心臟血管系統用藥

[D]: 循環系統用藥-

(a) cardiotonics

			副作用
Digoxin	Lanoxin (0.25mg/#) Lanoxin (0.5mg/2ml/amp) Cardiacin (0.05mg/ml, 60ml/bt)	CHF: PO 0.125-0.25mg/d   (0.5-1# qd) Af: 初:PO/iv 0.5mg, then 0.25mg q6h x2 ds; 維:0.125-0.375mg/d	C/I: WPW synd, 3AVB, HOCM	腎差: 減量 Af with ffg無效:  -甲亢, fever, hypoxia, 急性出血, 交感亢進者
Milrinone   PDE III inhibitor	Primacor (10mg/10ml/vial)	短期用於CHF: 初:50u/kg over 10min 維:0.375-0.75u/kg/min	[副]: PVCs, VT, Vf, PSVT, 低血壓

(b) Coronary dilator

Nitrate
Nitroglycerine (NTG)   稀釋:NS,D5W   50mg/250ml=200u/ml 10u/min=3ml/h 20u/min=6ml/h	Nitrostat SL (0.6mg/#) (25#/bt) Glyceryl trinitrate (50mg/10ml/amp)	Iv: 初: 5-10u/min (1.5-3ml/h), 每5-10min上調5-20ug/min   Max: angina:200u/min     HTN: 400u/min	C/I: RV MI, BP<90, 並用PDEi
Isosorbide 5-mononitrate	Isormol (20mg/#) Imdur (60mg/#)	Isormol: 0.5-1-2# bid Imdur: 0.5-1# qd (max 4#/d)
Nitrate with鉀通道活化劑
Nicorandil	Sigmart (5mg/#)	1# tid (1-4# b-tid) (max: 16#/d)	[副]: ALT上升
CCB
Diltiazem	Herbesser (30mg/#) Diltelan (90mg/cap) Herbesser (50mg/vial)	Angina, Raynaud’s synd, PSVT, Af, HTN 30mg (1#) tid (max: 360mg/d) Af: iv 0.25-0.35mg/kg x2min, + 5-15mg/h	[副]: 低血壓, 心跳變慢, 水腫, 惡化CHF, 便秘 [C/I]: AMI with 肺充血, SSS, 2-3°AVB
Verapamil	Vetrimil (40mg/#) Verelan SR (120mg/cap) Verapamil (5mg/2ml/amp)	Angina, migraine預防:  40-120mg q8h  SR: 1-4# qd (-qid) PSVT, Af, AF:  Iv (1-2min) 5-10mg (1-2amp)  (0.1-0.2mg/kg), q15-30min prn (~total 20-30mg)	[C/I]: sinus bradycardia, advanced heart block, Af with WPW -勿iv倂用BB

(c) 抗心律不整藥

Class IA
Quinidine	Quinidine (200mg/cap)	Af, AF
Class IB
Lidocaine	Xylocaine (2%, 5ml/amp=100mg)	心室心律不整(VT, Vf):  IV 1-1.5mg/kg + 1-4mg/min *(20支(100ml) in NS 400ml)		稀釋: NS, D5W Conc: 2g/500ml=4mg/ml Ivd: 1mg/min=15ml/h    2mg/min=30ml/h
Phenytoin	Dilantin (100mg/cap) Aleviatin (250mg/5ml/amp)	心室心律不整, prolonged QT  Iv:   1) 3.5-5mg/kg (≦50mg/min), repeat after 10min prn   2) 10-15mg/kg over 1h  PO: 1# t-qid or 3# hs	[C/I]: heart block, sinus bradycardia
Mexiletine	Mexitil (100mg/cap)	心室心律不整, 神經痛  1-4# tid	[副]: 胸痛, 心跳太慢, ALT上升
Class IC
Propafenone	Rytmonorm (150mg/#)	危及生命之心室心律不整, Af (無結構性心臟病): 1-2# b-tid	-QRS變寬需減量
Class II
Propranolol	Inderal (10mg/#) Propranolol (40mg/#)	心律不整, MI, essential tremor, angina, 嗜鉻細胞瘤, 偏頭痛預防, 焦慮, 預防食道靜脈曲張出血:  10-40mg t-qid or 20-80mg bid Max: 320mg/d	C/I: uncompensated CHF, 心因性休克, Heart block, Raynaud’s synd	在低血糖狀態, inderal 會mask低血糖症狀, selective BB較適宜用在糖尿病
Class III
Dronedarone	Multaq (400mg/#)	Af, AF: 1# q12h	C/I: CHF III/IV, 嚴重肝失能
Amiodarone	Cordarone (200mg/#) Cordarone (150mg/3ml/amp)	VF/pVT: ivp/IO 2支(300mg), then 1支(150mg) prn VT:  IV: 150mg iv x10min, iv prn; 900mg ivd x 24h  PO: 2-4# bid x7-14d ->taper 1-1.5# bid x7-14d ->taper 1-2# qd Af:  PO: 1.5-2# bid x 1-2wk, then 1# bid x 1-2wk, then 0.5-1# qd  IV: 1支x 10min + 500-1000mg x24h
Class IV
Verapamil	Vetrimil (40/#), Verelan SR (120/cap) Verapamil (5mg/2ml/amp)	PSVT, Af, AFL:   Iv (1-2min) 1-2支 (0.1-0.2mg/kg), q15-30min prn (max 4-6支) Angina, arrhythmia, migraine預防:   PO 1-3# q8h; SR 1-4# qd low-tension glaucoma: 1# b-tid	[副]: 低血壓, edema,使嚴重CHF惡化 C/I: Sinus bradycardia, advanced heart block, Af in WPW synd	[忌]: 勿併用iv verapamil & beta-blocker (因↓心收縮&AV conduction)
Diltiazem	Herbesser (30#), Diltelan (90/cap) Herbesser (50/vial)	PSVT, Af, HTN, angina, Raynaud’s synd  PO: 1# (30mg) tid (max 360mg/d)     長效(diltelan) 1-2 cap qd-bid  IV (for Af): 0.25-0.35mg/kg x2min,   + 5-15mg/h	[副]: 低血壓,心跳變慢, edema, 使CHF惡化, C/I: AMI with肺充血, SSS or 2°-3°AVB	Ivd: 2支(100mg) in N/S 100ml, run 5-10ml/h
其他
Adenosine	Adenozer (6mg/2ml/vial)	PSVT: iv 6mg-12-12 (q1-2min) (20ml NS flush if via週邊) 3mg if give via CVC
Mag sulfate  (MgSO4)	Mag sulfate (10%, 20ml/amp, 2g/amp, 0.8mEq/mL)	Torsades de pointes: -iv 2g (1支) x 1-15min, 低血鎂: iv 2-4g (1-2支) x 30min Severe asthma: iv 1.2-2g x 20min	[副]: 低血壓,↓心跳, C/I: 嚴重腎衰竭, complete AVB

[d] 抗高血壓藥

ACEi					In most pt, GFR↓<30%可被接受
		HTN	CHF	AMI
Captopril	Cabudan (25)	1-2# b-tid	0.25-0.5# tid, may to 2# tid	初: 0.25#, 24-48h titrate to 1-2# tid	C/I: 雙側腎動脈狹窄	使用前2m需f/u K, Cr
Ramipril	Tritace (10)	0.25-2# qd	0.25-0.5# qd-bid
Fosinopril	Fonosil (10)	1#qd (4#/d)	1#qd (4#/d)
Quinapril	Accupril (10)	1-2# qd	0.5-2# qd
Lisinopril	Zestril (10)	1-4# qd	0.5-2# qd
Imidapril	Tanatril (10)	0.5-2# qd	0.5-1# qd
Perindopril
ARB (AT1 antagonist)
Valsartan	Diovan (160)	0.5-2# qd	0.25-1# bid			CCr >30不調ds
Irbesartan	Aprovel (150)	1-2# qd				DM腎病變
Candesartan	Blopress (8)	1-4# qd
Olmesartan	Olmetec (20)	1-2# qd
Telmisartan	Micardis (40)	1-2# qd

		用途	副作用
CCB (Dihydropyridine)		HTN, angina
Nifedipine	Adalat OROS (30)	1-2# qd-tid
Nicardipine	Component (20) Perdipine(10mg/10ml/amp)	1-2# tid 初:5mg/h->15mg/h 維:1-3mg/h
Felodipine	Plendil (5,10)	5-20mg qd (or div)	[副]: 頭暈,水腫,心悸	合併ACEi may↓水腫
Amlodipine	Norvasc (5)	1-2# qd (or div)	腳踝水腫(19%)	腎差不調
Lercanidipine	Zanidip (10)	1-3# qd (or div)	腳踝水腫(9.3%)

Diuretics
Thiazide & related
Trichlormethiazide	Fluitrain (2)	HTN, edema, CHF, DI: 0.5-2#/d	[副]: 低血鉀/鈉/鎂, 低血氯鹼中毒, 姿態性低血壓, 高血鈣, 高尿酸	CCr <30: 無效, 但併用Loop may保有效果
Indapamide	Natrilix SR (1.5)	HTN: 1# qd 心因性水腫/利尿: 1.5-3# qd	Ditto	CCr<30: 無效
Loop
Furosemide	Rasitol (40) Fumide (10mg/ml, 120ml/bt) Rasitol (20mg/2ml/amp)	水腫:  PO, 溶液: 0.5-2# qd-b-tid  IV,IM: 1-2支q1-2h till desired response, then SC,IV,IM qd-bid (max single ds: 8-10支)  IV: 1-2支, + 5-40mg/h		* IVD 對於resistance care較佳
Aldosterone antagonist
Spironolactone	Aldactin (25)	HTN: 1-2#qd CHF(II,III,IV): 0.5-1#qd(max 2#/d) Ascites/aldosteronism:   4-8# qd-bid Hirsutism/acne/alopecia in female: 1-4# qd-bid (max 9mg/kg/d)	[副]: 高血鉀, drowsy, 陽痿, 男性女乳症/乳房壓痛, 月經不規則

BB
Propranolol	Inderal (10) Propranolol (40)	HTN: 10-20mg t-qid, or 20-40mg bid (通常ds: 40-160mg/d)	HTN, Af, angina, anxiety, akathisia
Carteolol	Mikelan (5)	5-30mg qd
Atenolol (β1)	Mirobect (50) Tenormin (100)	50-100mg qd-bid	HTN, Af, angina, MI	[副]: 低血壓, 徐脈, 夜尿/dysuria [C/I]: 肺水腫,心因性休克, AVB, 嚴重CHF
Bisoprolol (β1)	Concor (1.25, 5)	5-10mg/d (max 20)	HTN: (5) 1# QD-BID Stable CHF: 1.25 bid (q2wk)->2.5 bid (q2w) -> 3.75 bid
Carvedilol (αβ)	Dilatrend (6.25, 25)	12.5mg qd-bid or 25mg qd	HTN, angina Stable CHF: 3.125 bid (2wk), then 6.25 bid, then 12.5 bid
Labetalol (αβ)	Labtal (200) Trandate (25/5ml/amp)		HTN	[C/I]: 肺水腫,心因性休克, AVB, 嚴重CHF

αB
Terazosin	Hytrin (2)	初: 0.5# hs 維: 0.5-2.5# hs (10#)	HTN, BPH	[副]:姿態性低血壓, 心悸
Doxazosin	Doxaben (1) Doxaben XL (4)	AM or PM 1-16mg	HTN, BPH	同上

Vasodilator		HTN/ CHF
Hydralazine	Apresoline (10), (50) Apresoline (20/amp)	PO: 10-50mg t-qid IV, im: 10-40mg prn q4-6h	[副]: 高血鉀,咳, angioedema

Direct renin inhibitor
Aliskiren	Rasilez (150)	0.5-2# qd		[副]: 高血鉀,咳, angioedema

Central α2-agonist
Clonidine	Catapres (0.075mg)	HTN/ substance (abuse) w/d (菸酒鴉片) 1-3# b-tid Sialorrhea/ hot flash: 1/2-2/3# b-tid Child: ADHD with hyperactivity/Tourette’s d/o: 1/3# bid, may to 3-6ug/kg/d, (max 0.4mg/d) Test for GH defi. 4ug/kg or 0.15mg/m2.

Combo 高血壓藥:
C+ statin
Amlodipine (5)-atorvastatin (10)	Caduet	1-2# qd
A+C
Benazepril (10)-amlodipine (5)	Amtrel	1-2# qd
Olmesartan (20)-amlodipine (5)	Sevikar
Valsartan (80)-amlodipine (5)	Exforge
A+D
Perindopril (5)- indapamide (1.25)	Acertil-PLUS	1-2# qd
Valsartan (80)- HCT (12.5)	Co-Diovan
Irbesartan (150)-HCT (12.5)	Co-Aprovel
Losartan (100)- HCT (12.5)	Hyzaar	1# qd
A+C+D
Valsartan (160)-amlodipine (5)-HCT(12.5)	Exforge HCT	1-2# qd

高血脂症治療藥

藥物	↓LDL	↑HDL	↓TG	TC	忍受性	副作用
Statins	20-60%	5-10%	10-25%	15-30%	Good	↑ALT (0.5-3%) (dose-dependent) Myalgia <10%, myositis 0.5%, rhabdo < 0.1%
Ezetimibe	15-20%	-	-	?	Good
Fibrate	5-15% (↑LDL ?)	5-15%	35-50%	15%	Good	Myopathy risk↑with statin. Dyspepsia, 膽結石
Niacin*	10-25%	~30%	40%	25%	Poor – reasonable	NO clinical benefit (NEJM 2011;365:2255; THRIVE)
Resin	20%	3-5%	? ↑	20%	Poor	Bloating, 結合他藥
Ω-3 FA	↑5%	3%	25-30%			Dyspepsia, 腹瀉

Statins	HMG-CoA Reductase inhibitors	DOSE	標準劑量 QD	↓LDL
Rosuvastatin	Crestor (10)	0.5-2#	0.5-2# (max 40/d) CCr <30: 0.5-1#qd	39-55%	ALT (0.5-2%), 週邊神經炎, myopathy
Atorvastatin	Lipitor (10, 40)		10-20-40 (max 80/d)	39-50%	同上
Pitavastatin	Livalo (2)		0.5-2#	38-49%	C/I: 急性肝衰竭, 末期LC
Simvastatin	Vytorin (simva (20)-ezetimibe (10)		20-40mg (0.5-1-2#)	35-40%	ALT, myopathy, GI
Fluvastatin	Lescol XL (80)		0.5-1#	25-35%	C/I: 同上 TG: ↓19%
Lovastatin			40mg /d	31%

Combo
Ezetinibe (10)-simvastatin (20)	Vytorin

Fibrate	PPARα activator
Fenofibrate	Fenolip (200/cap)	1# qd		[副]:週邊神經炎, myopathy, rhabdo -與TZD併用, may↓HDL -may↑LDL, esp., in TG很高pt (due to improve VLDL to LDL轉化)

A. 強心劑

    Digoxin (C), (0.25mg/#; 0.25mg/1ml/ amp)
    Dobutamine (B), (dobuha 250mg/vial)

B. 抗心律不整

    Adenosine, (C), (adenocor 6mg/2ml/vial) (6-6-12mg, q1-2min)
    Amiodarone (C), (Cordarone 200mg/#; amiodarone 150mg/3ml/amp)
    Mexiletine (C), (mexitil 100mg/cap) (初: 200mg q8h, 每2-3天增減50-100mg)
    Propafenone (Rytmonorm 150mg/#) (PAf, flutter, PSVT) (初:1# q8h->增至1.5-2#q8h)


C. 抗高血壓藥

  ACEI
     Captopril (C)(1st trimester); (D)(2nd/3rd trimester) (capoten 25mg/#)
        HTN: 初12.5mg b-tid
     Fosinopril (C)(1st trimester); (D)(2nd/3rd trimester) (Monopril 10mg/#) (初10mg qd)
     Imidapril (tanatril 5mg/#) (5-40mg qd)
     Perindopril (acertil 4mg/#) (4-8mg qd)

  ARB (Angiotensin II receptor inhibitor)
     Candesartan (D), (Blopress 8mg/#) (16mg qd)
     Irbesartan (aprovel 150mg/#) (150mg qd)
     Olmesartan (D) (olmetac 20mg/#) (20mg qd)
     Valsartan (D) (diovan 160mg/#)

  Ca channel blocker (CCB)
     Amlodipine (C) (Norvasc 5mg/#) (5-10mg qd)
     Lacidipine (lacipil 4mg/#) (4-6mg qd)
     Nifedipine (C), (adalat 5mg/#; adalat OROS 30mg/#) (初10mg tid)
     Diltiazem (C), (Herbesser 30mg/#; cardizem 90mg/#)
     Verapamil (C), (Isoptin inj 5mg/2ml/amp; 40mg/#; isoptin SR 240mg/# )


  Diuretics 利尿劑
      Acetazolamide (C), (diamox 250mg/#) (用途:水腫(CHF相關), 青光眼, 高山症預防)
      Furosemide (C), (lasix 40mg/#; rasitol 20mg/1ml/amp)
      Indapamide (B), (Natrilix SR 1.5mg) (1#qd) (忌: 肝昏迷, 嚴重腎衰竭, 低血鉀)
      Trichlormethiazide (C), (Fluitran 2mg/#) (1-2# qd)
      hydrochlorothiazide 50mg/ amiloride 5mg (保鉀)) (moduretics) (1-2# qd)
      spironolactone (aldactone 25mg/#) (初: 25-200mg/d b-qid)

      mannitol (B), 20% 300ml/bot; 20% 100ml/bot
      Per L (glycerol 100g, glucose monohydrate 27.5g, NaCl 4.5g) (glycerol inj 10% 250ml/bot)

  Beta-blocker
     Atenolol (D), (tenormin 50mg/#) (初1#qd)
     Bisoprolol (C), (Concor 5mg/#; Concor F.C 1.25mg/#) (初5mg qd)
     Carvedilol (C), (Dilatrend 6.25mg/#; 25mg/#) (初6.25mg bid)
     Labetalol (C), (trandate 200mg/#, 25mg/5ml/amp) (初: 100mg PO bid)
     Propranolol (C), (Inderal 10mg/#)

  Alpha blocker
     Doxazosin (B), (doxaben XL 4mg/#) (1-16mg qd)
     Terazosin (C), (hytrin 2mg/#) (初1mg hs)

  Direct renin inhibitor
     Aliskireu Hemifumara (C)(1st trimester); (D)(2nd/3rd trimester)(Rasilez FC 150mg/#) (75-150mg qd)

  PGE1
    Alprostadil (X) (promostan 20mcg/amp) (vasodilator, erectile dysfunction) (IV, IA (intra-arterial) use) (IV 40-60mcg in N/S 500ml, run 2h)

 其他
   Clonidine (C) (catapres (75mcg/#) (75-150mcg bid) (鎮靜作用)
   Hydralazine (C) (apresoline inj 20mg/ml/amp; 25mg/#)
   Ubidecarenone (Q10, Neuqunon 10mg/#) (10mg tid) (CHF輔助)

 複方
   Amlodipine 5mg / benazepril 10mg (D) (Amtrel) 1-2# qd
   Amlodipine 5mg / Olmesartan 20mg (Sevikar) (1#qd)
   Amlodipine 5mg / valsartan 80mg (Exforge) (1#qd)

   Candesartan 16mg / hydrochlorothiazide 12.5mg (C,D) (Blopress Plus) (1#qd)
   Irbesartan 150mg /  hydrochlorothiazide 12.5mg (C,D) (CoAprovel) (1-2# qd)
   Losartan 100mg / hydrochlorothiazide 12.5mg (D) (Hyzzar) (0.5-1# qd)
   Telmisartan 40mg / hydrochlorothiazide 12.5mg (C,D) (Micardis plus) (1-2# qd)

   Perindopril 4mg / Indapamide 25mg (acertil plus) (1# qd) 
  
   


低血壓:

   Midodrine (gutron) (2.5mg)
[適]: 姿態性低血壓
[用]: 1# tid (白天)