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!