介紹SSRI抗憂鬱藥物的中毒情況，和serotonin syndrome

1. 1
Selective Serotonin Reuptake Inhibitor(SSRI)
Poisoning
加護病房 房日誌查
1Ref: Michael G, MD Selective serotonin reuptake inhibitor poisoning.
In: UpToDate, Jonathan G(Ed), UpToDate, Waltham, MA, 2011.
fluoxetine sertraline
paroxetine
citalopram

2. 2
藥理機轉
2Ref: Michael G, MD Selective serotonin reuptake inhibitor poisoning.
In: UpToDate, Jonathan G(Ed), UpToDate, Waltham, MA, 2011.

3. 3
SSRI 沒有 TCA 那麼毒
3
SSRI TCA
需插管 4-6% 31-32%
入加護病房 0-6% 31-35%
死亡率 1.6 人 /
每百萬人
34.8 人 /
每百萬人
Ref: Michael G, MD Selective serotonin reuptake inhibitor poisoning.
In: UpToDate, Jonathan G(Ed), UpToDate, Waltham, MA, 2011.
台灣資料 : 在民國 84 年 7 月至 85 年 6 月一年中
4,825 名中毒個案中，因 fluoxetine 中毒者 8 人、 fluvoxamine 中毒者 3 人
在這些個案中，並無因中毒而死亡者。

4. 4
SSRI 治療區間寬
4Ref: Michael G, MD Selective serotonin reuptake inhibitor poisoning.
In: UpToDate, Jonathan G(Ed), UpToDate, Waltham, MA, 2011.

5. 5
藥物動力學
5
CYP450: cytochrome p450
Ref: Michael G, MD Selective serotonin reuptake inhibitor poisoning.
In: UpToDate, Jonathan G(Ed), UpToDate, Waltham, MA, 2011.

6. 6
藥物動力學 -2
藥物 最高血中
濃度
排除半衰期 代謝 活性代謝物
Fluoxetine 6-8 小時 2-10 天 肝
(2D6, 2C9, 3A4)
Norfluoxetine
Sertraline 4-8 小時 26 小時 肝
(2C9, 2D6, 3A4)
Desmethylsertraline
Paroxetine 5 小時 21 小時 肝
(2D6)
無
Fluvoxamine 3-8 小時 16 小時 肝
(1A2, 2D6)
無
Citalopram 4 小時 35 小時 肝
(3A4, 2D6, 2C19)
Desmethylcitalopram,
didesmethylcitalopram
Escitalopram 5 小時 27-32 小時 肝
(3A4, 2D6, 2C19)
S-
desmethylcitalopram,
S-
didesmethylcitalopram
6Ref: Michael G, MD Selective serotonin reuptake inhibitor poisoning.
In: UpToDate, Jonathan G(Ed), UpToDate, Waltham, MA, 2011.

7. 7
若懷疑中毒時，藥師要問甚麼 ?
7Ref: Michael G, MD Selective serotonin reuptake inhibitor poisoning.
In: UpToDate, Jonathan G(Ed), UpToDate, Waltham, MA, 2011.

8. 理學檢查
• 就如一般中毒的情況，由醫師來做
• 藥師可特別注意是否出現
– Serotonin syndrome
– 其他症狀
8Ref: Michael G, MD Selective serotonin reuptake inhibitor poisoning.
In: UpToDate, Jonathan G(Ed), UpToDate, Waltham, MA, 2011.

9. 9
SSRI 中毒症狀
9Ref: Michael G, MD Selective serotonin reuptake inhibitor poisoning.
In: UpToDate, Jonathan G(Ed), UpToDate, Waltham, MA, 2011.

10. 10
Serotonin Syndrome 症狀
10Ref: Michael G, MD Selective serotonin reuptake inhibitor poisoning.
In: UpToDate, Jonathan G(Ed), UpToDate, Waltham, MA, 2011.

11. 可能造成 serotonin syndrome 之藥
物
11
Ref: Can Fam Physician 2008;54:988-92
10-14% 發生率
輕度症狀
Sertraline/paroxetine/fluvoxamine

12. 12
藥師應建議監測數據
12Ref: Michael G, MD Selective serotonin reuptake inhibitor poisoning.
In: UpToDate, Jonathan G(Ed), UpToDate, Waltham, MA, 2011.

13. 13
出現 serotonin syndrome 時
藥師應建議監測
13Ref: Michael G, MD Selective serotonin reuptake inhibitor poisoning.
In: UpToDate, Jonathan G(Ed), UpToDate, Waltham, MA, 2011.

14. 14
臨床處置 - 支持療法即可
14Ref: Michael G, MD Selective serotonin reuptake inhibitor poisoning.
In: UpToDate, Jonathan G(Ed), UpToDate, Waltham, MA, 2011.

15. 15
氣管 / 呼吸 / 循環
15Ref: Michael G, MD Selective serotonin reuptake inhibitor poisoning.
In: UpToDate, Jonathan G(Ed), UpToDate, Waltham, MA, 2011.

16. 16
活性 使用碳
16Ref: Michael G, MD Selective serotonin reuptake inhibitor poisoning.
In: UpToDate, Jonathan G(Ed), UpToDate, Waltham, MA, 2011.

17. 17
洗腎有用嗎 ?
17Ref: Michael G, MD Selective serotonin reuptake inhibitor poisoning.
In: UpToDate, Jonathan G(Ed), UpToDate, Waltham, MA, 2011.

18. 18
Serotonin Syndrome 處理
18Ref: Michael G, MD Selective serotonin reuptake inhibitor poisoning.
In: UpToDate, Jonathan G(Ed), UpToDate, Waltham, MA, 2011.

19. 19
QTc 延長
19
持續心電圖監測
小心 QTc interval>560 msec
Torsade de points
注意危險因子：
QTc interval>560 msec
先前發生過
心跳變慢
心室未成熟跳動 加增
成人治療藥物劑量：
MgSO4 2g over 2 分鐘
未改善， 10-15 分鐘再打
Ref: Michael G, MD Selective serotonin reuptake inhibitor poisoning.
In: UpToDate, Jonathan G(Ed), UpToDate, Waltham, MA, 2011.

20. 20
SSRI 中毒總複習
20

21. 21
感恩聆聽
21