高考申論題
105年
[藥事] 調劑學與臨床藥學
第 一 題
📖 題組：
請依據下列案例回答下列問題，並填寫「藥品不良反應評檢表」。 Wu, a 68-year-old male with Hx of cardiomyopathy, AF and HTN, had been treated with dipyridamole 75 mg tid, digoxin 0.125mg qd, and valsartan 80 mg qd. One week after addition of amiodarone 200 mg bid for refractory AF, he experienced syncope at home. At that time, his BP was 90/40, and HR was 40. He woke after lying down for 3 minutes. After consulting the doctor, amlodipine, digoxin and amiodarone were hold. His BP was 110/60 with a HR of 60 the next day. Digoxin and amlodipine were resumed afterwards. Patient did well until 1 week after resumption of amiodarone, when another episode of syncope occurred.
請依據下列案例回答下列問題，並填寫「藥品不良反應評檢表」。 Wu, a 68-year-old male with Hx of cardiomyopathy, AF and HTN, had been treated with dipyridamole 75 mg tid, digoxin 0.125mg qd, and valsartan 80 mg qd. One week after addition of amiodarone 200 mg bid for refractory AF, he experienced syncope at home. At that time, his BP was 90/40, and HR was 40. He woke after lying down for 3 minutes. After consulting the doctor, amlodipine, digoxin and amiodarone were hold. His BP was 110/60 with a HR of 60 the next day. Digoxin and amlodipine were resumed afterwards. Patient did well until 1 week after resumption of amiodarone, when another episode of syncope occurred.
📝 此題為申論題，共 3 小題
小題 (一)
病人發生何種不良反應？引起不良反應的藥品及原因為何？該不良反應屬於 type A 或 type B 反應，為什麼？（8 分）
思路引導 VIP
先抓出病人的關鍵臨床表現（心跳過慢 HR 40、低血壓、暈厥）與近期用藥異動（新增 Amiodarone）。接著聯想 Amiodarone 與原有藥物（特別是 Digoxin）的藥理特性，從「藥物動力學（P-gp抑制）」與「藥效學（心跳減慢）」雙管齊下分析交互作用。最後，依據該反應是否具備藥理可預期性與劑量相關性，來判定屬於 Type A 還是 Type B ADR。
小題 (二)
你會建議醫師怎樣處理？（6 分）
思路引導 VIP
本題重點在於辨識『藥物交互作用（DDI）』及『再次投與（Rechallenge）確認不良反應』。看到 amiodarone 加入後引發嚴重低血壓與心搏過緩，應直覺聯想到 amiodarone 是強效 P-gp 及 CYP3A4 抑制劑，會導致 digoxin 濃度倍增引起中毒，以及增加 amlodipine 的降壓作用。解題應包含交互作用機轉說明及具體的劑量調整建議。
小題 (三)
依照「藥品不良反應評檢表」，該不良反應與該藥品的相關性及評分如何？請逐項解釋。（11 分）
思路引導 VIP
看到此題，應立即聯想到使用臨床藥學通用的「Naranjo Algorithm（藥品不良反應機率量表）」來評估因果關係。解題時需依序回答量表的 10 個問題，從病史中抓取關鍵字：用藥時序（加入 amiodarone 一週後發生）、去激發（停藥後恢復）、再激發（重新用藥後又發生）以及客觀數據（BP、HR），最後加總分數並判定相關性等級（Definite/Probable/Possible/Doubtful）。
📜 參考法條
藥品不良反應評檢表 (Naranjo Algorithm)