98 年度台北縣藥師公會社區藥局用藥照護諮詢站

9898年度台北縣藥師公會年度台北縣藥師公會社區藥局用藥照護諮詢站社區藥局用藥照護諮詢站

前回春藥局陳雅德藥師

居家藥事服務居家藥事服務個案研討個案研討

居家個案居家個案研討研討


居家個案研討居家個案研討


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HMG-CoA Reductase Inhibitors AmiodaroneHMG-CoA Reductase Inhibitors AmiodaroneAtorvastatin (Lipitor) Amiodarone* (eg,Cordarone) Atorvastatin (Lipitor) Amiodarone* (eg,Cordarone) Lovastatin (eg,Mevacor) Lovastatin (eg,Mevacor) Simvastatin* (eg,Zocor)Simvastatin* (eg,Zocor)

SignificanceSignificance 11Onset Onset Rapid Delayed ☆ ★ Rapid Delayed ☆ ★ SeveritySeverity Major Moderate Minor★ ☆ ☆ Major Moderate Minor★ ☆ ☆DocumentationDocumentation Major Moderate Minor Established★ ☆ ☆ ☆ Major Moderate Minor Established★ ☆ ☆ ☆ ☆ ☆ Probable Suspected Possible Unlikely★ ☆ ☆Probable Suspected Possible Unlikely★ ☆ ☆



Effects:Effects: Plasma concentrations of certain HMG-CoA REDUCTA Plasma concentrations of certain HMG-CoA REDUCTASE INHIBITORS may be elevated, increasing the risk of toxicity SE INHIBITORS may be elevated, increasing the risk of toxicity (eg, myositis, rhabdomyolysis).(eg, myositis, rhabdomyolysis).Mechanism:Mechanism: Inhibition of HMG-CoA REDUCTASE INHIBITOR Inhibition of HMG-CoA REDUCTASE INHIBITOR metabolism (CYP3A4) is suspected.metabolism (CYP3A4) is suspected.Management: Management: If coadministration of these agents cannot be avo If coadministration of these agents cannot be avoided, use the lowest possible HMG-CoA REDUCTASE INHIBITOided, use the lowest possible HMG-CoA REDUCTASE INHIBITOR dose and advise patients to immediately report any unexplaineR dose and advise patients to immediately report any unexplained muscle pain, tenderness, or weakness. Fluvastatin (Lescol), prd muscle pain, tenderness, or weakness. Fluvastatin (Lescol), pravastatin (eg,Pravachol), and rosuvastatin (Crestor) are not metaavastatin (eg,Pravachol), and rosuvastatin (Crestor) are not metabolized by CYP3A4 and may be safer alternatives.bolized by CYP3A4 and may be safer alternatives.



Discussion:Discussion: Several cases of rhabdomyolysis, azotemia, and incr Several cases of rhabdomyolysis, azotemia, and increased liver function tests have been reported when high-dose simeased liver function tests have been reported when high-dose simvastatin 40 to 80 mg/day was given with amiodarone.1-3 Severe vastatin 40 to 80 mg/day was given with amiodarone.1-3 Severe myopathy developed in a 63-year-old man receiving simvastatin 4myopathy developed in a 63-year-old man receiving simvastatin 400 mg/day 21 days after amiodarone 1,000 mg/day for 10 days fol00 mg/day 21 days after amiodarone 1,000 mg/day for 10 days followed by 200 mg/day was added to his treatment regimen.1 The plowed by 200 mg/day was added to his treatment regimen.1 The patient developed diffuse muscle pain with generalized weakness, atient developed diffuse muscle pain with generalized weakness, and his creatine kinase level was elevated, peaking at 40,392 unitand his creatine kinase level was elevated, peaking at 40,392 units/L. Simvastatin and amiodarone were stopped. The creatine kinas/L. Simvastatin and amiodarone were stopped. The creatine kinase normalized over the next 8 days, and the patient made an unevse normalized over the next 8 days, and the patient made an uneventful recovery. The pharmacokinetics of simvastatin or pravastatientful recovery. The pharmacokinetics of simvastatin or pravastatin were studied in 12 healthy volunteers following 3 days of amiodan were studied in 12 healthy volunteers following 3 days of amiodarone 400 mg/day.4 Amiodarone increased simvastatin lactone and rone 400 mg/day.4 Amiodarone increased simvastatin lactone and simvastatin acid AUCs 73% and 78%, respectively. Pravastatin levsimvastatin acid AUCs 73% and 78%, respectively. Pravastatin levels were not affected.els were not affected.



第二次訪視第二次訪視









SulfonylureasLoop DiureticsSulfonylureasLoop DiureticsChlorpropamide (eg,Diabinese) Bumetanide (eg,Bumex) Chlorpropamide (eg,Diabinese) Bumetanide (eg,Bumex) Glimepiride (eg,Amaryl) Ethacrynic Acid (eg,Edecrin) Glimepiride (eg,Amaryl) Ethacrynic Acid (eg,Edecrin) Glipizide (eg,Glucotrol) Furosemide (eg,Lasix)Glipizide (eg,Glucotrol) Furosemide (eg,Lasix) Glyburide (eg,DiaBeta) Glyburide (eg,DiaBeta) TolazamideTolazamideTolbutamide (eg,Orinase)Tolbutamide (eg,Orinase)

Significance Significance 55Onset Onset Rapid Delayed☆ ★ Rapid Delayed☆ ★SeveritySeverity Major Moderate Minor☆ ☆ ★ Major Moderate Minor☆ ☆ ★DocumentationDocumentation Established Probable Suspected Possible☆ ☆ ☆ ★ Established Probable Suspected Possible☆ ☆ ☆ ★ ☆ ☆ UnlikelyUnlikely



Effects:Effects: LOOP DIURETICS may decrease glucose tolerance, resulting in LOOP DIURETICS may decrease glucose tolerance, resulting in hyperglycemia in patients previously well controlled on SULFONYLUREAhyperglycemia in patients previously well controlled on SULFONYLUREAS.S.

Discussion: Discussion: Although some data suggest that loop diuretics are capable Although some data suggest that loop diuretics are capable of causing hyperglycemia or altered carbohydrate metabolism, other studof causing hyperglycemia or altered carbohydrate metabolism, other studies report no significant alteration in blood sugar or carbohydrate metaboies report no significant alteration in blood sugar or carbohydrate metabolism.1-9No studies have been published that specifically examine the effelism.1-9No studies have been published that specifically examine the effect of the addition of a loop diuretic to the regimen of a non-insulin-dependct of the addition of a loop diuretic to the regimen of a non-insulin-dependent diabetic patient controlled on a sulfonylurea. Such controlled trials arent diabetic patient controlled on a sulfonylurea. Such controlled trials are necessary to clarify the importance of this interaction.e necessary to clarify the importance of this interaction.

研究報告發現當研究報告發現當 loop diureticsloop diuretics 類與類與 sulfonylureassulfonylureas 類併用時，類併用時， loop diureticsloop diuretics可能會降低葡萄糖耐受性，以致先前用可能會降低葡萄糖耐受性，以致先前用 sulfonylureassulfonylureas 控制很好的病人出現高血控制很好的病人出現高血糖，其作用機轉不明。報告發現，糖，其作用機轉不明。報告發現， loop diureticsloop diuretics 可能會改變碳水化合物之代謝，可能會改變碳水化合物之代謝，甚至導致血糖增高。這類對照組的試驗仍需澄清此交互作用的意義，依據現有資甚至導致血糖增高。這類對照組的試驗仍需澄清此交互作用的意義，依據現有資

料，當病人併用兩藥時，治療上並不需建議任何改變。料，當病人併用兩藥時，治療上並不需建議任何改變。


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98 年度台北縣藥師公會 社區藥局用藥照護諮詢站

98 年度台北縣藥師公會社區藥局用藥照護諮詢站