標題就是結論:洗腎患者不可使用Baclofen這種肌肉鬆弛劑。
為什麼不能使用baclofen?
Baclofen這種肌肉鬆弛劑,是一種作用位置在中樞神經裡的gamma-aminobutyric acid agonist,結構上非常類似於神經傳導物質GABA ,因此會導致神經抑制,而且主要負責這種藥物的代謝器官,是腎臟。除了治療肌肉痠痛或肌肉拉傷之外,也有治療打嗝的效果。
上面這一段的專有名詞看不懂沒關係,濃縮白話的重點在於:
1. 這種藥物會作用在大腦中,2. 這種藥物是藉由腎臟排出。
藥物會進入大腦作用沒啥問題,只要排出順暢,藥物濃度不會累積在體內,對於身體或中樞神經是沒有影響的,然而,腎臟功能不佳的人,尤其是已經開始洗腎的患者,這個藥物就容易累積在大腦中,造成整個中樞神經的抑制,導致問題。
會有甚麼症狀呢?
輕微的話,會嗜睡、頭痛、噁心、嘔吐。
嚴重過量的話,會抑制中樞神經,造成呼吸抑制、心跳減慢、肌張力下降、或者癲癇發作。
其他文獻中看到的還有: Fluent aphasia (Wernicke’s aphasia,中文為「感覺型失語」或「韋尼克失語症」,患者能夠講話,但是語意空洞、詞不達意),perseveration (語句反覆症,重複類似的語句),總之,可能會出現意識混亂、胡言亂語等等現象。
如何避免?
腎臟功能(eGFR)小於30分者,不得使用。
腎臟功能(eGFR) 30-60分者,建議要從最小劑量開始使用。
如何治療?
因為baclofen是小分子,血液透析(high-flux hemodialysis)能夠有效移除體內的baclofen,必要時,可以採用連續幾天透析來積極移除baclofen。值得一提的是,神經相關症狀的恢復,有時候不會在透析後馬上看到進步,有時會延遲幾個小時才看到效果,這和血腦障壁(BBB,blood-brain-barrier)有關係,藥物從腦中移除必須經過這道血腦障壁的阻礙,也就是說,移除在腦中的baclofen會比移除血中的慢得多,才會導致這樣延遲的恢復。
結論:
洗腎患者假如需要使用肌肉鬆弛劑,不要選擇baclofen,以免意識混亂,而血液透析可有效移除這個藥物。
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