[內科] 基本常識

[atpsam ()]

話說內科醫師對NSAID敬畏三分
Cre >1 能不用則不用
至於急診 動則Keto, Naposin
Cre 1.8以上也st在用

因為查paper太累, 查查micromedex好了
用頂頂有名的indomethacin做代表

首先contraindication:(也就是絕對不能用沒有討價還價餘地)
A)  treatment of peri-operative pain in setting of coronary artery bypass
graft (CABG) surgery (FDA, 2005)
B)  history of recent rectal bleeding or proctitis (indomethacin
suppositories)
C)  hypersensitivity to indomethacin (FDA, 2005)
D)  neonates with active bleeding, infection, necrotizing enterocolitis,
severe renal failure, thrombocytopenia, or coagulation defects
E)  patients who have experienced asthma, urticaria, or allergic-type
reactions after taking aspirin or other nonsteroidal anti-inflammatory
agents; severe, even fatal, anaphylactic-like reactions have been reported
(FDA, 2005)

沒有CKD喔, 上面只提到neonate

再看precaution: (也就是小心留意監控啦 有問題快停藥)
A)  increased risk of serious cardiovascular thrombotic events, myocardial
infarction, and stroke; risk may increase with duration of use and in
patients at risk for cardiovascular disease (FDA, 2005)
B)  increased risk of serious gastrointestinal adverse events (bleeding,
ulceration, perforation of stomach or intestines) that can occur at any time
and without warning; higher risk in elderly or debilitated patients (FDA,
2005)
C)  asthma (FDA, 2005)
D)  avoid in late pregnancy; may cause premature closure of the ductus
arteriosus (FDA, 2005)
E)  dehydration
F)  elderly (FDA, 2005)
G)  epilepsy, parkinsonism, depression, psychiatric conditions
H)  history of coagulation defects (FDA, 2005)
I)  history of GI ulceration, bleeding or perforation (FDA, 2005)
J)  history of liver dysfunction (FDA, 2005)
K)  history of renal disease (FDA, 2005)
L)  hypertension, fluid retention, or CHF (FDA, 2005)
M)  preexisting anemia
N)  when treating patent ductus arteriosus, do not give subsequent doses if
urinary output falls below 0.6 mL/kg/hr in response to indomethacin; resume
therapy when renal function returns to normal

啊哈 出現了 列在這裡
Indomethacin用在腎差的人 FDA告訴你要小心監控

好吧 看看adverse effect 是啥
3.3.13   Renal Effects
Drug-induced renal failure, acute
Kidney disease
Papillary necrosis
Renal failure
Urogenital finding
太多內容節錄重要者如下
In patients at high risk for renal failure, serum creatinine monitoring is
recommended during the first several weeks of treatment to identify early
changes in renal function. After discontinuation of the non-steroidal
anti-inflammatory drug (NSAID), renal function usually returns to
pretreatment levels (小心監控 通常停藥會好)
這是FDA說的

CKD用少量NSAID如何?
看Dose adjustment in renal failure
A)  No dosage adjustment is recommended for patients with renal dysfunction
or failure
這是因為indomethacin會經肝代謝成inactive metabolites 再60%由kidney排出
因此CKD病人就療效來說減量是沒意義的
當然這不代表CKD病人減量對腎沒有好處

至於NSAID究竟對腎造成何危害?
Micromedex也有這麼一句話
Renal failure induced by indomethacin is most likely related to inhibition of
renal prostaglandin synthesis by indomethacin
也就是它似乎造成腎動脈收縮而產生prerenal azotemia
並不是腎實質本身壞掉

這麼說來
NSAID對腎的壞處好像不是想像的這麼大
即使一時造成Cre升高在停藥後也有機會降回原值

不曉得大家怎麼想NSAID

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推 sunil:其實外科也不愛用.
> -------------------------------------------------------------------------- <

作者: cAMP (呼.) 看板: NTUH-INTERN
標題: Re: [內科] 基本常識
時間: Sat Sep  6 03:18:49 2008

※ 引述《atpsam ()》之銘言：
: 話說內科醫師對NSAID敬畏三分
: Cre >1 能不用則不用
: 至於急診 動則Keto, Naposin
: Cre 1.8以上也st在用
: 因為查paper太累, 查查micromedex好了
: 用頂頂有名的indomethacin做代表

話說...
提到Keto 結果查的是indomethacin會不會有點怪呢？

讓我們用一樣的micromedex查一下ketorolac好了

一樣查一下dosage in renal failure

1.3.2   Dosage in Renal Failure
A)  Ketorolac Tromethamine
1)  Ketorolac is contraindicated in patients with serum creatinine
concentrations indicating advanced renal impairment. In patients with
renal impairment, the intravenous bolus or intramuscular dose of ketorolac
is 15 milligrams which may be repeated every 6 hours or as needed to a
maximum of 60 milligrams daily. For single-dose therapy given
intramuscularly, the dose is 30 milligrams one time.
 For single-dose therapy given intravenously, the dose is 15 milligrams
one time. Hypovolemia should be corrected before using ketorolac
(Prod Info Toradol(R), 2002a).
2)  Patients with a wide range of renal impairment demonstrated reductions
in total plasma clearance and prolongation in elimination half-life after
both oral and intramuscular ketorolac administration compared to healthy
subjects. Reduction in protein binding in the renally impaired may also
result in increased unbound ketorolac in plasma. Dosage reduction in
indicated in the renally impaired patient (Buckley & Brogden, 1990).


那我們再看看contra-indication
1-17跳過 看18就好
18)  renal impairment, advanced, or risk of renal failure due to volume
depletion (Prod Info TORADOL(R) oral tablets, 2007; Prod Info ketorolac
tromethamine injection, 2002)

再看一下adverse reaction部份
3.3.13.A.9   Renal failure
a)  Summary
1)  Patients at greatest risk for acute renal failure include those with
reduced blood volume or a decrease in renal blood flow. Also, patients
with impaired renal function, dehydration, heart failure, liver dysfunction,
the elderly and those taking diuretics have an increased risk for developing
 acute renal failure (Schoch et al, 1992; Corelli & Gericke, 1993; Smith et
al, 1993). Acute renal failure has also occurred in younger patients and
patients receiving only a few doses (Perazella & Buller, 1993).
Renal function usually returns to baseline within a few days after stopping
ketorolac (Corelli & Gericke, 1993).

所以.....還是要小心使用的

--
提醒一下  會查micromedex真的是相當有求知的精神 該鼓勵一下
不過  要討論keto結果查的是indomethacin...
別拿明朝的劍斬清朝的官啊...

--
"你的誠意在那?"
"不知道"
"你的良知咧?"
"前一陣子掉了吧...你有看到的話...幫我跟它說一聲不用回來了.."

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◆ From: 140.112.125.84
推 minihair:也都還是pre-renal的問題