門 診疑義 處 方 討 論 use of methylphenidate in traumatic brain injury (tbi) 報告日期:...
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門 診疑義 處 方 討 論
Use of Methylphenidate
in Traumatic Brain Injury (TBI)
報告日期: 99.3.30
黃信裕 藥師
Content
1. Methylphenidate 之藥理作用2. Methylphenidate核准之適應症3. Methylphenidate in TBI之合理性4. Methylphenidate in TBI 之建議劑量5. Methylphenidate in TBI之證據等級6. Conclusion
7. References
Methylphenidate 之藥理作用
Mechanism of Action
•CNS stimulant•Reuptake of Dopamine inhibitor
Challman TD, Lipsky JJ. Methylphenidate: Its Pharmacology and Uses Mayo Clin Proc. 2000 Jul;75(7):711-21. Review
Methylphenidate 核准之適應症
衛生署核准適應症
FDA核准適應症
Methylphenidate in TBI之合理性
What are the most common problems after a TBI?
Thinking Changes (1)
Attention Reduced concentration Reduced visual attention Inability to divide attention
between competing tasks Processing speed
Slow thinking Slow reading Slow verbal and written responses
Thinking Changes (2) Communication
Difficulty finding the right words, naming objects
Disorganized in communication Learning and Memory
Information before TBI intact Reduced ability to remember new
information Problems with learning new skills
Methylphenidate in TBI之證據等級
FDA Approval: Adult, no; Pediatric, no
Efficacy: Adult, Evidence favors efficacy; Pediatric, Evidence favors efficacy
Recommendation: Adult, Class IIb; Pediatric, Class IIb
Strength of Evidence: Adult, Category B; Pediatric, Category B
MICROMEDEX(r) Healthcare Series 醫療照護系列資料庫 (Database) Thomson MICROMEDEX
Evidence (I)
Article EL Significant improvement No Significant improvement
Whyte et al., 1997
I Speed of information processing
Attentiveness during work task
Caregiver ratings of attention
Sustained attention
Divided attention
Distractibility
Whyte et al.,2004
I Speed of mental processing Distractibility,
Vigilance/sustained attention
Mooney and Haas, 1993
I Attention
Kim et al.,
2006
II Reaction time and accuracy of
Visuospatial attention
Lee et al., 2005 II Recognition reaction time and daytime alertness (when compared to sertraline)
Recognition reaction time
(when compared to placebo)
Plenger et al., 1996
II Attention span, divided attention and vigilance
(at one month)
Attention span, divided attention
and vigilance (at three months)
Kaelin et al., 1996
II Attention span, sustained attention, divided attention
Speech et al., 1993
II Sustained attention
Vigilance, Processing speed
Gualtieri and Evans, 1988
II 10 subjects – sustained attention,
divided attention, selective attention
5 subjects – no change
Grade et al.,
1988
II Cognitive function
Evidence (II)
Sivan M et al. Clin Rehabil. 2010 Feb;24(2):110-21
Methylphenidate in TBI 之建議劑量
1. Enhance attentional function Dose: 0.25–0.30 mg/kg bid2. Enhance the speed of cognitive processing Dose: 0.25–0.30 mg/kg bid3. Enhance learning and memory Dose: 0.30 mg/kg bid4. Improve speed in mental processing Dose: 0.30 mg/kg bid
Recommended Dose
Neurobehavioral Guidelines Working Group, Warden DL, Gordon B, McAllister TW, Silver JM, Barth JT, Bruns J, Drake A, Gentry T, Jagoda A, Katz DI, Kraus J, Labbate LA, Ryan LM, Sparling MB, Walters B, Whyte J, Zapata A, Zitnay G. Guidelines for the pharmacologic treatment of neurobehavioral sequelae of traumatic brain injury.J Neurotrauma. 2006 Oct;23(10):1468-501
醫師開立處方:
Methylphenidate 10mg/tab, 1tab, QD ?
結果:可能造成改善症狀之劑量不足
結論
Methylphenidate用於 TBI(創傷性腦損害 )乃屬於合理之治療,因為 TBI會造成腦部神經性病變,如:認知不足、注意力缺乏、記憶力減退…等。
但是衛生署核准之適應症為過動兒症候群及發作型嗜睡症,若醫師將Methylphenidate用於器質性腦徵候群或腦震盪後徵候群,需考慮以自費方式給予。
參考資料1. Siddall OM. Use of methylphenidate in traumatic brain injury. Ann
Pharmacother. 2005 Jul-Aug;39(7-8):1309-13. Epub 2005 May 24. Review. 2. Sivan M, Neumann V, Kent R, Stroud A, Bhakta BB Pharmacotherapy for
treatment of attention deficits after non-progressive acquired brain injury. A
systematic review. Clin Rehabil. 2010 Feb;24(2):110-21.3. Challman TD, Lipsky JJ. Methylphenidate: its pharmacology and uses.
Mayo Clin Proc. 2000 Jul;75(7):711-21. Review. 4. Neurobehavioral Guidelines Working Group, Warden DL, Gordon B,
McAllister TW, Silver JM, Barth JT, Bruns J, Drake A, Gentry T, Jagoda A, Katz DI, Kraus J, Labbate LA, Ryan LM, Sparling MB, Walters B, Whyte J, Zapata A, Zitnay
G. Guidelines for the pharmacologic treatment of neurobehavioral sequelae
of traumatic brain injury. J Neurotrauma. 2006 Oct;23(10):1468-501. 5. MICROMEDEX(r) Healthcare Series 醫療照護系列資料庫 (Database)
Thomson MICROMEDEX
Thank you for your attention
Background
Deficits in attention are commonly seen in non-progressive acquired brain injury.
The prevalence of attention deficits even after mild traumatic brain injury has been reported to range from 40-60% at 1-3 months post injury
Pierce SR. et al. Arch Phys Med Rehabil 2002
Attention
Focused Sustained Divided Alternating Selective
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