【案例一】
吳 xx
75 歲
男性
心臟內科
診斷：高血壓、高膽固醇血症、胃潰瘍、中風、長期鼻胃管灌食
門診處方：
藥品
數量
劑型
途徑
頻次
天數
Nifedipine OROS 30mg
1
Tab
PO
QD
28 days
Captopril 25mg
2
Tab
PO
TID
28 days
Simvastatin 40mg
2
Tab
PO
QD
28 days
Pantoprazole 40mg
1
Tab
PO
QD
28 days
Ticlopidine 100mg
1
Tab
PO
TID
28 days
46
Subjective and Objective
Problem (subjective and objective)
S: 無
Current medication
Nifedipine OROS 30mg 1# QD
Captopril 25mg 2# TID
Simvastatin 40mg 2# QD
Pantoprazole 40mg 1# QD
O: 75 歲男性
Ticlopidine 100mg 1# TID
Assessment
Etiology (or risk factors)
Evidence need for therapy evaluation (current/recommended therapy)
高血壓、高膽固醇血症、胃潰瘍、中風、長期鼻
胃管灌食
Plan
Recommended drug treatment, drug to be
Goal and monitoring parameters
Patient education
revised, further test
1. 病患接受長期鼻胃管灌食，處方中 Nifedipine 血壓: 美國全國聯合委員會（Joint National 1.
OROS 屬於緩釋劑型，磨粉後會破壞緩釋效 Committee，JNC） - 長期高血壓之治療，
果，無法維持整天的降壓效果，甚至可能因 血壓應控制在 140/90mmHg 之下，有糖尿
一次劑量太高導致低血壓；如果病患使用 病危險因子之病人，應更為嚴格，血壓宜 2.
Nifedipine 效果不錯，可建議醫師更改傳統劑 控制在 130/80mmHg。
型 Nifedipine 或其他同類非緩釋劑型之鈣離 Monitoring: 每天測量血壓
Nifedipine 及 Captopril 用於控制血壓。
Captopril 應空腹服用(至少飯前 1 小時服
用)；可能引起咳嗽副作用，可告知醫師。
Simvastatin 用於降低膽固醇，最適合的
服藥時間為夜間；服藥期間如有肌肉酸
痛時，應告知醫師。避免併服大量葡萄
子阻斷劑，或可改用其他類別降血壓藥物。 血脂: 健保局規範
Pantoprazole 屬於腸溶劑型，磨粉使用會造成 無心血管疾患 (冠狀動脈粥狀硬化者、 3.
藥物在胃中受到破壞，降低藥品效果；可建 腦血管病變、周邊血管粥狀硬化有缺血症
議醫師改用其他適合管灌的 PPI (如:
狀經證實者)
柚汁。
如果醫師更改藥品為 Esomeprazol，此藥
用於治療胃潰瘍。最好於早餐前 1 小時
服用，管灌時可將藥品溶於水中，立即
47
Esomeprazol, Lansoprazole)。
2. Captopril 應空腹服用。
3. Simvastatin 較適合的服藥時間為夜間。
有 2 個危險因子 (高血壓、M  45 歲)
Goal: Total cholesterol < 200mg/dl
LDL < 130 mg/dl
有心血管疾患
Goal: Total cholesterol < 160mg/dl
LDL < 100mg/dl
TG < 150mg/dl
Monitoring: 每 3-6 個月檢驗血脂值
48
灌入。
4. Ticlopidine 用於預防中風的再次發生；
可與食物併服以減少胃部不適；若有不
正常瘀青或其他出血問題，應立即就診。
【案例二】
王 xx
52 歲
男性
胸腔內科
診斷：氣喘、慢性氣道阻塞、過敏性鼻炎
門診處方：
藥品
數量
劑型
途徑
頻次
天數
Theophylline SR (250mg)
1
Cap
PO
BID
28 days
Gasgel
1
Tab
PO
BID
28 days
Prednisolone (5mg)
1
Tab
PO
QD
28 days
Symbicort Turbuhaler
1
Dose
IH
BID PRN
28 days
Buventol Easyhaler
1
Dose
IH
Q4H
28 days
49
Subjective and Objective
Problem (subjective and objective)
S: 無
Current medication
Theophylline 1# bid
Gasgel 1# bid
Prednisolone 1# qd
Symbicort 1dose bidprn
O: 52 歲男性
Buventol 1dose q4h
Assessment
Etiology (or risk factors)
氣喘
Evidence need for therapy evaluation (current/recommended therapy)
依據 National Institutes of Health, National Heart, Lung, and Blood Institute 發表之
Guidelines for the Diagnosis and Management of Asthma - Update on Selected Topics
2002 附註，病人應遵循藥囑正確使用藥物以期控制氣喘發作
Plan
Recommended drug treatment, drug to be Goal and monitoring parameters
revised, further test
1. Symbicort: budenoside 160ug + formoterol
fumarate dihydrate 4.5ug, 120 劑量/瓶，內含
steroid 及長效2-agonist，針對重度至嚴重持續
氣喘發作病人應固定使用，建議更改 bid prn 為
bid
2. Buventol: salbutamol sulfate 200ug, 200 劑量/
瓶，屬於短效2-agonist，多用於緩解急性氣喘
發作，建議更改 q4h 為 q4h prn
Patient education
1. Minimal or no chronic symptoms day 1. Symbicort:內含類固醇及支氣管擴張劑，
要固定每日使用 2 次，可以做為平日保養
or night
以減少氣喘發作。使用方法及注意事項：
2. Minimal or no exacerbations
旋轉並打開護蓋。
3. No limitations on activities; no
讓吸入器旋轉盤朝下，先將旋轉盤向右轉
school/work missed
到底，再向左轉到底直至聽到”喀擦”聲，
4. Maintain (near) normal pulmonary
表示已充填好一次的藥物劑量(初次使
function
用，此步驟再重覆二次)。
5. Minimal use of short-acting inhaled
先吐氣(千萬不要將氣吹入吸入器中)，然
beta2-agonist
50
6. Minimal or no adverse effects from
medications
後以口含住吸嘴，用力而深的吸飽氣
將吸嘴移離口部 摒息約 5~10 秒鐘 
慢慢呼氣。
蓋好護蓋。
吸入器上有一個劑量顯示孔，可顯示剩餘
的劑量數，將數量降至 0~20 次時，數字
會變成紅色。
使用後吸嘴可用乾布或乾棉花棒擦拭乾
淨，勿以水直接沖洗。
【注意事項】
1.勿直接朝吸嘴吹氣。
2.遵守”呼-吸-摒息“三要素。
3.吸入後務必漱口以防止口腔念珠菌感
染。
4.搖晃吸入器時聼到的聲音係由乾燥劑所
產生。
5.吸入後可能無法嚐知其味，但若依指示
使用，當可確定此劑量已被吸入。
2. Buventol: 是支氣管擴張劑，藥效發作很
快，必須讓病患隨時帶在身邊，急性發作
的時候趕快使用。使用方法及注意事項：
打開護蓋。
以直立方式握住吸入器，充分搖晃以利藥
物釋出。壓下吸入劑，鬆手後聽到”喀擦”
一聲，表示已完成藥劑充填。
51
先吐氣(千萬不要將氣吹入吸入器中)，然
後以口含住吸嘴，用力而深的吸飽氣
將吸嘴移離口部 摒息約 5~10 秒鐘 
慢慢呼氣。
蓋回護蓋。
若需吸入第二個劑量，請間隔 30 秒~1 分
鐘後再重覆上述步驟
吸入器側端有劑量器，可顯示剩餘的劑量
數。
使用後吸嘴可用乾布或乾棉花棒擦拭乾
淨，勿以水直接沖洗。
【注意事項】
1. 勿直接朝吸嘴吹氣。
2. 遵守 ” 呼-吸-摒息 “三要素。
3. 乾粉內含有乳糖，當吸入後感覺有甜味
時，便可確定有藥品被吸入。
52
附註
53
【案例三】
傅 xx
83 歲
男性
骨科
診斷：骨髓炎、骨質疏鬆併骨折
門診處方：
藥品
數量
劑型
途徑
頻次
天數
Ciprofloxacin (250mg)
2
Tab
PO
BID
28 days
MgO (250MG)
1
Tab
PO
QID
28 days
Alendronate (70mg)
1
Tab
PO
QD
28 days
Naproxen SR (750mg)
1
Tab
PO
QD
28 days
54
Subjective and Objective
Problem (subjective and objective)
S:無
O: 83 歲
Current medication
Ciprofloxacin 2# bid
MgO 1# qid
Alendronate 1# qd
男性
Naproxen SR 1# qd
Assessment
Etiology (or risk factors)
Evidence need for therapy evaluation (current/recommended therapy)
急性骨髓炎
骨質疏鬆併骨折
Plan
Recommended drug treatment, drug to be Goal and monitoring parameters
revised, further test
1. 與醫師溝通，病人是否一定須要 MGO，因
為 ciprofloxacin 若與制酸劑(多價陽離子)併
服，會減少 50-75%的吸收。
2. ciprofloxacin 一天使 用 兩次，可建議 改成
q12h，以維持穩定的血中濃度與藥效。
3. alendronate 劑量為 70mg，所以應改為 1# qw。
Patient education
1. ciprofloxacin:用於治療急性骨髓炎，12
小時吃一次，1 次吃 2 顆(告訴病人比較
明確的吃藥時間:早晚 7 點時吃藥)，吃藥
後 2 個小時才能吃制酸劑(或吃完制酸劑
後 6 個小時才能吃抗生素)；治療急性骨
髓炎的療程須 4-6 週，須按時吃藥，否
則容易復發且較難治癒。
2. alendronate 用於治療骨質疏鬆，只要一
55
週使用一次；飯前半小時整粒吞服，不
可嚼碎；服藥時請多喝水(200-250 西西
白開水)。服藥後至少 30 分鐘內不可躺
下及吃東西，盡量維持坐直或站直的姿
勢。有胸口痛或吞嚥困難時應告訴醫師。
56
【案例四】
病案討論 (Diabetes Mellitus)

Patient General Information (Gen)
Patient name: 劉先生
Chart no: xxxxxxxx
Age: 67
Sex: M
Weight: 111.5kg
Height: 165 cm
Marriage status: married
Allergies: NKDA

Chief Complaint (CC)
“Lately I feel extremely tired and now my vision is blurred.”

History of Present Illness (HPI)
67 y/o male seen in the family medicine clinic complaining of periodic blurred vision for the past 3
weeks. He further complains of severe fatigue and lack of energy, which limits his daily activities.
He states that he started taking a multiple vitamin 1 week ago but has not noticed any improvement
in his energy level.

Past Medical History (PMH)
HTN x 7 years
Hyperlipidemia x 5 years

Social History (SH)
Married x 43 years with 2 children. Works full-time as a parking lot attendant.
No alcohol or tobacco use
Rarely exercises and admits to trying fad diets for weight loss with little success.

Family History (FH)
Diabetes present in both father and paternal grandfather. Father died suddenly of a massive stroke
at age 62; mother died of breast cancer at age 49; 2 younger siblings are alive and apparently well.

Review of Systems (ROS)
Occasional polydipsia, polyphagia, fatigue, weakness, blurred vision.
Denies chest pain, dyspnea, tachycardia, dizziness or lightheadedness upon standing, tingling or
numbness in extremities, leg cramps, peripheral edema, changes in bowel movements, GI bloating
or pain, nausea or vomiting, urinary incontinence, or presence of skin lesions.

Physical Examination (PE)
Gen: obese man who seems restless and in mild distress
VS: BP 149/96 mmHg without orthostasis HR 80 beats/min RR 18 bpm T 37.2℃ Ht 165
cm BW 111.5 kg BMI 41Kg/m2
Skin: dry with poor skin turgor; no ulcers or rash
HEENT: PERRLA; EOMI; TMs intact; no hemorrhages or exudates on funduscopic examination;
mucous membranes normal; nose and throat clear w/o exudates or lesions
Neck / LN: supple; without lymphadenopathy, thyromegaly, or JVD
CV: RRR; normal S1 and S2; no S3, S4, rubs murmurs, or bruits
Lungs: CTA
Abd: soft, NT, central obesity; normal BS; no organomegaly, or distention
GU / Rect: normal external male genitalia
Ext: Normal ROM and sensation; peripheral pulses 2+ throughout; no lesions, ulcers, or edema
57
Neuro: A&O x 3, CN II-XII intact; DTRs 2+ throughout; feet with normal vibratory and pinprick
sensation (5.07 / 10g monofilament)

Medication Record (Prescription and OTC) (MedHx)
Propranolol LA 80mg po once daily
MVI po once daily

Laboratory and Diagnostic Tests (Labs)
Na 141 mEq/L
Ca 9.9 mg/dL
AST 21 IU/L
T. bili 0.9mg/dL
Random Glu 260mg/dL
UA(Urinary analysis)
(-) ketones
K 4.0 mEq/L
P 3.2 mg/dL
ALT 15 IU/L
BUN 24mg/dL
T. chol 285 mg/dL
Cl 96 mEq/L
CO2 22mEq/L
Alk phos 45 IU/L
Scr 1.6mg/dL
(-) protein
(-) microalbuminuria
The patient returned to clinic 3 days later for lab work, which revealed:
FPG 177mg/dL
A1C 9.1%
T chol 280mg/dL
LDL 176mg/dL
HDL 27mg/dL
TG 302mg/dL

Diagnosis
Type 2 DM
Hypertension
Hyperlipidemia
Obesity, metabolic syndrome
 Problem list (Drug Therapy Problems)
DRP 1: Type 2 DM--initiate OADs in a newly diagnosed DM patients
DRP 2: Hypertension--inappropriate drug of choice and inadequate BP control for HTN
DRP 3: Hyperlipidemia-- initiate lipid lowing agents for a patient with high CV risks
DRP 4: Obesity, metabolic syndrome--pharmacotherapy of obesity and metabolic syndrome
將 Medical problems(Dx)-->Medication problems(DRPs)
58
Problem list
Current medical problems
1)Type 2 DM
Goal of therapy
Blood sugar control
Prevent risk factors and macrovascular and
microvascular complication
Measurable endpoint
Polydipsia, polyphagia, fatigue, blurred vision
Blood sugar ac/pc, A1c
BP, lipid profile, BW
BUN/Scr, AST/ALT
U/A (microalbuminuria)
VA, Eye Fundus
2)Hypertension
Prevent macrovascular complication (CHD,
Stroke, PAD) and Nephropathy
BP
Prevent macrovascular complication (CHD,
Stroke, PAD)
Total chol, LDL, HDL
TG
BP, lipid, blood sugar control
Improve metabolic syndrome
BW
BP
Total chol, LDL, HDL, TG
Blood sugar ac/pc
腰圍
3) Hyperlipidemia
4) Obesity, metabolic syndrome
59
Current Drug-Therapy Problems
Subjective and Objective
Problem (subjective and objective)
Current medication
S:
Propranolol LA 80mg po once daily
Pertinent medical Hx: HTN x 7 years, Hyperlipidemia x 5 years
MVI po once daily
Periodic blurred vision for the past 3 weeks. He further complains of severe fatigue and lack of
energy, which limits his daily activities
(HPI / PMH)
ROS: Occasional polydipsia, polyphagia, fatigue, weakness, blurred vision
SH: Married x 43 years with 2 children. Works full-time as a parking lot attendant.
No alcohol or tobacco use. Rarely exercises and admits to trying fad diets for weight loss with little
success
FH: Diabetes present in both father and paternal grandfather. Father died suddenly of a massive
stroke at age 62; mother died of breast cancer at age 49; 2 younger siblings are alive and apparently
well
Allergies: NKDA
ADR:
60
Subjective and Objective
O:
165cm 111.5kg BMI 41Kg/m2 HR: 80 beats/min
RR: 18 bpm BT 37.2℃
BP: 149/96 mmHg without orthostasis
PE
Gen: obese man who seems restless and in mild distress
Skin: dry with poor skin turgor; no ulcers or rash
HEENT: PERRLA; EOMI; TMs intact; no hemorrhages or exudates on funduscopic examination;
mucous membranes normal; nose and throat clear w/o exudates or lesions
Neck / LN: supple; without lymphadenopathy, thyromegaly, or JVD
CV: RRR; normal S1 and S2; no S3, S4, rubs murmurs, or bruits
Lungs: CTA
Abd: soft, NT, central obesity; normal BS; no organomegaly, or distention
GU / Rect: normal external male genitalia
Ext: Normal ROM and sensation; peripheral pulses 2+ throughout; no lesions, ulcers, or edema
Neuro: A&O x 3, CN II-XII intact; DTRs 2+ throughout; feet with normal vibratory and pinprick
sensation (5.07 / 10g monofilament)
Labs
Na 141 mEq/L
Ca 9.9 mg/dL
AST 21 IU/L
T. bili 0.9mg/dL
RandomGlu 260mg/dL
UA
(-) ketones
K 4.0 mEq/L
P 3.2 mg/dL
ALT 15 IU/L
BUN 24mg/dL
T. chol 285 mg/dL
Cl 96 mEq/L
CO2 22mEq/L
Alk phos 45 IU/L
Scr 1.6mg/dL
(-) protein
(-) microalbuminuria
The patient returned to clinic 3 days later for lab work, which revealed:
FPG 177mg/dL
A1C 9.1%
T chol 280mg/dL
LDL 176mg/dL
HDL 27mg/dL
TG 302mg/dL
61
Current Drug-Therapy Problems
Assessment
Etiology (or risk factors)
Evaluate need for therapy; evaluate current therapy (Evidence need for therapy evaluation)
DRP Drug therapy problem 1
ADA(American Diabetes Association) / EASD (European Association for the Study of Diabetes)
Type 2 DM --initiate OADs in a newly diagnosed Clinical Practice Recommendations 2012
一、diagnosis of diabetes
DM patients
1.
Risk factors of DM
1. physical inactivity
2. first-degree relative with diabetes
3. hypertension (>=140/90 mmHg or on therapy
for hypertension)
4. HDL cholesterol level < 35 mg/dl and/or a
triglyceride level > 250 mg/dl
5. other clinical conditions associated with insulin
resistance (e.g., severe obesity)
6. history of CVD
In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random
plasma glucose ≥200 mg/dl
2. FPG  126mg/dL
3. HbA1c  6.5%
4. Two-hour plasma glucose ≥200 mg/dl during an OGTT.
二. OAD 的選用考慮因素：
診斷為 type 2 DM
(1) the amount and the rapidity of glucose lowering required
(2) the potential for adverse effects (toxicities, hypoglycemia, weight gain, etc)
(3) the potential for non-glycemic benefits (lipid lowering, insulin sensitization)
(4) compliance
(5) cost
三. HbA1c>9.0 %, 可考慮使用兩種或多種 OADs
四. Recommended Treatment Algorithm of type 2 DM
Start with lifestyle intervention + metformin
 Titrate metformin to the maximal effective dose over 1 to 2 weeks as tolerated
 If the HbA1c target is not achieved after ~3 months, consider one of the following five
treatment options combined with metformin: sulfonylurea, TZD, DPP-4 inhibitor,
GLP-1 receptor agonist or basal insulin. Choice is based on patient and drug
62
Assessment
Etiology (or risk factors)
Evaluate need for therapy; evaluate current therapy (Evidence need for therapy evaluation)
characteristics, with the overriding goal of improving glycaemic control while
minimising side effects. Rapid-acting secretagogues (meglitinides) may be used in place
of sulfonylureas
 three drugs combinations: choose a third agents from Sulfonylurea, Thiazolidinedione,
DPP-4 Inhibitor, GLP-1 receptor agonist, basal Insulin (不建議併用 DPP-4 Inhibitor
and GLP-1 receptor agonist)
Current OAD for type 2 DM
1. lifestyle intervention and metformin
- lifestyle modifications (eg, medical nutrition therapy (MNT), diabetes self
management education (DSME), and physical activity)
- Metformin in the obese patients is suitable since weight loss frequently and reduction
in macrovascular risk in the UKPDS, the contraindication is renal insufficiency (Scr
2.
3.
 1.5 in men,  1.4 in women)
TZD
Pioglitazone: potential decrease in MI, improve lipid profile,associated with a possible
increased risk of bladder cancer
Rosiglitazone: potential increase in MI (Current ADA guidelines do not recommend
adding rosiglitazone)
S/E: weight gain, fluid retention leading to oedema and/or heart failure
Glinides - Meglitinide is better than sulfonylureas in the patient (a parking lot attendant
with erratic meal schedules – quicker onset and shorter duration than SUs improve
post-prandial glucose control, decrease late post-prandial hypoglycemia)
renal excretion – repaglinide / nateglinide = 8% / 83% (16% as unchanged)
63
Assessment
Etiology (or risk factors)
Evaluate need for therapy; evaluate current therapy (Evidence need for therapy evaluation)
4.
5.
6.
Drugs focused on the incretin system: low risk of hypoglycaemia by themselves
- Injectable GLP-1 receptor agonists: advantage-weight loss
- oral DPP-4 inhibitors- eg. Sitagliptin: lower BS in glucose-dependent manner,
associated with no weight increase (may be used as monotherapy and in combination
with metformin or TZD therapy, increased risk of hypoglycemia when used in
combination with SU therapy)
Acarbose (optional): 25-50mg tid with meal to lower postprandial plasma glucose
可考慮 Combo 藥品的使用
* The glucose-lowering effectiveness: high for metformin, sulfonylureas, TZDs and GLP-1
agonists (expected HbA1c reduction ~1.0-1.5%), and generally lower for meglitinides, DPP-4
inhibitors, α-glucosidase inhibitors
五. ADA Clinical Practice Recommendations 2012– aspirin therapy in diabetes
Aspirin as a primary prevention in those with type 2 diabetes at increased CV risk, including
> 50 y/o or who have additional risk factors (family history of CVD, hypertension, smoking,
dyslipidemia, albuminuria)
DRP Drug therapy problem 2
Hypertension--inappropriate drug of choice and
inadequate BP control for HTN
(JNC VII)
Control of BP reduces vascular complication
Drug monotherapy with diabetes – ACEIs, ARBs, thiazides, -blockers, non-dihydropyridine
CCBs, ACEIs, ARBs - Beneficial effects on cardiovascular, microvascular risk and renal
endpoints
64
Assessment
Etiology (or risk factors)
DRP Drug therapy problem 3
Hyperlipidemia
Lipid abnormalities contributes to higher rate of
CVD
Evaluate need for therapy; evaluate current therapy (Evidence need for therapy evaluation)
Significant reductions in coronary and cerebrovascular events in statins therapy（Heart Protection
Study, HPS）
(NCEP ATP III, 2004 revised)
- In high risk patients(CHD or CHD risk equivalents): if LDL-C>= 100, an LDL-lowering drug is
indicated simultaneously with Therapeutic lifestyle changes (TLC)
- LDL-C <=100 mg/dL, drug therapy is an option for very high risk patients (aggressive dosing of
statins reduced lipid levels and CV mortality and morbidity to a significantly greater extent than
standard statin doses)
- statin is the most potent agent to lower LDL-C, and is the initial drug of choice
- if a high-risk person has high TGs or low HDL-C, consider add fibrate or nicotinic acid
- when statin combined with fibrate or ezetimibe, the risk of liver toxicity and myopathy may
increase
DRP Drug therapy problem 4
Obesity, metabolic syndrome
1.
2006 年台灣代謝症候群臨床診斷準則 - ≥ 3 of the following criteria: 腰圍 90cm, TG 
2.
150mg/dL, HDL <40mg/dL, BP  130/85mmHg, FPG  100mg/dL
NCEP metabolic syndrome (insulin resistance syndrome) -  3 of the following criteria
3.
Waist circumference: >102cm, TG  150mg/dL, HDL <40mg/dL, BP  130/85mmHg,
FPG  100mg/dL
WHO metabolic syndrome: DM +  3 of the criteria – BP  140/90, waist: hip ratio >0.9,
4.
or BMI >30Kg/m2, TG  150; HDL <35, microalbumin >30mcg/mg Cr
unified definition of metabolic syndrome from IDF、AHA/NHLBI、WHF、IASO (Lancet
2010; 375:181-183: 腰圍增加 (依照族群及國家特殊性定義，如華人男性腰圍 90cm)、
TG  150mg/dL、HDL <40mg/dL (有使用 fibrates, nicotinic acid 來降低 TG、升高 HDL 也
可作為診斷標準)、BP  130/85mmHg, FPG > 100mg/dL
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Assessment
Etiology (or risk factors)
Evaluate need for therapy; evaluate current therapy (Evidence need for therapy evaluation)
※Based on classification of BMI: 劉先生 – BMI 41Kg/m2 – extreme obesity (class 3)，診斷為
metabolic syndrome
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Current Drug-Therapy Problems
Plan
Recommended drug treatment, drug to be
revised, further test
Recommend 1
一. According to meal plan by dietitian
consultation
二. Individualized exercise program to
increase energy expenditure after
cardiac evaluation
三. OAD: Pioglitazone 15-30mg/day, max.
daily dose 45mg as monotherapy
Combine repaglinide 1-2mg tid, max.
daily dose 16mg initially, 因
pioglitazone delay onset, 需數星期才可
控制血糖 (when suboptimal control)
四. Optional: Sitagliptin 50mg qd（Ccr
30-50）, when administered with a SU, a
lower dose of SU may be required
五. If 24hr collection  30mg albumin (or
spot collection albumin/Cr  30 g/mg
Irbesartan: target maintenance dose:
300mg qd or fosinopril 10mg/day then
20-40mg/day
六. Aspirin 100mg qd
Goal and
monitoring parameters (toxic and therapeutic)
Patient education
(American Diabetes Association, 2013)
一. The goal of nutritional therapy is to
一. 遵醫囑給藥可使血糖控制良好
achieve: 1. ideal body weight, 2. blood
glucose levels as close to normal as
possible, 3. Optimal blood lipid
二. Diabetes monitor:
Target for glycemic control
A1C <7%, FPG 70-130mg/dL, peak
postprandial PG <180mg/dL
Assess for hypoglycemic /
hyperglycemic symptom
A1C q3-6m
三. Review diet, exercise, weight control
when visit the doctor
四. Complication monitor:
Screen for microalbuminuria, serum Cr
& U/A yearly
五. Retinal monitor once yearly
六. Inspect feet at each visit: neuropathy,
vascular disease (pulses), calluses, bony
deformities, incipient ulcerations, nail /
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二. Hyperglycemic symptom: polydipsia,
polyuria, unexplained weight loss
三. Hypoglycemic symptom
1. Warning signs – rapid heartbeat,
perspiration, shakiness, anxiety, hunger
2. Alteration of mental function that
proceeds to confusion, stupor,
unconsciousness if warning signs are
absent or ignored and the blood glucose
continues to fall
四. 低血糖的處理
1. 若病人意識清楚立刻給予 120cc 的果
汁、可樂或汽水，3-4 顆糖果，1 瓶養
樂多，每 10 分鐘一次，直到症狀改
善。(20 分鐘後，若仍未改善，立刻
2.
送醫院)。症狀改善後，再酌量吃些牛
奶、土司或餅乾等。
如果病人不合作或昏迷，家屬可選擇
下列方法處理：
將糖漿或蜂蜜、果糖滴入臉頰與牙齦
Plan
Recommended drug treatment, drug to be
revised, further test
Goal and
monitoring parameters (toxic and therapeutic)
foot fungus. Refer to vascular surgeon if
ulceration + abnormal pulses
七. Dental visits for cleaning & aggressive
treatment of periodontal disease every 6
months
八. Safety monitor of pioglitazone:
S/S of heart failure, liver enzyme prior to
initiation and periodically, (1)ALT >2.5X
the upper limit of normal, LFT follow
bimonthly x 12m then q3-6m, (2) >3X the
upper limit of normal, pioglitazone should
be discontinued
九. Safety monitor of sitagliptin: renal
function, electrolytes, serum calcium,
glucose, and lipase, if pancreatitis is
suspected
十. Safety monitor of fosinopril:
Orthostasis, serum potassium, BUN, Scr,
WBC
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Patient education
之間或舌下，每十分鐘一次，並立刻
送醫治療。肌肉或皮下注射昇糖素，
兒童 0.5 毫克、成人 1 毫克，約 5 - 15
分鐘內會醒過來，醒後給予麵包或餅
乾。若仍未醒，立刻送醫治療。
五. 鼓勵居家血糖監測，不只可清楚血糖的
控制狀況，也可在就診時提供醫師治療
的參考，衛教師教導居家生活的調整。
六. Pioglitazone
weight gain, edema in some patients
delayed onset – 6-12weeks to achieve
peak effect
七. Repaglinide
weight gain, lipid profile
Plan
Recommended drug treatment, drug to be
revised, further test
Recommend 2
一. Lifestyle modification
- weight reduction, DASH eating plan (a
diet rich in fruits, vegetables, and low fat
dairy products with a reduced content of
saturated and total fat), Dietary sodium
reduction (Na <2.4g/d), regular aerobic
exercise, moderation of alcohol intake
二. D/C propranolol
First-line therapy:
Goal and
monitoring parameters (toxic and therapeutic)
Patient education
(JNC VII)
一. Teach pt how to self measurement of BP
二. Remind pt that home measurement device
should be checked regularly for accuracy
一. BP check daily, target  130/80
二. Safety monitor of fosinopril:
Orthostasis, serum potassium, BUN, Scr,
WBC
三. Dry cough may occur in patient given
fosinopril
Irbesartan: 150mg qd , max. dose: 300mg
qd or fosinopril 10mg/day then
20-40mg/day
Recommend 3
(NCEP ATP III, 2004 revised)
一. <30% fat (saturated fats < 7% , cholesterol 一. Complete lipid profiles after 2-4weeks
<200mg/day) – NCEP step II diet
LDL reduction of 30%
二.
LDL  100mg/dL, HDL >40mg/dL, TG
1.
2.
Atorvastatin: 40-80mg/day
Ezetimibe 10mg qd combined with a
statin may be considered to attain LDL
goal
* Combo formula: Vytorin (ezetimibe
<150mg/dL
二. when TG>= 200 mg/dL, non-HDL-C is a
secondary target
non-HDL-C goal: LDL-C goal + 30
三. Safety monitor of atorvastatin:
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NCEP step II diet should be continued during
drug therapy
Plan
Recommended drug treatment, drug to be
revised, further test
3.
Goal and
monitoring parameters (toxic and therapeutic)
+ simvastatin)
If TG 200-499mg/dL after LDL goal
attained – increase dose of atorvastatin
LFTs prior to and at 12 weeks following
both the initiation and any elevation in
dose or there are S/S of hepatic toxicity
or add fenofibrate – 67mg / day (Clcr =
46ml/min)
(routine monitor LFTs may be not
necessary), CPK
Patient education
四. Safety monitor of fenofibrate
1. Lipid profile measured periodically, if
only marginal changes in 6-8 weeks,
D/C fenofibrate
2. LFTs regularly and D/C if levels >3X
normal limits
Recommend 4
(ADA 2012 MNT)
一. Comprehensive therapeutic lifestyle
changes: decrease in calorie intake,
increase in physical activity, nutritional
counseling, behavior modification,
(NHLBI Clinical Guidelines on Overweight
and Obesity 1998)
一. Side effect of orlistat: diarrhea, greasy
stools, malabsorption of fat-soluble
vitamins (A, D, E, K)
treatment of any psychiatric disorder,
especially depression
二. According to meal plan by dietitian
consultation
Usual caloric intake is reduced by
70
一. Comprehensive therapeutic lifestyle
changes is important
二. Based on the current clinical trials
No additive weight loss after 1year of
pharmacotherapy
Plan
Recommended drug treatment, drug to be
revised, further test
Goal and
monitoring parameters (toxic and therapeutic)
500-1000cal/d, gradual weight loss of 1-2
lb per week should occur,
weight-maintaining diets for moderately
active individuals 30-35cal/Kg/d
1200-1600 kcal/day (as a rule of thumb,
reducing calorie intake by 500-1000
kcal/day will result in a desirable
0.45-0.9Kg of weight loss per week
45-60% carbohydrate, 10% or 0.8g/Kg/d
protein, 25-30% fat (saturated fats < 7% ,
cholesterol <200mg/day) – NCEP step II
diet
20-35g/d of soluble and insoluble fiber
< 2400mg/d sodium, <2000mg/d sodium in
nephropathy and hypertension
 2drinks alcohol/d
Multivitamins on low-calorie diets and
non-nutritive artificial sweeteners in
moderate amounts
(NHLBI Clinical Guidelines on Overweight
and Obesity 1998)
三. Pharmacological therapy
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Patient education
Plan
Recommended drug treatment, drug to be
revised, further test
Goal and
monitoring parameters (toxic and therapeutic)
Orlistat 120mg tid with meals
not lost at least 2Kg after 4 weeks of
therapy, it is unlikely further benefit from
these drugs
四. Individualized exercise program to
increase energy expenditure after
cardiac evaluation
五. Bariatric surgery should be considered for
adults with BMI >35 kg/m2 and type 2
diabetes, especially if the diabetes or
associated comorbidities are difficult to
control with lifestyle and pharmacologic
therapy. (ADA 2013)
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Patient education
Current Drug-Therapy Problems
Subjective and Objective
Problem (subjective and objective)
Current medication
S:
Pertinent medical Hx:
(HPI / PMH)
ROS:
SH:
FH:
Allergies:
ADR:
O:
(PE /Labs)
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Current Drug-Therapy Problems
Assessment
Etiology (or risk factors)
Evaluate need for therapy; evaluate current therapy (Evidence need for therapy evaluation)
74
Current Drug-Therapy Problems
Plan
Recommended drug treatment, drug to be Goal and
revised, further test
monitoring parameters (toxic and therapeutic)
75
Patient education
【案例五】
Chronic kidney disease
Patient General Information:
Patient name：劉小姐
Age：55
Ht：162cm
Weight：59kg (IBW：55.2Kg)
Allergies: Amoxicillin (rash)，radiocontrast dye (pruritis)
Chief Complaint:
Increasing fatigue and joint pain for several weeks, 2 lb weight gain and slight
swelling of her ankles within the last week.
History of Present Illness:
Patient attributed several weeks of increasing joint pain and fatigue to arthritis and
started taking 2 tablets acetaminophen 650 mg q 6 hours PRN with no relief; HbA1c
12% (1 week ago).
Medical History:
Type 1 DM since childhood; HTN for 20 years; diabetic nephropathy
(microalbuminuria detected 2 years ago); chronic kidney disease (baseline SCr 1.6, 6
months ago); medication nonadherence; seasonal allergies.
Surgical History:
TAH ( total abdominal hysterectomy ) (10 years ago)
Family/Social History:
Father age 83 with HTN and CAD; mother age 83 with HTN. Married with two
children; occasional alcohol use; smoked 1 pack/day × 20 years; quit tobacco 1 year
ago.
Physical Examination
GEN: Looks older than her stated age and appears in moderate discomfort
VS: BP 154/90、HR 85、RR 18、T 37.8℃、Wt 59 kg ( IBW：55.2Kg , IBW + 6.9%）、
Ht 162 cm
HEENT: PEARLA ( pupils equal and react to light and accommodation)、EOMI
( extraocular muscles intact )
COR: RRR ( regular rate and rhythm)、nl S1，S2、no rubs or gallops
CHEST: CTA ( clear to auscultation )
76
ABD: Soft、NT/ND ( nontender , nondistended)、(-) HSM ( hepato-splenomegaly)
GU: Deferred
RECT: Deferred
EXT: Trace ankle edema bilaterally、good distal pulses、restricted ROM ( range of
motion) in joints; pain assessment 7/10
NEURO: A and O × 3 ( awake and oriented to person, place, and time)
Medications:
Regular/NPH 30/70 (Humulin) insulin, 30U SC AM, 20U SC PM
Hydrochlorothiazide 50 mg PO QD Lisinopril, 20 mg PO QD
Calcium carbonate, 1500 mg PO TID with meals
Calcitriol, 0.25 μg PO QD
Acetaminophen 650 mg 2 tabs q6h PRN for joint pain
Results of Pertinent Laboratory Tests, Serum Drug Concentrations, and
Diagnostic Tests
Na 140mEq/L
Hct 28%
Ferritin: Pending
K 5.2mEq/L
Hgb 9g/dL
Cl 100mEq/L
WBC 7.5 x 10 /μL
TSAT: Pending
Ca 8mg/dL
Platelet 210 x 10 /μL
ANA: negative
Glucose AC 260mg/dL
HbA1c 12%
Serum Iron: Pending
3
3
PO4 6.4mg/dL
Albumin 3.7g/dL
HCO3 20 mEq/L
BUN 28mg/dL
SCr. 1.9mg/dL
2
Estimated GFR = 29mL/min/1.73m (using MDRD formula)
Estimated CLcr = 34mL/min (using Cockroft and Gault formula)
Urinalysis: + protein, hyaline casts
Urine output: 10mL/hour
Guaiac stool: negative
Chest X-ray: unremarkable
ECG: normal tracings
77
Problem list
1.
2.
3.
4.
5.
Inappropriate of Diuretic selection in Chronic kidney disease for BP control
Dosage inappropriate in joint pain secondary to renal osteodystrophy
Poorly controlled HTN
Poorly controlled diabetes and worsening diabetic nephropathy
Pharmacologic management appropriateness in anemia treatment
78