浅山健氏提供 99.12.15
現実に行っている､薬剤処方でなく､毒物投与を送ります｡
84歳、体重50ｋｇの高齢男子で、その診断名は陳旧性心筋梗塞症、ウツ血性心不全症、度房室ブロック、高尿酸症、腎不全、脳梗塞症と多様です。
検査所見で、腎機能を表す BUN 48, Creatinine 2.2
と正常値を相当に上回っており、高度腎不全の証拠があります。
1. アンタップ、硝酸イソソルビド（血管拡張剤）貼付1日1枚
2. アシノン150mg X 2 X 2 in the morning & evening、ニサジチン（ゼリア）強力Ｈ２遮断剤
3. アカルデイ 1.25mg X 2 X 2 in the morning & evening、ピモベンダン（強心剤）
4. ロンゲス 10mg X 1/2 in the morning、リシノプリル（ＡＣ阻害剤）
5. フロセミド 40mg in the morning（降圧利尿剤）
6. 小児用バッファリン1 tab/day in the morning(１錠当りアスピリン81mgダイアルミネート
33mg合剤（抗血小板作用がある、NSAIDs）
7. アレキサン25mg/day、アルダクトン、スピノラクトン（抗アルドステロン利尿剤）
8. アロチーム（沢井）100mg/day、ザイロリック、アロブニノール製剤（通風治療剤）, Allopurinol
薬剤投与は40歳壮年者に対する量の故、最低の処方箋です。
その理由を以下に記します（時間が許す方は、添付の英文文献をご覧ください）。
内科の主治医は、この地方の名医として高名な"天皇"です。
壮年層を対象とする内科で、短期間の処方に認め得る可能性があっても、高齢で腎機能障害者に長期間処方するのは、無知に基づく毒物投与として、認める事は出来ません。 高齢者医療の世界的恥辱と思います。
問題は処方の間違いを組織の論理に基づいて私が指摘した結果は、俺の処方に文句があるかと、逆に怒鳴られた事実です。 日本の高齢者医療が英語文化圏と比べて、10年以上の遅れがある一例と、私は受け止めています。
NSAIDs と高血圧症に関して
Rochon: BMJ, Volume 315(7115).October 25, 1997.pp 1096-1099.
British Medical Journal
Non-steroidal anti-inflammatory drugs and starting antihypertensive treatment
Non-steroidal anti-inflammatory drugs are among the most frequently
prescribed drugs to elderly patients. An estimated 10-15% of people aged 65
years or older are prescribed such drugs. (5) Their anti-inflammatory
properties seem to result from their ability to inhibit cyclo-oxygenase, a
critical enzyme in the biosynthesis of prostaglandins. (6) Good evidence
exists to suggest that prostaglandins have an important role in the
modulation of two major determinants of blood pressure: vasoconstriction of
arteriolar smooth muscle and control of extracellular fluid volume. The
effects of non-steroidal anti-inflammatory drugs are most prominent in
patients with existing hypertension. (7)
The high prevalence of use of non-steroidal anti-inflammatory drugs among
older people emphasises the importance of studying the clinical impact of
these drugs on blood pressure in elderly people. To determine whether there
is an increased risk associated with starting antihypertensive treatment in
older people prescribed non-steroidal anti-inflammatory drugs (* Table 1*), a
case-control study was performed involving patients enrolled in the New
Jersey Medicaid programme who were aged 65 years or older. (8) Over 9000
patients who were newly started on an antihypertensive drug were compared
with a similar number of randomly selected control patients. The adjusted
odds ratio for starting antihypertensive treatment for recent users of
non-steroidal anti-inflammatory drugs compared with non-users was 1.66 (95%
confidence interval, 1.54 to 1.80). The odds ratio increased with increasing
daily dose of the anti-inflammatory drug: compared with non-users, the
adjusted odds ratio for users of low average daily doses was 1.55 (1.38 to
1.74), for medium dose users was 1.64 (1.44 to 1.87), and for high dose users
was 1.82 (1.62 to 2.05). The conclusion was that the use of non-steroidal
anti-inflammatory drugs may increase the risk associated with starting
antihypertensive treatment in older people. Given the high prevalence of use
of non-steroidal anti-inflammatory drugs by elderly people, this association
could have important public health implications for the care of older
patients.
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*Table 1. Examples of prescribing cascade*
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This relation also shows a clear sequence of events where the use of one
treatment leads to the start of a second that might have been avoided. Based
on the findings of numerous epidemiological and clinical studies that have
characterised the adverse consequences of use of non-steroidal
anti-inflammatory drugs in older people, recommendations have been made to
avoid using these agents when clinically feasible. (5) As with other drugs
prescribed to elderly patients, the most prudent approach is to limit
prescribing non-steroidal anti-inflammatory drugs to situations in which
benefits clearly outweigh risks and to use them only after potentially safer
alternatives have been tried. (11) Because of the multiple adverse effects
attributable to these drugs, for some indications (such as osteoarthritis)
treatments such as acetaminophen, gentle exercise, and weight reduction may
be effective alternatives. (12-14) When treatment with non-steroidal
anti-inflammatory drugs is necessary, the lowest feasible dose should be used
for the shortest time required to achieve the desired effect.
Furthermore, if patients require extended treatment with non-steroidal
anti-inflammatory drugs, periodic monitoring of blood pressure is warranted,
as such treatment may contribute to newly detected rises in pressure. With
recognition of this association between non-steroidal anti-inflammatory drugs
and rises in blood pressure, the starting or intensifying of antihypertensive
treatment may be avoided.
フロセミドと痛風に関して
Thiazide diuretics and starting treatment for gout
The development of some degree of hyperuricaemia is a well documented side
effect of treatment with thiazide diuretics. (15-18) Population based
studies have shown an association between hyperuricaemia and the development
of gout. For example, data from the Framingham study document a cumulative
incidence of gout of 36% over 12 years in patients with serum uric acid
concentrations >476 micromol/l, compared with less than 3% in those with
lower concentrations. (19) The occurrence of hyperuricaemia that has been
induced by thiazide diuretics raises some important issues about the use of
these diuretics in elderly people. Ample data show the efficacy of these
agents in treating hypertension in elderly patients and in preventing major
sequelae such as stroke-data that are absent for many other commonly used
antihypertensive drugs. (20-22) The impact of thiazide diuretics on serum
uric acid concentrations, however, raises questions about whether this
treatment may precipita!
te the use of additional drugs.
This question was recently examined in a retrospective cohort study of 9249
patients enrolled in the New Jersey Medicaid programme aged 65 or older who
had been started on a variety of antihypertensive agents. (9) None of the
patients in the cohort had previously used treatment for gout (allopurinol,
colchicine, or uricosuric agent). Follow up extended for up to two years, and
exposure to antihypertensive drugs was characterised over this period
according to the following categories: thiazide diuretics alone; non-thiazide
antihypertensive drugs alone; thiazide diuretics combined with any
non-thiazide antihypertensive drug; and no use of antihypertensive drugs. The
relative risk for starting treatment for gout was 1.00 (0.65 to 1.53) for
non-thiazide antihypertensive drugs alone, 1.99 (1.21 to 3.26) for thiazide
diuretics alone, and 2.29 (1.55 to 3.37) for thiazide diuretics combined with
any non-thiazide drug. Risk for starting treatment for gout was significantly
increased for thiazide doses of 25 mg/day (in hydrochlorothiazide
equivalents) or more; no significant increase in risk was seen for lower
doses. It was concluded that the use of thiazide diuretics in doses of >
or = to 25 mg/day was associated with a significantly increased risk for
starting treatment for gout, relative to antihypertensive regimens that did
not include the use of a thiazide diuretic.
Considerable evidence supports the efficacy of low doses of thiazide
diuretics in the treatment of hypertension in elderly people. (13-15) The
dose-response relations found in this study support the use of lower doses of
thiazide diuretics when treatment is indicated. Although the recommendations
of the United States's joint national committee on detection, evaluation and
treatment of high blood pressure suggest starting antihypertensive treatment
at low doses in all patients, (17) thiazide diuretics are commonly started
at doses that extend well beyond the low dose range. Low doses of thiazide
diuretics-for example, 12.5 mg of hydrochlorothiazide-often produce as large
an antihypertensive effect as larger doses, with a reduced risk of metabolic
abnormalities. In fact, evidence exists that a dose of hydrochlorothiazide as
low as 6.25 mg can be as efficacious in treating hypertension in many older
patients, when combined with a low dose of another antihypertensive drug.
(23-25) When hyperuricaemia does occur during treatment with a thiazide
diuretic, clinicians should bear in mind that asymptomatic hyperuricaemia
alone does not warrant treatment.
Ｈ２遮断剤と腎・精神症状に関して
CHUTKA: Mayo Clin Proc, Volume 70(7).July 1995.pp 685-693.
Mayo Clinic Proceedings
H sub 2-Receptor Antagonists.
H sub 2-receptor histamine antagonists, such as cimetidine, ranitidine,
famotidine, and nizatidine, are commonly prescribed in elderly patients. These
agents are all well tolerated and are generally equally efficacious in the
treatment of peptic ulcer disease, gastroesophageal reflux, and pathologic
hypersecretory disorders. Initial duodenal ulcer disease should be treated
withshort-term, full-dose therapy. Duodenal ulcers tend to heal in 4 to 8 weeks;
however, some patients may require long-term maintenance therapy at a reduced
dose. (42) In hypersecretory disorders, such as the Zollinger-Ellison
syndrome, H sub 2-receptor antagonists are considered the preferred therapy over
surgicalintervention because of the decreased risks involved. H sub 2-receptor
antagonists are also useful in the short-term management of active, benign
gastric ulcers. In patients with gastroesophageal reflux disease unresponsive
toconventional therapy, relief may be obtained with H sub 2-receptor antagonist
therapy. (43) Some evidence suggests that H sub 2-receptor antagonists have
been commonly used for reasons not substantiated in the medical literature and
often prescribed for excessively long periods. (44-46)
Cimetidine was the first H sub 2-receptor antagonist to be released and is a
cytochrome P-450 enzyme inhibitor. It reduces the metabolism of drugs such as
phenytoin, carbamazepine, theophylline, warfarin, and quinidine. As a result,
the t sub 1/2 of these drugs can be increased when they are used in
conjunction with cimetidine. Ranitidine has a similar but less effect. Close monitoring
and dose adjustment may be necessary. The other H sub 2-receptor antagonists do
not exhibit this enzyme inhibition and thus would not be expected to interact with
the previously described medications.
The H sub 2-receptor antagonists are excreted primarily by the kidneys, and
patients with impairment in renal function may have accumulation of the drug.
Insuch patients, dosage adjustment may be necessary. Concomitant hepatic
dysfunction may necessitate further dose adjustment. The H sub 2-receptor
antagonists have a relatively benign adverse reaction profile. (47) The most
common adverse effects include headache, dizziness, and dermatologic
reactions.
Rare hematologic abnormalities such as leukopenia and anemia have been
reported.
Cimetidine has also been associated with reversible CNS effects such as
confusion, psychosis, and hallucinations--most commonly, in elderly or
severely ill patients. These states usually develop within a few days after initiation
of therapy and are reversible within a few days after therapy has been
discontinued.
