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如何在臨床工作中找到實證解答？臺大醫院藥師 陳建豪
2015.07.23
2015 Micromedex使用者分享大會
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自我介紹－ Who Am I ？ 台大臨床藥學研究所
Ohio State University 海外交換計畫
台大醫院藥劑部藥師 住院藥局 門診藥局 急診藥局
每日一冷 Mr. Thursday Jr.
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病人
同事
醫療團隊
電話諮詢
醫師
學生自己
病人家屬
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Outline Find an evidence-based answer
FDA & Non-FDA Uses Pharmacodynamics & Pharmacokinetics Comparative Efficacy Place In Therapy
Interpret drug Interactions mobile Micromedex®
Discussion
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What we’ve known…. Case-oriented
user experiences
Clinical pharmacists General pharmacists Drug information 藥師周刊記者
Integrate Micromedex® into clinical decision supporting system (CDSS)
Formulary Drug interaction detecting
system IV Compatibility
information
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Case 1 65 歲男性，懷疑因 MRSA 造成腦膜炎而住院，病
人過去住院有 vancomycin 過敏紀錄 (skin rash) 。
醫師詢問：對 vancomycin 過敏的病人是否可以改用 teicoplanin 進行治療？ Adverse Effects
Teicoplanin 是否可用來治療 MRSA 造成的腦膜炎？ FDA uses/Non-FDA uses Pharmacokinetics/Pharmacodynamics Search in Full Document
* MRSA: methicillin-resistant Staphylococcus aeruginosa
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Case 2 65 歲男性，有心衰竭病史，本次因懷疑因 MRSA
造成骨髓炎而住院。 醫師詢問使用 vancomycin 或 teicoplanin 治療
MRSA 造成的骨髓炎是否有實證上的差異？ Comparative Efficacy Place In Therapy
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Teicoplanin vs. Vancomycin Comparative efficacy Less nephrotoxicity Less CNS penetration Once-daily dosing (for outpatient) IV/IM administration (for water-restriction) TDM not warranted in NTUH Higher cost
Teicoplanin 200 mg/vial : NTD 728/vial; 10 mg/kg daily for a 60 kg patient : NTD 2184/day
Vancomycin 500 mg/vial : NTD 101/vial 15 mg/kg Q12H for a 60 kg patient : NTD 404/day
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Other instances Ticagrelor (Brilinta®)
Comparative efficacy: acute coronary syndrome Doripenem (Finibax®)
Place in therapy: nosocomial pneumonia Tranexamic acid (Transamin®)
Non-FDA uses: postoperative bleeding Sulcrafate (Sucrate®)
Non-FDA uses: Hyperphosphatemia
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Drug Interactions User friendly
Index by drug name / brand name Various contents
– Food, – Tobacco, – Ethanol, – Lab, – Allergy, – Pregnancy, – Lactation
Evidence-based drug interaction Illustrated by icons
1) Warfarin – Benzbromarone2) Warfarin – Cefmetazole3) Warfarin – Cyclosporine4) Warfarin – Valproic acid 5) Levothyroxine – Digoxin6) Levothyroxine – Theophylline
Which drug combinations have interactions?
(A)- 2) 3) 4) 5)
(B)- 3) 4) 5)
(C)- 1) 2) 4) 6)(D)- 4) 6)
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Correct answer (B)- 3) 4) 5)
21 Correct answer: (D)- 4) 6)
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Drug Interactions Variable results within Micromedex® database
Warfarin – Benzbromarone Warfarin – Cefmetazole
Variable results between different databases Thyroxin – Digoxin Thyroxin – Theophylline Cyclosporine – Warfarin
Variable degrees between different databases Warfarin – Valproic acid : different significance
level
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Discrepancies between database Evidence-based interactions
More applicable in clinical setting With stronger evidence level & more clinical
significance Pharmacokinetics- & pharmacodynamics-
proposed interactions Class effects warrant close monitoring
Especially not yet American-approved medications Exploring under-reporting interactions
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Variable data might be expected while exploring interactions within different database, emphasizing
the importance of clinical observation and background
pharmacological knowledge.
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mobile Micromedex Free Micromedex® Drug Reference
for Internet Subscribers
Micromedex ® Drug Interactions
Micromedex ® IV Compatibility
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溫故知新… .
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Other Clinical Questions Drug dosing in extremes of body weight
Drug Dosing in Extremes of Body Weight (UKCPA) Medication Dosing Guidelines in Obese Adults (RQHR)
Quick index of drug-disease interaction Myasthenia gravis (MG) Glucose-6-phosphate dehydrogenase defect (G-6PD)
Discrepancy of American references with other nations’ Infusion rate of fluconazole (Diflucan®) Infusion rate of albumin 20% “ 國血製劑益康”
Thanks For Your
Attention!
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