精神分裂症治療之選藥原則

Selection of Antipsychotics for the Treatment of Schizophrenia

10.29478/TJP.200512.0002

張文和(Wen-Ho Chang)

精神分裂症 ； 抗精神病藥物 ； 副作用 ； 代謝性疾病 ； schizophrenia ； antipsychotics ； side effects ； metabolic disease

台灣精神醫學

19卷4期（2005 / 12 / 01）

264 - 282

繁體中文

作者將精神分裂症治療的主要選藥原則歸納成五個方面，即療效、副作用、價格、方便性，及藥物對受體影響的「由簡而繁」之先後用藥順序。希望能符合「五要」原則，即「要有效」、「要安全」、「要便宜」、「要方便」及「要單純」。其中，以藥物的安全性（副作用）最為重要。而在所有的副作用當中，又以是否會引起代謝性疾病為首要考量因素，其他如錐外症候群，高泌乳素血症引起之性功能障礙，以及心室性傳導障礙也是選藥的參考標準。在安全性方面，作者進一步強調，使用抗精神病藥物時，尤其是第一線藥物，應避免出現五種情況，亦即「五不要」原則，包括：(A)避免出現錐外症候群；(B)避免出現高泌乳素血症；(C)避免合併使用多種抗精神病藥物；(D)避免與抗膽鹼能藥物合併使用；及(E)避免出現體重增加。此外，作者所提出的「先簡後繁」的用藥順序，頗具創意，文中並就此提出相關「證據」，醫師在選擇藥物時，也要就這一因素加以考量。最後，作者對於下一代新藥多巴胺系絲穩定劑進行了簡要介紹，希望能對臨床醫師理解這類全新藥物的作用機轉有所助益。由於藥物的優缺點比較事涉敏感，其影響可能關係到商業利益，為了保持本刊及作者的客觀性與公正性，首先聲明本文之撰寫絕無任何營利團體之贊助，並在參考文獻的處理上做了嚴格而謹慎的選擇，舉凡重大問題之意見，一律以權威機構（如世界精神醫學會、英國精神醫學研究院、美國精神醫學會、美國糖尿病醫學會等）所發表之資料為準則。

This article reviews guidelines for the selection of antipsychotics in the treatment of schizophrenia. At least five major areas of consideration are essential for the selection of antipsychotics in clinical practice. These include efficacy, side effects, cost, convenience of use and the relative position of an agent in the sequence from pure dopamine receptor targeted (so-called ”clean” drug) to multiple receptor targeting (”dirty” drug). The side-effect profile plays the most important role in the determination of drug choice. Among side effects, differential weight gain associated with the use of various antipsychotics has become an increasingly important factor in the selection of a first- line medication. Other adverse events such as dose-dependent extrapyramidal symptoms, hyperprolactinemia-sexual dysfunction, and cardiac conduction effects should also be taken into consideration. Five important safety considerations which should be emphasized in the selection and use of first-line atypical antipsychotics are as follows: (1) to avoid extrapyramidal symptoms; (2) to avoid hyperprolactinemia; (3) to avoid antipsychotic polypharmacy; (4) to avoid anticholinergic medication; and (5) to avoid weight gain.

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