1、用藥安全專題 (一 ): 心血管相關藥物之 高危險 用藥為 恭 紀 念 醫 院 藥 劑 部莊 惠 評 藥師常見的心血管疾病 Hyperlipidemia Ischemic heart disease (angina, myocardial infarction) Heart failure Cardiac arrhythmias Hypertension缺血性心臟病病程的發展HTN、 DM、 HyperlipidemiaAtherosclerosis、 Left ventricular hypertrophyCoronary artery diseaseMyocardium ischemicC
2、oronary thrombosisMyocardium infarctionArrhythmia、 Loss of muscle、 Sudden death RemodelingVentricular dilationHeart failureEnd-stage heart disease心血管治療用藥 Lipid lowering agents Nitrates -blockers Calcium channel blockers Diuretics Vasodilators Angiotensin converting enzyme inhibitors (ACE-I) Angioten
3、sin II receptor-antagonists Digitalis Antiplatelets Anticoagulants Thrombolytic agents Antiarrhythmic drugsMyocardial infarction Lipid lowering agentsHMG-CoA Reductase-IFibratesBile acid sequestrant resins Lipid lowering agents學名 Effects on lipidsEffects on lipoproteinsDosage Side effectsBile acid s
4、equestrant resinsCholestyraminecholesterol LDLVLDL8 mg TID/ACMax.32 mg 藥物交互作用 胃腸不適 影響脂溶性 A、D、 E、 K 之吸收Fibric acidsGemfibrozilFenofibrateTG & cholesterolVLDL & LDLHDL 300-600 mg BID/ AC,Max.1200 mg200 mg/Qpm 腸胃不適 膽結石 肌肉病變HMG-CoA reductase inhibitorsSimvastatinAtrovastatincholesterol LDL10-20 mg/day/Q
5、pm10-80 mg/day 肌肉病變 肝功能異常 (建議隔 46週檢 查一次肝功能 )Fibrates 類與 statin 類併用時可能會發生橫紋肌溶解症之副作用 (5%)，應小心併用 。劑量增加 , 發生機率亦增加 。若須併用，建議 statin類以晚飯後低劑量 給予 ， 而fibrates以早上飯前或飯後 給予以避免橫紋肌溶解症之副作用產生。具合併症時治療藥物之選擇Concomitant diseaseNone Recent myocardial infarctionAsthma, COPDHypertensionDiabetes Chronic renal disease Drugs
6、commonly used in treating anginaLong-acting nitrateLong-acting nitrateLong-acting nitrateLong-acting nitrateLong-acting nitrateLong-acting nitrate-blockers-blockers-blockers1-selective blockers-blockersCa+ channel blockersCa+ channel blockersCa+ channel blockersCa+ channel blockersCa+ channel blocke
7、rs Nitrates:經體內代謝後會轉變成 NO, 先擴張靜脈preload及 afterload, 使心臟工作量減低 , 而大劑量時會使得冠狀動脈舒張 , 緩解因 vasospasm所引起的心絞痛 。Class and agent Dosage Onset (mins)Duration Class comments Sublingual nitroglycerin (避光儲存 , 若含在口中無辛辣感則表示藥物已無效 )0.3-0.6 mg prn2-5 10-30 mins High doses needed Tolerance can be prevented by overnight
8、dose interval 8h Protective effect against cardiac ischemia Preload reducing agents Isosorbibide dinitrate (Isoket, Isodil) 5-40 mg tid 2-7 mg/hr, Max. 10 mg30-60 4-6 hrsIsosorbibide 5- mononitrate (Ismo)10-20 mg bid30-60 6-8 hrs -blockers: 抑制交感神經對心臟的作用 , 使心臟收縮力及傳導速率下降 , 降低心肌的需氧量而有效的治療心絞痛。學名 商品名 建議劑
9、量 (mg/day) CommentPropranolol Inderal 40-240 mg/day (Hypertension)10-30 mg (tid, qid)Non-selectiveAtenolol Tenormin 50-100 mg/qd, Max. 200 mg 1-selectiveLabetalol Trandate 2 mg/min, 需要時可逐步增加最大至 300 mgNonselective -blocker/1-blockerBisoprolol Monocor 1.25-10 1-selective Carvedilol Dilatrend Initial dose: 3.125-6.250Target dose: 25-50-FDA approved for heart failure-Nonselective -blocker/1-blocker
