1、門 診疑義 處 方 討 論Use of Methylphenidate in Traumatic Brain Injury (TBI)報告日期：99.3.30黃信裕 藥師ContentMethylphenidate 之藥理作用Methylphenidate核準之適應癥Methylphenidate in TBI之合理性Methylphenidate in TBI之建議劑量Methylphenidate in TBI之證據(jù)等級ConclusionReferencesMethylphenidate 之藥理作用Mechanism of Action CNS stimulantReuptake of

2、Dopamine inhibitor Challman TD, Lipsky JJ. Methylphenidate: Its Pharmacology and Uses Mayo Clin Proc. 2000 Jul;75(7):711-21. Review Methylphenidate核準之適應癥衛(wèi)生署核準適應癥FDA核準適應癥Methylphenidate in TBI之合理性What are the most common problems after a TBI? Thinking Changes (1) Attention Reduced concentrationReduce

3、d visual attentionInability to divide attention between competing tasks Processing speed Slow thinkingSlow readingSlow verbal and written responsesThinking Changes (2)CommunicationDifficulty finding the right words, naming objectsDisorganized in communicationLearning and Memory Information before TB

4、I intactReduced ability to remember new informationProblems with learning new skillsMethylphenidate in TBI之證據(jù)等級FDA Approval: Adult, no; Pediatric, noEfficacy: Adult, Evidence favors efficacy; Pediatric, Evidence favors efficacyRecommendation: Adult, Class IIb; Pediatric, Class IIbStrength of Evidenc

5、e: Adult, Category B; Pediatric, Category BMICROMEDEX(r) Healthcare Series 醫(yī)療照護系列資料庫 (Database) Thomson MICROMEDEX Evidence (I)ArticleELSignificant improvementNo Significant improvementWhyte et al., 1997ISpeed of information processingAttentiveness during work taskCaregiver ratings of attentionSusta

6、ined attention Divided attention DistractibilityWhyte et al.,2004ISpeed of mental processingDistractibility, Vigilance/sustained attentionMooney and Haas, 1993IAttentionKim et al.,2006IIReaction time and accuracy of Visuospatial attentionLee et al., 2005IIRecognition reaction time and daytime alertn

7、ess (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 (at three months)Kaelin et al., 1996IIAttention span, sustained attention, divided a

8、ttentionSpeech et al., 1993IISustained attentionVigilance, Processing speedGualtieri and Evans, 1988II10 subjects sustained attention, divided attention, selective attention5 subjects no changeGrade et al.,1988IICognitive functionEvidence (II) Sivan M et al. Clin Rehabil. 2010 Feb;24(2):110-21Methyl

9、phenidate in TBI之建議劑量1. Enhance attentional function Dose: 0.250.30 mg/kg bid2. Enhance the speed of cognitive processing Dose: 0.250.30 mg/kg bid3. Enhance learning and memory Dose: 0.30 mg/kg bid4. Improve speed in mental processing Dose: 0.30 mg/kg bidRecommended DoseNeurobehavioral Guidelines Wo

10、rking 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 traumatic brain injury.J N

11、eurotrauma. 2006 Oct;23(10):1468-501醫(yī)師開立處方：Methylphenidate 10mg/tab, 1tab, QD ?結(jié)果：可能造成改善癥狀之劑量不足結(jié)論 Methylphenidate用於TBI(創(chuàng)傷性腦損害)乃屬於合理之治療，因為TBI會造成腦部神經(jīng)性病變，如：認知不足、注意力缺乏、記憶力減退等。 但是衛(wèi)生署核準之適應癥為過動兒癥候群及發(fā)作型嗜睡癥，若醫(yī)師將Methylphenidate用於器質(zhì)性腦徵候群或腦震盪後徵候群，需考慮以自費方式給予。參考資料Siddall OM. Use of methylphenidate in traumatic br

12、ain injury. Ann Pharmacother. 2005 Jul-Aug;39(7-8):1309-13. Epub 2005 May 24. Review. 2. Sivan M, Neumann V, Kent R, Stroud 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. Challm

13、an TD, Lipsky JJ. Methylphenidate: its pharmacology and uses. Mayo Clin Proc. 2000 Jul;75(7):711-21. Review. 4. Neurobehavioral 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,

14、 Walters B, Whyte J, Zapata A, Zitnay G. Guidelines for the pharmacologic treatment of neurobehavioral sequelae of traumatic brain injury. J Neurotrauma. 2006 Oct;23(10):1468-501. 5. MICROMEDEX(r) Healthcare Series 醫(yī)療照護系列資料庫(Database) Thomson MICROMEDEX Thank you for your attentionBackgroundDeficits in attention are commonly seen in non-progressive acquired brain injury.The prevalenc