门诊处方讨论.ppt

門診處方討論 Fludrocortisone (Florinef)用於 Orthostatic hypotension 報告者: 黃玉鈴 94.11 Fludrocortisone 之 Clinical Applications A potent oral mineralocorticoid FDA Approved Indications ? Addison’s disease-Adrenal insufficency ? Adrenogenital disorder Effective in treating orthostatic hypotension Orthostatic hypotension發生之原因 神經性—中樞或週邊神經病變所致 1.原發性 2.次發性—腫瘤.中風.感染.糖尿病.酒精神 經性病變 非神經性— 心衰竭.血管內容積不足.血液滯留靜脈.藥 物 Orthostatic hypotension發生之原因 血容量不足,減少 1.貧血 2.電解質失衡 3.長期臥床 4.藥物 Diuretics, ACEI; Vasodilators: NTG, Isosorbide dinitrate; Calcium channel blockers Orthostatic hypotension之症狀 坐/站立之間血壓過度下降(典型者20/10mmHg) 血壓明顯改變,躺臥的時候即恢復 頭暈..軟弱無力..眩暈..視力模糊 臨床證據1 Fludrocortisone has been effective in the treatment of hypotension, achieving clinical improvement in 84.3% of patients with doses as high as 2mg/d (Frick, 1966). The initial dose is usually 0.1 mg daily, increased by 0.1 mg every 5 to 7 days as needed. The usual maintenance dose ranges from 0.1 to 1.0 mg/day because treatment limit it’s side effect (Van Lieshout et al, 2000; Watt et al, 1981a; Chobanian, 1979a); (Holh et al, 1965). 臨床證據2 Stroke volume (SV), cardiac output (CO), and standing blood pressure improved significantly following treatment of neurogenic orthostatic hypotension (NOH) with fludrocortisone and elevated-head sleep positioning, in an open label, controlled clinical study Fludrocortisone於Orthostatic hypotension治療之機轉 ↑ the resorption of Na+ and increase the urinary excretion of K+ and H+ at the distal tubule in the kidney ↑plasma volume (a increases in blood pressure due to Na+ retaining-effects) ↑ the sympathetic response to norepinephrine ↑ increased peripheral resistance Fludrocortisone於Orthostatic hypotension之Pharmacokinerics Absorbed from the GI: 100% Peak blood levels : 1.7 hours after P.O.