1、門 診 處 方 討 論,Zinc gluconate 用於小兒腸炎報告日期：99.1.28曾淑美 藥師,Outline,小兒腹瀉的類型？ 小兒腹瀉臨床表徵？ 小兒腹瀉的治療？ Zinc的生理功能？ Zinc用於腹瀉的機轉？ Zinc用於治療腹瀉的劑量是否合理？ 證據等級？ Zinc的注意事項？ 結論,小兒腹瀉類型,Reference:,World Gastroenterology Organisation practice guideline,Causative agents and pathogenic mechanisms,Reference:,World Gastroenterology
2、 Organisation practice guideline,World Gastroenterology Organisation practice guideline,Reference:,小兒腹瀉臨床表徵,Reference:,World Gastroenterology Organisation practice guideline,小兒腹瀉的治療,藥物治療非藥物治療,藥物治療 -本院有的藥品品項, AdsorbentsKaolin-pectinAdult：60 to 120 mL /dayChildren： (3 to 6 y) 15 to 30 ml/day(6 to 12 y
3、) 30 to 60 ml/day(12 y and over) 45 to 60 ml/day Antimotility agents （Opiate derivatives ）Loperamide（Imodin）Adult ：4 mg ORALLY followed by 2 mg after each loose stool up to amaximum of 16mg/dayChildren ：(2 to 5 y, 13 to 20 kg) 1 mg ORALLY 3 times daily (6 to 8 y, 20 to 30 kg) 2 mg ORALLY twice daily
4、 (8 to 12 y, greater than 30 kg) 2 mg ORALLY 3 times daily,Reference: micromedex, Toxin binders cholestyramine（Questran ）Adults: 4g qd-bid AC & HS, max: 24g/day and 6 doses/dayChildren: 240mg/kg/day tid 抗菌殺菌劑Nifuroxazide（Anti-dia ）Adults and children 12yrs: 1 tab qidChildren (4-8 yrs): 3 tab/day,Ref
5、erence: micromedex,藥物治療 -本院有的藥品品項, 其他 - Zinc1、 zinc sulfate2、zinc acetate3、zinc gluconateall water-soluble compounds Lactobacillus casei variety rhamnosusChildren 3 yrs and adults: 2 cap bid-qid,藥物治療 -本院有的藥品品項,非藥物治療, Oral rehydration solutions (ORS) 口服脫水補充液,什麼情況下不可給ORS？, If vomiting is persistent, t
6、he patient (child or adult) will not take ORS and is likely to need intravenous fluids. Reference: World Gastroenterology Organisation practice guideline,Zinc的生理功能,維持免疫功能人體鋅不足會出現淋巴球數量低落、血中免疫球蛋白降低、自然殺手功能減弱、皮膚免疫測試反應降低等狀況，臨床的結果就是肺炎、念珠球菌感染，甚至傷風感冒。 生長與發育促進生長、性器官的發育、傷口癒合，參與皮膚、毛髮、指甲，以及口腔黏膜等多處位置的修補作用。 調節基因表
7、現許多蛋白質轉錄因子的分子中含有鋅指結構，負責與DNA結合，而改變基因的表現功能，是很重要的調控機制。,Zinc的生理功能,酵素組成分已知的含鋅酵素超過200多種，鋅位於催化中心，或穩定酶蛋白質的立體結構，失去鋅會使酵素失去活性。 促進胰島素分泌,Zinc用於腹瀉的機轉,鋅缺乏導致腹瀉的過程包括：腸細胞絨毛結構破壞、含鋅消化酵素減少、發炎造成腸壁水腫、消化道免疫力變差。 缺鋅與腹瀉容易形成惡性循環，腹瀉更減少鋅吸收，增加鋅的流失，造成雙重的缺鋅原因 常發生在老人、嬰幼兒、胰臟功能不全、腸病變或腸手術者的身上。,腹瀉、鋅缺乏和免疫力降低的三角關係,Zinc用於腹瀉的劑量是否合理,Zinc dos
8、e The World Health Organization (WHO) and United Nations Childrens Fund (UNICEF) recommend 10 to 20 mg of zinc per day for children with diarrhoea, at least twice the recommended daily allowance (WHO/UNICEF 2004).Reference: Cochrane Database Syst Rev. 2008 Jul 16;(3):CD005436. Review. For all childr
9、en with diarrhea: 20 mg zinc for 14 days.(developing countries )Reference: World Gastroenterology Organisation practice guideline,證據（1）, FDA Approval: Adult, no; Pediatric, no Efficacy: Pediatric, Evidence favors efficacy Recommendation: Pediatric, Class IIb Strength of Evidence: Pediatric, Category
10、 B,Reference: micromedex,證據（1）,收錄對象：3-24個月的小孩 鋅治療的期限：14天 鋅的劑量：20 mg/day 實驗結果：有補充鋅的實驗組在腹瀉糞便產量降低28、腹瀉持續時間縮短為14。 結論:補充鋅可以減少營養不良兒童腹瀉的發生率和持續時間,Reference: micromedex,證據（2）,Reference: Cochrane Database Syst Rev. 2008 Jul 16;(3):CD005436. Review.,收錄對象： The review of trials identified 18 trials involving 616
11、5 children of all ages. Children aged between one month and five years with acute or persistent diarrhoea, including dysentery.Reference: Cochrane Database Syst Rev. 2008 Jul 16;(3):CD005436. Review.,證據（2）, used zinc 5 mg20 mg/day. two trials administered higher zinc doses: 40 mg/dayReference: Cochr
12、ane Database Syst Rev. 2008 Jul 16;(3):CD005436. Review.,Zinc 用於腹瀉的劑量, In areas where diarrhoea is an important cause of child mortality, research evidence shows zinc is clearly of benefit in children aged six months or more.,Reference: Cochrane Database Syst Rev. 2008 Jul 16;(3):CD005436. Review.,S
13、ummary,病患的衛教,飲食方面的控制治療1、先暫停飲食，到流質、半流質、稀飯、軟食，一步一步的給予。2、選擇的食物應要纖維少及容易消化。3、儘量少服用以下食物：茄子，菠菜，菇類，碳酸飲 料及螃蟹、烏賊等生的魚類，以免刺激腸道或 增加病菌感染的可能性。 輸液治療補充水份及電解質，避免其他嚴重狀況如脫水等情形發生。 其他：保持身體的清潔，肛門部份的清理，予以溫和坐浴及保持肛門周圍的乾燥。,注意事項, Zinc的副作用Zinc can cause vomiting because of its metallic taste. In high doses, zinc can also cause
14、epigastric pain, lethargy and fatigue. Zn過量後果：大量鋅會引發噁心、嘔吐、發燒、血液中高密度脂蛋白減少，進而提高心血管疾病發生機率。,結論, Diarrhoea causes around two million child deaths annually. Zinc supplementation could help reduce the duration and severity of diarrhoea, and is recommended by the World Health Organization and UNICEF.,Refere
15、nce: Cochrane Database Syst Rev. 2008 Jul 16;(3):CD005436. Review.,醫師處方分別開立於98/07/11和98/07/18，給予zinc gluconate 10 mg 0.5 tab bid 治療期間各為7天，是屬於合理，然後衛生署所核准的適應症為鋅不足的補充，病患沒有驗鋅的濃度，不知是否缺鋅，所以不符合健保規範，故病患須以自費的方式,結論,The end,Zinc 臨床用途,Zinc deficiency25 to 50 mg elemental zinc ORALLY per day Zinc deficiency; Pro
16、phylaxis25 to 50 mg elemental zinc ORALLY per day Wilsons disease（zinc acetate）1) adult50 mg ORALLY 3 times a day (Prod Info GALZIN(TM) oral capsules, 2002) 2) Pediatric (10 y and older) 25 mg ORALLY 3 times a day; may be increased to 50 mg ORALLY 3 times a day as needed (Prod Info GALZIN(TM) oralcapsules, 2002) ContraindicationsReference: micromedex,Epidemiology of acute diarrhea,本院含有zinc的品項,Zinc acetate,Zinc oxide,Minimal or no dehydration,Mild to moderate dehydration,Severe dehydration,
