#1
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Íàïîìíèòå ïîæàëóéñòà
Óâàæàåìûå ãîñïîäà íå ìîãëè áû âû íàïîìíèòü ìíå î äîçèðîâêå ïàíàíãèíà â ïðîôèëàêòè÷åñêèõ öåëÿõ (ïîñêîëüêó ÿ î òàêèõ íàçíà÷åíèÿõ ñëûøó ïåðâûé ðàç â æèçíè! Åãî âîîáùå íàçíà÷àþò â êà÷åñòâå ïðîôèëàêòèêè è ïðîôèëàêòèêè ÷åãî?)
âîçìîæíûå îñëîæíåíèÿ ïðè ïåðåäîçèðîâêå ïðåïàðàòà |
#2
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Òåîðåòè÷åñêè ïàíàíãèí ìîæåò ïðèìåíÿòüñÿ äëÿ ïðîôèëàêòèêè äåôèöèòîâ òåõ èîíîâ, êîòîðûå âõîäÿò â åãî ñîñòàâ (ò.å. êàëèÿ è ìàãíèÿ) íà ôîíå êàêîé-òî îñíîâíîé òåðàïèè, êîòîðàÿ ìîæåò âûçûâàòü ïîâûøåííîå âûâåäåíèå äàííûõ èîíîâ (íàïð. òèàçèäíûìè ìî÷åãîííûìè). Äîçèðîâêà: èëè ñîãëàñíî èíñòðóêöèè èëè ñîãëàñíî ðåêîìåíäàöèè âðà÷à èëè ïî ìîíèòîðèíãó ýòèõ èîíîâ â ñûâîðîòêå êðîâè.
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#3
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ñïàñèáî!
Ñïàñèáî îãðîìíîå! Ïðîñòî òàì ãäå ÿ íàõîæóñü â äàííûé ìîìåíò àáñîëþòíî íåò ìåäëèòåðàòóðû! Äà êñòàòè íà âàøåì ôîðóìå ìíîãî âðà÷åé èç Êàçàõñòàíà?Åñëè òàêîâûå åñòü òî ìíå î÷åíü ïðèÿòíî! Çíà÷èò ÿ íå îäèí!
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#4
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Óâàæàåìûé MAKE!
Ïàíàíãèí â ïðîôèëàêòè÷åñêèõ öåëÿõ íå íàçíà÷àþò. Íè÷åãî îí íå ïðîôèëàêòèðóåò. Ïîêàçàíèÿ äëÿ íàçíà÷åíèÿ - ýòî íåäîñòàòîê êàëèÿ è ìàãíèÿ â îðãàíèçìå. Ïðè÷åì ýòî òàêîå ñíèæåíèå, êîãäà ïàíàíãèí íóæíî ââîäèòü âíóòðèâåííî. Äëÿ ïðèåìà òàáëåòîê ïàíàíãèíà íåò ïîêàçàíèé âîîáùå. Åñëè â êà÷åñòâå ãèïîòåíçèâíîãî ñðåäñòâà ïðèìåíÿþòñÿ äèóðåòèêè ïðèåì ïàíàíãèíà íå ïîêàçàí. Ñ÷èòàåòñÿ ÷òî ïîòåðè èîíîâ íå âåëèêè è ïðîèñõîäèò âîñïîëíåíèå ñ ïèùåé. Ó áîëüíûõ ñ õðîíè÷åñêîé ñåðäå÷íîé íåäîñòàòî÷íîñòè, êîòîðûì ââîäÿò áîëüøèå äîçû äèóðåòèêîâ ìîæåò ïîòðåáîâàòüñÿ ââåäåíèå êàëèÿ è ìàãíèÿ, îïÿòü æå âíóòðèâåííî, íî ýòî ìîæåò áûòü êàëèÿ õëîðèä èëè ìàãíèÿ ñóëüôàò. È óæ ñîâñåì íåò åìó ìåñòà â ëå÷åíèè àðèòìèé ñåðäöà èëè âåãåòîñîñóäèñòûõ äèñòîíèé íà àìáóëàòîðíîì ýòàïå. Ïðè âûñîêîì óðîâíå êàëèÿ â êðîâè (7 ììîëü/ë è âûøå) âîçìîæíà àñèñòîëèÿ (îñòàíîâêà ñåðäöà). Íî òðóäíî ïðåäñòàâèòü ýòî, åñëè ÷åëîâåê ïðèíèìàåò òàáëåòêè ïàíàíãèíà. |
#5
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Óâàæàåìûé Þðèé Àíäðååâè÷!
Âñå æå ïðèåì òèàçèäîâ íåðåäêî ñîïðîâîæäàåòñÿ ãèïîêàëèåìèåé/ãèïîìàãíèåìèåé è çàâèñèò îò äîçû: Ther Umsch. 2000 Jun; 57(6): 398-9. Cardiac risks of hypokalemia and hypomagnesemia Kramer BK, Endemann D. Klinik und Poliklinik fur Innere Medizin II, Universitat Regensburg. [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] During treatment with low to moderate doses of thiazides or loop diuretics, hypokalemia is dose-dependently demonstrated in 2-11% of patients. Additional hypomagnesemia is present in about 40% of hypokalemic patients. High doses of diuretics were routinely used in the past for treatment of hypertension or heart failure, causing ventricular arrhythmias and sudden cardiac death. Low-dose thiazides +/- potassium-sparing diuretic are not associated with these severe adverse effects, but improve in contrast (to high-dose diuretics) survival and cardiovascular morbidity in hypertensive patients. Higher doses of diuretics often necessary in the treatment of patients with severe heart failure are today no longer regularly associated with hypokalemia/hypomagnesemia because of the concomitant treatment with an ACE inhibitor and low-doses of spironolactone. Âñå æå áîëåå ñêëîíåí ê ñëåäóþùåìó ìíåíèþ: Am J Med Sci. 2000 Jan; 319(1): 10-24. Diuretic complications. Greenberg A. Division of Nephrology, Duke University Medical Center, Durham, North Carolina 27710, USA. ...Thiazide diuretics, in particular, have been linked to glucose intolerance, which may be an effect of hypokalemia rather than the diuretic itself. Whether diuretic-induced hypokalemia increases cardiovascular risk is controversial... CONCLUSIONS: Potential side effects of a diuretic can often be anticipated from its mode of action on the kidney. These complications may be mitigated with careful monitoring, dosage adjustment, and replacement of electrolyte losses. Other side effects are idiosyncratic and cannot be prevented. òå, â àìáóëàòîðíîé ïðàêòèêå, êîãäà íå ïîëó÷àåòñÿ òùàòåëüíûé ìîíèòîðèíã èëè ïîäáîð äîçû, íàçíà÷àòü ïðîôèëàêòè÷åñêîå çàìåùåíèå òåðÿåìûõ èîíîâ. Äóìàþ, èç-çà íåâûñîêîé öåíû ýòî áîëåå ðàöèîíàëüíûé ïîäõîä, íåæåëè ïåðèîäè÷åñêèé ìîíèòîðèíã è îáñëåäîâàíèÿ. Ñîãëàñåí, ÷òî äåëî íå â ïðåïàðàòå (ïîäîéäåò è îòå÷åñòâåííûé àñïàðêàì èëè íàèäåøåâûé êàëèÿ õëîðèä), à â äîçå ïîñòóïàåìûõ/âñàñûâàåìûõ èîíîâ. |
#6
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Çäðàâñòâóéòå! ß ïîíèìàþ, ÷òî ñ ìîìåíòà îòêðûòèÿ òåìû ïðîøëî ìíîãî âðåìåíè, íî ÿ õîòåë áû çàäàòü âîïðîñ ã-íó Kosolapov. Íà îñíîâàíèè ÷åãî âû ðåøèëè, ÷òî "Ïàíàíãèí â ïðîôèëàêòè÷åñêèõ öåëÿõ íå íàçíà÷àþò. Íè÷åãî îí íå ïðîôèëàêòèðóåò. Ïîêàçàíèÿ äëÿ íàçíà÷åíèÿ - ýòî íåäîñòàòîê êàëèÿ è ìàãíèÿ â îðãàíèçìå. Ïðè÷åì ýòî òàêîå ñíèæåíèå, êîãäà ïàíàíãèí íóæíî ââîäèòü âíóòðèâåííî. Äëÿ ïðèåìà òàáëåòîê ïàíàíãèíà íåò ïîêàçàíèé âîîáùå. Åñëè â êà÷åñòâå ãèïîòåíçèâíîãî ñðåäñòâà ïðèìåíÿþòñÿ äèóðåòèêè ïðèåì ïàíàíãèíà íå ïîêàçàí." Îáúÿñíèòå ïîæàëóéñòà, íà êàêèõ äàííûõ âû îñíîâûâàåòåñü, ãîâîðÿ ýòî.
Ëè÷íî ÿ, êîãäà ïðîâîæó òåðàïèþ òèàçèäíûìè äèóðåòèêàìè èëè ñàëóðåòèêàìè â êà÷åñòâå ïðîôèëàêòèêè ãèïîêàëèåìèè íàçíà÷àþ ïàíàíãèí è ñ÷èòàþ, ÷òî ýòî ïðàâèëüíûé ïîäõîä ê äåëó. Äà, âîçìîæíî ïîòåðÿ êàëèÿ è ìàãíèÿ îò 40 ìã ëàçèêñà èëè 50 - 100 ìã ãèïîõëîðòèàçèäà èçìåíåíèé íà ÝÊà íå âûçîâóò, õîòÿ òàõèêàðäèéêà ÷àñòåíüêî ïîÿâëÿåòñÿ. À âîò ìûøöû ïàëüöåâ ðóê è íîã ñòÿãèâàåò îé êàê ÷àñòî, ÷òî òîæå íåïðèÿòíî, ñîãëàñèòåñü. |
#7
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Öèòàòà:
Íè â îäíèõ ðåêîìåíäàöèÿõ ïî ëå÷åíèþ Àà íå ãîâîðèòñÿ î íåîáõîäèìîñòè "âîñïîëíåíèÿ êàëèÿ" íà ôîíå òåðàïèè òèàçèäíûìè äèóðåòèêàìè. Ñòàíäàðòíûå äîçû ãèäðîõëîðòèàçèäà, ïðèìåíÿåìûå äëÿ ëå÷åíèÿ ÀÃ, íå òðåáóþò äîïîëíèòåëüíîãî íàçíà÷åíèÿ ïðåïàðàòîâ êàëèÿ. À äîçó ãèäðîõëîðòèàçèäà â 100 ìã ÿ è íå ïîìíþ, êîãäà â ïîñëåäíèé ðàç âèäåë. ×òî êàñàåòñÿ ëå÷åíèÿ ñåðäå÷íîé íåäîñòàòî÷íîñòè, òî ãîðàçäî öåëåñîîáðàçíåå êîìáèíèðîâàòü ïåòëåâûå äèóðåòèêè ñî ñïèðîíîëàêòîíîì è, ðàçóìååòñÿ, ñ èíãèáèòîðàìè ÀÏÔ. È âðÿä ëè â ýòîé êîìáèíàöèè âñåãäà íàéäåòñÿ ìåñòî ïàíàíãèíó. Öèòàòà:
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#8
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Öèòàòà:
Ïðîôèëàêòè÷åñêè êóøàéòå àáðèêîñû, áàíàíû, ôèíèêè, âèíîãðàä, àïåëüñèíû, àïåëüñèíîâûé ñîê, ìàíãî, äûíÿ, àðáóçû, ïåðñèêè, àíàíàñû, ñëèâà, èçþì, êëóáíèêà (íà âûáîð) è íèêàêîãî ïàíàíãèíà íå íàäî. ÂÎÎÁÙÅ ÍÈÊÀÊÎÉ ÔÀÐÌÀÊÎËÎÃÈÈ íå íàäî. |
#9
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Öèòàòà:
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#10
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Óâàæàåìûé äîêòîð Ðîäèîíîâ! Íå ìîãó íå îòìåòèòü - âîïðîñ Âû çàäàëè õîðîøèé! Äåëî â òîì, ÷òî ðóêîâîäñòâóþñü òî ÿ òîëüêî ëèøü ëè÷íûì îïûòîì. Íåðåäêî ïðèõîäèëîñü íàáëþäàòü, ÷òî áîëüíûå ïîëó÷àþùèå äèóðåòèêè æàëîâàëèñü, ÷òî ó íèõ "ñòÿãèâàëî ðóêè è íîãè", ÿ íàçíà÷àë èì ïàíàíãèí - è îí îòëè÷íî ñïðàâëÿëñÿ ñî ñâîåé çàäà÷åé! Ïàíàíãèí ÿ íàçíà÷àþ íå âñåãäà è íå âñåì. Ñòàðàþñü íàçíà÷àòü ïîæèëûì ëþäÿì ïîñëå äèóðåòèêà (ãèäðîõëîðòèàçèä, ëàçèêñ) è òîëüêî ïîñëå òîãî êàê ïðîéäåò äåéñòâèå äèóðåòèêà (ïî ïîíÿòíûì ñîîáðàæåíèÿì). Âîçìîæíî ÿ çàáëóæäàþñü. À âû áû íå ñòàëè? È åùå, áîëüíûì ïðèíèìàþùèì äèóðåòèêè ïî ñõåìå (ïîñòîÿííî), ÿ ïàíàíãèí íàçíà÷àþ ïî÷àùå (çäåñü ðå÷ü íå èäåò îá ÀÃ). ß íè÷åãî íå èìåþ ïðîòèâ ïîçèöèè äîêòîðà Êîñîëàïîâà, õî÷ó òîëüêî ïîíÿòü, ïî÷åìó "Äëÿ ïðèåìà òàáëåòîê ïàíàíãèíà íåò ïîêàçàíèé âîîáùå". Íà õóäîé êîíåö, äëÿ ÷åãî - òî æå èõ ñäåëàëè...
Ñ óâàæåíèåì, Dishifrator. P.S: À åùå ïàíàíãèí õîðîø êàê äîïîëíåíèå ê ãëèêîçèäàì. |
#11
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Èíòåðåñíî, à äëÿ ÷åãî ñäåëàëè ðèáîêñèí, ìèëäðîíàò è òîìó ïîäîáíûå âåùè? Äåéñòâèòåëüíî, ïðè äåôèöèòå êàëèÿ è ìàãíèÿ ïàíàíãèí èìååò ñìûñë. Òîëüêî, âîò, íàñêîëüêî ÷àñòî ýòî âñòðå÷àåòñÿ. Ó íåòÿæåëûõ áîëüíûõ (ò.å. áåç âûðàæåííîé ÕÑÍ) è íîðìàëüíî ïèòàþùèõñÿ ïî÷òè íèêîãäà (ýíäîêðèíîëîãè÷åñêàÿ ýêçîòèêà - îòäåëüíàÿ òåìà). Åñëè æå îäíîâðåìåííî áîëüíîé ïîëó÷àåò âåðîøïèðîí è ÈÀÏÔ (èõ äîëæíû ïîëó÷àòü 100% áîëüíûõ ñ ÕÑÍ è çíà÷èòåëüíàÿ äîëÿ ãèïåðòîíèêîâ), òî íè î êàêîì äåôèöèòå è ðå÷è áûòü íå ìîæåò. Çàòî õîðîøåå ïñèõîëîãè÷åñêîå íàçíà÷åíèå, òî ëè äëÿ áîëüíîãî, òî ëè äëÿ äîêòîðà.
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#12
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Óâàæàåìûå êîëëåãè!
èç íåäàâíèõ ïóáëèêàöèé "ïî òåìå" íî íàîáîðîò: ñî âðåìåí ïóáëèêàöèè âñåì èçâåñòíîãî RALES, â Êàíàäå íàîáîðîò îòìå÷àåòñÿ ïîâûøåíèå ÷àñòîòû ãîñïèòàëèçàöèé è ñìåðòíîñòè îò ÃÈÏÅÐêàëèåìèè íà ôîíå ó÷àùåíèÿ íàçíà÷åíèÿ ñïèðîíîëàêòîíà ïðè ÕÑÍ, îäíèìè èç âîçìîæíûõ ïðè÷èí (êðîìå êîíå÷íî ìåíåå ñåëåêòèâíîãî ïîäõîäà ê âûáîðêå ïàöèåíòîâ ïî ñðàâíåíèþ ñ îðèãèíàëüíûì èññëåäîâàíèåì) óêàçûâàþòñÿ ïðîô. íàçíà÷åíèå êàëèÿ òàêèì ïàöèåíòàì è ïîâûøåííàÿ äîçà ñïèðîíîëàêòîíà: N Engl J Med. 2004 Aug 5;351(6):543-51. Rates of hyperkalemia after publication of the Randomized Aldactone Evaluation Study. Juurlink DN, Mamdani MM, Lee DS, Kopp A, Austin PC, Laupacis A, Redelmeier DA. Department of Medicine University of Toronto, Toronto. [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] BACKGROUND: The Randomized Aldactone Evaluation Study (RALES) demonstrated that spironolactone significantly improves outcomes in patients with severe heart failure. Use of angiotensin-converting-enzyme (ACE) inhibitors is also indicated in these patients. However, life-threatening hyperkalemia can occur when these drugs are used together. METHODS: We conducted a population-based time-series analysis to examine trends in the rate of spironolactone prescriptions and the rate of hospitalization for hyperkalemia in ambulatory patients before and after the publication of RALES. We linked prescription-claims data and hospital-admission records for more than 1.3 million adults 66 years of age or older in Ontario, Canada, for the period from 1994 through 2001. RESULTS: Among patients treated with ACE inhibitors who had recently been hospitalized for heart failure, the spironolactone-prescription rate was 34 per 1000 patients in 1994, and it increased immediately after the publication of RALES, to 149 per 1000 patients by late 2001 (P<0.001). The rate of hospitalization for hyperkalemia rose from 2.4 per 1000 patients in 1994 to 11.0 per 1000 patients in 2001 (P<0.001), and the associated mortality rose from 0.3 per 1000 to 2.0 per 1000 patients (P<0.001). As compared with expected numbers of events, there were 560 (95 percent confidence interval, 285 to 754) additional hyperkalemia-related hospitalizations and 73 (95 percent confidence interval, 27 to 120) additional hospital deaths during 2001 among older patients with heart failure who were treated with ACE inhibitors in Ontario. Publication of RALES was not associated with significant decreases in the rates of readmission for heart failure or death from all causes. CONCLUSIONS: The publication of RALES was associated with abrupt increases in the rate of prescriptions for spironolactone and in hyperkalemia-associated morbidity and mortality. Closer laboratory monitoring and more judicious use of spironolactone may reduce the occurrence of this complication. |
#13
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Ñîãëàñåí ñ óâàæàåìûì Åâãåíèåì Èâàíîâè÷åì. ÀÄåêâàòíàÿ äèóðåòè÷åñêàÿ òåðàïèÿ + ñïèðîíîëàêòîí + èÀÏÔ + ðàçóìíîå ïèòàíèå ðåäêî âûçîâóò êëèíè÷åñêè çíà÷èìóþ ãèïîêàëèåìèþ.
Åñëè ìû äîãîâîðèëèñü, ÷òî ãèïåðòîíèêîâ ìû ïàíàíãèíîì íå ëå÷èì, èáî òàêàêÿ äèóðåòè÷åñêàÿ òåðàïèÿ ÀÃ, êîòîðàÿ âûçîâåò ñóäîðîãè - ýòî óæå õóëèãàíñòâî, òî âîïðîñ ñâîäèòñÿ òîëüêî ê ëå÷åíèþ ÕÑÍ. Èíîãäà ïðèõîäèòñÿ ñòàëêèâàòüñÿ ñ òåì, ÷òî áîëüíûå ïðèíèìàþò, ñêàæåì, 2 òàáëåòêè ôóðîñåìèäà 1 ðàç â íåäåëþ "÷òîáû ñîãíàòü ëèøíþþ âîäó". À ïîòîì ñèäÿò ïîëäíÿ íà ãîðøêå ñ ñóäîðîãàìè â íîãàõ. Âîò õîðîøèé ïðèìåð íåàäåêâàòíîé äèóðåòè÷åñêîé òåðàïèè. Ãèäðîõëîðòèàçèä â äîçàõ áîëåå 50 ìã - òîæå íå÷àñòîå ÿâëåíèå. À â ìåíüøèõ äîçàõ ïðîáëåì ñ ãèïîêàëèåìèåé áûòü íå äîëæíî. Äàæå ïðè òÿæåëîé ÕÑÍ ñ ìàññèâíîé äèóðåòè÷åñêîé òåðàïèé äîáàâëåíèå ñïèðîíîëàêòîíà (òàêæå â äîñòàòî÷íûõ äîçàõ) â áîëüøèíñòâå ñëó÷àåâ ïîçâîëÿåò îáõîäèòüñÿ áåç ïàíàíãèíà. Âîò ãðóïïà, êîòîðàÿ ó íàñ äîñòàòî÷íî ÷àñòî ïîëó÷àåò ïàíàíãèí â òàáëåòêàõ - ýòî áîëüíûå ñ àóòîèììóííûìè çàáîëåâàíèÿìè íà âûñîêèõ äîçàõ ñòåðîèäîâ. Äàæå ó áîëüíûõ ñ ïåðâè÷íûì ãèïåðàëüäîñòåðîíèçìîì, ãäå íèçêèé êàëèé - çàêîíîìåðíî, â áîëüøèíñòâå ñëó÷àåâ äîñòàòî÷íî òîëüêî ñïèðîíîëàêòîíà (â òÿæåëûõ - êàëèé â âåíó). Êñòàòè, óâàæàåìûé Dishifrator, à ÷òî òàêîå "äèóðåòèêè ïî ñõåìå"? |
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Íà ñàìîì äåëå, åñëè óæ åñòü íóæäà â ïåðîðàëüíîì íàçíà÷åíèè ïðåïàðàòîâ êàëèÿ, ëó÷øå íàçíà÷àòü êàëèéíîðìèí.
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À ñêîëüêî êàëèÿ â ïàíàíãèíå è êàëèéíîðìèíå?
 òàáëåòêå ïàíàíãèíà 158 ìã êàëèÿ àñïàðòàòà. 39 ìã êàëèÿ – ýòî 1 ììîëü (ìýêâ). Íå çíàþ, ñêîëüêî êàëèÿ â êàëèé àñïàðòàòå, íî äàæå åñëè ýòî âñå îäèí êàëèé, òî 158/39 = 4. Òî åñòü, íå áîëåå 4 ììîëü êàëèÿ â îäíîé òàáëåòêå. Ñóòî÷íàÿ ïîòðåáíîñòü êàëèÿ, êàæåòñÿ, 2 – 3 ììîëü/êã. Çíà÷èò íà 75 êèëîãðàììîâîãî ïàöèåíòà íàäî îêîëî 190 ììîëü êàëèÿ â ñóòêè, èëè 47.5 òàáëåòîê ïàíàíãèíà . Ïîìíèòñÿ, ÷òî ïðè ñíèæåíèè êàëèÿ â ñûâîðîòêå íà 1 ììîëü/ë äåôèöèò êàëèÿ ñîñòàâëÿåò 200 – 400 ììîëü/ë (ãðóáî). Òî åñòü – 50 – 100 òàáëåòîê ! Ñ àðèôìåòèêîé è õèìèåé ó ìåíÿ ïðîáëåìû – ïîïðàâüòå, ïîæàëóéñòà, åñëè ÷òî-òî íå òàê. |