11-研究生臨床藥理9(存儲(chǔ)版)
【正文】 給予合適的 劑型 和恰當(dāng)?shù)?劑量? 最好劑量個(gè)體化 ：最少藥物、最低有效量開始 (一般用成人量的 1/5～ 3/4)，以腎排為主且TI 較小的藥物尤其應(yīng)如此? 血濃監(jiān)測(cè) 對(duì)合理、安全用藥有重要意義? 避免長(zhǎng)期用藥 ，以防蓄積中毒? 宜多用液體 /半固體制劑；不宜服緩釋劑 ：胃腸功能不穩(wěn)定；蠕動(dòng)加快釋放不充分，相反吸收量增加產(chǎn)生不良反應(yīng)40三、掌握用藥最佳 時(shí)間 ：? 大多數(shù)藥物應(yīng)飯前服 ，而具消化道刺激性藥物則應(yīng)飯后服? 應(yīng)用生物鐘節(jié)律知識(shí)選擇給藥時(shí)間 ：如降糖藥 10am用藥作用最強(qiáng)，而糖皮質(zhì)激素類藥物隔日 68am 頓服不良反應(yīng)最小等41四、控制 嗜好與飲食 ：? 控制煙、酒、茶? 補(bǔ)充營(yíng)養(yǎng) ：老年患者常有消瘦、貧血、低蛋白血癥等，使其對(duì)抗癌、抗菌化療藥物耐受力降低，極需注意補(bǔ)充營(yíng)養(yǎng)，否則無(wú)法接受治療或影響療效? 控制飲食： 糖尿病 患者? 限鹽 ： 使用 強(qiáng)心苷、降壓藥時(shí)? 補(bǔ)充富含 vit. B類的食物 ： 飲酒患者42五、提高對(duì)用藥的 依從性? 最好 一日一次 ，不宜間隙和長(zhǎng)期用藥? 盡量 簡(jiǎn)化 治療 方案 。 長(zhǎng)期用可的松易發(fā)生 股骨頸 骨折等；長(zhǎng)期大量使用應(yīng) 合用鈣劑及 vit. D? 糖尿病： 一般只需口服降糖藥–D860較適用 (t1/2僅 5h)； 不用 氯磺丙脲(t1/236h)–格列吡嗪、格列喹酮 主經(jīng)膽汁排泄， 適用–格列齊特 降糖作用強(qiáng)，且抗血小板和改善微循環(huán)， 最適合 有并發(fā)癥的老年糖尿病人49? 雌激素 : –最 常用于 : 更年期綜合征、絕經(jīng)期后的乳癌、骨質(zhì)疏松和前列腺癌轉(zhuǎn)移等–禁用于 : 雌激素性高血壓，進(jìn)展性乳腺纖維瘤及進(jìn)展性子宮平滑肌瘤及有乳癌史者–嚴(yán)加 控制使用 : 肥胖癥、糖尿病、高血壓、膠原纖維病、膽石癥、高脂血癥、曾患心?；蛐难芤馔狻⒎嗡ㄈ办o脈血栓等50Principles of drug therapy in the elderly? Avoid unnecessary drug therapy? Treat the cause rather than the symptom? Choosing the drug? Dose titration? Choosing the right dosage form? Good record keeping? Regular supervision and review of treatment? Adverse drug reactions? Compliance51Case study? An 80year old woman presented to an outpatient clinic with a history of severe giddiness and a few episodes of blackouts. She was being treated for angina and hypertension. She had been on bendrofluazide , and slowrelease isosorbide dinitrate 60mg/d for a few years. Her general practitioner had recently menced nifedipine SR 20mg twice daily for poorly controlled hypertension. On examination her blood pressure was 120/70 whilst supine and 90/60 on standing up.52Question? What is the underlying problem and could it be caused by any of the medications that the patient is taking?Answer? The woman obviously has significant postural hypotension. All the drugs she was on have the potential to produce postural hypotension, and when used together they may produce symptomatic postural hypotension.53? It is important to recognize that some drugs such as nifedipine and nitrates have impaired firstpass metabolism in the elderly and that their clinical effects are enhanced. In additi
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