71.3 🩺 內科專科考前版

71.3.0.1 📌 䞀頁重點

  • 22E: vancomycin AUC-guided > trough, DOAC reversal, biologic PK
  • Taiwan: 健保藥物絊付 + drug-drug interaction warning

71.3.0.2 💊 進階

71.3.0.2.1 Vancomycin Modern Monitoring
  • AUC 24-hr 400-600 mg×hr/L (severe MRSA infection)
  • AUC > Trough alone for nephrotoxicity reduction
  • Bayesian estimation software preferred
71.3.0.2.2 Biologic PK
  • Monoclonal Ab: tÂœ 14-21 days
  • Subcutaneous bioavailability ~60-80%
  • Anti-drug antibody (ADA) reduce efficacy
  • TDM emerging for infliximab, adalimumab
71.3.0.2.3 Drug-Drug Interaction Severity
  • Contraindicated: ergotamine + macrolide (cardiotoxicity)
  • Major: warfarin + sulfa
  • Moderate: monitor
  • Minor: clinical insignificant
71.3.0.2.4 Special Populations
  • Critical illness: 變異 large, augmented renal clearance, fluid shifts
  • Obesity: hydrophilic 甹 IBW or AdjBW; lipophilic 甹 TBW
  • CRRT: hemofiltration affects clearance differently
71.3.0.2.5 Pharmacogenomicsintrosee Ch 72
  • HLA-B*1502 + CBZ
  • HLA-B*5801 + allopurinol
  • TPMT + thiopurine
  • CYP2C19 + clopidogrel
  • VKORC1/CYP2C9 + warfarin

71.3.0.3 🌟 Pearls (10)

  1. Vancomycin AUC-guided > trough (2020+)
  2. Phenytoin albumin correction: corrected = measured / (0.2 × albumin + 0.1)
  3. Loading dose required when target needed quickly
  4. First-pass effect: SL nitroglycerin > PO
  5. Augmented renal clearance in young trauma/sepsis
  6. Therapeutic equivalence (FDA AB rating) for generic
  7. Biosimilar ≠ identical biologic but interchangeable
  8. Drug eluting local kinetics (DES, glaucoma drops)
  9. PROTAC new modality (proteolysis-targeting chimera)
  10. AI-augmented dosing software emerging

71.3.0.4 🔍 特殊情境

71.3.0.4.1 Critically Ill Pharmacokinetics
  • Augmented renal clearance (hyperdynamic state)
  • Capillary leak → ↑ Vd hydrophilic
  • Hypoalbuminemia → ↑ free fraction
  • CRRT modifies clearance
71.3.0.4.2 Geriatric Adjustments
  • Renal: 䌰 CrCl
  • Hepatic: dose down hepatic-cleared
  • CYP variability + polypharmacy
  • Beers + STOPP/START criteria
71.3.0.4.3 Pregnancy
  • Increased Vd, GFR (50%)
  • Decreased albumin
  • CYP induction (3A4) / inhibition (1A2)
  • Drug-specific lactation risk

71.3.0.5 📍 Taiwan

  • 健保藥物資料庫 + 倚重共甚藥譊瀺
  • HLA testing carbamazepine 健保
  • 健保 drug review system

71.3.0.6 🎓 內專重點

  1. PK fundamentals
  2. CYP450 interactions
  3. TDM 6 + biologic
  4. Special populations
  5. Pharmacogenomics 基瀎

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