門 診疑義 處 方 討 論
Use of Methylphenidate
in Traumatic Brain Injury (TBI)
報告日期：99.3.30
黃信裕 藥師
Content
1. Methylphenidate 之藥理作用
2. Methylphenidate核准之適應症
3. Methylphenidate in TBI之合理性
4. Methylphenidate in TBI之建議劑量
5. Methylphenidate in TBI之證據等級
6. Conclusion
7. References
Methylphenidate 之藥理作用
Mechanism of Action
•CNS stimulant
•Reuptake of Dopamine inhibitor
Challman TD, Lipsky JJ. Methylphenidate: Its Pharmacology and Uses
Mayo Clin Proc. 2000 Jul;75(7):711-21. Review
Methylphenidate核准之適應症
衛生署核准適應症
FDA核准適應症
Methylphenidate in TBI之合理性
What are the most common
problems after a TBI?
Thinking Changes (1)


Attention
 Reduced concentration
 Reduced visual attention
 Inability to divide attention
between competing tasks
Processing speed
 Slow thinking
 Slow reading
 Slow verbal and written responses
Thinking Changes (2)


Communication
 Difficulty finding the right words, naming
objects
 Disorganized in communication
Learning and Memory
 Information before TBI intact
 Reduced ability to remember new
information
 Problems with learning new skills
Methylphenidate in TBI之證據等級
Evidence (I)
FDA Approval: Adult, no;
Pediatric, no
Efficacy: Adult, Evidence favors efficacy;
Pediatric, Evidence favors efficacy
Recommendation: Adult, Class IIb;
Pediatric, Class IIb
Strength of Evidence: Adult, Category B;
Pediatric, Category B
MICROMEDEX(r) Healthcare Series 醫療照護系列資料庫 (Database) Thomson MICROMEDEX
Evidence (II)
Article
EL
Significant improvement
No Significant improvement
Whyte et al.,
1997
I
Speed of information processing
Attentiveness during work task
Caregiver ratings of attention
Sustained attention
Divided attention
Distractibility
Whyte et
al.,2004
I
Speed of mental processing
Distractibility,
Vigilance/sustained attention
Mooney and
Haas, 1993
I
Attention
Kim et al.,
2006
II
Reaction time and accuracy of
Visuospatial attention
Lee et al., 2005
II
Recognition reaction time and daytime alertness (when
compared to sertraline)
Recognition reaction time
(when compared to placebo)
Plenger et al.,
1996
II
Attention span, divided attention and vigilance
(at one month)
Attention span, divided attention
and vigilance (at three months)
Kaelin et al.,
1996
II
Attention span, sustained attention, divided attention
Speech et al.,
1993
II
Gualtieri and
Evans, 1988
II
Grade et al.,
1988
II
Sustained attention
Vigilance, Processing speed
10 subjects – sustained attention,
divided attention, selective attention
5 subjects – no change
Cognitive function
Sivan M et al. Clin Rehabil. 2010 Feb;24(2):110-21
Methylphenidate in TBI之建議劑量
Recommended Dose
1. Enhance attentional function
Dose: 0.25–0.30 mg/kg bid
2. Enhance the speed of cognitive processing
Dose: 0.25–0.30 mg/kg bid
3. Enhance learning and memory
Dose: 0.30 mg/kg bid
4. Improve speed in mental processing
Dose: 0.30 mg/kg bid
Neurobehavioral Guidelines Working Group, Warden DL, Gordon B, McAllister TW,
Silver JM, Barth JT, Bruns J, Drake A, Gentry T, Jagoda A, Katz DI, Kraus J,
Labbate LA, Ryan LM, Sparling MB, Walters B, Whyte J, Zapata A, Zitnay G. Guidelines
for the pharmacologic treatment of neurobehavioral sequelae of traumatic brain injury.
J Neurotrauma. 2006 Oct;23(10):1468-501
醫師開立處方：
Methylphenidate 10mg/tab, 1tab, QD
結果：可能造成改善症狀之劑量不足
?
結論
Methylphenidate用於TBI(創傷性腦損害)
乃屬於合理之治療，因為TBI會造成腦部神經性病變，
如：認知不足、注意力缺乏、記憶力減退…等。
但是衛生署核准之適應症為過動兒症候群及
發作型嗜睡症，若醫師將Methylphenidate用於
器質性腦徵候群或腦震盪後徵候群，需考慮以自費
方式給予。
參考資料
1. Siddall OM. Use of methylphenidate in traumatic brain injury. Ann Pharmacother.
2005 Jul-Aug;39(7-8):1309-13. Epub 2005 May 24. Review.
2. Sivan M, Neumann V, Kent R, Stroud A, Bhakta BB Pharmacotherapy for treatment
of attention deficits after non-progressive acquired brain injury. A systematic
review. Clin Rehabil. 2010 Feb;24(2):110-21.
3. Challman TD, Lipsky JJ. Methylphenidate: its pharmacology and uses. Mayo Clin
Proc. 2000 Jul;75(7):711-21. Review.
4. Neurobehavioral Guidelines Working Group, Warden DL, Gordon B, McAllister TW,
Silver JM, Barth JT, Bruns J, Drake A, Gentry T, Jagoda A, Katz DI, Kraus J,
Labbate LA, Ryan LM, Sparling MB, Walters B, Whyte J, Zapata A, Zitnay G.
Guidelines for the pharmacologic treatment of neurobehavioral sequelae of
traumatic brain injury. J Neurotrauma. 2006 Oct;23(10):1468-501.
5. MICROMEDEX(r) Healthcare Series 醫療照護系列資料庫(Database) Thomson
MICROMEDEX
Thank you for your attention
Background


Deficits in attention are commonly seen in
non-progressive acquired brain injury.
The prevalence of attention deficits even
after mild traumatic brain injury has been
reported to range from 40-60% at 1-3
months post injury
Pierce SR. et al. Arch Phys Med Rehabil 2002
Attention





Focused
Sustained
Divided
Alternating
Selective