2014年5月28日 星期三

CNS drugs


[A] CNS drugs

(a) gen anesthetics
商品名



 inhalation




  Desflurane
Suprane 240ml/bt
維持全麻


  Sevoflurane
Ultane 250ml/bt
引導/維持全麻


IV




  Etomidate
Etomidate-lipuro 20mg/10ml/amp
引導全麻,
短效安眠藥
 Iv 0.2-0.3mg/kg
[]: myoclonus

  Thiamylal sod
Citosol (500mg/20ml/vial, 2.5%)
引導全麻
Sedation:
iv 0.5-1.5mg/kg
Status epilepticus:
 Iv 3-5mg/kg +
2-5mg/kg/h ivd
C/I:
 -resp obst
 -severe CV instability or shock
 -status asthmaticus

  Propofol
(GABAa agonist)
Fresofol (200mg/20ml/amp)

稀釋 by D5W或直接用
引導/維持全麻
Total IV anesthesia (TIVA),
ICU sedation,
 Iv 0.25-1mg/kg + 1.5-4.5mg/kg/h
status epilepticus:
  1-2mg/kg+ 2-4mg/kg/h
[]: apnea, myoclonus, 低血壓, 高血脂,
Rare: 靜脈栓塞
尿液變色<1%
用超過2 (≥4mg/kg/h) 可導致propofol infusion synd (Major risk factor:
 -poor oxygen delivery
 -sepsis
 -嚴重大腦受傷
 -高劑量
  Ketamine
Ketalar (50mg/ml, 10ml/vial=500mg)
Induction: iv 0.5-2mg/kg
維持: iv 30-90 ug/kg/min
 (60kg=1.8-5.4mg/min= 120mg/h
Sedation, analgesia: iv (2-3’) 0.2-0.8mg/kg
Ivd 5-10ug/kg/min

Barbiturate & ketamine 勿併用(ppt)
 麻醉藥輔助治療




  Fentanyl citrate
Fentanyl (0.1mg/2ml/amp)
(0.5mg/10ml/amp)
Premedication: iv 25-100ug or 0.5-2ug/kg
Adjunct to anesthesia:
 Iv 1-3ug/kg
Stress response to插管:  Iv 2-6ug/kg
[]: 口乾, CNS抑制, 呼吸抑制
腎差不需調整劑量
  Midazolam
Dormicum (5mg/1ml/amp)
Midation (15mg/3ml/amp)
Pre-OP sedation: im 0.07-0.08 mg/kg
全麻:
 導引:0.05-0.15 mg/kg維持: 0.05mg/kg prn
 0.06mg/kg/h
ICU sedation:
 0.02-0.1mg/kg + 0.04-0.2mg/kg/h
Status epilepticus: IM, intranasal: 0.1-0.2mg/kg
 Iv: 0.1-0.2mg/kg + 0.05-0.6/kg/h
[]: 低血壓, 呼吸抑制,

Ffg需減低劑量:
 -老者
 -虛弱者
 -併用CNS抑制劑時
-Tachyphylaxis in status epilepticus (24-48h,需調高劑量數倍)
-給藥48h,常會蓄積,造成過度sedation


(B) Sedation & hypnotics





(1) BZD (GABAA W1+W2)




  Brotizolam
Lendormin (0.25mg/#)
Insomnia: 0.5-1# hs
術前sedation: SL 1-2#
 Duration 7h

小心: 嚴重重症肌無力, COPD
  Flunitrazepam
Modipanol (1mg/#) (FM2)
Insomnia: 0.5-4# hs

小心: 嚴重重症肌無力, COPD
  Estazolam
Eurodine (2mg/#)
Insomnia: 0.5-1# hs
[]: asthenia, hypokinesia
Ditto
  Nitrazepam
Limin (5mg/#)
Insomnia: 1-2# hs

Ditto
(2) Imidazopyridine (GABAA-W1)




  Zolpidem
Stilnox (10mg/#)
Stilnox CR (6.25mg/#)
Insomnia: 0.5-2# hs
 CR 1-2#hs
[]:夢遊,
 依賴/rebound insomnia
Ditto
  Zaleplon
Sonimax (10mg/#)
Insomnia: 0.5-2# hs


(3) Barbiturate




  Phenobarbital
Phenobarbital 30mg/#
Phenobital 100mg/ml/amp
Sedation:
PO, 1#tid, 2#bid
IM: 0.5-1 amp
抗痙攣:
PO, 2# b-tid
IM: 0.5-1amp b-tid
Status epilepticus:
 IM: 20mg/kg (60mg/min), 20分後仍SZ, add another 10mg/kg




(C) 抗焦慮藥





(1) BZD




  Diazepam
Diazepam (2mg/#)
Dupin (5mg/#)
Dupin (10mg/2ml/amp)
Anxiety: PO 1# tid,
Deep IM 1
肌肉鬆弛: PO 2-10mg tid
 IM, IV 5-10mg
Status epilepticus
 IV 10mg (0.3mg/kg), may repeat after 10-20’
Acute Alc w/d:
 PO 10mg t-qid
 IV 5-10mg q5-10’ until calm
Insomnia: 1-5mg hs
[]: 呼吸變慢
Prefer slow iv, if iv not available, ->IM deltoid only
  Lorazepam
Lowen (0.5mg/#)
Anxicam (2mg/ml/amp)
Hypnotics: 1-8#hs
焦慮: 1-4# tid (max 20#/d)
Acute Alc w/d:
 PO,SL: 2-4# q4-6h
 IM,IV: 1-2q15-20’ till calm或改ivd
Status epilepticus:
 Iv,IM 2(0.1mg/kg), 10-20’repeat
止吐: IV, PO/SL: 1-2mgq4-6

小心: 嚴重重症肌無力, COPD
  Bromazepam
Lexotan (1.5mg/#)
焦慮: 1-2-4-6# tid
老人: 減半


  Alprazolam
Xanax (0.25mg/#)
Anxiety, depression, panic d/o
 1-2# tid, max 5-6mg/d

小心: 嚴重重症肌無力, COPD
  Oxazolam
Secorin (10mg/#)
Anxiety: 1-2# tid

Ditto

(D) Antidepressants
SSRI/ SNRI w/d syndrome
Criterion A: 使用該藥4-8wk , 停藥/interrupted or 減藥
Criterion B: 使用該藥4-8wk , /減藥 1-10天內, 產生至少2ffg symp
  Dizziness; N and/or V; HA; lethargy; anxiety and/or agitation; or四肢有tingling(paresthesia),numbness, “’electric”-shock-like
  Tremors; sweating; insomnia; irritability; vertigo; diarrhea
(1) SSRI




  Fluoxetin
Fluronin (20mg/cap)
Depression, OCD, panic d/o: 1# qd (max 80mg/d)
[]: 緊張,HA,GI, insomnia, anorgasm, bruising, mydriasis, delayed ejaculation

  Sertraline
Zoloft (50mg/#)
Depression, OCD, Panic
  1-2#/d (max 4#)
Ditto

  Paroxetine
Seroxat (20mg/#)
Depression, OCD, panic
  1-2#/d (max 3#)
Ditto

  Escitalopram
Lexapro (10mg/#)
Depression, OCD, panic
  1-2# qd
Ditto

(2) SNRI (serotonin/NE reuptake inhibitors)



  Venlafaxine
Efexor XR (3.75mg/cap)
Efexor XR (75mg/cap)
Depression, OCD, panic
  :1-2 cap qd (max 75mg x3-4 cap/d)
Ditto
BWor(edema)
<150mg: serotonergic effect
150mg: dual effect (+NE)
  Duloxetine
Cymbalta (30mg/cap)
Depression, anxiety, neuropathic pain, stress incontinence, fibromyalgia
  1-2 cap qd (max 4#/d)
Ditto

(3) NE/dopamine reuptake inhibitor (NDRI)



  Bupropion
Wellbutrin XL (150mg/#)
Depression
 1-2# qd (max 3)
[]: agitation, tremor, insomnia, Nausea, nightmare,
SZ (0.1%)
小心: epilepsy
(4) 5HT2 /α2/ 5HT3 antagonist




  Mirtazapine
Smilon (30mg/#)
Depression, pruritus, migraine: 0.5-2#/d hs-bid
頭嗜睡, 口乾, 便秘
REM behavior d/o
特性: block major receptor s/w pruritus (H1, 5HT2, 5HT3)
(5) 5HT2 antagonist




  Trazodone
Mesyrel (50mg/#)
Depression: 1# b-tid (max 8-12#)
Insomnia: 0.5-3# hs, Erectile dysfxn: 1-2# hs
[]: 嗜睡, GI, 姿態低血壓, priapism, HA

(6) melatonergic agonist/ 5-HT2C antagonist



Agomelatine
Valdoxan (25mg/#)
Depression: 1-2# hs
S/E: GI, drowsy

(7) Tricyclic drugs




  Imipramine
Fronil (25mg/#)
Depression, enuresis, neuralgia: 1-4#/d or hs
Insominia: 1-4# hs
S/E: 心悸,口乾,便秘,尿滯留,視力模糊

  Doxepine
Sinequan (2mg/cap)
Depression< anxiety, insomnia, urticaria:
 1-6# hs or divided (max 12#)
Ditto

  Deanxit 複方
Flupentixol 0.5mg (neuroleptics極低劑量)
Melitracen 10mg (TCA)
Depression, anxiey, apathy:
 :1-2# om, 1# noon
 : 1# om


(8) Reversible MAO-A inhibitor



  Moclobemide
Moclod (150mg/#)
Atypical depression, depression in dementia, resistant depression:
 1-2# b-tid (max 4-6#/d)
S/E: sleep disturbance, dizziness, nausea, HA
tyramine高食物勿食用過量

(e) anti-manic drug





Lithium carbonate
Ligilin (300mg/cap)
Acute mania or 預防
預防migraine or cluster HA: 1-4 cap HS or 2 cap bid
S/E: 多尿/口渴,無力, tremor, 水腫, vertigo, acne
下列情形很易造成鋰中毒: 嚴重腎病,脫水,低血鈉,利尿劑

(f) Anti-psychotic drug
   -突然停用此類藥, 可能在數日到數周內導致psychotic symp rebound akathisia / Parkinsonism or w/d dyskinesia惡化/復發,
   -如果需停藥, taper it over 4-8 wks
(1) Typical anti-psychotic



  Flupentixol
Fluanxol depot
(20mg/amp)
Psychotic d/o:
 1-2 amp deep IM q2-4wk


  Prochlorperazine
Novamin (5mg/#)
Novamin (5mg/1ml/amp)
Nausea/ vomiting, acute or chronic psychosis:
 1-2# t-qid; IM 1-2 amp q3-4h (max 8/d)
Post-OP N/V: 術後1-2IM
S/E: EPS, dyspnea, HA, drowsy, 姿態低血壓

  Haloperidol
Binin-U (5mg/#)
Haldol (5mg/1ml/amp)
Haldol decanoas (50mg/1ml/amp)
Psychotic d/o:
 1-5mg hs-tid (max 6#/d)
 IM 1-2, q1-4h prn
 Decanoas: IM 1-3q4wk
Tourette’s d/o, hiccup
 PO: 0.5-5mg hs (max 2-3#/d)
S/E: EPS, drowsy, 姿態低血壓, QT延長
甲狀腺亢進病人May cause嚴重neurotoxic 反應
  Sulpiride
Dogmatyl (50mg/#)
Sulpin (200mg/#)
Depression: 50-100-200 tid
Psychosis/schizophrenia:
 100-200mg tid or
200-400mg bid (max 1.2-2.4g/d

[]: agitation, dizzy, sedation, 乳漏, 無月經, ESP (rare)

(2) Novel anti-psychotic



Multi-receptor antagonist



   Clozapine
Clozaril (25mg/#)
Clozaril (100mg/#)
Schizophrenia:
 : 0.5-1#/d(12.5-25mg/d), then 1-2#/d (25-50mg/d) q2-3 wk
 Dose range 200mg hs or 100-150mg b-tid (max: 600-900mg/d)
: 姿態低血壓, 體重, granulocytopenia, drowsy, SZ,
便秘,尿失禁, 流口水,
高血糖 (in wks to yrs)
C/I: WBC 3000
   Olanzapine
Zyprexa zydis (5mg/#)
口溶錠
Schizophrenia, bipolar d/o,
1-4# qd
Depression:輔助藥 1-2.5#qd
: HA, 嗜睡, dizzy,
乳漏 (PRL)
體重/水腫,
口渴,便秘,尿失禁,
高血糖 (in wks to yrs)
TG.

   Zotepine
Lodopin (50mg/#)
Schizophrenia:
0.5-1# tid (max 6-9#/d)
S/E: 嗜睡/失眠, dizzy 心悸,
口渴, 便秘,體重(less), 乳漏(PRL),

   Quetiapine
Seroquel XR (50mg/#)
Seroquel XR (300mg/#)
Schizophrenia/ bipolar d/o:
 300-600mg qd (晚上) (max 800-1200mg/d)
MDD (major depressive d/o):
 輔助藥::50mg, then 150-300mg qd
失眠: 25-100mg
Anxiety: 50-150mg/d
: 姿態低血壓,
嗜睡/失眠, HA, dizzy, 水腫,
口乾, 體重(less),

 5HT2/D2 antagonist




   Risperidone
Risperdal (2mg/#)
Risperdal oral solution (1mg/ml, 30ml/bt)
Risperdal Consta 25mg/vial
Risperdal Consta 37.5mg/vial
Schizophrenia, bipolar d/o:
 PO: 0.5-4# qd or divided
 IM: 1-2Q2WK
   Onset: 3wk duration:3-4wk
[]: Sedation, HA,
口乾/便秘,尿滯留
乳漏(PRL), 水腫
EPS (≥6mg/d)

   Paliperidone
Invega ER (6mg/#)
Invega ER (9mg/#)
Schizophrenia, bipolar d/o:
  6-12mg (1-2#) qd

-risperidone之主要活性代謝物
   Zaprasidone
Geodon (60mg/cap)
Schizophrenia, bipolar d/o:
  1 cap qd-bid (max 4 cap/d)
S/E: sedation, HA, N/V, rash, 便秘, EPS(rare), QT延長(rare)

 D2/D3 antagonist




   Amisulpride
Solian (200mg/#)
Schizophrenia
 Negative synd: 0.25-1.5# qd
 Positive synd: 2# hs-bid (max 3# bid)
S/E: 嗜睡,乳漏,
姿態低血壓(rare)

 Dopamine/5-HT partial agonist




   Aripiprazole
Abilify (10mg/#)
Schizophrenia, bipolar d/o:
  1-3# qd
憂鬱症: 輔助藥 0.25-1.5# qd
S/E: HA, 失眠, 嗜睡,
體重(less)
PRL(No or輕微)


(g) Anti-convulsants
(1) Hydantoin




  Phenytoin (DPH)
Dilantin (100mg/cap)
Aleviatin (250mg/5ml/amp)

-give undiluted or in N/S
Grand mal, complex partial SZ, neuralgia
Seizure d/o: PO
 Load: 3 cap tid or 5 cap bid (15-20mg/kg/d)
 :3 cap hs
Status epilepticus: IV
 15-20mg/kg (60kg=900-1200mg=4) (25-50mg/min)
S/E: N/V, 嗜睡, nystagmus,
牙齦hyperplasia,
acne, 多毛
Give additional 5-10mg/kg if SZ 持續
  L.A 複方
Phenytoin 50mg
Phenobarbital 20mg
1-2# tid


(2) Barbiturate




  Phenobarbital
Phenobarbital 30mg/#
Phenobital (100mg/amp)



(3) BZD




  Diazepam
Diazepam (2mg/#)
Dupin (5mg/#)
Diazepam (10mg/2ml/amp)



  Nitrazepam
Limin (5mg/#)






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