发信人: chipmunk (花栗鼠), 信区: Pre_Resident_Club
标 题: Re: 深更半夜写医学八卦：一只拯救人类的蜥蜴
发信站: BBS 未名空间站 (Sat Dec 4 14:29:02 2010, 美东)
Saw one patient a few of weeks ago. A 58 yo M, psychiatrist, with h/o
complicated DM insulin dependent, GERD, presented with recurrent sore throat
, hoarseness, nausea and vomiting. He was initiated with Byetta 5mg SQ Q12h
in July. The dose was increased to 10mg later in September. He never
realized it was his medication's side effect as he responded to the
medication very well. He lost 10+ lbs and his blood sugar was under better
control, bla bla. To me, his symptoms were most likely secondary to his
diabetes associated autonomic neuropathy and gastroparesis caused by Byetta.
Thankfully his diabetes mellitus was still under good control. He did not
develop any glycemia-associated complications.
多谢风MM指点。我可能不应该用gastroparesis来解释byetta的副作用, other meds
may also contribute his symptoms。这个病人是DM type I, on insulin pump since
2005, f/u by his endocrinogist, prolonged GERD on Nexium. 他的主诉听起来象
是nausea and vomiting为主，一个多月内有好几次吐得一整天almost no oral intake
，喉咙也痛，这才来找PCP看的。刚好我在clinic with my preceptor。他本人是本院
的医生，很注意，血糖一直控制得很好，看门诊当天fast glucose才104, 中午210，马
上调insulin pump了。所以一直没想到可能是exenatide的原因。We asked him to
lower his Byetta's dose, 过了一个星期他也没来followup。刚才查了一下他的EMR，
已经三个星期没有任何新的records，I thought his symptoms had been resolved therefore he
didn't show up。He didn't have swallow difficulty. The symptoms seemed to be related to his increased dose of byetta. 当然如果his symptoms persist, he shall get a GI consult for at least a barium swallow test.
Here is side effect of Byetta I found:
Nausea -- occurring in up to 44 percent of people
Hypoglycemia -- up to 35.7 percent
Vomiting -- up to 13 percent
Diarrhea -- up to 13 percent
Feeling jittery -- up to 9 percent
Dizziness -- up to 9 percent
Headache -- up to 9 percent
Upset stomach or heartburn -- up to 6 percent.
Concerns related to adverse effects:
1.Anti-exenatide antibodies: Use may be associated with the development of
anti-exenatide antibodies; low titers are not associated with a loss of
efficacy, however high titers (observed in 6% of patients in clinical
studies) may result in an attenuation of response.
2.GI symptoms: Most common reactions are gastrointestinal related; these
symptoms may be dose-related and may decrease in frequency/severity with
gradual titration and continued use. 3.Pancreatitis: Cases of acute
pancreatitis (including hemorrhagic and necrotizing with some fatalities)
have been reported; monitor for unexplained severe abdominal pain, and if
pancreatitis is suspected, discontinue use. Do not resume unless an
alternative etiology of pancreatitis is confirmed. Consider alternative
antidiabetic therapy in patients with a history of pancreatitis.
4.Weight loss: Use may be associated with weight loss (due to reduced intake
) independent of the change in hemoglobin A1c
Here is his major problem list:
1.diabetes type 1 with insulin pump
5.focal segmental glomerulosclerosis renal disease
1. Neurontin/gabapentin 300 mg 2 tabs oral each am (600 mg total), 3
tablets each evening (900 mg total).
2. Metformin ER 500 mg tabs 2 tablets am, 2 tablets pm (total 2000 mg).
3. NovoLog regular insulin/insulin pump.
4. Advair Diskus 250/50 one puff twice daily (bronchial asthma maintenance).
5. Albuterol 2 puffs q4 hours prn rescue.
6. Plavix 75 mg daily (intolerant to aspirin/NSAIDS).
7. Simvastatin 20 mg each evening.
8. Moexipril 15 mg twice daily.
9. Cozaar 100 mg daily.
10. Nexium as omeprazole 40 mg daily.
11. Clobetasol 0.05% cream twice daily x2 weeks chronic eczema.
12. Triamcinolone acetate cream 0.1% apply twice daily chronic eczema.
13. Cymbalta 120 mg daily.
14. Fluoxetine 40 mg daily.
15. Klonopin 0.5 mg to 1 mg oral at bedtime (chronic stable anxiety).
16. Lumigan eyedrop 1 twice daily both eyes (chronic glaucoma).
17. Cosopt 1 drop both eyes bid.
18. Prednisolone acetate 1 drop both eyes bid.
19. CPAP, obstructive sleep apnea, nightly.
20. Flomax 0.4 mg 2 caplets every evening.
21. Proscar 5 mg daily (Urology 2009).
22. Insulin pump for diabetes.
23. Viagra 100-mg tablet, takes 1/2 tablet to 1 tablet as needed, dispense 6, per Urology.
24. Byetta 5 mcg SQ bid.
【 在 againstwind (逆风而行) 的大作中提到: 】
: byetta的主要副作用是胃不舒服加上腹泻。但是应该不会引起sore throat和
: 50岁的病人，严重的GERD，weight loss，不知道有没有做胃镜，不能完全assume是