快樂小藥師 Im pharmacist nichts glücklich

今天健保課來請我們提供Spironolactone及Lasix的仿單。

其實給仿單也沒有什麼了不起，影印一下而已，不過我很好奇為何要提供仿單，他們就回答我：因為健保局來查一個病患，問為何要這樣用。

我只好笑一笑，的確，在藥理的基礎上，Spironolactone是保鉀利尿劑，而Lasix會幫助排出血鉀，不能併用看起來好像合情合理。
不過根據美國肝病研究協會( American Association for the Study of Liver Disease ; AASLD )的建議，合併使用spironolactone與furosemide，起始劑量分別為100毫克/天，40毫克/天，如此劑量結合比例，將可達到每天減少0.5公斤水分的目標，又能保持正常血鉀濃度。

附上ASSLD的Guideline
The usual diuretic regimen consists of single morning doses of oral spironolactone and furosemide, beginning
with 100 mg of the former and 40 mg of the latter.^12,13 Previously, single-agent spironolactone was advocated,
but hyperkalemia and the long half-life of this drug have resulted in its use as a single agent only in patients with
minimal fluid overload.38 Single-agent furosemide has been shown in a randomized controlled trial to be less
efficacious than spironolactone.³⁹ The good oral bioavailability of furosemide in the cirrhotic patient, together
with the acute reductions in glomerular filtration rate associated with intravenous furosemide, favor use of the oral
route of administration.^40,41

12. Runyon BA. Care of patients with ascites. N Engl J Med 1994;330:337–342.
13. Runyon BA. Ascites and spontaneous bacterial peritonitis. In: Feldman M, Friedman LS, Sleisenger MH, eds. Sleisenger and Fordtran’s Gastrointestinal and Liver Disease. 7th ed. Philadelphia: Saunders, 2002:1517–
1542.
39. Perez-Ayuso RM, Arroyo V, Planas R, Gaya J, Bory F, Rimola A, Rivera F, et al. Randomized comparative study of efficacy of furosemide vs. spironolactone in nonazotemic cirrhosis with ascites. Gastroenterology 1983;84:961–968.
40. Sawhney VK, Gregory PB, Swezey SE, Blaschke TF. Furosemide disposition in cirrhotic patients. Gastroenterology 1981;81:1012–1016.
41. Daskalopoulos G, Laffi G, Morgan T, Pinzani G, Harley H, Reynolds T, Zipser RD. Immediate effects of furosemide on renal hemodynamics in chronic liver disease with ascites. Gastroenterology 1987;92:1859–1863.

不知道這樣健保局有沒有懂一點了