【病例学习第35期】Test Your Skills

clinphar · 发表于 2010-7-24 18:23:58

From Pharmacy Times
Thanks to the author Craig I. Coleman, PharmD(Dr. Coleman is an assistant professor of pharmacy practice and director of the pharmacoeconomics and outcomes studies group at the University of Connecticut School of Pharmacy.)

AD is a 55-year-old man with a history of alcoholic liver cirrhosis. Over the prior 6 months, he reports experiencing 2 episodes of markedly elevated serum ammonia levels (normal levels are <35 μmol/L) accompanied by an altered level of consciousness (an episode of overt hepatic encephalopathy) despite being on 3 (10 g/15 mL) cups of lactulose a day. At his most recent visit, AD’s gastroenterologist provided him with a prescription for rifaximin 550 mg to be taken by mouth twice daily to prevent recurrent bouts of hepatic encephalopathy. AD, while searching a consumer medical Web site, reads that rifaximin is an antibiotic. When dropping off his prescription, AD asks the pharmacist, “Did my doctor make a mistake? He said nothing about an infection!”

How should the pharmacist respond to AD?

ANSWER

Hepatic encephalopathy is a worsening of brain function—ranging from confusion to coma—that often occurs repeatedly in patients with liver dysfunction. When the liver is not working properly, it no longer optimally removes nitrogenous waste from the bloodstream. The increased levels of nitrogenous waste are converted to ammonia, which is thought to play a role in the development of hepatic encephalopathy. The pharmacist should explain to AD that rifaximin is in fact an antibacterial agent. It kills off gut bacteria responsible for the generation and conversion of nitrogenous waste to ammonia. Consequently, it can reduce ammonia levels in the bloodstream and prevent the recurrence of overt hepatic encephalopathy. In March 2010, the FDA approved rifaximin for this indication. The pharmacist should inform AD that the addition of rifamixin to his lactulose is not a mistake. The pharmacist should also notify AD that rifaximin, unlike antibiotics he may have previously taken for infections, will likely be prescribed to him for an extended period of time.

AD，55岁，男性，有酒精性肝硬化病史。每日口服乳果糖3杯 (10 g/15 mL)。在过去的6个月内，患者血氨大幅升高（正常血氨值<35μmol/L），同时伴有意识改变（发生过一次严重的肝性脑病）。最近，消化科医生给AD开了个处方，嘱利福昔明550mg po Bid，以预防肝性脑病的发生。AD上网查询了一家消费者医药网站。得知利福昔明是一种抗生素后，他没有取药。AD咨询药师，“医生没说我有感染啊！是他弄错了吧！”药师该如何答复呢？
答复：
肝功能不全的患者经常发生肝性脑病。肝性脑病是大脑功能的严重失调，表现为意识模糊，甚至昏迷。患有肝病时，肝脏不能将血液中的含氮废物及时排出。在体内积聚的含氮废物被转变为氨，而血氨的升高在肝性脑病的发病机制中起着重要的作用。药师应向AD说明，肠道细菌能将含氮废物转变为氨，而利福昔明可杀灭肠道细菌，从而起到降低血氨，预防肝性脑病的作用。2010年3月，FDA批准了利福昔明此项适应症。药师还应告诉AD，乳果糖和利福昔明合用并没有错。此外，与用于抗感染治疗不同的是，利福昔明用于降血氨时，用药时间将大大延长。

chaochao628 · 发表于 2010-7-24 19:15:48

天，我的英语各是有点差的哟

haojili2005 · 发表于 2010-7-25 13:32:41

回复 1# clinphar

AD，55岁，男性，有酒精性肝硬化病史。每日口服乳果糖3杯 (10 g/15 mL)。在过去的6个月内，患者血氨大幅升高（正常血氨值<35μmol/L），同时伴有意识改变（发生过一次严重的肝性脑病）。最近，消化科医生给AD开了个处方，嘱利福昔明550mg po Bid，以预防肝性脑病的发生。AD上网查询了一家消费者医药网站。得知利福昔明是一种抗生素后，他没有取药。AD咨询药师，“医生没说我有感染啊！是他弄错了吧！”药师该如何答复呢？
答复：
肝功能不全的患者经常发生肝性脑病。肝性脑病是大脑功能的严重失调，表现为意识模糊，甚至昏迷。患有肝病时，肝脏不能将血液中的含氮废物及时排出。在体内积聚的含氮废物被转变为氨，而血氨的升高在肝性脑病的发病机制中起着重要的作用。药师应向AD说明，肠道细菌能将含氮废物转变为氨，而利福昔明可杀灭肠道细菌，从而起到降低血氨，预防肝性脑病的作用。2010年3月，FDA批准了利福昔明此项适应症。药师还应告诉AD，乳果糖和利福昔明合用并没有错。此外，与用于抗感染治疗不同的是，利福昔明用于降血氨时，用药时间将大大延长。