Transcript Isoniazid於膀胱癌case之處方討論

Isoniazid於膀胱癌case
之處方討論
報告者:梁心怡
94-1-6
Malignant neoplasm of bladder
Hematuria
泌尿道感染,未標示位置者
12/29
Isoniazide100mg/tab
3# QD
PO X 14 days
膀胱癌是生殖泌尿系統腫瘤中很常見的一種，其中表淺性膀
胱癌約佔7成左右，在治療上如果早期發現，可以經尿道使用
膀胱鏡刮除膀胱腫瘤(TUR-BT)，再使用抗癌藥物/BCG由膀胱
灌注治療，可達到相當好的治療效果。
ImmuCyst® (BCG免疫治療劑)
-是由Bacilus Calmmette-Guerin(BCG)之Connaught菌株(一
種牛的結核桿菌Mycobacterium bovis的活減毒菌株)所製成
的凍 晶乾燥製劑.
-美國FDA於1990 年核准BCG用於治療膀胱癌。
臨床上BCG主要是用來：
1.膀胱原位癌(CIS)的治療。
2.預防表淺性膀胱癌TUR(經尿道切除術)手術後的復發
3.殘留膀胱腫瘤的治療
治療計劃
-經膀胱投予ImmuCyst ®須開始於生檢或經尿道切除術
(TUR)後7-14days。包括induction therapy and
maintenance therapy。
induction therapy(誘導療程)
- qwk X 6 wks.暫停6wks,再qwk X 1~3wks。
maintenance therapy(維持療程)
-開始治療後6個月,q6mth X 1~3wks,直到第36個月為止。
Immucyst
副作用： >95%無嚴重副作用
局部
induction
短暫性無尿
26%
頻尿
14%
血尿
11~19%
嚴重 GU 副作用
< 0.5
全身
< 38.5℃/ < 48hr
17%
嚴重副作用
< 1%
全身性 BCG 反應：
定義：
易發生於：
正常現象：
不可用 BCG：
maintenance
46%
34%
BCG 作用正常現象
V
V
V
31%
V
極少發生. infection? 發炎性過敏反應?
> 39.5℃，>12 hr；38.5℃，>48hr；pneumonitis， hepatitis…
TUR 或挫傷性導尿管(致血尿)一週內即用 BCG
發燒、血尿、頻尿、急尿…等，表示 BCG 已開始作用
長期免疫抑制、移植、活動性 TB、AIDS、白血病、Hodgkin’s
disease
延後使用 BCG： 不明發燒、嚴重膀胱/尿道疼痛，UTI、挫傷(膀胱鏡、導尿)
BCG免疫治療劑相關的不良反應與治療建議
症狀或症候群
治療
(1)刺激性膀胱症狀<48小時
症狀治療
(2)刺激性膀胱症狀>48小時
症狀治療
延遲下一次ImmuCyst®療程至症狀消除為止。
若一週內症狀能未消除，可投與isoniazid 300mg qd直到
完全緩解為止
(3)伴隨UTI(細菌性尿路感染)
延遲下一次ImmuCyst®療程至抗微生物療程完成後，且
尿液培養呈現陰性反應為止
(4)其他生殖泌尿系統不良反應:症候
性肉芽腫性攝護腺炎，副睪丸炎，輸
尿管阻塞，或腎臟膿腫。
停用ImmuCyst®
投與isoniazid 300mg qd和 rifampin 600mg qd 3-6 months
(5)fever<38.5OC; 持續＜４８hrs
使用acetaminophen做症狀治療
(6)皮膚發癢，關節痛，或遷移性關
節炎
使用antihistmines或NSAIDS
若無效，停用ImmuCyst® ，並投與isoniazide 300mg qd
3months
(7)全身性的BCG反應不具敗血性休
克症候群
停用ImmuCyst® ，尋求傳染病諮詢。
投與isoniazide300mg qd ，RIF 600mg qd and
EMB 1000mg qd 6months
(8)全身性的BCG反應具有敗血性休
克症候群
同(7)
考慮短時間投與高劑量corticosteroids治療
ISONIAZIDE THERAPEUTIC
USES IN MICROMEX
ISONIAZID
• THERAPEUTIC USES
– ACETYLATOR STATUS DETERMINATION
– BLADDER CANCER - PREVENTION OF TOXICITY
–
–
–
–
–
–
–
CEREBELLAR TREMOR
HUNTINGTON'S DISEASE
MULTIPLE SCLEROSIS
MYCOBACTERIAL INFECTIONS - NON-TUBERCULOUS
TUBERCULOSIS - IN HIV-INFECTED PERSONS
TUBERCULOSIS - LATENT
TUBERCULOSIS - PULMONARY
• CLINICAL APPLICATIONS
– THERAPEUTIC USES
• BLADDER CANCER - PREVENTION OF TOXICITY
– 1. OVERVIEW:
FDA APPROVAL: Adult, no; pediatric, no
EFFICACY: Adult, possibly effective
DOCUMENTATION: Adult, poor
– 2. SUMMARY:
Isoniazid maybe useful in reducing local adverse
effects associated with BCG bladder instillations in
patients with superficial bladder cancer .
- Isoniazid administered concomitantly with bladder instillations
of bacillus Calmette-Guerin (BCG) significantly reduced local
BCG-related adverse effects in adult patients with superficial
bladder cancer. In this randomized, prospective, double-blind
study, 160 patients received isoniazid 300 milligrams (mg) or
placebo daily for 3 days after each of 6 consecutive weekly
BCG bladder instillations (81 mg). All patients underwent
transurethral tumor resection or bladder biopsies 1 to 3 weeks
prior to initiating BCG treatment.
- Local effects, including dysuria, hematuria, and increased
micturation frequency, occurred less frequently in isoniazidtreated patients (35% versus 48%, p less than 0.01). This
may be a result of decreased exposure to live bacilli.
- Systemic side effects, such as fever and nausea, were
unaffected by the addition of isoniazid. Treatment withdrawals
due to adverse effects, as well as tumor recurrences over a 2year follow-up period, were not different between groups
(Al Khalifa, 2000).
ISONIAZID MECHANISM OF ACTION
IN MICROMEDEX
-Isoniazid is a synthetic antimycobacterial agent
which is bacteriocidal for both extracellular and
intracellular organisms. The drug is thought to act
by interfering with cell wall mycolic acid synthesis
(AMA, 1986). Isoniazid is the hydrazide derivative
of isonicotinic acid. While isoniazid is bacteriostatic
for "resting bacilli", it is bactericidal for rapidly
dividing organisms. In contrast to streptomycin,
another antitubercular agent, isoniazid penetrates
cells easily and is equally effective against
intracellular bacilli as it is against those growing in
culture media (Mandell & Saude, 1985).
ImmuCyst®(BCG免疫治療劑)所含的為活的減毒的分枝桿菌
故isoniazid可預防及治療BCG免疫治療劑經膀胱灌注所引起的不良反應。
DM
Malignant neoplasm of bladder
11/24 Metformin 500mg/tab
Amoxacillin 500mg/cap
1# PO TID X 7days
1# PO QID X 7days
Bacillus Calmette-Guerin(BCG)81mg/vail 1vial IVCT ST
11/29
Tranexamic acid 250mg/cap
2# PO TID X 3days
Alfuzosin XL 10mg/tab
1# PO HS X 3days
Hematuria
12/3 Tranexamic acid 250mg/cap
Alfuzosin XL 10mg/tab
Amoxacillin 500mg/cap
2# PO TID X 3days
1# PO HS X 3days
1# PO TID X 3days
Hematuria
12/23
Isoniazide100mg/tab
3# QD PO X 7 days
Malignant neoplasm of bladder
Hematuria
泌尿道感染,未標示位置者
12/29
Isoniazide100mg/tab
3# QD
PO X 14 days