Acetazolamide (Diamox),這個藥物常用來降眼壓、以及治療高山症,如果一般有青光眼的患者,眼科醫師有可能會使用這個藥物治療,或有的要爬山攻頂的山友,上山的時候也可能會攜帶這個藥物,不過在洗腎的患者,大概所有腎臟科醫師都認為這個藥不能用吧,但是我還是想查查看evidence如何?打開了pubmed,輸入Acetazolamide & hemodialysis,發現大部分文獻都很舊了,舊到我都看不到全文了……
文獻裡頭的資料
1992年AJKD的文章,是一個患者在眼睛手術之後,使用了Acetazolamide治療眼壓高,而產生了“可回復性”的神經學副作用(可惜的是,我也只能看到這些內容)。
1995年的這篇算是case report性質的報導,提到兩個洗腎患者,在服用了Acetazolamide之後,產生了倦怠、嗜睡、以及神智不清的症狀,好在,幾天之後,這些症狀就消失了,文章結論說,這個藥物應該要避免使用在這類病人身上,除非劑量減少,而且得要監測血中濃度才安全。
再過來,1997年也是case report,報導一個腎功能不好的患者服用Acetazolamide 500 mg每天服用一次,七天之後,出現昏睡、腎功能變差、骨髓抑制(白血球、紅血球、血小板全部低下)、且出現廣泛性胃出血,住院當中,檢查患者體內藥物濃度確實過高,不幸的這位患者最後因為免疫力低下,造成敗血症去世。
這些算是案例的報導,只告訴我們要小心、減量使用,而且要監測血中藥物濃度。
真的不能用嗎?
在2013年一月,AJKD的小測驗,一個長期洗腎的患者,因為idiopathic intracranial hypertension(不明原因的顱內壓升高)而造成突發性失明,在治療當中,每天使用一次 500mg的 Acetazolamide來降腦壓,效果很好,患者的失明問題也恢復了,也沒有任何 Acetazolamide的副作用發生,雖然文中討論沒有著墨在這個藥物上,但是,他們用了,病人沒事!
有沒有替代方案來降眼壓?
2014年3月時,AJKD有篇報導提出,在洗腎當中使用20%的葡萄糖液,以每小時 100 cc的速度持續輸注給眼壓高的患者,效果蠻好的,唯一缺點就是:糖化血色素升高到8.0%,在他們積極治療之後,醣化血色素則回到7.4%。值得一提的是,在使用葡萄糖液治療之前,他們也曾經試過“與 Acetazolamide同一類”的藥物治療(brinzolamide),患者也沒事!
藥典怎麼建議?
查詢我認為最好的藥典–Micromedex中的建議為:
腎功能指數 | 調整Acetazolamide劑量 或服用間隔 |
---|
稍差 (>50 ml/min) | 延長服藥間隔為6小時一次 |
差 (10-50 ml/min) | 延長服藥間隔為12小時一次 |
很差 ( <10 ml/min) | 不建議服用 |
洗腎患者 | 劑量減為 62.5 to 125 mg,每天一次。 洗腎後服用。看反應調整劑量。 |
我的個人心得
能不用盡量不用,若眼科醫師真的需要用這個藥,我會照藥典Micromedex的建議來減量使用,而且告知患者有以上曾經發生過的案例情形,小心注意副作用。
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