11

Selective Serotonin Reuptake Inhibitor(SSRI) 中毒的治療

加護病房查房日誌

2

Selective Serotonin Reuptake Inhibitor(SSRI) Poisoning

2Ref: Michael G, MD Selective serotonin reuptake inhibitor poisoning. In: UpToDate, Jonathan G(Ed), UpToDate, Waltham, MA, 2011.

fluoxetine sertraline

paroxetinecitalopram

3

藥理機轉

3Ref: Michael G, MD Selective serotonin reuptake inhibitor poisoning. In: UpToDate, Jonathan G(Ed), UpToDate, Waltham, MA, 2011.

4

SSRI 沒有 TCA 那麼毒

4

SSRI TCA需插管 4-6% 31-32%入加護病房 0-6% 31-35%

死亡率 1.6 人 /每百萬人

34.8 人 /每百萬人

Ref: Michael G, MD Selective serotonin reuptake inhibitor poisoning. In: UpToDate, Jonathan G(Ed), UpToDate, Waltham, MA, 2011.

台灣資料 : 在民國 84 年 7 月至 85 年 6 月一年中4,825 名中毒個案中，因 fluoxetine 中毒者 8 人、 fluvoxamine 中毒者 3 人在這些個案中，並無因中毒而死亡者。

5

SSRI 治療區間寬

5Ref: Michael G, MD Selective serotonin reuptake inhibitor poisoning. In: UpToDate, Jonathan G(Ed), UpToDate, Waltham, MA, 2011.

6

藥物動力學

6CYP450: cytochrome p450

Ref: Michael G, MD Selective serotonin reuptake inhibitor poisoning. In: UpToDate, Jonathan G(Ed), UpToDate, Waltham, MA, 2011.

7

藥物動力學 -2

藥物 最高血中濃度 排除半衰期 代謝 活性代謝物

Fluoxetine 6-8 小時 2-10 天 肝 (2D6, 2C9, 3A4)

Norfluoxetine

Sertraline 4-8 小時 26 小時 肝 (2C9, 2D6, 3A4)

Desmethylsertraline

Paroxetine 5 小時 21 小時 肝 (2D6)

無

Fluvoxamine 3-8 小時 16 小時 肝 (1A2, 2D6)

無

Citalopram 4 小時 35 小時 肝(3A4, 2D6, 2C19)

Desmethylcitalopram, didesmethylcitalopram

Escitalopram 5 小時 27-32 小時 肝 (3A4, 2D6, 2C19)

S-desmethylcitalopram, S-didesmethylcitalopram7Ref: Michael G, MD Selective serotonin reuptake inhibitor poisoning.

In: UpToDate, Jonathan G(Ed), UpToDate, Waltham, MA, 2011.

8

若懷疑中毒時，藥師要問甚麼 ?

8Ref: Michael G, MD Selective serotonin reuptake inhibitor poisoning. In: UpToDate, Jonathan G(Ed), UpToDate, Waltham, MA, 2011.

理學檢查• 就如一般中毒的情況，由醫師來做• 藥師可特別注意是否出現

– Serotonin syndrome– 其他症狀

9Ref: Michael G, MD Selective serotonin reuptake inhibitor poisoning. In: UpToDate, Jonathan G(Ed), UpToDate, Waltham, MA, 2011.

10

SSRI 中毒症狀

10Ref: Michael G, MD Selective serotonin reuptake inhibitor poisoning. In: UpToDate, Jonathan G(Ed), UpToDate, Waltham, MA, 2011.

11

Serotonin Syndrome 症狀

11Ref: Michael G, MD Selective serotonin reuptake inhibitor poisoning. In: UpToDate, Jonathan G(Ed), UpToDate, Waltham, MA, 2011.

可能造成 serotonin syndrome 之藥物

12

Ref: Can Fam Physician 2008;54:988-92

10-14% 發生率輕度症狀Sertraline/paroxetine/fluvoxamine

13

藥師應建議監測數據

13Ref: Michael G, MD Selective serotonin reuptake inhibitor poisoning. In: UpToDate, Jonathan G(Ed), UpToDate, Waltham, MA, 2011.

14

出現 serotonin syndrome 時藥師應建議監測

14Ref: Michael G, MD Selective serotonin reuptake inhibitor poisoning. In: UpToDate, Jonathan G(Ed), UpToDate, Waltham, MA, 2011.

15

臨床處置 - 支持療法即可

15Ref: Michael G, MD Selective serotonin reuptake inhibitor poisoning. In: UpToDate, Jonathan G(Ed), UpToDate, Waltham, MA, 2011.

16

氣管 / 呼吸 / 循環

16Ref: Michael G, MD Selective serotonin reuptake inhibitor poisoning. In: UpToDate, Jonathan G(Ed), UpToDate, Waltham, MA, 2011.

17

活性碳使用

17Ref: Michael G, MD Selective serotonin reuptake inhibitor poisoning. In: UpToDate, Jonathan G(Ed), UpToDate, Waltham, MA, 2011.

18

洗腎有用嗎 ?

18Ref: Michael G, MD Selective serotonin reuptake inhibitor poisoning. In: UpToDate, Jonathan G(Ed), UpToDate, Waltham, MA, 2011.

19

Serotonin Syndrome 處理

19Ref: Michael G, MD Selective serotonin reuptake inhibitor poisoning. In: UpToDate, Jonathan G(Ed), UpToDate, Waltham, MA, 2011.

20

QTc 延長

20

持續心電圖監測小心 QTc interval>560 msec

Torsade de points注意危險因子：QTc interval>560 msec先前發生過心跳變慢心室未成熟跳動增加

成人治療藥物劑量：MgSO4 2g over 2 分鐘未改善， 10-15 分鐘再打

Ref: Michael G, MD Selective serotonin reuptake inhibitor poisoning. In: UpToDate, Jonathan G(Ed), UpToDate, Waltham, MA, 2011.

21

SSRI 中毒總複習

21