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120-7-第七节 抗疟药的用药原则
前已提到,视网膜的毒性反应限制抗疟药的剂量。提高剂量,虽可提高疗效,然而毒性反应也相应提高。当前国内外常用的剂量为:经氯喳400mg/d,氯喳250mg/d。如按体重计算,每日剂量分别为6.5mg/kg和4mg/kg。把剂量控制在这种水平以下,一般是比较安全的。但是因为服药时间很长,累积剂量很高,也有视网膜病变的可能性。定期做视野和眼底等检查,能及早发现早期的轻微病变,及时停药。因此,眼科检查已成为常规(表120一2).- A3 {3 P& H9 b$ E" J0 U% }. q1 _
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& r5 t3 n `+ ~5 s6 ? 按照表120一2中规定,病人在服药前应先做视野检查,确定病人服药前的视野基线,然后每6个月做一次眼科检查。如检查中发现任何一种异常变化,立即停药,可避免受监察病人发生严重的视网膜病。由于病人接受抗疟药初期副作用较多,疗效又不能很快显示,如病人对副作用能耐受的话,应劝病人坚持服药满6个月,再决定是否停药还是继续治疗。显效后继续用到病情缓解,然后适当减量,控制病情在稳定期。
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综上所述,抗疟药治疗各种风湿病都有一定疗效,副作用较其他抗风湿病药为轻。采取控制剂量和定期眼科检查等措施后,眼视网膜病变的发生率很低,因此,国内外仍被广泛应用。
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" a' G0 L o9 R; F' i" e 参考文献:, P7 Y& Q/ X f$ X- S
4 r" R2 C) i) H$ \/ K 叶益新,汪中.抗疟药.见:蒋明,朱立平,林孝义主编,风湿病学.第一版,北京:科学出版社,1995. 1798一1806
" \8 O4 v0 V* y0 e& m7 ~+ ?2 \8 r0 G4 o' g# m
余碧娥,方丽.经抓唆的眼科不良反应分析.中国新药与临床杂志,2001. 20(3):235一236 % A, ]) K) w8 ]* l
, N3 B/ d5 H4 h* D Rynes RI. Antimalarial drugs. In: Shaun R, Edward DH,Clement BS et al eds, Kelley's Textbook of Rheumatology. 6thed, Philadelphia: Saunders, 2001.859一867
& n7 Q( R& @" u0 ~8 y$ [& M: h
7 J9 m: @0 O3 Y Avina-Zubieta 1A, Galindo-Rodriguez G, Newman S et al.Long-term effectiveness of antimalarial drugs in rheumatic dis-eases. Ann Rheum Dis, 1998. 57(10):582一587
' m+ H- F" d' m$ o$ a7 y" E* F1 U' J" [" r1 V% `
Biasi D, Caramaschi P, Carletto A, et al. Combination ther-apy with hydroxychloroquine, gold sodium thiomalate andmethotrexate in early rheumatoid arthritis. An open 3-yearstudy. Clin Rheumatol, 2000. 19(6):505一507 R# ~7 _7 L! j" v
) S! C7 j) d) _% M8 D6 X Block 7A. Hydroxychroloquine and retina safety. Lancet,1998. 351:771
. ^, d5 k2 T% ]9 I
8 n: j, ~, H5 P Borden MB, Parke AL. Antimalarial drugs in systemic lupuserythematosus: use in pregnancy. Drug Saf 2001. 24(14):1055一1063
' Z* v! x# j1 E5 j2 [3 A; C; f7 k& G5 c A2 B, u
Case JP. Old and new drugs used in rheumatoid arthritis: ahistorical perspective partl:the older drugs. Am J Therapeutics,2001. 8:123一143 3 q6 m3 m8 m F( c; J
6 g+ {( v! j* q2 C
Clegg D O, Dietz F, Duffy J, et al. Safety and efficacy ofhydroxychloroquine as maintenance therapy for rheumatoid arthri-tis after combination therapy with methotrexate and hydroxy-chloroquine. J Rheumatol, 1997. 24:1896一1902( G) V) D0 |3 w* t! i8 C- ?+ a
, R2 y+ }/ P0 Y( z' u
Coutinho MB, Duarte 1. Hydroxychloroquine ototoxicity ina child with idiopathic pulmonary haemosiderosis. Int J PediatrOtorhinolaryngol 2002.62(l):53一57 ; k0 a% H; P: L# p
6 o, p1 J* G, a1 {. A Duncan MR, Capell HA. The use of antimalarials in combi-nation with other disease modifying agents in RA一the British ex-perience. Lupus, 1996.5 Suppl 1:S50一58 : @! l0 q3 D/ o) Q( G
/ T3 R" K) z8 Z. Z5 ^) p Felson DJ,Anderson JJ, Meenan RF. The comparative effi-cacy and toxicity of second-line drugs in rheumatoid arthritis. Re-sults of two meta-analyses. Arthritis Rheum, 1999. 33: 1449一1461.
+ Q! k. d: H- \
6 ~8 ]* s% _8 Y* e$ _; L. X Fox R. Anti-malarial drugs: possible mechanisms of actionin autoimmune disease and prospects for drug development. Lupus, 1996. 5 Suppl 1: S4一10 0 h2 u- ~0 H) ~4 ^- ]% D' X! B
( d; g" X3 u: Z1 o Fox RI, Dixon R, Guarrasi V, et al. Treatment of primarySjogren' s syndrome with hydroxychloroquine: a retrospective,open-label study. Lupus, 1996. 5 Suppl 1:S31一36 + }! i9 M* \8 k9 K: E
; J( T) \) v$ w; [
Furst DE. The combination of methotrexate, sulfasalazineand hydroxychloroquine is highly effective in rheumatoid arthri-tis. Clin Exp Rheumatol, 1999. 17(1):39一40 & Q! p5 g% o( R( a
9 Y2 k% P: R# \5 Z5 u& Y% |
Garrood T, Scott DL. Combination therapy with diseasemodifying anti-rheumatic drugs in rheumatoid arthritis. BioDrugs2001. 15(8):543一561
, W0 N: H6 C' L3 i' d! T/ N0 a; T0 m6 z8 C7 H, m
Goekoop YP, Allaart CF, Breedveld FC, et al. Combinationtherapy in rheumatoid arthritis. Curr Opin Rheumatol, 2001. 13(3):177一1831 P# ^$ a( p1 ~) |# y
/ {/ O9 u; {3 o( ^5 w
Guedira N, Hajjaj-Hassouni N, Srairi JE, et al. Third-de-gree atrioventricular block in a patient under chloroquine therapy.Rev Rhum E心 ,1998. 650):58一62 ' x# ? T( S& G! @- c' l. a
3 p9 f4 X$ c4 O4 C; P" T
Hawley DJ, Wolfe F, Pincus T. Use of combination therapyin the routine care of patients with rheumatoid arthritis: physicianand patient surveys. Clin Exp Rheumatol, 1999. 17 ( 6 Suppl18):S78一82 5 t2 @, {% y9 U, D! {- ^ i
$ O1 F! Q+ `" x' h% N) y& D Janssen NM, Genta MS. The effects of immunosuppressiveand anti-inflammatory medications on fertility, pregnancy, andlactation. Arch Intern Med, 2000. 160(5):610一619
$ j$ o4 Z" m, \( L9 l+ p' x* N* S; ~" y3 U; o
Jones SK. Ocular toxicity and hydroxychloroquine: guide-lines for screening. Br J Dermatol,1999. 140(l) : 3一7
1 n. d4 V. \; i7 j
2 p3 M2 ^" r' I) x/ L: ~4 I& D# y Keyszer G, Keysser C, Keysser M. Efficacy and safety of acombination therapy of methotrexate, chloroquine and cyclophos-phamide in patients with refractory rheumatoid arthritis: resultsof an observational study with matched-pair analysis. ClinRheumatol, 1999. 18(2) :145一151 . a3 Z" z r5 E; z2 s& W
9 P. R$ R. \( S7 t0 F Koren G. Antimalarial drugs for rheumatoid disease duringpregnancy. Can Fam Physician, 1999. 5:2869一287。* k% H9 c j" K$ f! h7 n2 ]+ q
- q; S" _5 A/ x Kremer JM. Rational use of new and existing disease-modi-fying agents in rheumatoid arthritis. Ann Intern Med, 2001. 134(8):695一706
7 @. P/ G; U. ? B! R
2 j/ U% h) q4 `/ ^8 O+ |- p Nayak V, Esdaile JM. The efficacy of antimalarials in sys-temic lupus erythematosus. Lupus 1996. 5 Suppl 1:S23一27
6 E" x) {! H* ?4 Y5 | g
1 ^# `$ m2 F- d& ~8 f2 x O'Dell JR, Blakely KW, Mallek JA, et al. Treatment ofearly seropositive rheumatoid arthritis: a two-year, double-blindcomparison of minocycline and hydroxychloroquine. ArthritisRheum, 2001. 44(10):2235一2241 & F# P3 x( d7 W1 c& q* d
V( m, N) T% d3 d; f O'Dell JR. Triple therapy with methotrexate, sulfasalazine,and hydroxychloroquine in patients with rheumatoid arthritis.Rheum Dis Clin North Am, 1998. 24(3) :465一477
/ J# ?9 S4 j; q& c/ h) }
1 C7 P9 N( S! J, U* B O} Dell JR. Combination DMARD therapy with hydroxy-chloroquine, sulfasalazine, and methotrexate. Clin Exp Rheuma-tol, 1999.17(6 Suppl 18):S53一58 $ W& y0 ^- V- o: K2 p) [( Q
/ L4 \: h6 H9 f' E! H* G5 w$ V Ostensen M, Ramsey-Goldman R. Treatment of inflamma-tory rheumatic disorders in pregnancy: what are the safest treat-ment options? Drug Saf, 1998. 19(5) :389一41。
) p+ r9 E( i3 T3 s- A, t" D$ W. m5 B
5 b" }) L: u7 z7 B0 o; L4 S Parke AL, Rothfield NF. Antimalarial drugs in pregnancy一the North American experience. Lupus, 1996 . 5 Suppl 1: S67一69
8 R9 |& n" p& Q, ^
8 a0 ?4 [" v3 V' l1 r3 p2 o; r! ^ Pincus T, O} Dell JR, Kremer JM. Combination therapywith multiple disease-modifying antirheumatic drugs in rheuma-toid arthritis: a preventive strategy. Ann Intern Med, 1999. 131(10):768一774 - @1 ^) e" L. {( \+ B& I9 u
- j/ K4 S- d3 }. D, `. N( _
Riise T, Jacobsen BE,Gran JT. Changes in therapy ofrheumatoid arthritis during the period 1979 to 1996. Scand JRheumatol, 2001. 30(4):199一2026 I6 q$ D2 W1 m/ @, m0 x
% V$ e( ^0 I% ~# Q# p
Rynes RI. Ophthalmologic considerations in using antimalar-ials in the United States. Lupus, 1996. 5 Suppl 1:573一74
/ {3 d' Z. I# |9 Z
% Q& h4 X1 g8 _! @$ m7 m1 G Spalton DJ. Retinopathy and antimalarial drugs-the Britishexperience. Lupus, 1996. 5 Suppl1:S70一72
P7 E M3 v; ^; a
v3 C6 x! e! s, G$ v9 c Seckin U, zoran A, Ikinciogullari A. Hydroxychloroquine o-totoxicity in a patient with rheumatoid arthritis. Rheumatol Int,2000. 19:203一204( |) ~5 i7 x0 B$ e, I6 q+ r2 H
; N# M8 K# s( x% \# x& L q" J% Z
Tett SE, Cutler DJ, Beck C, et al. Concentration-effect re-lationship of hydroxychloroquine in patients with rheumatoidarthritis一a prospective, dose ranging study. J Rheumatol,2000. 27(7):1656一1660
2 A% A8 [' Q- C6 h8 Z' ^/ b5 E1 q
3 S5 z. N. p9 G+ \, u8 C Tishler M, Yaron 1, Shirazi I, et al. Hydroxychloroquinetreatment for primary Sjogren's syndrome: its effect on salivaryand serum inflammatory markers. Ann Rheum Dis, 1999. 58(4):253一256; g* N1 A' J% X+ h& R1 c
1 j1 G: Y3 Z; R# x9 h2 x1 q3 r, r
Tsakonas E, Fitzgerald AA, Fitzcharles MA, et al. Conse-quences of delayed therapy with second-line agents in rheumatoidarthritis: a 3 year follow up on the hydroxychloroquine in earlyrheumatoid arthritis (HERA) study. J Rheumatol, 2000. 27(3):623一629, o, O- x2 X8 D' P
1 }0 @/ u) T" L5 u van Jaarsveld CH, Jahangier ZN, Jacobs JW, et al. Toxicityof anti-rheumatic drugs in a randomized clinical trial of earlyrheumatoid arthritis. Rheumatology (Oxford) 2000. 39(12):1374一1382
( X4 z! j( L3 ]" U- _7 u" M/ e; i
Veinnl JP, Mai KT, Zarychanski R. Chloroquine relatescardiac toxicity. J Rheumatol, 1998. 25:1221一1225 |
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