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1、門門 診診疑義疑義 處處 方方 討討 論論Use of Methylphenidate in Traumatic Brain Injury (TBI)報告日期：報告日期：99.3.30黃信裕黃信裕 藥師藥師Content1.Methylphenidate 之藥理作用之藥理作用2.Methylphenidate核准之適應症核准之適應症3.Methylphenidate in TBI之合理性之合理性4.Methylphenidate in TBI之建議劑量之建議劑量5.Methylphenidate in TBI之證據等級之證據等級6.Conclusion7.ReferencesMethylphe
2、nidate 之藥理作用之藥理作用Mechanism of ActionCNS stimulantReuptake of Dopamine inhibitorChallman TD, Lipsky JJ. Methylphenidate: Its Pharmacology and Uses Mayo Clin Proc. 2000 Jul;75(7):711-21. ReviewMethylphenidate核准之適應症核准之適應症衛生署核准適應症衛生署核准適應症FDA核准適應症核准適應症Methylphenidate in TBI之合理性之合理性What are the most commo
3、n problems after a TBI? Thinking Changes (1) Attention Reduced concentrationReduced visual attentionInability to divide attention between competing tasks Processing speed Slow thinkingSlow readingSlow verbal and written responsesThinking Changes (2)CommunicationDifficulty finding the right words, na
4、ming objectsDisorganized in communicationLearning and Memory Information before TBI intactReduced ability to remember new informationProblems with learning new skillsMethylphenidateinTBI之證據等級之證據等級FDA Approval: Adult, no; Pediatric, noEfficacy: Adult, Evidence favors efficacy; Pediatric, Evidence fav
5、ors efficacyRecommendation: Adult, Class IIb; Pediatric, Class IIbStrength of Evidence: Adult, Category B; Pediatric, Category BMICROMEDEX(r) Healthcare Series 醫療照護系列資料庫 (Database) Thomson MICROMEDEX Evidence (I)ArticleELSignificant improvementNo Significant improvementWhyte et al., 1997ISpeed of in
6、formation processingAttentiveness during work taskCaregiver ratings of attentionSustained attention Divided attention DistractibilityWhyte et al.,2004ISpeed of mental processingDistractibility, Vigilance/sustained attentionMooney and Haas, 1993IAttentionKim et al.,2006IIReaction time and accuracy of
7、 Visuospatial attentionLee et al., 2005IIRecognition reaction time and daytime alertness (when compared to sertraline) Recognition reaction time (when compared to placebo)Plenger et al., 1996IIAttention span, divided attention and vigilance(at one month)Attention span, divided attentionand vigilance
8、 (at three months)Kaelin et al., 1996IIAttention span, sustained attention, divided attentionSpeech et al., 1993IISustained attentionVigilance, Processing speedGualtieri and Evans, 1988II10 subjects sustained attention, divided attention, selective attention5 subjects no changeGrade et al.,1988IICog
9、nitive functionEvidence(II) Sivan M et al. Clin Rehabil. 2010 Feb;24(2):110-21MethylphenidateinTBI之建議劑量之建議劑量1.EnhanceattentionalfunctionDose:0.250.30mg/kgbid2.EnhancethespeedofcognitiveprocessingDose:0.250.30mg/kgbid3.EnhancelearningandmemoryDose:0.30mg/kgbid4.ImprovespeedinmentalprocessingDose:0.30
10、mg/kgbidRecommendedDoseNeurobehavioral Guidelines Working Group, Warden DL, Gordon B, McAllister TW, Silver JM, Barth JT, Bruns J, Drake A, Gentry T, Jagoda A, Katz DI, Kraus J, Labbate LA, Ryan LM, Sparling MB, Walters B, Whyte J, Zapata A, Zitnay G. Guidelines for the pharmacologic treatment of ne
11、urobehavioral sequelae of traumatic brain injury.J Neurotrauma. 2006 Oct;23(10):1468-501醫師開立處方：醫師開立處方：Methylphenidate10mg/tab,1tab,QD?結果：可能造成改善症狀之劑量不足結果：可能造成改善症狀之劑量不足結論結論Methylphenidate用於用於TBI(創傷性腦損害創傷性腦損害)乃屬於合理之治療，因為乃屬於合理之治療，因為TBI會造成腦部神經會造成腦部神經性病變，性病變，如：如：認知不足認知不足、注意力缺乏、記憶力減退注意力缺乏、記憶力減退等等。但是衛生署核准之適
12、應症為過動兒症候群及但是衛生署核准之適應症為過動兒症候群及發作型嗜睡症，若醫師將發作型嗜睡症，若醫師將Methylphenidate用於用於器質性腦徵候群或腦震盪後徵候群器質性腦徵候群或腦震盪後徵候群，需考慮以自費需考慮以自費方式給予方式給予。參考資料參考資料1.Siddall OM. Use of methylphenidate in traumatic brain injury. Ann Pharmacother. 2005 Jul-Aug;39(7-8):1309-13. Epub 2005 May 24. Review. 2. Sivan M, Neumann V, Kent R, S
13、troud A, Bhakta BB Pharmacotherapy for treatment of attention deficits after non-progressive acquired brain injury. A systematic review. Clin Rehabil. 2010 Feb;24(2):110-21.3. Challman TD, Lipsky JJ. Methylphenidate: its pharmacology and uses. Mayo Clin Proc. 2000 Jul;75(7):711-21. Review.4. Neurobe
14、havioral Guidelines Working Group, Warden DL, Gordon B, McAllister TW, Silver JM, Barth JT, Bruns J, Drake A, Gentry T, Jagoda A, Katz DI, Kraus J, Labbate LA, Ryan LM, Sparling MB, Walters B, Whyte J, Zapata A, Zitnay G. Guidelines for the pharmacologic treatment of neurobehavioral sequelae of trau
15、matic brain injury. J Neurotrauma. 2006 Oct;23(10):1468-501. 5. MICROMEDEX(r) Healthcare Series 醫療照護系列資料庫(Database) Thomson MICROMEDEX ThankyouforyourattentionBackgroundnDeficits in attention are commonly seen in non-progressive acquired brain injury.nThe prevalence of attention deficits even after mild traumatic brain injury has been reported to range from 40-60% at 1-3 months post injury Pierce SR. et al. Arch Phys Med Rehabil 2002Attention nFocusednSustainednDividednAlternatingnSelective
