。
● 血液中測不到B肝病毒量。

降血脂藥物對LDL-C 低密度膽固醇效果 Rosuvastatin 最強

Effect on LDL cholesterol

Potency — Aside from proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, statins are the most powerful drugs for lowering low-density lipoprotein (LDL) cholesterol, with reductions in the range of 30 to 63 percent (table 3) [6-10]. When switching between statin drugs, equipotent doses with regard to LDL cholesterol reduction can be found in the figure (figure 2).

Rosuvastatin 效果比 Atorvastatin 強

Rosuvastatin 和 Atorvastatin 兩者又比其他四種 statin 強 (simvastatin, lovastatin, pravastatin. fluvastatin) 

當使用至每種藥物各自的最大劑量, 降低 LDL-C 的效果, rosuvastatin 和 atorvastatin 比其他 statin 強

Rosuvastatin is somewhat more potent than atorvastatin [10,11], and both these agents are significantly more potent than simvastatin, lovastatin, pravastatin, and fluvastatin [11,12]. At maximal prescribed doses, LDL cholesterol reduction is greater with rosuvastatin and atorvastatin than with the other available statins (figure 2).

Fluvastatin 40mg QD 效果最弱. 但如果使用到 80mg QD 效果與其他三種(除Rosuvastatin 和 Atorvastatin外)降血脂藥物相近

At doses of up to 40 mg/day, fluvastatin is the least potent statin (figure 2). However, at doses of 80 mg/day, fluvastatin is as effective on lowering LDL cholesterol as most statins other than rosuvastatin and atorvastatin [13]. Fluvastatin, pitavastatin, and pravastatin are less likely to have drug interactions or produce muscle toxicity than some other statins. (See 'Side effects' below.)

Simvastatin 不建議使用至每天 80 mg. 雖然降血脂效果強, 但副作用例如橫紋肌溶解會增加

因此simvastatin 建議每天不要超過 40 mg. 此外, 若病患先前曾經服用 simvastatin 80mg 而無副作用, 仍建議換成其他種類statin, 因為如果之後持續服用 simvastatin 80 mg qd 會增加肌病變機率

高劑量 simvastatin 適合一小部分患者, 包括服用多年仍沒有不良反應, 或無法忍受其他降血脂藥物副作用. 

Although simvastatin 80 mg/day is a high-intensity dose of statin, given high rates of adverse muscle symptoms including rhabdomyolysis [14] and the availability of generic rosuvastatin and atorvastatin, we suggest not treating patients with doses of simvastatin above 40 mg/day. Additionally, clinicians should strongly consider switching even patients who are currently tolerating simvastatin 80 mg/day to one of these other statin options, since future medication therapy or illness could increase the risk for development of myopathy on high-dose simvastatin. High-dose simvastatin may be appropriate for a small number of patients who have tolerated it well for many years or who are intolerant of other high-potency statin options.

Statins類藥物與 bile acid sequestrant 或 cholesterol absorption inhinitor ezetimibe 合併使用有加成作用
There is an additive hypolipidemic effect when any of the statins is used in combination with a bile acid sequestrant (figure 3) [15-17], or the cholesterol absorption inhibitor ezetimibe.

兒童感染水痘需要使用抗病毒藥物嗎?

uptodate 對於抗病毒藥物的敘述.
對於健康成人或免疫功能不全的人, 抗病毒藥物治療水痘感染很有效.

ANTIVIRAL THERAPYAcyclovir and its analogues (valacyclovir, famciclovir) are effective for the treatment of primary varicella in both healthy and immunocompromised hosts [4-11]. Higher doses of acyclovir are used to treat VZV compared with herpes simplex virus (HSV). VZV is less susceptible to acyclovir, and 50 percent inhibition of VZV replication requires about 10-fold higher levels of acyclovir than those typically required for HSV [8,12]. Acyclovir and its analogues are dependent upon renal function for clearance and dose adjustment is needed in moderate to severe renal insufficiency.

成人口服抗病毒藥耐受性通常不錯. 

Oral agents are generally very well tolerated, especially in adults; however, gastrointestinal side effects or headache may occur. Acyclovir is also available in an intravenous form which can cause local reactions (phlebitis) and reversible acute kidney injury. Risk factors for acute kidney injury include dehydration, failure to dose adjust for reduced kidney function, and overly rapid infusion (eg, <1 hour) [13]. In addition, for obese adults, weight-based dosing should be scaled to ideal body weight (IBW) rather than actual body weight (ABW) to avoid an increased risk of toxicity (calculator 1).
Additional discussions on the use of acyclovir and its analogues are found in the Lexicomp drug information topics within UpToDate and within individual topic reviews.

全民健保對於抗病毒製劑的給付規定

降血脂藥物 statins 類早上或晚上服用?空腹或飯後服用?

有些 STATIN 建議空腹服用. 有些建議飯後服用.
.
人體的膽固醇, 80% 來自於體內合成, 通常是在晚上產生., 因此半衰期短的藥物建議晚上吃,

simvastatin 在傍晚服用的效果優於早上服用

半衰期長的藥物例如 atovastatin. 在早上或傍晚服用, 藥效沒有差異

Pitavastatin 和 Pravastatin 會因食物而減少吸收
Lovastatin 會因食物增加吸收率, 建議飯後服用.

至於服用時間應該挑早上還是晚上
Lovastatin IR 和 Fluvastatin IR 劑型建議與晚餐一起吃.
Lovastatin XR 和 Fluvastatin XR劑型則可以在任何時間服用.
其他的都可以在任何時間服用.

腎功能不良,. Atorvasatin 和 fluvastatin 不需調整劑量.

下面表格來自於 2014壢新藥訊: 降血脂藥物比較

但

Gemfibrozil和Fenofibrate的比較

臨床藥物治療學 102-03-13 高血脂症的防治觀念與用藥選擇
Gemfibrozil和Fenofibrate的比較

FDA 2016-04-19最新報告指出，從ACCORD study做出的結論，statins與fibrate並用，跟單純使用Statins相比，在糖尿病患中，兩者的心血管疾病發生並無不同。另外，根據AIM-HIGH study指出，statins與niacin併用與statins單獨使用相比，雖然可以改善HDL以及TG，但是對於心血管疾病和改善LDL並沒有明顯差別，而HPS2-THRIVE study也同樣指出statins與niacin同時使用，與單用statins相比，並不會更改善心血管疾病的發生，所以FDA取消了statins + fibrate
以及statin + niacin的合併劑型。

不建議併用 repaglinide (novonorm 諾和隆) 及 gemfibrozil， 此兩藥併用會增加低血糖風險，在歐洲是禁止同時使用這兩種藥物。如有需要使用 fibrate 類 藥物，可以選擇將 gemfibrozil 改為 fenofibrate。