คู่มือยาจิตเวช

คู่มือการใช้ยาทางจิตเวช
โรงพยาบาลพระศรีมหาโพธิ์
โดยกลุ่มงานเภสัชกรรม โรงพยาบาลพระศรีมหาโพธิ์
ËÅÑ¡¡ÒÃ·íÒ§Ò¹¢Í§ÊÒÃÊ×èÍ»ÃÐÊÒ·ã¹ÊÁÍ§
ÊÒÃà¤ÁÕã¹ÊÁÍ§ (brain chemicals) ËÁÒÂ¶Ö§ ÊÒÃÊ×èÍ¹íÒ¡ÃÐáÊ»ÃÐÊÒ·
â´Âà»š¹ÊÒÃà¤ÁÕ·Õèà«ÅÅ»ÃÐÊÒ·ÊÃŒÒ§¢Öé¹ÁÒà»š¹Ê‹Ç¹ãËÞ‹ à¾×èÍ·íÒË¹ŒÒ·Õèã¹¡ÒÃãËŒ
¡ÃÐáÊ»ÃÐÊÒ· (ÊÑÞÞÒ³»ÃÐÊÒ·) ¨Ò¡à«ÅÅË¹Öè§¼‹Ò¹ä»ÂÑ§ÍÕ¡à«ÅÅË¹Öè§
ÊÁÍ§à»š¹ÍÇÑÂÇÐÊíÒ¤ÑÞ·ÕèÊØ´ »¡µÔÊÁÍ§à»š¹ÈÙ¹Â¡ÅÒ§¢Í§¤ÇÒÁÃÙŒÊÖ¡ ¹Ö¡¤Ô´
¨íÒ ¡ÒÃÃÙŒàÃ×èÍ§µ‹Ò§ æ ·Õèà¡Ô´¢Öé¹ ÃÇÁ·Ñé§ÊÑè§¡ÒÃãËŒà¡Ô´¡ÒÃ¡ÃÐ·íÒµ‹Ò§ æ ¨Ö§¤ÇÃÃÙŒàÃ×èÍ§
µ‹Ò§ æ ¢Í§ÊÁÍ§à¾×èÍ´ÙáÅÊÁÍ§ãËŒãªŒ§Ò¹ä´Œ´ÕáÅÐ¹Ò¹·ÕèÊØ´
(การเคลื่อนไหว)
(øĆïÙüćöøĎšÿċÖ)
(ÖćøöĂÜđĀĘî)
(ÖćøóĎé)
(Öćøĕéš÷ĉî)
1
ĝ
¤Ù‹Á×Í...¡ÒÃãªŒÂÒ·Ò§¨ÔµàÇª 1
ËÅÑ¡¡ÒÃ·íÒ§Ò¹¢Í§ÊÒÃÊ×èÍ¹íÒ»ÃÐÊÒ·ËÃ×Í
ÊÒÃà¤ÁÕã¹ÊÁÍ§à«ÅÅ»ÃÐÊÒ·»ÅÒÂ·Ò§
(ìĊęđÖĘïÿćøÿČęĂðøąÿćì)
Postsynaptic
(đàúúŤðøąÿćìðúć÷ìćÜ)
(đàúúŤðøąÿćìêšîìćÜ)
Ref: Textbook of Medical Physiology 11th
¡ÒÃ·íÒ§Ò¹¢Í§à«ÅÅ»ÃÐÊÒ·
1. ·íÒãËŒÊÒÁÒÃ¶ÃÑºáÅÐÊ‹§¡ÃÐáÊ»ÃÐÊÒ· (ÊÑÞÞÒ³)
2. Ã‹Ò§¡ÒÂ¨ÐÁÕÃÐºº¤Çº¤ØÁäÁ‹ãËŒÊÒÃ¹ÕéÁÕÁÒ¡à¡Ô¹ä»
3. ÁÕÃÐºº´Ù´ÊÒÃà¤ÁÕ¡ÅÑºÁÒäÇŒ·Õèà«ÅÅ»ÃÐÊÒ·Ê‹Ç¹µŒ¹
«Öè§¨ÐÊÃØ»º·ºÒ·Ë¹ŒÒ·ÕèÊÒÃÊ×èÍ»ÃÐÊÒ· ·Õèà¡ÕèÂÇ¢ŒÍ§¡ÑºÂÒ·Ò§¨ÔµàÇª àª‹¹
Acetylcholine, Norepinephrine, Dopamine, GABA, Serotonin
2 ¤Ù‹Á×Í...¡ÒÃãªŒÂÒ·Ò§¨ÔµàÇª
ࡤࡧࡂ࡫ࡌ࡜
࡫ ࡵ࠻࡜࡬ࡐ$FHW\OFKROLQH
º·ºÒ·ÊÒÃÊ×èÍ»ÃÐÊÒ··ÕèÁÕ¤ÇÒÁÊíÒ¤ÑÞã¹ÊÁÍ§
From: http://dericbownds.net/uploaded_images/synapseLTP.png
1. ÍÐ«ÔµÔÅâ¤ÅÕ¹ (Acetylcholine) Ë¹ŒÒ·Õè¢Í§ÍÐ«ÔµÔÅâ¤ÅÕ¹ (Acetylcholine)

ã¹ÊÁÍ§
1) ¤ÇÒÁ¨íÒ
2) ¡ÃÐºÇ¹¡ÒÃàÃÕÂ¹ÃÙŒ
3) ¤Çº¤ØÁ¾ÄµÔ¡ÃÃÁ
4) ¡ÒÃà¤Å×èÍ¹äËÇ
¶ŒÒÁÕÍÐ«ÔµÔÅâ¤ÅÕ¹ã¹ÃÐ´ÑºµíèÒ·ÕèÊÁÍ§ ¨Ð·íÒãËŒÊÁÒ¸ÔÊÑé¹ ¢ÕéÅ×Á ¤ÇÒÁ¨íÒäÁ‹´Õ
â´Âà©¾ÒÐ¤ÇÒÁ¨íÒÃÐÂÐÊÑé¹ ¹Í¹ËÅÑºäÁ‹Ê¹Ô· â´Âà©¾ÒÐÍÂ‹Ò§ÂÔè§ã¹ÃÐÂÐËÅÑºÅÖ¡
âÃ¤ÊÁÍ§àÊ×èÍÁÍÑÅä«àÁÍÃ ¾ºÇ‹Òã¹ÊÁÍ§¢Í§¼ÙŒ»†ÇÂÍÑÅä«àÁÍÃ ÁÕ»ÃÔÁÒ³¢Í§ÍÐ«ÔµÔÅ
â¤ÅÕ¹Å´Å§¶Ö§ 90%
ࡐࡤ࡚ᕑࡤࡒ
࡫ ࡳᕄ ࡐࡖ࡚࡫ࡐ1RUHSLQHSKULQH
2. ¹ÍÃÍÔ»à¹¿ÃÔ¹ (Norepinephrine)
Ë¹ŒÒ·Õè¢Í§¹ÍÃÍÔ»à¹¿ÃÔ¹·ÕèÊíÒ¤ÑÞã¹ÊÁÍ§
1) à»š¹ÎÍÃâÁ¹áÅÐÊÒÃà¤ÁÕã¹ÊÁÍ§·Õè¡ÃÐµØŒ¹¡ÒÃ·íÒ§Ò¹¢Í§ÃÐºº
»ÃÐÊÒ·ÍÑµâ¹ÁÑµÔ ª¹Ô´«ÔÁ¾Òà¸µÔ¡ à»š¹¼ÅãËŒà¾ÔèÁÍÑµÃÒ¡ÒÃàµŒ¹¢Í§ËÑÇã¨ à¾ÔèÁ¤ÇÒÁ
´Ñ¹âÅËÔµ/àÅ×Í´ä»ÂÑ§¡ÅŒÒÁà¹×éÍ à¾ÔèÁ¡ÅÙâ¤Ê à¾×èÍ¾ÃŒÍÁ·Õè¨ÐÊÙŒËÃ×ÍË¹Õ»˜ÞËÒµ‹Ò§ æ ·Õè
à¡Ô´¢Ö¹é µÍ¹àªŒÒàÁ×Íè µ×¹è ¢Ö¹é ÁÒ µÒä´ŒÃºÑ áÊ§ÊÇ‹Ò§ ¡ç¨Ð¡ÃÐµØ¹Œ ãËŒÃÒ‹ §¡ÒÂÊÃŒÒ§ÎÍÃâÁ¹
¨Ò¡µ‹ÍÁËÁÇ¡äµ ·íÒãËŒ¤ÇÒÁ´Ñ¹âÅËÔµÊÙ§¢Öé¹ µ×è¹µÑÇ ¾ÃŒÍÁ·íÒ¡Ô¨ÇÑµÃ»ÃÐ¨íÒÇÑ¹ ¼ÙŒ·Õè
à»š¹¤ÇÒÁ´Ñ¹âÅËÔµÊÙ§ ¤ÇÒÁ´Ñ¹ÁÑ¡¨Ð¢Ö¹é ÊÙ§ã¹ª‹Ç§àªŒÒ ¨Ö§¤ÇÃÇÑ´¤ÇÒÁ´Ñ¹µÍ¹µ×¹è ¹Í¹
à¾×èÍ»ÃÑºÂÒ
2) ¡ÒÃ¤Çº¤ØÁ¤ÇÒÁµ×¹è µÑÇ ¤ÇÒÁ¨íÒ áÅÐ¡ÒÃàÃÕÂ¹ÃÙŒ ¶ŒÒ¢Ò´¹ÍÃÍ»Ô à ¹¿
ÃÔ¹ÍÒ¨à¡Ô´¤ÇÒÁäÁ‹µ×è¹µÑÇ ¤ÇÒÁ¨íÒáÅÐ¡ÒÃàÃÕÂ¹ÃÙŒÅ´Å§ ÍÒ¨à¡Ô´âÃ¤«ÖÁàÈÃŒÒ
3. â´»ÒÁÕ¹ (Dopamine)

From: http://www.unifr.ch/biochem/assets/images/dreyer/research/kandelda.jpg
Ë¹ŒÒ·Õè¢Í§â´»ÒÁÕ¹ã¹ Dopamine pathway ·ÕèÊÁÍ§
1) Mesolimbic pathway : ËÒ¡ÁÕ Dopamine ã¹ÊÁÍ§Ê‹Ç¹¹ÕéÁÒ¡¡Ç‹Ò
»¡µÔ ¨Ðà¡Ô´ÍÒ¡ÒÃ´ŒÒ¹ºÇ¡ ¢Í§âÃ¤¨ÔµàÀ·
2) Mesocortical pathway : ËÒ¡ÁÕ Dopamine ã¹ÊÁÍ§Ê‹Ç¹¹Õé¹ŒÍÂ¡Ç‹Ò
»¡µÔ ¨Ðà¡Ô´ÍÒ¡ÒÃ´ŒÒ¹Åº ¢Í§âÃ¤¨ÔµàÀ· áÅÐÁÕ»˜ÞËÒ´ŒÒ¹ÊÁÒ¸Ô ¤ÇÒÁ¨íÒ
3) Nigrostriatal pathway : ËÒ¡ÁÕ Dopamine ã¹ÊÁÍ§Ê‹Ç¹¹Õé¹ŒÍÂ¡Ç‹Ò
»¡µÔ ¨Ðà¡Ô´ Extrapyramidal symptom (EPS)
4) Tuberoinfundibular pathway : ËÒ¡ÁÕ Dopamine ã¹ÊÁÍ§Ê‹Ç¹¹Õé
¹ŒÍÂ¡Ç‹Ò»¡µÔ ¨Ð·íÒãËŒ prolactin ËÅÑè§à¾ÔèÁÁÒ¡¢Öé¹ Ê‹§¼ÅãËŒ¹éíÒ¹ÁäËÅ »ÃÐ¨íÒà´×Í¹
äÁ‹ÁÒ Ë¹ŒÒÍ¡âµã¹¼ÙŒªÒÂ
4. ¡ÒºÒ (GABA, gammabutyric acid)
¡ÒºÒ à»š¹ÊÒÃÊ×èÍ»ÃÐÊÒ·ª¹Ô´ÍÍ¡Ä·¸ÔìÂÑºÂÑé§¡ÃÐáÊ (ÊÑÞÞÒ³) »ÃÐÊÒ·
·Õè¼‹Ò¹ºÃÔàÇ³àª×èÍÁµ‹ÍÃÐËÇ‹Ò§à«ÅÅ»ÃÐÊÒ· ¨Ö§·íÒãËŒ¡ÃÐáÊ»ÃÐÊÒ·¼‹Ò¹ä´Œ¹ŒÍÂÅ§
Ref: Essentials of Anatomy and Physiology

Ë¹ŒÒ·Õè¢Í§¡ÒºÒ
1) ÊÒÃÂÑºÂÑ§é (inhibitor) à¾×Íè ÃÑ¡ÉÒÊÁ´ØÅã¹ÊÁÍ§·Õäè ´ŒÃºÑ ¡ÒÃ¡ÃÐµØ¹Œ ·íÒãËŒ
¼‹Í¹¤ÅÒÂáÅÐËÅÑºÊºÒÂ
2) ª‹ÇÂ¡ÃÐµØŒ¹µ‹ÍÁäÃŒ·‹Í (anterior pituitary) ·Õè¼ÅÔµÎÍÃâÁ¹·Õèª‹ÇÂã¹¡ÒÃ
à¨ÃÔÞàµÔºâµ (growth hormone) ·íÒãËŒÊÃŒÒ§à¹×éÍàÂ×èÍ ¡ÅŒÒÁà¹×éÍ¡ÃÐªÑº »‡Í§¡Ñ¹¡ÒÃ
ÊÐÊÁä¢ÁÑ¹
5. ࡂ࡬«Õࡵâ࡚ࡵࡎࡐ࡫
Ãâ·¹Ô¹ࡐ6HURWRQLQ
(Serotonin)
Ë¹ŒÒ·Õè¢Í§«ÕâÃâ·¹Ô¹
ÊÒÃáË‹§¤ÇÒÁÊØ¢ª‹ÇÂãËŒ¤Ô´ã¹á§‹´Õ ã¨Ê§º ÁÕÍÒÃÁ³´Õ ¼‹Í¹¤ÅÒÂ â¡Ã¸/
¡ŒÒÇÃŒÒÇÂÒ¡¢Öé¹ ËÅÑº§‹ÒÂ/ÊºÒÂ ·Ò¹ÍÒËÒÃä´Œ
From: http://www.cmaj.ca/content/180/3/305/F1.large.jpg
ÍÒ¡ÒÃ¢Í§¡ÒÃÁÕ«ÕâÃâ·¹Ô¹¹ŒÍÂ
«ÖÁàÈÃŒÒ ¡Ñ§ÇÅ ÂéíÒ¤Ô´ ¡ÅÑÇ ¤Ô´á§‹äÁ‹´Õ Ë§Ø´Ë§Ô´ äÁ‹Í´·¹ ¤Ô´¦‹ÒµÑÇµÒÂ
¤ÇÒÁàª×èÍÁÑè¹Å´Å§ â¡Ã¸§‹ÒÂ ¡ŒÒÇÃŒÒÇ ¹Í¹äÁ‹ËÅÑº ËÅÑºµ×é¹
ÍÒ¡ÒÃ¢Í§¡ÒÃÁÕ«ÕâÃâ·¹Ô¹ÁÒ¡
âÃ¤¨Ôµ âÃ¤¨ÔµàÀ· ºŒÒ¤ÅÑè§ ÍÒÃÁ³¼Ô´»¡µÔ á»Ã»ÃÇ¹ »˜ÞÞÒÍ‹Í¹ã¹à´ç¡
ÍÍµÔÊµÔ¡ (self-centered or self-focused mental state with no basis in
reality) ÍÑÅä«ÁàÁÍÃ à»š¹µŒ¹
ÂÒ·Ò§¨ÔµàÇª
¨íÒá¹¡à»š¹ 4 ¡ÅØ‹Á
1. ÂÒÃÑ¡ÉÒâÃ¤¨Ôµ (Antipsychotic Drugs)
2. ÂÒÃÑ¡ÉÒÍÒ¡ÒÃàÈÃŒÒ (Antidepressant Drugs)
3. ÂÒ·íÒãËŒÍÒÃÁ³¤§·Õè (Mood Stabilizers)
4. ÂÒ¤ÅÒÂ¡Ñ§ÇÅ (Antianxiety Drugs)
áÁŒÇ‹ÒÂÒ·Ò§¨ÔµàÇªáµ‹ÅÐ¡ÅØ‹Á¨ÐÁÕÄ·¸Ôìã¹¡ÒÃÃÑ¡ÉÒáµ¡µ‹Ò§¡Ñ¹ áµ‹¨ÐÁÕ¼Å
¢ŒÒ§à¤ÕÂ§¤ÅŒÒÂ æ ¡Ñ¹ àÁ×èÍÁÕ¡ÒÃ¨Ñº·Õè receptor à´ÕÂÇ¡Ñ¹ áÅÐ¼Å¢Öé¹ÍÂÙ‹¡Ñº¡ÒÃÍÍ¡
Ä·¸Ôì·Õè receptor ª¹Ô´µ‹Ò§ æ
¡ÒÃÍÍ¡Ä·¸Ôì¢Í§ÂÒ¨ÔµàÇª
¼Å¢Í§ÂÒ·Ò§¨ÔµàÇª (+) ËÁÒÂ¶Ö§ ¼Å´Õ, (-) ËÁÒÂ¶Ö§ ¼ÅàÊÕÂËÃ×ÍÍÒ¡ÒÃ¢ŒÒ§à¤ÕÂ§
Dopaminergic Receptors (D)

¡ÒÃ»´¡Ñé¹ dopamine D2 receptors
(+) Å´ÍÒ¡ÒÃâÃ¤¨Ôµª¹Ô´ºÇ¡ (positive psychotic symptoms) àª‹¹ ¡ÒÃ
ËÅ§¼Ô´, »ÃÐÊÒ·ËÅÍ¹, ËÙáÇ‹Ç (¼‹Ò¹ mesolimbic pathway)
(-) extrapyramidal side effects : dystonia, parkinsonism, akathisia
áÅÐ tardive dyskinesia (¼‹Ò¹ nigrostriatal pathway)
(-) ¼Åµ‹ÍÃÐººµ‹ÍÁäÃŒ·‹Í : ¡ÒÃà¾ÔèÁ¢Öé¹¢Í§ prolactin ·íÒãËŒà¡Ô´ÍÒ¡ÒÃ
¹éÒí ¹ÁäËÅ, àµŒÒ¹Áâµ, »ÃÐ¨íÒà´×Í¹ÁÒäÁ‹ÊÁèÒí àÊÁÍ áÅÐ¡ÒÃàÊ×Íè ÁÊÁÃÃ¶ÀÒ¾·Ò§à¾È
(¼‹Ò¹ tuberoinfundibular pathway)
Adrenergic Receptors (Ad.)
¡ÒÃ»´¡Ñé¹ alpha 1 - adrenergic receptors
(-) ¤ÇÒÁ´Ñ¹âÅËÔµÅ´Å§, ÁÖ¹ÈÕÃÉÐ, §‹Ç§¹Í¹ áÅÐ reflex tachycardia
¡ÒÃ»´¡Ñé¹ alpha2 -adrenergic receptors
(+) Å´ÍÒ¡ÒÃ«ÖÁàÈÃŒÒ
(-) priapism (ÍÇÑÂÇÐà¾ÈªÒÂá¢ç§µÑÇµÅÍ´àÇÅÒ ·íÒãËŒÁÕÍÒ¡ÒÃà¨çº»Ç´)
(-) »´¡Ñ¹é ¡ÒÃÍÍ¡Ä·¸Ô¢ì Í§ÂÒÅ´¤ÇÒÁ´Ñ¹âÅËÔµ àª‹¹ Clonidine hydrochlo-
ride, guanabenz acetate, Methyldopa
Cholinergic Receptors
¡ÒÃ»´¡Ñé¹ muscarinic M1 receptors
(+) Å´ÍÒ¡ÒÃ extrapyramidal side effects
(-) peripheral antimuscarinic effects : µÒ¾Ã‹Ò, ¡ÒÃ¡íÒàÃÔº¢Í§âÃ¤µŒÍËÔ¹
ª¹Ô´ÁØÁ»´ (narrow angle glaucoma), »Ò¡áËŒ§, ËÑÇã¨àµŒ¹àÃçÇ, ·ŒÍ§¼Ù¡ áÅÐ
»˜ÊÊÒÇÐ¤Ñè§
(-) central antimuscarinic effects : ¤ÇÒÁ¨íÒ (cognition) àÊ×èÍÁ
Histaminergic Receptors
¡ÒÃ»´¡Ñé¹ histaminergic H1 Receptors
(+) §‹Ç§¹Í¹ (sedation)
(-) §‹Ç§¹Í¹, ¹éíÒË¹Ñ¡à¾ÔèÁ áÅÐàÊÃÔÁÄ·¸ÔìÂÒ¡´»ÃÐÊÒ·Ê‹Ç¹¡ÅÒ§ (central
nervous system depressants)
¡ÒÃ»´¡Ñé¹ histaminergic H2 Receptors
(+) Å´¡ÒÃËÅÑè§¡Ã´ã¹¡ÃÐà¾ÒÐÍÒËÒÃ
Serotonergic Receptors (5-HT)
¡ÒÃ»´¡Ñé¹µÑÇ serotonin 5 -HT2A receptors
(+) Å´ÍÒ¡ÒÃâÃ¤¨Ôµª¹Ô´Åº (negative psychotic symptoms) àª‹¹
ÍÒÃÁ³·×èÍ (blunted affect), ¡ÒÃáÂ¡µÑÇ¨Ò¡ÊÑ§¤Á
(+) Å´ÍÒ¡ÒÃ extrapyramidal side effects
(-) §‹Ç§¹Í¹ áÅÐÍ‹Í¹à»ÅÕéÂ (asthenia)
¡ÒÃ¡ÃÐµØŒ¹ serotonin 5 -HT1A receptors
(+) Å´ÍÒ¡ÒÃ«ÖÁàÈÃŒÒ
(+) Å´ÍÒ¡ÒÃÂéíÒ¤Ô´ (obsession) áÅÐÂéíÒ·íÒ (compulsion)
(+) Å´ÍÒ¡ÒÃµ×è¹µÃÐË¹¡ (panic) áÅÐ¡ÒÃ¡ÅÑÇÊÑ§¤Á (social phobia)
(+) Å´ÍÒ¡ÒÃËÔÇäÁ‹ËÒÂ (bulimia)
¡ÒÃ¡ÃÐµØŒ¹ serotonin 5 -HT1D receptors
(+) Å´ÍÒ¡ÒÃäÁà¡Ã¹ (antimigraine actions) ¡ÒÃ¡ÃÐµØŒ¹ serotonin
5-HT2 receptors
(-) ÀÒÇÐ¡ÒÂã¨äÁ‹Ê§º (agitation), ÃÙŒÊÖ¡äÁ‹ÊºÒÂ·Õè¡ÅŒÒÁà¹×éÍ (akathisia),
ÇÔµ¡¡Ñ§ÇÅ, ÍÒ¡ÒÃµ×è¹µÃÐË¹¡ (panic attacks), ¹Í¹äÁ‹ËÅÑº áÅÐ¡ÒÃàÊ×èÍÁ
ÊÁÃÃ¶ÀÒ¾·Ò§à¾È
¡ÒÃ¡ÃÐµØŒ¹ serotonin 5 -HT3 receptors
(-) ¤Å×è¹äÊŒ, ·ŒÍ§äÊŒ»˜›¹»†Ç¹ (gastrointestinal distress), ·ŒÍ§à´Ô¹ áÅÐ
»Ç´ÈÕÃÉÐ
ÂÒÃÑ¡ÉÒâÃ¤¨Ôµ (Antipsychotics, Neuroleptic, Major tranquilizers)

¡ÒÃ¾Ñ²¹ÒÂÒÃÑ¡ÉÒâÃ¤¨Ôµ ÁÕ·ÁÕè Ò¨Ò¡ÊÁÁµÔ°Ò¹¡ÒÃà¡Ô´âÃ¤·Õàè ª×Íè Ç‹ÒâÃ¤¨ÔµàÀ·
à¡ÕèÂÇ¢ŒÍ§¡ÑºÊÒÃªÕÇà¤ÁÕã¹ÊÁÍ§ËÃ×ÍÊÒÃÊ×èÍ»ÃÐÊÒ· (neurotransmitter) â´Â
ÊÁÁµÔ°Ò¹·Õèà»š¹·ÕèÂÍÁÃÑºã¹»˜¨¨ØºÑ¹ ÁÕ´Ñ§¹Õé
1. ÊÁÁµÔ°Ò¹·Õèà¡ÕèÂÇ¢ŒÍ§¡Ñº dopamine àª×èÍÇ‹Òà¡Ô´¨Ò¡¡ÒÃà¾ÔèÁ¢Öé¹¢Í§
dopaminergic activity ·Õè Ê ÁÍ§Ê‹ Ç ¹ mesolimbic áÅÐ ¡ÒÃÅ´Å§¢Í§
dopaminergic activity ·ÕèÊÁÍ§Ê‹Ç¹ mesocortical ¹íÒä»ÊÙ‹¡ÒÃ¾Ñ²¹ÒÂÒÃÑ¡ÉÒ
âÃ¤¨ÔµÃØ‹¹áÃ¡ (first generation, typical, conventional antipsychotics) ·ÕèÁÕÄ·¸Ôì
»´¡Ñé¹ dopamine receptors (dopamine receptor antagonists) à»š¹ËÅÑ¡ àª‹¹
Haloperidol, Perphenazine, CPZ à»š¹µŒ¹
2. ÊÁÁµÔ°Ò¹·Õèà¡ÕèÂÇ¢ŒÍ§¡Ñº serotonin ¾ºÇ‹ÒÁÕ¡ÒÃ·íÒ§Ò¹·ÕèÅ´Å§¢Í§
serotonin-2 receptor (5-HT2A) ã¹ÊÁÍ§Ê‹Ç¹ frontal cortex ¢Í§¼ÙŒ»†ÇÂ¨ÔµàÀ·
¹íÒä»ÊÙ¡‹ ÒÃ¾Ñ²¹ÒÂÒÃÑ¡ÉÒâÃ¤¨ÔµÃØ¹‹ ãËÁ‹·ÍÕè Í¡Ä·¸Ôàì ¡ÕÂè Ç¢ŒÍ§¡ÑºÃÐºº serotonin ´ŒÇÂ
â´ÂÂÒ¡ÅØ‹ÁãËÁ‹¹Õé¨Ð¶Ù¡àÃÕÂ¡Ç‹Ò¡ÅØ‹Á serotonin-dopamine antagonists (SDAs)
ËÃ×Í second generation ËÃ×Í atypical antipsychotics àª‹¹ Risperidone,
Clozapine, Quetiapine à»š¹µŒ¹
3. ÊÁÁµÔ°Ò¹·Õèà¡ÕèÂÇ¢ŒÍ§¡Ñº glutamate ¡ÒÃÈÖ¡ÉÒã¹ÃÐÂÐËÅÑ§¾ºÇ‹Ò
N-methyl-D-aspartic acid (NMDA) receptor «Öè§à»š¹ receptor ¢Í§ gluta-
mate àÁ×èÍ¶Ù¡ÂÑºÂÑé§ ¨Ð·íÒãËŒ glutamatergic neurotransmission Å´Å§ ¨Ðà¡Ô´
ÍÒ¡ÒÃ·Ò§¨ÔµàËÁ×Í¹·Õè¾ºã¹âÃ¤¨ÔµàÀ· ÃÇÁ·Ñé§ÂÑ§¾ºÍÒ¡ÒÃ´ŒÒ¹Åº áÅÐ cognitive
dysfunction ´ŒÇÂ

áÊ´§ dopamine pathway áÅÐ serotonin pathway ã¹ÊÁÍ§
ࡴࡡࡋ࠾GRSDPLQHSDWKZD\ࡴ࡜ࡧVHURWRQLQSDWKZD\ࡶࡐࡡࡘࡤ࠾
ÂÒÃÑ¡ÉÒâÃ¤¨Ôµ áº‹§ÍÍ¡à»š¹ 2 ¡ÅØ‹Á ´Ñ§¹Õé
1. ÂÒÃÑ¡ÉÒâÃ¤¨ÔµÃØ‹¹áÃ¡, ¡ÅØ‹Á´Ñé§à´ÔÁ (First generations, Conventional,
Typical Antipsychotics)
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2. ÂÒÃÑ¡ÉÒâÃ¤¨ÔµÃØ¹‹ ãËÁ‹ (Second generations, Atypical Antipsychotics)
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1.1 Mesolimbic pathway ¡ÒÃÁÕ dopamine hyperactivity ã¹ÊÁÍ§
Ê‹Ç¹¹Õé (Dopamine à¾ÔèÁ¢Öé¹) ·íÒãËŒà¡Ô´ÍÒ¡ÒÃ·Ò§¨Ôµ ¡ÒÃ»´¡Ñé¹ dopamine ã¹Ê‹Ç¹
¹Õé ¨ÐÃÑ¡ÉÒÍÒ¡ÒÃ·Ò§¨Ôµª¹Ô´ positive symptoms
1.2 Mesocortical pathway à¡ÕèÂÇ¢ŒÍ§¡Ñº attention, motivation, prob-
lem solving ability áÅÐ executive planning áÅÐ ÁÕ¤ÇÒÁÊÑÁ¾Ñ¹¸¡Ñº¤ÇÒÁ¼Ô´
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»¡µÔ¢Í§¤ÇÒÁ¤Ô´ áÅÐÍÒÃÁ³ ¡ÒÃ»´¡Ñé¹ dopamine ã¹Ê‹Ç¹¹Õé (Dopamine Å´
Å§) ·íÒãËŒà¡Ô´ÍÒ¡ÒÃ·Ò§¨Ôµª¹Ô´ negative symptom áÅÐÊ‹§¼Åµ‹Í cognitive
function ¢Í§¼ÙŒ»†ÇÂáÂ‹Å§
1.3 Nigrostriatal pathway à¡ÕèÂÇ¢ŒÍ§¡Ñº motor activity, muscle tone
¡ÒÃ»´¡Ñé¹ dopamine ã¹Ê‹Ç¹¹Õé (Dopamine Å´Å§) ·íÒãËŒà¡Ô´¼Å¢ŒÒ§à¤ÕÂ§¤ÅŒÒÂ
âÃ¤ Parkinson’s disease ¤×Í ÁÕ extrapyramidal symptoms (EPS)
1.4 Tuberoinfundibular pathway à¡ÕèÂÇ¢ŒÍ§¡Ñº¡ÒÃ¤Çº¤ØÁ¡ÒÃËÅÑè§
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Prolactin ¡ÒÃ»´¡Ñé¹ dopamine ã¹Ê‹Ç¹¹Õé (Dopamine Å´Å§) ·íÒãËŒà¡Ô´¡ÒÃËÅÑè§
¢Í§ prolactin à¾ÔèÁ¢Öé¹ à¡Ô´¼Å¢ŒÒ§à¤ÕÂ§¤×Í ÁÕ¹íÒé ¹ÁËÅÑè§ÁÒ¡¢Öé¹ (galactorrhea)
áÅÐË¹ŒÒÍ¡âµ (gynecomastia)
ÂÒ¨ÐÁÕ»ÃÐÊÔ·¸ÔÀÒ¾ã¹¡ÒÃÃÑ¡ÉÒ àÁ×èÍÁÕ¡ÒÃ¨Ñº¡Ñº D2 receptor ã¹ÊÁÍ§
»ÃÐÁÒ³ ÃŒÍÂÅÐ 60-80 ¡ÒÃä´ŒÃºÑ ÂÒ·Õàè ¡Ô¹¡Ç‹Ò¹Õ¨é Ð·íÒãËŒà¡Ô´¼Å¢ŒÒ§à¤ÕÂ§ ´Ñ§¹Ñ¹é ËÒ¡
¾º¼Ù»Œ Ç† Â·ÕÁè ÍÕ Ò¡ÒÃ¢ŒÒ§à¤ÕÂ§¨Ò¡¡ÒÃãªŒÂÒÃÑ¡ÉÒâÃ¤¨ÔµáÊ´§Ç‹Ò¼Ù»Œ Ç† Âä´ŒÃºÑ ÂÒÁÒ¡à¡Ô¹
ÃÐ´Ñº·ÕèãªŒÃÑ¡ÉÒ
• Ä·¸Ôì»´¡Ñé¹ histamine receptor ÁÕ¼ÅãËŒ§‹Ç§«ÖÁ à¨ÃÔÞÍÒËÒÃ ¹éíÒË¹Ñ¡
µÑÇà¾ÔèÁ
• Ä·¸Ôì»´¡Ñé¹ alpha-1-adrenergic receptor ·íÒãËŒà¡Ô´ orthostatic
hypotension (postural hypotension)
• Ä·¸Ôì»´¡Ñé¹ muscarinic cholinergic receptor ·íÒãËŒà¡Ô´Ä·¸Ôì¢Í§
Anticholinergic ä´Œá¡‹ »Ò¡áËŒ§ ¤ÍáËŒ§ µÒ¾Ã‹Ò ·ŒÍ§¼Ù¡ »˜ÊÊÒÇÐ¤Ñè§
¡ÒÃ¨Ñ´»ÃÐàÀ·¢Í§ÂÒÃÑ¡ÉÒâÃ¤¨ÔµÃØ‹¹áÃ¡µÒÁ¤ÇÒÁáÃ§ (Potency)
1. ÂÒÃÑ¡ÉÒâÃ¤¨Ôµª¹Ô´¤ÇÒÁáÃ§ÊÙ§ (high potency antipsychotic drugs)
àª‹¹ Haloperidol, Trifluoperazine, Fluphenazine, Flupenthixol, Pimozide
à»š¹µŒ¹
2. ÂÒÃÑ¡ÉÒâÃ¤¨Ôµª¹Ô´¤ÇÒÁáÃ§»Ò¹¡ÅÒ§ (medium potency antipsy-
chotic drugs) àª‹¹ Perphenazine, Zuclopenthixol à»š¹µŒ¹
3. ÂÒÃÑ¡ÉÒâÃ¤¨Ôµª¹Ô´¤ÇÒÁáÃ§µèÒí (low potency antipsychotic drugs)
àª‹¹ Chlorpromazine, Thioridazine à»š¹µŒ¹
µÒÃÒ§·Õè 1 áÊ´§ÂÒÃÑ¡ÉÒâÃ¤¨ÔµÃØ‹¹áÃ¡µÒÁ potency
áÅÐ¢¹Ò´ã¹¡ÒÃÃÑ¡ÉÒ ·ÕèÁÕ¨íÒË¹‹ÒÂã¹»ÃÐà·Èä·Â
¢¹Ò´·ÕèãËŒÄ·¸Ôìã¡ÅŒà¤ÕÂ§¡Ñ¹ ¢¹Ò´ã¹¡ÒÃÃÑ¡ÉÒ ¢¹Ò´ÊÙ§ÊØ´
ª×èÍÂÒ ª×èÍÂÒµŒ¹áºº
(equivalent dose, Á¡.) (Á¡./ÇÑ¹) (Á¡./ÇÑ¹)
High Potency
Haloperidol, Oral: Hadol® 2-5 Oral : 5-20 Oral : 30
Haloperidol Inj. : Halodec® Inj. : 50-100
decanoate ·Ø¡ 4 ÊÑ»´ÒË
Pimozide Orap® 1-2 1-10 20
Trifluoperazine Stelazine® 5 5-30 40
Fluphenazine Inj. : Modecate® 2 Inj. : 25-100
decanoate ·Ø¡ 2-4 ÊÑ»´ÒË
Flupenthixol Inj : Fluanxol depot® 2 Inj. : 20-80
decanoate ·Ø¡ 2-4 ÊÑ»´ÒË
Medium Potency
Perphenazine Trilafon® 10 2-64 64
Zuclopenthixol Inj : Clopixol depot® 60 Inj. : 100-600
·Ø¡ 2-4 ÊÑ»´ÒË
Low Potency
Chlorpromazine Largactil® 100 200-600 1000
Thioridazine Melleril® 100 200-600 1000
¼Å¢ŒÒ§à¤ÕÂ§¨Ò¡ÂÒÃÑ¡ÉÒâÃ¤¨ÔµÃØ‹¹áÃ¡
ÂÒÁÕ»ÃÐÊÔ·¸ÔÀÒ¾ã¹¡ÒÃÃÑ¡ÉÒÍÒ¡ÒÃ·Ò§¨Ôµä´ŒäÁ‹áµ¡µ‹Ò§¡Ñ¹ áµ‹à¹×Íè §¨Ò¡ÂÒ
äÁ‹ä´ŒÍÍ¡Ä·¸Ôì»´¡Ñé¹à©¾ÒÐ dopamine receptor à·‹Ò¹Ñé¹ áµ‹ÂÒÂÑ§ÍÍ¡Ä·¸Ôì»´¡Ñé¹
receptor ª¹Ô´Í×è¹ æ ·íÒãËŒà¡Ô´¼Å¢ŒÒ§à¤ÕÂ§ «Öè§ÂÒáµ‹ÅÐµÑÇÁÕ¤ÇÒÁáÃ§ã¹¡ÒÃ»´¡Ñé¹
receptor ä´ŒÁÒ¡¹ŒÍÂáµ¡µ‹Ò§¡Ñ¹
â´ÂÂÒ¡ÅØ‹Á High potency ¨Ð·íÒãËŒà¡Ô´¼Å¢ŒÒ§à¤ÕÂ§ EPS ä´ŒÊÙ§¡Ç‹Ò áµ‹
¼Å¢ŒÒ§à¤ÕÂ§ anticholinergic áÅÐ sedative µèíÒ¡Ç‹Ò¡ÅØ‹Á low potency ã¹·Ò§
µÃ§¡Ñ¹¢ŒÒÁ ¡ÅØ‹Á low potency áÁŒ·íÒãËŒà¡Ô´ EPS ä´ŒµèíÒ¡Ç‹Ò áµ‹¼Å¢ŒÒ§à¤ÕÂ§
anticholinergic áÅÐ sedative ¨ÐÊÙ§¡Ç‹Ò
µÒÃÒ§·Õè 2 à»ÃÕÂºà·ÕÂº¼Å¢ŒÒ§à¤ÕÂ§¢Í§ÂÒÃÑ¡ÉÒâÃ¤¨ÔµÃØ‹¹áÃ¡
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Sedative Anticholinergic Hypotensive Extrapyramidal
Potency Drugs
Effect effect effect effect
Chlorpromazine +++ +++ +++ ++
Low
Thioridazine +++ ++ ++ +
Perphenazine ++ + + ++
Moderate
Zuclopenthixol +++ ++ + +++
Trifluoperazine + + + +++
Fluphenazine + + + +++
High
Flupenthixol + ++ + ++
Haloperidol + + + +++
+++ ËÁÒÂ¶Ö§ ÊÙ§, ++ ËÁÒÂ¶Ö§ »Ò¹¡ÅÒ§, + ËÁÒÂ¶Ö§ µèíÒ
â´Â¼Å¢ŒÒ§à¤ÕÂ§·Õè¾ºä´Œº‹ÍÂä´Œá¡‹
1. Anticholinergic effect
- Ä·¸Ôì»´¡Ñé¹ muscarinic cholinergic receptor ·íÒãËŒà¡Ô´¼Å
¢ŒÒ§à¤ÕÂ§ª¹Ô´ anticholinergic
- ÍÒ¡ÒÃ ä´Œá¡‹ »Ò¡áËŒ§ µÒ¾Ã‹Ò ·ŒÍ§¼Ù¡ »˜ÊÊÒÇÐ¤Ñè§ sinus
tachycardia áÅÐÍÒ¨·íÒãËŒà¡Ô´ÍÒ¡ÒÃÊÑºÊ¹ (confusion) ä´Œ
- Chlorpromazine áÅÐ Thioridazine ã¹¡ÅØÁ‹ low potency ·íÒãËŒ
à¡Ô´¼Å¢ŒÒ§à¤ÕÂ§¹ÕéÊÙ§·ÕèÊØ´àÁ×èÍà·ÕÂº¡ÑºÂÒÃÑ¡ÉÒâÃ¤¨ÔµÃØ‹¹áÃ¡µÑÇÍ×è¹
- ¡ÒÃá¡Œä¢ ËÒ¡¼Å¢ŒÒ§à¤ÕÂ§¹ÕéÃØ¹áÃ§ ÍÒ¨µŒÍ§¾Ô¨ÒÃ³ÒÅ´¢¹Ò´ÂÒ
ËÃ×Íà»ÅÕèÂ¹ÂÒµÑÇãËÁ‹
- ¤íÒá¹Ð¹íÒÊíÒËÃÑº¼ÙŒ»†ÇÂ ÍÒ¡ÒÃ»Ò¡áËŒ§¤ÍáËŒ§ ÊÒÁÒÃ¶ºÃÃà·Ò
ä´Œ´ŒÇÂ¡ÒÃ¨Ôº¹éíÒº‹ÍÂ æ ËÒ¡ÁÕÍÒ¡ÒÃ»˜ÊÊÒÇÐÅíÒºÒ¡ µŒÍ§¾Ô¨ÒÃ³ÒÊÒàËµØÍ×è¹Ã‹ÇÁ
´ŒÇÂ àª‹¹ ¡ÃÐà¾ÒÐ»˜ÊÊÒÇÐÍÑ¡àÊº ËÃ×Í»ÃÐÇÑµÔà¨çº»†ÇÂ·Ò§¡ÒÂÍ×è¹
2. Sedative
- Ä·¸Ôì»´¡Ñé¹ Adrenergic áÅÐ histaminergic receptors ÂÒ
Chlorpromazine áÅÐ Thioridazine ·Õè¨Ñ´ÍÂÙ‹ã¹¡ÅØ‹Á low potency ·íÒãËŒà¡Ô´¼Å
¢ŒÒ§à¤ÕÂ§¹ÕéÊÙ§àÁ×èÍà·ÕÂº¡ÑºÂÒÃÑ¡ÉÒâÃ¤¨ÔµÃØ‹¹áÃ¡µÑÇÍ×è¹
- ÍÒ¡ÒÃ§‹Ç§«ÖÁÁÑ¡à»š¹ÁÒ¡ã¹ª‹Ç§µŒ¹¢Í§¡ÒÃÃÑ¡ÉÒáÅÐ¨Ð¤‹ÍÂ æ ´Õ
¢Öé¹àÁ×èÍä´ŒÃÑºÂÒµ‹Íà¹×èÍ§
- ¡ÒÃá¡Œä¢ ËÒ¡ÍÒ¡ÒÃ§‹Ç§«ÖÁäÁ‹´¢Õ ¹Öé ÍÒ¨¾Ô¨ÒÃ³ÒÅ´¢¹Ò´ÂÒ ËÃ×Í
»ÃÑºÁ×éÍÂÒ
- ¤íÒá¹Ð¹íÒÊíÒËÃÑº¼ÙŒ»†ÇÂ ÍÒ¡ÒÃ§‹Ç§«ÖÁ¨Ð¤‹ÍÂ æ ´Õ¢Öé¹àÁ×èÍä´ŒÃÑºÂÒ
µ‹Íà¹×èÍ§
3. Extrapyramidal
- Ä·¸Ôì»´¡Ñé¹ dopamine receptors ·Õè nigrostriatal pathway «Öè§
ÂÒ·ÕèÍÍ¡Ä·¸Ôì»´¡Ñé¹ä´ŒáÃ§ ¨Ð·íÒãËŒà¡Ô´¼Å¢ŒÒ§à¤ÕÂ§ª¹Ô´ extrapyramidal ä´ŒÁÒ¡
- ÂÒÃÑ¡ÉÒâÃ¤¨ÔµÃØ¹‹ áÃ¡¡ÅØÁ‹ High potency àª‹¹ Haloperidol áÅÐ
Trifluoperazine ¨Ðà¡Ô´¼Å¢ŒÒ§à¤ÕÂ§¹ÕéÊÙ§àÁ×èÍà·ÕÂº¡ÑºÂÒÃÑ¡ÉÒâÃ¤¨ÔµÃØ‹¹áÃ¡µÑÇÍ×è¹
¼Å¢ŒÒ§à¤ÕÂ§ã¹¡ÅØ‹Á extrapyramidal »ÃÐ¡Íº´ŒÇÂ
1) Acute dystonia à»š¹ÍÒ¡ÒÃ·Õàè ¡Ô´¡ÒÃà¡Ãç§ËÃ×ÍË´µÑÇ¢Í§¡ÅŒÒÁà¹×Íé
¤Í ËÅÑ§ µÒ ·íÒãËŒÁÕÍÒ¡ÒÃ¤ÍºÔ´ ËÅÑ§áÍ‹¹ ÍÒ¨ÁÕáÅºÅÔé¹ ÅÔé¹ºÔ´ µÒàËÅ×Í¡¢Öé¹
(oculogyric crisis) â´ÂäÁ‹ÊÒÁÒÃ¶¤Çº¤ØÁä´Œ ÁÑ¡à¡Ô´ã¹¼ÙŒ»†ÇÂÍÒÂØ¹ŒÍÂ (¹ŒÍÂ¡Ç‹Ò
40 »‚) â´Âà©¾ÒÐà¾ÈªÒÂ ¼Å¢ŒÒ§à¤ÕÂ§¹ÕéÍÒ¨¾ºä´Œã¹¼ÙŒ»†ÇÂ·Õèä´ŒÃÑºÂÒ·ÕèÍÍ¡Ä·¸Ôì»´
¡Ñ¹é dopamine receptors ä´ŒáÃ§ (àª‹¹ Haloperidol ËÃ×Í Fluphenazine) ÁÒ¡¡Ç‹Ò
ÂÒ·ÕèÍÍ¡Ä·¸Ôì»´¡Ñé¹ dopamine receptors ä´ŒÍ‹Í¹ã¹¢¹Ò´ÊÙ§ â´ÂäÁ‹ÁÕ¡ÒÃãªŒÂÒ
antiparkinsonism Ã‹ÇÁ
ÀÒ¾áÊ´§ÍÒ¡ÒÃ Acute dystonia : ÇÔ¸ÕÊÑ§à¡µÍÒ¡ÒÃ ¡ÅŒÒÁà¹×éÍºÔ´à¡Ãç§
·Ñ¹·Õ µÒàËÅ×Í¡ ¤ÍºÔ´ ËÅÑ§áÍ‹¹ ÅÔé¹á¢ç§ ¾Ù´ÅíÒºÒ¡ ¡Å×¹ÅíÒºÒ¡
ࡗࡩࡕࡴࡡࡋ࠾ࡤࡩ࠸ࡩ࡚$FXWHG\VWRQLD
¡ÒÃÃÑ¡ÉÒ ÂÒ©Õ´ ÍÒ¨ãËŒ Benztropine ËÃ×Í Diphenhydramine ËÃ×Í
Diazepam ©Õ´à¢ŒÒ·Ò§ËÅÍ´àÅ×Í´´íÒ ¨ÐÃÑ¡ÉÒÍÒ¡ÒÃä´ŒÀÒÂã¹ 2-3 ¹Ò·Õ ËÃ×Í ÂÒ
ª¹Ô´¡Ô¹¨ÐãªŒàÇÅÒ 15-30 ¹Ò·Õ
µÒÃÒ§·Õè 3 áÊ´§ÃÒÂ¡ÒÃÂÒáÅÐ¢¹Ò´ÂÒ·ÕèãªŒÃÑ¡ÉÒ¼Å¢ŒÒ§à¤ÕÂ§ã¹
¡ÅØ‹Á extrapyramidal
ª×èÍÂÒÊÒÁÑÞ (ª×èÍ¡ÒÃ¤ŒÒ) ª¹Ô´¢Í§ÂÒ ¢¹Ò´ÂÒµ‹ÍÇÑ¹ ¢ŒÍº‹§ãªŒ
Benztropine (Cogentin®) Anticholinergics Oral: 1-4 mg acute dystonia,
IM/IV 1-2 mg parkinsonism
Trihexyphenidyl (Artane®, Anticholinergics Oral: 2-15 mg/day acute dystonia,
Benzhexol®) parkinsonism
Diphenhydramine (Benadryl®) Antihistaminergics Oral: 25-100 mg/day acute dystonia,
IM/IV: 25 mg parkinsonism,
rabbit syndrome
Propranolol (Inderal®) Beta-adrenergic Oral: 20-40 mg/day akathisia, tremor
antagonists
Diazepam (Valium®) Benzodiazepines Oral: 15 mg/day acute dystonia, akathisia
IV: 5-10 mg
Clonazepam (Rivotril®) Benzodiazepines Oral : 0.5-3 mg/day acute dystonia, akathisia
Cyproheptadine (Periactin®) Antihistamine Oral : 16 mg/day akathisia (off-label use)
2) Parkinsonism ËÃ×Í Pseudoparkinsonism à¡Ô´¨Ò¡Ä·¸Ôì»´¡Ñé¹
dopamine receptors ·Õè nigrostriatal pathway ·íÒãËŒà¡Ô´ÍÒ¡ÒÃàËÁ×Í¹¡ÑºâÃ¤
¾ÒÃ¡Ô¹ÊÑ¹ (Parkinson’s disease) «Öè§»ÃÐ¡Íº´ŒÇÂÍÒ¡ÒÃ¡ÅŒÒÁà¹×éÍá¢ç§ (muscle
stiffness), cogwheel rigidity, masked face, à¤Å×èÍ¹äËÇªŒÒ (bradykinesia),
áÅÐ¹éíÒÅÒÂäËÅ (drooling) ¾º»ÃÐÁÒ³ÃŒÍÂÅÐ 15 ¢Í§¼ÙŒ·Õèä´ŒÃÑºÂÒÃÑ¡ÉÒâÃ¤¨ÔµÃØ‹¹
áÃ¡ ÁÑ¡¾ºã¹ 30-72 ÇÑ¹ ËÅÑ§ä´ŒÃÑºÂÒ ÂÒ·ÕèÍÍ¡Ä·¸Ôì»´¡Ñé¹ dopamine receptors
ä´ŒáÃ§áÅÐÁÕ¼Å¢ŒÒ§à¤ÕÂ§ª¹Ô´ anticholinergic µèíÒ¨ÐÁÕâÍ¡ÒÊà¡Ô´ parkinsonism
ä´ŒÊÙ§ ¼ÙŒËÞÔ§ÁÕâÍ¡ÒÊà¡Ô´¼Å¢ŒÒ§à¤ÕÂ§¹Õéà»š¹ÊÍ§à·‹Ò¢Í§¼ÙŒªÒÂ
üĉíĊÿĆÜđÖêĂćÖćø
- ÖúšćöđîČĚĂĒ×ĘÜđÖøĘÜ
- ÿĆęî×èąóĆÖ
- đÙúČęĂîĕĀüđßČęĂÜßšć
- đéĉîĕöŠĒÖüŠÜĒ×î
- ÿĊĀîšćđøĊ÷ïđÞ÷
- êĆüÜĂ ĀúĆÜÙčšö
ภาพแสดงอาการของ Parkinsonism หรือČ Pseudoparkinsonism
¡ÒÃÃÑ¡ÉÒ ÂÒ¡ÅØ‹Á anticholinergic àª‹¹ Benztropine ËÃ×Í Trihexyphe-
nidyl ËÃ×ÍÂÒ·ÕèÍÍ¡Ä·¸Ôì antihistaminergic àª‹¹ Diphenhydramine ÃÙ»áººÂÒ
¡Ô¹ ÂÒ·Õèª‹ÇÂÃÑ¡ÉÒÍÒ¡ÒÃ¢ŒÒ§à¤ÕÂ§¹ÕéàÁ×èÍãËŒ¤Çº¤Ù‹¡ÑºÂÒÃÑ¡ÉÒâÃ¤¨Ôµ¹Ò¹ 4-6 ÊÑ»´ÒË
ÍÒ¨ÅÍ§ËÂØ´ÂÒ´ÙÇ‹ÒÂÑ§ÁÕÍÒ¡ÒÃ¢ŒÒ§à¤ÕÂ§·ÕèµŒÍ§ãªŒÂÒÃÑ¡ÉÒÍÕ¡ËÃ×ÍäÁ‹ ËÒ¡äÁ‹ÁÕÍÒ¡ÒÃ
¢ŒÒ§à¤ÕÂ§´Ñ§¡Å‹ÒÇáÅŒÇÍÒ¨äÁ‹¨íÒà»š¹µŒÍ§ãªŒÂÒ¹Õéµ‹Íä´Œ
3) Akathisia à»š¹¼Å¢ŒÒ§à¤ÕÂ§·Õ¼è »ÙŒ Ç† Â¨ÐÃÙÊŒ ¡Ö äÁ‹ÊºÒÂ·Õ¡è ÅŒÒÁà¹×Íé ¨¹·íÒãËŒ
¼ÙŒ»†ÇÂÁÕÍÒ¡ÒÃ¡ÃÐÇ¹¡ÃÐÇÒÂ (agitation) ÍÂÙ‹äÁ‹¹Ôè§ (restlessness) ¼Ø´ÅØ¡¼Ø´¹Ñè§
à´Ô¹ä»ÁÒâ´ÂäÁ‹ÊÒÁÒÃ¶½„¹ä´ŒáÅÐÃÙŒÊÖ¡äÁ‹à»š¹ÊØ¢ (dysphoria) ¼ÙŒ»†ÇÂÍÒ¨ÁÕÍÒ¡ÒÃ¹Ñè§
¢ÂÑºµÑÇ ËÃ×ÍâÂ¡µÑÇº‹ÍÂ ¹Ñè§ä¢ÇŒ¢ÒÊÅÑºä»ÁÒ ¶ÙÁ×Í¡ÑºµŒ¹¢Ò à¢‹Ò ËÃ×Íà¡ŒÒÍÕé·Õè¹Ñè§ ÍÒ¨
ÅØ¡¢Ö¹é Â×¹ËÃ×Íà´Ô¹ä»ÁÒâ´Â·Ñ¹·Õ ¡Åä¡¡ÒÃà¡Ô´ÍÒ¡ÒÃ¢ŒÒ§à¤ÕÂ§¹ÕÂé §Ñ äÁ‹à»š¹·Õáè ¹‹ª´Ñ ÍÒ¨
à¡Ô´¨Ò¡¤ÇÒÁäÁ‹ÊÁ´ØÅ¢Í§ÃÐºº noradrenergic áÅÐ dopaminergic ÍÒ¨à¡Ô´¢Öé¹
àÁ×èÍã´¢Í§¡ÒÃÃÑ¡ÉÒ¡çä´Œ â´Â·ÑèÇä»ÁÑ¡à¡Ô´ËÅÑ§¨Ò¡ÃÑ¡ÉÒä»áÅŒÇ 5 ÇÑ¹¢Öé¹ä»
¡ÒÃÃÑ¡ÉÒ ¤ÇÃàÃÔÁè µŒ¹¨Ò¡¡ÒÃÅ´ÂÒÃÑ¡ÉÒâÃ¤¨ÔµãËŒä´Œ¢¹Ò´µèÒí ÊØ´·Õ¤è ÁØ ÍÒ¡ÒÃ
âÃ¤¨Ôµä´Œ áÅÐãËŒ Propranolol ËÃ×Í ÂÒã¹¡ÅØ‹Á Benzodiazepines
4) Tardive dyskinesia ; TD ÁÕÍÒ¡ÒÃà¤Å×èÍ¹äËÇªŒÒ æ â´Â¼ÙŒ»†ÇÂäÁ‹
ÊÒÁÒÃ¶¤Çº¤ØÁä´Œ àª‹¹ ¡ÒÃµÇÑ´ÅÔé¹ áÅºÅÔé¹ ÁŒÇ¹ÅÔé¹ à¤ÕéÂÇ»Ò¡ Ë‹ÍÃÔÁ½‚»Ò¡ ·íÒ
¢ÁÇ´¤ÔéÇ/àÅÔ¡¤ÔéÇ ËÂÕµÒ (blepharospasm) ÍÒ¨ÁÕÍÒ¡ÒÃºÔ´¤Í ºÔ´µÑÇ ËÃ×ÍÂ¡äËÅ‹
ÍÒ¡ÒÃ¨Ðà»š¹ÁÒ¡¢Öé¹àÁ×èÍ¼ÙŒ»†ÇÂà¤ÃÕÂ´áÅÐ¨ÐËÒÂä»ã¹ÃÐËÇ‹Ò§ËÅÑº ÁÑ¡à¡Ô´ËÅÑ§¨Ò¡
ä´ŒÃÑºÂÒÃÑ¡ÉÒâÃ¤¨Ôµà¡Ô¹ 6 à´×Í¹ ÂÒÃÑ¡ÉÒâÃ¤¨ÔµÃØ‹¹áÃ¡·Ø¡µÑÇÁÕÃÒÂ§Ò¹Ç‹Ò·íÒãËŒà¡Ô´
TD â´Âà©¾ÒÐÂÒ·ÕÍè Í¡Ä·¸Ô»ì ´ ¡Ñ¹é dopamine receptors ä´ŒáÃ§¨Ð·íÒãËŒà¡Ô´ÍÒ¡ÒÃ
ä´ŒÊ§Ù ¡Ç‹Ò ¼Ù»Œ Ç† Â·Õäè ´ŒÃºÑ ÂÒÃØ¹‹ áÃ¡à»š¹ÃÐÂÐàÇÅÒ¹Ò¹ ÂÔ§è ÁÕâÍ¡ÒÊà¡Ô´¼Å¢ŒÒ§à¤ÕÂ§¹Õäé ´Œ
ÊÙ§ ÂÒÃÑ¡ÉÒÍÒ¡ÒÃ·Ò§¨ÔµÃØ‹¹áÃ¡à¡Ô´¼Å¢ŒÒ§à¤ÕÂ§¹Õéä´ŒÊÙ§¡Ç‹ÒÂÒÃÑ¡ÉÒÍÒ¡ÒÃ·Ò§¨Ôµ
ÃØ‹¹ãËÁ‹ ¡Åä¡¡ÒÃà¡Ô´¼Å¢ŒÒ§à¤ÕÂ§¹ÕéÍÒ¨à¡Ô´¨Ò¡ dopamine receptor super-
sensitivity «Öè§à»š¹¼Å¨Ò¡ÂÒ»´¡Ñé¹ dopamine receptor à»š¹ÃÐÂÐàÇÅÒ¹Ò¹
¡ÒÃÃÑ¡ÉÒ ¤ÇÃ¤‹ÍÂ æ Å´¢¹Ò´ÂÒ·Õãè ªŒ ¨¹ËÂØ´ÂÒä´Œ ¼Ù»Œ Ç† Â·ÕÂè §Ñ ÁÕÍÒ¡ÒÃ·Ò§
¨Ôµ·Õè¨íÒà»š¹µŒÍ§ãªŒÂÒ ¾Ô¨ÒÃ³ÒãËŒÂÒÃÑ¡ÉÒâÃ¤¨ÔµÃØ‹¹ãËÁ‹ (atypical antipsychotics)
àª‹¹ Clozapine «Öè§ÁÕÍÑµÃÒ¡ÒÃà¡Ô´¼Å¢ŒÒ§à¤ÕÂ§¹ÕéµèíÒ ¼ÙŒ»†ÇÂ·ÕèÁÕÍÒ¡ÒÃ TD äÁ‹ÃØ¹áÃ§
ÃŒÍÂÅÐ 50-90 ËÅÑ§¨Ò¡à»ÅÕèÂ¹ÂÒãËÁ‹¨ÐËÒÂ¨Ò¡ÍÒ¡ÒÃ ¹Í¡¨Ò¡¹ÕéÂÑ§ÁÕ¡ÒÃÈÖ¡ÉÒÂÒ
·ÕèÊÒÁÒÃ¶¹íÒÁÒÃÑ¡ÉÒ TD ´Ñ§µÒÃÒ§
µÒÃÒ§·Õè 4 áÊ´§ÃÒÂ¡ÒÃÂÒ·ÕèÁÕ¡ÒÃÈÖ¡ÉÒ¶Ö§»ÃÐÊÔ·¸ÔÀÒ¾
ã¹¡ÒÃÃÑ¡ÉÒ Tardive dyskinesia
ÂÒ ¼Å¡ÒÃÈÖ¡ÉÒ
Benzodiazepines ÁÕ¡ÒÃãªŒÍÂ‹Ò§á¾Ã‹ËÅÒÂ »ÃÐÊÔ·¸ÔÀÒ¾ÂÑ§ÍÂÙ‹ã¹ÃÐËÇ‹Ò§¡ÒÃÈÖ¡ÉÒ
¾ºÇ‹Ò¡ÒÃãËŒ Clonazepam 1-4 mg/day áÅÐ
Diazepam 6-25 mg/day ª‹ÇÂãËŒÍÒ¡ÒÃ TD ´Õ¢Öé¹
Propranolol ÁÕ¡ÒÃãªŒÍÂ‹Ò§¡ÇŒÒ§¢ÇÒ§ Propranolol 40-120 mg/day
Vitamin E ÁÕËÅÒÂ¡ÒÃÈÖ¡ÉÒ áµ‹»ÃÐÊÔ·¸ÔÀÒ¾ÂÑ§äÁ‹ªÑ´à¨¹ ¢¹Ò´·ÕèÁÕ¡ÒÃÈÖ¡ÉÒ
Ç‹ÒãËŒáÅŒÇä´Œ¼Å¤×Í 400-1,600 IU/day
5) Neuroleptic malignant syndrome ; NMS à»š¹¼Å¢ŒÒ§à¤ÕÂ§·Õè¾ºäÁ‹

º‹ÍÂáµ‹ÁÕ¤ÇÒÁÃØ¹áÃ§ ÍÒ¨·íÒãËŒ¼ÙŒ»†ÇÂàÊÕÂªÕÇÔµä´Œ ÍØºÑµÔ¡ÒÃ³¡ÒÃà¡Ô´ÃŒÍÂÅÐ 0.04
áÅÐÍÑµÃÒ¡ÒÃµÒÂÃŒÍÂÅÐ 16.67 ÍÒ¨à¡Ô´¢Öé¹ã¹ª‹Ç§àÇÅÒã´ æ ·Õèä´ŒÃÑºÂÒÃÑ¡ÉÒâÃ¤¨Ôµ
áµ‹ÃŒÍÂÅÐ 80 ¢Í§¼ÙŒ»†ÇÂ·Õèà¡Ô´ NMS ¨Ðà¡Ô´ã¹ª‹Ç§ 2 ÊÑ»´ÒËáÃ¡¢Í§¡ÒÃàÃÔèÁãªŒ
ÂÒ ÍÒ¡ÒÃáÊ´§ªÑ´à¨¹ÀÒÂã¹ 24-72 ªÑèÇâÁ§ áÅÐÍÒ¨ÁÕÍÒ¡ÒÃ¹Ò¹¶Ö§ 10-14 ÇÑ¹
ÁÑ¡à¡Ô´ã¹¼Ù»Œ Ç† Â·Õäè ´ŒÃºÑ ÂÒª¹Ô´ÍÍ¡Ä·¸Ô»ì ´ ¡Ñ¹é dopamine receptors ä´ŒáÃ§ ä´Œ¢¹Ò´
ÂÒÊÙ§ áÅÐ/ËÃ×ÍÁÕ¡ÒÃ»ÃÑºÂÒ¢Ö¹é àÃçÇ ÃÇÁ·Ñ§é ¡ÒÃãªŒÂÒÃÑ¡ÉÒâÃ¤¨ÔµÃØ¹‹ áÃ¡ª¹Ô´©Õ´ÍÍ¡
Ä·¸Ôì¹Ò¹
ÍÒ¡ÒÃ·Ò§¤ÅÔ¹Ô¡·ÕèÊíÒ¤ÑÞ
- ä¢ŒÊÙ§ (hyperthermia)
- ¡ÅŒÒÁà¹×éÍá¢ç§à¡Ãç§ÍÂ‹Ò§ÃØ¹áÃ§ (muscle rigidity)
- ÃÐºº»ÃÐÊÒ·ÍÑµâ¹ÁÑµÔ·íÒ§Ò¹äÁ‹¤§·Õè (autonomic instability) ä´Œá¡‹
ÍÒ¡ÒÃËÒÂã¨àÃçÇ ËÑÇã¨àµŒ¹àÃçÇ ¤ÇÒÁ´Ñ¹âÅËÔµÊÙ§ àË§×èÍÍÍ¡ÁÒ¡
- ÁÕ¡ÒÃà»ÅÕèÂ¹á»Å§ÊµÔÊÑÁ»ªÑÞÞÐ (fluctuation consciousness)
¡ÒÃµÃÇ¨·Ò§ËŒÍ§»¯ÔºÑµÔ¡ÒÃ
- ÃÐ´ÑºàÍÁä«Á creatinine phosphokinase (CPK) ÊÙ§¢Öé¹ ( >15,000/
mm )
3
- àÍÁä«ÁµÑºÊÙ§¢Öé¹
- ¾º myoglobulin ã¹¾ÅÒÊÁÒáÅÐã¹»˜ÊÊÒÇÐ
¡ÒÃÃÑ¡ÉÒ µŒÍ§ËÂØ´ÂÒ·ÕèÍÍ¡Ä·¸Ôì»´¡Ñé¹ dopamine receptor ·Ñ¹·Õ áÅÐ

ãËŒ¡ÒÃÃÑ¡ÉÒµÒÁÍÒ¡ÒÃ (supportive care) ÃÑ¡ÉÒÀÒÇÐä¢Œ µÔ´µÒÁÊÑÞÞÒ³ªÕ¾
ÃÐ´ÑºÍÔàÅ¤âµÃäÅ· ÃÑ¡ÉÒÊÁ´ØÅ»ÃÔÁÒ³¹éíÒã¹Ã‹Ò§¡ÒÂ ãËŒÂÒ dantrolene ËÃ×Í
bromocriptine ·Ò§ËÅÍ´àÅ×Í´´íÒ à¾×Íè ãËŒ¡ÅŒÒÁà¹×Íé ¤ÅÒÂµÑÇ ÃÑ¡ÉÒ´ŒÇÂÇÔ¸¹Õ ¹Õé Ò¹ 5-10
ÇÑ¹ ¼ÙŒ»†ÇÂ·ÕèËÒÂ¨Ò¡ÍÒ¡ÒÃ NMS ·ÕèÂÑ§¨íÒà»š¹µŒÍ§ãªŒÂÒÃÑ¡ÉÒâÃ¤¨Ôµµ‹Í ¤ÇÃàÅ×Í¡ÂÒ
ª¹Ô´·Õè»´¡Ñé¹ dopamine receptors ä´ŒÍ‹Í¹ËÃ×ÍÂÒÃÑ¡ÉÒâÃ¤¨ÔµÃØ‹¹·ÕèÊÍ§ (second
generation, atypical antipsychotics) «Öè§ÁÕ¤ÇÒÁàÊÕèÂ§µ‹Í¡ÒÃà¡Ô´ NMS µèíÒ¡Ç‹Ò
4. ¼Åµ‹ÍÃÐººËÑÇã¨áÅÐËÅÍ´àÅ×Í´ ÂÒª¹Ô´ÍÍ¡Ä·¸Ôì»´¡Ñé¹ dopamine
receptors ä´ŒÍ‹Í¹ ¨ÐÁÕ¾ÔÉµ‹ÍËÑÇã¨ (cardiotoxic) ä´ŒÁÒ¡¡Ç‹ÒÂÒª¹Ô´·ÕèÍÍ¡Ä·¸Ôì»´
¡Ñé¹ dopamine receptors ä´ŒáÃ§ ¼Åµ‹ÍÃÐººËÑÇã¨áÅÐËÅÍ´àÅ×Í´ÁÕ´Ñ§¹Õé
- EKG changed â´Â Thioridazine à»š¹ÂÒ·ÕèÁÕ¼Åµ‹Í T wave áÅÐ
·íÒãËŒà¡Ô´ prolong QT intervals ä´ŒÁÒ¡·ÕèÊØ´ ´Ñ§¹Ñé¹¡‹Í¹àÃÔèÁãËŒ Thioridazine ¤ÇÃ
µÃÇ¨ EKG ¡‹Í¹ ¶ŒÒ¾º QT interval ÁÒ¡¡Ç‹Ò 520 ms ã¹¼ÙŒãËÞ‹ ËÃ×Í ÁÒ¡¡Ç‹Ò
470 ms ã¹à´ç¡ äÁ‹¤ÇÃãªŒÂÒ¹Õé áÅÐËÒ¡µÃÇ¨¾ºàÁ×èÍã´ ¤ÇÃËÂØ´ÂÒ·Ñ¹·Õ
- Postural hypotension ËÃ×Í Orthostatic hypotension «Öè§à¡Ô´¨Ò¡
Ä·¸Ôì»´¡Ñé¹ alpha-1 adrenergic receptors ·íÒãËŒ¤ÇÒÁ´Ñ¹âÅËÔµµèíÒàÁ×èÍÁÕ¡ÒÃ»ÃÑº
à»ÅÕèÂ¹ÍÔÃÔÂÒº¶ ·íÒãËŒà¡Ô´ÍÒ¡ÒÃËÑÇã¨àµŒ¹àÃçÇ (tachycardia) ÇÔ§àÇÕÂ¹ (dizziness)
Ë¹ŒÒÁ×´à»š¹ÅÁÅŒÁä´Œ ÂÒ Chlorpromazine áÅÐ Thioridazine ·ÕèÍÂÙ‹ã¹¡ÅØ‹Á low
potency (»´¡Ñé¹ dopamine receptors ä´ŒÍ‹Í¹) à¡Ô´¼Å¢ŒÒ§à¤ÕÂ§¹Õéä´ŒÊÙ§ÊØ´ ¼Å
¢ŒÒ§à¤ÕÂ§¹ÕéÁÑ¡à¡Ô´ã¹ª‹Ç§áÃ¡·Õèä´ŒÃÑºÂÒ â´Â·ÑèÇä»¼ÙŒ»†ÇÂ¨ÐÊÒÁÒÃ¶»ÃÑºµÑÇ¡ÑºÂÒä´Œã¹
·ÕÊè ´Ø ¤ÇÃà¾ÔÁè ¢¹Ò´ÂÒÍÂ‹Ò§ªŒÒ æ áÅÐãËŒ¤Òí á¹Ð¹íÒ¡ÒÃÅØ¡¹Ñ§è ËÃ×Í»ÃÑºà»ÅÕÂè ¹ÍÔÃÂÔ Òº¶
ÍÂ‹Ò§ªŒÒ æ
5. ¼Åµ‹ÍÃÐººµ‹ÍÁäÃŒ·‹Í ¡ÒÃÍÍ¡Ä·¸Ôì»´¡Ñé¹ dopamine receptors ·Õè
tuberoinfundibular pathway áÅÐã¹ pituitary ·íÒãËŒà¡Ô´¡ÒÃà¾ÔèÁÃÐ´ÑºÎÍÃâÁ¹
prolactin ã¹¡ÃÐáÊàÅ×Í´ ã¹à¾ÈËÞÔ§ÁÕ¼Å·íÒãËŒÁÕàµŒÒ¹ÁãËÞ‹¢Öé¹ (gynecomastia)
¹éÒí ¹ÁäËÅ (galactorrhea) ÍÒÃÁ³·Ò§à¾ÈÅ´Å§ ÂÑºÂÑ§é ÀÒÇÐ orgasm »ÃÐ¨íÒà´×Í¹
ÁÒäÁ‹ÊÁèíÒàÊÁÍ (irregular menses) ËÃ×ÍäÁ‹ÁÕ»ÃÐ¨íÒà´×Í¹ (amenorrhea)
Ê‹Ç¹ã¹à¾ÈªÒÂ¡ÒÃ·ÕèÎÍÃâÁ¹ prolactin à¾ÔèÁ¢Öé¹ÁÕ¼Å¡´¡ÒÃ·íÒ§Ò¹¢Í§ÎÍÃâÁ¹
testosterone ·íÒãËŒàÊ×Íè ÁÊÁÃÃ¶ÀÒ¾·Ò§à¾È (impotence) â´ÂÁÕ¤ÇÒÁµŒÍ§¡ÒÃ·Ò§
à¾ÈÅ´Å§ ÃÇÁ¶Ö§ÍÇÑÂÇÐà¾ÈäÁ‹á¢ç§µÑÇ (erectile dysfunction) ÁÕ¤ÇÒÁ¼Ô´»¡µÔã¹
¡ÒÃËÅÑ§è ¹éÒí ÍÊØ¨Ô (ejaculatory disturbance) «Ö§è ÍÒ¨à¡ÕÂè Ç¢ŒÍ§¡ÑºÄ·¸Ô»ì ´ ¡Ñ¹é alpha-2
adrenergic receptors ´ŒÇÂ
ÁÕ¡ÒÃÈÖ¡ÉÒ¢Í§ Berner MM áÅÐ¤³Ð ¾ºÇ‹Ò¡ÒÃà»ÅÕèÂ¹ÂÒÃÑ¡ÉÒâÃ¤¨Ôµ
ÃØ‹¹áÃ¡à»š¹ÂÒÃÑ¡ÉÒâÃ¤¨ÔµÃØ‹¹ÊÍ§ºÒ§µÑÇ àª‹¹ Olanzapine áÅÐ Quetiapine ¾º
Ç‹Ò·íÒãËŒà¡Ô´¼Å¢ŒÒ§à¤ÕÂ§´ŒÒ¹¹Õéä´Œ¹ŒÍÂ¡Ç‹Ò â´ÂÂÒ·ÕèÁÕÃÒÂ§Ò¹¡ÒÃà¡Ô´ hyper-
prolactinemia ÊÙ§ ¤×Í Haloperidol áÅÐ Risperidone
6. ¼Å¡ÃÐ·ºµ‹ÍÃÐººàÅ×Í´ ÂÒÃÑ¡ÉÒâÃ¤¨ÔµÃØ‹¹áÃ¡ÍÒ¨·íÒãËŒ¨íÒ¹Ç¹àÁç´
àÅ×Í´¢ÒÇÅ´Å§ (leukopenia) (WBC< 3,500/mm3) ä´Œº‹ÍÂ »ÃÐÁÒ³ÃŒÍÂÅÐ 10
¢Í§¼ÙäŒ ´ŒÃºÑ ÂÒ áµ‹Á¡Ñ à»š¹à¾ÕÂ§ªÑÇè ¤ÃÒÇáÅÐ¨íÒ¹Ç¹àÁç´àÅ×Í´¢ÒÇ¨Ð¡ÅÑºÁÒ»¡µÔä´ŒàÍ§
Ê‹Ç¹¡ÒÃÅ´Å§¢Í§¨íÒ¹Ç¹àÁç´àÅ×Í´¢ÒÇª¹Ô´ÃØ¹áÃ§ (WBC<500/mm3) ¾ºä´Œã¹
ÍÑµÃÒ¹ŒÍÂ¡Ç‹Ò (1:10,000) ÁÑ¡¾ºã¹ª‹Ç§ 3 à´×Í¹áÃ¡¢Í§¡ÒÃÃÑºÂÒ ÂÒª¹Ô´·Õè»´¡Ñé¹
dopamine receptors ä´ŒÍ‹Í¹ ÁÕâÍ¡ÒÊà¡Ô´ agranulocytosis ä´ŒÁÒ¡¡Ç‹Ò Ê‹Ç¹
¡ÒÃÅ´Å§¢Í§à¡Åç´àÅ×Í´ (thrombocytopenia) áÅÐ¡ÒÃÅ´Å§·Ñé§àÁç´àÅ×Í´á´§
àÁç´àÅ×Í´¢ÒÇ áÅÐà¡Åç´àÅ×Í´ (pancytopenia) ÍÒ¨à¡Ô´¢Öé¹ä´Œ áµ‹¾ºä´Œ¹ŒÍÂÁÒ¡
7. ¼Å¡ÃÐ·ºµ‹Í¡ÒÃ·íÒ§Ò¹¢Í§µÑº ÂÒÃÑ¡ÉÒâÃ¤¨ÔµÃØ‹¹áÃ¡ÍÒ¨·íÒãËŒà¡Ô´
¡ÒÃà¾ÔèÁ¢Öé¹¢Í§àÍ¹ä«ÁµÑºªÑèÇ¤ÃÒÇ
8. ¼Å¢ŒÒ§à¤ÕÂ§·Ò§¼ÔÇË¹Ñ§ ÍÒ¡ÒÃá¾Œ·Ò§¼ÔÇË¹Ñ§ ÁÑ¡¾ºã¹ÊÑ»´ÒËáÃ¡
¢Í§¡ÒÃä´ŒÃÑºÂÒ ÂÒ·ÕèÍÍ¡Ä·¸Ôì»´¡Ñé¹ dopamine receptors ä´ŒÍ‹Í¹ â´Âà©¾ÒÐ
Chlorpromazine ÍÒ¨¾º¼×è¹äÇµ‹ÍáÊ§ (photosensitivity reaction) ä´Œ
9. ¼Å¢ŒÒ§à¤ÕÂ§µ‹ÍµÒ Thioridazine ¢¹Ò´ÁÒ¡¡Ç‹Ò 800 mg/day ¨Ð
ÊÑÁ¾Ñ¹¸¡Ñº¡ÒÃà¡Ô´ pigmentation ·Õè retina ·íÒãËŒÁÍ§àËç¹äÁ‹ªÑ´ã¹àÇÅÒ¡ÅÒ§¤×¹
áÁŒËÂØ´ÂÒáÅŒÇÍÒ¡ÒÃ¨ÐäÁ‹ËÒÂà»š¹»¡µÔ´Ñ§à´ÔÁ áÅÐÍÒ¨à»š¹ÁÒ¡¢Öé¹¨¹·íÒãËŒµÒºÍ´
ä´Œ ¡ÒÃä´ŒÃÑº Chlorpromazine ã¹ÃÐÂÐÂÒÇ ÍÒ¨à¡Ô´¼§ÊÕ¹éíÒµÒÅ¢ÒÇ (whitish
brown granular) ÊÐÊÁ·ÕèËÅÑ§ cornea áÅÐ´ŒÒ¹Ë¹ŒÒ lens «Öè§ÊÒÁÒÃ¶µÃÇ¨¾ºä´Œ
¨Ò¡à¤Ã×èÍ§µÃÇ¨µÒ áµ‹¨ÐäÁ‹¡ÃÐ·ºµ‹ÍÊÒÂµÒ¢Í§¼ÙŒ»†ÇÂ
»¯Ô¡ÔÃÔÂÒÃÐËÇ‹Ò§ÂÒ (Drug interaction)

1) ÂÒÅ´¡Ã´ Antacid, Cimetidine, Ranitidine ÁÕ¼Å·íÒãËŒ¡ÒÃ´Ù´«ÖÁÂÒ
ÃÑ¡ÉÒâÃ¤¨ÔµÃØ‹¹áÃ¡Å´Å§ ¹Í¡¨Ò¡¹Õé Activated charcoal, Kaolin pectin, áÅÐ
Cholestyramine ãËŒ¼Åàª‹¹à´ÕÂÇ¡Ñ¹
2) Anticholinergics drugs ·Õè ÁÑ ¡ãËŒ Ã‹ Ç Áà¾×è Í Å´¼Å¢Œ Ò §à¤Õ Â §ª¹Ô ´
Extrapyramidal ¢Í§ÂÒÃÑ¡ÉÒâÃ¤¨ÔµÃØ¹‹ áÃ¡ ¨Ð·íÒãËŒ¡ÒÃ´Ù´«ÖÁÂÒÃÑ¡ÉÒâÃ¤¨ÔµÅ´Å§
¹Í¡¨Ò¡¹Õé ÂÑ § àÊÃÔ Á ¼Å¢Œ Ò §à¤Õ Â §ª¹Ô ´ anticholinergics (»Ò¡áËŒ § ·Œ Í §¼Ù ¡
»˜ÊÊÒÇÐ¤Ñè§) ¢Í§ÂÒÃÑ¡ÉÒâÃ¤¨Ôµ
3) Antiepileptics
- Thioridazine ÁÕ¼ÅÅ´ metabolism ¢Í§ÂÒ¡ÅØ‹Á Diphenylhydantoin
(Phenytoin) ÍÒ¨ÁÕ¼Å·íÒãËŒÃÐ´Ñº Phenytoin à»š¹¾ÔÉä´Œ
- ÂÒ¡Ñ¹ªÑ¡¡ÅØ‹Á Barbiturates (Phenobarbital), Diphenylhydantoin
(Phenytoin), áÅÐ Carbamazepine ¨Ðà¾ÔèÁ metabolism ¢Í§ÂÒÃÑ¡ÉÒâÃ¤¨ÔµÃØ‹¹
áÃ¡ ·íÒãËŒÃÐ´ÑºÂÒÃÑ¡ÉÒâÃ¤¨ÔµÅ´Å§ àª‹¹ Carbamazepine Å´ÃÐ´Ñº¤ÇÒÁà¢ŒÁ¢Œ¹
¢Í§ÂÒ Haloperidol ä´ŒÃŒÍÂÅÐ 50
4) Antidepressants
- Tricyclic antidepressants ãËŒÃ‹ÇÁ¡ÑºÂÒÃÑ¡ÉÒâÃ¤¨Ôµ ÂÒ·Ñé§ÊÍ§¡ÅØ‹Á
¨ÐÂÑºÂÑé§¡ÒÃ metabolism «Öè§¡Ñ¹áÅÐ¡Ñ¹ ·íÒãËŒÃÐ´ÑºÂÒ·Ñé§ÊÍ§¡ÅØ‹ÁÊÙ§¢Öé¹ ÂÒÃÑ¡ÉÒ
âÃ¤¨ÔµÃØ‹¹áÃ¡Ê‹Ç¹ãËÞ‹¶Ù¡ metabolize ´ŒÇÂàÍ¹ä«Á CYP 2D6 áÅÐ 3A4 ´Ñ§¹Ñé¹
àÁ×èÍãËŒÃ‹ÇÁ¡ÑºÂÒµŒÒ¹àÈÃŒÒ·ÕèÂÑºÂÑé§àÍÁä«Á´Ñ§¡Å‹ÒÇ ¨Ð·íÒãËŒÃÐ´ÑºÂÒÃÑ¡ÉÒâÃ¤¨ÔµÊÙ§
¢Öé¹ àª‹¹ Fluoxetine ÂÑºÂÑé§àÍÁä«Á CYP 2D6, 3A4 àÁ×èÍãËŒÃ‹ÇÁ¡Ñº Haloperidol
¨Ðà¾ÔèÁÃÐ´ÑºÂÒ Haloperidol «Öè§ÍÒ¨·íÒãËŒà¡Ô´¼Å¢ŒÒ§à¤ÕÂ§ª¹Ô´ EPS ÃØ¹áÃ§¢Öé¹ ÂÒ
Í×è¹ æ ·Õè·íÒãËŒà¡Ô´¼Åà´ÕÂÇ¡Ñ¹ àª‹¹ Cimetidine (2D6), Ketoconazole (3A4)
5) ÂÒÅ´¤ÇÒÁ´Ñ¹âÅËÔµ ¡ÒÃãËŒÂÒÃÑ¡ÉÒÍÒ¡ÒÃ·Ò§¨ÔµÃ‹ÇÁ¡ÑºÂÒÅ´¤ÇÒÁ´Ñ¹
Ê‹§¼Å´Ñ§µ‹Íä»¹Õé
- Propranolol ¼Å·íÒãËŒÃÐ´Ñº¤ÇÒÁà¢ŒÁ¢Œ¹¢Í§ÂÒ·Ñé§ÊÍ§à¾ÔèÁ¢Öé¹
- Clonidine, Methyldopa ¼Å¨ÐÅ´¡ÒÃÍÍ¡Ä·¸Ôì¢Í§ÂÒÅ´¤ÇÒÁ´Ñ¹
- Captopril, Enalapril, Hydralazine ¼Åà¾ÔÁè ¡ÒÃÍÍ¡Ä·¸ÔÂì ÒÅ´¤ÇÒÁ´Ñ¹
6) ÂÒàºÒËÇÒ¹ àÁ×èÍãËŒÂÒÃÑ¡ÉÒâÃ¤¨ÔµÃØ‹¹áÃ¡Ã‹ÇÁ¡ÑºÂÒÅ´¹éíÒµÒÅã¹àÅ×Í´
ª¹Ô´¡Ô¹ (oral hypoglycemic) ¾ºÇ‹ÒÂÒÃÑ¡ÉÒâÃ¤¨ÔµÃØ‹¹áÃ¡¨Ðà¾ÔèÁÄ·¸Ôì¢Í§ÂÒÅ´
¹éíÒµÒÅã¹àÅ×Í´
7) ÂÒ¡´»ÃÐÊÒ· (CNS depressants) àÁ×èÍãËŒÂÒÃÑ¡ÉÒâÃ¤¨ÔµÃØ‹¹áÃ¡Ã‹ÇÁ
¡ÑºÂÒÍÍ¡Ä·¸Ôì¡´»ÃÐÊÒ· àª‹¹ ÂÒ¤ÅÒÂ¡Ñ§ÇÅ ÂÒ¹Í¹ËÅÑº ÂÒá¡Œá¾Œ áÍÅ¡ÍÎÍÅ
áÅÐ Opiate ¨ÐàÊÃÔÁÄ·¸Ôì¡ÒÃ¡´»ÃÐÊÒ·
Haloperidol
ßČęĂÿćöĆâ (Generic name) Haloperidol Lactate, Haloperidol Decanoate
Haldol®, Haridol®, Halolop®, Halo-P®, Halomed®, Haricon®,
ßČęĂÖćøÙšć (Trade name)
Polyhadol®
ēÙøÜÿøšćÜ (Structure) Butyrophenone
Tablet : 0.5, 1, 2, 5, 10 mg
Solution: 0.1 mg/drop ĀøČĂ 2 mg/ml (15 ml)
øĎðĒïï÷ć (Dosage Forms)
Injection: Haloperidol Lactate 5 mg/ml
Haloperidol Decanoate (Halodec®) 50 mg/ml, 100 mg/2ml
Schizophrenia
×šĂïŠÜĔßš (Indication) Tourette’s disorder
behavioral problem in children
emergency sedation of severe agitation or delirium
adjunctive treatment of alcohol dependence
×šĂïŠÜĔßšĂîČę ė (Off-label use)
antiemetic
psychosis/agitation related to Alzheimer’s dementia
Psychosis
Oral : 0.5-5 mg 2-3 times/day ; maximum 30 mg/day
IM (lactate) : 2-5 mg ìčÖ 4-8 ßĆęüēöÜ
IM (decanoate) :50-100 ÞĊé ìčÖ 4 ÿĆðéćĀŤ (đøĉęöêšî ēé÷đìĊ÷ïÖĆï 10-
20 đìŠć×ĂÜ×îćé÷ćøĆïðøąìćîêŠĂüĆî)
Delirium (Off-label use)
IV : 2-10 mg ìčÖ 20-30 îćìĊ ÝîÿÜï ÝćÖîĆĚîĔĀš 25% ×ĂÜ
×îćé÷ć (Dosage) ĒúąÖćø
maximum dose ìčÖ 6 ßĆęüēöÜ Monitor: EKG, QTc interval
ïøĉĀćø÷ć (Administration)
Severe agitation
Oral/IM: 10-20 mg ìčÖ 30-60 îćìĊ
Dementia behavior (Off-label use) Oral : 0.25-0.5 1-2
times/day
Injections
Haloperidol Decanoate ÞĊéđ×šćÖúšćöđîČĚĂ (IM) đìŠćîĆĚî
Haloperidol Lactate ÞĊéđ×šćÖúšćöđîČĚĂ (IM)
Trifluoperazine
ßČęĂÿćöĆâ (Generic name) Trifluoperazine Hydrochloride
ßČęĂÖćøÙšć (Trade name) Stelazine®, Psyrazine®, Triflazine®, Triflumed®, Tiplex®
ēÙøÜÿøšćÜ (Structure) Phenothiazine
øĎðĒïï÷ć (Dosage Forms) Tablet : 5, 10 mg
×šĂïŠÜĔßš (Indication) Schizophrenia
psychotic disorders
×šĂïŠÜĔßšĂîČę ė (Off-label use) dementia behavior (elderly)
psychosis agitation related to Alzheimer’s dementia
×îćé÷ć (Dosage) Schizophrenia/psychosis
15-20 mg/d ; maximum dose 40 mg/day
Nonpsychotic anxiety (ĔßšßŠüÜøą÷ąÿĆĚî ĕöŠđÖĉî 12 ÿĆðéćĀŤ)
1-2 mg/d twice daily ; maximum dose 6 mg/day
Dementia behavior
0.5-1 mg twice daily ; maximum dose 40 mg/day
Fluphenazine
ßČęĂÿćöĆâ (Generic name) Fluphenazine Decanoate
ßČęĂÖćøÙšć (Trade name) Modecate®, Deca®, Fluzine-P®, Fendec®, Phenazine®
ēÙøÜÿøšćÜ (Structure) Phenothiazine
øĎðĒïï÷ć (Dosage Forms) Injections : Fluphenazine Decanoate 25 mg/ml, 50 mg/2ml
Schizophrenia
×šĂïŠÜĔßš (Indication) psychotic disorders
non-adherent oral antipsychotics
Pervasive developmental disorder
×šĂïŠÜĔßšĂîČę ė (Unlable use) dementia behavior (elderly)
psychosis agitation related to Alzheimer’s dementia
Schizophrenia/psychosis
×îćé÷ć (Dosage)
Injections : Decanoate 25-100 mg ìčÖ 2-4 ÿĆðéćĀŤ
ÖćøïøĉĀćø÷ć (Administration) Fluphenazine decanoate ÞĊéđ×šćÖúšćöđîČĚĂ (IM)
Flupenthixol
ßČęĂÿćöĆâ (Generic name) Flupenthixol Decanoate, Flupenthixol Dihydrochloride
ßČęĂÖćøÙšć (Trade name) Fluanxol depot®
ēÙøÜÿøšćÜ (Structure) Thioxanthenes
øĎðĒïï÷ć (Dosage Forms) Injection : Flupenthixol Decanoate 20 mg/ml, 100 mg/ml
Maintenance therapy of chronic schizophrenia
×šĂïŠÜĔßš (Indication) (ĕöŠöĊ×šĂïŠÜĔßšÿĞćĀøĆï agitation ĀøČĂ hyperactivity)
Non-adherent to oral antipsychotics
×šĂïŠÜĔßšĂîČę ė (Off-label use) -
×îćé÷ć (Dosage) IM : 20-80 mg ìčÖ 2-4 ÿĆðéćĀŤ
ÖćøïøĉĀćø÷ć (Administration) Injection : ÞĊéđ×šćÖúšćöđìŠćîĆĚî ĀšćöÞĊéđ×šćĀúĂéđúČĂééĞć
Perphenazine
ßČęĂÿćöĆâ (Generic name) Perphenazine
ßČęĂÖćøÙšć (Trade name) Trilafon®, Trinazine®, Pernamed®, Pernazine®, Conazine®
ēÙøÜÿøšćÜ (Structure) Phenothiazines
øĎðĒïï÷ć (Dosage Forms) Tablet : 2, 4, 8, 16 mg
Schizophrenia
×šĂïŠÜĔßš (Indication)
Severe nausea and vomiting
psychosis
Alcohol withdrawal
dementia behavior (elderly)
Tourette’s syndrome
Huntington’s chorea
Spasmodic torticollis
Reye’s syndrome
Psychosis/agitation related to Alzheimer’s dementia
Schizophrenia/psychosis 12-64 mg/day (maximum 64 mg/day)
×îćé÷ć (Dosage) Nausea/Vomiting 8-16 mg/day (maximum 24 mg/day)
Dementia behavior (elderly) 4-8 mg/day (maximum 32 mg/day)
Zuclopenthixol
ßČęĂÿćöĆâ (Generic name) Zuclopenthixol decanoate, Zuclopenthixol acetate
ßČęĂÖćøÙšć (Trade name) Clopixol depot®, Clopixol acuphase®
ēÙøÜÿøšćÜ (Structure) -
Injection
øĎðĒïï÷ć (Dosage Forms) Clopixol acuphase® : 50 mg/ml, 100 mg/2 ml
Clopixol decanoate® : 200 mg/ml
Zuclopenthixol acuphase® management short-term
(acute treatment)
Zuclopenthixol decanoate® manage management long-term
long-term
Psychosis ; agitated states (đÞóćą Zuclopenthixol acuphase)
Bipolar disorder
Injection
Zuclopenthixol acuphase : 50-150 mg/day ÞĊé IM ìčÖ 2-3 üĆî
×îćé÷ć (Dosage) (ÞĊé 1 course êĉéêŠĂÖĆîĕéšĕöŠđÖĉî 4 ÙøĆĚÜ) maximum 400 mg/course
Zuclopenthixol decanoate : 100-200 mg/day ÞĊé IM ìčÖ 1-4
ÿĆðéćĀŤ maximum 600 mg/week
Thioridazine
ßČęĂÿćöĆâ (Generic name) Thioridazine Hydrochloride
ßČęĂÖćøÙšć (Trade name) Melleril®, Ridazine®, Thiomed®, Calmaril®, Dazine-P®, Thiosia®
øĎðĒïï÷ć (Dosage Forms) Tablet : 10, 25, 50, 100 mg
Schizophrenia ìĊęĕöŠêĂïÿîĂÜêŠĂ÷ćÝĉêđüßĂČęî ĀøČĂĕöŠÿćöćøëìî
ñú×šćÜđÙĊ÷ÜÝćÖ÷ćĂČęîĕéš
Schizophrenia/psychosis (children)
Behavior problem (children)
Severe psychosis (children)
Depressive disorder dementia (children and adults)
Thioridazine
dementia behavior (elderly)
Schizophrenia/psychosis (children >12 ðŘ and adults)
150-300 mg/day (maximum 800 mg/day) ĒïŠÜĔĀšüîĆ úą 2-4 ÙøĆĚÜ
×îćé÷ć (Dosage) Depressive disorder dementia 20-200 mg/day
Dementia behavior (elderly)
10-50 mg/day (maximum 400 mg/day)
Chlorpromazine
ßČęĂÿćöĆâ (Generic name) Chlorpromazine
ßČęĂÖćøÙšć (Trade name) Largactil®, Chlorpromed®, Matcine®, Prozine®, Chlormazine®
Tablet : 25, 50, 100, 200 mg
øĎðĒïï÷ć (Dosage Forms)
Injection : 50 mg/2 ml
Schizophrenia ìĊęöĊĂćÖćø mania
Severe nausea and vomiting
Hiccups (ÿąĂċÖ)
×šĂïŠÜĔßš (Indication) Hyperactive children
Relief of restlessness and apprehension before surgery
Acute intermittent porphyria
Adjunct in treatment of tetanus
psychosis
×šĂïŠÜĔßšĂîČę ė (Off-label use) dementia behavior (elderly)
Oral : 400-600 mg/day (maximum 1,000-2,000 mg/day)
Injection : IM/IV 25-50 mg ìčÖ 1-4 ßĆęüēöÜ (maximum 400
×îćé÷ć (Dosage) mg/dose ìčÖ 4-6 ßĆęüēöÜ, usual dose 300-800 mg/day)
Hiccups
Oral, IM 25-50 mg 3-4 ÙøĆÜĚ /üĆî
Nausea/Vomiting
Chlorpromazine
Oral : 10-25 mg ìčÖ 4-6 ßĆęüēöÜ
IM / IV : 25-50 mg ìčÖ 4-6 ßĆęüēöÜ
Dementia behavior (elderly)
10-50 mg/day (maximum 800 mg/day)
µÒÃÒ§·Õè 5 áÊ´§ Pharmacokinetic Parameters ¢Í§ Antipsychotic drugs
2. ÂÒÃÑ¡ÉÒâÃ¤¨ÔµÃØ‹¹ãËÁ‹
(Second generation, Atypical antipsychotics)
áÊ´§¡Åä¡¡ÒÃÍÍ¡Ä·¸Ôì¢Í§ Atypical antipsychotics

ÂÒÃÑ ¡ ÉÒâÃ¤¨Ô µ ÃØ‹ ¹ãËÁ‹ ËÃ× Í àÃÕ Â ¡ÂÒ¡ÅØ‹ Á ¹Õé Ç‹ Ò serotonin-dopamine
antagonists (SDAs) ËÃ×Í second generation antipsychotics ËÃ×Í atypical
antipsychotics µ‹Ò§¨Ò¡ÂÒÃÑ¡ÉÒâÃ¤¨ÔµÃØ‹¹áÃ¡ ¤×Í ¤ÇÒÁÊÒÁÒÃ¶ã¹¡ÒÃ¨Ñº¡Ñº
receptors (receptor affinities) áÅÐ¼Å¢ŒÒ§à¤ÕÂ§¨Ò¡ÂÒ
atypical antipsychotics ÊÒÁÒÃ¶»´¡Ñé¹·Ñé§ dopamine receptors áÅÐ
serotonin receptors ·íÒãËŒà¡Ô´¤ÇÒÁÊÁ´ØÅÃÐºº¡ÒÃ·íÒ§Ò¹ÃÐËÇ‹Ò§ serotonin
áÅÐ dopamine â´Â atypical antipsychotics ÁÕÊÑ´Ê‹Ç¹¤ÇÒÁÊÒÁÒÃ¶ã¹¡ÒÃ»´
¡Ñé¹ 5-HT2 (serotonin receptor type 2) µ‹Í dopamine-2 receptors ÊÙ§¡Ç‹Ò
ÁÕ¤ÇÒÁ¨íÒà¾ÒÐã¹¡ÒÃ»´¡Ñé¹ dopamine-2 receptor ·Õè mesolimbic ÁÒ¡¡Ç‹Ò ¡ÒÃ
¨Ñº¡Ñº dopamine receptors ¨ÑºÍÂ‹Ò§ËÅÇÁ æ ·íÒãËŒà¡Ô´¼Å¢ŒÒ§à¤ÕÂ§µèíÒ¡Ç‹Ò
ÂÒÃÑ¡ÉÒâÃ¤¨Ôµ¡ÅØÁ‹ ãËÁ‹¨ÐÍÍ¡Ä·¸Ôºì ÃÔàÇ³ mesolimbic áÅÐ mesocortical
¢Í§ÊÁÍ§ÁÒ¡¡Ç‹ÒºÃÔàÇ³ nigrostriatal ËÃ×Í tuberoinfundibular ÍÒ¡ÒÃ¢ŒÒ§à¤ÕÂ§
·Ò§ extrapyramidal ¨Ö§¾ºäÁ‹ÁÒ¡ ¹Í¡¨Ò¡¹ÕéÂÒÃÑ¡ÉÒâÃ¤¨Ôµ¡ÅØ‹ÁãËÁ‹ÂÑ§¨Ñº¡Ñº
5-HT2A receptor «Ö§è àª×Íè Ç‹Ò¨Ðä»ÁÕ¼Åà¾ÔÁè ¡ÒÃËÅÑ§è dopamine ºÃÔàÇ³ nigrostriatal
·íÒãËŒ¡ÒÃà¡Ô´ EPS Å´Å§ Å‹ÒÊØ´¹Õé¾ºÇ‹ÒÂÒÃÑ¡ÉÒâÃ¤¨Ôµ¡ÅØ‹ÁãËÁ‹¨Ð¨Ñº¡Ñº D2
receptor äÁ‹á¹‹¹ÁÒ¡à·‹Ò¡ÑºÂÒ¡ÅØ‹Áà´ÔÁ ¡ÒÃ·ÕèÂÒ¨Ñº¡Ñº receptor áÅŒÇËÅØ´ÍÍ¡ä»
àÃçÇ ·íÒãËŒÁÕ dopamine ¨Ò¡ºÃÔàÇ³¹Ñé¹à¢ŒÒä»¨Ñº¡Ñº receptor á·¹·Õè ¨Ö§¾º¡ÒÃ
à¡Ô´ EPS «Öè§à¡Ô´¨Ò¡¡ÒÃ·íÒ§Ò¹¢Í§ dopamine µèíÒ¡Ç‹Ò»¡µÔ ¹ŒÍÂ¡Ç‹ÒÂÒ¡ÅØ‹Áà´ÔÁ
¼Å¢ŒÒ§à¤ÕÂ§ EPS, prolactin elevated áÅÐ¼Å¢ŒÒ§à¤ÕÂ§ª¹Ô´ NMS à¡Ô´
ä´ŒµèíÒ¡Ç‹ÒÂÒÃÑ¡ÉÒâÃ¤¨ÔµÃØ‹¹áÃ¡ Ê‹Ç¹¼Å¢ŒÒ§à¤ÕÂ§¹éíÒË¹Ñ¡à¾ÔèÁ ÃÐ´Ñºä¢ÁÑ¹ã¹àÅ×Í´ÊÙ§
à¾ÔèÁ¤ÇÒÁàÊÕèÂ§µ‹Í metabolic syndrome ÂÒ¡ÅØ‹ÁãËÁ‹¨Ðà¡Ô´ä´ŒÁÒ¡¡Ç‹Ò ´Ñ§¹Ñé¹¤ÇÃ
ãËŒ¤ÇÒÁÃÙŒàÃ×èÍ§¡ÒÃ»¯ÔºÑµÔµÑÇ à¾×èÍ¤Çº¤ØÁÀÒÇÐ´Ñ§¡Å‹ÒÇá¡‹¼ÙŒ»†ÇÂµÑé§áµ‹àÃÔèÁãªŒÂÒ áÅÐ
¤ÇÃªÑè§¹éíÒË¹Ñ¡µÔ´µÒÁà»š¹ÃÐÂÐ
´ŒÒ¹»ÃÐÊÔ·¸ÔÀÒ¾¡ÒÃÃÑ¡ÉÒ ÂÒÃÑ¡ÉÒâÃ¤¨Ôµ·Ñé§ÊÍ§ÃØ‹¹ÁÕ»ÃÐÊÔ·¸ÔÀÒ¾äÁ‹áµ¡
µ‹Ò§¡Ñ¹ áµ‹¨Ò¡¡ÒÃÈÖ¡ÉÒ¾ºÇ‹Ò¡ÅØÁ‹ ÍÒ¡ÒÃÅº (negative symptoms) ¢Í§âÃ¤¨ÔµàÀ·
¨ÐµÍºÊ¹Í§µ‹ÍÂÒ atypical antipsychotics ä´Œ´Õ¡Ç‹Ò «Öè§¡ÅØ‹ÁÍÒ¡ÒÃÅº¨Ðà»š¹µÑÇ
¡í Ò Ë¹´¤ÇÒÁÊÒÁÒÃ¶ã¹¡ÒÃãªŒ ªÕ ÇÔ µã¹ÊÑ § ¤ÁáÅÐ¡ÒÃ·í Ò §Ò¹¢Í§¼ÙŒ »† Ç Â ´Ñ § ¹Ñé ¹
atypical antipsychotics ¹‹Ò¨Ðª‹ÇÂãËŒ¼ÙŒ»†ÇÂâÃ¤¨ÔµàÀ·ÁÕ¤Ø³ÀÒ¾ªÕÇÔµ´Õ¢Öé¹
µÒÃÒ§·Õè 6 áÊ´§ÃÒÂ¡ÒÃÂÒ atypical antipsychotics
¡ÒÃ¨Ñº¡Ñº Receptor ¢¹Ò´ÂÒ·ÕèãªŒ áÅÐ¢¹Ò´ÂÒÊÙ§ÊØ´µ‹ÍÇÑ¹
×îćé÷ćìĊęĒîąîĞćêŠĂüĆî ×îćéÿĎÜÿčéêŠĂüĆî
ßČęĂ÷ć ÖćøÝĆïÖĆï Receptor
(öÖ./üĆî) (öÖ./üĆî)
Clozapine 150-600 900
Risperidone 2-8 16
Olanzapine 10-20 20
Quetiapine 400-600 800
Ziprasidone 80-120 160
Aripiprazole 10-30 30
µÒÃÒ§·Õè 7 áÊ´§¼Å¢ŒÒ§à¤ÕÂ§¢Í§ÂÒ atypical antipsychotics
ADR Clozapine Risperidone Olanzapine Quetiapine Ziprasidone Aripiprazole
EPS 0? + + + + +
Prolactin elevation 0 +++ 0 0 + 0
Weight gain +++ ++ +++ ++ 0 0
Glucose abnormal +++ ++ +++ ++ 0 0
Lipid abnormal +++ ++ +++ ++ 0 0
QTc prolongation 0 + 0 0 + 0
Sedation +++ + +++ +++ 0 +
Hypotension +++ + + ++ 0 0
Anticholinergics +++ 0 + ++ 0 0
á¼¹ÀÒ¾áÊ´§¼Å¢Í§ Atypical antipsychotics µ‹Í¼Å·Ò§´ŒÒ¹ Metabolic syndrome

From: http://img.medscape.com/fullsize/migrated/493/571/bjdvd493571.fig1.gif
Clozapine
ßČęĂÿćöĆâ (Generic name) Clozapine
ßČęĂÖćøÙšć (Trade name) Clozaril®, Clopaze®
ēÙøÜÿøšćÜ (Structure) DiBenzodiazepine derivatives
øĎðĒïï÷ć (Dosage form) Oral : 25, 100 mg
ēøÙÝĉêđõììĊęéČĚĂêŠĂÖćøøĆÖþć (resistant to treatment) éšü÷÷ćøĆÖþćēøÙ
×šĂïŠÜĔßš (Indication) ÝĉêßîĉéĂČęî
ñĎšðśü÷ìĊęìîñú×šćÜđÙĊ÷ÜÝćÖÖćøøĆÖþćéšü÷÷ćøĆÖþćēøÙÝĉêøčŠîĒøÖĕöŠĕéš
Schizoaffective disorder
Bipolar disorder
×šĂïŠÜĔßšĂîČę (Off-label use)
Childhood psychosis
Severe obsessive compulsive disorder
Childhood psychosis (Unlabeled use)
25-400 mg/day
Schizophrenia
target dose 300-450 mg/day (slow titration)
maximum dose 600-900 mg/day
75-100 mg/day
ñúêŠĂøąïïđúČĂé
Agranulocytosis ÙČĂ absolute neutrophil count ĀøČĂ ANC < 500
đàúúŤ/úï.öö. óïøć÷ÜćîÖćøđÖĉéøšĂ÷úą 0.38
Neutropenia ÙČĂ ANC < 1,500 đàúúŤ/úï.öö. óïøć÷ÜćîÖćøđÖĉé
øšĂ÷úą 2.95
อาการไมพึงประสงค ÙüćöđÿĊę÷ÜĔîÖćøđÖĉé agranulocytosis ðŘĒøÖóïĕéšøšĂ÷úą 0.73 Ēúą
úéúÜđĀúČĂ 0.07 ĔîðŘìĊęÿĂÜ
Ùüøêĉéêćö đøĉęöĔßš÷ćÙøĆĚÜĒøÖ ÙüøêøüÝ CBC ìčÖÿĆðéćĀŤêĉéêŠĂÖĆî 18
ĂćÖćøĕöŠóċÜðøąÿÜÙŤ ÿĆðéćĀŤ (ĔîßŠüÜĒøÖ) ĀøČĂĂ÷ŠćÜîšĂ÷êšĂÜêøüÝ CBC ìčÖ 1 đéČĂîĔîðŘĒøÖ
ĒúąìčÖ 2-3 đéČĂîĔîðŘêŠĂ ė ĕð ĀøČĂìčÖÙøĆĚÜìĊęöĊĂćÖćøêĉéđßČĚĂ
ÖćøĀ÷čé÷ć WBC < 3,500 3.500 đàúúŤ/úï.öö. Ēúą/ĀøČĂ
1,500 đàúúŤ/úï.öö. ÙüøĀ÷čé÷ćìĆîìĊ
ANC <1500
Clozapine
ĀúĆÜĀ÷čé÷ć đöĘéđúČĂé×ćüÝąÖúĆïöćðÖêĉĔî 14-21 üĆî
îĚĞćúć÷ĕĀú (hypersalivation)
îĚĞćúć÷ĕĀúöćÖ ēé÷đÞóćąĔîßŠüÜîĂîĀúĆï ìĞćĔĀšñĎšðśü÷øĎšÿċÖøĞćÙćâ
ÖćøĒÖšĕ× ÖćøĔĀšการใหaanticholinergics
nticholinergics đßŠเชîน Benztropine
Benztropine ĀøČ
หรืĂอ
Trihexyphenidyl ßŠü÷úéĂćÖćøĕéš ĔĀšñĎšðśü÷îĂîĀîčîĀĆüÿĎÜ ĒúąòřÖ
ÖúČîîĚĞćúć÷ïŠĂ÷ ė
ñúêŠĂîĚĞćĀîĆÖêĆü
ĂćÝìĞćĔĀšîĚĞćĀîĆÖêĆüđóĉęöđÞúĊę÷ 4.5 kg ĀúĆÜĕéš÷ć 10 ÿĆðéćĀŤ ĒúąĂćÝìĞćĔĀš
îĚĞćĀîĆÖîĚĞćĀîĆÖêĆüđóĉęöđÞúĊę÷ 6.9 kg ĀúĆÜĕéš÷ć 6 đéČĂî
đðøĊ÷ïđìĊ÷ïÖĆï÷ćøĆÖþćēøÙÝĉêøčŠîĒøÖ Clozapine ìĞćĔĀšîĚĞćĀîĆÖêĆüđóĉęö×ċĚî
øšĂ÷úą 7 Ĕî×èąìĊę÷ćøĆÖþćēøÙÝĉêøčŠîĒøÖìĞćĔĀšîĚĞćĀîĆÖêĆüđóĉęö×ċĚîøšĂ÷úą 4
Clozapine Ĕî×îćéÿĎÜ ÝąìĞćĔĀšîĚĞćĀîĆÖêĆüđóĉęööćÖÖüŠć
×îćé 600 mg/day îĚĞćĀîĆÖêĆüÝąđóĉęö 4.4 kg,
300 mg/day îĚĞćĀîĆÖêĆüÝąđóĉęö 2.6 kg Ēúą
100 mg/day îĚĞćĀîĆÖêĆüÝąđóĉęö 1.3 kg
อาการไมพึงประสงค ñĎšðśü÷ìĊęđÖĉéñú×šćÜđÙĊ÷ÜîĊĚöćÖ ÙüøĒîąîĞćđøČęĂÜĂćĀćøĒúąÖćøĂĂÖÖĞćúĆÜ
Öć÷ ĀćÖĕöŠĕéšñúĂćÝÝĞćđðŨîêšĂÜóĉÝćøèćđðúĊę÷îđðŨî÷ćìĊęöĊñúêŠĂîĚĞćĀîĆÖ
êĆüîšĂ÷úÜ
ñúêŠĂēøÙđïćĀüćî
ñĎšðśü÷ìĊęĕéš Clozapine ÝąöĊÙüćöđÿĊę÷ÜìĊęÝąđÖĉéēøÙđïćĀüćîĕéšøšĂ÷úą
ĂćÖćøĕöŠóċÜðøąÿÜÙŤ 25.7 % (Lamberti JS ĒúąÙèą)
ÙüøđÝćąđúČĂéêøüÝêĉéêćöîĚĞćêćúĔîđúČĂé (fasting blood sugar) đðŨî
øą÷ąĂ÷ŠćÜÿöęĞćđÿöĂ
ñúêŠĂĕ×öĆîĔîđúČĂé
öĊÖćøýċÖþćóïüŠć Clozapine Ēúą Olanzapine öĊÙüćöÿĆöóĆîíŤÖĆïøąéĆï
triglyceride ìĊęÿĎÜ×ċĚîĂ÷ŠćÜöĊîĆ÷ÿĞćÙĆâ
ñúêŠĂøąïïĀĆüĔÝĒúąĀúĂéđúČĂé
Tachycardia ĂćÝđÖĉéÝćÖ anticholinergic àċęÜöĆÖđÖĉéĔîßŠüÜĒøÖìĊęĕéš
ĒúąÝąÿćöćøëðøĆïêĆüÝćÖĂćÖćø×šćÜđÙĊ÷ÜîĊĚĕéšđöČęĂĔßš÷ćêŠĂđîČęĂÜøą÷ąĀîċęÜ
Orthostatic hypotension (Postural hypotension) đÖĉéÝćÖùìíĉĝ
alpha adrenergic receptor ÿŠüîĔĀâŠĕöŠøčîĒøÜ öĆÖđÖĉéĔîßŠüÜìĊęðøĆï÷ć
Clozapine
×ċĚîđøĘü ĒúąÝąÿćöćøëðøĆïêĆüÝćÖĂćÖćø×šćÜđÙĊ÷ÜîĊĚĕéšđöČęĂĔßš÷ćêŠĂđîČęĂÜ
øą÷ąĀîċęÜ
Myocarditis öĊēĂÖćÿđÖĉ éĕéš îšĂ÷ ĒêŠĀćÖđÖĉé×ċĚîÝąîĞćĕðÿĎŠ õćüąĀĆüĔÝ
úšöđĀúü (heart failure) øšĂ÷úą 20 ×ĂÜñĎšđÖĉéĂćÖćøÝąđÿĊ÷ßĊüĉê đöČęĂÿÜÿĆ÷
üŠćĂćÝđÖĉé myocarditis ÙüøĀ÷čé Clozapine ìĆîìĊ ĒúąêøüÝ EKG
üĆéđĂöĕàöŤ creatinine kinase Ēúą erythrocyte sedimentation rate
ñúêŠĂÖćøßĆÖ
อาการไมพึงประสงค ēé÷ĂĆêøćÖćøßĆÖÿĆöóĆîíŤÖĆï×îćé÷ć
×îćé÷ćêęĞćÖüŠć 300 mg/day ÝąöĊĂĆêøćÖćøßĆÖøšĂ÷úą 1
×îćé 300-599 mg/day ÝąöĊĂĆêøćÖćøßĆÖøšĂ÷úą 2.7
×îćéêĆĚÜĒêŠ 600 mg/day ÝąöĊĂĆêøćÖćøßĆÖøšĂ÷úą 4.4
ÙüøöĊÖćøêøüÝ EEG ÖŠĂîđøĉęö÷ć×îćé 600 mg/day
ĂćÖćøĕöŠóċÜðøąÿÜÙŤ ëšćóïÙüćöñĉéðÖêĉ×ĂÜÙúČęîÿöĂÜĂćÝĔĀš÷ćÖĆîßĆÖøŠüöĕéš ĒöšÝąđðŨîÖćøßĆÖ
ÝćÖ Clozapine ĒêŠĕöŠĕéšđðŨî×šĂĀšćöĔîÖćøĔßš Clozapine ĒêŠÙüøúé
×îćé÷ćúÜĒúąĔĀš÷ćÖĆîßĆÖøŠüö
Risperidone
ßČęĂÿćöĆâ (Generic name) Risperidone
ßČęĂÖćøÙšć (Trade name) Risperdal®, Neuris®, Risperidone GPO®
ēÙøÜÿøšćÜ (Structure) Benzisoxaxole
Tablet : 1, 2 mg
øĎðĒïï÷ć (Dosage form) Solution : 1 mg/ml (30 ml)
Injection : 50 mg/vial (IM q 2 wk)
Schizophrenia
Mania or mixed episode bipolar type 1
(monotherapy or combine with Lithium or Valproate)
Irritability/aggression autistic disorder
Tourette’s disorder
Pervasive developmental disorder
Risperidone
Schizophrenia
Oral : usual dose 2-8 mg/day (maximum 16 12 mg/day)
IM : 25-50 mg q 2 week
Bipolar mania 1-6 mg/day
Elderly
Oral : 0.25-1 mg/day (maximum 1.5-2 mg/day)
IM : 12.5 mg q 2 week
EPS
ñú×šćÜđÙĊ÷Ü EPS ÿĆöóĆîíŤÖĆï×îćé÷ć ēé÷×îćé 4-16 mg/d ĂćÝóï
ñú×šćÜđÙĊ÷ÜìĆĚÜ dystonia Ēúą akathisia ĕéš
Hyperprolactinemia
ĔîđóýĀâĉÜ ìĞćĔĀšđÖĉé galactorrhea ðøąÝĞćđéČĂîñĉéðÖêĉ Ĕîđóýßć÷
ĂćÖćøĕöŠóċÜðøąÿÜÙŤ
ìĞćĔĀšđÖĉé sexual dysfunction
Orthostatic hypotension (postural hypotension) öĆÖđÖĉé
ßŠมัüกÜĒøÖ×ĂÜÖćøĕéš øĆï÷ć ĀúĆรับÜÝćÖĕéš
เกิดชวงแรกของการได ยา หลัøงĆïจากได
êŠĂđîČęĂรับÜ ตÝąéĊ
อเนื×่อċĚîงจะดีขึ้น
ÜŠüÜàċö Ă÷ćÖĂćĀćøđóĉęö×ċîĚ îĚĞćĀîĆÖêĆüđóĉöę ×ċĚî
đöČęĂđðøĊ÷ïđìĊ÷ïÖĆï Clozapine Ēúą Olanzapine óïüŠć Risperidone öĊñú
ÜŠüÜàċö ĒúąîĚĞćĀîĆÖêĆüđóĉęö×ċĚîîšĂ÷ÖüŠć
Olanzapine
ßČęĂÿćöĆâ (Generic name) Olanzapine
ßČęĂÖćøÙšć (Trade name) Zyprexa®, Olapine®
ēÙøÜÿøšćÜ (Structure) ThienoBenzodiazepine
øĎðĒïï÷ć (Dosage form) 5, 10 mg
Schizophrenia
Acute or mixed mania episode bipolar type 1
×šĂïŠÜĔßš (Indication) (monotherapy or combine Lithium or Valproate)
Maintenance bipolar disorder
Acute agitation (Schizophernia or bipolar mania)
×šĂïŠÜĔßšĂîČę (Off-label use) Schizophrenia/psychosis (children and adolescents)
Chronic pain
Olanzapine
Prevention chemotherapy associated delayed nausea or
vomiting
Schizophrenia
5-20 mg once daily (max 20 mg/day)
Bipolar type I acute mixed or manic episodes
Monotherapy : 5-20 mg once daily (max 20 mg/day)
Combination (Li, VPA) : 5-20 mg/day
Agitation (Schizophrnia, acute bipolar I mania)
×îćé÷ć (Dosage) 5-10 mg/day (maximum 30 mg/day)
Prevention nausea or vomiting in chemotherapy
10 mg/day for 3-5 days ĀøČĂ 5 mg once daily ÖŠĂîđøĉęö
chemotherapy 2 üĆî Ēúą 10 mg once daily ĔîüĆîìĊęđøĉęöĔĀš chemo
3-8 üĆî
Elderly
1.25-5 mg/day (max 10 mg/day)
ÜŠüÜàċö (sedation)
ìĞćĔĀšÜŠüÜàċööćÖ ēé÷×ċĚîÖĆï×îćé÷ćìĊęĔßš öĆÖđÖĉéĔîßŠüÜĒøÖ×ĂÜÖćøĕéšøĆï÷ć
Orthostatic hypotension (Postural hypotension)
óïĕéšîšĂ÷ÖüŠć Clozapine
Anticholinergic
óïĕéšîšĂ÷
îĚĞćĀîĆÖêĆüđóĉöę
đÖĉéñú×šćÜđÙĊ÷ÜîĊĚĕéšöćÖìĊęÿčé đöČęĂđìĊ÷ïÖĆï Ziprasidone Ēúą
Aripiprazole ēé÷ÿĆöóĆîíŤÖĆï×îćé÷ćìĊęĔßš
öĊÖćøýċÖþćđðøĊ÷ïđìĊ÷ï óïüŠć Olanzapine öĊÙüćöđÿĊę÷ÜÖćøđÖĉé
ēøÙđïćĀüćîöćÖÖüŠć÷ćøĆÖþćēøÙÝĉêøčŠîĒøÖ
ñúêŠĂĕ×öĆîĔîđúČĂé
ÙüćöđÿĊę÷Ü hyperlipidemia ÿĎÜÖüŠć÷ćøĆÖþćēøÙÝĉêøčŠîĒøÖ ĒêŠîšĂ÷ÖüŠć
Clozapine
Quetiapine
ßČęĂÿćöĆâ (Generic name) Quetiapine fumarate
ßČęĂÖćøÙšć (Trade name) Seroquel®, Seroquel XR®, Quania®, Neutrapin®,
ēÙøÜÿøšćÜ (Structure) DiBenzodiazepine
øĎðĒïï÷ć (Dosage form) 25, 100, 200 mg, XR 50, XR 300, XR 400 mg
Schizophrenia
Acute manic episodes bipolar disorder
Depressive episodes bipolar disorder
Maintenance treatment bipolar disorder
Autism
Psychosis (children)
Bipolar disorder
depression 300-600 mg/day
mania 400-800 mg/day
300-800 mg/day
(maximum 800 mg/day)
ÜŠüÜàċö (sedation)
óïĕéšïŠĂ÷ Ēúą×ċĚîÖĆï×îćé÷ćìĊęĔßš öĆÖđÖĉéĔîßŠüÜĒøÖ×ĂÜÖćøĕéšøĆï÷ć
Orthostatic hypotension (Postural hypotension)
óïĕéšîšĂ÷ öĆÖđÖĉéĔîßŠüÜĒøÖìĊęĕéšøĆï÷ć
Anticholinergic
óïĕéšîšĂ÷
ĂćÖćøĕöŠóċÜðøąÿÜÙŤ îĚĞćĀîĆÖêĆüđóĉöę
ĂćÝìĞćĔĀšîĚĞćĀîĆÖêĆüđóĉęöĕéš 1.7-2.3 kg ĒêŠñú×šćÜđÙĊ÷ÜîĊĚóïĕéšîšĂ÷ÖüŠć
Clozapine
Hyperglycemia öĆÖóï 6 đéČĂîĒøÖ ×ĂÜÖćøĔßš÷ć
EPS
ĂćÝìĞćĔĀšđÖĉéñú×šćÜđÙĊ÷ÜîĊĚĕéš ĒêŠđÖĉéĕéšîšĂ÷öćÖ
Ziprasidone
Quetiapine
ßČęĂÿćöĆâ (Generic name) Ziprasidone
ßČęĂÖćøÙšć (Trade name) Zeldox®
ēÙøÜÿøšćÜ (Structure) Benzisothaizolyl piperazine
øĎðĒïï÷ć (Dosage form) 20, 40, 60, 80 mg
Schizophrenia
×šĂïŠÜĔßš (Indication) Acute manic or mixed episodes bipolar with or without psychosis
Acute agitation schizophrenia
×šĂïŠÜĔßšĂîČę (Off-label use) Tourette’s syndrome
Schizophrenia
20-100 mg twice daily
Bipolar mania
40-80 mg twice daily
Acute agitation
10 mg ìčÖ 2 ßĆęüēöÜ (maximum 40 mg/day)
Elderly
No dosage adjustment is recommend, slower titration
ÜŠüÜàċö
øąéĆïîšĂ÷ëċÜðćîÖúćÜ
QTc prolongation
ĕöŠÿĎÜđĀöČĂî Thioridazine US. FDA ÝċÜĕöŠĕéšÖĞćĀîéĔĀšêøüÝ EKG ÖŠĂîĔßš÷ć
îĚĞćĀîĆÖêĆüđóĉöę
öĊñúđóĉęöîĚĞćĀîĆÖĕéšîšĂ÷öćÖ ðøąöćè 0.04 kg Ĕî 10 ÿĆðéćĀŤ
Aripiprazole
ßČęĂÿćöĆâ (Generic name) Aripiprazole
ßČęĂÖćøÙšć (Trade name) Abilify®
ēÙøÜÿøšćÜ (Structure) dihydroquinolone
Tablet : 10, 15 mg
øĎðĒïï÷ć (Dosage form)
Solution : 1 mg/ml (150ml)
Schizophrenia
×šĂïŠÜĔßš (Indication) Adjunctive therapy of bipolar (acute manic or mixed episodes)
Adjunctive therapy of major depressive disorder
Depression with psychotic features
Aggression (children)
Conduct disorder (children)
Tourette’ssyndrome
Tourette syndrome(children’s)
(children’s)
Schizophrenia
10-15 mg once daily (maximum 30 mg/day)
Bipolar (acute manic or mixed episodes)
×îćé÷ć (Dosage) Monotherapy : 15 mg once daily
Combination (Li, VPA) : 15 mg once daily
Depression (adjunctive with antidepressants)
2-15 mg/day
îĚĞćĀîĆÖêĆüđóĉęö öĊñúđóĉęöîĚĞćĀîĆÖĕéšîšĂ÷öćÖ
EPS đÖĉéĔîĂĆêøćìĊęêęĞćöćÖ
ĂćÖćøĕöŠóċÜðøąÿÜÙŤ ĕöŠöĊñú×šćÜđÙĊ÷ÜêŠĂ prolactin
ĕöŠìĞćĔĀšđÖĉéÖćøđðúĊę÷îĒðúÜøąéĆïîĚĞćêćúĒúąĕ×öĆîĔîđúČĂé
ĕöŠöĊñúêŠĂ QTc prolongation
Paliperidone
ßČęĂÿćöĆâ (Generic name) Paliperidone
ßČęĂÖćøÙšć (Trade name) Invega®, Invega sustenna®
ēÙøÜÿøšćÜ (Structure) Benzisoxazole derivatives
Tablet : 3, 6, 9 mg (extended release)
øĎðĒïï÷ć (Dosage form)
Injection : 50, 75, 100, 150 mg
×šĂïŠÜĔßš (Indication) Schizophrenia
×šĂïŠÜĔßšĂîČę (Off-label use) Psychosis/agitation related to Alzheimer’s dementia
Schizophrenia
Oral : usual 6 mg once daily (maximum 12 mg/day)
Injection :
Initial 150 mg IM then
Day8 100 mg IM then ðøąđöĉîñúĒúąĔĀš×îćé÷ćêćö
clinical 75-150 mg IM q 1 đéČĂî
êćøćÜĒÿéÜÖćøđðúĊę÷îÝćÖ oral đðŨî injection
Paliperidone Paliperidone
Oral Injection
12 mg OD 150 mg q mo
6 mg OD 75 mg q mo
3 mg OD 25-50 mg q mo
îĚĞćĀîĆÖêĆüđóĉęöĕ×öĆîĔîđúČĂéÿĎÜ öĊñúîšĂ÷
EPS đÖĉéĔîĂĆêøćìĊęêęĞć
ñú×šćÜđÙĊ÷ÜĂČęî ė đßŠî ðüéĀĆü (14%), îĂîĕöŠĀúĆï (12%)
ñú×šćÜđÙĊ÷ÜĂČęî ė øĂÖćøýċÖþćđóĉęöđêĉöĔîĂîćÙê
àÍ¡ÊÒÃÍŒÒ§ÍÔ§
ªÁÀÙ¹Øª ÇÕÃÐÇÑ¸¹ªÑÂ. ¤Ù‹Á×Í¡ÒÃãªŒÂÒ·Ò§¨ÔµàÇªÊíÒËÃÑºà¨ŒÒË¹ŒÒ·ÕèÊÒ¸ÒÃ³ÊØ¢.
¡ÅØ‹Á§Ò¹àÀÊÑª¡ÃÃÁ âÃ§¾ÂÒºÒÅ¾ÃÐÈÃÕÁËÒâ¾¸Ôì; 2553
ÁÒâ¹ª ËÅ‹ÍµÃÐ¡ÙÅ, »ÃÒâÁ·Â ÊØ¤¹ÔªÂ. ¨ÔµàÇªÈÒÊµÃ ÃÒÁÒ¸Ôº´Õ. ¡ÃØ§à·¾Ï
ºÕÂÍ¹´ àÍç¹à·ÍÃä¾Ãª; 2552.
¾Ôàª° ÍØ´ÁÃÑµ¹, ÊÃÂØ·¸ ÇÒÊÔ¡¹Ò¹¹·. µíÒÃÒâÃ¤¨ÔµàÀ·
(Textbook of Schizophrenia). ¡ÃØ§à·¾Ï:
ÊÁÒ¤Á¨Ôµá¾·ÂáË‹§»ÃÐà·Èä·Â; 2552.
Joseph T. Dipiro, Robrert L Talbert and et al, Pharmacotherapy
A Pathophysiologic Approach, 8th ed., 2011.
Matthew A. Fuller, Martha Sajatovic. Drug information handbook for
Psychiatry 7 th edition: American Pharmacists Association; 2009.
Stephen M. Stahl: Stahl’s Essential Psycopharmacology: neuroscientific
basis and practical application.-3 ed. Cambridge University
Press 2008.
ÂÒ¤ÅÒÂ¡Ñ§ÇÅ (Antianxiety Drugs)
ÂÒ¡ÅØ‹Áàº¹â«ä´ÍÐ«ÕºÕ¹ (Benzodiazepine) ·Õè¾ºª¹Ô´áÃ¡¤×Í ¤ÅÍÃä´ÍÐ
«Õ»Í¡ä«´ (Chlordiazepoxide) ã¹»‚ ¤.È. 1959 µ‹ÍÁÒÁÕ¡ÒÃ¤Œ¹¾ºä´ÍÐ«Õ»‚¹ã¹»‚
¤.È. 1963 áÅÐÁÕ¡ÒÃ¤Œ¹¾ºà¾ÔèÁàµÔÁÍÕ¡ËÅÒÂª¹Ô´ ¨¹¡ÃÐ·Ñè§ »‚ ¤.È. 1981 ä´Œ¤Œ¹
¾º ÍÑÅ»ÃÒâ«áÅÁ (Alprazolam) «Öè§à»š¹¡ÅØ‹Á Triazolobenazepine «Öè§¶Ù¡¹íÒÁÒ
ãªŒã¹¡ÒÃÃÑ¡ÉÒÀÒÇÐÇÔµ¡¡Ñ§ÇÅ ÂÑ§ÁÕ»ÃÐÊÔ·¸ÔÀÒ¾ã¹¡ÒÃÃÑ¡ÉÒÀÒÇÐµ×è¹µÃÐË¹¡
(Panic disorder) «Öè§ä´ŒÃÑº¡ÒÃÃÑºÃÍ§¨Ò¡ FDA ª¹Ô´áÃ¡ µ‹ÍÁÒä´ŒÁÕ¡ÒÃÃÑºÃÍ§ÂÒ
Clonazepam ÁÕ»ÃÐÊÔ·¸ÔÀÒ¾ã¹¡ÒÃÃÑ¡ÉÒÀÒÇÐµ×è¹µÃÐË¹¡à¾ÔèÁàµÔÁ
ã¹·Ò§¡ÒÃá¾·Âä´ŒÁÕ¡ÒÃÊÑè§ãªŒÃÑ¡ÉÒ¼ÙŒ»†ÇÂ·ÕèÁÕÀÒÇÐÇÔµ¡¡Ñ§ÇÅµÑé§áµ‹»‚ ¤.È.
1960 «Ö§è ÁÕ»ÃÐÊÔ·¸ÔÀÒ¾áÅÐ»ÅÍ´ÀÑÂ¡Ç‹ÒÂÒ¡ÅØÁ‹ Barbiturate ËÃ×Í Meprobamate
«Öè§à»š¹ÂÒª¹Ô´áÃ¡ æ ·Õè¹íÒÁÒãªŒÃÑ¡ÉÒÀÒÇÐÇÔµ¡¡Ñ§ÇÅ áµ‹ÍÂ‹Ò§äÃ¡çµÒÁ¹ÑºµÑé§áµ‹»‚
¤.È. 1990 «Öè§ÁÕ¡ÒÃ¤Œ¹¾ºÂÒ¡ÅØ‹Á SSRI ä´Œ¶Ù¡¹íÒÁÒãªŒ·Ò§¡ÒÃá¾·Â·´á·¹
ÂÒàº¹â«ä´ÍÐ«Õ»‚¹ (Benzodiazepine) «Öè§ÁÕ¢ŒÍàÊÕÂ·íÒãËŒà¡Ô´¡ÒÃµÔ´ÂÒ (¡ÒÃÊÑè§¨‹ÒÂ
ÂÒ Benzodiazepine ã¹»‚ ¤.È. 1979 ÃŒÍÂÅÐ 11.1 Å´Å§ÁÒàËÅ×ÍÃŒÍÂÅÐ 8.3
ã¹»‚ ¤.È. 1990 ¨Ò¡¡ÒÃà¡çº¢ŒÍÁÙÅ¡ÒÃÊÑè§ãªŒÂÒã¹ÊËÃÑ°ÍàÁÃÔ¡Ò)
( )
Left: The 1,4-Benzodiazepine ring system. Right: 5-phenyl-1H-benzo[e][1,4]diazepin-2(3H)-
2-keto compounds: Chlordiazepoxide, Clorazepate, Diazepam, Flurazepam, Prazepam, etc.
3-hydroxy compounds: Lorazepam, Lormetazepam, Oxazepam, Temazepam
7-nitro compounds: Clonazepam, Flunitrazepam, Nimetazepam, Nitrazepam
Triazolo compounds: Adinazolam, Alprazolam, Estazolam, Triazolam
Imidazo compounds : Climazolam, Loprazolam, Midazolam
Benzodiazepine ÍÍ¡Ä·¸Ôâì ´Â¨ÑºµÑÇ¡Ñº GABA-A receptor ã¹ÊÁÍ§ à»š¹
GABA-Benzodiazepine receptor complex ·íÒãËŒ chloride ion channel
ÁÕ¡ÒÃà»´µÑÇÃÑº chloride à¢ŒÒà«ÅÅ à«ÅÅ»ÃÐÊÒ·ÍÂÙ‹ã¹ÀÒÇÐ hyperpolarization
(«Ö§è àÃÕÂ¡ÍÕ¡ª×Íè Ë¹Ö§è Ç‹Ò GABA-A BDZ receptor-Chloride ion channel complex)
´Ñ§¹Ñé¹ Benzodiazepine ·ÕèÁÕ¤Ø³ÊÁºÑµÔà»š¹ GABA Agonist ·íÒË¹ŒÒ·ÕèàÊÁ×Í¹¡Ñº
ÊÒÃÊ×èÍ»ÃÐÊÒ· GABA «Öè§¶Ù¡ÊÃŒÒ§¨Ò¡¡Ã´¡ÅÙµÒÁÔ¡ (Glutamic acid) ·ÕèàËÁ×Í¹
¡ÑºÊÒÃÊ×èÍ»ÃÐÊÒ·Í×è¹ æ â´Â»¡µÔ¨ÐÁÕµÑÇÃÑºÊíÒËÃÑºÊÒÃ¡ÒºÒ 2 ª¹Ô´ ¤×Í
- GABA-A receptor «Öè§¤Çº¤ØÁ chloride ion channel â´ÂÂÒ·Õè¨Ñº
¡ÑºµÑÇÃÑºª¹Ô´¹Õé ä´Œá¡‹ ÂÒ¡ÅØ‹Á Benzodiazepine, ÂÒ¡ÅØ‹Á Barbiturate, Alcohol,
ÂÒ¡ÅØ‹ Á nonBenzodiazepine àª‹ ¹ Zolpidem, Zaleplon áÅÐÊÒÃ¡ÅØ‹ Á
proconvulsant àª‹¹ Picrotoxin
ºÃÔ à Ç³ GABA receptor ¹Õé ¹Í¡¨Ò¡à¡Õè Â Ç¢Œ Í §¡Ñ º ¡ÒÃÍÍ¡Ä·¸Ôì ¢ Í§
Benzodiazepine áÅŒÇÂÑ§ÃÇÁä»¶Ö§ barbiturate áÅÐ ethanol ´ŒÇÂ ¨Ö§ÁÕ¼Å·Ò§àÀÊÑªÇÔ·ÂÒ
·ÕèàÊÃÔÁ¡Ñ¹ àÃÕÂ¡Ç‹Ò ÁÕ cross-tolerance µ‹Í¡Ñ¹ ¼ÙŒ»†ÇÂ·ÕèÁÕÍÒ¡ÒÃ¨Ò¡¡ÒÃËÂØ´ÊØÃÒ¨Ö§ÃÑ¡ÉÒ
â´Â Benzodiazepine ä´Œ¼Å´Õ
GABA-A BDZ receptor-Chloride ion channel complex ÁÕâ¤Ã§ÊÃŒÒ§à»š¹
pentametric ÁÕ 5 Ë¹‹ÇÂÂ‹ÍÂ ¨Ò¡â¾ÅÕà»»ä·´ 8 ª¹Ô´ä´Œá¡‹ α, β, γ, δ, ε, ¶,
ρ áÅÐ τ â´ÂÊ‹Ç¹ãËÞ‹¨Ð»ÃÐ¡Íº´ŒÇÂ 6 α, 3 β, 3 γ áÅÐ 2 δ
- GABA-B receptor â´ÂÂÒ·Õ¨è ºÑ ¡ÑºµÑÇÃÑºª¹Ô´¹Õäé ´Œá¡‹ ÂÒ¤ÅÒÂ¡ÅŒÒÁà¹×Íé
ºÒâ¤Åà¿¹ (Baclofen)
¤Ø ³ ÊÁºÑ µÔ · Ò§àÀÊÑ ª ÇÔ · ÂÒ·Õè Â Ò¡ÅØ‹ Á Benzodiazepine ä»¨Ñ º ¡Ñ º µÑ Ç ÃÑ º
Benzodiazepine (BDZ receptor) ·íÒãËŒà¡Ô´¼ÅÅÑ¾¸·Ò§àÀÊÑªÇÔ·ÂÒ 4 »ÃÐ¡ÒÃ ä´Œá¡‹
• ¤ÅÒÂÀÒÇÐÇÔµ¡¡Ñ§ÇÅ (anxiolytic)
• ·íÒãËŒ¹Í¹ËÅÑº (hypnotic)
• ÃÑ¡ÉÒâÃ¤ÅÁªÑ¡ (anticonvulsant)
• ¡ÅŒÒÁà¹×éÍ¤ÅÒÂµÑÇ (muscle relaxant)
¢ŒÍº‹§ªÕéã¹¡ÒÃãªŒÂÒ
ÂÒ¡ÅØ‹Á Benzodiazepine ÍÍ¡Ä·¸Ôì·Õè receptor ºÃÔàÇ³µ‹Ò§ æ ã¹ÊÁÍ§
àª‹¹ ¼Åµ‹Íà«ÅÅ»ÃÐÊÒ·ºÃÔàÇ³ cerebellum ·íÒãËŒà¡Ô´ÍÒ¡ÒÃ ataxia ¼Åµ‹ÍºÃÔàÇ³
reticular formation ·íÒãËŒà¡Ô´ÍÒ¡ÒÃ§‹Ç§«ÖÁ ¼Åµ‹ÍºÃÔàÇ³ hippocampus ·íÒãËŒ
ÂÒÁÕ»Þ˜ ËÒ´ŒÒ¹¤ÇÒÁ¨íÒ áÅÐ¼Åµ‹ÍºÃÔàÇ³ spinal cord ·íÒãËŒÁÕ muscle relaxation
à»š¹µŒ¹ â´ÂÊÃØ»¨Ò¡¡ÒÃ·ÕèÁÕÄ·¸Ôì·Ò§àÀÊÑªÇÔ·ÂÒËÅÒÂ»ÃÐ¡ÒÃ¢ŒÒ§µŒ¹ ·íÒãËŒÁÕ¡ÒÃ¹íÒ
ä»ãªŒ·Ò§¤ÅÔ¹Ô¡ÍÂ‹Ò§¡ÇŒÒ§¢ÇÒ§
¼Å·Ò§¤ÅÔ¹Ô¡ Therapeutic Uses

1. ¡ÅØ‹ÁâÃ¤ÇÔµ¡¡Ñ§ÇÅ (anxiety disorders) áÅÐÀÒÇÐµ×è¹µÃÐË¹¡
(Panic attack)
ÂÒ¡ÅØ‹Á Benzodiazepine (BZD) ÂÒã¹¡ÅØ‹Á¹Õé¨ÐÁÕËÅÒÂ¢¹Ò¹ áµ‹¡çÁÕ
»ÃÐÊÔ·¸ÔÀÒ¾ã¹¡ÒÃÅ´¤ÇÒÁÇÔµ¡¡Ñ§ÇÅä´Œ¾Í æ ¡Ñ¹ ¢¹Ò´ÂÒ·ÕèàËÁÒÐÊÁã¹¼ÙŒ»†ÇÂ
áµ‹ÅÐÃÒÂ¢Öé¹¡ÑºÍÒÂØáÅÐ¤ÇÒÁÃØ¹áÃ§¢Í§ÍÒ¡ÒÃ â´Â·ÑèÇ æ ä»¢¹Ò´ÂÒ·ÕèàËÁÒÐÊÁ
¢Í§¼ÙŒ»†ÇÂÇÑÂ¼ÙŒãËÞ‹ ÊíÒËÃÑºâÃ¤âÃ¤¡Ñ§ÇÅ·ÑèÇä»ÍÂÙ‹ã¹ª‹Ç§ 5-15 Á¡./ÇÑ¹ ¢Í§
Diazepam Ê‹Ç¹âÃ¤ Panic ¢¹Ò´ÂÒ Alprazolam ¢¹Ò´à©ÅÕèÂ 5.7 Á¡./ÇÑ¹ (¢¹Ò´
¡ÒÃÃÑ¡ÉÒ 1-10 Á¡./ÇÑ¹) â´Â·ÕèÂÒ Alprazolam ¢¹Ò´ 5.3 Á¡./ÇÑ¹ ÁÕ»ÃÐÊÔ·¸ÔÀÒ¾
à·ÕÂºà·‹Ò¡ÑºÂÒ Clonazepam 2.5 Á¡./ÇÑ¹ ÊíÒËÃÑº¼ÙŒ»†ÇÂÊÙ§ÍÒÂØ¤ÇÃµÑé§µŒ¹ãËŒÂÒã¹
¢¹Ò´ 1/2 - 1/3 ¢Í§¢¹Ò´ÂÒã¹¼ÙŒãËÞ‹
2. âÃ¤ËÃ× Í ÀÒÇÐ¨Ô µ àÇªÍ×è ¹ æ ·Õè ÁÕ Í Ò¡ÒÃÇÔ µ ¡¡Ñ § ÇÅÃ‹ Ç Á´Œ Ç Â àª‹ ¹
adjustment disorder, depressive disorder
ÂÒ¤Çº¤ØÁÀÒÇÐÇÔ¡ÄµÔ¨Ò¡ÍÒ¡ÒÃÇØ‹¹ÇÒÂ·Ò§¨Ôµ (Acute management of
agitation) àª‹¹ ¡ÒÃãªŒÂÒ Clonazepam ÃÙ»áºº©Õ´à¢ŒÒ¡ÅŒÒÁà¹×éÍà·ÕÂº¡ÑºÂÒ
Haloperidol ÃÙ»áºº©Õ´à¢ŒÒ¡ÅŒÒÁà¹×éÍÃÑ¡ÉÒ Acute psychotic agitation ¾ºÇ‹Ò
ÂÒ Clonazepam Å´¡ÒÃà¡Ô´ÀÒÇÐÇØ¹‹ ÇÒÂ·Ò§¨Ôµ Agitation ä´Œ áµ‹ÂÒ Haloperidol
ÁÕÃÐÂÐàÇÅÒ¡ÒÃÍÍ¡Ä·¸ÔìÊÑé¹¡Ç‹Ò
ÀÒÇÐ¤ÅØŒ Á ¤ÅÑè § (Acute management of mania) «Öè § ¾ºÇ‹ Ò ÂÒ
Benzodiazepine ª‹ÇÂ·íÒãËŒÅ´ÀÒÇÐ¤ÅØŒÁ¤ÅÑè§·Ò§¨Ôµ (Antimanic effect) â´Âª‹ÇÂ
Ê§ºàË¹ÕèÂÇ¹íÒãËŒ¼ÙŒ»†ÇÂËÅÑº áÅÐª‹ÇÂÅ´¢¹Ò´ÂÒÃÑ¡ÉÒâÃ¤¨Ôµ·ÕèãªŒã¹ÀÒÇÐà©ÕÂº¾ÅÑ¹
â´ÂÁÕ Ë ÅÑ ¡ °Ò¹¡ÒÃÈÖ ¡ ÉÒãªŒ Â Ò Clonazepam à·Õ Â º¡Ñ º ÂÒ Lithium ¾ºÇ‹ Ò
Clonazepam ÁÕ»ÃÐÊÔ·¸ÔÀÒ¾´Õ¡Ç‹ÒáÅÐÍÍ¡Ä·¸Ôàì ÃçÇ¡Ç‹ÒÂÒ Lithium (¡ÒÃÈÖ¡ÉÒ¢Í§
Chouinard et al. 1983) áÅÐ¾ºÇ‹Ò Clonazepam ÁÕ»ÃÐÊÔ·¸ÔÀÒ¾Å´ÍÒ¡ÒÃ
¤ÅØŒÁ¤ÅÑè§ä´Œ´Õ¡Ç‹Ò¡ÒÃãËŒÂÒ Lorazepam
ÀÒÇÐ¡ÅÑÇ¡ÒÃà¢ŒÒÊÑ§¤Á (Social phobia) àª‹¹ ¡ÒÃãËŒÂÒ Alprazolam ÂÒ
Clonazepam ¢¹Ò´ 2.4 Á¡./ÇÑ¹ ÂÒ Bromazepam ¢¹Ò´ 21 Á¡./ÇÑ¹
3. ÀÒÇÐ¶Í¹¾ÔÉ¨Ò¡¡ÒÃ´×Áè ÊØÃÒ ( Alcohol withdrawal syndrome) áÅÐ
ã¹¼ÙŒ»†ÇÂ·ÕèÁÕÀÒÇÐ delirium (Alcohol withdrawal delirium)
ÂÒ¡ÅØ‹Á Benzodiazepine àª‹¹ Lorazepam ¢¹Ò´ 1-2 Á¡. ª¹Ô´
ÃÑº»ÃÐ·Ò¹, Diazepam ¢¹Ò´ 5-10 Á¡. ª¹Ô´ÃÑº»ÃÐ·Ò¹ËÃ×Í©Õ´à¢ŒÒàÊŒ¹ ÍÒ¨ãªŒä´Œ
¼Å´Õã¹ÃÒÂ·Õè agitation ËÃ×Í¹Í¹äÁ‹ËÅÑº ËÃ×Íã¹ÃÒÂ·ÕèÁÕâÍ¡ÒÊ¨ÐªÑ¡ÊÙ§ àª‹¹
¼ÙŒ»†ÇÂã¹ÀÒÇÐ¢Ò´áÍÅ¡ÍÎÍÅËÃ×Í¢Ò´ÂÒ¹Í¹ËÅÑºµ‹Ò§ æ áµ‹µŒÍ§¤íÒ¹Ö§¶Ö§Ç‹Ò
Benzodiazepine ¨Ð·íÒãËŒ cognitive function ¢Í§¼ÙŒ»†ÇÂàÅÇÅ§ä´ŒÁÒ¡¡Ç‹Ò¡ÒÃãËŒ
Haloperidol
4. ÀÒÇÐ¹Í¹äÁ‹ËÅÑº
¤ÇÃãªŒÂÒ Benzodiazepine à»š¹¤ÃÑé§¤ÃÒÇ â´ÂÁØ‹§ËÒÊÒàËµØ¢Í§ÍÒ¡ÒÃ¹Í¹
äÁ‹ËÅÑº áÅŒÇá¡Œä¢µÒÁÊÒàËµØ¹Ñé¹ ÂÒ¹Í¹ËÅÑº Benzodiazepine ¢¹Ò´ÂÒ·Õèà¾ÕÂ§
¾Í¢Í§ÂÒã¹¡ÅØ‹Á¹Õé·Ø¡ª¹Ô´ÊÒÁÒÃ¶ª‹ÇÂãËŒà¡Ô´¡ÒÃ¹Í¹ËÅÑºä´Œ ¤ÇÒÁáµ¡µ‹Ò§Ê‹Ç¹
ãËÞ‹ÁÒ¨Ò¡¤Ø³ÊÁºÑµãÔ ¹¡ÒÃ¶Ù¡´Ù´«ÖÁà¢ŒÒÊÙ¡‹ ÃÐáÊàÅ×Í´ áÅÐ¤‹Ò¤ÃÖ§è ªÕÇµÔ ¢Í§ÂÒáµ‹ÅÐ
µÑÇ ¶Ö§áÁŒÇÒ‹ ÍÒ¡ÒÃäÁ‹¾§Ö »ÃÐÊ§¤¨Ò¡ÂÒ¡ÅØÁ‹ ¹Õàé ¡Ô´¢Ö¹é ¹ŒÍÂà¾ÕÂ§ 1 ã¹¡ÒÃÊÑ§è ÂÒ 10,000
¤ÃÑé§ áµ‹¡çÁÕ»˜ÞËÒ·Õè¤ÇÃÃÐÇÑ§ ¤×Í ¡ÒÃ´×éÍÂÒ·íÒãËŒµŒÍ§à¾ÔèÁ¢¹Ò´ÂÒ ÍÒ¡ÒÃ¢Ò´ÂÒ
(withdrawal syndrome) áÅÐ rebound insomnia ¶ŒÒËÂØ´ÂÒ¡Ð·Ñ¹ËÑ¹ËÃ×ÍàÃçÇ
à¡Ô¹ä» ÂÒºÒ§ª¹Ô´ã¹¡ÅØ‹Á¹ÕéÁÕ¤Ø³ÊÁºÑµÔà©¾ÒÐ´ŒÒ¹ª‹ÇÂ¡ÒÃ¹Í¹ËÅÑº â´Â·ÑèÇä»ÂÒ·Õè
àËÁÒÐÊÁ¤ÇÃà»š¹ÂÒ·ÕèÁÕ¤‹Ò¤ÃÖè§ªÕÇÔµäÁ‹ÂÒÇà¡Ô¹ä» àª‹¹ »ÃÐÁÒ³ 8 ªÑèÇâÁ§ à¾×èÍäÁ‹ãËŒ
¡ÃÐ·ºµ‹Í¡ÒÃ´íÒà¹Ô¹ªÕÇÔµª‹Ç§¡ÅÒ§ÇÑ¹ÁÒ¡ áµ‹¶ŒÒá¾·ÂµŒÍ§¡ÒÃ¼Å¢Í§¡ÒÃÅ´¤ÇÒÁ
ÇÔµ¡¡Ñ§ÇÅ´ŒÇÂ¡çÍÒ¨àÅ×Í¡ÂÒ·ÕèÁÕ¤‹Ò¤ÃÖè§ªÕÇÔµÂÒÇ ÂÒ·ÕèÁÕ¤‹Ò¤ÃÖè§ªÕÇÔµÊÑé¹ÁÒ¡ÁÑ¡à»š¹ÂÒ·Õè
ÁÕ¤ÇÒÁáÃ§ÁÒ¡áÅÐÍÍ¡Ä·¸ÔìàÃçÇ áµ‹¡çÍÒ¨ÁÕ¼Å·íÒãËŒÃÐÂÐ¹Í¹ËÅÑºÊÑé¹Å§ áÅÐ
ÁÕâÍ¡ÒÊ´×éÍÂÒÃÇÁ·Ñé§àÊ¾µÔ´ÂÒà¾ÔèÁ¢Öé¹
5. ãªŒà»š¹ÂÒ¤ÅÒÂ¡ÅŒÒÁà¹×éÍ
6. ãªŒÃÑ¡ÉÒÍÒ¡ÒÃªÑ¡
ÍÒ¨ÁÕ»ÃÐÊÔ·¸ÔÀÒ¾ã¹¡ÒÃãªŒ·Ò§¤ÅÔ¹Ô¡ ã¹¼ÙŒ»†ÇÂ·ÕèÁÕÍÒ¡ÒÃ·Ò§¨ÔµºÒ§ÍÂ‹Ò§
àª‹¹ ¼Åª‹ÇÂÃÑ¡ÉÒÀÒÇÐ PTSD (Post-traumatic stress disorder) áµ‹»ÃÐÊÔ·¸ÔÀÒ¾
µèíÒ¡Ç‹Ò¡ÒÃãËŒ SSRI áÅÐÍÒ¡ÒÃÂéíÒ¤Ô´ÂéíÒ·íÒ (OCD-Obsessive compulsive
disorder) ¾ºÇ‹ÒÂÒ¡ÅØ‹Á¹ÕéäÁ‹¤‹ÍÂä´Œ¼Å·Ò§¤ÅÔ¹Ô¡ Â¡àÇŒ¹ºÒ§§Ò¹ÇÔ¨ÑÂ·ÕèáÊ´§Ç‹Ò
Clonazepam ÍÒ¨ª‹ÇÂÃÑ¡ÉÒ OCD
µÒÃÒ§·Õè 8 áÊ´§¢ŒÍº‹§ãªŒ áÅÐ¢¹Ò´ÂÒ·Õèà·ÕÂºà·‹Ò¡Ñ¹
(Equivalent dose) ¢Í§ÂÒ¡ÅØ‹Á Benzodiazepine
Approximate
Approved oral
ßČęĂ÷ć øĎðĒïï÷ć ×šĂïŠÜĔßš Equivalent Doses
dosage range
(DZP 5 mg/day)
Alprazolam đöĘé Anxiety disorder 0.75-4 mg/day 0.5 mg/day
Panic disorder 1.5-10 mg/day
Bromazepam đöĘé Anxiety disorder 3-6 mg/day 3 mg/day
Chlordiazepoxide đöĘé, ÞĊé Anxiety disorder 5-300 mg/day 10 mg/day
Preanesthetic
Alcohol withdrawal
Clonazepam đöĘé Seizure disorders 1-6 mg/day 0.25 mg/day
Panic disorder
Others : Social phobia
Akathisia
Akathesia , Acute mania
Restless leg syndrome &
neuralgic pain
Clorazepate đöĘé Anxiety disorder 7.5-60 mg/day 7.5 mg/day
Seizure disorders
Alcohol withdrawal
Diazepam đöĘé, ÞĊé Anxiety disorder 2-20 mg/day 5 mg/day
Preanesthetic
Alcohol withdrawal
Muscle-spasm
Status epilepticus
Lorazepam đöĘé, ÞĊé Anxiety disorder 0.5-10 mg/day 1 mg/day
Preanesthetic
Alcohol withdrawal
Muscle-spasm
Status epilepticus
Prazepam đöĘé Anxiety disorder 20- 60 mg/day 10 mg/day
Triazolam đöĘé Hypnotic /sedative 0.125-0.25
mg/day
Flurazepam đöĘé Hypnotic /sedative 15-30 mg/day 15 mg/day
Approximate
Approved oral
ßČęĂ÷ć øĎðĒïï÷ć ×šĂïŠÜĔßš Equivalent Doses
dosage range
(DZP 5 mg/day)
Temazepam đöĘé Hypnotic /sedative 15-30 mg/day
Nitrazepam đöĘé Hypnotic /sedative 5-10 mg/day 2.5 mg/day
Myoclonic seizure
àÀÊÑª¨Å¹ÈÒÊµÃ
ÂÒ¡ÅØÁ‹ Benzodiazepine áµ‹ÅÐª¹Ô´ÁÕ¤³ Ø ÊÁºÑµ·Ô Ò§àÀÊÑªÈÒÊµÃ·áÕè µ¡µ‹Ò§
¡Ñ¹ ¨Ðª‹ÇÂ·íÒãËŒá¾·ÂÊÒÁÒÃ¶ÊÑè§¨‹ÒÂÂÒ¡ÅØ‹Á¹Õéä´ŒÍÂ‹Ò§ÁÕ»ÃÐÊÔ·¸ÔÀÒ¾
¡ÒÃ´Ù´«ÖÁ (Absorption)
Benzodiazepine ¶Ù¡´Ù´«ÖÁä´Œ´Õ¨Ò¡·Ò§à´Ô¹ÍÒËÒÃ ÂÒ¨Ð¶Ö§ÃÐ´ÑºÊÙ§ÊØ´
ÀÒÂã¹ 30 ¹Ò·Õ ¶Ö§ 6-8 ªÑèÇâÁ§ ÂÒ¨ÑºµÑÇ¡Ñºâ»ÃµÕ¹ä´Œ´ÕáÅÐÁÕ¤ÇÒÁÊÒÁÒÃ¶ã¹¡ÒÃ
ÅÐÅÒÂä¢ÁÑ¹ (lipid solubility) ÊÙ§
Benzodiazepine ·Õè¶Ù¡´Ù´«ÖÁä´Œ´Õ¨ÐÍÍ¡Ä·¸Ôì¤‹Í¹¢ŒÒ§àÃçÇ ÃÐÂÐàÇÅÒã¹¡ÒÃ
´Ù´«ÖÁ¢Í§ Benzodiazepine áµ‹ÅÐª¹Ô´áµ¡µ‹Ò§¡Ñ¹ ¢Ö¹é ¡ÑºÍÑµÃÒàÃçÇã¹¡ÒÃ´Ù´«ÖÁ áº‹§
ä´Œà»š¹ 3 ¡ÅØ‹Á ä´Œá¡‹ÍÑµÃÒàÃçÇã¹¡ÒÃ´Ù´«ÖÁàÃçÇ àª‹¹ Clorazepate ¹Ò¹ 0.5 ªÑèÇâÁ§,
Diazepam ¹Ò¹ 1 ªÑèÇâÁ§, Triazolam ¹Ò¹ 1.3 ªÑèÇâÁ§, ÍÑµÃÒàÃçÇã¹¡ÒÃ´Ù´«ÖÁ
»Ò¹¡ÅÒ§ àª‹¹ Alprazolam áÅÐ Lorazepam ¹Ò¹ 2 ªÑèÇâÁ§ áÅÐ Chlordiazepoxide
à»š¹µŒ¹ áÅÐÍÑµÃÒàÃçÇã¹¡ÒÃ´Ù´«ÖÁªŒÒ àª‹¹ Prazepam à»š¹µŒ¹
¤ÇÒÁÊÒÁÒÃ¶ã¹¡ÒÃÅÐÅÒÂã¹ä¢ÁÑ¹¨Ðº‹§ºÍ¡¶Ö§¡ÒÃ·ÕèÂÒ¨Ð¡ÃÐ¨ÒÂä»ÊÙ‹
ÊÁÍ§ä´Œ´Õà¾ÕÂ§ã´ ¨Ðá»Ã¼Ñ¹µÒÁ¤ÇÒÁÊÒÁÒÃ¶¢Í§ÂÒã¹¡ÒÃÅÐÅÒÂã¹ä¢ÁÑ¹ à¾ÃÒÐ
¨ÐÊÒÁÒÃ¶¼‹Ò¹ blood brain barrier ä´Œ´Õ¡Ç‹ÒÂÒ·ÕèÅÐÅÒÂã¹ä¢ÁÑ¹µèíÒ ÂÒ¡ÅØ‹Á
Benzodiazepine ·ÕèÍÍ¡Ä·¸Ôìä´Œ´ÕáÅÐàÃçÇ¤×Í Diazepam ¾ºÇ‹ÒÁÕ¤Ø³ÊÁºÑµÔÅÐÅÒÂ
ã¹ä¢ÁÑ¹ä´Œ´Õ¡Ç‹Ò Lorazepam áÅÐ Chlordiazepoxide à»š¹µŒ¹
ÃÐÂÐàÇÅÒ¡ÒÃÍÍ¡Ä·¸Ôì (Duration of action)
¹Í¡¨Ò¡¹Õ¡é ÒÃÍÍ¡Ä·¸Ô¢ì Í§ÂÒ ¢Ö¹é ÍÂÙ¡‹ ºÑ ¤ÇÒÁÊÒÁÒÃ¶ã¹¡ÒÃÅÐÅÒÂã¹ä¢ÁÑ¹
¢Í§ÂÒ â´ÂÂÒ·ÕèÅÐÅÒÂã¹ä¢ÁÑ¹ä´Œ´Õ¨ÐÍÍ¡Ä·¸ÔìàÃçÇ à¹×èÍ§¨Ò¡ÂÒ¡ÃÐ¨ÒÂä»µÒÁÊ‹Ç¹
µ‹Ò§ æ ¢Í§Ã‹Ò§¡ÒÂä´ŒàÃçÇ (ÁÕ distribution half-life µèíÒ) ÃÐ´ÑºÂÒã¹àÅ×Í´¨Ö§Å´Å§
àÃçÇ¡Ç‹ÒÂÒ·ÕèÅÐÅÒÂä¢ÁÑ¹ä´Œ¹ŒÍÂ ÂÒ·ÕèÅÐÅÒÂã¹ä¢ÁÑ¹ä´Œ´Õ ä´Œá¡‹ Diazepam,
Alprazolam, Chlordiazepoxide áÅÐ Lorazepam µÒÁÅíÒ´Ñº
¡ÒÃ¢¨Ñ´ÂÒ (Elimination and Biotransformation pathway)

Benzodiazepine Ê‹Ç¹ãËÞ‹¶Ù¡·íÒÅÒÂ·ÕèµÑºâ´Â¡ÃÐºÇ¹¡ÒÃ oxidation
(phase I metabolism) µÒÁ´ŒÇÂ¡ÃÐºÇ¹¡ÒÃ conjugation (phase II
metabolism) áÅŒÇ¢ÑºÍÍ¡·Ò§»˜ÊÊÒÇÐ Â¡àÇŒ¹ Lorazepam, Temazepam áÅÐ
Oxazepam (äÁ‹ÁÕ¨íÒË¹‹ÒÂã¹»ÃÐà·È) ·Õè¶Ù¡·íÒÅÒÂâ´Â¡ÃÐºÇ¹¡ÒÃ conjugation
µÑé§áµ‹áÃ¡ ¡ÒÃ¢¨Ñ´ÂÒ·Ñé§ 3 ª¹Ô´¹ÕéÍÍ¡¨Ò¡Ã‹Ò§¡ÒÂÂÑ§ÊÒÁÒÃ¶·íÒä´Œ áÁŒ¡ÒÃ·íÒ§Ò¹
¢Í§µÑº¨ÐàÊ×èÍÁä»ÁÒ¡ àª‹¹ ã¹¼ÙŒ·Õèà»š¹âÃ¤µÑº ËÃ×Í¼ÙŒ»†ÇÂÊÙ§ÍÒÂØ
áÊ´§¡ÃÐºÇ¹¡ÒÃ Metabolism ¢Í§ÂÒ¡ÅØ‹Á Benzodiazepine
µÒÃÒ§·Õè 9 áÊ´§¤Ø³ÊÁºÑµÔ·Ò§àÀÊÑª¨Å¹ÈÒÊµÃ·ÕèÊíÒ¤ÑÞ¢Í§ÂÒã¹¡ÅØ‹Á
Benzodiazepine ·ÕèãªŒº‹ÍÂ
Öćøÿúć÷÷ć
ĂĆêøćÖćø Tmax ÙŠćÙøċęÜßĊüĉê CYP 450 Active
ÖúčŠö÷ć / ßČęĂ÷ć (metabolic
éĎéàċö (hr) (half-life-hours) enzyme(s) metabolites
pathway)
TriazoloBenzodiazepine Group
Triazolam đøĘü 0.5-1.5 po 2-4 ÿĆĚî 3A4 Oxidation None
Alprazolam ðćîÖúćÜ 1-2 po 10-15 ðćîÖúćÜ 3A4 Oxidation Į-OH Alprazolam
OxazoloBenzodiazepine Group ( 3-Hydroxy )
Lorazepam ðćîÖúćÜ 1-4 po 10-20 ðćîÖúćÜ Conjugation None
Oxazepam ßšć 1-4 po 5-15 ðćîÖúćÜ Conjugation None
Temazepam ðćîÖúćÜ 2-3 po 6-16 ðćîÖúćÜ Conjugation None
DesmethylDiazepam Group (2-keto)
1-2 po desmethylDZP
2C19
Diazepam đøĘü 1 IM 26-50 ÷ćü Oxidation 3-OH Diazepam
3A4
8 min IV Oxazepam
Bromazepam ðćîÖúćÜ 1-4 po 1-5 ÿĆĚî 3A4 Oxidation
Prazepam ßšć > 21 ÷ćü Oxidation
desmethylCDX
demOxazepam
Chlordiazepoxide ðćîÖúćÜ 1-4 po > 21 ÷ćü 3A4 Oxidation
desmethylDZP
Oxazepam
desmethylDZP
Clorazepate đøĘü 0.5-2 po 100 ÷ćü Oxidation
Oxazepam
DesalkylFlurazepam Group (2-keto)
Clonazepam đøĘü 1-4 po 24-56 ÷ćü Oxidation None
OH ethylFlurazepam
Flurazepam đøĘü 0.5-1 po 40-120 ÷ćü Oxidation
N-desalkyl-F.
ImidazoBenzodiazepine Group
Midazolam đøĘü 7.5-15 po 1-3 ÿĆĚî 3A4 Oxidation
Thienodiazepine Group
Nitrazepam ðćîÖúćÜ 0.5-2 po 20-50 ÷ćü 3A4, 2D6 Reduction None
Flunitrazepam đøĘü 15-30 po 10-25 ðćîÖúćÜ Reduction
¡ÒÃ¨íÒá¹¡ª¹Ô´¢Í§ÂÒ BZD
¡ÒÃ¨Ñ´¨íÒá¹¡¡ÅØ‹ÁÂÒ Benzodiazepine ÊÒÁÒÃ¶¨íÒá¹¡ä´ŒËÅÒÂáºº àª‹¹
¡. ÊÙµÃâ¤Ã§ÊÃŒÒ§ ´Ñ§áÊ´§ã¹µÒÃÒ§¤Ø³ÊÁºÑµÔ·Ò§àÀÊÑª¨Å¹ÈÒÊµÃ·ÕèÊíÒ¤ÑÞ¢Í§ÂÒ
ã¹¡ÅØ‹Á Benzodiazepine ·ÕèãªŒº‹ÍÂ ¢. ÍÑµÃÒàÃçÇã¹¡ÒÃ´Ù´«ÖÁ ´Ñ§áÊ´§ã¹µÒÃÒ§
¤Ø³ÊÁºÑµÔ·Ò§àÀÊÑª¨Å¹ÈÒÊµÃ·ÕèÊíÒ¤ÑÞ¢Í§ÂÒã¹¡ÅØ‹Á Benzodiazepine ·ÕèãªŒº‹ÍÂ
ËÑÇ¢ŒÍÍÑµÃÒ¡ÒÃ´Ù´«ÖÁ ¤. ¤ÇÒÁáÃ§¢Í§ÂÒ áÅÐ §. ¡ÃÐºÇ¹ biotransformation
áµ‹ã¹·Ò§¤ÅÔ¹Ô¡¹ÔÂÁáº‹§à»š¹ 2 áºº ¤×Í
1. áº‹§µÒÁ¡ÃÐºÇ¹¡ÒÃ biotransformation ËÃ×ÍµÒÁ¤‹Ò¤ÃÖè§ªÕÇÔµ¢Í§ÂÒ
«Öè§áº‹§ÍÍ¡ä´Œà»š¹
- ¡ÅØ‹Á·ÕèÁÕ¤‹Ò¤ÃÖè§ªÕÇÔµÂÒÇ (ÁÒ¡¡Ç‹Ò 20 ªÑèÇâÁ§) ¨Ð¼‹Ò¹ metabolic
transformation ËÅÒÂ¢Ñé ¹ µÍ¹áµ‹ Å Ð¢Ñé ¹ ¡ç ¨ Ð·í ÒãËŒ à ¡Ô ´ active metabolite
·í ÒãËŒ ÁÕ Â ÒÊÐÊÁÍÂÙ‹ ã ¹Ã‹ Ò §¡ÒÂä´Œ ¹ Ò¹ àÁ×è Í ÁÕ ¡ ÒÃËÂØ ´ ÂÒ¡Ð·Ñ ¹ ËÑ ¹ ¨Ö § ÁÑ ¡äÁ‹ à ¡Ô ´
discontinuation syndrome µÑÇÍÂ‹Ò§¢Í§ÂÒ¡ÅØÁ‹ ¹Õé àª‹¹ Diazepam, Clonazepam
- ¡ÅØ‹Á·ÕèÁÕ¤‹Ò¤ÃÖè§ªÕÇÔµÊÑé¹ (¹ŒÍÂÇ‹Ò 20 ªÑèÇâÁ§) ¶Ö§»Ò¹¡ÅÒ§ ¨ÐäÁ‹·íÒãËŒ
à¡Ô´ active metabolite µÑÇÂÒ¨Ðä» conjugate ¡Ñº glucuronic acid áÅŒÇ¶Ù¡¢Ñº
¶‹ÒÂÍÍ¡ÁÒàÅÂ àª‹¹ Lorazepam, Temazepam Ê‹Ç¹ÂÒ Alprazolam áÅÐ
Triazolam ¹Ñé¹ áÁŒ¨ÐãËŒ active metabolite áµ‹¡çäÁ‹ÁÕ¤ÇÒÁÊíÒ¤ÑÞ·Ò§¤ÅÔ¹Ô¡¨Ö§¶Ù¡
¨Ñ´äÇŒã¹¡ÅØ‹Á¹Õé´ŒÇÂ
2. áº‹§µÒÁ¤ÇÒÁáÃ§ (potency) ¢Í§ÂÒ ¨Ðáº‹§ÍÍ¡ä´Œà»š¹
- High therapeutic potency ¡ÅØ‹Á¹Õé¨ÐãªŒÂÒ¢¹Ò´ÁÔÅÅÔ¡ÃÑÁ¹ŒÍÂ æ ¡ç
ÍÍ¡Ä·¸Ôìä´Œ¾Í æ ¡ÑºÂÒã¹¡ÅØ‹Á low therapeutic potency ã¹¢¹Ò´ÊÙ§ µÑÇÍÂ‹Ò§
¢Í§ÂÒã¹¡ÅØ‹Á¹Õé ä´Œá¡‹ Alprazolam, Lorazepam, Triazolam áÅÐ Clonazepam
à»š¹µŒ¹
- Low therapeutic potency ¡ÅØ‹Á¹Õé¨ÐãªŒÂÒã¹¢¹Ò´ÁÔÅÅÔ¡ÃÑÁ·ÕèÊÙ§¡Ç‹Ò
¡ÅØÁ‹ áÃ¡ ä´Œá¡‹ Diazepam, prazepam, Clorazepate, áÅÐ Temazepam à»š¹µŒ¹
¤ÇÒÁ¨ÃÔ§ÂÒ·Ñé§ 2 ¡ÅØ‹Á¹Õé ¡ÅØ‹Á·Õèáº‹§µÒÁ¡ÃÐºÇ¹¡ÒÃ biotransformation
ËÃ×ÍµÒÁ¤‹Ò¤ÃÖè§ªÕÇÔµ¢Í§ÂÒ áÅÐ¡ÅØ‹Á·Õèáº‹§µÒÁ¤ÇÒÁáÃ§ (potency) ¢Í§ÂÒµ‹Ò§¡çÁÕ
Ä·¸Ôìã¹¡ÒÃÃÑ¡ÉÒà·‹Ò æ ¡Ñ¹ ¶ŒÒ¹íÒä»à»ÃÕÂºà·ÕÂºã¹¢¹Ò´·Õè equivalent ¡Ñ¹ àª‹¹
Diazepam 10 Á¡. ÁÕ¤ÇÒÁáÃ§à·‹Ò¡Ñº Alprazolam 0.5 Á¡. à»š¹µŒ¹ ä´ŒáÊ´§
à»ÃÕÂºà·ÕÂº equivalent potency ¢Í§ÂÒ¡Ñº¡ÒÃáº‹§ÂÒ·Ñé§µÒÁ¤‹Ò¤ÃÖè§ªÕÇÔµáÅÐµÒÁ
¤ÇÒÁáÃ§ (potency) äÇŒã¹´Ñ§µÒÃÒ§
µÒÃÒ§·Õè 10 áÊ´§¤Ø³ÊÁºÑµÔ·Ò§àÀÊÑª¨Å¹ÈÒÊµÃáÅÐ¢¹Ò´ÂÒ
·Õèà·‹Òà·ÕÂº¡Ñ¹ (Equivalent dose)
×îćé÷ćìĊęĔßšøÖĆ þć
ĂĆêøć ÙŠćÙøċęÜßĊüĉê Öćøÿúć÷÷ć ×îćé÷ćìĊęđìĊ÷ïđìŠćÖĆî
ßČęĂ÷ć ĔîñĎšĔĀâŠ
ÖćøéĎéàċö (half-life) (metabolism) (equivalent dose, mg)
(mg/day)
Triazolo-BDZ
Triazolam đøĘü ÿĆĚî Oxidation 0.25-0.5 0.125-0.25
Alprazolam ðćîÖúćÜ ðćîÖúćÜ Oxidation 0.25 0.5-4
3-hydroxy
Lorazepam ðćîÖúćÜ ðćîÖúćÜ Conjugation 1 1-6
Oxazepam ßšć ðćîÖúćÜ Conjugation 15 30-120
Temazepam ðćîÖúćÜ ðćîÖúćÜ Conjugation 5 7.5-30
2-keto
Chlordiazepoxide ðćîÖúćÜ ÷ćü Oxidation 10 10-150
Clonazepam đøĘü ÷ćü Oxidation 0.5 1-6
Clorazepate đøĘü ÷ćü Oxidation 7.5 15-30
Diazepam đøĘü ÷ćü Oxidation 5 2-40
Flurazepam đøĘü ÷ćü Oxidation 5 15-30
Halazepam ðćîÖúćÜ ÷ćü Oxidation 20 60-160
Prazepam ßšć ÷ćü Oxidation 10 20-60
¢ŒÍ¤ÇÃÃÐÇÑ§
äÁ‹ÁÕ¢ŒÍËŒÒÁâ´Âà´ç´¢Ò´ã¹¡ÒÃãªŒÂÒ¡ÅØ‹Á¹Õé (absolute contraindication) áµ‹
¤ÇÃËÅÕ¡àÅÕèÂ§ã¹¼ÙŒ»†ÇÂâÃ¤ myasthenia gravis, ¼ÙŒ»†ÇÂ·ÕèÁÕá¹Çâ¹ŒÁ¨ÐãªŒÂÒ¼Ô´
ÇÑµ¶Ø»ÃÐÊ§¤ (abuse potential) ¼Ù»Œ Ç† Â·ÕÁè »Õ Þ ˜ ËÒ¢Í§ÃÐºº·Ò§à´Ô¹ËÒÂã¨ËÃ×ÍÁÕ»ÃÐÇÑµÔ
¹Í¹¡Ã¹ ¼ÙŒ»†ÇÂ·Õè·íÒ§Ò¹à¡ÕèÂÇ¡Ñºà¤Ã×èÍ§¨Ñ¡Ã ËÃ×ÍµŒÍ§¡ÒÃÊÁÒ¸ÔÊÙ§ã¹¡ÒÃ·íÒ§Ò¹ ÊµÃÕ·Õè
µÑ§é ¤ÃÃÀáÅÐÊµÃÕ·ãÕè ËŒ¹ÁºØµÃ Ê‹Ç¹ã¹¼ÙÊŒ §Ù ÍÒÂØ ¼Ù»Œ Ç† ÂâÃ¤µÑº äµ ¤ÇÃãªŒÂÒ·ÕÁè ¤Õ Ò‹ ¤ÃÖ§è ªÕÇµÔ
ÊÑ¹é äÁ‹¤ÇÃãªŒÂÒÃ‹ÇÁ¡Ñºà¤Ã×Íè §´×Áè áÍÅ¡ÍÎÍÅ ËÃ×ÍÂÒ·ÕÁè ÄÕ ·¸Ô¡ì ´»ÃÐÊÒ·Ê‹Ç¹¡ÅÒ§ ¡Ã³Õ
¼Ù»Œ Ç† ÂÊÙ§ÍÒÂØáÅÐ¼Ù»Œ Ç† ÂâÃ¤µÑº¤ÇÃãªŒÂÒ·Õ¶è ¡Ù ·íÒÅÒÂâ´Â¡ÃÐºÇ¹¡ÒÃ conjugation ËÃ×Í
ÁÕ¤‹Ò¤ÃÖè§ªÕÇÔµÊÑé¹
¼Å¢ŒÒ§à¤ÕÂ§
¡ÒÃãªŒÂÒ¡ÅØ‹Á Benzodiazepine ¤‹Í¹¢ŒÒ§»ÅÍ´ÀÑÂ áµ‹à¡Ô´¼Å¢ŒÒ§à¤ÕÂ§
áµ¡µ‹Ò§¡Ñ¹µÒÁ¤Ø³ÊÁºÑµÔ·Ò§àÀÊÑª¨Å¹ÈÒÊµÃ¢Í§ÂÒáµ‹ÅÐª¹Ô´ àª‹¹ Diazepam
Flurazepam ÁÕÍÑµÃÒ¡ÒÃ¢¨Ñ´ÂÒµèíÒ áÅÐÁÕ¤ÇÒÁ¨íÒà¾ÒÐà¨ÒÐ¨§ã¹¡ÒÃ¨Ñº¡ÑºµÑÇÃÑºµèíÒ
ÁÑ¡à¡Ô´¼Å¢ŒÒ§à¤ÕÂ§·íÒãËŒà¡Ô´¡ÒÃ§‹Ç§«ÖÁã¹àÇÅÒ¡ÅÒ§ÇÑ¹ Lorazepam Flunitrazepam
ÁÕ¤ÇÒÁáÃ§ÊÙ§áÅÐ¤‹Ò¤ÃÖè§ªÕÇÔµÊÑé¹ ÁÑ¡·íÒãËŒà¡Ô´¡ÒÃ´×éÍµ‹ÍÂÒáÅÐ·¹µ‹ÍÂÒÊÙ§ ·íÒãËŒµŒÍ§
à¾ÔèÁ¢¹Ò´ã¹¡ÒÃÃÑ¡ÉÒ áÅÐ·íÒãËŒà¡Ô´ÍÒ¡ÒÃ¶Í¹ÂÒä´Œ§‹ÒÂ¡Ç‹ÒÂÒ·ÕèÁÕ¤‹Ò¤ÃÖè§ªÕÇÔµÂÒÇ
ã¹¢³Ð·ÕèÂÒ¡ÅØ‹Á TriazoloBenzodiazepine ·ÕèÁÕ¤ÇÒÁáÃ§ÊÙ§áÅÐ¤‹Ò¤ÃÖè§ªÕÇÔµÊÑé¹
ÁÑ¡·íÒãËŒà¡Ô´¡ÒÃÊÙÞàÊÕÂ¤ÇÒÁ·Ã§¨íÒä´Œ§Ò‹ Â ÀÒÇÐ¹Í¹äÁ‹ËÅÑºã¹ª‹Ç§àªŒÒÁ×´ ¡ÒÃ¶Í¹ÂÒ
áÅÐ·íÒãËŒà¡Ô´ÀÒÇÐÇÔµ¡¡Ñ§ÇÅ ËÃ×Í ÍÒ¡ÒÃÅÁªÑ¡ä´Œ ÍÒ¡ÒÃ¢ŒÒ§à¤ÕÂ§·Õè¾ºä´Œº‹ÍÂ æ
¨íÒá¹¡ä´Œ´Ñ§¹Õé
1. ¡ÒÃ¡´»ÃÐÊÒ·Ê‹Ç¹¡ÅÒ§ â´Â¼ÙŒ»†ÇÂ¨ÐÁÕÍÒ¡ÒÃ§‹Ç§«ÖÁ Í‹Í¹áÃ§ à´Ô¹à«
nystagmus áÅÐ dysarthria ¼ÙŒÊÙ§ÍÒÂØ«Öè§ÁÕ serum globulin µèíÒ ÁÕâÍ¡ÒÊà¡Ô´¼Å¢ŒÒ§
à¤ÕÂ§àËÅ‹Ò¹Õäé ´Œ§Ò‹ Â ÃÐ´ÑºÍÒ¡ÒÃÊÑÁ¾Ñ¹¸¡ºÑ ¢¹Ò´ÂÒáÅÐÊ‹Ç¹ãËÞ‹ÍÒ¡ÒÃ¹Õ¨é Ð´Õ¢¹Öé ÀÒÂã¹
2 ÊÑ»´ÒË ´Ñ§¹Ñ¹é ã¹ª‹Ç§áÃ¡¢Í§¡ÒÃãªŒÂÒ¤ÇÃàµ×Í¹¼Ù»Œ Ç† ÂäÁ‹ãËŒ¢ºÑ Ã¶ ËÃ×ÍàÅÕÂè §¡ÒÃ·íÒ§Ò¹
¡Ñºà¤Ã×èÍ§¨Ñ¡Ã¡Å·ÕèÍÒ¨à¡Ô´ÍÑ¹µÃÒÂ ã¹¼ÙŒÊÙ§ÍÒÂØµŒÍ§àµ×Í¹ãËŒÃÐÇÑ§Ë¡ÅŒÁËÒ¡ÁÕÍÒ¡ÒÃ
à´Ô¹à« â´Âà©¾ÒÐËÒ¡ÅØ¡à¢ŒÒËŒÍ§¹éíÒ¡ÅÒ§´Ö¡
- ÍÒ¡ÒÃ§‹Ç§«ÖÁ à»š¹¼Å¢ŒÒ§à¤ÕÂ§·Õè¾ºä´Œº‹ÍÂ·ÕèÊØ´ ÁÑ¡à¡Ô´¢Öé¹ã¹ 1-2 ªÑèÇâÁ§
áÃ¡ËÅÑ§¨Ò¡ä´ŒÃºÑ ÂÒ ÍÒ¨¡‹ÍãËŒà¡Ô´ÍÑ¹µÃÒÂµ‹Í¤¹·íÒ§Ò¹·Õµè ÍŒ §ãªŒÊÁÒ¸ÔÁÒ¡ æ ¤¹·Õµè ÍŒ §
¢ÑºÃ¶ËÃ×Í·íÒ§Ò¹à¡ÕèÂÇ¡Ñºà¤Ã×èÍ§¨Ñ¡Ã ¨Ö§¤ÇÃá¹Ð¹íÒ¼ÙŒ»†ÇÂãËŒÃÐÁÑ´ÃÐÇÑ§ ËÃ×ÍãËŒ¡Ô¹ÂÒ
¡‹Í¹¹Í¹ ¾ºÇ‹ÒÄ·¸Ôì§‹Ç§«ÖÁ¹Õéà»š¹ individual susceptibility ¼ÙŒ»†ÇÂºÒ§ÃÒÂäÁ‹Ç‹Ò¡Ô¹
ÂÒ Benzodiazepine ª¹Ô´ã´¡ç§‹Ç§ ã¹·Ò§¡ÅÑº¡Ñ¹ ¼ÙŒ»†ÇÂºÒ§ÃÒÂ¡çäÁ‹§‹Ç§àÅÂ
- ÍÒ¡ÒÃá¢¹¢ÒÍ‹Í¹áÃ§ ¡ÅŒÒÁà¹×éÍà»ÅÕéÂáÅÐà´Ô¹à« à¹×èÍ§¨Ò¡Ä·¸Ôì¤ÅÒÂ
¡ÅŒÒÁà¹×éÍ¢Í§ÂÒ ¨Ö§¤ÇÃÃÐÇÑ§ã¹¼ÙŒÊÙ§ÍÒÂØ ËÃ×Í¼ÙŒ·ÕèÁÕ»˜ÞËÒàÃ×èÍ§¡ÅŒÒÁà¹×éÍ à¾ÃÒÐÍÒ¨·íÒ
ãËŒà¡Ô´ÍÒ¡ÒÃá¢¹¢ÒËÁ´áÃ§ áÅÐà´Ô¹äÁ‹ä´Œ¨Ò¡ÂÒ ËÃ×Íà¡Ô´ÍÒ¡ÒÃÁÖ¹§§ à´Ô¹áÅŒÇà«ä´Œ
â´Â¾ºÍØºÑµÔ¡ÒÃ³¤ÇÒÁÃØ¹áÃ§ ´Ñ§¹Õé
- §‹Ç§«ÖÁ ¹Í¹ËÅÑº ¾ºÃŒÍÂÅÐ 4-9
- Ataxia ¾ºÃŒÍÂÅÐ 2
2. ÍÒ¡ÒÃËÅ§Å×Á â´Âà©¾ÒÐ anterograde amnesia ÁÑ¡à¡Ô´¢Öé¹¡ÑºÂÒ·ÕèÁÕ
ÃÐÂÐàÇÅÒÍÍ¡Ä·¸ÔìàÃçÇ «Öè§¢Öé¹ÍÂÙ‹¡Ñº¤ÇÒÁáÃ§áÅÐÇÔ¸Õ¡ÒÃãËŒÂÒ àª‹¹ ¡ÒÃãËŒ Diazepam
â´Â¡ÒÃ©Õ´à¢ŒÒËÅÍ´àÅ×Í´´íÒ ÍÒ¨à¡Ô´¡ÒÃÊÙÞàÊÕÂ¤ÇÒÁ¨íÒä´Œ§‹ÒÂ¡Ç‹Ò¡ÒÃãËŒ·Ò§¡ÅŒÒÁà¹×éÍ
ËÃ× Í äÁ‹ ¤‹ Í Âà¡Ô ´ ËÃ× Í ¾º¹Œ Í ÂÁÒ¡ã¹¡ÒÃãËŒ â ´Â¡ÒÃÃÑ º »ÃÐ·Ò¹ ã¹¢³Ð·Õè Â Ò
Lorazepam, Flunitrazepam â´Â¡ÒÃÃÑº»ÃÐ·Ò¹ÁÕÍºØ µÑ ¡Ô ÒÃ³à¡Ô´ÊÙÞàÊÕÂ¤ÇÒÁ¨íÒä´Œ§Ò‹ Â
¡Ç‹ÒÂÒ Diazepam, Flurazepam áÅÐ¾º¡ÒÃÊÙÞàÊÕÂ¤ÇÒÁ¨íÒã¹ÂÒ¹Í¹ËÅÑº Triazolam
ä´Œº‹ÍÂ¡Ç‹ÒÂÒ¹Í¹ËÅÑºª¹Ô´Í×è¹ àª‹¹ Flurazepam, Temazepam à»š¹µŒ¹ ÁÑ¡¾ºËÅÑ§
¡ÒÃä´Œ Benzodiazepine à¢ŒÒàÊŒ¹ËÃ×ÍËÅÑ§¡Ô¹ÂÒ Triazolam â´ÂËÅÑ§¡Ô¹ÂÒ¼ÙŒ»†ÇÂÂÑ§
ÊÒÁÒÃ¶·íÒ¡Ô¨¡ÃÃÁµ‹Ò§ æ ä´Œ áµ‹àÁ×èÍàÇÅÒ¼‹Ò¹ä»áÅŒÇÁÑ¡¹Ö¡ÂŒÍ¹ä»¶Ö§àËµØ¡ÒÃ³¢³Ð¹Ñé¹
äÁ‹ÍÍ¡ ¨Ö§¤ÇÃàÅÕÂè §¡ÒÃ¡Ô¹ÂÒ¡‹Í¹·íÒ¡Ô¨¡ÃÃÁ·Õµè ÍŒ §ÍÒÈÑÂ¤ÇÒÁ¨íÒËÃ×Í¡ÒÃµÑ´ÊÔ¹ã¨·ÕÊè Òí ¤ÑÞ
3. Disinhibition ä´Œá¡‹ ¡ÅŒÒáÊ´§ÍÍ¡ã¹ÊÔè§«Öè§µÒÁ»¡µÔáÅŒÇ¼ÙŒ»†ÇÂäÁ‹¡ÅŒÒ·íÒ
´Ñ§·Õè¾ºã¹¼ÙŒ´×èÁÊØÃÒ
4. »¯Ô¡ÔÃÔÂÒµÃ§¢ŒÒÁ¡ÑºÄ·¸Ôì¢Í§ÂÒ (paradoxical reaction) ¾ºä´Œà»š¹¤ÃÑé§
¤ÃÒÇ ÁÑ¡áÊ´§ÍÍ¡â´Âà¡Ô´ÍÒ¡ÒÃµ×è¹àµŒ¹ (paradoxical excitement) ¡Ñ§ÇÅ ¹Í¹äÁ‹
ËÅÑº ã¹ºÒ§ÃÒÂÍÒ¨¶Ö§¢Ñé¹áÊ´§¾ÄµÔ¡ÃÃÁ¡ŒÒÇÃŒÒÇ ÇØ‹¹ÇÒÂ ÍÒÅÐÇÒ´ ·íÒÃŒÒÂµ¹àÍ§
ËÃ×Í¼ÙŒÍ×è¹ä´Œ ¨Ö§¤ÇÃÃÐÁÑ´ÃÐÇÑ§à»š¹¾ÔàÈÉ¡Ñº¡ÒÃãËŒÂÒ Benzodiazepine ã¹¼ÙŒ·ÕèÁÕÍÒ¡ÒÃ
·Ò§ÊÁÍ§ (organic mental disorder ËÃ×Í organic brain syndrome) ¼ÙŒÊÙ§ÍÒÂØ
ËÃ×Í¼ÙŒ·ÕèÁÕºØ¤ÅÔ¡ÀÒ¾á»Ã»ÃÇ¹ (personality disorder) ÍÂÙ‹¡‹Í¹
5. ¡ÒÃ´×éÍÂÒ (tolerance) áÅÐÀÒÇÐ¾Öè§¾Ô§ÂÒ (dependence) ¾ºÇ‹Ò ¼ÙŒ»†ÇÂ
ºÒ§ÃÒÂàÁ×èÍãªŒ Benzodiazepine ä»¹Ò¹ æ ÍÒ¨à¡Ô´¡ÒÃ´×éÍÂÒ¢Öé¹ä´Œ ¤×Í µŒÍ§ãªŒÂÒã¹
»ÃÔÁÒ³·ÕèÊÙ§¢Öé¹¡Ç‹Òà´ÔÁ áµ‹ºÒ§ÃÒÂ¡çà»š¹á¤‹ psychic dependence à·‹Ò¹Ñé¹
¡ÒÃá¡Œä¢¾ÔÉ¢Í§ÂÒ Benzodiazepine
ÃÑ¡ÉÒµÒÁÍÒ¡ÒÃ·Õèà¡Ô´¢Öé¹¨Ò¡¡ÒÃ¡´ÃÐºº»ÃÐÊÒ·Ê‹Ç¹¡ÅÒ§ ãËŒ Antidote
¢Í§¡ÅØ‹ÁÂÒ Benzodiazepines ä´Œá¡‹ Flumazenil ÍÂ‹Ò§äÃ¡çµÒÁÂÒ¡ÅØ‹Á¹ÕéÁÕ¤ÇÒÁ
»ÅÍ´ÀÑ Â ¤‹ Í ¹¢Œ Ò §ÊÙ § ¨Ò¡¡ÒÃä´Œ ÃÑ º ÂÒà¡Ô ¹ ¢¹Ò´ à¾ÃÒÐÂÒ¡ÅØ‹ Á à´Ô Á ·Õè ã ªŒ ¤× Í ¡ÅØ‹ Á
barbiturates «Ö§è à¡Ô´¼Å¡´¡ÒÃËÒÂã¨áÅÐÃÐºº»ÃÐÊÒ·Ê‹Ç¹¡ÅÒ§·íÒãËŒÃÐºº¡ÒÃËÒÂã¨
ÅŒÁàËÅÇ¶Ö§¢Ñé¹àÊÕÂªÕÇÔµä´Œ§‹ÒÂ¡Ç‹Ò¡ÅØ‹ÁÂÒ Benzodiazepine «Öè§à»š¹ÂÒ¡ÅØ‹ÁãËÁ‹
ËÅÑ¡¡ÒÃáÅÐá¹Ç·Ò§ã¹¡ÒÃÊÑè§ÂÒ Benzodiazepine
¡ÅØ‹ÁÂÒ Benzodiazepine ÁÕËÅÒ¡ËÅÒÂª¹Ô´·ÕèÇÒ§¨íÒË¹‹ÒÂã¹·ŒÍ§µÅÒ´ áÅÐ
á¾·Â¹ÔÂÁÊÑè§¨‹ÒÂ¡ÅØ‹Á¹ÕéÍÂ‹Ò§¡ÇŒÒ§¢ÇÒ§ã¹ËÅÒ¡ËÅÒÂ¢ŒÍº‹§ãªŒ¢Í§ÂÒ à¾×èÍ¡‹ÍãËŒà¡Ô´
¤ÇÒÁ»ÅÍ´ÀÑÂµ‹Í¡ÒÃÊÑè§¨‹ÒÂÂÒã¹¡ÅØ‹Á¹Õé ´Ñ§¹Ñé¹¨Ö§¤ÇÃÁÕá¹Ç·Ò§ã¹¡ÒÃàÅ×Í¡ãªŒÂÒÍÂ‹Ò§
àËÁÒÐÊÁà¾×èÍà»š¹ËÅÑ¡»¯ÔºÑµÔã¹¡ÒÃàÅ×Í¡ãªŒÂÒ´Ñ§¡Å‹ÒÇ â´ÂÁÕËÅÑ¡¡ÒÃ¡ÇŒÒ§ æ ·Õè¤ÇÃ
¤íÒ¹Ö§¶Ö§ã¹¡ÒÃÊÑè§ãªŒÂÒ Benzodiazepine ´Ñ§¹Õé
• ËÅÑ¡ “7 ¶Ù¡” ¢Í§¡ÒÃãªŒÂÒ Benzodiazepine ·ÕèàËÁÒÐÊÁ
• ËÅÑ ¡ ¡ÒÃàÅ× Í ¡ÊÑè § ãªŒ Â Ò Benzodiazepine µÒÁ¤Ø ³ ÊÁºÑ µÔ · Ò§
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¡. ËÅÑ¡ “7 ¶Ù¡” ¢Í§¡ÒÃãªŒÂÒ Benzodiazepine ·ÕèàËÁÒÐÊÁ
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1. ¶Ù¡âÃ¤ (right diagnosis) ¤ÇÃÇÔ¹Ô¨©ÑÂâÃ¤ËÃ×ÍÀÒÇÐ¢Í§¼ÙŒ»†ÇÂãËŒªÑ´à¨¹
¡‹Í¹¡ÒÃãËŒÂÒ àª‹¹ ¶ŒÒÇÔ¹Ô¨©ÑÂÇ‹Ò¼ÙŒ»†ÇÂà»š¹ major depression áµ‹ÁÕÍÒ¡ÒÃÇÔµ¡¡Ñ§ÇÅ
Ã‹ÇÁ´ŒÇÂ ¡ÒÃãËŒÂÒ Benzodiazepine ¨Ö§à»š¹¡ÒÃãËŒÃ‹ÇÁä»¡ÑºÂÒËÅÑ¡¤×ÍÂÒá¡Œ«ÖÁàÈÃŒÒ
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Benzodiazepine
2. ¶Ù¡ª¹Ô´ (right drug) ËÒ¡ÇÔ¹Ô¨©ÑÂâÃ¤ã¹¢ŒÍ 1 ä´Œ¶Ù¡ ¡ç¨Ð·íÒãËŒàÅ×Í¡ÂÒ
Benzodiazepine ä´Œ¶Ù¡ª¹Ô´´ŒÇÂ àª‹¹ ¶ŒÒÇÔ¹Ô¨©ÑÂÇ‹Òà»š¹ nocturnal myoclonus
(periodic limb movement syndrome, PLMS) ¡ç¤ÇÃàÅ×Í¡ÂÒ Clonazepam ËÃ×Í
Temazepam áµ‹äÁ‹¤ÇÃãËŒÂÒ Benzodiazepine 2 ª¹Ô´ã¹¼ÙŒ»†ÇÂ¤¹à´ÕÂÇ¡Ñ¹
3. ¶Ù¡¢¹Ò´ (right dose) àª‹¹ àÁ×èÍÇÔ¹Ô¨©ÑÂÇ‹Òà»š¹âÃ¤á¾¹Ô¤ (Panic) ¶ŒÒ¨Ð
ãËŒ Alprazolam ¤ÇÃãËŒµÑé§µŒ¹ÍÂ‹Ò§µíèÒ 0.75 Á¡./ÇÑ¹ (ãËŒ¢¹Ò´ 0.25 Á¡. ÇÑ¹ÅÐ 3
¤ÃÑé§) äÁ‹ãª‹ãËŒ¡Ô¹á¤‹ 0.25 Á¡. 1 àÁç´¡‹Í¹¹Í¹
4. ¶Ù¡·Ò§ (right route of administration) àª‹¹ äÁ‹¤ÇÃ©Õ´ Diazepam à¢ŒÒ
¡ÅŒÒÁà¾ÃÒÐ¡ÒÃ©Õ´à¢ŒÒ¡ÅŒÒÁµŒÍ§ãªŒàÇÅÒ 10-12 ªÑèÇâÁ§ ¡Ç‹Ò¨Ð¶Ö§ÃÐ´ÑºÂÒÊÙ§ÊØ´ ¢³Ð
·Õè¡ÒÃ¡Ô¹ÂÒ¨Ðä´ŒÃÐ´ÑºÂÒÊÙ§ÊØ´ã¹àÅ×Í´ÍÂ‹Ò§ªŒÒà¾ÕÂ§ 2 ªÑèÇâÁ§à·‹Ò¹Ñé¹ áÅÐÃÐ´ÑºÂÒ
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Benzodiazepine ©Õ´à¢ŒÒ¡ÅŒÒÁ á¹Ð¹íÒãËŒãªŒ Clonazepam ËÃ×Í Lorazepam ©Õ´à¢ŒÒ
¡ÅŒÒÁá·¹ (áµ‹äÁ‹ÁÕã¹»ÃÐà·Èä·Â)
5. ¶Ù¡àÇÅÒ (right time, right duration) ¤×Í ãËŒÂÒ¨¹¤Ãº course µÒÁ
ÃÐÂÐàÇÅÒ·Õ¡è Òí Ë¹´ àª‹¹ ¶ŒÒÇÔ¹¨Ô ©ÑÂÇ‹Òà»š¹âÃ¤á¾¹Ô¤ (Panic) ¡ç¤ÇÃãËŒÂÒ¹Ò¹»ÃÐÁÒ³
8-12 à´×Í¹ áÅŒÇ¨Ö§¤‹ÍÂ æ Å´¢¹Ò´ÂÒÅ§ (¤ÇÒÁÅŒÁàËÅÇã¹¡ÒÃÃÑ¡ÉÒÊ‹Ç¹Ë¹Öè§¾ºÇ‹Ò
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6. ¶Ù¡ã¨ (right choice for patient, right preference) à¹×èÍ§¨Ò¡âÃ¤ÇÔµ¡
¡Ñ§ÇÅÊ‹Ç¹ãËÞ‹µŒÍ§¡Ô¹ÂÒµÔ´µ‹Í¡Ñ¹à»š¹ÃÐÂÐàÇÅÒ¹Ò¹ ËÒ¡ÊÒÁÒÃ¶àÅ×Í¡ÂÒ Benzodi-
azepine ·Õ¼è »ÙŒ Ç† ÂªÍº àª‹¹ ºÒ§ÃÒÂªÍº¡Ô¹ÂÒá¤‹¤ÃÖ§è àÁç´ à¾ÃÒÐãËŒ¤ÇÒÁÃÙÊŒ ¡Ö Ç‹ÒÁÕÍÒ¡ÒÃ
äÁ‹ÃØ¹áÃ§ ¡Ô¹ÂÒ¹Ô´à´ÕÂÇ ã¹¡Ã³Õ¹Õéá¾·ÂÍÒ¨àÅ×Í¡ÂÒàÁç´·ÕèÁÕÁÔÅÅÔ¡ÃÑÁÊÙ§áÅŒÇãËŒ¼ÙŒ»†ÇÂ
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7. ¶Ù¡à§Ô¹ (right for economic reason) ÂÒ Benzodiazepine Ê‹Ç¹ãËÞ‹
ã¹¢³Ð¹ÕéÁÕ·Ñé§ÂÒµŒ¹áºº (original) áÅÐÂÒã¹»ÃÐà·È áÅÐàÁ×èÍà·ÕÂº¡ÑºÂÒá¡Œ«ÖÁàÈÃŒÒ
ª¹Ô´ãËÁ‹ æ áÅŒÇ ¨ÐàËç¹Ç‹ÒÁÕÃÒ¤Ò¶Ù¡¡Ç‹ÒÁÒ¡ ÍÂ‹Ò§äÃ¡çµÒÁ ÊíÒËÃÑº Benzodiazepine
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¶Ö§ risk and benefit ratio ·Õè¼ÙŒ»†ÇÂ¨Ðä´ŒÃÑº¨Ò¡¡ÒÃ¡Ô¹ÂÒ Benzodiazepine áÅÐ
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¢. ËÅÑ¡¡ÒÃàÅ×Í¡ÊÑè§ãªŒÂÒ Benzodiazepine µÒÁ¤Ø³ÊÁºÑµÔ·Ò§àÀÊÑª¨Å¹ÈÒÊµÃ

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BZD â´ÂäÁ‹ÅÑ§àÅ à¾ÃÒÐÊ‹Ç¹ÁÒ¡áÅŒÇ¼ÙŒ»†ÇÂ·Õèä´ŒÃÑºÂÒ Benzodiazepine ã¹ª‹Ç§ÊÑé¹ æ
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ÖúčŠö÷ć ×šĂđéŠî ×šĂéšĂ÷
ÖúčŠöÙŠćÙøċęÜßĊüêĉ ÿĆĚî • ĕöŠđÖĉéÖćøÿąÿö÷ć • êšĂÜĔĀš÷ćĀúć÷öČĚĂ
• ìĞćĔĀšÜŠüÜêĂîÖúćÜüĆîĕéšîĂš ÷ÖüŠć • đÖĉéĂćÖćø severe withdrawal
syndrome ĕéšöćÖÖüŠć
• đÖĉé rebound insomnia Ēúą
anterograde amnesia ĕéšïŠĂ÷ÖüŠć
ÖúčŠöÙŠćÙøċęÜßĊüêĉ ÷ćü • ĕöŠêšĂÜĔĀš÷ćĀúć÷öČĚĂ • đÖĉéÖćøÿąÿö÷ć
• øąéĆï÷ćĔîóúćÿöŠćĒðøðøüîîšĂ÷ÖüŠć • öĊÙüćöđÿĊę÷ÜìĊÝę ąđÖĉé psychomotor
impairment ßŠüÜÖúćÜüĆîĕéšöćÖÖüŠć
• đÖĉéĂćÖćø severe withdrawal • ìĞćĔĀšÜŠüÜêĂîÖúćÜüĆîĕéšöćÖÖüŠć
syndrome ĕéšîšĂ÷ÖüŠć
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2-keto ¨ÐÁÕ¤‹Ò¤ÃÖè§ªÕÇÔµÂÒÇ ÊÒÁÒÃ¶ÃÑº»ÃÐ·Ò¹ÇÑ¹ÅÐ¤ÃÑé§ä´Œ Ê‹Ç¹ÂÒã¹¡ÅØ‹Á 3-hy-
droxy áÅÐ triazolo ÁÕ¤‹Ò¤ÃÖè§ªÕÇÔµÊÑé¹ ¨Ö§¤ÇÃÃÑº»ÃÐ·Ò¹ÍÂ‹Ò§¹ŒÍÂÇÑ¹ÅÐ 2-3 ¤ÃÑé§
1.2. ¤‹Ò¤ÃÖè§ªÕÇÔµÁÕ¼Åµ‹Í¡ÒÃàÅ×Í¡ãªŒÂÒ àª‹¹ ¡ÒÃãªŒÂÒ·ÕèÁÕ¤‹Ò¤ÃÖè§ªÕÇÔµÊÑé¹ ÍÒ¨
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1.3. ÂÒ·ÕèÁÕ¤‹Ò¤ÃÖè§ªÕÇÔµÊÑé¹ËÃ×Í»Ò¹¡ÅÒ§ ¨Ð·íÒãËŒÁÕÍÒ¡ÒÃµÔ´ÂÒËÃ×ÍÁÕÍÒ¡ÒÃ
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ãËŒ¾Ô¨ÒÃ³ÒÇ‹Ò¨ÐàÅ×Í¡ÂÒ·ÕèÍÍ¡Ä·¸ÔìàÃçÇ ËÃ×ÍÍÍ¡Ä·¸ÔìªŒÒ à¾ÃÒÐ¶ŒÒÍÂÒ¡ä´Œ
ÂÒ·ÕÍè Í¡Ä·¸Ôàì ÃçÇ¡çµÍŒ §àÅ×Í¡ÂÒ·ÕÅè ÐÅÒÂµÑÇã¹ä¢ÁÑ¹ä´ŒÊ§Ù àª‹¹ Diazepam, Midazolam
áµ‹¶ÒŒ ÍÂÒ¡ä´ŒÂÒ·ÕÍè Í¡Ä·¸Ôªì ÒŒ ¡çµÍŒ §àÅ×Í¡ÂÒ·ÕÅè ÐÅÒÂµÑÇã¹ä¢ÁÑ¹ä´ŒµÒíè àª‹¹ Clobazam
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áÁŒÂÒ Benzodiazepine ¨ÐÁÕËÅÒÂª¹Ô´ áµ‹¢ÍàÊ¹ÍãËŒàÅ×Í¡ãªŒÂÒã¹áµ‹ÅÐ
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¡ÅØ‹ÁÍÒ¡ÒÃ·Õè¾ºº‹ÍÂ æ àª‹¹ ÇÔµ¡¡Ñ§ÇÅ Í‹Í¹áÃ§ ¹Í¹äÁ‹ËÅÑº ÀÒÇÐÇØ‹¹ÇÒÂ
(agitation) ¡ÅŒÒÁà¹×éÍµÖ§µÑÇ áÅÐÊÑè¹
¡ÅØ‹ÁÍÒ¡ÒÃ·Õè¾ºä´ŒàÅç¡¹ŒÍÂ àª‹¹ ¤Å×è¹äÊŒ àË§×èÍÍÍ¡ ¤Ñ´¨ÁÙ¡ áÅÐäÇµ‹Í¡ÒÃ
¶Ù¡¡ÃÐµØŒ¹
¡ÅØ‹ÁÍÒ¡ÒÃ¶Í¹ÂÒ·ÕèÃØ¹áÃ§ àª‹¹ ÍÒ¡ÒÃ·Ò§¨Ôµ ªÑ¡ »ÃÐÊÒ·ËÅÍ¹ ËÅ§¼Ô´
áÅÐÍÒ¡ÒÃËÙÍ×éÍµÅÍ´àÇÅÒ âÍ¡ÒÊà¡Ô´ÍÒ¡ÒÃ´Ñ§¡Å‹ÒÇ¾ºÂÒ¡ÁÒ¡ ÁÑ¡¾ºã¹¼ÙŒ»†ÇÂÊÙ§
ÍÒÂØ·ÕèËÂØ´ÂÒ¡ÅØ‹Á¤ÇÒÁáÃ§ÊÙ§ÍÂ‹Ò§·Ñ¹·Õ·Ñ¹ã´
´Ñ§¹Ñé¹à¾×èÍËÅÕ¡àÅÕèÂ§»˜ÞËÒ¨Ò¡¡ÒÃ¶Í¹ÂÒ ¤ÇÃ¤‹ÍÂ æ Å´¢¹Ò´ÂÒ·ÕèãªŒÅ§·Õ
ÅÐ¹ŒÍÂ â´Â»¡µÔÂÒ Alprazolam, Clonazepam äÁ‹¤ÇÃÅ´¢¹Ò´ÁÒ¡¡Ç‹Ò 0.5
ÁÔÅÅÔ¡ÃÑÁ·Ø¡ 2-3 ÊÑ»´ÒË ËÒ¡Å´¢¹Ò´Å§àÃçÇ¡Ç‹ÒÍÒ¨¾ºÍÒ¡ÒÃ¼Ô´»¡µÔ àª‹¹
ªÑ¡¨Ò¡¡ÒÃ¶Í¹ÂÒ (withdrawal seizure) µÑÇÍÂ‹Ò§àª‹¹ ã¹¼ÙŒ»†ÇÂ·Õèà¤Âä´ŒÃÑºÂÒ
´Ñ§¡Å‹ÒÇ¢¹Ò´ 6 ÁÔÅÅÔ¡ÃÑÁµ‹ÍÇÑ¹ ÍÒ¨ãªŒÃÐÂÐàÇÅÒã¹¡ÒÃÅ´¢¹Ò´ÂÒäÁ‹µèíÒ¡Ç‹Ò
2-3 à´×Í¹ ¨Ö§¨ÐÊÒÁÒÃ¶ËÂØ´ÂÒä´Œ à»š¹µŒ¹
§Ò¹ÇÔ¨ÑÂ·Ò§¤ÅÔ¹Ô¡·ÕèÁÕ¡ÒÃãËŒÂÒ·ÕèÍÒ¨ª‹ÇÂÅ´¤ÇÒÁÃØ¹áÃ§¢Í§ÍÒ¡ÒÃ¶Í¹ÂÒ
¨Ò¡¡ÒÃËÂØ´ÂÒ Benzodiazepine àª‹¹ Propranolol, Progesterone, Dothiepine,
Buspirone (äÁ‹ÁÕ¨íÒË¹‹ÒÂã¹»ÃÐà·Èä·Â) äÁ‹ä´Œ¼Åã¹¡ÒÃÃÑ¡ÉÒÍÒ¡ÒÃ¶Í¹ÂÒ·Õèà¡Ô´
¨Ò¡¡ÒÃä´ŒÃÑº Benzodiazepine ÁÒà»š¹ÃÐÂÐàÇÅÒ¹Ò¹ æ áµ‹¾ºÇ‹Ò Buspirone
ÍÒ¨ÁÕ»ÃÐâÂª¹ã¹¼ÙŒ»†ÇÂ·ÕèËÂØ´ÂÒ Lorazepam ã¹ÃÐÂÐàÇÅÒäÁ‹à¡Ô¹ 2-3 à´×Í¹áÅÐ
ÂÒ Carbamazepine ã¹¢¹Ò´ 200-600 Á¡./ÇÑ¹ ÍÒ¨ÁÕ»ÃÐâÂª¹ã¹¡ÒÃª‹ÇÂÅ´
ÍÒ¡ÒÃ¶Í¹ÂÒä´ŒºŒÒ§
¡ÒÃµÔ´ÂÒ (drug abuse)

à§×èÍ¹ä¢·Õè·íÒãËŒà¡Ô´¡ÒÃµÔ´ÂÒ Benzodiazepine 4 »ÃÐ¡ÒÃ ä´Œá¡‹ ¡ÒÃä´ŒÃÑº
ÂÒ¢¹Ò´ÊÙ§ ÊÀÒÇÐ¶´¶ÍÂ·Ò§¨Ôµã¨¢Í§¼ÙŒ»†ÇÂ (psychological regression) ¡ÒÃ
ä´ŒÃÑºÂÒã¹¢¹Ò´·ÕèÊÙ§¡Ç‹Òá¾·ÂÊÑè§¨‹ÒÂ (¼ÙŒ»†ÇÂ¡Ô¹ÂÒà¡Ô¹¢¹Ò´ÃÑ¡ÉÒ) áÅÐ¡ÒÃä´ŒÃÑº
ÂÒËÅÑ§¨Ò¡·Õèá¾·ÂÊÑè§ËÂØ´ÂÒ (¼ÙŒ»†ÇÂ«×éÍÂÒ¡Ô¹àÍ§)
¨Ò¡¢ŒÍÁÙÅÊÒ¸ÒÃ³ÊØ¢¢Í§ÊËÃÑ°ÍàÁÃÔ¡Ò»‚ ¤.È. 1979 ¾ºÇ‹ÒÁÕ¡ÒÃÊÑè§¨‹ÒÂÂÒ
Benzodiazepine ÍÂ‹Ò§¹ŒÍÂ 1 »‚ ÃŒÍÂÅÐ 1.6 ¡ÒÃãËŒÂÒÃÑ¡ÉÒÍÒ¡ÒÃÇÔµ¡¡Ñ§ÇÅ¾ºÇ‹Ò
ÃŒÍÂÅÐ 15 ¢Í§¼ÙŒ»†ÇÂä´ŒÃÑºÂÒ·Ø¡ÇÑ¹ ÁÒ¡¡Ç‹Ò 1 »‚ ã¹»ÃÐà·ÈÍÑ§¡ÄÉ ¾ºÇ‹ÒÁÕ¡ÒÃÊÑè§
¨‹ÒÂÂÒ Benzodiazepine ÍÂ‹Ò§¹ŒÍÂ 1 »‚ ÃŒÍÂÅÐ 1.6 Ê‹Ç¹¢ŒÍÁÙÅ¡ÒÃãªŒÂÒã¹
àÇª»¯ÔºÑµÔ·ÑèÇä»¢Í§»ÃÐà·ÈÍÍÊàµÃàÅÕÂ ¾ºÇ‹Ò¼ÙŒ»†ÇÂ·ÕèÁÕ¡ÒÃãªŒÂÒ Benzodiazepine
¤ÃÑé§áÃ¡»ÃÐÁÒ³ ÃŒÍÂÅÐ 10 ÂÑ§¤§ãªŒÂÒµ‹Íà¹×èÍ§¹Ò¹ 6 à´×Í¹ â´ÂäÁ‹ÁÕ¡ÒÃà¾ÔèÁ¢¹Ò´
¡ÒÃãªŒ ÍØºÑµÔ¡ÒÃ³¡ÒÃµÔ´ÂÒ Benzodiazepine ã¹¡ÃÐºÇ¹¡ÒÃÃÑ¡ÉÒ¢Í§á¾·Â¾º
»ÃÐÁÒ³ 1 ÃÒÂ µ‹Í 50 ÅŒÒ¹¼ÙŒ»†ÇÂµ‹Íà´×Í¹ (â´Â¼ÙŒ»†ÇÂä´ŒÃÑº¡ÒÃÊÑè§¨‹ÒÂÂÒÍÂ‹Ò§
¶Ù¡µŒÍ§µÒÁËÅÑ¡¡ÒÃ·Ò§¡ÒÃá¾·Â) ã¹¨íÒ¹Ç¹´Ñ§¡Å‹ÒÇ¾ºÇ‹Ò ÃŒÍÂÅÐ 92 à¡Ô´¨Ò¡
¼ÙŒ»†ÇÂ·ÕèµÔ´ÊØÃÒËÃ×ÍµÔ´ÂÒª¹Ô´Í×è¹ æ (alcohol or other drug of abuse) «Öè§ÁÕÍØºÑµÔ
¡ÒÃ³µÔ´ÂÒ Benzodiazepine µèíÒ¡Ç‹Ò·Õè¼Å¡ÒÃÈÖ¡ÉÒÃÐËÇ‹Ò§»‚ ¤.È. 1961-1977
¨Ò¡¢Œ Í ÁÙ Å ¼ÙŒ »† Ç ÂµÔ ´ ÂÒ ¾ºÇ‹ Ò »ÃÐÁÒ³ 1 ã¹ 3 à¡Ô ´ ¨Ò¡¡ÒÃãªŒ Â Ò
Benzodiazepine à»š¹Ê‹Ç¹ãËÞ‹ ¾ºÇ‹Ò ÃŒÍÂÅÐ 29 µÔ´ÂÒ Diazepam ÃŒÍÂÅÐ 40
µÔ ´ ÂÒ Methadone ¨Ò¡¢Œ Í ÁÙ Å ¡ÒÃµÃÇ¨»˜ Ê ÊÒÇÐã¹¼ÙŒ »† Ç Â·Õè µÔ ´ ÂÒ ¡Ã³Õ Â Ò
Benzodiazepine ¾ºÂÒ Diazepam, Lorazepam áÅÐ Alprazolam ÁÒ¡¡Ç‹Ò
Chlordiazepoxide áÅÐ Oxazepam Ê‹Ç¹¡Ã³ÕÂÒ©Õ´¾ºÇ‹Òã¹ÍÍÊàµÃàÅÕÂ ¼ÙŒ»†ÇÂ
·Õè©Õ´àÎâÃÍÕ¹ ÃŒÍÂÅÐ 48 ÁÕ¡ÒÃ©Õ´ÂÒ Benzodiazepine Ã‹ÇÁ´ŒÇÂ áÅÐ¾ºÊ‹Ç¹ÁÒ¡
©Õ´ Temazepam áÅÐ Diazepam ã¹»ÃÐà·ÈÍÑ§¡ÄÉ¾ºÊ‹Ç¹ÁÒ¡©Õ´ Temazepam
áÅÐäÁ‹¾º¤ÇÒÁáµ¡µ‹Ò§ÃÐËÇ‹Ò§ÃÙ»áººÂÒÍÍ¡Ä·¸Ôàì ¹Ô¹è áÅÐÂÒ·ÕÍè Í¡Ä·¸Ô·ì ¹Ñ ·Õã¹¡ÒÃ
Å´¡ÒÃµÔ´ÂÒ Benzodiazepine
â´ÂÊÃØ»¢ŒÍÁÙÅ¨Ò¡ËÅÑ¡°Ò¹·Õ¾è ºã¹¢³Ð¹Õªé ãÕé ËŒàËç¹Ç‹Ò ¤ÇÒÁªØ¡ã¹¡ÒÃà¡Ô´¡ÒÃ
µÔ´ÂÒ Benzodiazepine äÁ‹»¡µÔã¹¼Ù»Œ Ç† Â·Õµè ´Ô ÊØÃÒËÃ×ÍµÔ´ÂÒÍ×¹è æ â´ÂÁÕÍµÑ ÃÒÊÙ§¡Ç‹Ò
¼ÙŒ»†ÇÂ·ÑèÇ æ ä»·ÕèãªŒÂÒ Benzodiazepine ã¹¢ŒÍº‹§ªÕéÍ×è¹ æ
¡ÒÃÊÙÞàÊÕÂ¤ÇÒÁ¨íÒ (anterograde amnesia)

ÁÑ¡à¡Ô´¢Öé¹¡ÑºÂÒ·ÕèÁÕÃÐÂÐàÇÅÒÍÍ¡Ä·¸ÔìàÃçÇ «Öè§¢Öé¹ÍÂÙ‹¡Ñº¤ÇÒÁáÃ§áÅÐÇÔ¸Õ¡ÒÃ
ãËŒÂÒ àª‹¹
- ¡ÒÃãËŒ Diazepam â´Â¡ÒÃ©Õ´à¢ŒÒËÅÍ´àÅ×Í´´íÒ ÍÒ¨à¡Ô´¡ÒÃÊÙÞàÊÕÂ
¤ÇÒÁ¨íÒä´Œ§Ò‹ Â¡Ç‹Ò¡ÒÃãËŒ·Ò§¡ÅŒÒÁà¹×Íé ËÃ×ÍäÁ‹¤Í‹ Âà¡Ô´ËÃ×Í¾º¹ŒÍÂÁÒ¡ã¹¡ÒÃãËŒâ´Â
¡ÒÃÃÑº»ÃÐ·Ò¹
- ¡ÒÃÃÑº»ÃÐ·Ò¹ÂÒ Triazolam ¾º¡ÒÃÊÙÞàÊÕÂ¤ÇÒÁ¨íÒä´Œº‹ÍÂ¡Ç‹ÒÂÒ
¹Í¹ËÅÑºª¹Ô´Í×è¹ àª‹¹ Flurazepam, Temazepam à»š¹µŒ¹ â´ÂËÅÑ§¡Ô¹ÂÒ¼ÙŒ»†ÇÂ
ÂÑ§ÊÒÁÒÃ¶·íÒ¡Ô¨¡ÃÃÁµ‹Ò§ æ ä´Œ áµ‹àÁ×èÍàÇÅÒ¼‹Ò¹ä»áÅŒÇÁÑ¡¹Ö¡ÂŒÍ¹ä»¶Ö§àËµØ¡ÒÃ³
¢³Ð¹Ñé¹äÁ‹ÍÍ¡ ¨Ö§¤ÇÃàÅÕèÂ§¡ÒÃ¡Ô¹ÂÒ¡‹Í¹·íÒ¡Ô¨¡ÃÃÁ·ÕèµŒÍ§ÍÒÈÑÂ¤ÇÒÁ¨íÒËÃ×Í¡ÒÃ
µÑ´ÊÔ¹ã¨·ÕèÊíÒ¤ÑÞ áÅÐ¾ºã¹ÂÒ Alprazolam «Öè§¶Ù¡¹íÒä»ãªŒà»š¹ÂÒàÊÕÂÊÒÇ ËÃ×Í
ÁÍÁàËÂ×èÍãËŒ§‹Ç§«ÖÁ â´Â¼ÊÁã¹à¤Ã×èÍ§´×èÁ·ÕèÁÕáÍÅ¡ÍÎÍÅ ã¹¢³Ð·Õè Lorazepam,
Flunitrazepam ÁÕ ÍØ ºÑ µÔ ¡ ÒÃ³ à ¡Ô ´ ÊÙ Þ àÊÕ Â ¤ÇÒÁ¨í Òä´Œ §‹ Ò Â¡Ç‹ Ò ÂÒ Diazepam,
Flurazepam
ÁÒâ¹ª ËÅ‹ÍµÃÐ¡ÙÅ, ¤Ù‹Á×Í¡ÒÃãªŒÂÒ·Ò§¨ÔµàÇª. ¡ÃØ§à·¾ÁËÒ¹¤Ã : ËÁÍªÒÇºŒÒ¹,
2547.
¨ØÁÀ® ¾ÃÁÊÕ´Ò, ¤Ù‹Á×ÍÂÒ·Ò§¨ÔµàÇªÊíÒËÃÑººØ¤ÅÒ¡ÃÊÒ¸ÒÃ³ÊØ¢. ¡ÃÐ·ÃÇ§
ÊÒ¸ÒÃ³ÊØ¢, 2547. 62
A Pathophysiologic Approach, 8th ed., 2011.
¡ÅØ‹ÁÂÒÃÑ¡ÉÒÍÒ¡ÒÃàÈÃŒÒ (Antidepressant drugs)
âÃ¤«ÖÁàÈÃŒÒ (major depressive disorder) à»š¹âÃ¤ÊíÒ¤ÑÞã¹·Ò§
¨ÔµàÇªÈÒÊµÃ à¹×èÍ§¨Ò¡à»š¹¤ÇÒÁ¼Ô´»¡µÔ·Ò§¨ÔµàÇª·Õè¾ºä´Œº‹ÍÂ ¼ÙŒ»†ÇÂä´ŒÃÑº¼Å
¡ÃÐ·ºÁÒ¡ ÍÕ¡·Ñé§à»š¹âÃ¤·ÕèÃÑ¡ÉÒä´ŒËÒ¡¼ÙŒ»†ÇÂä´ŒÃÑº¡ÒÃ´ÙáÅÍÂ‹Ò§àËÁÒÐÊÁ
¡ÒÃàÃÔèÁà¡Ô´ÍÒ¡ÒÃ¹Ñé¹ÍÒ¨ÁÕ»˜¨¨ÑÂ¡ÃÐµØŒ¹ àª‹¹ ÊÙÞàÊÕÂ¤¹·Õèµ¹ÃÑ¡ µ¡§Ò¹
¡ÒÃËÂ‹ÒÃŒÒ§ ËÃ×ÍºÒ§¤ÃÑé§äÁ‹ÁÕ¡çä´Œ ¡ÒÃ¾Ô¨ÒÃ³ÒÇ‹Ò¡ÒÃà»ÅÕèÂ¹á»Å§¢Í§¼ÙŒ»†ÇÂ·Õèà¡Ô´
¢Öé¹¹Ñé¹¼Ô´»¡µÔËÃ×ÍäÁ‹ àÃÒ´Ù¨Ò¡¡ÒÃÁÕÍÒ¡ÒÃµ‹Ò§ æ áÅÐ¤ÇÒÁÃØ¹áÃ§¢Í§ÍÒ¡ÒÃà»š¹
ËÅÑ¡ ¼ÙŒ»†ÇÂ·ÕèÁÕÍÒ¡ÒÃà¢ŒÒ¡Ñºà¡³±¡ÒÃÇÔ¹Ô¨©ÑÂâÃ¤«ÖÁàÈÃŒÒ¹Ñé¹ º‹§¶Ö§ÀÒÇÐ¢Í§¤ÇÒÁ
¼Ô´»¡µÔ·Õè¨íÒµŒÍ§ãËŒ¡ÒÃª‹ÇÂàËÅ×Í
ÊÒàËµØ¢Í§¡ÒÃà¡Ô´âÃ¤«ÖÁàÈÃŒÒ
»˜¨¨ÑÂ·Õàè »š¹ÊÒàËµØãËŒà¡Ô´âÃ¤«ÖÁàÈÃŒÒÁÕËÅÒÂ»˜¨¨ÑÂ ·Ñ§é »˜¨¨ÑÂ·Ò§ªÕÇÀÒ¾ »˜¨¨ÑÂ
·Ò§¾Ñ¹¸Ø¡ÃÃÁ áÅÐ»˜¨¨ÑÂ·Ò§¨ÔµÊÑ§¤Á «Öè§»˜¨¨ÑÂ·Ñé§ËÅÒÂàËÅ‹Ò¹Õé¨ÐÃ‹ÇÁà»š¹ÊÒàËµØ
¡ÃÐµØŒ¹ãËŒ¼ÙŒ»†ÇÂà¡Ô´âÃ¤«ÖÁàÈÃŒÒ ã¹·Õè¹Õè¨Ð¡Å‹ÒÇ¶Ö§à©¾ÒÐ»˜¨¨ÑÂ·Ò§ªÕÇÀÒ¾·ÕèÊíÒ¤ÑÞ·Õè
à¡ÕèÂÇ¢ŒÍ§¡ÑºÂÒ·ÕèãªŒÃÑ¡ÉÒâÃ¤«ÖÁàÈÃŒÒ
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Biogenic Amines
ÁÕËÅÒÂ¡ÒÃÈÖ¡ÉÒ·Õè¾º¤ÇÒÁ¼Ô´»¡µÔ¢Í§ biogenic amine ã¹¼ÙŒ»†ÇÂâÃ¤
«ÖÁàÈÃŒÒ ·ÕèÁÕ¤ÇÒÁÊíÒ¤ÑÞáÅÐ¾ºº‹ÍÂ ä´Œá¡‹ ÃÐºº Norepinephrine, Serotonin
áÅÐ Dopamine
Norepinephrine
¾ºÇ‹ÒÁÕ¤ÇÒÁÊÑÁ¾Ñ¹¸ÃÐËÇ‹Ò§ down regulation ¢Í§ beta-adrenergic
receptors ¡Ñº¡ÒÃµÍºÊ¹Í§µ‹Í¡ÒÃÃÑ¡ÉÒ´ŒÇÂÂÒµŒÒ¹«ÖÁàÈÃŒÒ áÅÐÁÕ¢ÍŒ ÁÙÅ·ÕÊè ¹ÑºÊ¹Ø¹
Ç‹Ò¡ÒÃ¡ÃÐµØ¹Œ Presynaptic beta-2 receptors ã¹âÃ¤«ÖÁàÈÃŒÒ¨ÐÊ‹§¼ÅãËŒÁ¡Õ ÒÃËÅÑ§è
norepinephrine Å´Å§ ¹Ñ¹è ¡ç¤Í× ã¹âÃ¤«ÖÁàÈÃŒÒ ¾ºÇ‹ÒÁÕ¡ÒÃËÅÑ§è ¢Í§ norepinephrine
Å´Å§ ÂÒµŒÒ¹«ÖÁàÈÃŒÒ·ÕèÁÕ¼Åä»Å´¡ÒÃ reuptake ¢Í§ norepinephrine àª‹¹
Venlafaxine (Efexor®) à»š¹µÑÇÊ¹ÑºÊ¹Ø¹Ç‹Ò norepinephrine ÁÕº·ºÒ·ã¹ÀÒÇÐ
«ÖÁàÈÃŒÒ («Öè§ Venlafaxine ¨Ðä»Å´¡ÒÃ reuptake ¢Í§ serotonin ´ŒÇÂ)
Serotonin
Serotonin à»š¹ biogenic amine ·Õ¾è ºÇ‹ÒÁÕÊÁÑ ¾Ñ¹¸¡ºÑ âÃ¤«ÖÁàÈÃŒÒÁÒ¡·ÕÊè ´Ø
¡ÒÃÅ´Å§¢Í§ serotonin ÍÒ¨¡ÃÐµØ¹Œ ãËŒà¡Ô´ÀÒÇÐ«ÖÁàÈÃŒÒ ã¹¼Ù»Œ Ç† ÂºÒ§¤¹·Õ¢è Ò´¡ÒÃ
¤Çº¤Ø Á à¡Õè Â Ç¡Ñ º ¡ÒÃ¦‹ Ò µÑ Ç µÒÂ (suicidal impulse) ¨ÐÁÕ ¤ ÇÒÁà¢Œ Á ¢Œ ¹ ¢Í§
serotonin metabolite ã¹ CSF µèíÒ áÅÐÁÕ¤ÇÒÁà¢ŒÁ¢Œ¹¢Í§ serotonin uptake
site ·Õè platelet µèíÒ
Dopamine
ÁÕ¢ŒÍÁÙÅÊ¹ÑºÊ¹Ø¹Ç‹Ò dopamine Å´Å§ã¹ÀÒÇÐ«ÖÁàÈÃŒÒ áÅÐ à¾ÔèÁ¢Öé¹ã¹
mania .ÂÒ·ÕèÅ´¤ÇÒÁà¢ŒÁ¢Œ¹¢Í§ dopamine àª‹¹ reserpine áÅÐâÃ¤·ÕèÁÕÃÐ´Ñº
dopamine Å´µíèÒÅ§ àª‹¹ âÃ¤ parkinson’s ¨ÐÁÕ¤ÇÒÁÊÑÁ¾Ñ¹¸¡ÑºÍÒ¡ÒÃ«ÖÁàÈÃŒÒ
ã¹·Ò§µÃ§¡Ñ¹¢ŒÒÁÂÒä»à¾ÔÁè ¤ÇÒÁà¢ŒÁ¢Œ¹¢Í§ dopamine ¨Ð·íÒãËŒÍÒ¡ÒÃ¢Í§«ÖÁàÈÃŒÒ
Å´Å§ àª‹¹ tyrosine, amphetamine áÅÐ Bupropion
Neuroendocrine regulation
¾ºÇ‹Òã¹¡ÅØ‹Á mood disorder ÁÕ¡ÒÃ¤Çº¤ØÁ neuroendocrine axes ·Õè
¼Ô´»¡µÔä» ËÅÑ¡ æ ·Õè¾ºä´Œá¡‹ adrenal, thyroid áÅÐ growth hormone axes
¤ÇÒÁ¼Ô´»¡µÔ·Ò§ neuroendocrine ÍÂ‹Ò§Í×è¹ æ ·Õè¾º ä´Œá¡‹ Å´¡ÒÃËÅÑè§¢Í§
melatonin ã¹ª‹Ç§¡ÅÒ§¤×¹, Å´¡ÒÃËÅÑè§¢Í§ prolactin ã¹¡ÒÃµÍºÊ¹Í§µ‹Í¡ÒÃãËŒ
tryptophan, ÃÐ´Ñº¢Í§ FSH áÅÐ LH Å´µèíÒÅ§, áÅÐÃÐ´ÑºÎÍÃâÁ¹ testosterone
Å´µèíÒÅ§ã¹à¾ÈªÒÂ
¹Í¡¨Ò¡¹Õé¨Ò¡¡ÒÃÈÖ¡ÉÒ¢Í§ Boyle áÅÐ¤³Ð (2005) ¾ºÇ‹Ò ¡ÒÃä»
¢Ñ´¢ÇÒ§ glucocorticoid receptor ã¹ÊÁÍ§Ê‹Ç¹Ë¹ŒÒ¢Í§Ë¹Ù¹Òí ä»ÊÙ¡‹ ÒÃà»ÅÕÂè ¹á»Å§
¢Í§¾ÄµÔ¡ÃÃÁ áÅÐ ¡ÒÃà»ÅÕèÂ¹á»Å§ã¹ÃÐºº neuroendocrine «Öè§àËÁ×Í¹¡Ñº¡ÒÃ
à»ÅÕèÂ¹á»Å§·Õèà¡Ô´¢Öé¹ã¹ÀÒÇÐ«ÖÁàÈÃŒÒã¹Á¹ØÉÂ
Adrenal axis
¾ºÇ‹ÒÃŒÍÂÅÐ 50 ¢Í§¼ÙŒ»†ÇÂ«ÖÁàÈÃŒÒÁÕÃÐ´Ñº¢Í§ cortisol ÊÙ§¢Öé¹
Neuronã¹ paraventricular nucleus (PVN) ¨ÐËÅÑè§
corticotropin-releasing hormone (CRH)
¡ÃÐµØŒ¹¡ÒÃËÅÑè§¢Í§ adrenocorticotropic hormone (ACTH)

¨Ò¡µ‹ÍÁãµŒÊÁÍ§Ê‹Ç¹Ë¹ŒÒ
¡ÃÐµØŒ¹¡ÒÃËÅÑè§ cortisol ¨Ò¡ adrenal cortex
Thyroid axis
¾º¤ÇÒÁ¼Ô´»¡µÔ¢Í§ thyroid »ÃÐÁÒ³ÃŒÍÂÅÐ 5-10 ¢Í§¼Ù»Œ Ç† ÂâÃ¤«ÖÁàÈÃŒÒ
¹Í¡¨Ò¡¹Õé ¾ºÇ‹Ò 1 ã¹ 3 ¢Í§¼ÙŒ»†ÇÂ major depressive disorder ËÅÑ§ä´ŒÃÑº¡ÒÃ
©Õ´ thyrotropin-releasing hormone (TRH) protirelin ¾ºÇ‹ÒäÁ‹ÁÕ¡ÒÃËÅÑè§
thyrotropin áÅÐ thyroid-stimulating hormone ·Õèà¾ÔèÁ¢Öé¹ ¡ÒÃÇÔ¨ÑÂàÁ×èÍäÁ‹¹Ò¹ÁÒ
¹Õé ¾ºÇ‹Ò¼ÙŒ»†ÇÂâÃ¤«ÖÁàÈÃŒÒÊ‹Ç¹Ë¹Öè§ ÍÒ¨ÁÕÊÒàËµØÁÒ¨Ò¡ autoimmune ·ÕèÁÕ¼Åµ‹Í
µ‹ÍÁä·ÃÍÂ´ä´Œ
Growth hormone
ËÅÒÂ¡ÒÃÈÖ¡ÉÒ¾ºÇ‹Ò¼ÙŒ·Õè»†ÇÂ´ŒÇÂâÃ¤«ÖÁàÈÃŒÒ ¨ÐäÁ‹ÁÕ¡ÒÃËÅÑè§¢Í§ growth
hormone ·Õèà¾ÔèÁ¢Öé¹ã¹ª‹Ç§¡ÒÃ¹Í¹ËÅÑº (Blunted sleep-induced stimulation of
growth hormone release)
Somatostatin
¾ºÇ‹Òã¹¼ÙŒ»†ÇÂ«ÖÁàÈÃŒÒ ¨ÐÁÕÃÐ´Ñº¢Í§ somatostatin ã¹ CSF µèíÒ
Neuroanatomy
¨Ò¡¡ÒÃÈÖ¡ÉÒ¾ºÇ‹Òã¹¼ÙŒ»†ÇÂ·ÕèÁÕÍÒ¡ÒÃ«ÖÁàÈÃŒÒ ¨Ð¾º¾ÂÒ¸ÔÊÀÒ¾ã¹ÊÁÍ§
Ê‹Ç¹ medial limbic structure àª‹¹ orbito-frontal , cingulate cortex
áÅÐ basal ganglia ¹Í¡¨Ò¡¹ÕéºÒ§¡ÒÃÈÖ¡ÉÒÂÑ§¾ºÇ‹ÒÁÕ¡ÒÃ·íÒ§Ò¹·ÕèÁÒ¡¢Öé¹
(hyperactivity) ¢Í§ÊÁÍ§Ê‹Ç¹ amygdala áÅÐ hippocampus áÅÐºÒ§Ê‹Ç¹¢Í§
temporal lobe àÁ×èÍÍÂÙ‹ã¹ÀÒÇÐ«ÖÁàÈÃŒÒáÅÐ¡ÅÑºÊÙ‹ÀÒÇÐ»¡µÔàÁ×èÍÃÑ¡ÉÒÀÒÇÐ«ÖÁàÈÃŒÒ
¨¹ËÒÂ áÅÐÂÑ § ÁÕ ¡ ÒÃÈÖ ¡ ÉÒ·Õè ¾ ºÇ‹ Ò »ÃÔ Á ÒµÃ¢Í§ÊÁÍ§Ê‹ Ç ¹ hippocampus
Å´Å§ã¹¡ÅØ‹ÁµÑÇÍÂ‹Ò§à¾ÈËÞÔ§ÊÙ§ÍÒÂØ·Õè»†ÇÂ´ŒÇÂâÃ¤«ÖÁàÈÃŒÒ recurrent unipolar
depression »ÃÔÁÒµÃ¢Í§ hippocampus ·ÕèÅ´Å§àª×èÍÇ‹Òà¡Ô´¨Ò¡¡ÒÃË´Å§¢Í§
dendrites, ¡ÒÃÅ´ neurogenesis ¢Í§ dentate gyrus áÅÐ glia cell «Öè§¡ÒÃ
à»ÅÕèÂ¹á»Å§·Õèà¡Ô´¢Öé¹ÍÒ¨ÊÑÁ¾Ñ¹¸¡Ñº¤ÇÒÁ¼Ô´»¡µÔã¹ÃÐºº¡ÒÃ¤Çº¤ØÁ¡ÒÃËÅÑè§¢Í§
glucocorticoid «Öè§¾ºÇ‹ÒÃÐ´Ñº¢Í§ glucocorticoid ·Õèà¾ÔèÁ¢Öé¹¹Ñé¹ ÊÑÁ¾Ñ¹¸¡Ñº¡ÒÃ
½†Í¢Í§ÊÁÍ§Ê‹Ç¹ hippocampus (hippocampal atrophy) «Öè§¨ÐÁÕ¼Å¡‹ÍãËŒà¡Ô´
ÍÒÃÁ³«ÖÁàÈÃŒÒµÒÁÁÒ
1. ¼Åã¹ÃÐÂÐáÃ¡ (short-term effect)
1) ËÅÑ§¨Ò¡ monoamine ¶Ù¡»Å´»Å‹ÍÂÍÍ¡¨Ò¡ presynaptic neuron
áÅÐÍÍ¡Ä·¸Ôì·Õè receptor áÅŒÇ ¨Ð¶Ù¡¡íÒ¨Ñ´ä» 3 ·Ò§´ŒÇÂ¡Ñ¹ â´ÂÊ‹Ç¹ãËÞ‹¨Ð¶Ù¡
reuptake ¡ÅÑºÊÙ‹ presynaptic neuron Ê‹Ç¹¹ŒÍÂ·ÕèàËÅ×Í¨Ð¶Ù¡·íÒÅÒÂâ´ÂàÍ¹ä«Á
catechol-o-netgyl transferase (COMT) áÅÐàÍ¹ä«Á monoamine oxidase
(MAO)
ÂÒÃÑ ¡ ÉÒÍÒ¡ÒÃàÈÃŒ Ò Ê‹ Ç ¹ãËÞ‹ Í Í¡Ä·¸Ôì â ´Â¡ÒÃÂÑ º ÂÑé § reuptake ¢Í§
norepinephrine áÅÐ/ËÃ×Í serotonin ¡ÅÑºÊÙ‹ presynaptic neuron ·íÒãËŒ»ÃÔÁÒ³
¢Í§ neurotransmitter ÃÐËÇ‹Ò§ neuron à¾ÔèÁ¢Öé¹
2) ÂÒÃÑ¡ÉÒÍÒ¡ÒÃàÈÃŒÒÂÑ§ä»»´¡Ñé¹ receptor µ‹Ò§ æ ä´Œá¡‹ muscarinic
receptor (M1), histaminergic receptor (H1), alpha receptor, dopaminergic
receptor (D2) áÅÐ serotonin receptor (5-HT2) Ê‹§¼ÅãËŒà¡Ô´ÍÒ¡ÒÃ¢ŒÒ§à¤ÕÂ§¢Í§
ÂÒáµ‹ÅÐª¹Ô´áµ¡µ‹Ò§¡Ñ¹ä»µÒÁ receptor ·ÕèÂÒä»»´¡Ñé¹
From: http://www.cnsforum.com/content/pictures/imagebank/hirespng/desens_ssri_dpn.png
2. ¼Åã¹ÃÐÂÐÂÒÇ (long-term effect)
àÁ×èÍãËŒÂÒÃÑ¡ÉÒÍÒ¡ÒÃàÈÃŒÒä»ÃÐÂÐË¹Öè§ ¨Ð¾ºÇ‹Ò density áÅÐ function
¢Í§ beta-2-adrenergic receptor áÅÐ serotonin type 2 receptors Å´Å§
àÃÒàÃÕÂ¡¡ÃÐºÇ¹¡ÒÃ¹ÕéÇ‹Ò down regulation ¢Í§ receptor
¡ÒÃáº‹§¡ÅØ‹ÁÂÒá¡Œ«ÖÁàÈÃŒÒ áº‹§µÒÁ¡Åä¡¡ÒÃÍÍ¡Ä·¸Ôì ´Ñ§¹Õé
1. Tricyclic Antidepressants (TCA) àª‹¹ Amitriptyline, Nortriptyline,
Imipramine à»š¹µŒ¹
2. Selective Serotonin Reuptake Inhibitors (SSRI) ä´Œá¡‹
Fluoxetine, Sertraline, EsCitalopram (Lexapro®), Paroxetine
(Seroxat®), Fluvoxamine à»š¹µŒ¹
3. Tetracyclic Antidepressant àª‹¹ Mianserin (Tolvon®), Maprotiline
(Ludiomil®)
4. Monoamine Oxidase Inhibitors (MAOIs) àª‹¹ Phenelzine,
Moclobemide à»š¹µŒ¹
5. Selective Serotonin Noradrenaline Reuptake Inhibitors (SNRI)
ä´Œá¡‹ Venlafaxine (Efexor®), Duloxetine (Cymbalta®)
6. Norepinephrine Reuptake Inhibitors (NaRIs) ä´Œá¡‹ Reboxetine
(Edronax®)
7. Dopamine Noradrenaline Reuptake Inhibitors (DNRI)
ä´Œá¡‹ Bupropion (Wellbutrin®)
8. Selective Serotonin Reuptake Enhancer (SSRE) ä´Œá¡‹
Tianeptine (Stablon®)
9. Serotonin Antiagonist and Reuptake Inhibitors (SARIs)
ä´Œá¡‹ Trazodone (Desyrel®)
10. Noradrenaline & Specific Serotonin Antidepressant (NaSSA)
ä´Œá¡‹ Mirtazapine (Remeron®)
11. Norepinephrine-dopamine disinhibitors ä´Œá¡‹ Agomelatine
(Valdoxan®)
µÒÃÒ§·Õè 13 áÊ´§ª×èÍÂÒ ª×èÍ¡ÒÃ¤ŒÒ áÅÐ¢¹Ò´ÂÒ Antidepressant ·ÕèãªŒã¹¼ÙŒãËÞ‹a
Initial dose Usual dosage range
Generic name Trade name
(mg/day) (mg/day)
Serotonin selective reuptake inhibitors: SSRIs
Citalopram Cipram® 20 20–60
®
EsCitalopram Lexapro 10 10–20
Fluoxetine Prozac® 20 20–60
®
Fluvoxamine Faverin 50 50–300
®
Paroxetine Seroxat 20 20–60
®
Sertraline Zoloft 50 50–200
Serotonin/norepinephrine reuptake inhibitors: SNRIs
®
Venlafaxine Efexor
Effexor 37.5–75 75–225
®
Desvenlafaxine Pristiq 50 50
®
Duloxetine Cymbalta 30 30–90
®
Milnacipran Ixel 50 100-200
Dopamine Noradrenaline Reuptake Inhibitors : DNRI
Bupropion Wellbutrin® 150 150–300
Serotonin Antiagonist and reuptake inhibitors: SARIs

Trazodone Desyrel® 50 150–300
Noradrenaline & Specific Serotonin Antidepressant: NaSSA
Mirtazapine Remeron® 15 15–45
Tricyclics: TCA
Tertiary amines
Amitriptyline Tryptanol® 25 100–300
Clomipramine Anafranil® 25 100–250
®
Imipramine Tofranil 25 100–300
Secondary amines
Nortriptyline Nortrilen® 25 50–200
Initial dose Usual dosage range
Generic name Trade name
(mg/day) (mg/day)
Norepinephrine Reuptake inhibitors : NaRIs
Reboxetine Edronax® 8 8-10
Norepinephrine-dopamine disinhibitors: SNRIs
Agomelatine Valdoxan® 25 25-50
Selective Serotonin Reuptake Enhancer: SSRE
Tianeptine Stablon® 37.5 37.5
Monoamine oxidase inhibitors: MAOIs
Phenelzine Nardil® 15 30–90
® d
Selegeline (transdermal) Emsam 6 6–12d
Tranylcypromine Parnate® 10 20–60
a
Doses listed are total daily doses; elderly patients are usually treated with approximately one-half of the dose listed.
b
Parent drug plus metabolite.
c
It has been suggested that combined Imipramine + Desipramine concentrations should fall between 150–240 ng/mL (535–900
nmol/L).
d
Transdermal delivery system designed to deliver stated dose continuously over a 24-hour period.
Data from references 2, 15, 33, 42, and 67.
µÒÃÒ§·Õè 14 áÊ´§àÀÊÑª¨Å¹ÈÒÊµÃ (Pharmacokinetic) ¢Í§ÂÒ Antidepressants áµ‹ÅÐµÑÇ
Time of Peak Plasma
Elimination Percentage Clinically Important
Generic Name a Plasma Protein
Half-Life (h) Bioavailable Metabolites
Concentration (hr) Binding (%)
Citalopram 33 2–4 80 > 80 None
EsCitalopram 27–32 5 56 80 None
Fluoxetine 4–6 daysb 4–8 94 95 NorFluoxetine
Fluvoxamine 15–26 2–8 77 53 None
Paroxetine 24–31 5–7 95 36c None
Sertraline 27 6–8 99 None
Venlafaxine 5 2 27–30 45 O-DesmethylVenlafaxine
Desvenlafaxine 11 7.5 30 80 None
Duloxetine 12 6 90 50 None
Dopamine Noradrenaline Reuptake Inhibitors (DNRI) : Aminoketone
HydroxyBupropion,
d
Bupropion 10–21 3 82–88 ThreohydroBupropion
ErythrohydroBupropion
Noradrenaline & Specific Serotonin Antidepressant (NaSSA): Tetracyclic
Mirtazapine 20–40 2 85 50 None
Serotonin Antiagonist and reuptake inhibitors (SARIs):Triazolopyridines
Nefazodone 2–4 1 99 20 Meta-chlorophenylpiperazine
d
Trazodone 6–11 1–2 92 Meta-chlorophenylpiperazine
Tricyclics : TCAs
Tertiary amines
Amitriptyline 9–46 1–5 90–97 30–60 Nortriptyline
Clomipramine 20–24 2–6 97 36–62 DesmethylClomipramine
Doxepin 8–36 1–4 68–82 13–45 Desmethyldoxepin
Imipramine 6–34 1.5–3 63–96 22–77 Desipramine
Time of Peak Plasma
Elimination Percentage Clinically Important
Generic Name Plasma Protein
Half-Life (h)a Bioavailable Metabolites
Concentration (hr) Binding (%)
Secondary amines
Desipramine 11–46 3–6 73–92 33–51 2-HydroxyDesipramine
Nortriptyline 16–88 3–12 87–95 46–70 10-HydroxyNortriptyline
a b
Biologic half-life in slowest phase of elimination. 4–6 days with chronic dosing; norFluoxetine, 4–16 days.
c
Increases 30%–40% when taken with food. d
No data available.
Data from: Joseph T. Dipiro, Robrert L Talbert and et al, Pharmacotherapy A Pathophysiologic Approach, 8th ed., 2011.
µÒÃÒ§·Õè 15 áÊ´§¤ÇÒÁÊÒÁÒÃ¶ã¹¡ÒÃ¨Ñº Receptor

áÅÐÍÒ¡ÒÃ¢ŒÒ§à¤ÕÂ§¢Í§ÂÒ Antidepressants ª¹Ô´µ‹Ò§ æ
Reuptake Antagonism
Drug Anticholinergic Orthostatic Conduction
NE Serotonin Sedation Seizuresa
Effects Hypotension Abnormalitiesa
Serotonin Selective Reuptake Inhibitors: SSRIs
Citalopram 0 ++++ 0 + 0 ++ 0
EsCitalopram 0 ++++ 0 0 0 0 0
Fluoxetine 0 +++ 0 0 0 ++ 0
Fluvoxamine 0 ++++ 0 0 0 ++ 0
Paroxetine 0 ++++ + + 0 ++ 0
Sertraline 0 ++++ 0 0 0 ++ 0
Serotonin/Norepinephrine Reuptake Inhibitors: SNRIs
b
Venlafaxine & ++++ ++++ + + 0 ++ +
Desvenlafaxine
Duloxetinec ++++ ++++ + 0 + 0 0
Dopamine Noradrenaline Reuptake Inhibitors (DNRI)
d
Bupropion + 0 + 0 0 ++++ +
Noradrenaline & Specific Serotonin Antidepressant (NaSSA)
Mirtazapine 0 0 + ++ ++ 0 +
Reuptake Antagonism
Drug Anticholinergic Orthostatic Conduction
NE Serotonin Sedation Seizuresa
Effects Hypotension Abnormalitiesa
Serotonin Antiagonist and Reuptake Inhibitors (SARIs)
Nefazodone 0 ++ 0 +++ +++ ++ +
Trazodone 0 ++ 0 ++++ +++ ++ +
Tricyclics
Tertiary amines
Amitriptyline ++ ++++ ++++ ++++ +++ +++ +++
Clomipramine ++ +++ ++++ ++++ ++ ++++ +++
Doxepin ++ ++ +++ ++++ ++ +++ ++
Imipramine +++ +++ +++ +++ ++++ +++ +++
Secondary amines
Desipramine ++++ + ++ ++ ++ ++ ++
Nortriptyline +++ ++ ++ ++ + ++ ++
Monoamine oxidase inhibitors

Phenelzine ++ ++ + ++ ++ + 0
Selegiline 0 0 0 + ++ 0 +
Tranylcypromine ++ + + + ++ +
++++, high; +++, moderate; ++, low; +, very low; 0, absent.

a
These are uncommon side effects of antidepressant drugs, particularly when used at normal therapeutic doses.
b
Venlafaxine: primarily 5-HT at lower doses, NE at higher doses and DA at very high doses.
c
Duloxetine: balanced 5-HT and NE reuptake inhibition.
d
Bupropion: also blocks dopamine reuptake.
µÒÃÒ§·Õè 16 áÊ´§ Neurotransmitter reuptake áÅÐ neuroreceptors
·Õèà¡ÕèÂÇ¢ŒÍ§¡Ñº¡ÒÃÍÍ¡Ä·¸Ôì ¢Í§ Antidepressants
Reuptake blockade Receptor blockade
Drugs
5-HT NE DA 5-HT2A 5-HT2c 5-HT3 MT1 Į1 Į2 M1 H1
TCAs 9 9 9 9 9
MAOIs 9 9
SSRIs 9
NRIs 9
NDRIs 9 9
SNRIs 9
NaSSAs 9 9 9 9 9
SARIs 9 9 9 9
Agomelatine 9 9
µÒÃÒ§·Õè 17 áÊ´§¡ÒÃ¨Ñº Receptor ·ÕÁè ¼Õ Åã¹¡ÒÃÃÑ¡ÉÒ áÅÐ¡ÒÃà¡Ô´ÍÒ¡ÒÃäÁ‹¾§Ö »ÃÐÊ§¤

Receptors Therapeutics Adverse events
Dopamine receptor: D2 Antipsychotic, Antimanic EPS, akathisia, increased prolactin
Agonist at 5-HT1A Anxiolytic, Antidepressant, Anti-EPS Weight gain
Antipsychotic, Anti-EPS,
5-HT2A Sexual dysfunction ??
improve sleep
Weight gain, increased appetite,
5-HT2c Anti-EPS
Ç risk of diabetes
Sedation, weight gain,
Histamine receptor: H1 Anxiolytic, Anti-EPS
Ç risk of diabetes
Anticholinergic side effects
Muscarinic receptor: M1
(memory, cognition, dry mouth,
M1 (central) Anti-EPS
constipation, tachycardia,
M2-4 (peripheral)
blurred vision, urinary retention)
Adrenergic receptor: Į Postural hypotension, dizziness,
-
1. D1 syncope, nasal congestion
2. D2 Antidepressant Alertness, increased BP/HR
Melatonin receptor: MT1 ÖćøÙüïÙčö Circadian rhythms,

Antidepressant
From:Gardner DM et al. (2005), CMAJ 172(13):1703-1711; Jibson MD et al. (1998), J Psychiatr Res 32(3-4):215-228
1. ÂÒã¹¡ÅØ‹Á tricyclic antidepressants (TCAs)
ÂÒã¹¡ÅØ‹Á TCAs à»š¹ÂÒÃÑ¡ÉÒÍÒÃÁ³«ÖÁàÈÃŒÒ·ÕèãªŒ¡Ñ¹ÁÒà»š¹àÇÅÒ¹Ò¹ à¹×èÍ§¨Ò¡

ÁÕ»ÃÐÊÔ·¸ÔÀÒ¾ã¹¡ÒÃÃÑ¡ÉÒ´Õ ¡ÒÃ»ÃÑº¢¹Ò´äÁ‹ÂØ‹§ÂÒ¡ áÅÐÃÒ¤Ò¶Ù¡ ¹Í¡¨Ò¡¹Õé TCA ÂÑ§
¹íÒÁÒãªŒã¹¡ÒÃÃÑ¡ÉÒã¹¢ŒÍº‹§ãªŒÍ×è¹´ŒÇÂ àª‹¹ »‡Í§¡Ñ¹äÁà¡Ã¹ ËÃ×ÍÃÑ¡ÉÒ¡ÒÃ»Ç´àÃ×éÍÃÑ§
¢ŒÍàÊÕÂ¢Í§ÂÒã¹¡ÅØ‹Á TCAs ¤×Í ÁÕ´Ñª¹Õã¹¡ÒÃÃÑ¡ÉÒµèíÒ ·íÒãËŒà¡Ô´ÍÒ¡ÒÃäÁ‹¾Ö§»ÃÐÊ§¤ä´Œ
ÁÒ¡ µÑé§áµ‹äÁ‹ÃØ¹áÃ§ àª‹¹ »Ò¡áËŒ§ §‹Ç§¹Í¹ ·ŒÍ§¼Ù¡ ¨¹¶Ö§ÃØ¹áÃ§ÁÒ¡ àª‹¹ ÍÒ¡ÒÃµ‹Í
ËÑÇã¨áÅÐËÅÍ´àÅ×Í´ ¡ÒÃà¡Ô´ÍÒ¡ÒÃäÁ‹¾§Ö »ÃÐÊ§¤´§Ñ ¡Å‹ÒÇ·íÒãËŒÂÒã¹¡ÅØÁ‹ TCAs äÁ‹àËÁÒÐ
ÊÁ·Õ¨è ÐãªŒÃ¡Ñ ÉÒã¹¼Ù»Œ Ç† ÂÊÙ§ÍÒÂØËÃ×Í¼Ù»Œ Ç† Â·Õäè Çµ‹ÍÍÒ¡ÒÃäÁ‹¾§Ö »ÃÐÊ§¤àËÅ‹Ò¹Ñ¹é àª‹¹ ¼Ù»Œ Ç† Â
·ÕèÁÕÀÒÇÐµ‹ÍÁÅÙ¡ËÁÒ¡âµ ËÑÇã¨àµŒ¹¼Ô´¨Ñ§ËÇÐ µŒÍËÔ¹ª¹Ô´ narrow angle ËÃ×ÍÊÁÍ§àÊ×èÍÁ
ÍÒ¡ÒÃäÁ‹¾Ö§»ÃÐÊ§¤
Ä·¸Ôì anticholinergic ¾ºä´ŒÁÒ¡¨Ò¡¡ÒÃãªŒÂÒã¹¡ÅØ‹Á TCAs â´Âà©¾ÒÐÂÒã¹
¡ÅØ‹Á tertiary amines àª‹¹ Amitriptyline Ê‹Ç¹ Desipramine ·íÒãËŒà¡Ô´Ä·¸Ôì
anticholinergic ¹ŒÍÂ·ÕèÊØ´ ÍÒ¡ÒÃ·Õèà¡Ô´¢Öé¹ä´Œá¡‹ »Ò¡áËŒ§ µÒ¾Ã‹Ò ·ŒÍ§¼Ù¡ áÅÐ»˜ÊÊÒÇÐ
¤Ñè§ áÁŒÇ‹Ò¼ÙŒ»†ÇÂ¨Ð´×éÍµ‹ÍÄ·¸Ôì¹Õé áµ‹ÍÒ¡ÒÃ´Ñ§¡Å‹ÒÇ¨ÐäÁ‹ËÒÂä»·Ñé§ËÁ´ ¼ÙŒ»†ÇÂ¤ÇÃä´ŒÃÑº¤íÒ
á¹Ð¹íÒã¹¡ÒÃ»‡Í§¡Ñ¹áÅÐá¡Œä¢ÍÒ¡ÒÃ·Õàè ¡Ô´¢Ö¹é àª‹¹ ´×Áè ¹éÒí ËÃ×Íà¤Ã×Íè §´×Áè (·ÕÁè ¹Õ Òéí µÒÅ¹ŒÍÂ)
ÁÒ¡ æ ËÃ×ÍÍÒ¨ãªŒÅÙ¡ÍÁËÃ×ÍËÁÒ¡½ÃÑè§Ã‹ÇÁ´ŒÇÂ áÅÐ¤ÇÃãËŒ¼ÙŒ»†ÇÂÃÑº»ÃÐ·Ò¹ÍÒËÒÃ·ÕèÁÕ
¡Ò¡ãÂÊÙ§ æ à¾×èÍÅ´ÍÒ¡ÒÃ·ŒÍ§¼Ù¡
ÂÒã¹¡ÅØ‹Á TCAs ·íÒãËŒ§‹Ç§¹Í¹ä´ŒÁÒ¡ â´Âà©¾ÒÐÂÒã¹¡ÅØ‹Á tertiary amines
àª‹ ¹ Amitriptyline ¨Ö § ÁÑ ¡ãËŒ ¡‹ Í ¹¹Í¹áÅÐ¨ÐàËÁÒÐ¡Ñ º ¡ÒÃãªŒ ã ¹¼ÙŒ »† Ç Â·Õè ÁÕ Í Ò¡ÒÃ
¡ÃÐÇ¹¡ÃÐÇÒÂ ¹Í¹äÁ‹ËÅÑº ¹Í¡¨Ò¡¹ÕéÂÒã¹¡ÅØ‹Á TCAs ÂÑ§·íÒãËŒà¡Ô´ÍÒ¡ÒÃÊÑºÊ¹áÅÐ
¤ÇÒÁ¨íÒÅ´Å§«Öè§¨Ðà¡Ô´ä´ŒÁÒ¡ã¹¼ÙŒ»†ÇÂÊÙ§ÍÒÂØ ÂÒã¹¡ÅØ‹Á secondary amines ÍÒ¨·íÒãËŒ
à¡Ô´¼Å´Ñ§¡Å‹ÒÇä´Œ¹ŒÍÂ¡Ç‹Ò â´Â Desipramine ·íÒãËŒ§‹Ç§¹Í¹¹ŒÍÂ·ÕèÊØ´
¼Å¢Í§ÂÒã¹¡ÅØ‹Á TCAs µ‹Í¡ÒÃ·íÒ§Ò¹¢Í§ËÑÇã¨áÅÐËÅÍ´àÅ×Í´à»š¹ÊÔè§ÊíÒ¤ÑÞ·Õè
µŒÍ§¾Ô¨ÒÃ³Òà»š¹ÍÂ‹Ò§ÂÔè§ ÍÒ¡ÒÃäÁ‹¾Ö§»ÃÐÊ§¤·ÕèÍÑ¹µÃÒÂ·ÕèÊØ´¢Í§ÂÒã¹¡ÅØ‹Á TCAs ¤×Í
¡ÒÃ·íÒãËŒ¡ÒÃ¹íÒ¡ÃÐáÊä¿¿‡Ò·ÕèËÑÇã¨¼‹Ò¹ His-Perkinje system ÂÒÇ¹Ò¹¢Öé¹ ËÃ×Í
quinidine-like properties ¹Í¡¨Ò¡¹ÕéÂÒã¹¡ÅØ‹Á TCAs ÂÑ§·íÒãËŒËÑÇã¨àµŒ¹àÃçÇ¢Öé¹áÅÐÁÕ
Ä·¸ÔìÂÑºÂÑé§ adrenergic «Öè§·íÒãËŒà¡Ô´¼Åâ´ÂÃÇÁ¤×Í ÀÒÇÐ re-entry arrhythmias àª‹¹
torsades de pointes áÅÐ ventricular arrhythmias ¤ÇÒÁ´Ñ¹âÅËÔµÅ´Å§àÁ×èÍà»ÅÕèÂ¹
·‹Ò·Ò§à»š¹¼Åµ‹ÍËÑÇã¨áÅÐËÅÍ´àÅ×Í´·Õèà¡Ô´¢Öé¹º‹ÍÂ¨Ò¡¡ÒÃãªŒÂÒã¹¡ÅØ‹Á TCAs «Öè§·íÒãËŒ
à¡Ô´¡ÒÃà¨çº»†ÇÂáÅÐàÊÕÂªÕÇµÔ ä´ŒÁÒ¡ ¨Ò¡¡ÒÃÅŒÁ¨¹·íÒãËŒ¡ÃÐ´Ù¡ËÑ¡áÅÐà¡Ô´ºÒ´á¼Å©Õ¡¢Ò´
(lacerations) ÃÇÁ·Ñé§·íÒãËŒ¡ÅŒÒÁà¹×éÍËÑÇã¨¢Ò´àÅ×Í´ä»àÅÕéÂ§ (myocardial infarction) ´Ñ§
¹Ñ¹é ¼Ù»Œ Ç† Â·ÕÁè ¡Õ ÒÃ·íÒ§Ò¹¢Í§ËÑÇã¨¼Ô´»¡µÔ¤ÇÃãªŒÂÒã¹¡ÅØÁ‹ TCAs ´ŒÇÂ¤ÇÒÁÃÐÁÑ´ÃÐÇÑ§ ÂÒ
ã¹¡ÅØ‹Á tertiary amines àª‹¹ Amitriptyline áÅÐ Imipramine ·íÒãËŒ¤ÇÒÁ´Ñ¹âÅËÔµÅ´
Å§ä´ŒÃØ¹áÃ§¡Ç‹ÒÂÒã¹¡ÅØ‹Á secondary amines àª‹¹ Nortriptyline áÅÐ¨Ò¡¡ÒÃÈÖ¡ÉÒ
áÊ´§ãËŒàËç¹Ç‹Ò Nortriptyline ·íÒãËŒ¤ÇÒÁ´Ñ¹âÅËÔµÅ´Å§¹ŒÍÂ·ÕÊè ´Ø ã¹ºÃÃ´ÒÂÒã¹¡ÅØÁ‹ TCAs
¼ÙŒ»†ÇÂ·ÕèãªŒÂÒã¹¡ÅØ‹Á TCAs ¤ÇÃä´ŒÃÑº¤íÒá¹Ð¹íÒ¡Ã³Õà»ÅÕèÂ¹ÍÔÃÔÂÒº¶ â´Âà»ÅÕèÂ¹·‹Ò·Ò§
¨Ò¡¹Í¹à»š¹¹Ñè§ËÃ×Í¹Ñè§à»š¹Â×¹ÍÂ‹Ò§ªŒÒ æ áÅÐ¤ÇÃ´×èÁ¹éíÒãËŒà¾ÕÂ§¾Í
ÂÒã¹¡ÅØ‹Á TCAs ·Ø¡µÑÇÊÒÁÒÃ¶·íÒãËŒÊÁÃÃ¶ÀÒ¾·Ò§à¾Èº¡¾Ã‹Í§ àª‹¹ ¤ÇÒÁ
ÃÙŒÊÖ¡·Ò§à¾ÈÅ´Å§ ¡ÒÃËÅÑè§ÍÊØ¨ÔªŒÒÅ§áÅÐäÁ‹ÊÒÁÒÃ¶¶Ö§¨Ø´ÊØ´ÂÍ´ã¹¢³ÐÁÕà¾ÈÊÑÁ¾Ñ¹¸
â´Â¾ºÇ‹Ò Amitriptyline ·íÒãËŒà¡Ô´ÍÒ¡ÒÃ´Ñ§¡Å‹ÒÇº‹ÍÂ¡Ç‹ÒÂÒµÑÇÍ×è¹
ÂÒã¹¡ÅØ‹Á TCAs ÍÒ¨·íÒãËŒà¡Ô´ÍÒ¡ÒÃäÁ‹¾Ö§»ÃÐÊ§¤Í×è¹ àª‹¹ ÊÑè¹ àË§×èÍÍÍ¡ÁÒ¡
ºÇÁ à¡Ô´¼×è¹¤Ñ¹ ·íÒãËŒÍÒ¡ÒÃ¢Í§µŒÍËÔ¹ª¹Ô´ narrow angle ÃØ¹áÃ§¢Öé¹ áÅÐÍÒ¨¡ÃÐµØŒ¹
ãËŒà¡Ô´ÍÒ¡ÒÃ mania ËÃ×ÍÍÒ¡ÒÃ¼Ô´»¡µÔ·Ò§¨Ôµ
2. ÂÒã¹¡ÅØ‹Á selective serotonin reuptake inhibitors (SSRIs)
ÖúĕÖÖćøĂĂÖùìíĉĝĀúĆÖÙČĂ Block reuptake ×ĂÜ Serotonin (SRI)
ÂÒ SSRI áµ‹ÅÐµÑÇ¨ÐÁÕ¡ÒÃ¨Ñº·Õè receptor Í×è¹ æ Ã‹ÇÁ´ŒÇÂ ¨Ö§·íÒãËŒÂÒ

áµ‹ÅÐµÑÇÁÕ Side effect ·Õèµ‹Ò§¡Ñ¹ áÅÐÍÒ¨à»š¹ÊÒàËµØ·Õè·íÒãËŒ SSRI áµ‹ÅÐª¹Ô´µ‹Ò§
¡Ñ¹ã¹¼Å¡ÒÃÃÑ¡ÉÒ´ŒÇÂ «Öè§¨Ð¾ºÇ‹Ò¡Ã³Õ·ÕèãªŒ SSRI µÑÇË¹Öè§äÁ‹ä´Œ¼Å ËÃ×ÍäÁ‹ÊÒÁÒÃ¶
·¹µ‹ÍÍÒ¡ÒÃ¢ŒÒ§à¤ÕÂ§ä´Œ àÁ×èÍÁÕ¡ÒÃà»ÅÕèÂ¹à»š¹ SSRI µÑÇÍ×è¹ ¨ÐµÍºÊ¹Í§µ‹Í¡ÒÃ
ÃÑ¡ÉÒËÃ×ÍÁÕÍÒ¡ÒÃ¢ŒÒ§à¤ÕÂ§µèíÒ¡Ç‹Òä´Œ
¡ÒÃà¡Ô´ÍÒ¡ÒÃäÁ‹¾§Ö »ÃÐÊ§¤¨Ò¡ÂÒã¹¡ÅØÁ‹ SSRIs ÍÒ¡ÒÃ·Õàè ¡Ô´¢Ö¹é ¨ÐÁÕ¤ÇÒÁ
ÃØ¹áÃ§¹ŒÍÂ¡Ç‹ÒÂÒã¹¡ÅØ‹Á TCAs ´Ñ§¹Ñé¹ÂÒã¹¡ÅØ‹Á SSRIs ¨Ö§¶Ù¡¹íÒÁÒãªŒã¹¡ÒÃÃÑ¡ÉÒ
¼ÙŒ»†ÇÂÍÒÃÁ³«ÖÁàÈÃŒÒ¤‹Í¹¢ŒÒ§ÁÒ¡ ÂÒ·Ø¡µÑÇã¹¡ÅØ‹Á SSRIs ·íÒãËŒà¡Ô´ÍÒ¡ÒÃäÁ‹¾Ö§
»ÃÐÊ§¤àËÁ×Í¹¡Ñ¹ ä´Œá¡‹ ÍÒ¡ÒÃ·Ò§ÃÐºº·Ò§à´Ô¹ÍÒËÒÃ ÍÒ¡ÒÃ·Ò§ÃÐºº»ÃÐÊÒ·
Ê‹Ç¹¡ÅÒ§ áÅÐÊÁÃÃ¶ÀÒ¾·Ò§à¾Èº¡¾Ã‹Í§ ÂÒã¹¡ÅØ‹Á SSRIs ·Ø¡µÑÇÍÒ¨·íÒãËŒà¡Ô´
ÍÒ¡ÒÃ¤Å×è¹äÊŒ áµ‹¨Ðà¡Ô´à¾ÕÂ§ªÑèÇ¤ÃÒÇà·‹Ò¹Ñé¹ áÅÐ¨ÐÅ´Å§ËÅÑ§¨Ò¡ÊÑ»´ÒËáÃ¡¢Í§
¡ÒÃÃÑ¡ÉÒ â´Â·ÑèÇä»ÂÒã¹¡ÅØ‹Á SSRIs ·íÒãËŒà¡Ô´¡ÒÃÃÐ¤ÒÂà¤×Í§·Ò§à´Ô¹ÍÒËÒÃ 1-2
ªÑèÇâÁ§ËÅÑ§¨Ò¡ÃÑº»ÃÐ·Ò¹ ´Ñ§¹Ñé¹¨Ö§¤ÇÃá¹Ð¹íÒãËŒ¼ÙŒ»†ÇÂÃÑº»ÃÐ·Ò¹ÂÒËÅÑ§ÍÒËÒÃ
·Ñ¹·Õ â´Âà©¾ÒÐÊÑ»´ÒËáÃ¡¢Í§¡ÒÃÃÑº»ÃÐ·Ò¹ÂÒ
ÍÒ¡ÒÃäÁ‹¾§Ö »ÃÐÊ§¤Í¹×è æ à¡ÕÂè Ç¡ÑºÃÐºº·Ò§à´Ô¹ÍÒËÒÃ ä´Œá¡‹ ·ŒÍ§àÊÕÂ áµ‹
ÂÒã¹¡ÅØ‹Á SSRIs áµ‹ÅÐµÑÇ·íÒãËŒà¡Ô´ÍÒ¡ÒÃ·ŒÍ§àÊÕÂä´ŒäÁ‹à·‹Ò¡Ñ¹ â´Â Sertraline,
Fluoxetine áÅÐ Citalopram ·íÒãËŒà¡Ô´ÍÒ¡ÒÃ·ŒÍ§àÊÕÂ»ÃÐÁÒ³ 15-20% áµ‹ÍÒ¡ÒÃ
·ŒÍ§àÊÕÂ·Õèà¡Ô´¢Öé¹¨ÐËÒÂä»ËÅÑ§¨Ò¡ãªŒÂÒä»áÅŒÇ 1 ÊÑ»´ÒË áÅÐäÁ‹¨íÒà»š¹µŒÍ§ËÂØ´ÂÒ
ã¹·Ò§µÃ§¡Ñ¹¢ŒÒÁ Paroxetine ÁÕÄ·¸Ôì anticholinergic ·íÒãËŒà¡Ô´ÍÒ¡ÒÃ·ŒÍ§¼Ù¡
»Ò¡áËŒ§ áÅÐ»˜ÊÊÒÇÐÅíÒºÒ¡ ¨Ö§¤ÇÃËÅÕ¡àÅÕèÂ§¡ÒÃãªŒ Paroxetine ã¹¼ÙŒ»†ÇÂ«Öè§ÁÕ
ÍÒ¡ÒÃ·ŒÍ§¼Ù¡ÍÂÙ‹¡‹Í¹ËÃ×Í¼ÙŒ»†ÇÂ·Õèä´ŒÃÑºÂÒ·ÕèÁÕÄ·¸Ôì anticholinergic Ã‹ÇÁ´ŒÇÂ
ÍÒ¡ÒÃäÁ‹¾Ö§»ÃÐÊ§¤·Ò§ÃÐºº»ÃÐÊÒ·Ê‹Ç¹¡ÅÒ§·Õè¾ºä´Œ¨Ò¡¡ÒÃãªŒ SSRIs
¤×Í EPS â´Â·íÒãËŒà¡Ô´ÍÒ¡ÒÃ akathisia, dystonia, tardive dyskinesia áÅÐ
parkinsonism ã¹ÃÐ´Ñºà´ÕÂÇ¡Ñº·Õè¾º¨Ò¡¡ÒÃãªŒÂÒÃÑ¡ÉÒâÃ¤¨Ôµ·ÕèÁÕ¤ÇÒÁáÃ§ÊÙ§ áµ‹
ÍØºÑµÔ¡ÒÃ³¡ÒÃà¡Ô´¨Ð¹ŒÍÂ¡Ç‹ÒÂÒÃÑ¡ÉÒâÃ¤¨Ôµ ÍÂ‹Ò§äÃ¡çµÒÁ áÁŒÇ‹ÒÂÒã¹¡ÅØ‹Á SSRIs
·Ø¡µÑÇ¨ÐÁÕÃÒÂ§Ò¹Ç‹Ò·íÒãËŒà¡Ô´ EPS áµ‹ Paroxetine ÁÕÃÒÂ§Ò¹¤‹Í¹¢ŒÒ§ÁÒ¡ ¡ÒÃ
ÃÑ¡ÉÒ¡ÒÃà¡Ô´ EPS ¨Ò¡ÂÒã¹¡ÅØ‹Á SSRIs ¨Ð·íÒã¹ÅÑ¡É³Ðà´ÕÂÇ¡ÑºÂÒÃÑ¡ÉÒâÃ¤¨Ôµ
«Öè§ÍÒ¡ÒÃ dystonia áÅÐ parkinsonism ¨ÐÃÑ¡ÉÒâ´ÂãªŒ anticholinergic drugs
áÅÐÅ´¢¹Ò´ÂÒ Ê‹Ç¹ akathisia ¨ÐÃÑ¡ÉÒâ´ÂÅ´¢¹Ò´ÂÒ áÅÐãËŒÂÒ beta-blockers
ã¹¢¹Ò´µèíÒ
ÂÒã¹¡ÅØ‹Á SSRIs ·íÒãËŒÊÁÃÃ¶ÀÒ¾·Ò§à¾Èº¡¾Ã‹Í§ä´Œ»ÃÐÁÒ³ 30-50%
áÅÐ¨Ðà¡Ô´ã¹¼ÙŒªÒÂÁÒ¡¡Ç‹Ò¼ÙŒËÞÔ§àÅç¡¹ŒÍÂ â´Âã¹¼ÙŒªÒÂÁÑ¡¨Ð¾º¡ÒÃËÅÑè§ÍÊØ¨ÔªŒÒÅ§
(delayed ejaculation) áÅÐ¡ÒÃäÁ‹ÊÒÁÒÃ¶¶Ö§¨Ø´ÊØ´ÂÍ´ã¹¡ÒÃÁÕà¾ÈÊÑÁ¾Ñ¹¸
(anorgasmia) Ê‹Ç¹ã¹¼ÙŒËÞÔ§¾ºÇ‹ÒÊÒÁÒÃ¶¶Ö§¨Ø´ÊØ´ÂÍ´ã¹¡ÒÃÁÕà¾ÈÊÑÁ¾Ñ¹¸ä´ŒÂÒ¡
¢Öé¹ ËÃ×ÍÁÕ¡Ô¨¡ÃÃÁ·Ò§à¾ÈÅ´Å§ ¼Å´Ñ§¡Å‹ÒÇ¨Ðà»š¹¼Å´Õã¹¼ÙŒ»†ÇÂ·ÕèÁÕÀÒÇÐËÅÑè§àÃçÇ
(premature ejaculation) áµ‹¼ÙŒ»†ÇÂªÒÂÊ‹Ç¹ãËÞ‹ÁÑ¡¨ÐäÁ‹ªÍº ÂÒã¹¡ÅØ‹Á SSRIs
·Ø¡µÑÇ·íÒãËŒÊÁÃÃ¶ÀÒ¾·Ò§à¾Èº¡¾Ã‹Í§ä´Œ áµ‹ Paroxetine ÁÕâÍ¡ÒÊ·íÒãËŒà¡Ô´ä´ŒÁÒ¡
·ÕèÊØ´
ÍÒ¡ÒÃäÁ‹¾Ö§»ÃÐÊ§¤Í×è¹·Õè¾ºä´Œ¨Ò¡¡ÒÃãªŒÂÒã¹¡ÅØ‹Á SSRIs áµ‹äÁ‹ÁÒ¡¹Ñ¡
ä´Œá¡‹ »Ò¡áËŒ§ »Ç´ÈÕÃÉÐ àË§×èÍÍÍ¡ÁÒ¡
ÂÒã¹¡ÅØ‹Á SSRIs ·Ø¡µÑÇÃÇÁ¶Ö§ Venlafaxine ·íÒãËŒà¡Ô´ÀÒÇÐ hyponatremia
ËÃ×Í syndrome of inappropriate antidiuretic hormone (SIADH) «Öè§¼ÙŒÊÙ§ÍÒÂØ
¨Ðà¡Ô´ÍÒ¡ÒÃ¹Õéä´Œ§‹ÒÂ
ÍÒ¡ÒÃäÁ‹¾§Ö »ÃÐÊ§¤·¾Õè º¨Ò¡¡ÒÃä´ŒÃºÑ ÂÒ¡ÅØÁ‹ ¹Õé áÅÐÍÒ¨ÁÕÍ¹Ñ µÃÒÂ¨¹¶Ö§¢Ñ¹é
àÊÕÂªÕÇÔµ·ÕèµŒÍ§ÁÕ¡ÒÃà½‡ÒÃÐÇÑ§ ¤×Í Serotonin syndrome
3. Serotonin-norepinephrine reuptake inhibitors (SNRIs) :
Venlafaxine, Desvenlafaxine, Duloxetine, Milnacipran
ÂÒã¹¡ÅØ‹Á¹Õé¨ÐÍÍ¡Ä·¸ÔìÂÑºÂÑé§¡ÒÃà¡çº¡ÅÑº¢Í§ÊÒÃÊ×èÍ»ÃÐÊÒ· serotonin
áÅÐ norepinephrine ÍÂ‹Ò§ÁÒ¡ áÅÐÂÑºÂÑé§ dopamine ÍÂ‹Ò§Í‹Í¹ æ â´ÂäÁ‹ÁÕ¼Å
ÂÑºÂÑé§ muscarinic, H1- áÅÐ alpha1 receptors â´ÂÍÒ¡ÒÃäÁ‹¾Ö§»ÃÐÊ§¤·ÕèÍÒ¨
¾ºä´ŒáÅÐÁÕÍÑ¹µÃÒÂ¨¹¶Ö§¢Ñé¹àÊÕÂªÕÇÔµ ¤×Í Serotonin syndrome
Venlafaxine
Venlafaxine à»š¹ÂÒµÑÇáÃ¡¢Í§ÂÒÃÑ¡ÉÒÍÒÃÁ³«ÖÁàÈÃŒÒ¡ÅØ‹ÁãËÁ‹ ·ÕèàÃÕÂ¡Ç‹Ò
Serotonin Norepinephrine Reuptake Inhibitors (SNRI) ¨Ò¡¡ÒÃÈÖ¡ÉÒ¾ºÇ‹Ò
Venlafaxine ã¹¢¹Ò´ 75-375 Á¡./ÇÑ¹ ÁÕ»ÃÐÊÔ·¸ÔÀÒ¾´Õã¹¡ÒÃÃÑ¡ÉÒÍÒÃÁ³
«ÖÁàÈÃŒÒ·Õ´è Í×é µ‹Í¡ÒÃÃÑ¡ÉÒ àª‹¹à´ÕÂÇ¡ÑºÂÒã¹¡ÅØÁ‹ TCAs áÅÐ SSRIs ¼Åã¹¡ÒÃÃÑ¡ÉÒ
¢Í§ Venlafaxine à¡Ô´¼‹Ò¹¡ÒÃÂÑºÂÑé§ serotonin reuptake à»š¹ËÅÑ¡ ´Ñ§¹Ñé¹¡ÒÃà¡Ô´
ÍÒ¡ÒÃäÁ‹¾Ö§»ÃÐÊ§¤ã¹¢¹Ò´µèíÒ¨ÐàËÁ×Í¹¡Ñº·Õè¾º¨Ò¡¡ÒÃãªŒÂÒã¹¡ÅØ‹Á SSRIs àª‹¹
äÁ‹ÊºÒÂ·ŒÍ§ ¤Å×è¹äÊŒ ¡ÒÃ¹Í¹ËÅÑº¼Ô´»¡µÔ áÅÐÊÁÃÃ¶ÀÒ¾·Ò§à¾Èº¡¾Ã‹Í§ «Öè§
¡ÒÃãªŒÂÒã¹ÃÙ»áºº capsule ·ÕèÍÍ¡Ä·¸Ôìà¹Ôè¹ (Venlafaxine XR) ¨ÐÅ´ÍÒ¡ÒÃäÁ‹¾Ö§
»ÃÐÊ§¤´§Ñ ¡Å‹ÒÇä´Œ ã¹¢¹Ò´ÊÙ§¨Ðà¡Ô´¼Åµ‹Í norepinephrine «Ö§è ·íÒãËŒ¡ÒÃà¡Ô´ÍÒ¡ÒÃ
äÁ‹¾Ö§»ÃÐÊ§¤¨Ò¡ Venlafaxine µ‹Ò§¨Ò¡ SSRI àª‹¹ ·íÒãËŒà¡Ô´¤ÇÒÁ´Ñ¹âÅËÔµÊÙ§
Venlafaxine äÁ‹ÁÕÄ·¸ÔìÂÑºÂÑé§ CYP450 ¨Ö§à¡Ô´»¯Ô¡ÔÃÔÂÒ¡ÑºÂÒÍ×è¹ä´Œ¹ŒÍÂ¡Ç‹Ò
ÂÒã¹¡ÅØ‹Á SSRIs áµ‹¡ÒÃà¡Ô´ serotonin syndrome ¨Ðà¡Ô´¢Öé¹¨Ò¡¡ÒÃãªŒ
Venlafaxine Ã‹ÇÁ¡ÑºÂÒã¹¡ÅØ‹Á·Õèà¾ÔèÁ¡ÒÃ·íÒ§Ò¹¢Í§ serotonin
¼ÙŒ»†ÇÂÊ‹Ç¹ãËÞ‹µÍºÊ¹Í§µ‹Í Venlafaxine ¢¹Ò´ 75-225 mg ¢¹Ò´àÃÔèÁ
µŒ¹¢Í§ Venlafaxine ¤×Í 37.5 Á¡./ÇÑ¹ ËÒ¡¼ÙŒ»†ÇÂ·¹µ‹ÍÂÒà»š¹àÇÅÒ 1 ÊÑ»´ÒË ãËŒ
à¾ÔèÁ¢¹Ò´ÂÒà»š¹ 75 Á¡./ÇÑ¹ ËÒ¡¼ÙŒ»†ÇÂÂÑ§äÁ‹µÍºÊ¹Í§µ‹ÍÂÒã¹¢¹Ò´ 75 Á¡./ÇÑ¹
ËÅÑ§¨Ò¡ 4 ÊÑ»´ÒËä»áÅŒÇ ¤ÇÃà¾ÔèÁ¢¹Ò´ÂÒ¤ÃÑé§ÅÐ 37.5-75 Á¡. ·Ø¡ 2-3 ÊÑ»´ÒË
¨¹¶Ö§¢¹Ò´ÊÙ§ÊØ´ 225 Á¡./ÇÑ¹
Desvenlafaxine
ÂÒ¹Õé¨Ñ´à»š¹ active metabolite ¢Í§ Venlafaxine ¹Ñè¹¤×Í àÁ×èÍ¡Ô¹ÂÒà¢ŒÒä»
áÅŒÇ¨Ð¶Ù¡´Ù´«ÖÁáÅŒÇÍÍ¡Ä·¸Ôìä´ŒàÅÂ ¡Åä¡¡ÒÃÍÍ¡Ä·¸ÔìáÅÐÍÒ¡ÒÃäÁ‹¾Ö§»ÃÐÊ§¤
¨Ö§¤ÅŒÒÂ¡Ñº Venlafaxine ¢¹Ò´ÂÒã¹¼ÙŒ»†ÇÂ¼ÙŒãËÞ‹‹·ÑèÇä» ¤×Í ÃÑº»ÃÐ·Ò¹¤ÃÑé§ÅÐ
50 mg ÇÑ¹ÅÐ 1 ¤ÃÑé§
Duloxetine
ÂÒ¹ÕéÁÕ¢ŒÍº‹§ãªŒä´ŒËÅÒÂ¡ÅØ‹ÁâÃ¤ â´Â US FDA ãËŒ¡ÒÃÃÑºÃÍ§ã¹¡ÒÃãªŒÃÑ¡ÉÒ
âÃ¤«ÖÁàÈÃŒÒã¹¼ÙŒãËÞ‹ (major depressive disorder) ¡ÒÃÃÑ¡ÉÒÍÒ¡ÒÃ»Ç´
àÊŒ¹»ÃÐÊÒ·Ê‹Ç¹»ÅÒÂà¹×èÍ§¨Ò¡âÃ¤àºÒËÇÒ¹ã¹¼ÙŒãËÞ‹(Diabetic peripheral
neuropathic pain) ÃÑ¡ÉÒâÃ¤ÇÔµ¡¡Ñ§ÇÅ·ÑèÇä»ã¹¼ÙŒãËÞ‹ (generalized anxiety
disorder) ãªŒÃÑ¡ÉÒâÃ¤ Fibromyalgia (FM) ã¹¼ÙŒãËÞ‹·ÕèÁÕÍÒ¡ÒÃ«ÖÁàÈÃŒÒÃ‹ÇÁ´ŒÇÂ
â´ÂÂÒ¹Õ¨é ÐÍÍ¡Ä·¸ÔÂì ºÑ ÂÑ§é ¡ÒÃ¹íÒ¡ÅÑº¢Í§ serotonin (5-HT) áÅÐ norepinephrine
â´Â¨ÐÂÑºÂÑé§¡ÒÃ reuptake ¢Í§ 5-HT ÁÒ¡¡Ç‹Ò norepinephrine ¨Ö§ÁÕ¼Åµ‹Í¡ÒÃ
ÃÑ¡ÉÒâÃ¤«ÖÁàÈÃŒÒ áÅÐÂÑºÂÑé§ dopamine ÍÂ‹Ò§Í‹Í¹ æ â´ÂäÁ‹ÁÕ¼ÅÂÑºÂÑé§µ‹Í
histaminergic, dopaminergic, cholinergic áÅÐ adrenergic ÍÒ¡ÒÃäÁ‹¾§Ö »ÃÐÊ§¤
·Õè¾ºä´Œº‹ÍÂ ¤×Í ¹Í¹äÁ‹ËÅÑº ¤Å×è¹äÊŒ »Ò¡áËŒ§ »Ç´ÈÕÃÉÐáÅÐ·ŒÍ§¼Ù¡ ¢¹Ò´ÂÒã¹
¡ÒÃÃÑ¡ÉÒâÃ¤«ÖÁàÈÃŒÒ ¤×Í 60 mg ÃÑº»ÃÐ·Ò¹ ÇÑ¹ÅÐ 1 ¤ÃÑé§
4. Norepinephrine-dopamine reuptake inhibitors (NDRIs)
Bupropion à»š¹ÂÒ·ÕÁè ¡Õ Åä¡¡ÒÃÍÍ¡Ä·¸Ôµì Ò‹ §¨Ò¡ÂÒÃÑ¡ÉÒÍÒÃÁ³«ÁÖ àÈÃŒÒµÑÇ

Í×è¹ â´Â¼Åµ‹Í¡ÒÃ·íÒ§Ò¹¢Í§ serotonin ÁÕ¹ŒÍÂ áµ‹¨ÐÍÍ¡Ä·¸Ôìà¾ÔèÁ¡ÒÃ·íÒ§Ò¹¢Í§
dopamine áÅÐ norepinephrine ã¹¢¹Ò´·ÕèãËŒ¼Åã¹¡ÒÃÃÑ¡ÉÒ Bupropion ·íÒãËŒ
à¡Ô´ÍÒ¡ÒÃäÁ‹¾Ö§»ÃÐÊ§¤àÅç¡¹ŒÍÂ ä´Œá¡‹ ¤Å×è¹äÊŒ ¹Í¹äÁ‹ËÅÑº ËÃ×Í ¡ÃÐÊÑº¡ÃÐÊ‹ÒÂ
(jitteriness) Bupropion äÁ‹·íÒãËŒÊÁÃÃ¶ÀÒ¾·Ò§à¾Èº¡¾Ã‹Í§ ÍÒ¨à¹×èÍ§ÁÒ¨Ò¡¡ÒÃ
·ÕèÂÒÁÕ¼Åà¾ÔèÁ¡ÒÃ·íÒ§Ò¹¢Í§ dopamine ¹Í¡¨Ò¡¹Õé Bupropion ÁÕ¼Åµ‹Í¡ÒÃ·íÒ§Ò¹
¢Í§ËÑÇã¨áÅÐËÅÍ´àÅ×Í´¹ŒÍÂáÅÐÁÕÄ·¸Ôì anticholinergic ¹ŒÍÂ ¨Ö§àËÁÒÐ·Õè¨ÐãªŒã¹
¼ÙÊŒ §Ù ÍÒÂØ Bupropion à»š¹Ë¹Ö§è ã¹ÂÒÃÑ¡ÉÒÍÒÃÁ³«ÁÖ àÈÃŒÒà¾ÕÂ§äÁ‹¡µÕè ÇÑ ·ÕÅè ´¤ÇÒÁÍÂÒ¡
ÍÒËÒÃ ¤ÇÃËÅÕ¡àÅÕèÂ§¡ÒÃãªŒÂÒ¹Õéã¹¼ÙŒ»†ÇÂÅÁªÑ¡à¹×èÍ§¨Ò¡ÁÕÃÒÂ§Ò¹¡ÒÃà¡Ô´ÍÒ¡ÒÃªÑ¡
ä´Œ â´ÂäÁ‹ÊÑÁ¾Ñ¹¸¡Ñº¢¹Ò´·ÕèãËŒ¼Åã¹¡ÒÃÃÑ¡ÉÒ
à¹×èÍ§¨Ò¡·Ñé§ Bupropion áÅÐ active metabolite ÁÕ¤‹Ò¤ÃÖè§ªÕÇÔµ¤‹Í¹¢ŒÒ§
ÊÑé¹ ¨Ö§µŒÍ§ãËŒÇÑ¹ÅÐËÅÒÂ¤ÃÑé§ áµ‹ã¹»˜¨¨ØºÑ¹ÁÕÃÙ»áºº·ÕèÍÍ¡Ä·¸Ôì¹Ò¹¢Öé¹·ÕèÊÒÁÒÃ¶ãËŒ
ÇÑ¹ÅÐ¤ÃÑé§ ¢¹Ò´àÃÔèÁµŒ¹¢Í§ÂÒã¹ÃÙ»áºº»¡µÔ ¤×Í 100 mg ÇÑ¹ÅÐ 2 ¤ÃÑé§ ¨Ò¡¹Ñé¹
ÍÂ‹Ò§¹ŒÍÂ 3 ÇÑ¹¨Ö§à¾ÔèÁ¢¹Ò´à»š¹ 100 mg ÇÑ¹ÅÐ 3 ¤ÃÑé§ ¢¹Ò´ã¹áµ‹ÅÐ¤ÃÑé§äÁ‹¤ÇÃ
à¡Ô¹ 150 mg áÅÐ¤ÇÃãËŒË‹Ò§¡Ñ¹ÍÂ‹Ò§¹ŒÍÂ 6 ªÑèÇâÁ§ ÊíÒËÃÑºÂÒÃÙ»áººÍÍ¡Ä·¸Ôì
à¹Ôè¹ ¢¹Ò´àÃÔèÁµŒ¹¤×Í 150 mg ÇÑ¹ÅÐ¤ÃÑé§ ¨Ò¡¹Ñé¹ã¹ÇÑ¹·Õè 4 à¾ÔèÁ¢¹Ò´à»š¹ 150
mg ÇÑ¹ÅÐ 2 ¤ÃÑé§ áÅÐ¤ÇÃãËŒË‹Ò§¡Ñ¹ÍÂ‹Ò§¹ŒÍÂ 8 ªÑèÇâÁ§ «Öè§¡ÒÃãËŒ Bupropion
ÃÙ»áººÍÍ¡Ä·¸Ôìà¹Ôè¹ã¹¢¹Ò´ 150 mg ÇÑ¹ÅÐ 3 ¤ÃÑé§ ¨Ðà·ÕÂºà·‹Ò¡Ñº¡ÒÃãËŒã¹
ÃÙ»áºº»¡µÔ¢¹Ò´ 100 mg ÇÑ¹ÅÐ 3 ¤ÃÑé§ ¢¹Ò´ÊÙ§ÊØ´¢Í§ Bupropion äÁ‹¤ÇÃà¡Ô¹
450 mg/day à¹×èÍ§¨Ò¡ã¹¢¹Ò´ÊÙ§¨Ðà¾ÔèÁÍØºÑµÔ¡ÒÃ³¡ÒÃà¡Ô´ÍÒ¡ÒÃªÑ¡ãËŒÁÒ¡¢Öé¹
à¹×èÍ§¨Ò¡ Bupropion äÁ‹ÁÕÄ·¸Ôìã¹¡ÒÃÂÑºÂÑé§ CYP450 ¨Ö§à¡Ô´»¯Ô¡ÔÃÔÂÒ¡Ñº
ÂÒÍ×è¹ä´Œ¹ŒÍÂ ÍÂ‹Ò§äÃ¡çµÒÁ¡ÒÃãªŒ Bupropion Ã‹ÇÁ¡Ñº Venlafaxine ¨Ð·íÒãËŒÃÐ´Ñº
¢Í§ Venlafaxine ã¹àÅ×Í´à¾ÔèÁ¢Öé¹ 3 à·‹Ò
5. Noradrenergic and Specific-Serotonergic

Antidepressants (NaSSAs)
Mirtazapine à»š ¹ ÂÒãËÁ‹ ·Õè à ¾Ôè Á ¡ÒÃ·í Ò §Ò¹¢Í§ serotonin áÅÐ

norepinephrine ¼‹Ò¹¡Åä¡·Õ«è ºÑ «ŒÍ¹ Ê‹§¼ÅÅ´ÍÒÃÁ³«ÁÖ àÈÃŒÒáÅÐÅ´ÍÒ¡ÒÃÇÔµ¡¡Ñ§ÇÅ
áÅÐÂÑ§ÁÕ¼Åµ‹Í¡ÒÃà¡Ô´ÍÒ¡ÒÃäÁ‹¾Ö§»ÃÐÊ§¤¨Ò¡ serotonin Å´Å§ àª‹¹ ÊÁÃÃ¶ÀÒ¾
·Ò§à¾Èº¡¾Ã‹Í§ áÅÐÍÒ¡ÒÃäÁ‹ÊºÒÂ·ŒÍ§ ¹Í¡¨Ò¡¹Õé Mirtazapine ÂÑ§ÁÕÄ·¸ÔìÂÑºÂÑé§
serotonin reuptake transporters ¨Ö§ÍÍ¡Ä·¸Ôìà¾ÔèÁ¡ÒÃ·íÒ§Ò¹¢Í§ serotonin áÅÐ
norepinephrine ã¹ÅÑ¡É³Ð·Õèµ‹Ò§¨Ò¡ÂÒÃÑ¡ÉÒÍÒÃÁ³«ÖÁàÈÃŒÒµÑÇÍ×è¹
ÍÒ¡ÒÃäÁ‹¾§Ö »ÃÐÊ§¤·¾Õè ºÁÒ¡¨Ò¡¡ÒÃãªŒ Mirtazapine ä´Œá¡‹ §‹Ç§¹Í¹ à¹×Íè §¨Ò¡
Mirtazapine ÁÕÄ·¸Ôì antihistamine ·ÕèáÃ§ ¨Ö§·íÒãËŒ§‹Ç§¹Í¹ä´ŒÁÒ¡ áÅÐ·íÒãËŒà¾ÔèÁ¤ÇÒÁ
ÍÂÒ¡ÍÒËÒÃáÅÐ¹éíÒË¹Ñ¡à¾ÔèÁ ¨Ò¡¡ÒÃÂÑºÂÑé§ 5-HT2C receptor ¹Í¡¨Ò¡¹Ñé¹ Mirtazapine
ÂÑ§·íÒãËŒ total cholesterol áÅÐ triglycerides à¾ÔèÁ¢Öé¹ ¢¹Ò´àÃÔèÁµŒ¹ã¹¡ÒÃÃÑ¡ÉÒ ¤×Í
15 mg ¡‹Í¹¹Í¹ ¢¹Ò´·ÕèãËŒ¼Åã¹¡ÒÃÃÑ¡ÉÒÍÂÙ‹ã¹ª‹Ç§ 15-45 mg/day
6. Selective Norepinephrine Reuptake Inhibitors
(NRIs)
Reboxetine ÂÒ¨ÐÍÍ¡Ä·¸ÔÂì ºÑ ÂÑ§é ¡ÒÃ¹íÒ nore-
pinephrine ¡ÅÑºà¢ŒÒÊÙ‹ presynaptic neuron «Öè§ÍÒ¨
·í Ò ãËŒ Í Í¡Ä·¸Ôì à »š ¹ ÂÒµŒ Ò ¹ÍÒ¡ÒÃ«Ö Á àÈÃŒ Ò ·Õè ÁÕ
»ÃÐÊÔ·¸ÔÀÒ¾ä´ŒáÅÐÁÕ¼Å¢ŒÒ§à¤ÕÂ§µèíÒ ÍÂ‹Ò§äÃ¡çµÒÁ¼Å
¢Œ Ò §à¤Õ Â §·Õè Í Ò¨à¡Ô ´ ¢Öé ¹ä´Œ º‹ Í Â ¤× Í ÁÖ ¹ §§ »Ç´ËÑ Ç
»˜ÊÊÒÇÐ¤Ñ§è »Ò¡áËŒ§ àË§×Íè ÍÍ¡áÅÐ¹Í¹äÁ‹ËÅÑº ¢¹Ò´
ÂÒ·Õáè ¹Ð¹íÒ ¤×Í ÃÑº»ÃÐ·Ò¹ 4 mg ÇÑ¹ÅÐ 2 ¤ÃÑ§é ã¹ÃÒÂ·Õäè ´ŒÃºÑ ÂÒä»áÅŒÇ 3 ÊÑ»´ÒË
áÅŒÇÂÑ§äÁ‹´Õ¢Öé¹ ÊÒÁÒÃ¶à¾ÔèÁ¢¹Ò´ÂÒä´Œ¶Ö§ 10 mg/day
7. Serotonin Antiagonist and Reuptake Inhibitors (SARIs)

Trazodone à»š¹ÂÒÃÑ¡ÉÒÍÒÃÁ³«ÖÁàÈÃŒÒ·ÕèÍÂÙ‹
ã¹¡ÅØ‹Á phenylpiperazines ¡ÒÃÍÍ¡Ä·¸Ôì¢Í§ÂÒà¡Ô´
¨Ò¡¡ÒÃà»ÅÕèÂ¹á»Å§¡ÒÃ·íÒ§Ò¹¢Í§ serotonin â´Â
¡ÒÃÂÑ º ÂÑé § serotonin reuptake áÅÐÂÑ º ÂÑé §
postsynaptic 5-HT2 receptors àÁ×èÍà»ÃÕÂºà·ÕÂº¡Ñº
ÂÒã¹¡ÅØ‹Á TCAs ÂÒã¹¡ÅØ‹Á phenylpiperazines à»š¹
ÂÒ·Õè » ÅÍ´ÀÑ Â ¡Ç‹ Ò à¹×è Í §¨Ò¡ Trazodone ÁÕ Ä ·¸Ôì
anticholinergic ·ÕèÍ‹Í¹ «Öè§¨ÐàËÁÒÐÊíÒËÃÑº¼ÙŒ»†ÇÂ·ÕèÁÕ
ÀÒÇÐµ‹ÍÁÅÙ¡ËÁÒ¡âµáÅÐ·ŒÍ§¼Ù¡ áÅÐäÁ‹·íÒãËŒ¹éíÒË¹Ñ¡à¾ÔèÁËÃ×ÍÊÁÃÃ¶ÀÒ¾·Ò§à¾È
º¡¾Ã‹Í§ äÁ‹ÁÕ¼Åµ‹Í¡ÒÃ¹íÒ¡ÃÐáÊä¿¿‡Òã¹¡ÅŒÒÁà¹×éÍËÑÇã¨
ÍÒ¡ÒÃ¢ŒÒ§à¤ÕÂ§·Õè¾ºº‹ÍÂ ä´Œá¡‹ ¤Å×è¹äÊŒ »Ò¡áËŒ§ ÁÖ¹§§ ·ŒÍ§¼Ù¡ áÅÐ§‹Ç§
¹Í¹ Trazodone ÍÒ¨·íÒãËŒ¡ÒÃµ×è¹µÑÇÅ´Å§áÅÐ·íÒãËŒà¡Ô´ÍÒ¡ÒÃ§‹Ç§¹Í¹ã¹µÍ¹àªŒÒ
ËÃ×ÍàÁÒ¤ŒÒ§ (hangover) áÁŒÇÒ‹ ¨Ðä´ŒÃºÑ ÂÒ¡‹Í¹¹Í¹¡çµÒÁ «Ö§è ¨Ò¡¡ÒÃ·Õè Trazodone
·íÒãËŒ§‹Ç§¹Í¹ÁÒ¡ »˜¨¨ØºÑ¹ Trazodone ÁÑ¡¶Ù¡¹íÒÁÒãªŒã¹¡Ã³Õ·Õè¼ÙŒ»†ÇÂ·Õèä´ŒÃÑº¡ÒÃ
ÃÑ¡ÉÒ´ŒÇÂÂÒã¹¡ÅØ‹Á SSRIs ÁÕÍÒ¡ÒÃ¹Í¹äÁ‹ËÅÑº â´ÂãªŒã¹¢¹Ò´ 25-100 mg ¡‹Í¹
¹Í¹ áÅÐãªŒÅ´ÍÒ¡ÒÃ¡ÃÐÇ¹¡ÃÐÇÒÂã¹¼ÙŒ»†ÇÂºÒ§ÃÒÂ
¤ÇÒÁ´Ñ¹âÅËÔµÅ´Å§àÁ×Íè à»ÅÕÂè ¹·‹Ò·Ò§à»š¹ÍÒ¡ÒÃ¢ŒÒ§à¤ÕÂ§ÍÕ¡ÍÂ‹Ò§Ë¹Ö§è ·Õàè ¡Ô´
¢Ö¹é ä´Œ¨Ò¡¡ÒÃãªŒÂÒã¹¡ÅØÁ‹ phenylpiperazines ¨Ö§µŒÍ§ÃÐÇÑ§ã¹¼ÙÊŒ §Ù ÍÒÂØà¹×Íè §¨Ò¡·íÒãËŒ
ÅŒÁä´Œ§‹ÒÂ ÍÂ‹Ò§äÃ¡ç´Õ ¡ÒÃà¡Ô´Ä·¸Ôì´Ñ§¡Å‹ÒÇ¨Ðà¡Ô´àÁ×èÍÃÐ´ÑºÂÒã¹ plasma ÊÙ§ÊØ´ «Öè§
à¡Ô´¢Öé¹ËÅÑ§¨Ò¡ÃÑº»ÃÐ·Ò¹ÂÒä»áÅŒÇ 4-6 ªÑèÇâÁ§ «Öè§¨Ðà»š¹ª‹Ç§·Õè¼ÙŒ»†ÇÂËÅÑº áµ‹¡ç
¤ÇÃÁÕ¡ÒÃà½‡ÒÃÐÇÑ§¡ÒÃà¡Ô´ÍÒ¡ÒÃ¢ŒÒ§à¤ÕÂ§´Ñ§¡Å‹ÒÇã¹¼ÙŒ»†ÇÂÊÙ§ÍÒÂØ áÅÐ»‡Í§¡Ñ¹¡ÒÃ
à¡Ô´â´Â¡ÒÃãËŒ¤Òí á¹Ð¹íÒ¡Ñº¼Ù»Œ Ç† ÂãËŒËÅÕ¡àÅÕÂè §¡ÒÃÅØ¡¨Ò¡¡ÒÃ¹Í¹ËÃ×Í¹Ñ§è ÍÂ‹Ò§ÃÇ´àÃçÇ
´×èÁ¹éíÒÁÒ¡ æ áÅÐäÁ‹¤ÇÃ·íÒ¡Ô¨¡ÃÃÁ¨¹àÊÕÂàË§×èÍÁÒ¡à¡Ô¹ä»
Trazodone ·íÒãËŒà¡Ô´ÍÒ¡ÒÃÍÇÑÂÇÐà¾Èá¢ç§µÑÇ¤ŒÒ§ (priapism) «Öè§à¡Ô´ä´Œ
¹ŒÍÂ»ÃÐÁÒ³ 1 ã¹ 7,000 ¢Í§¼ÙŒ»†ÇÂªÒÂ áµ‹àÁ×èÍà¡Ô´¢Öé¹áÅŒÇ ·íÒãËŒ¼ÙŒ»†ÇÂà¡Ô´¤ÇÒÁ
äÁ‹ÊºÒÂ áÅÐµŒÍ§·íÒ¡ÒÃ¼‹ÒµÑ´à¾×Íè ÃÑ¡ÉÒÍÂ‹Ò§ÃÇ´àÃçÇáÅÐàÁ×Íè ÃÑ¡ÉÒËÒÂáÅŒÇÍÒ¨·íÒãËŒ
à»š¹ËÁÑ¹ä´Œ
8. Norepinephrine-dopamine disinhibitors
Agomelatine ËÃ×Íª×èÍ·Ò§à¤ÁÕ Beta-methyl-6-
chloromelatonin à»š ¹ ÂÒ·Õè ÁÕ â ¤Ã§ÊÃŒ Ò §à·Õ Â ºà¤Õ Â §
(homologue) ÊÒÃ melatonin ã¹ÊÁÍ§ Agomelatine
ÁÕ¡Åä¡¡ÒÃÍÍ¡Ä·¸Ôì agonist µ‹Í melatonin1 (MT1),
melatonin2 (MT2) receptors ·Õè SCN53 ã¹ÊÁÍ§ áÅÐ
ÍÍ¡Ä·¸Ôì antagonist µ‹Í serotonin ª¹Ô´ 5-HT2c receptor
ã¹ÊÑµÇ·´ÅÍ§ ¡ÒÃ¡ÃÐµØŒ¹ MT1/MT2 receptors ·Õè
suprachiasmatic nucleus (SCN) ã¹Ê‹Ç¹ hypothalamus ¢Í§ÊÁÍ§ ¨Ð·íÒãËŒ
Ç§¨ÃÃÍºÇÑ¹ (Circadian rhythm) àÅ×èÍ¹àÃçÇ¢Öé¹ áÅÐÊÑÁ¾Ñ¹¸¡Ñº¡ÒÃ¹Í¹ËÅÑº ã¹
¤¹àÃÒÊÒÃ melatonin ã¹ÊÁÍ§¨Ð·íÒË¹ŒÒ·Õè»ÃÑºÇ§¨ÃÃÍºÇÑ¹ÀÒÂã¹ãËŒÊÍ´¤ÅŒÍ§¡Ñº
àÇÅÒÀÒÂ¹Í¡ «Ö§è ¶ŒÒà¡Ô´¤ÇÒÁäÁ‹ÊÍ´¤ÅŒÍ§¢Í§Ç§¨ÃàÇÅÒÀÒÂã¹/ÀÒÂ¹Í¡¨Ð·íÒãËŒà¡Ô´
âÃ¤·Ò§ÍÒÃÁ³ÃÇÁ·Ñé§¤ÇÒÁ¼Ô´»¡µÔã¹ÃÙ»áºº¡ÒÃ¹Í¹ËÅÑº ÊÒÃ melatonin àÍ§
¨Ö§ÁÑ¡¶Ù¡ãªŒª‹ÇÂãËŒ¹Í¹ËÅÑºã¹¡Ã³Õ·Õèà¡Ô´ jet lag syndrome ¡ÒÃÍÍ¡Ä·¸Ôìª‹ÇÂ¡ÒÃ
¹Í¹¹Õé äÁ‹ä´Œà¡Ô´¨Ò¡¡ÒÃ¡´¡ÒÃ·íÒ§Ò¹¢Í§ÊÁÍ§¼‹Ò¹ Benzodiazepine-GABA
receptor ÍÂ‹Ò§ÂÒ¹Í¹ËÅÑº¡ÅØ‹Á Benzodiazepine
Ê‹Ç¹¡ÒÃÍÍ¡Ä·¸Ôìà»š¹ 5-HT2C antagonist ÁÕ¼Åµ‹Í¡ÒÃÅ´ÍÒ¡ÒÃÇÔµ¡¡Ñ§ÇÅ
ÍÕ ¡ ·Ñé § ÂÑ § ·í ÒãËŒ à ¡Ô ´ ¡ÒÃ»Å´»Å‹ Í Â·Ñé § norepinephrine áÅÐ dopamine ·Õè
frontocortical dopaminergic and adrenergic pathway «Öè§ÍÒ¨ÊÑÁ¾Ñ¹¸¡Ñº¡ÒÃ
ÍÍ¡Ä·¸Ôìá¡Œ«ÖÁàÈÃŒÒä´Œ àª‹¹à´ÕÂÇ¡ÑºÂÒá¡Œ«ÖÁàÈÃŒÒÍÂ‹Ò§ Mirtazapine ·ÕèÍÍ¡Ä·¸Ôì
ÂÑºÂÑé§ 5-HT2c receptor ¡çãËŒ¼Åàª‹¹à´ÕÂÇ¡Ñ¹
¹Í¡¨Ò¡¹Õé¡ÒÃãËŒ Agomelatine ã¹ÊÑµÇ·´ÅÍ§¹Ò¹ 3 ÊÑ»´ÒËÂÑ§¾º
¤Ø³ÊÁºÑµÔ neuroprotective effect â´Âà¾ÔèÁ cell proliferation, maturation,
survival áÅÐ neurogenesis ã¹ÊÁÍ§Ê‹Ç¹ ventral hippocampus «Öè§à»š¹ºÃÔàÇ³
ÊÁÍ§·ÕèÊíÒ¤ÑÞµ‹ÍâÃ¤¤ÇÒÁ¼Ô´»¡µÔ·Ò§ÍÒÃÁ³ Ã‹ÇÁ¡Ñº¡ÒÃà¾ÔèÁ¢Öé¹¢Í§ÃÐ´Ñº BDNF
(brain-derived neurotrophic factor)
¨Ò¡¡ÒÃÈÖ¡ÉÒ»ÃÐÊÔ·¸ÔÀÒ¾¢Í§ÂÒ ¾ºÇ‹Ò Agomelatine ÁÕ»ÃÐÊÔ·¸ÔÀÒ¾
·Ñé§ã¹¡ÒÃÃÑ¡ÉÒÍÒ¡ÒÃ«ÖÁàÈÃŒÒáÅÐ¡ÒÃ»‡Í§¡Ñ¹¡ÒÃ¡íÒàÃÔº¢Í§âÃ¤«ÖÁàÈÃŒÒä´Œ´Õ¡Ç‹ÒÂÒ
ËÅÍ¡ â´Âà©¾ÒÐã¹¼ÙŒ»†ÇÂâÃ¤«ÖÁàÈÃŒÒ·ÕèÁÕÍÒ¡ÒÃÃØ¹áÃ§ áÅÐàÁ×èÍÈÖ¡ÉÒà»ÃÕÂºà·ÕÂº
»ÃÐÊÔ·¸ÔÀÒ¾ã¹¡ÒÃÃÑ¡ÉÒâÃ¤«ÖÁàÈÃŒÒ¡ÑºÂÒÍ×¹è ¡ç¾ºÇ‹Ò Agomelatine ÁÕ»ÃÐÊÔ·¸ÔÀÒ¾
à·ÕÂºà¤ÕÂ§¡ÑºÂÒá¡Œ«ÖÁàÈÃŒÒã¹¡ÅØ‹Á SSRI áÅÐ SNRI áµ‹¼ÙŒ»†ÇÂ·Õèä´Œ Agomelatine
¨Ðª‹ÇÂà¾ÔèÁ»ÃÐÊÔ·¸ÔÀÒ¾¡ÒÃ¹Í¹ËÅÑºä´Œ´Õ¡Ç‹Ò ÍÕ¡·Ñé§à¡Ô´¼ÅäÁ‹¾Ö§»ÃÐÊ§¤¹ŒÍÂ¡Ç‹Ò
â´ÂÍÒ¡ÒÃäÁ‹¾Ö§»ÃÐÊ§¤·Õè¾ºº‹ÍÂ ¤×Í ÍÒ¡ÒÃ¤Å×è¹äÊŒáÅÐàÇÕÂ¹ÈÕÃÉÐ
¡ÒÃãËŒÂÒ¨ÐàÃÔèÁãËŒ·Õè 25 mg ÇÑ¹ÅÐ¤ÃÑé§ ÃÑº»ÃÐ·Ò¹àÇÅÒ¡‹Í¹¹Í¹ ËÅÑ§¨Ò¡
ä´ŒÃÑºÂÒä»áÅŒÇ 2 ÊÑ»´ÒË ËÒ¡ÍÒ¡ÒÃäÁ‹´Õ¢Öé¹ ÊÒÁÒÃ¶à¾ÔèÁ¢¹Ò´ÂÒä´Œ¨¹¶Ö§ 50 mg
ÇÑ¹ÅÐ¤ÃÑé§ â´ÂËÒ¡µŒÍ§¡ÒÃËÂØ´ÂÒÊÒÁÒÃ¶ËÂØ´ä´Œ·Ñ¹·Õ
ÂÒ Antidepressant â´Âà©¾ÒÐÍÂ‹Ò§ÂÔè§ ¡ÅØ‹Á SSRIs ÁÕ¡ÒÃÃº¡Ç¹¡ÒÃ
·íÒ§Ò¹¢Í§ Cytochrome P450 áÅÐºÒ§µÑÇà»š¹ potent enzyme inhibitor
´Ñ§¹Ñé¹ ¨Ö§¤ÇÃÁÕ¡ÒÃà½‡ÒÃÐÇÑ§ã¹¡ÒÃãªŒÂÒÃ‹ÇÁ¡Ñ¹
µÒÃÒ§·Õè 18 ¼Å¢Í§ Antidepressants µ‹Í¡ÒÃÂÑºÂÑé§¡ÒÃ·íÒ§Ò¹

(Inhibition potential) ¢Í§ CYP450 enzyme systems
µÒÃÒ§·Õè 19 áÊ´§ÂÒ Antidepressants ¡ÅØ‹ÁãËÁ‹
·ÕèÁÕ¼Åµ‹Í Cytochrome (CYP) P450 Enzyme
Drug CYP 1A2 CYP 2C CYP 2D6 CYP 3A4
Bupropion 0 0 + 0
Citalopram 0 0 + NA
EsCitalopram 0 0 + 0
Fluoxetine 0 ++ ++++ ++
Fluvoxamine ++++ ++ 0 +++
Mirtazapine 0 0 0 0
Nefazodone 0 0 0 ++++
Paroxetine 0 0 ++++ 0
Sertraline 0 ++ + +
(des)Venlafaxine 0 0 0/+ 0
++++, high; +++, moderate; ++, low; +, very low; 0, absent.
µÒÃÒ§·Õè 20 áÊ´§ Drug Interactions ¢Í§ÂÒ Antidepressants ¡ÅØ‹ÁãËÁ‹ æ

Interacting Drug/
Antidepressant Effect
Drug Class
Citalopram and MAOIs Potential for hypertensive crisis, serotonin syndrome,
esCitalopram delirium
Linezolid (MAOI effects) Serotonin syndrome
Sibutramine Serotonin syndrome
Triptans Serotonin syndrome
Fluoxetine Increased plasma concentrations and half-life of
Alprazolam
Alprazolam; increased psychomotor impairment
Antipsychotics (e.g., Increased antipsychotic concentrations; increased
Haloperidol, Risperidone) extrapyramidal side effects
E-Adrenergic blockers Increased metoprolol serum concentrations; increased
Interacting Drug/
Drug Class
Increased plasma concentrations of Carbamazepine;
Carbamazepine
symptoms of Carbamazepine toxicity
Potential for hypertensive crisis, serotonin syndrome,
MAOIs
delirium
Increased plasma concentrations of phenytoin;
Phenytoin
symptoms of phenytoin toxicity
Markedly increased TCA plasma concentrations;
TCAs
symptoms of TCA toxicity
Sibutramine Triptans Serotonin syndrome
Thioridazine Thioridazine Cmax increased; prolonged QTc interval
Fluvoxamine Alosetron Increased alosetron AUC (6-fold) and half-life (3-fold)
Increased AUC of Alprazolam by 96%, increased
Alprazolam Alprazolam half-life by 71%; increased psychomotor
impairment
Fivefold increase in Propranolol serum concentration;
E-Adrenergic blockers
bradycardia and hypotension
Increased plasma concentrations of Carbamazepine;
Carbamazepine
symptoms of Carbamazepine toxicity
Increased Clozapine serum concentrations; increased risk
Clozapine
for seizures and orthostatic hypotension
Diltiazem Bradycardia
MAOIs
delirium
Increased methadone plasma concentrations; symptoms
Methadone
of methadone toxicity
Ramelteon Increased AUC (190-fold) and Cmax (70-fold)
Interacting Drug/
Drug Class
Increased TCA plasma concentration; symptoms of TCA
TCAs
toxicity
Increased serum concentrations of theophylline or
Theophylline and caffeine
caffeine; symptoms of theophylline or caffeine toxicity
Warfarin Increased hypoprothrombinemic response to warfarin
Paroxetine Antipsychotics (e.g., Increased antipsychotic concentrations; increased central
Haloperidol, Perphenazine and nervous system and extrapyramidal side effects
Risperidone)
Increased metoprolol serum concentrations; increased
E-Adrenergic blockers
bradycardia; possible heart block
MAOIs
delirium
Markedly increased TCA plasma concentrations;
TCAs
symptoms of TCA toxicity
Sertraline Linezolid (MAOI effects) Serotonin syndrome
MAOIs
delirium
Interacting Drug/
Drug Class
Venlafaxine and MAOIs Potential for hypertensive crisis, serotonin syndrome,
Desvenlafaxine delirium
Duloxetine MAOIs Potential for hypertensive crisis, serotonin syndrome,

delirium
Dopamine Noradrenaline Reuptake Inhibitors (DNRI) : Aminoketone
Bupropion MAOIs Potential for hypertensive crisis
Medications that lower seizure Increased incidence of seizures
threshold
Noradrenaline & Specific Serotonin Antidepressant (NaSSA): Tetracyclic
Mirtazapine Carbamazepine Mirtazapine concentration decrease (60%)
MAOIs Theoretically central serotonin syndrome could occur
UC, area under the curve, Cmax, maximum concentration; MAOI, monoamine oxidase inhibitor
Serotonin Syndrome
Serotonin syndrome à»š¹ÍÒ¡ÒÃ·Õàè ¡Ô´ä´Œ¹ÍŒ Â áµ‹àÁ×Íè à¡Ô´¢Ö¹é áÅŒÇ·íÒãËŒàÊÕÂªÕÇµÔ

ä´Œ à¡Ô´¢Öé¹àÁ×èÍãªŒÂÒ·ÕèÁÕÄ·¸Ôìà¾ÔèÁ¡ÒÃ·íÒ§Ò¹¢Í§ serotonin Ã‹ÇÁ¡Ñ¹ ÍÒ¡ÒÃ·Õèà¡Ô´¢Öé¹ä´Œá¡‹
ÇÔµ¡¡Ñ§ÇÅ ÊÑè¹ (shivering) àË§×èÍÍÍ¡ ¤ÇÒÁ´Ñ¹âÅËÔµáÅÐÍÑµÃÒ¡ÒÃàµŒ¹ªÕ¾¨ÃÊÙ§¢Öé¹ËÃ×Í
Å´Å§ ¡ÒÃµÒÂ¨Ðà¡Ô´¢Öé¹¨Ò¡¡ÒÃ·ÕèÁÕÍØ³ËÀÙÁÔã¹Ã‹Ò§¡ÒÂÊÙ§¢Öé¹ÁÒ¡ ã¹ÃÒÂ·ÕèÁÕÍÒ¡ÒÃäÁ‹
ÃØ¹áÃ§ ÍÒ¡ÒÃ¨ÐËÒÂä»ËÅÑ§¨Ò¡ËÂØ´ÂÒ·Õèà»š¹ÊÒàËµØä»áÅŒÇ 24-48 ªÑèÇâÁ§
ã¹ÃÒÂ·ÕèÁÕÍÒ¡ÒÃÃØ¹áÃ§ ¡ÒÃÃÑ¡ÉÒ»ÃÐ¡Íº´ŒÇÂËÅÑ¡¡ÒÃ´Ñ§¹Õé »ÃÐ¡ÒÃáÃ¡ ËÂØ´
ÂÒ·Õè·íÒãËŒà¡Ô´·Ñ¹·Õ â´Â¨ÐµŒÍ§ãËŒ¤ÇÒÁÊ¹ã¨¡ÑºÂÒºÒ§¡ÅØ‹Á·ÕèÍÒ¨¨Ðà»š¹ÊÒàËµØ¢Í§
serotonin syndrome »ÃÐ¡ÒÃ·ÕèÊÍ§ ÃÑ¡ÉÒáºº»ÃÐ¤Ñº»ÃÐ¤Í§ (supportive) ´ŒÇÂ
¡ÒÃÃÑ¡ÉÒáÅÐ»‡Í§¡Ñ¹ÍÒ¡ÒÃá·Ã¡«ŒÍ¹·ÕèÍÒ¨¨Ð¾ºº‹ÍÂ àª‹¹ ÀÒÇÐä¢ŒÊÙ§, ÍÒ¡ÒÃªÑ¡,
coma, disseminated intravascular coagulopathy (DIC), rhabdomyolysis
electrolyte imbalance áÅÐ organ failure à»š¹µŒ¹ ¡ÒÃÅ´ä¢Œ´ŒÇÂ¡ÒÃàªç´µÑÇ´ŒÇÂ¹éíÒ
àÂç¹áÅÐà»†Ò¾Ñ´ÅÁä´Œ¼Å´Õ ¤ÇÃËÅÕ¡àÅÕèÂ§¡ÒÃãªŒÂÒÅ´ä¢Œ »ÃÐ¡ÒÃ·ÕèÊÒÁ ÃÑ¡ÉÒÍÒ¡ÒÃ
muscle rigidity â´Â¡ÒÃãËŒ Benzodiazepine ã¹¼ÙŒ»†ÇÂ·Õèà»š¹ÁÒ¡ÍÒ¨ãªŒ Dantrolene
»ÃÐ¡ÒÃÊØ ´ ·Œ Ò Â ¤× Í ¡ÒÃãªŒ Â ÒµŒ Ò ¹Ä·¸Ôì ¢ Í§ 5-HT ã¹»˜ ¨ ¨Ø ºÑ ¹ ÁÕ Ã ÒÂ§Ò¹¡ÒÃãªŒ Â Ò
Cyproheptadine (Periactin) â´ÂÍÍ¡Ä·¸Ôìà»š¹ 5-HT1A áÅÐ 5-HT2A antagonist
¢¹Ò´·ÕèãªŒ 4-8 mg ·Ø¡ 1-4 hr ¨¹ÍÒ¡ÒÃ´Õ¢Öé¹ ËÃ×Í¢¹Ò´ÊÙ§ÊØ´ 32 mg/day
µÒÃÒ§·Õè 21 µÑÇÍÂ‹Ò§ÂÒ·Õè·íÒãËŒà¡Ô´ Serotonin syndrome (From: uptodate 2013)
ÃÒÂ¡ÒÃÂÒ·Õè¤ÇÃà½‡ÒÃÐÇÑ§¡ÒÃà¡Ô´ Drug interaction áÅÐ·íÒãËŒà¡Ô´
Serotonin syndrome ´Ñ§áÊ´§ã¹µÒÃÒ§ áÅÐÃÒÂ¡ÒÃ·ÕèÁÕ¡ÒÃãªŒº‹ÍÂ µÑÇÍÂ‹Ò§àª‹¹
Mild severity
- SSRI + Li or Buspirone/Bupropion
Moderate severity
- overdose of SSRIs
- SSRIs + Serotonergic drugs (eg. Sibutramine, Tramadol,
Ergotamine, Triptans, Ecstasy, Dextromethorphan, Pethidine)
Severe severity
- SSRIs + MAOI or RIMA (include Linezolid, Zyvox®)
Fuller MA, Sajatovic M. Drug information handbook for psychiatry.
7th ed.Ohio: lexi-comp; 2009.
Joseph T. Dipiro, Robrert L Talbert and et al, Pharmacotherapy A
Pathophysiologic Approach, 8th ed., 2011.
MICROMEDEX® Healthcare Series. Available at URL :
http://www.micromedexsolutions.com/micromedex2/librarian/
Accessed on July 22, 2013.
Serotonin syndrome. Available at URL :
http://www.ra.mahidol.ac.th/poisoncenter/bulletin/bul2000/v8n3/
Serotonin.html. Bulletin (July - September 2000 Vol.8 No.3).
Stephen M. Stahl: Stahl’s Essential Psycopharmacology:
neuroscientific basis and practical application.-3 ed. Cambridge
University Press 2008.
´ÅÄ´Õ à¾ªÃÊØÇÃÃ³, ÁÒâ¹ª ËÅ‹ÍµÃÐ¡ÙÅ: Depressive disorder: etiology and
clinical feature. Available at URL : http://ramamental.com/
topics/int494.pdf Accessed on July 31, 2013.
¸¹ÈÑ¡´Ôì à·ÕÂ¡·Í§. àÍ¡ÊÒÃ»ÃÐ¡Íº¡ÒÃàÃÕÂ¹ÇÔªÒ àÀÊÑªºíÒºÑ´»ÃÐÂØ¡µ 4.
àÀÊÑªºíÒºÑ´ã¹¤ÇÒÁ¼Ô´»¡µÔ·Ò§¨ÔµàÇª. 2550.
ÁÒâ¹ª ËÅ‹ÍµÃÐ¡ÙÅ áÅÐ»ÃÒâÁ·Â ÊØ¤¹ÔªÂ. ¨ÔµàÇªÈÒÊµÃ ÃÒÁÒ¸Ôº´Õ.
¾ÔÁ¾¤ÃÑé§·Õè 2. ¡ÃØ§à·¾Ï: ÀÒ¤ÇÔªÒ¨ÔµàÇªÈÒÊµÃ ¤³Ðá¾·ÂÈÒÊµÃ
âÃ§¾ÂÒºÒÅÃÒÁÒ¸Ôº´Õ ÁËÒÇÔ·ÂÒÅÑÂÁËÔ´Å; 2548.
ÊÃÂØ·¸ ÇÒÊÔ¡¹Ò¹¹·. ÂÒá¡Œ«ÖÁàÈÃŒÒÃØ‹¹ãËÁ‹ : ÍÐâ¡àÁÅÒ·Õ¹.
ÇÒÃÊÒÃÊÁÒ¤Á¨Ôµá¾·ÂáË‹§»ÃÐà·Èä·Â 2554; 56(3): 311-336
ÅÒÇÑÅÂ à«ÕèÂ§¨§. âÃ¤«ÖÁàÈÃŒÒ. ÇÒÃÊÒÃ ä·ÂäÀÉÑªÂ¹Ô¾¹¸ (©ºÑº online).
»‚·Õè 1 ©ºÑº·Õè 3 ¡Ñ¹ÂÒÂ¹ 2547.
ÂÒ·íÒãËŒÍÒÃÁ³¤§·Õè (Mood Stabilizers)
ÂÒ·íÒãËŒÍÒÃÁ³¤§·Õè à»š¹ÂÒ·Õãè ªŒÃ¡Ñ ÉÒ Bipolar disorder â´Âà©¾ÒÐã¹ÃÐÂÐ
mania áÅÐÁÕ¤Ø³ÊÁºÑµÔ»‡Í§¡Ñ¹¡ÒÃ¡ÅÑºà»š¹«éíÒ¢Í§âÃ¤
1. Lithium
2. ¡ÅØ‹ÁÂÒ¡Ñ¹ªÑ¡ºÒ§ª¹Ô´ : Valproate, Carbamazepine, Lamotrigine
3. ÂÒ Atypical antipsychotic (ÃÒÂÅÐàÍÕÂ´´Ñ§áÊ´§ã¹ËÑÇ¢ŒÍ
antipsychotic drug)
Lithium
ÁÕ»ÃÐÊÔ·¸ÔÀÒ¾ã¹ Bipolar mania, Bipolar depression ·Ñé§ÃÐÂÐ acute
áÅÐ maintenance ª‹ÇÂÅ´¡ÒÃ¦‹ÒµÑÇµÒÂã¹¼ÙŒ»†ÇÂ Bipolar Ê‹Ç¹»ÃÐÊÔ·¸ÔÀÒ¾ã¹
Mixed state, Rapid cycling äÁ‹¤‹ÍÂ´Õ¹Ñ¡
• ÂÑºÂÑé§ Phosphatidylinositol signaling system
• ÂÑºÂÑé§ glycogen synthase kinase -3- (GSK-3-)
• à¾ÔèÁÃÐ´Ñº¢Í§ BDNF, bcl-2
• à¾ÔèÁÃÐ´Ñº¢Í§ GABA ã¹ÊÁÍ§
¨Ò¡¡Åä¡´Ñ§¡Å‹ÒÇÊ‹§¼ÅãËŒà«ÅÅÊÁÍ§ÁÕ¡ÒÃµÒÂÅ´Å§ ¡ÒÃãªŒ Lithium ·íÒãËŒ
ÁÕ¡ÒÃ«‹ÍÁá«Áà«ÅÅÊÁÍ§ãËŒ¡ÅÑºÁÒ·íÒ§Ò¹ä´Œ»¡µÔ (Neuroprotective effect) ÂÑºÂÑ§é
¡ÒÃ·íÒ§Ò¹¢Í§ÃÐºº»ÃÐÊÒ··ÕèÁÒ¡à¡Ô¹ä»
• ¶Ù¡´Ù´«ÖÁã¹ÃÐºº·Ò§à´Ô¹ÍÒËÒÃä´ŒÃÇ´àÃçÇáÅÐÊÁºÙÃ³
• ÃÐ´ÑºÂÒã¹àÅ×Í´ÊÙ§ÊØ´ÀÒÂã¹àÇÅÒ 1.5-2 ªÑèÇâÁ§
• ÅÐÅÒÂã¹¹éíÒä´Œ´Õ äÁ‹¨Ñº¡Ñºâ»ÃµÕ¹ã¹àÅ×Í´
• ÂÒ¨Ð¡ÃÐ¨ÒÂä»·ÑèÇÃ‹Ò§¡ÒÂ·Ñé§ã¹áÅÐ¹Í¡à«ÅÅ
• ÃÐ´ÑºÂÒã¹Ã‹Ò§¡ÒÂ¨Ð¤§·ÕèËÅÑ§¨Ò¡ãËŒÂÒµ‹Íà¹×èÍ§ 5-7 ÇÑ¹
• ¤‹Ò¤ÃÖè§ªÕÇÔµ 18-24 ªÑèÇâÁ§ (ÍÒ¨à¾ÔèÁà»š¹ÁÒ¡¡Ç‹Ò 36 ªÑèÇâÁ§ ã¹¼ÙŒ»†ÇÂ
ÊÙ§ÍÒÂØËÃ×Í¼ÙŒ»†ÇÂ·ÕèÁÕ¡ÒÃ·íÒ§Ò¹¢Í§äµº¡¾Ã‹Í§)
• ¡íÒ¨Ñ´ÍÍ¡·Ò§äµ ã¹ÃÙ»à´ÔÁäÁ‹à»ÅÕÂè ¹á»Å§ (¡ÒÃ¡íÒ¨Ñ´ÂÒÊÑÁ¾Ñ¹¸¡ºÑ ¡ÒÃ
·íÒ§Ò¹¢Í§äµ)
ÃÙ»áººÂÒ·ÕèÁÕã¹âÃ§¾ÂÒºÒÅ
• Lithium carbonate capsule ¢¹Ò´ 300 mg
¢¹Ò´ã¹¡ÒÃÃÑ¡ÉÒ
• ¼ÙŒãËÞ‹ : àÃÔèÁãËŒã¹¢¹Ò´ 300 mg ÇÑ¹ÅÐ 2-3 ¤ÃÑé§ ¢¹Ò´ã¹¡ÒÃÃÑ¡ÉÒ
¤×Í 900-1,800 mg/day
• ¼ÙŒÊÙ§ÍÒÂØ : àÃÔèÁãËŒã¹¢¹Ò´ 300 mg ÇÑ¹ÅÐ 1-2 ¤ÃÑé§ ÊÒÁÒÃ¶à¾ÔèÁ
¢¹Ò´ÂÒä´ŒÊÑ»´ÒËÅÐ 300 mg/day â´Â·ÑèÇä»äÁ‹ÁÒ¡¡Ç‹Ò 900-1,200 mg/day
• ¼ÙŒ»†ÇÂäµº¡¾Ã‹Í§ : CrCl 10-50 ml/min ¤ÇÃÅ´ÂÒàËÅ×Í 50-75%
¢Í§¢¹Ò´»¡µÔ, CrCl < 10 ml/min ¤ÇÃÅ´ÂÒàËÅ×Í 25-50% ¢Í§¢¹Ò´»¡µÔ
• ã¹ª‹Ç§áÃ¡¢Í§¡ÒÃãËŒÂÒ¹ÔÂÁáº‹§ãËŒÇÑ¹ÅÐËÅÒÂ¤ÃÑé§à¾×èÍ»‡Í§¡Ñ¹ÍÒ¡ÒÃ
¢ŒÒ§à¤ÕÂ§·Õàè ¡Ô´ã¹ª‹Ç§·ÕÃè Ð´ÑºÂÒã¹àÅ×Í´ÊÙ§ÊØ´ Ê‹Ç¹ã¹¡ÒÃãªŒÂÒÃÐÂÐÂÒÇÊÒÁÒÃ¶»ÃÑº
ãËŒà»š¹ÇÑ¹ÅÐ 1 ¤ÃÑé§ ¡‹Í¹¹Í¹ à¾×èÍà¾ÔèÁ¤ÇÒÁÃ‹ÇÁÁ×Íã¹¡ÒÃãªŒÂÒ¢Í§¼ÙŒ»†ÇÂä´Œ
¡ÒÃà¨ÒÐÇÑ´ÃÐ´ÑºÂÒã¹àÅ×Í´
• ¤ÇÃä´ŒÃÑº¡ÒÃµÔ´µÒÁÃÐ´ÑºÂÒã¹àÅ×Í´ à¹×èÍ§¨Ò¡ Lithium ¨Ñ´à»š¹ÂÒ·Õè
ÁÕ¤ÇÒÁàÊÕèÂ§ÊÙ§ ÃÐ´ÑºÂÒ·Õè·íÒãËŒà¡Ô´¼Åã¹¡ÒÃÃÑ¡ÉÒã¡ÅŒà¤ÕÂ§¡ÑºÃÐ´ÑºÂÒ·Õè·íÒãËŒà¡Ô´
• ÃÐ´ÑºÂÒã¹àÅ×Í´·ÕÍè ÂÙã‹ ¹ª‹Ç§ÃÑ¡ÉÒ ¤×Í 0.6-1.2 mmol/L (ã¹ª‹Ç§ Acute
mania ÍÒ¨ä´Œ¶Ö§ 1.5 mmol/L) ¡ÒÃÃÑ¡ÉÒÃÐ´ÑºÂÒãËŒÍÂÙ‹ã¹ª‹Ç§ 0.8-1.0 mmol/L
ã¹ÃÐÂÐ maintenance phase ¨Ðª‹ÇÂ»‡Í§¡Ñ¹¡ÒÃà¡Ô´âÃ¤¤ÃÑé§ãËÁ‹ä´Œ ËÒ¡ÃÐ´ÑºÂÒ
¹ŒÍÂ¡Ç‹Ò 0.4 mmol/L ¨Ðà¾ÔèÁÍÑµÃÒ¡ÒÃ¡ÅÑºà»š¹«éíÒä´Œ
• ÃÐ´ÑºÂÒã¹Ã‹Ò§¡ÒÂ¨Ð¤§·Õè (Steady state) ËÅÑ§¨Ò¡ãËŒÂÒµ‹Íà¹×èÍ§
5-7 ÇÑ¹ ´Ñ§¹Ñé¹ ¤ÇÃà¨ÒÐÇÑ´ÃÐ´ÑºÂÒËÅÑ§¨Ò¡ä´ŒÃÑºÂÒ Lithium µ‹Íà¹×èÍ§ä»ÍÂ‹Ò§¹ŒÍÂ
7 ÇÑ¹ (·Ñé§¡Ã³ÕàÃÔèÁãªŒ¤ÃÑé§áÃ¡áÅÐ¡Ã³Õ»ÃÑºà»ÅÕèÂ¹¢¹Ò´ÂÒ)
• àÇÅÒ·ÕèàËÁÒÐÊÁã¹¡ÒÃà¨ÒÐÇÑ´ ¤×Í ËÅÑ§ÃÑº»ÃÐ·Ò¹ÂÒÁ×éÍÊØ´·ŒÒÂÁÒ
12 ªÑèÇâÁ§ Â¡àÇŒ¹¡Ã³ÕÊ§ÊÑÂ Lithium intoxication ÊÒÁÒÃ¶à¨ÒÐÇÑ´àÇÅÒã´¡çä´Œ
ĂćÖćøĕöŠóċÜðøąÿÜÙŤ ÖćøĒÖšĕ×ĒúąøĆÖþć
ðŦÿÿćüąïŠĂ÷ ðćÖĒĀšÜ ÖøąĀć÷îĚĞć - ĂćÖćøðŦÿÿćüąïŠĂ÷ĕöŠéĊ×ċĚîĂćÝøüïđðŨî÷ćöČĚĂđéĊ÷üÖŠĂîîĂî ĀøČĂúé
- óï 40 % đîČęĂÜÝćÖ÷ćĕð÷Ćï÷ĆĚÜ ×îćé÷ćúÜ
ÖćøêĂïÿîĂÜ×ĂÜĕêêŠĂ ADH - ĀćÖĂćÖćøĕöŠéĊ×ċĚî ÙüøóĉÝćøèćëċÜēĂÖćÿĔîÖćøđðŨî Nephrogenic
diabetes insipidus ĒúąĔĀšÖćøøĆÖþćêćöĒîüìćÜêŠĂĕð
öČĂÿĆęî - ÖøèĊđðŨîöćÖĔîßŠüÜìĊęøąéĆï÷ćÿĎÜÿčé (peak level) ÙüøðøĆïÖćøĔĀš

- óï 30-60% ßîĉé fine tremor ÷ćđðŨîĀúć÷ÙøĆĚÜêŠĂüĆî
ñĎšÿĎÜĂć÷čĂćÝđÖĉéĂćÖćøĕéšÜŠć÷×ċĚî - ĂćÝĔĀš Propranolol 40-120 mg/day đðŨîßŠüÜ ė ĀøČĂÖĉîđðŨîÙøĆĚÜ
(ëšćđðŨî coarse tremor ÝąđðŨî ÙøćüÖŠĂîĂĂÖÜćî đîČĂę ÜÝćÖëšćĔßšîćîĂćÝöĊ tolerance ĕéš
ĂćÖćøĒÿéÜĔîõćüąđðŨîóĉþ) - ÖøèĊĂćÖćøđðŨîöćÖĕöŠéĊ×ċĚî ĂćÝÝĞćđðŨîêšĂÜðøĆïúé×îćé÷ć
ÙúČęîĕÿš ĂćđÝĊ÷î ðüéìšĂÜ ìšĂÜđÿĊ÷ - ÙüøðøĆïÖćøĔĀš÷ćđðŨîĀúć÷ÙøĆĚÜêŠĂüĆî

- öĆÖđÖĉéÝćÖÖćøđøĉęöĔßš÷ćĔî×îćé - ĔîÖćøĔßš÷ćÙüøÙŠĂ÷ ė ðøĆïđóĉęö×îćé÷ć
ÿĎÜ ĀøČĂðøĆïđóĉęö÷ćĂ÷ŠćÜøüéđøĘü - ÖøèĊöĊĂćÖćøìšĂÜđÿĊ÷ĀøČĂĂćđÝĊ÷î ÙüøĔĀšîĚĞćđÖúČĂĒøŠìéĒìîđóČęĂ
ðŜĂÜÖĆî Lithium intoxication
- ÖøèĊ öĊ ĂćÖćøöćÖ ĂćÝđðŨîĂćÖćø×ĂÜõćüąđðŨîóĉþ êš ĂÜđÝćąüĆ é
øąéĆï÷ćĔîđúČĂéìĆîìĊ àċęÜĂćÝĕéšøĆïÖćøúé×îćé÷ćêŠĂĕð
Ě Ě
ĂćÖćøĂŠĂîđóúĊ÷ ÖúšćöđîČĚĂĕöŠöĊĒøÜĚ - ĂćÖćøÝąéĊ×ċĚîđöČęĂúé×îćé÷ćúÜ
ĂćÖćøìćÜñĉüĀîĆÜ - ëšćĂćÖćøĕöŠøčîĒøÜöĆÖéĊ×ċĚîđĂÜ ÙüøĔĀšÖćøøĆÖþćĂćÖćøìćÜñĉüĀîĆÜ

- Acneiform eruption ÙüïÙĎŠĕðéšü÷ đßŠî ĀćÖđðŨîÿĉüÝćÖ÷ć Lithium ĒúąÝĞćđðŨîêšĂÜĕéšøĆï
maculopapular eruption ÷ć Lithium êŠĂĕð ÙüøĔĀš÷ćøĆÖþćÿĉüÙüïÙĎŠĕðÖĆïÖćøĔßš÷ć Lithium
follicular eruption éšü÷
exfoliative dermatitis - ĀćÖöĊĂćÖćøñöøŠüÜÙüøóĉÝćøèćõćüą hypothyroidism àċęÜĂćÝ
hair loss đðŨîñúÝćÖ÷ć Lithium øŠüöéšü÷
- ëšćĂćÖćøđðŨîöćÖ Ùüøúé×îćé÷ćĀøČĂĀ÷čé÷ć
ñúêŠĂĀĆüĔÝ - ÙüøĀ÷čé÷ć Lithium

- T wave inversion - đðŨî benign effect Āć÷ĕðđĂÜđöČęĂ÷ćëĎÖ×ĆïĂĂÖÝćÖøŠćÜÖć÷
- ÖéÖćøìĞćÜćî×ĂÜ sinus node
- Ĕî×îćéđðŨîóĉþÝąóï ST
segment depression Ēúą QT
interval prolongation
îĚĞćĀîĆÖđóĉęö - ĒîąîĞćðøĆïóùêĉÖøøöÖćøøĆïðøąìćîĂćĀćøĒúąÖćøĂĂÖÖĞćúĆÜÖć÷
- óïïŠĂ÷ĔîñĎšðśü÷ĀâĉÜ ĂćÝđóĉęöĕéš - ĀćÖóïÙüćöđÿĊę÷ÜêŠĂÖćøđÖĉéēøÙĒìøÖàšĂîìĊęđðŨîñúöćÝćÖîĚĞćĀîĆÖ
ëċÜ 8-10 ÖĉēúÖøĆö öĆÖóïĔîßŠüÜ ìĊęđóĉęö×ċĚî ĂćÝóĉÝćøèćđðúĊę÷îĕðĔßš÷ćĂČęî
1-2 ðŘ Ē ø Ö × Ă Ü Ö ć ø øĆ Ö þ ć
ĀúĆÜÝćÖîĆĚîöĆÖÙÜìĊę
Āîšćïüö ×šĂđìšćïüö - ĀćÖđðŨîñúÝćÖ÷ć Lithium ĂćÖćøöĆÖéĊ×ċĚîđĂÜ

- ĂćÝóïĕéš ĔîïćÜÙøĆĚ Ü ēé÷ìĊę Ö ćø - ëšć÷ĆÜĕöŠéĊ×ċĚîĂćÝĔĀš Spironolactone 50 mg/day
ìĞćÜćî×ĂÜĕêđðŨîðÖêĉ - ëšćđðŨîöćÖĂćÝÝĞćđðŨîêšĂÜĀ÷čé÷ć
ñúêŠĂêŠĂöĕìøĂ÷éŤ - ðøĆïúé×îćé÷ćĀøČĂĀ÷čé÷ć Lithium

- Simple goiter, euthyroid - ĔĀšĕìøĂ÷éŤăĂøŤēöîđÿøĉö
- Clinical hypothyroid ēé÷öĊ ÖćøĔĀšĕìøĂ÷éŤăĂøŤēöîđÿøĉöÙüøđøĉęöĔĀšĔî×îćé 25-50 mcg
ĀøČĂĕöŠöĊ Goiter øŠüö ÿćöćøëđóĉęöĕéšÙøĆĚÜúą 25 mcg ìčÖ 6 ÿĆðéćĀŤ ÝîÖøąìĆęÜ TSH Ă÷ĎŠ
- øąéĆ ï ăĂøŤ ē öîĕìøĂ÷éŤ ñĉ é ðÖêĉ ĔîøąéĆïðÖêĉ (öĆÖĔßšĔî×îćé 50-100 mcg)
đßŠî TSH ÿĎÜ ĀøČĂøąéĆï T4 đóĉęö ÖćøĔĀšĕìøĂ÷éŤăĂøŤēöîđÿøĉöĔîñĎšðśü÷ÿĎÜĂć÷čĀøČĂñĎšìĊęöĊÖćøìĞćÜćî
×ĂÜĀĆüĔÝñĉéðÖêĉ ÙüøđøĉęöĔĀšĔî×îćé 12.5-25 mcg ĒúšüÙŠĂ÷ ė
ðøĆïđóĉęö×îćé÷ćóøšĂöìĆĚÜêĉéêćöĂćÖćø×šćÜđÙĊ÷ÜÝćÖ÷ć
µÒÃÒ§·Õè 22 áÊ´§á¹Ç·Ò§¡ÒÃ¨Ñ´¡ÒÃ¡Ã³Õ Subclinical hypothyroidism
Serum TSH (mU/L) ĒîüìćÜÖćøÝĆéÖćø
5-10 ēé÷ĕöŠöĊĂćÖćøĒÿéÜ - ÷ĆÜĕöŠÝĞćđðŨîêšĂÜĔĀšĕìøĂ÷éŤăĂøŤēöîđÿøĉö

hypothyroidism - ĂĊÖðøąöćè 1 đéČĂî ĔĀšđÝćą TSH àĚĞćĂĊÖÙøĆÜĚ ëšć TSH ÷ĆÜÙÜÿĎÜĂ÷ĎŠ
ĔĀšêĉéêćöĂ÷ŠćÜĔÖúšßĉéìčÖ 3 đéČĂî
5-10 øŠüöÖĆïöĊĂćÖćøĒÿéÜ - đøĉęöĔĀšĕìøĂ÷éŤăĂøŤēöîđÿøĉö
hypothyroidism - ÙüøöĊÖćøðøąđöĉî baseline neurocognitive
>10 - đøĉęöĔĀšĕìøĂ÷éŤăĂøŤēöîđÿøĉö ĒöšÝąöĊĂćÖćøĒÿéÜĀøČĂĕöŠÖêĘ ćö
µÒÃÒ§·Õè 23 áÊ´§ÃÐ´ÑºÂÒã¹àÅ×Í´áÅÐÍÒ¡ÒÃáÊ´§¡Ã³Õà¡Ô´ Lithium intoxication

øąéĆïÙüćöøčîĒøÜ &
ĂćÖćøĒÿéÜ
øąéĆï÷ćĔîđúČĂé
Mild toxicity
öČĂÿĆęî (Fine tremors), ÙúČęîĕÿš, ĂćđÝĊ÷î, ìšĂÜđÿĊ÷, ĂŠĂîđóúĊ÷
(>1.5 mmol/L)
Moderate toxicity öČĂÿĆęî (Coarse hand tremors), ÙúČęîĕÿš, ĂćđÝĊ÷îöćÖ, êćöĆü, ÖúšćöđîČĚĂöĆéđúĘÖ ė ÖøąêčÖ,
(1.5-2.5 mmol/L) deep tendon reflex ĕü, øąïïĕĀúđüĊ÷îēúĀĉêúšöđĀúü, đéĉîđà, óĎéøĆü, êćÖøąêčÖ
Severe toxicity
Delirium, Generalize seizures, øąïïĀć÷ĔÝúšöđĀúü, ĕêüć÷, đÿĊ÷ßĊüĉê
(>2.5 mmol/L)
¡ÒÃ¨Ñ´¡ÒÃá¡Œä¢ Lithium intoxication

• ËÂØ´ÂÒ Lithium ·Ñ¹·Õ
• overdose : ÀÒÂã¹ 1 ªÑèÇâÁ§ ¤ÇÃ·íÒ gastric lavage (äÁ‹á¹Ð¹íÒ¡ÒÃãËŒ
Charcoal)
• µÃÇ¨ blood Lithium ·Ø¡ 12 ªÑèÇâÁ§ , Electrolyte , BUN, Scr, V/S, EKG
• Blood Lithium < 3 mEq/L ãËŒ 0.9 % NSS 150-200 ml/hr
• ÃÑ¡ÉÒÃÐ´Ñº¹éíÒáÅÐà¡Å×ÍáÃ‹ãËŒÍÂÙ‹ã¹ÀÒÇÐÊÁ´ØÅ
• Hemodialysis ã¹¡Ã³Õ´Ñ§µ‹Íä»¹Õé
- Blood Lithium > 4 mmol/L ·Ø¡ÃÒÂ
- Blood Lithium 2.5–4 mmol/L ã¹¼Ù»Œ Ç† Â renal insufficiency ËÃ×ÍÁÕ severe
neurologic symptoms
- blood Lithium < 2.5 mmol/L ã¹¼ÙŒ»†ÇÂ End stage renal disease ËÃ×Í
¼ÙŒ»†ÇÂ·ÕèÅ´ÃÐ´Ñº Lithium ä´ŒµèíÒ¡Ç‹Ò 1 mmol/L ã¹ 30 ªÑèÇâÁ§
¢ŒÍËŒÒÁãªŒáÅÐÃÐÁÑ´ÃÐÇÑ§
• ËŒÒÁãªŒã¹¼ÙŒ»†ÇÂ·ÕèÁÕ»ÃÐÇÑµÔá¾Œ Lithium
• ËŒÒÁãªŒã¹¼ÙŒ»†ÇÂ·ÕèÁÕÀÒÇÐäµÇÒÂà©ÕÂº¾ÅÑ¹ ÃÐÇÑ§¡ÒÃãªŒã¹¼ÙŒ»†ÇÂ·ÕèÁÕ¡ÒÃ·íÒ§Ò¹
¢Í§äµº¡¾Ã‹Í§à¹×èÍ§¨Ò¡ Lithium ÁÕ¡ÒÃ¡íÒ¨Ñ´ÍÍ¡·Ò§äµ ã¹¼ÙŒ»†ÇÂ·ÕèÁÕ¡ÒÃ·íÒ§Ò¹¢Í§äµ
º¡¾Ã‹Í§ ÍÒ¨à¡Ô´ Lithium intoxication µÒÁÁÒä´Œ ´Ñ§¹Ñé¹¡‹Í¹ãªŒÂÒáÅÐÃÐËÇ‹Ò§ãªŒÂÒ¤ÇÃ
ÁÕ¡ÒÃµÔ´µÒÁ¡ÒÃ·íÒ§Ò¹¢Í§äµ
• ËŒÒÁãªŒã¹¼ÙŒ»†ÇÂ severe cardiovascular disease ÃÐÇÑ§¡ÒÃãªŒã¹¼ÙŒ»†ÇÂ·ÕèÁÕ
ÀÒÇÐËÑÇã¨ÅŒÁàËÅÇ ã¹¼ÙŒ»†ÇÂ·ÕèÁÕÍÒÂØÁÒ¡¡Ç‹Ò 50 »‚ ËÃ×ÍÁÕ»ÃÐÇÑµÔà»š¹âÃ¤ËÑÇã¨ÁÒ¡‹Í¹
«Öè§¤ÇÃä´ŒÃÑº¡ÒÃµÃÇ¨µÔ´µÒÁ EKG ¡‹Í¹áÅÐËÅÑ§ãªŒÂÒ
• ËŒÒÁãªŒã¹¼ÙŒ»†ÇÂµÑé§¤ÃÃÀ à¹×èÍ§¨Ò¡¨Ð·íÒãËŒà¡Ô´ cardiac malformation
ã¹à´ç¡ä´Œ
• ËŒÒÁãªŒã¹¼ÙŒ»†ÇÂ·ÕèÁÕÀÒÇÐÃ‹Ò§¡ÒÂ¢Ò´¹éíÒ
• ÃÐÇÑ§¡ÒÃãªŒã¹¼ÙŒ»†ÇÂâÃ¤ä·ÃÍÂ´ ã¹¼ÙŒ»†ÇÂ·Õèä´ŒÃÑºÂÒ Lithium ¤ÇÃä´ŒÃÑº¡ÒÃ
µÃÇ¨µÔ´µÒÁ Thyroid function tests ¡‹Í¹áÅÐËÅÑ§ä´ŒÃÑºÂÒ
Drug interaction
• ÃÐ´ÑºÂÒ Lithium ÍÒ¨à¾ÔèÁ¢Öé¹àÁ×èÍä´ŒÃÑºÃ‹ÇÁ¡ÑºÂÒËÃ×ÍÀÒÇÐ´Ñ§µ‹Íä»¹Õé
- ACEI àª‹¹ Enalapril, Captopril
- ARBs àª‹¹ Valsartan
- NSAIDs àª‹¹ Ibuprofen, Piroxicam, Diclofenac (Â¡àÇŒ¹ Aspirin, Sulindac)
- Thiazide àª‹¹ HCTZ
- Loop diuretics àª‹¹ Furosemide
- ÀÒÇÐ¢Ò´¹éíÒËÃ×ÍÊÙÞàÊÕÂ¹éíÒ
- ÀÒÇÐ·ÕèÃ‹Ò§¡ÒÂÁÕ¡ÒÃÊÙÞàÊÕÂ Sodium ·íÒãËŒÃ‹Ò§¡ÒÂÁÕ¡ÒÃ´Ù´¡ÅÑº sodium
ÁÒ¡¢Öé¹Ê‹§¼ÅãËŒ Lithium ¶Ù¡´Ù´¡ÅÑºÁÒ¡¢Öé¹àª‹¹¡Ñ¹
- ¼ÙŒÊÙ§ÍÒÂØ à¹×èÍ§¨Ò¡ÁÕ¡ÒÃ·íÒ§Ò¹¢Í§äµº¡¾Ã‹Í§
• ÃÐ´ÑºÂÒ Lithium ÍÒ¨Å´Å§àÁ×èÍä´ŒÃÑºÃ‹ÇÁ¡ÑºÂÒËÃ×ÍÀÒÇÐ´Ñ§µ‹Íä»¹Õé
- Methylxanthines àª‹¹ Caffeine, Theophylline
- ä´ŒÃÑº sodium ã¹»ÃÔÁÒ³ÁÒ¡
• ¤ÇÒÁàÊÕèÂ§ã¹¡ÒÃà¡Ô´ CNS toxicity ¢Í§ Lithium ÍÒ¨à¾ÔèÁ¢Öé¹ àÁ×èÍä´ŒÃÑºÃ‹ÇÁ
¡ÑºÂÒ Carbamazepine, CCBs, Methyldopa
• ¤ÇÒÁàÊÕèÂ§ã¹¡ÒÃà¡Ô´ Extrapyramidal symptoms ÍÒ¨à¾ÔèÁ¢Öé¹ àÁ×èÍä´ŒÃÑº
Ã‹ÇÁ¡ÑºÂÒ antipsychotic àª‹¹ Haloperidol
Valproate
ÁÕ»ÃÐÊÔ·¸ÔÀÒ¾ã¹¡ÒÃÃÑ¡ÉÒ Bipolar mania, Bipolar depression, ·Ñé§ã¹ÃÐÂÐ
Acute áÅÐ Maintenance «Öè§ÂÒ Valproate ÁÕ»ÃÐÊÔ·¸ÔÀÒ¾à·ÕÂºà·‹ÒÂÒ Lithium ã¹¡ÒÃ
ÃÑ¡ÉÒ Manic episode áÅÐÁÕ»ÃÐÊÔ·¸ÔÀÒ¾àË¹×Í¡Ç‹Ò Lithium ã¹¡ÒÃÃÑ¡ÉÒ Mixed episode
áÅÐ Rapid cycling
• ÂÑºÂÑé§ Phosphatidylinositol signaling system
• ÂÑºÂÑé§ glycogen synthase kinase -3- (GSK-3-)
• à¾ÔèÁÃÐ´Ñº¢Í§ BDNF, bcl-2
• ÂÑºÂÑé§¡ÒÃ·íÒÅÒÂ¢Í§ GABA
¨Ò¡¡Åä¡´Ñ§¡Å‹ÒÇÊ‹§¼ÅãËŒà«ÅÅÊÁÍ§ÁÕ¡ÒÃµÒÂÅ´Å§ ÁÕ¡ÒÃ«‹ÍÁá«Áà«ÅÅÊÁÍ§ãËŒ
¡ÅÑºÁÒ·íÒ§Ò¹ä´Œ»¡µÔ (Neuroprotective effect) ÂÑºÂÑé§¡ÒÃ·íÒ§Ò¹¢Í§ÃÐºº»ÃÐÊÒ··ÕèÁÒ¡
à¡Ô¹ä» ¡ÒÃÈÖ¡ÉÒ»˜¨¨ØºÑ¹ÊÑ¹¹ÔÉ°Ò¹Ç‹Ò¡Åä¡ã¹¡ÒÃ»ÃÑºÍÒÃÁ³¢Í§ Valproate ÁÕ¤ÇÒÁ
à¡ÕèÂÇ¢ŒÍ§¡Ñº¡ÒÃáÊ´§ÍÍ¡¢Í§ÂÕ¹Ê
• ¶Ù¡´Ù´«ÖÁä´Œ´Õ¨Ò¡·Ò§à´Ô¹ÍÒËÒÃ
Enteric coated tablets : ÀÒÂã¹ 2-4 ªÑèÇâÁ§
Controlled release (CR) tablets : ÀÒÂã¹ 3-8 ªÑèÇâÁ§
• ÂÒ¨Ñº¡Ñºâ»ÃµÕ¹ã¹àÅ×Í´ä´ŒÊÙ§ 90-95%
• ËÅÑ§´Ù´«ÖÁÂÒ¨Ð¡ÃÐ¨ÒÂÍÂ‹Ò§ÃÇ´àÃçÇà¢ŒÒÊÙ‹ÃÐºº»ÃÐÊÒ·Ê‹Ç¹¡ÅÒ§
• ÂÒ¶Ù¡·íÒÅÒÂ·ÕèµÑºâ´Â¼‹Ò¹ glucuronide conjugation (30-50%),
mitochondrial beta-oxidation (40%), CYP450 àª‹¹ CYP 2C9, 2C19
• ¤‹Ò¤ÃÖè§ªÕÇÔµ (¨Ðà¾ÔèÁ¢Öé¹ã¹·ÒÃ¡ ¼ÙŒÊÙ§ÍÒÂØ ¼ÙŒ»†ÇÂâÃ¤µÑº)
¼ÙŒãËÞ‹ : 9-16 ªÑèÇâÁ§
à´ç¡ÍÒÂØ > 2 à´×Í¹ : 7-13 ªÑèÇâÁ§
• Valproate enteric coated tablets ¢¹Ò´ 200 mg
• Valproate controlled release (CR) tablets ¢¹Ò´ 200, 500 mg
• Valproate oral solution ¢¹Ò´ 200 mg/ml
• ¼ÙŒãËÞ‹ : àÃÔèÁãËŒã¹¢¹Ò´ 20 mg/kg/day áº‹§ãËŒ·Ø¡ 12 ªÑèÇâÁ§ ÊÒÁÒÃ¶»ÃÑº
à¾ÔèÁ¢¹Ò´ÂÒ¤ÃÑé§ÅÐ 250-500 mg ·Ø¡ 1-3 ÇÑ¹ ¢¹Ò´ÂÒÊÙ§ÊØ´·Õèá¹Ð¹íÒ¤×Í 60 mg/kg/day
• ¼ÙŒÊÙ§ÍÒÂØ : á¹Ð¹íÒàÃÔèÁãËŒã¹¢¹Ò´·ÕèµèíÒÅ§ à¹×èÍ§¨Ò¡ÁÕ¡ÒÃ¡íÒ¨Ñ´ÂÒÅ´Å§
• ¼ÙŒ»†ÇÂäµº¡¾Ã‹Í§ : äÁ‹¨íÒà»š¹µŒÍ§»ÃÑº¢¹Ò´ÂÒ (ã¹¼ÙŒ»†ÇÂ¡ÅØ‹Á¹ÕéÍÒ¨ÁÕÃÐ´Ñº
albumin Å´Å§ ·íÒãËŒÁÕÂÒã¹ÃÙ»ÍÔÊÃÐà¾ÔèÁÁÒ¡¢Öé¹ ÂÒÍÍ¡Ä·¸Ôìä´ŒÁÒ¡¢Öé¹ËÃ×Íà¡Ô´ÍÒ¡ÒÃäÁ‹¾Ö§
»ÃÐÊ§¤â´ÂäÁ‹ÊÑÁ¾Ñ¹¸¡ÑºÃÐ´ÑºÂÒã¹àÅ×Í´·ÕèµÃÇ¨ÇÑ´ä´Œ) ÂÒäÁ‹¶Ù¡¡íÒ¨Ñ´â´Â dialysis
• Controlled release (CR) tablets ·ÕèãªŒã¹ Bipolar disorder ÊÒÁÒÃ¶ãËŒ
ÇÑ¹ÅÐ 1 ¤ÃÑé§ä´Œ áµ‹ËÒ¡ãªŒã¹ Epilepsy á¹Ð¹íÒáº‹§ãËŒ·Ø¡ 12 ªÑèÇâÁ§
• Controlled release (CR) tablets ËŒÒÁà¤ÕéÂÇËÃ×Íº´àÁç´ÂÒ
• ¡Ã³ÕµÍŒ §¡ÒÃËÂØ´ÂÒ¤ÇÃ¤‹ÍÂ æ Å´¢¹Ò´ÂÒÅ§ã¹ÃÐÂÐàÇÅÒÍÂ‹Ò§¹ŒÍÂ 1 à´×Í¹
• ÃÐ´ÑºÂÒã¹àÅ×Í´·ÕèÍÂÙ‹ã¹ª‹Ç§ÃÑ¡ÉÒ Bipolar disorder ¤×Í 50-125 mg/L
(ª‹Ç§ÃÑ¡ÉÒ Epilepsy ¤×Í 50-100 mg/L)
• ÃÐ´ÑºÂÒã¹Ã‹Ò§¡ÒÂ¨Ð¤§·Õè (Steady state) ËÅÑ§¨Ò¡ãËŒÂÒµ‹Íà¹×èÍ§ 3 ÇÑ¹
´Ñ§¹Ñé¹ ¤ÇÃà¨ÒÐÇÑ´ÃÐ´ÑºÂÒËÅÑ§¨Ò¡ä´ŒÃÑºÂÒ Valproate µ‹Íà¹×èÍ§ä»ÍÂ‹Ò§¹ŒÍÂ 3 ÇÑ¹
(·Ñé§¡Ã³ÕàÃÔèÁãªŒ¤ÃÑé§áÃ¡áÅÐ¡Ã³Õ»ÃÑºà»ÅÕèÂ¹¢¹Ò´ÂÒ)
• àÇÅÒ·ÕèàËÁÒÐÊÁã¹¡ÒÃà¨ÒÐÇÑ´ ¤×Í ¡‹Í¹ÃÑº»ÃÐ·Ò¹ÂÒÁ×éÍ¶Ñ´ä» Â¡àÇŒ¹ ¡Ã³Õ
Ê§ÊÑÂ Valproate toxicity ÊÒÁÒÃ¶à¨ÒÐÇÑ´àÇÅÒã´¡çä´Œ
Acute dose related
ÙúČęîĕÿš ĂćđÝĊ÷î ìšĂÜđÿĊ÷ - ĔĀšøĆïðøąìćîóøšĂöĂćĀćøĀøČĂĀúĆÜĂćĀćø
đïČęĂĂćĀćø ðüéìšĂÜ - ðøĆïĕðĔßš÷ćøĎðĒïï Controlled release (CR) tablets
- ĂćÝúé×îćé÷ćúÜÖŠĂîĒúąÙŠĂ÷ ė ðøĆïđóĉęö×îćé÷ćĂ÷ŠćÜßšć ė
ÜŠüÜîĂî đéĉîđà öČĂÿĆęî - ðøĆïĕðĔßš÷ćøĎðĒïï Controlled release (CR) tablets ĂćÝßŠü÷úé

ĂćÖćøĕéš
- ÖøèĊöĊĂćÖćøÿĆęîĂćÝóĉÝćøèćĔĀš÷ćÖúčŠö Beta-blocker đßŠî Propranolol
ĀøČĂ÷ćÖúčŠö Benzodiazepine đßŠî Diazepam
- ĀćÖöĊĂćÖćøøčîĒøÜ øïÖüîßĊüĉêðøąÝĞćüĆîĀøČĂđÿĊę÷ÜêŠĂĂčïĆêĉđĀêč Ùüøúé
×îćé÷ćĀøČĂĀ÷čé÷ć
- ÖøèĊđðŨîĂćÖćøĒÿéÜ×ĂÜ Valproate toxicity (óĉÝćøèćøąéĆï÷ćĔîđúČĂé
óïüŠćÿĎÜÖüŠćßŠüÜøĆÖþć) ÙüøðøĆïúé×îćé÷ćĀøČĂĀ÷čé÷ć
ÖøèĊñĎšðśü÷øĆïðøąìćî÷ć Valproate - ĂćÝóĉÝćøèćĔĀš Activated charcoal (1 ÖøĆö Activated charcoal

đÖĉî×îćéöć ÿćöćøëéĎéàĆï÷ć Valproate ĕéš 100-1,000 mg) àċęÜÝąöĊðøąÿĉìíĉõćó
ÿĎÜÿčéđöČęĂĔĀšõć÷Ĕî 0.5-1 ßĆęüēöÜ ĀúĆÜøĆïðøąìćî Valproate đÖĉî×îćé
Idiosyncratic
Thrombocytopenia - ĒÖšĕ×ēé÷Öćøúé×îćé÷ćĀøČĂĀ÷čé÷ć
Fatal hepatotoxicity - ĒÖšĕ×ēé÷ÖćøĀ÷čé÷ć

- đðŨî ADR øčîĒøÜ ĒêŠóïĕéšîšĂ÷
- ðŦÝÝĆ÷đÿĊę÷ÜÙČĂ đéĘÖĂć÷č < 2 ðŘ, ĕéšøĆï
÷ć antiepileptic Āúć÷øć÷Öćø,
Mental retardation
Hepatitis, đĂîĕàöŤêĆïđóĉęö×ċĚî - ĀćÖóïüŠć AST, ALT ÿĎÜ×ċĚîĕöŠöćÖ ÙüøêĉéêćöđòŜćøąüĆÜĂ÷ŠćÜêŠĂđîČęĂÜ

(ĂćÝđðŨîđóĊ÷ÜßĆęüÙøćü)
- ĀćÖóïüŠć AST, ALT ÿĎÜêŠĂđîČęĂÜĒúąÿĎÜÖüŠćÙŠćðÖêĉđÖĉî 3 đìŠć ÝĞćđðŨîêšĂÜ
Ā÷čé÷ć
Prancreatitis - Ā÷čé÷ć ĒúąĕöŠÙüøĔĀšàĚĞć đîČęĂÜÝćÖöĊøć÷ÜćîÖćøÖúĆïđðŨîàĚĞćĕéšÿĎÜ
đðŨî ADR øčîĒøÜ ĒêŠóïĕéšîšĂ÷
Menstrual disorder and PCOS - ĔĀš÷ćÙčöÖĞćđîĉéßîĉéøĆïðøąìćî, Cyclic progesterone, Metformin

(Polycystic ovaries)
Long term
Weight gain - ĒîąîĞćðøĆïóùêĉÖøøöÖćøøĆïðøąìćîĂćĀćøĒúąÖćøĂĂÖÖĞćúĆÜÖć÷
ÙüøøąöĆéøąüĆÜđöČęĂĔĀšøŠüöÖĆï - ĀćÖóïÙüćöđÿĊę ÷ ÜêŠ Ă ÖćøđÖĉ é ēøÙĒìøÖàš Ă îìĊę đ ðŨ î ñúöćÝćÖîĚĞ ć ĀîĆ Ö
ìĊęđóĉęö×ċĚî ĂćÝóĉÝćøèćđðúĊę÷îĕðĔßš÷ćĂČęî
Clozapine, Olanzapine, Lithium,
Carbamazepine TCAs, Mirtazapine
Alopecia - ĒîąîĞćñĎšðśü÷ĔĀšðäĉïĆêĉêĆüđóČęĂúéĂćÖćøñöøŠüÜ đßŠî ÖćøĔßšĒßöóĎÿøąñö

đÖĉéĔîđóýĀâĉÜöćÖÖüŠćđóýßć÷ ßîĉéĂŠĂî ĀúĊÖđúĊę÷ÜÖćøĀüĊñöĒøÜ ė ĀøČĂĀüĊñö×èąñöđðŘ÷Ö ĔßšĀüĊàĊęĀŠćÜ
ĀüĊñö ĀúĊÖđúĊę÷ÜÖćøĔßšÙüćöøšĂîÖĆïđÿšîñö
- úé×îćé÷ćĀćÖöĊñöøŠüÜöćÖĀøČĂñĎšðśü÷ÖĆÜüúÖĆïĂćÖćøéĆÜÖúŠćü ĂćÝĔĀš
ÿćøĂćĀćøđÿøĉöìĊęöĊ Zinc ĀøČĂ Selenium đóČęĂúéĂćÖćøñöøŠüÜĒúąÿøšćÜ
đÿšîñö×ċĚîöćĔĀöŠ
• ËŒÒÁãªŒã¹¼ÙŒ»†ÇÂ·ÕèÁÕ»ÃÐÇÑµÔá¾Œ Valproate
• ËŒÒÁãËŒã¹ severe AV block
• ËŒÒÁãËŒã¹¼ÙŒ»†ÇÂâÃ¤µÑº·ÕèÃØ¹áÃ§ äÁ‹á¹Ð¹íÒãËŒãªŒã¹¼ÙŒ»†ÇÂâÃ¤µÑº à¹×èÍ§¨Ò¡
¨ÐÁÕ¡ÒÃ¡íÒ¨Ñ´ÂÒ Valproate ÍÍ¡¨Ò¡Ã‹Ò§¡ÒÂÅ´Å§
• ¼ÙŒ»†ÇÂµÑé§¤ÃÃÀäµÃÁÒÊ·Õè 3 ¨ÐÁÕ¡ÒÃ¡íÒ¨Ñ´ÂÒ Valproate ÍÍ¡¨Ò¡Ã‹Ò§¡ÒÂ
Å´Å§ ´Ñ§¹Ñé¹¤ÇÃä´ŒÃÑº¡ÒÃ»ÃÑº¢¹Ò´ÂÒ
Drug interaction
• ÂÒ Valproate ÊÒÁÒÃ¶ÂÑºÂÑé§ CYP 2C9, 2C19 ´Ñ§¹Ñé¹ ÁÕ¼Å·íÒãËŒÃÐ´ÑºÂÒ
NSAIDs, Sulfonylurea, Diazepam, Warfarin à¾ÔèÁ¢Öé¹
• ÂÒ Valproate ÊÒÁÒÃ¶ÂÑºÂÑé§ UGTs ´Ñ§¹Ñé¹ ÁÕ¼Å·íÒãËŒÂÒ AZT, Morphine,
Lorazepam à¾ÔèÁ¢Öé¹ ÁÕ¼Å·íÒãËŒÂÒ Lamotrigine ¶Ù¡·íÒÅÒÂ¼‹Ò¹ CYP 450 à¾ÔèÁ¢Öé¹ «Öè§à¾ÔèÁ
¤ÇÒÁàÊÕèÂ§ã¹¡ÒÃà¡Ô´ Steven Johnson syndrome ¨Ò¡ Lamotrigine
• ÂÒÁÕ¤ÇÒÁÊÒÁÒÃ¶ã¹¡ÒÃ¨Ñºâ»ÃµÕ¹ä´ŒÊ§Ù àÁ×Íè ãËŒÃÇ‹ Á¡ÑºÂÒÍ×¹è ·ÕÁè ¡Õ ÒÃ¨Ñº¡Ñºâ»ÃµÕ¹
·ÕèµèíÒ¡Ç‹Ò¨ÐÊ‹§¼ÅãËŒ free drug ¢Í§ÂÒÍ×è¹à¾ÔèÁ¢Öé¹ä´Œ áµ‹àÁ×èÍãËŒÃ‹ÇÁ¡ÑºÂÒ·ÕèÁÕ¡ÒÃ¨Ñº¡Ñºâ»ÃµÕ¹
·ÕèÊÙ§¡Ç‹Ò àª‹¹Aspirin ¨ÐÊ‹§¼ÅãËŒ free drug ¢Í§ÂÒ Valproate à¾ÔèÁ¢Öé¹áÅÐàÊÕèÂ§µ‹Í¡ÒÃ
à¡Ô´ Valproate toxicity ä´Œ
Carbamazepine
à»š¹ÂÒ·Ò§àÅ×Í¡¡Ã³ÕäÁ‹µÍºÊ¹Í§µ‹Í¡ÒÃÃÑ¡ÉÒ´ŒÇÂ Lithium ËÃ×Í Valproate
ä´ŒÃÑº¡ÒÃÃÑºÃÍ§ãËŒãªŒã¹ Bipolar I disorder ª¹Ô´ acute manic áÅÐ mixed episode
áÁŒÃÙ»áººÂÒ·Õè US FDA ÃÑºÃÍ§ãËŒãªŒÃÑ¡ÉÒÀÒÇÐ mania ¤×Í Extended release áµ‹¡çÁÕ
¡ÒÃÈÖ¡ÉÒÇ‹ÒÃÙ»áºº Immediate release ¡çÁÕ»ÃÐÊÔ·¸ÔÀÒ¾ã¹ÀÒÇÐ mania àª‹¹¡Ñ¹
• ª‹ÇÂàÊÃÔÁ¡ÒÃ·íÒ§Ò¹¢Í§ GABA
• ÂÑ º ÂÑé § voltage-gated sodium channels ·í ÒãËŒ Å ´¡ÒÃ»Å´»Å‹ Í Â
Excitatory amino acid àª‹¹ glutamate
• ÂÑºÂÑé§ Calcium influx ¼‹Ò¹ NMDA receptor «Öè§à»š¹ glutamate receptor
·íÒãËŒ glutamate ·íÒ§Ò¹Å´Å§
• ¶Ù¡´Ù´«ÖÁä´Œ´Õã¹·Ò§à´Ô¹ÍÒËÒÃ
• ÃÐ´ÑºÂÒã¹àÅ×Í´ÊÙ§ÊØ´ËÅÑ§¡Ô¹ÂÒ 2-8 ªÑèÇâÁ§
• ¨Ñº¡Ñºâ»ÃµÕ¹ÃŒÍÂÅÐ 70-80
• ËÅÑ§¨Ò¡ Carbamazepine ¶Ù¡ metabolism ¨Ðä´Œà»š¹ active metabolite
«Öè§ÁÕÄ·¸Ôìã¹¡ÒÃÃÑ¡ÉÒàª‹¹¡Ñ¹
• ËÅÑ§ä´ŒÂÒä» 2-3 ÊÑ»´ÒË ÂÒ¨Ðä»¡ÃÐµØŒ¹ CYP 450 ·ÕèµÑº ·íÒãËŒÁÕ¡ÒÃ·íÒÅÒÂ
ÂÒà¾ÔèÁÁÒ¡¢Öé¹ (autoinduction) Ê‹§¼ÅãËŒ¤‹Ò¤ÃÖè§ªÕÇÔµ¢Í§ÂÒã¹ª‹Ç§áÃ¡ÁÒ¡¡Ç‹Òª‹Ç§ËÅÑ§
«Öè§ËÅÑ§ãªŒÂÒä» 3-5 ÊÑ»´ÒË ÂÒ¨Ðà¡Ô´ full autoinduction Ê‹§¼ÅãËŒÃÐ´ÑºÂÒã¹àÅ×Í´Å´Å§
à¢ŒÒÊÙ‹ÃÐ´Ñº¤§·Õè
• ¶Ù¡·íÒÅÒÂâ´Â CYP 3A4
• ¤‹Ò¤ÃÖè§ªÕÇÔµàÁ×èÍàÃÔèÁãªŒ¤×Í 15-30 ªÑèÇâÁ§ àÁ×èÍãªŒ chronic ¨ÐÅ´Å§à»š¹
10-15 ªÑèÇâÁ§ (ãËŒÇÑ¹ÅÐ 2 ¤ÃÑé§)
• Carbamazepine Immediate release tablets 200 mg
• Carbamazepine Controlled release (CR) tablets 200 mg
• àÃÔèÁãËŒã¹¢¹Ò´ 200-400 mg/day áº‹§ãËŒÇÑ¹ÅÐ 2 ¤ÃÑé§ ¾ÃŒÍÁÍÒËÒÃ
(·Ñé§ÃÙ»áºº Immediate áÅÐ Controlled release ) ÊÒÁÒÃ¶à¾ÔèÁä´Œ¤ÃÑé§ÅÐ 200 mg
·Ø¡ 2-4 ÇÑ¹ ¨¹¶Ö§ 10-15 mg/kg/day ¢¹Ò´ÊÙ§ÊØ´·Õèá¹Ð¹íÒ¤×Í 1,600 mg/d
• ¼ÙŒ»†ÇÂÊÙ§ÍÒÂØÁÕ¡ÒÃ¡íÒ¨Ñ´ÂÒÅ´Å§ ´Ñ§¹Ñé¹¤ÇÃä´ŒÃÑºã¹¢¹Ò´µèíÒ æ ¡‹Í¹áÅŒÇ
¤‹ÍÂ æ »ÃÑºà¾ÔèÁ¢¹Ò´ÂÒ
• ¼ÙŒ»†ÇÂâÃ¤äµ äÁ‹¨Òí à»š¹µŒÍ§»ÃÑº¢¹Ò´ÂÒ ¡Ã³Õ¼ÙŒ»†ÇÂ GFR < 10 ml/min ËÃ×Í
Hemodialysis, Peritoneal dialysis ÍÒ¨¾Ô¨ÒÃ³ÒãËŒà»š¹ 75% ¢Í§¢¹Ò´»¡µÔ
• Carbamazepine Controlled release tablets ËŒÒÁº´ËÃ×Íà¤ÕéÂÇ
• ËÒ¡µŒÍ§¡ÒÃËÂØ´ÂÒ¤ÇÃ¤‹ÍÂ æ »ÃÑºÅ´¢¹Ò´ÂÒÍÂ‹Ò§ªŒÒ æ ÍÂ‹Ò§¹ŒÍÂ 1 à´×Í¹
• ã¹¡ÒÃàÃÔèÁãªŒÂÒ Carbamazepine ·Ø¡¤ÃÑé§¤ÇÃ¤‹ÍÂ æ ãËŒã¹¢¹Ò´µèíÒ¡‹Í¹ áÁŒ
¼Ù»Œ Ç† Â¨Ðà¤Âä´ŒÃºÑ ÂÒ Carbamazepine ã¹¢¹Ò´·ÕÊè §Ù ÁÒ¡‹Í¹áÅŒÇ¡çµÒÁ à¾ÃÒÐËÒ¡ãËŒã¹¢¹Ò´
ÊÙ§à·‹Òà´ÔÁµÑé§áµ‹ª‹Ç§áÃ¡ (ÂÑ§äÁ‹¼‹Ò¹ª‹Ç§ full autoinduction) ÍÒ¨·íÒãËŒÃÐ´ÑºÂÒã¹àÅ×Í´ÊÙ§
¢Öé¹¨¹¶Ö§ÃÐ´Ñºà»š¹¾ÔÉä´Œ
• ÃÐ´ÑºÂÒã¹àÅ×Í´·ÕèÍÂÙ‹ã¹ª‹Ç§ÃÑ¡ÉÒ Bipolar disorder ¤×Í 4-12 mg/L
• ÃÐ´ÑºÂÒã¹Ã‹Ò§¡ÒÂ¨Ð¤§·Õè (Steady state) ËÅÑ§¨Ò¡àÃÔÁè ãËŒÂÒ¤ÃÑ§é áÃ¡»ÃÐÁÒ³
3 ÊÑ»´ÒË ´Ñ§¹Ñé¹ ¤ÇÃà¨ÒÐÇÑ´ÃÐ´ÑºÂÒËÅÑ§¨Ò¡ä´ŒÃÑºÂÒ Carbamazepine µ‹Íà¹×èÍ§ä»ÍÂ‹Ò§
¹ŒÍÂ 3 ÊÑ»´ÒË
• ÃÐ´ÑºÂÒã¹Ã‹Ò§¡ÒÂ¨Ð¤§·Õè (Steady state) ËÅÑ§¨Ò¡»ÃÑº¢¹Ò´ÂÒä» 7 ÇÑ¹ ´Ñ§
¹Ñé¹ ¤ÇÃà¨ÒÐÇÑ´ÃÐ´ÑºÂÒËÅÑ§¨Ò¡»ÃÑº¢¹Ò´ÂÒ Carbamazepine ä»ÍÂ‹Ò§¹ŒÍÂ 7 ÇÑ¹
• àÇÅÒ·ÕèàËÁÒÐÊÁã¹¡ÒÃà¨ÒÐÇÑ´ ¤×Í ¡‹Í¹ÃÑº»ÃÐ·Ò¹ÂÒÁ×éÍ¶Ñ´ä» Â¡àÇŒ¹ ¡Ã³Õ
Ê§ÊÑÂ Carbamazepine toxicity ÊÒÁÒÃ¶à¨ÒÐÇÑ´àÇÅÒã´¡çä´Œ
Dose related
ÙúČęîĕÿš ĂćđÝĊ÷î - ĔĀšøĆïðøąìćîóøšĂöĂćĀćøĀøČĂĀúĆÜĂćĀćø
- óïïŠ Ă ÷ĔîßŠ ü ÜĒøÖ×ĂÜÖćøøĆ Ö þć đðŨ î ñú - ĂćÝĒïŠÜĔĀšĀúć÷öČĚĂđóČęĂúéĂćÖćø×šćÜđÙĊ÷Ü
ÝćÖÖćøđóĉęö×îćé÷ćđøĘüĕð - ĂćÝúé×îćé÷ćúÜÖŠ Ă îĒúąÙŠ Ă ÷ ė ðøĆ ï đóĉę ö ×îćé÷ć
Ă÷ŠćÜßšć ė
ÜŠüÜàċö đéĉîđà đĀĘîõćóàšĂî êćóøŠć - ÖøèĊđÖĉéÝćÖÖćøđóĉęö×îćé÷ćĂ÷ŠćÜøüéđøĘü ÙüøĒÖšēé÷úé
- ÿĆöóĆîíŤÖĆï×îćé÷ćìĊęÿĎÜ ĀøČĂđóĉęö×îćé÷ć ×îćé÷ćúÜÖŠĂîĒúąÙŠĂ÷ ė ðøĆïđóĉęö×îćé÷ćĂ÷ŠćÜßšć ė
Ă÷ŠćÜøüéđøĘü - ÖøèĊđðŨîĂćÖćøĒÿéÜ×ĂÜ Carbamazepine toxicity
- ĂćÝóïĂćÖćøÿĆïÿîĔîñĎšðśü÷ÿĎÜĂć÷č ñĎšðśü÷ìĊę (óĉÝćøèćøąéĆï÷ćĔîđúČĂéóïüŠćÿĎÜÖüŠćßŠüÜøĆÖþć) Ùüø
öĊÙüćöñĉéðÖêĉìćÜÿöĂÜ ēé÷đÞóćąĀćÖĔßš ðøĆïúé×îćé÷ćĀøČĂĀ÷čé÷ć
øŠüöÖĆï÷ć Lithium, Antipsychotic
ÖøèĊñĎšðśü÷øĆïðøąìćî÷ć Carbamazepine đÖĉî - ĂćÝóĉÝćøèćìĞć gastric larvage

×îćéöć - ĔĀš Activated charcoal 10-100 mg ĔîÙøĆĚÜĒøÖ Ēúą
êŠĂĕðĔĀš 12.5 mg/hr ÝîÖüŠćĂćÖćøìĊęĕéšøĆï÷ćđÖĉî×îćéÝą
Āöéĕð
Idiosyncratic
Steven johnson syndrome - Ā÷čé÷ćìĆîìĊ ĒúąĔĀšÖćøøĆÖþćêćöĂćÖćø
- đðŨîĂćÖćøĒóš÷ćìĊęøčîĒøÜ
- prevalence rate ĔîÙîĕì÷ÙČĂ 0.27%
ĔîÙîđĂđßĊ÷ ðøąöćè 7%
Anticonvulsant hypersensitivity - Ā÷čé÷ćìĆîìĊ ĒúąĔĀšÖćøøĆÖþćêćöĂćÖćø đßŠî ĔĀšÿćøîĚĞć,

syndrome (AHS) ĀøČĂ Drug eruption with Antihistamine, Topical steroids ĀćÖĂćÖćøđðŨî
eosinophilia and systemic symptoms øčîĒøÜĀøČĂöĊ systemic involve ĂćÝĔĀš Steroids
(DRESS) syndrome ĔîøĎðĒïïøĆïðøąìćîĀøČĂÞĊé
- Mortality rate 50% - ĂćÖćøĕ×šĂćÝÙÜĂ÷ĎŠĀúć÷ÿĆðéćĀŤĀúĆÜĀ÷čé÷ć
- øą÷ąđüúćĔîÖćøđÖĉé : 1-12 ÿĆðéćĀŤ ĀúĆÜ - đðŨîĂćÖćøĒóš÷ćìĊęøčîĒøÜÝċÜĕöŠÙüøĔĀš÷ćàĚĞćĂĊÖ
ĕéšøĆï÷ć - ÷ćìĊęöĊÿĎêøēÙøÜÿøšćÜÙúšć÷ÖĆîÿćöćøëĒóš×šćöÖĆîĕéš
- ĂćÖćøĒÿéÜìĊęÿĞćÙĆâ : 3 ĂćÖćøĀúĆÖ ĕéšĒÖŠ (÷ćÖĆîßĆÖìĊęöĊēÙøÜÿøšćÜđðŨî aromatic ring đßŠî
ĕ×š, ñČęîñĉüĀîĆÜ, ĂćÖćøàċęÜĒÿéÜÙüćöñĉéðÖêĉ Carbamazepine, Phenytoin, Phenobarbital àċęÜöĊ
×ĂÜĂüĆ÷üąõć÷Ĕî (êŠĂöîĚĞćđĀúČĂÜēêóïĕéš ēĂÖćÿĒóš×šćöÖĆîĕéš)
ïŠĂ÷ìĊęÿčé)
Bone marrow suppression - Leukopenia óïĕéšïŠĂ÷ĒêŠĕöŠøčîĒøÜ ĕöŠöĊÙüćöÿĞćÙĆâ
- ÙüćöđÿĊę ÷ ÜĂćÝđóĉę ö ×ċĚ î đöČę Ă ĔĀš øŠ ü öÖĆ ï ìćÜÙúĉîĉÖ
Clozapine - Agranulocytosis ĀøČĂ aplastic anemia đðŨîĂćÖćø
×šćÜđÙĊ÷ÜìĊęóïîšĂ÷öćÖ ĒêŠøčîĒøÜëċÜßĊüĉêĕéš éĆÜîĆĚîÙüø
ĕéšøĆïÖćøêĉéêćö CBC ĀćÖóïÙüøĕéšøĆïÖćøĀ÷čé÷ć
- Thrombocytopenia öĆÖđÖĉéßĆęüÙøćü
Hepatitis, đĂîĕàöŤêĆïđóĉęö×ċĚî - ĀćÖóïüŠć AST, ALT ÿĎÜ×ċĚîĕöŠöćÖ ÙüøêĉéêćöđòŜćøąüĆÜ

Ă÷ŠćÜêŠĂđîČęĂÜ (ĂćÝđðŨîđóĊ÷ÜßĆęüÙøćü)
- ĀćÖóïüŠć AST, ALT ÿĎÜêŠĂđîČęĂÜĒúąÿĎÜÖüŠćÙŠćðÖêĉđÖĉî
3 đìŠć ÝĞćđðŨîêšĂÜĀ÷čé÷ć
Hyponatremia, SIADH - Ā÷čé÷ć Carbamazepine

- ĀćÖđÖĉéõćüąîĊĚĔî×èąìĊęĕéšøĆï÷ć Lithium - ÝĞćÖĆéîĚĞćĒúąĔĀšēàđéĊ÷öÙúĂĕøéŤìćÜĀúĂéđúČĂééĞć
ÙüøđòŜćøąüĆÜ Lithium intoxication - ĂćÝĔĀš÷ć Furosemide øŠüöéšü÷
• ËŒÒÁãªŒã¹¼ÙŒ»†ÇÂ·ÕèÁÕ»ÃÐÇÑµÔá¾Œ Carbamazepine
• ËŒÒÁãªŒã¹ severe AV block
• ËŒÒÁãËŒã¹âÃ¤µÑº·ÕèÃØ¹áÃ§ ãªŒÍÂ‹Ò§ÃÐÁÑ´ÃÐÇÑ§ã¹¼ÙŒ»†ÇÂâÃ¤µÑº
• ËŒÒÁãªŒã¹¼ÙŒ»†ÇÂ·ÕèÁÕ»ÃÐÇÑµÔá¾ŒÂÒ¡ÅØ‹Á TCA à¹×èÍ§¨Ò¡ÂÒÁÕâ¤Ã§ÊÃŒÒ§
àËÁ×Í¹ÂÒ¡ÅØ‹Á TCA
• ¼ÙŒ»†ÇÂµÑé§¤ÃÃÀäµÃÁÒÊ·Õè 3 ¡ÒÃ¡íÒ¨Ñ´ÂÒ¨ÐÅ´Å§ ÍÒ¨µŒÍ§ÁÕ¡ÒÃ»ÃÑº
¢¹Ò´ÂÒ
• ËŒ Ò ÁãªŒ Ã‹ Ç Á¡Ñ º MAOI (ËÃ× Í ÀÒÂã¹ 14 ÇÑ ¹ ËÅÑ § ËÂØ ´ MAOI),
Nefazodone, Delavirdine, ÂÒ¡ÅØ‹Á Non-nucleoside reverse transcriptase
inhibitors
Drug interaction
• Carbamazepine à»š¹ CYP 3A4, 2C9, 2C19, 1A2, UGTs
inducer ´Ñ§¹Ñé¹ÍÒ¨·íÒãËŒÃÐ´ÑºÂÒµ‹Íä»¹ÕéµèíÒÅ§
Alprazolam, Amitriptyline, Aripiprazole, Clomipramine, Clonazepam,
Clozapine, Fluphenazine, Haloperidol, Hormonal contraceptives, Imipramine
Lamotrigine, Olanzapine, Paracetamol, Phenytoin, Prednisolone,
Quetiapine, Simvastatin, Theophylline, Valproate, Warfarin
• Carbamazepine ÍÒ¨·í ÒãËŒ Ã Ð´Ñ º ÂÒ Clozapine, Lithium,
Clomipramine, Phenytoin, Mirtazapine à¾ÔèÁ¢Öé¹
• Carbamazepine ¶Ù¡·íÒÅÒÂâ´Â CYP 3A4 ´Ñ§¹Ñé¹ Carbamazepine
ÍÒ¨ÁÕ Ã Ð´Ñ º Å´Å§àÁ×è ÍãËŒ Ã‹ Ç Á¡Ñ º CYP 3A4 inducer àª‹ ¹ Phenytoin,
Phenobarbital, Rifampin, Theophylline
• Carbamazepine ¶Ù¡·íÒÅÒÂâ´Â CYP 3A4 ´Ñ§¹Ñé¹ Carbamazepine
ÍÒ¨ÁÕÃÐ´Ñºà¾ÔÁè ¢Ö¹é àÁ×Íè ãËŒÃÇ‹ Á¡Ñº CYP 3A4 inhibitor àª‹¹ Allopurinol, Cimetidine,
Clarithromycin, Diltiazem, Erythromycin, Fluoxetine, Fluvoxamine,
Isoniazid, Ketoconazole, Lamotrigine, Loratadine, Verapamil
Lamotrigine
ÁÕ»ÃÐÊÔ·¸ÔÀÒ¾ã¹¡ÒÃ»‡Í§¡Ñ¹ Bipolar depression Ê‹Ç¹»ÃÐÊÔ·¸ÔÀÒ¾ã¹
¡ÒÃ»‡Í§¡Ñ¹ Bipolar mania äÁ‹´Õ¹Ñ¡
• ÂÑºÂÑé§ voltage sensitive sodium current ·íÒãËŒà¡Ô´ stabilizing
neuronal membranes
• Å´¡ÒÃËÅÑè§ excitatory amino acids àª‹¹ glutamate, aspartate
• 5-HT1A agonist
• ÂÒ¶Ù¡´Ù´«ÖÁÍÂ‹Ò§ÃÇ´àÃçÇáÅÐÊÁºÙÃ³ã¹·Ò§à´Ô¹ÍÒËÒÃ
• ¨Ñº¡Ñºâ»ÃµÕ¹ 55%
• ÂÒ¶Ù¡·íÒÅÒÂ·ÕèµÑºâ´Â¼‹Ò¹ glucuronide conjugation (UGTs)
• ¤‹Ò¤ÃÖè§ªÕÇÔµ
- ã¹¼ÙŒãËÞ‹ : 25-33 ªÑèÇâÁ§
- ã¹¼ÙŒÊÙ§ÍÒÂØ : 25-43 ªÑèÇâÁ§
- ¡Ã³Õä´ŒÃÑºÃ‹ÇÁ¡Ñº Valproate ¤‹Ò¤ÃÖè§ªÕÇÔµà»š¹ 48-70 ªÑèÇâÁ§
- ¡Ã³Õä´ŒÃÑºÃ‹ÇÁ¡Ñº Phenytoin, Phenobarbital, Carbamazepine ¤‹Ò
¤ÃÖè§ªÕÇÔµà»š¹ 13-14 ªÑèÇâÁ§
• Lamotrigine tablet ¢¹Ò´ 25, 100 mg
µÒÃÒ§·Õè 24 áÊ´§¢¹Ò´ÂÒ¢Í§ Lamotrigine
ÖøèĊĕöŠĕéš ÖøèĊĕéš
ÿĆðéćĀŤìĊęĔĀš÷ć ÖøèĊĕéš VPA øŠüö
VPA, CBZ, PHT, PHB øŠüö CBZ, PHT, PHB øŠüö
ÿĆðéćĀŤ 1-2 25 mg/day 25 mg üĆîđüšîüĆî 50 mg/day
ÿĆðéćĀŤ 3-4 50 mg/day 25 mg/day 50 mg bid
ÿĆðéćĀŤ 5 100 mg/day 50 mg/day 100 mg bid
ÿĆðéćĀŤ 6 200 mg/day 100 mg/day 150 mg bid
ÿĆðéćĀŤ 7 200 mg/day 100 mg/day ĔĀšĕéšëċÜ 200 mg bid
đðŨîêšîĕð
VPA = Valproate, CBZ = Carbamazepine, PHT = Phenytoin, PHB = Phenobarbital
¡Ã³ÕµŒÍ§¡ÒÃËÂØ´ÂÒ¤ÇÃ¤‹ÍÂ æ Å´¢¹Ò´Å§ÊÑ»´ÒËÅÐ 50% ãªŒÃÐÂÐàÇÅÒÍÂ‹Ò§¹ŒÍÂ 2 ÊÑ»´ÒË
• »Ç´ÈÕÃÉÐ : ¾ºº‹ÍÂ ÁÑ¡à»š¹ªÑèÇ¤ÃÒÇã¹ª‹Ç§áÃ¡¢Í§¡ÒÃãªŒÂÒËÃ×Í»ÃÑº
à¾ÔèÁ¢¹Ò´ÂÒ
• §‹Ç§¹Í¹ ÁÖ¹§§ ÁÍ§ÀÒ¾«ŒÍ¹ «Öè§ÍÒ¡ÒÃàËÅ‹Ò¹Õé à»š¹ÍÒ¡ÒÃ¢ŒÒ§à¤ÕÂ§·Õè
¾ºä´Œº‹ÍÂ áµ‹ÁÑ¡à»š¹ªÑèÇ¤ÃÒÇ ¢Öé¹¡Ñº¢¹Ò´ÂÒ ¨Ðà¡Ô´ÁÒ¡¢Öé¹àÁ×èÍä´ŒÃÑºÃ‹ÇÁ¡Ñº
Carbamazepine
• Steven Johnson Syndrome (SJS) à»š¹ÍÒ¡ÒÃá¾ŒÂÒ·Õè¾ºäÁ‹º‹ÍÂáµ‹
ÃØ¹áÃ§ ¤ÇÒÁàÊÕÂè §´Ñ§¡Å‹ÒÇ¨ÐÁÒ¡¢Ö¹é àÁ×Íè ä´ŒÃºÑ ¡ÒÃ»ÃÑºà¾ÔÁè ÂÒÍÂ‹Ò§ÃÇ´àÃçÇËÃ×Íä´ŒÃºÑ
Ã‹ÇÁ¡ÑºÂÒ Valproate ËÒ¡¾º SJS ¤ÇÃËÂØ´ÂÒ·Ñ¹·Õ
• ËŒÒÁãªŒã¹¼ÙŒ»†ÇÂ·ÕèÁÕ»ÃÐÇÑµÔá¾Œ Lamotrigine
• ÃÐÇÑ§¡ÒÃãªŒã¹¼Ù»Œ Ç† Â·ÕÁè »Õ ÃÐÇÑµáÔ ¾Œ aromatic antiepileptic drugs àª‹¹
Phenytoin, Phenobarbital, Carbamazepine (à¹×èÍ§¨Ò¡ÁÕºÒ§ÃÒÂ§Ò¹¾º Cross
hypersensitivity)
Drug interaction
• ÂÒ Lamotrigine ¨ÐÁÕÃÐ´Ñºà¾ÔèÁ¢Öé¹àÁ×èÍãËŒÃ‹ÇÁ¡ÑºÂÒ Valproate
• ÂÒ Lamotrigine ¨ÐÁÕÃÐ´ÑºÅ´Å§àÁ×èÍãËŒÃ‹ÇÁ¡ÑºÂÒ Carbamazepine,
Contraceptives (estrogens), Phenobarbital, Phenytoin, Rifampin
Dana WJ, Fuller MA, Goldman MP, Golembiewski JA, Gonzales JP,
Lowe JF, et al. Drug information handbook with international
trade names index. 22 nd ed. Lexi comp; 2013-2014.
Dipiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM.
Pharmacotherapy: A pathophysiologic approach. 7th ed.
New York: McGraw-Hill; 2005: 1099-1122.
Taylor D, Paton C, Kapur S. Prescribing Guidelines in Psychiatry.
11th ed. Wiley-Blackwell; 2012.
ÁÒâ¹ª ËÅ‹ÍµÃÐ¡ÙÅ, »ÃÒâÁ·Â ÊØ¤¹ÔªÂ. ¨ÔµàÇªÈÒÊµÃÃÒÁÒ¸Ôº´Õ (àÃÕÂºàÃÕÂ§ãËÁ‹).
¾ÔÁ¾¤ÃÑé§·Õè 2. ¡ÃØ§à·¾ÁËÒ¹¤Ã: ÀÒ¤ÇÔªÒ¨ÔµàÇªÈÒÊµÃ
¤³Ðá¾·ÂÈÒÊµÃâÃ§¾ÂÒºÒÅÃÒÁÒ¸Ôº´Õ ÁËÒÇÔ·ÂÒÅÑÂÁËÔ´Å; 2548.
¸ÇÑªªÑÂ ÅÕÌËÒ¹Ò¨, ÊÃÂØ·¸ ÇÒÊÔ¡¹Ò¹¹·. µíÒÃÒâÃ¤äºâ¾ÅÒÃ (Textbook of
Bipolar disorder). ¡ÃØ§à·¾ÁËÒ¹¤Ã: ÊÁÒ¤Á¨Ôµá¾·ÂáË‹§»ÃÐà·Èä·Â;
2549.
¨Ñ¹·ÔÁÒ âÂ¸Ò¾Ô·Ñ¡É, »ÃÒâÁ·Â µÃÐ¡ÙÅà¾ÕÂÃ¡Ô¨. µÃ§»ÃÐà´ç¹...àÃ×èÍ§ Adverse
drug reaction 2 ¡ÒÃ»ÃÐàÁÔ¹¼×¹è á¾ŒÂÒ. ¾ÔÁ¾¤ÃÑ§é ·Õè 2. ¡ÃØ§à·¾ÁËÒ¹¤Ã:
»ÃÁÑµ¶¡ÒÃ¾ÔÁ¾; 2551.
Lamictal [package insert]. Research Triangle Park,
NC: GlaxoSmithKline; 2012.
Graylands Hospital. Lithium induced hypothyroidism.
Drug bulletin 2003;11(3).
Timmer RT, Sands JM. Lithium Intoxication. J Am Soc
Nephrol 1999;10:666-74.
Drugs to Treat Extrapyramidal Side Effects
Antiparkinson Drugs
Extrapyramidal side effects (EPS) áº‹§ÍÍ¡à»š¹

1. Acute dystonia à¡Ô´¨Ò¡¡ÅŒÒÁà¹×éÍºÔ´à¡Ãç§à»š¹¾Ñ¡ æ ÍÂ‹Ò§ÃØ¹áÃ§¨¹
¼ÙŒ»†ÇÂºÒ§¤¹à¢ŒÒã¨Ç‹Òà»š¹¡ÒÃªÑ¡ ÁÑ¡à¡Ô´¡Ñº¡ÅŒÒÁà¹×éÍ·ÕèµÒ (oculogyric crisis) ·Õè
¤Í (torticollis)
2. Akathisia ¤×Í ¤ÇÒÁÃÙÊŒ ¡Ö ¡ÃÐÇ¹¡ÃÐÇÒÂ·Ñ§é ã¹ã¨áÅÐ¡ÅŒÒÁà¹×Íé ·Õ¢è ÒáÅÐ
á¢¹ ·íÒãËŒµŒÍ§¼Ø´ÅØ¡¼Ø´¹Ñè§ à´Ô¹ä»ÁÒ ÂèíÒà·ŒÒ ÊÑè¹¢Òá¢¹ ºÒ§¤¹¶Ö§¡Ñº¾ÂÒÂÒÁ
·íÒÃŒÒÂµ¹àÍ§¨Ò¡¤ÇÒÁ¡ÃÐÇ¹¡ÃÐÇÒÂ¹Õé ¼Å¢ŒÒ§à¤ÕÂ§ 2 ª¹Ô´¹Õé à¡Ô´¢Öé¹ä´Œã¹ª‹Ç§
äÁ‹¡ÕèÇÑ¹áÃ¡¢Í§¡ÒÃä´ŒÂÒ
3. Parkinsonism à»š¹ÍÒ¡ÒÃà´Ô¹µÑÇá¢ç§ æ ¡ÅŒÒÁà¹×éÍá¢ç§ Á×ÍÊÑè¹
¡ŒÒÇà´Ô¹ÊÑé¹ æ Ë¹ŒÒµÒà©ÂàÁÂ ¡Å×¹¹éíÒÅÒÂÅíÒºÒ¡ ÁÑ¡à¡Ô´ã¹ª‹Ç§ 2-3 ÊÑ»´ÒËáÃ¡
¢Í§¡ÒÃä´ŒÂÒ
4. Tardive dyskinesia à»š¹¡ÒÃ¢ÂÑº¢Í§¡ÅŒÒÁà¹×Íé ·Õ¤è Çº¤ØÁäÁ‹ä´Œ·ºÕè ÃÔàÇ³
»Ò¡ ÅÔé¹ ãºË¹ŒÒ á¢¹¢ÒËÃ×ÍÅíÒµÑÇ ÁÑ¡à¡Ô´ËÅÑ§¨Ò¡ä´ŒÂÒã¹ÃÐÂÐÂÒÇ¡Ç‹Ò 6 à´×Í¹
áÅÐÍØºÑµÔ¡ÒÃ³¨ÐÊÙ§¢Öé¹àÃ×èÍÂ æ »ÃÐÁÒ³ÃŒÍÂÅÐ 3-5 µ‹Í»‚ ËÒ¡ÂÑ§¤§ä´ŒÃÑºÂÒÍÂÙ‹
5. Neuroleptic malignant syndrome ¤×Í ¡ÒÃ·Õ¡è ÅŒÒÁà¹×Íé á¢ç§à¡Ãç§ÍÂ‹Ò§
ÃØ¹áÃ§µ‹Íà¹×èÍ§¡Ñ¹à»š¹àÇÅÒ¹Ò¹ ÁÕ autonomic nervous system ÅŒÁàËÅÇ ä´Œá¡‹
ªÕ¾¨ÃàÃçÇËÃ×ÍªŒÒ ÁÕä¢ŒÊÙ§ ¤ÇÒÁ´Ñ¹âÅËÔµà»ÅÕèÂ¹á»Å§ áÅÐÁÕÃÐ´Ñº¤ÇÒÁÃÙŒÊÖ¡µÑÇàÅÇÅ§
ÍØºÑµÔ¡ÒÃ³»ÃÐÁÒ³ÃŒÍÂÅÐ 0.1 «Öè§ÁÕÍÑµÃÒ¡ÒÃàÊÕÂªÕÇÔµÊÙ§ÃÒÇ ÃŒÍÂÅÐ 10-20
¡ÒÃÃÑ¡ÉÒ Extrapyramidal side effects

Anticholinergic drugs à»š¹ÂÒ¡ÅØ‹Á·ÕèÊÒÁÒÃ¶ÃÑ¡ÉÒ EPS ä´Œ´Õ·Ø¡ª¹Ô´
Â¡àÇŒ¹à¾ÕÂ§ akathisia ·Õè Propranolol áÅÐ Benzodiazepine ä´Œ¼Å´Õ¡Ç‹Ò ·Ñé§¹Õé
äÁ‹Á¤Õ ÇÒÁ¨íÒà»š¹·Õ¨è ÐãËŒ Anticholinergic drugs ¡Ñº¼Ù·Œ äÕè ´ŒÂÒÃÑ¡ÉÒâÃ¤¨Ôµ·Ø¡ÃÒÂà¾×Íè
»‡Í§¡Ñ¹ EPS Â¡àÇŒ¹ ¼ÙŒ·ÕèàÊÕèÂ§µ‹Í¡ÒÃà¡Ô´ EPS àª‹¹ ¼ÙŒ»†ÇÂªÒÂ·ÕèÍÒÂØäÁ‹ÁÒ¡ à´ç¡
ËÃ×Í¼ÙŒ·ÕèÁÕ¾ÂÒ¸ÔÊÀÒ¾·Ò§ÊÁÍ§
ËÒ¡¼ÙŒ»†ÇÂÁÕÍÒ¡ÒÃ acute dystonia ¤ÇÃ©Õ´ Benztropine (Cogentin®)
1-2 Á¡. IM ËÃ×Í IV ËÃ×Í Diphenhydramine (Benadryl®) 50 Á¡. IV ËÃ×Í
Diazepam 5-10 Á¡. IV ÊÒÁÒÃ¶·íÒãËŒ¼ÙŒ»†ÇÂËÒÂ¨Ò¡ÍÒ¡ÒÃä´Œã¹ 15 ¹Ò·Õ
Ê‹Ç¹ÍÒ¡ÒÃ Parkinsonism ¹Ñé¹ ÊÒÁÒÃ¶ÃÑ¡ÉÒä´Œ´ŒÇÂÂÒ¡ÅØ‹Á¹Õé´ŒÇÂ¢¹Ò´ÂÒ´Ñ§áÊ´§
ã¹µÒÃÒ§ ÍÒ¨ãËŒÂÒ¹Ò¹ 4-8 ÊÑ»´ÒË áÅŒÇ»ÃÐàÁÔ¹ÍÕ¡¤ÃÑé§Ç‹ÒÂÑ§¨íÒà»š¹µŒÍ§ä´ŒÂÒÍÕ¡
ËÃ×ÍäÁ‹ ËÒ¡äÁ‹¨íÒà»š¹¤ÇÃÅ´ÂÒÅ§¨¹ËÁ´ã¹ 2 ÊÑ»´ÒË à¹×èÍ§¨Ò¡ÂÒÁÕÄ·¸Ôì
anticholinergic ¨Ö§ÁÕ¼Å¢ŒÒ§à¤ÕÂ§ä´Œá¡‹ »Ò¡¤ÍáËŒ§ ·ŒÍ§¼Ù¡ µÒ¾Ã‹Ò »˜ÊÊÒÇÐÅíÒºÒ¡
ªÕ¾¨ÃàÃçÇ áÅÐÍÒ¨·íÒãËŒà¡Ô´ delirium ËÃ×Í·íÒãËŒÍÒ¡ÒÃ dementia áÂ‹Å§ ¹Í¡¨Ò¡
¹Õé ¼ÙŒ»†ÇÂºÒ§ÃÒÂÍÒ¨µÔ´¡ÑºÄ·¸Ôì·Õè·íÒãËŒÊºÒÂã¨ÍÂ‹Ò§Í‹Í¹ æ ¢Í§ÂÒ
µÒÃÒ§·Õè 25 áÊ´§ Pharmacological agents for the treatment of

neuroleptic-induced parkinsonism and acute dystonic reactions
ADHD (Attention-deficit/hyperactivity disorder)
à»š¹¤ÇÒÁ¼Ô´»¡µÔ·Ò§¨ÔµËÃ×Í¾ÄµÔ¡ÃÃÁª¹Ô´Ë¹Öè§·Õè»ÃÐ¡Íº´ŒÇÂ ÍÒ¡ÒÃ¢Ò´
ÊÁÒ¸ÔËÃ×ÍÊÁÒ¸ÔäÁ‹¨´¨‹Í (Inattentive type) áÅÐ/ËÃ×Í äÁ‹ÍÂÙ‹¹Ôè§ (Hyperactive
type) ¤ÇÒÁªØ¡¢Í§âÃ¤ ADHD ÇÑÂà´ç¡ 4-12% áÅÐ¢Í§¼ÙŒãËÞ‹ 4% à´ç¡·Õè»†ÇÂÍÂ‹Ò§
¹ŒÍÂ 25% ¨ÐÂÑ§ÁÕÍÒ¡ÒÃà¨çº»†ÇÂ·ÕèÍÒÂØ 30 »‚ â´Â¾Ñ¹¸Ø¡ÃÃÁà»š¹»˜¨¨ÑÂàÊÕèÂ§·ÕèÊíÒ¤ÑÞ
ÍØºÑµÔ¡ÒÃ³ã¹¾Õè¹ŒÍ§ÊÙ§¶Ö§ 25% à´ç¡·Õèà»š¹âÃ¤¹Õé¨ÐáÊ´§ÍÒ¡ÒÃµÑé§áµ‹ÍÒÂØ¡‹Í¹ 7 »‚
¡ÒÃÇÔ¹Ô¨©ÑÂâÃ¤ ADHD ¨ÐµŒÍ§»ÃÐàÁÔ¹ã¹ËÅÒÂ æ ´ŒÒ¹ â´Â¼ÙŒàªÕèÂÇªÒÞà©¾ÒÐ â´Â
·ÑèÇä»¨Ðà»š¹á¾·Â·Õè¨º·Ò§´ŒÒ¹¨ÔµàÇªà´ç¡ ËÃ×Í á¾·Âà´ç¡·Õè¼‹Ò¹¡ÒÃ½ƒ¡½¹ã¹àÃ×èÍ§
âÃ¤ ADHD
ÍÒ¡ÒÃ¢Í§¾Ç¡·Õè¢Ò´ÊÁÒ¸Ô ËÃ×ÍÊÁÒ¸ÔäÁ‹¨´¨‹Í
à´ç¡ - ¢Ò´ÊÁÒ¸Ô ËÃ×ÍÊÁÒ¸ÔäÁ‹ÍÂÙ‹¡ÑºµÑÇ ·íÒ¢Í§ËÒÂº‹ÍÂ ·íÒ§Ò¹äÁ‹àÊÃç¨
äÁ‹ÊÒÁÒÃ¶ÇÒ§á¼¹¨Ñ´¡ÒÃ§Ò¹ä´Œ
¼ÙãŒ ËÞ‹ - ÁÕÅ¡Ñ É³Ð·íÒ§Ò¹äÁ‹àÊÃç¨µÒÁàÇÅÒ ºÃÔËÒÃàÇÅÒäÁ‹à»š¹ »ÃÐÊÔ·¸ÔÀÒ¾
ã¹¡ÒÃ·íÒ§Ò¹µèíÒ ÍÖ´ÍÑ´ äÁ‹à»š¹ÊØ¢ ÃÙŒÊÖ¡äÁ‹ä´Œ´Ñè§ã¨
ÍÒ¡ÒÃ¢Í§¾Ç¡·ÕèäÁ‹ÍÂÙ‹¹Ôè§
à´ç¡ - ÍÂÙ‹äÁ‹ÊØ¢ ÍÂÙ‹äÁ‹¹Ôè§ ÇÔè§ÇØ‹¹ »‚¹»†ÒÂã¹ËŒÍ§àÃÕÂ¹ ÊÍ´á·Ã¡áÂ‹§¾Ù´
¼ÙãŒ ËÞ‹ – ¹Ñ§è »ÃÐªØÁ¨¹¨ºäÁ‹ä´Œ à¢ŒÒ¤ÔÇÃÍ¤ÍÂäÁ‹ä´Œ ¢ÑºÃ¶àÃçÇà¡Ô¹¤ÇÒÁ¨íÒà»š¹
¢ÕéâÁâËàÇÅÒ¢ÑºÃ¶ ¾Ù´¨ÒÇÔ¾Ò¡ÉÇÔ¨ÒÃ³â´ÂäÁ‹¤Ô´ (Poor mental filtering) ËØ¹ËÑ¹
´×èÁ¨Ñ´ ·íÒµ¹àÍ§ãËŒºÒ´à¨çº
¡ÒÃÃÑ¡ÉÒ
¡ÒÃÃÑ¡ÉÒÁÑ¡¨ÐµŒÍ§ãªŒËÅÒÂ æ ÍÂ‹Ò§»ÃÐ¡Íº¡Ñ¹ ä´Œá¡‹ ¡ÒÃãªŒÂÒ ¾ÄµÔ¡ÃÃÁ
ºíÒºÑ´ »ÃÑºÃÙ»áºº¡ÒÃ´íÒà¹Ô¹ªÕÇÔµ áÅÐ¡ÒÃãËŒ¤íÒ»ÃÖ¡ÉÒ ã¹ÃÒÂ·ÕèÁÕÍÒ¡ÒÃàÅç¡¹ŒÍÂ
¶Ö§»Ò¹¡ÅÒ§ ¡ÒÃÃÑ¡ÉÒ¨ÐãªŒ¡ÒÃ·íÒ¾ÄµÔ¡ÃÃÁºíÒºÑ´ áÅÐ¡ÒÃãËŒ¤íÒ»ÃÖ¡ÉÒ ¡ÒÃÃÑ¡ÉÒ
´ŒÇÂÂÒ¨ÐãªŒà»š¹ First line ã¹ÃÒÂ·Õè»†ÇÂÃØ¹áÃ§ áÅÐ¨ÐãªŒáºº second line ËÒ¡
¡ÒÃÃÑ¡ÉÒ´ŒÇÂÇÔ¸Õ¢ŒÒ§µŒ¹äÁ‹ä´Œ¼ÅµÒÁàÇÅÒ·ÕèÊÁ¤ÇÃ (ÀÒÂã¹ 8 ÊÑ»´ÒË)
Methylphenidate ÁÑ¡¨Ðà»š¹µÑÇàÅ×Í¡áÃ¡ æ ËÒ¡µŒÍ§ÃÑ¡ÉÒ´ŒÇÂÂÒ â´ÂÂÒ
ÁÕÄ·¸Ô¡ì ÃÐµØ¹Œ ÃÐºº»ÃÐÊÒ·Ê‹Ç¹¡ÅÒ§ áÅÐÁÕ§Ò¹ÇÔ¨ÂÑ ÃÍ§ÃÑºÁÒ¡ÁÒÂ ÍÂ‹Ò§äÃ¡ç´Õ ¡ÒÃ
µÑ´ÊÔ¹ã¨¨ÐµŒÍ§¾Ô¨ÒÃ³Ò¶Ö§
- âÃ¤·Õèà»š¹Ã‹ÇÁ (àª‹¹ Tics, Tourette’s syndrome, Epilepsy)
- ¤ÇÒÁ·¹µ‹ÍÂÒáÅÐÍÒ¡ÒÃ¢ŒÒ§à¤ÕÂ§·Õèà¡Ô´¢Öé¹
- ¤ÇÒÁÊÐ´Ç¡ã¹¡ÒÃÃÑº»ÃÐ·Ò¹ÂÒ
- âÍ¡ÒÊ·Õè¼ÙŒ»†ÇÂ¨ÐËÂØ´ÂÒàÍ§
- ¤ÇÒÁ¾Íã¨¢Í§¼ÙŒ»†ÇÂ/¼ÙŒ»¡¤ÃÍ§
¶ŒÒàÅ×Í¡ãªŒÂÒ ¨ÐµŒÍ§¾Ô¨ÒÃ³Ò´ŒÇÂÇ‹Ò¨ÐãªŒÂÒã¹ÃÙ»áºº»Å´»Å‹ÍÂà¹Ôè¹
(ÊÐ´Ç¡ã¹¡ÒÃãËŒÇÑ¹ÅÐ¤ÃÑé§, ¼ÙŒ»†ÇÂÃ‹ÇÁÁ×Íã¹¡ÒÃãªŒÂÒ, Å´ Stigma, ÊÐ´Ç¡ã¹¡ÒÃ
ä»âÃ§àÃÕÂ¹) ËÃ×Í ¨ÐãËŒÂÒã¹ÃÙ»áººÍÍ¡Ä·¸ÔìÊÑé¹ (ÁÕ¤ÇÒÁÂ×´ËÂØ‹¹ÊÙ§ã¹¡ÒÃ¡íÒË¹´
ãËŒÂÒÍÍ¡Ä·¸Ôìà©¾ÒÐàÇÅÒ·ÕèµŒÍ§¡ÒÃ, ª‹Ç§¤‹ÍÂ æ »ÃÑºà¾ÔèÁ¢¹Ò´ÂÒ·íÒä´Œ´Õ¡Ç‹Ò)
¡Ã³Õ·ÕèÁÕâÃ¤Í×è¹´ŒÇÂ ãËŒ¡ÒÃÃÑ¡ÉÒµÒÁÅíÒ´Ñº´Ñ§¹Õé
- ¡ÒÃµÔ´ÊÔè§àÊ¾µÔ´
- ÃÑ¡ÉÒâÃ¤·Ò§ÍÒÃÁ³ (Mood disorders)
- âÃ¤ÇÔµ¡¡Ñ§ÇÅ (Anxiety disorders)
- âÃ¤àÍ´ÕàÍª´Õ (ADHD)
Methylphenidate (MPH) [Ritalin®, Concerta®]
ÂÒ¨Ñ´ÍÂÙ‹ã¹¡ÅØ‹Á CNS Stimulant (Psychostimulant) ÁÕ·Ñé§ª¹Ô´ÍÍ¡Ä·¸Ôì
ÊÑé¹ (Ritalin®) áÅÐª¹Ô´ÍÍ¡Ä·¸Ôì¹Ò¹ (Concerta®) ãªŒã¹¡ÒÃÃÑ¡ÉÒâÃ¤ ADHD
(Attention-deficit/hyperactivity disorder)
ÍÍ¡Ä·¸Ôìà»š¹ sympathomimetic agent â´ÂÁÕÄ·¸Ôì stimulant CNS
dopamine (DA) áÅÐ Norepinephrine (NE) ·Õè pathway crucial ¼Åµ‹Í¡ÒÃ
·íÒ§Ò¹·Õè frontal lobe â´Âä»à¾ÔèÁ¡ÒÃËÅÑè§áÅÐÃÐ§Ñº¡ÒÃ´Ù´¡ÅÑº¢Í§ central
catecholamine
• ÂÒ´Ù ´ «Ö Á ä´Œ ¤‹ Í ¹¢Œ Ò §àÃç Ç , ÁÕ protein binding µèí Ò áÅÐà¡Ô ´
extracellular metabolism ä´ŒàÃçÇ
• ÂÒ¨ÐàÃÔèÁÍÍ¡Ä·¸Ôì ÀÒÂã¹»ÃÐÁÒ³ 30-60 ¹Ò·Õ ËÅÑ§ÃÑº»ÃÐ·Ò¹
(maximum drug concentration ËÅÑ§ÃÑº»ÃÐ·Ò¹»ÃÐÁÒ³ 2 ªÑèÇâÁ§)
• Duration of action ÍÂÙ‹·Õè 1-4 ªÑèÇâÁ§, Half life »ÃÐÁÒ³ 2-3 ªÑèÇâÁ§
´Ñ§¹Ñé¹¨íÒà»š¹µŒÍ§ãËŒÂÒµÑÇ¹Õé 2-3 ¤ÃÑé§µ‹ÍÇÑ¹
• ÃÐÂÐàÇÅÒ¡ÒÃÍÍ¡Ä·¸Ôì¢Í§ÂÒ
- Ritalin® : 2-4 ªÑèÇâÁ§
- Concerta® : 12 ªÑèÇâÁ§
• ¢¹Ò´ÂÒ·Õãè ªŒ¤Òí ¹Ç³µÒÁ¹éÒí Ë¹Ñ¡µÑÇ ¤×Í »ÃÐÁÒ³ 0.5-1 mg/kg/day ¢¹Ò´
à©ÅÕèÂ·Õèä´Œ¼Å´Õ ¤×Í 0.7 mg/kg/day ¢¹Ò´ÂÒÊÙ§ÊØ´µ‹ÍÇÑ¹ äÁ‹¤ÇÃà¡Ô¹ 1 mg/kg/day
Â¡àÇŒ¹ ã¹ºÒ§ÃÒÂ·Õè¾ºÇ‹ÒäÁ‹ÁÕ¼Å¢ŒÒ§à¤ÕÂ§áÅÐ¨íÒà»š¹µŒÍ§ä´ŒÃÑºÂÒ¢¹Ò´ÊÙ§¢Öé¹
• ª¹Ô´ÍÍ¡Ä·¸ÔìÊÑé¹ : à´ç¡ 6 »‚¢Öé¹ä» áÅÐ¼ÙŒãËÞ‹ àÃÔèÁãËŒã¹¢¹Ò´ 5 mg/
dose ÇÑ¹ÅÐ 2 ¤ÃÑ§é µÍ¹àªŒÒáÅÐµÍ¹à·ÕÂè § ÊÒÁÒÃ¶à¾ÔÁè ¢¹Ò´ä´ŒÊ»Ñ ´ÒËÅÐ¤ÃÑ§é â´Â
à¾ÔèÁ¤ÃÑé§ÅÐ 5-10 mg/ÇÑ¹ ¢¹Ò´ÂÒÊÙ§ÊØ´äÁ‹à¡Ô¹ 60 mg/ÇÑ¹
• ª¹Ô´ÍÍ¡Ä·¸Ôì¹Ò¹ (Concerta®) ¡Ã³Õ¼ÙŒ»†ÇÂäÁ‹à¤Âä´ŒÃÑº methylphe-
nidate ÁÒ¡‹Í¹ : àÃÔèÁ·Ò¹ÂÒã¹¢¹Ò´ 18 mg ÇÑ¹ÅÐ¤ÃÑé§ µÍ¹àªŒÒ
• ª¹Ô´ÍÍ¡Ä·¸Ô¹ì Ò¹ (Concerta®) ¡Ã³Õ¼»ÙŒ Ç† Âà¤Âä´ŒÃºÑ methylphenidate
ÁÒ¡‹Í¹ ãËŒÂÒâ´ÂÊÑÁ¾Ñ¹¸¡Ñº¢¹Ò´·Õèà¤Âä´ŒÃÑº ´Ñ§¹Õé
- ä´ŒÃÑº methylphenidate 5 mg ÇÑ¹ÅÐ 2-3 ¤ÃÑé§
ãËŒ Concerta® 18 mg ÇÑ¹ÅÐ 1 ¤ÃÑé§
• ¶ŒÒ¼ÙŒ»†ÇÂµÍºÊ¹Í§µ‹Í¡ÒÃÃÑ¡ÉÒ ãËŒµÔ´µÒÁ´Ù¼Å¡ÒÃÃÑ¡ÉÒáÅÐÍÒ¡ÒÃ
¢ŒÒ§à¤ÕÂ§ ¶ŒÒäÁ‹ä´Œ¼ÅãËŒ·º·Ç¹¡ÒÃÇÔ¹Ô¨©ÑÂ ¤Œ¹ËÒâÃ¤·Õèà¡Ô´Ã‹ÇÁ´ŒÇÂáÅÐ¾Ô¨ÒÃ³Ò
»ÃÑºÂÒ
• ÂÒ Concerta® ËŒÒÁº´ËÃ×Íà¤ÕéÂÇ ãËŒ¡Å×¹·Ñé§àÁç´
• à¾×èÍËÅÕ¡àÅÕèÂ§»˜ÞËÒ¹Í¹äÁ‹ËÅÑº ¤ÇÃãËŒÂÒãËŒáÅŒÇàÊÃç¨¡‹Í¹à·ÕèÂ§
• ÂÒ Concerta® ãËŒÇÑ¹ÅÐ¤ÃÑé§µÍ¹àªŒÒ ¨Ð·Ò¹µÍ¹·ŒÍ§Ç‹Ò§ËÃ×ÍäÁ‹¡çä´Œ
à»‡ÒËÁÒÂ¡ÒÃÃÑ¡ÉÒ´ŒÇÂÂÒ
ª‹ÇÂãËŒ¼»ÙŒ Ç† ÂÁÕÊÁÒ¸Ôã¹¡ÒÃ·íÒ¡Ô¨¡ÃÃÁµ‹Ò§ æ â´Âà©¾ÒÐÍÂ‹Ò§ÂÔ§è ¡ÒÃàÃÕÂ¹ã¹
ËŒÍ§àÃÕÂ¹ ¤ÇÒÁ¨íÒ´Õ¢Öé¹ Ê¹ã¨ÊÔè§áÇ´ÅŒÍÁ´Õ Å´¾ÄµÔ¡ÃÃÁáÅÐÍÒÃÁ³ËØ¹ËÑ¹¾ÅÑ¹
áÅ‹¹ Å´¤ÇÒÁ«¹áÅÐÍÂÙ‹äÁ‹¹Ôè§ã¹¢³Ð·ÕèÂÒÍÍ¡Ä·¸Ôì áÅÐ·íÒãËŒà´ç¡ÁÕ¤ÇÒÁ¾ÃŒÍÁ·Õè¨Ð
àÃÕÂ¹ÃÙŒ ½ƒ¡áÅÐÊÃŒÒ§¾ÄµÔ¡ÃÃÁ·Õè´Õ «Öè§à´ç¡áµ‹ÅÐ¤¹µÍºÊ¹Í§µ‹ÍÂÒäÁ‹àËÁ×Í¹¡Ñ¹
ã¹¡ÒÃãªŒÂÒÃÑ¡ÉÒà´ç¡·Õèà»š¹âÃ¤ ADHD ÊÁ¤ÇÃ»ÃÐàÁÔ¹¤ÇÒÁ¤Ô´ ¤ÇÒÁÃÙŒÊÖ¡
ËÃ×Í¤ÇÒÁµŒÍ§¡ÒÃ¢Í§¾‹ÍáÁ‹µ‹Í¡ÒÃãªŒÂÒ»ÃÐ¡Íº´ŒÇÂ à¹×èÍ§¨Ò¡ ¾‹ÍáÁ‹Ê‹Ç¹ãËÞ‹äÁ‹
¤‹ÍÂÍÂÒ¡ãËŒÅÙ¡ÃÑº»ÃÐ·Ò¹ÂÒ â´Âà©¾ÒÐ¶ŒÒÅÙ¡ÍÒÂØ¹ŒÍÂ ËÒ¡¨íÒà»š¹µŒÍ§Â×¹ÂÑ¹¡ÒÃ
ãªŒÂÒ ¤ÇÃãËŒàÇÅÒ¾‹ÍáÁ‹ãªŒÇÔ¸Õ»ÃÑº¾ÄµÔ¡ÃÃÁà´ç¡ä»¡‹Í¹ÊÑ¡ÃÐÂÐË¹Öè§ (äÁ‹à¡Ô¹ 1-2
à´×Í¹) áÅÐ¾Ù´¤ØÂ¡Ñ¹¶Ö§»˜ÞËÒ¾ÄµÔ¡ÃÃÁËÃ×Í¼Å¡ÃÐ·º¨Ò¡âÃ¤ ADHD ¢Í§à´ç¡ÍÕ¡
¤ÃÑé§ «Öè§ÍÒ¨·íÒãËŒ¾‹ÍáÁ‹ÂÍÁÃÑºÁÒ¡¢Öé¹
• ·Õè¾ºº‹ÍÂä´Œá¡‹ »Ç´ÈÃÕÉÐ ¹Í¹äÁ‹ËÅÑº àº×èÍÍÒËÒÃ ¤Å×è¹äÊŒ ÍÒà¨ÕÂ¹
¹éíÒË¹Ñ¡Å´ Tics
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manic episode) ã¹¼ÙŒ»†ÇÂ¨ÔµàÇª ÂÒÍÒ¨·íÒãËŒÍÒ¡ÒÃ¢Í§¾ÄµÔ¡ÃÃÁ ËÃ×Í¤ÇÒÁ¤Ô´
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µÒÃÒ§·Õè 26 áÊ´§¡ÒÃÊÑè§¨‹ÒÂÂÒ Methylphenidate ã¹¼ÙŒ»†ÇÂ ADHD

÷ćìĊęĔßš øą÷ąđüúćÖćøĂĂÖùìíĉĝ ×îćé÷ć Āöć÷đĀêč
Methylphenidate Onset : 20-60 îćìĊ - đøĉęöêšî 5-10 mg ÙŠĂ÷ ė đóĉęö×îćéĕéšÝîëċÜ - öĆÖĔßšđðŨî÷ćêĆüĒøÖìĊĔę ßš
ßîĉéĂĂÖùìíĉÿĝ îĆĚ Duration : 2-4 ßö. ×îćéÿĎÜÿčéìĊę 2 mg/kg/day ēé÷ĒïŠÜĔĀšüĆî øĆÖþć
(Ritalin®) úąĀúć÷ÙøĆĚÜ - ñĎðš śü÷öĆÖìîêŠĂ÷ćĕéšéĊ
- ÿćöćøëđóĉęö×îćé÷ćĕéšÿĆðéćĀŤúą 5-10 mg
Methylphenidate Onset : 30 îćìĊ - 2 ßö. - đøĉęöĔĀš 18 mg ĔîêĂîđßšć ÙŠĂ÷ ė đóĉęö×îćé - đéĘÖïćÜøć÷ĂćÝÝĞćđðŨîêšĂÜ
ßîĉéĂĂÖùìíĉĝîćî Duration : 12 ßö. ĕéšÝîëċÜ×îćéÿĎÜÿčéìĊę 54 mg ĔîđéĘÖ Ēúą ĔĀš Ritalin® ĔîöČĚĂđ÷Ęî
(Concerta®) 108 mg ĔîñĎšĔĀâŠ đóČęĂĔĀšÖćøøĆÖþćöĊ
- Concert® 18 mg đìĊ÷ïđìŠćÖĆï Ritalin® ðøąÿĉìíĉõćóÿĎÜÿčé
15 mg
Ref: Prescribing Guideline in Psychiatry
µÒÃÒ§·Õè 27 áÊ´§ÍÒ¡ÒÃ¢ŒÒ§à¤ÕÂ§·Õè¾ºº‹ÍÂ áÅÐá¹Ç·Ò§¡ÒÃá¡Œä¢
ã¹¼ÙŒ»†ÇÂ·Õèä´ŒÃÑºÂÒ Methylphenidate
ĂćÖćø×šćÜđÙĊ÷Ü ĒîüìćÜÖćøĒÖšĕ×
- ĔĀšđéĘÖÖĉî÷ćĀúĆÜĂćĀćø
ĕöŠĂ÷ćÖĂćĀćø - ëšćÖĉîĂćĀćøĒêŠúąöČĚĂĕöŠöćÖ ĂćÝĔĀšÖĉîïŠĂ÷ ė
(úéÙüćöĂ÷ćÖĂćĀćø ìĞćĔĀšîĚĞćĀîĆÖúé) - ĂîčâćêĔĀšđéĘÖøĆïðøąìćîĂćĀćøđóĉęöĕéšĂĊÖ 1 öČĚĂ (öČĚĂÖŠĂîîĂî)
- ĔĀšîöĀøČĂĂćĀćøìĊęöĊĒÙúĂøĊęÿĎÜđÿøĉöĒÖŠđéĘÖ
- ðøċÖþćĒóì÷Ť Ēóì÷ŤĂćÝðøĆïöČĚĂ÷ć đßŠî ëšćđéĘÖïćÜÙîÖĉî÷ćêĂîïŠć÷ ĂćÝ

đéĘÖïćÜøć÷ îĂîĕöŠĀúĆï
ÜéĀøČĂúé×îćé÷ćöČĚĂïŠć÷ đðŨîêšî
- ĀćÖĂćÖćøĕöŠøčîĒøÜ ĔĀšóŠĂĒöŠÿĆÜđÖêĂćÖćøĒúąøĆïðøąìćî÷ćêŠĂĕð ĂćÖćø

ðüéýĊøþą
öĆÖÙŠĂ÷ ė Āć÷ĕðđĂÜ ĀćÖĂćÖćøøčîĒøÜ ÙüøðøċÖþćĒóì÷Ť
- øĆïðøąìćî÷ćĀúĆÜĂćĀćøìĆîìĊ
ðüéìšĂÜ ÙúČęîĕÿš
- ÿĆÜđÖêĂćÖćøĒúąøĆïðøąìćî÷ćêŠĂĕð ĂćÖćøðüéìšĂÜöĆÖÙŠĂ÷ ė Āć÷ĕðđĂÜ
éĎüčŠîüć÷ ÷čÖ÷ĉÖ ĂćøöèŤĕöŠéĊ đĀöČĂîøĎšÿċÖĕöŠ - ĒÝšÜĒóì÷Ť đõÿĆßÖø ĀøČĂó÷ćïćúĀĂñĎšðśü÷ đóČęĂàĆÖðøąüĆêĉĀøČĂÿĆÜđÖêĂćÖćø

ÿïć÷êĆü ÖøąêčšîêĆüđĂÜ đßŠî ìčïĀĆü ìčïêĆü ĀøČĂ đóĉęöđêĉö đéĘÖĂćÝøĎšÿċÖĕöŠÿïć÷ìĊęÿŠüîĀîċęÜÿŠüîĔé×ĂÜøŠćÜÖć÷
àċö ė ĕöŠÿéßČęî (irritability)
öĊĂüĆ÷üąÿŠüîĀîċęÜÿŠüîĔéÖøąêčÖàĚĞć ė ìĊęÙüïÙčö - ðøċÖþćĒóì÷ŤĀøČĂđõÿĆßÖø đóČęĂðøĆï÷ć

úĞćïćÖ đßŠî ïøĉđüèĀîšć êć ĀøČĂìĞćðćÖ×öčï
×öĉï ÿąïĆéöČĂ Ē×îĀøČĂ×ć ĀøČĂóĎéêĉéĂŠćÜ
(Tics) ÖĆéôŦî ĀøČĂöĊĂćÖćøÖøąêčÖĀúć÷ ė
(Tourette’ssyndrome)
ĂüĆ÷üąøŠüöÖĆî (Tourette syndrome)
đĀÜČęĂĂĂÖöćÖ ĀîšćĒéÜ ĔÝÿĆęî ĀĆüĔÝđêšîđøĘü - Ā÷čéĔßš÷ć ĒúąĔĀšĒÝšÜĒóì÷ŤñĎšĔĀš÷ćĀøČĂđõÿĆßÖøìøćï
ĂćÝöĊĂćÖćøöČĂ-đìšćđ÷ĘîøŠüöéšü÷
Growth (¡ÒÃà¨ÃÔÞàµÔºâµ)
¡ÒÃÈÖ¡ÉÒ·Õèà¡ÕèÂÇ¡Ñº¼Å¡ÒÃà¨ÃÔÞàµÔºâµ ¨Ò¡¼Å Short-term ·ÕèÁÕ¼ÅãËŒ
¹éÒí Ë¹Ñ¡Å´Å§ áµ‹àÁ×Íè ÁÕ¡ÒÃÈÖ¡ÉÒà»š¹ prospective µÔ´µÒÁä»¨¹à´ç¡µ‹Íä»à»š¹¼ÙãŒ ËÞ‹
¾ºÇ‹ÒäÁ‹Á¤Õ ÇÒÁáµ¡µ‹Ò§ÍÂ‹Ò§ÁÕ¹ÂÑ ÊíÒ¤ÑÞ áµ‹¡Áç ¼Õ Å¨Ò¡ºÒ§ÃÒÂ·ÕÈè ¡Ö ÉÒ¾ºÇ‹ÒÁÕÍÒ¡ÒÃ
¢ŒÒ§à¤ÕÂ§ ¡ÒÃãªŒÂÒª‹Ç§ 14-24 à´×Í¹áÅŒÇ´Ù·Ñé§àÃ×èÍ§¹éíÒË¹Ñ¡áÅÐÊ‹Ç¹ÊÙ§ ¼Å¤ÇÒÁµ‹Ò§
¡Ñ¹¢Í§ÍÑµÃÒ¡ÒÃà¨ÃÔÞàµÔºâµÍÂ‹Ò§ÁÕ¹ÑÂÊíÒ¤ÑÞ ã¹´ŒÒ¹¤ÇÒÁÊÙ§ ÊíÒËÃÑº¡ÅØ‹Á·ÕèãËŒ¡ÒÃ
ÃÑ¡ÉÒáºº¡ÅØ‹Áä´ŒÂÒáÅÐ¡ÅØ‹Áä´ŒÃÑºÂÒÃ‹ÇÁ¡Ñº¡ÒÃ·íÒ¾ÄµÔ¡ÃÃÁºíÒºÑ´ µ‹Ò§¨Ò¡¡ÅØ‹Á·Õè
·íÒ¾ÄµÔ¡ÃÃÁºíÒºÑ´ÍÂ‹Ò§à´ÕÂÇ ¼ÅÊÃØ»¨Ò¡¡ÒÃÈÖ¡ÉÒ¾ºÇ‹Òà»š¹ mild growth
suppression áÅÐ¨Ðà¡Ô´ä´ŒàÁ×èÍä´ŒÂÒ long-term
Dependence (¡ÒÃµÔ´)
¡ÒÃÈÖ¡ÉÒ·Õèà¡ÕèÂÇ¡Ñº¡ÒÃ Dependence ÂÒ ã¹¡ÒÃãªŒÂÒà»š¹ÃÐÂÐàÇÅÒ¹Ò¹
«Öè§¾ºÇ‹ÒÍÒ¨à»š¹µÑÇ predispose ã¹à´ç¡ ADHD ã¹¡ÒÃä»ÁÕâÍ¡ÒÊ abuse
Cocaine ËÃ×ÍÂÒàÊ¾µÔ´Í×è¹ä´Œ Ê‹Ç¹¡ÒÃ dependence Methylphenidate (MPH)
àÍ§ äÁ‹¾ºÇ‹ÒÁÕ ÍÒ¨à¾ÃÒÐ¡ÅØ‹ÁÂÒ stimulant ¨ÐäÁ‹·íÒãËŒà¡Ô´ÍÒ¡ÒÃ euphoria àÁ×èÍ
ãËŒ´ŒÇÂ¡ÒÃÃÑº»ÃÐ·Ò¹ ¨Ò¡¡ÒÃÈÖ¡ÉÒ´ŒÇÂ PET Scan áÊ´§ãËŒàËç¹àÁ×èÍà»ÃÕÂºà·ÕÂº
¨Ò¡¡ÒÃãËŒ Cocaine ´ŒÇÂÇÔ¸Õ¡ÒÃ©Õ´·Ò§àÊŒ¹àÅ×Í´ Ê‹Ç¹¡ÒÃãËŒáºº oral MPH
´Ù´«ÖÁªŒÒ¡Ç‹ÒÁÒ¡áÅÐ¡ÒÃ¨Ñº¡Ñº Dopamine transporter à»š¹ª‹Ç§àÇÅÒ·Õè¹Ò¹¡Ç‹Ò
¢¹Ò´¢Í§ÂÒ·ÕèãËŒ¡çäÁ‹ÊÒÁÒÃ¶ÁÕ¼ÅãËŒà¡Ô´ euphoria ä´Œ áÅÐ¨Ò¡ÃÒÂ§Ò¹¢Í§ Drug
Abuse Warning Network (DAWN) ¾ºÇ‹Ò¡ÒÃ abuse MPH à·ÕÂº¡Ñº abuse
Cocaine ÁÕÍÑµÃÒà»š¹ 1 µ‹Í 40 ¹Í¡¨Ò¡¹Õé ÁÕÃÒÂ§Ò¹ã¹»‚ 1999 Ç‹ÒÇÑÂÃØ‹¹·Õèä´ŒÃÑ¡ÉÒ
ÍÒ¡ÒÃ ADHD ¾ºÍÑµÃÒ¡ÒÃà¡Ô´ substance use ¹ŒÍÂ¡Ç‹Òã¹¤¹·ÕèäÁ‹ÃÑ¡ÉÒ ÁÕ¡ÒÃ
ÈÖ¡ÉÒµ‹Íâ´Â¡ÒÃÅÍ§à¾ÔèÁ dose ¢Í§ MPH ¡ç¾ºÇ‹Ò¼ÅÅÑ¾¸·Õèä´Œ ¡çäÁ‹áµ¡µ‹Ò§¡Ñ¹
áµ‹¶Ö§ÍÂ‹Ò§äÃ ¼ÅÊÃØ»§Ò¹ÇÔ¨ÑÂ¡çàµ×Í¹Ç‹Ò ¶Ö§áÁŒ·Õè¼‹Ò¹ÁÒÂÑ§äÁ‹¾ºÇ‹ÒÁÕ¡ÒÃà¡Ô´ abuse
¡çäÁ‹ä´ŒÂ×¹ÂÑ¹Ç‹Ò¨ÐäÁ‹ÁÕ à¾ÃÒÐÂÒ¡ÅØ‹Á stimulant ·Ø¡µÑÇÁÑ¡ÁÕÄ·¸Ôìà»š¹ abuse
potential ä´Œ
Atomoxetine (Strattera®
(Strattera®)
Atomoxetine «Öè§ÂÒ¹Õé¨Ñ´ÍÂÙ‹ã¹¡ÅØ‹Á·ÕèäÁ‹ÁÕÄ·¸Ôì¡ÃÐµØŒ¹ (Non stimulant) µÑÇ
áÃ¡·ÕèãªŒã¹¼ÙŒ»†ÇÂâÃ¤ÊÁÒ¸ÔÊÑé¹ ãªŒ¡Ñºà´ç¡ÍÒÂØµÑé§áµ‹ 6 ¢Çº¢Öé¹ä»áÅÐã¹¼ÙŒãËÞ‹·Õèà»š¹
âÃ¤ÊÁÒ¸ÔÊÑé¹
Atomoxetine à»š¹ Selective Norepinephrine Reuptake Inhibitor «Öè§
ÁÕ¼Åà¾ÔèÁÃÐ´Ñº Norepinephrine ã¹ Prefrontal cortex ¢Í§ÊÁÍ§ â´ÂäÁ‹ÁÕ¼Åµ‹Í
ÃÐ´Ñº Serotonin áµ‹ÂÒ¨Ðà¾ÔèÁÃÐ´Ñº Dopamine ã¹ Prefrontal cortex â´ÂäÁ‹ÁÕ
¼Åµ‹ÍÃÐ´Ñº Dopamine ã¹ Striatum or nucleus accumbens «Öè§àª×èÍÇ‹Ò¡ÒÃ
¢Ò´ Norephinephrine áÅÐ Dopamine ·ÕèÊÁÍ§Ê‹Ç¹ prefrontal cortex ¨Ð·íÒãËŒ
ÁÕ¼Åµ‹Í¡ÒÃ¤Çº¤ØÁ¤ÇÒÁµÑé§ã¨ áÅÐÊÁÒ¸Ô áÅÐ·íÒãËŒ¡ÒÃµÍºÊ¹Í§µ‹ÍÊÔè§àÃŒÒµ‹Ò§ æ
¶Ù¡ÂÑºÂÑé§ áÅÐ¡ÒÃ¢Ò´´Ñ§¡Å‹ÒÇ¨Ð·íÒãËŒà¡Ô´ immature behavior, ¢Ò´¡ÒÃÂÑºÂÑé§
ªÑè§ã¨ áÅÐà¾ÔèÁ motor activity
¡ÒÃ·Õè Atomoxetine äÁ‹ÁÕ¼Åµ‹Í Dopamine ã¹ÊÁÍ§Ê‹Ç¹ Striatum or
nucleus accumbens ¨Ö§äÁ‹ÍÍ¡Ä·¸Ôìµ‹ÍÊÁÍ§Ê‹Ç¹ÍÒÃÁ³ «Öè§¾ºã¹ÂÒ·Õèà»š¹ÇÑµ¶Ø
ÍÍ¡Ä·¸Ôìµ‹Í¨Ôµ»ÃÐÊÒ· ·íÒãËŒÁÕ¤ÇÒÁàÊÕèÂ§µèíÒ·Õè¨Ð·íÒãËŒà¡Ô´¡ÒÃãªŒã¹·Ò§·Õè¼Ô´ (Drug
abuse) ¨Ö§·íÒãËŒÂÒ Atomoxetine à»š¹ÂÒ·Õè¨Ð¶Ù¡¹íÒÁÒãªŒã¹¼ÙŒ»†ÇÂ·ÕèÁÕá¹Çâ¹ŒÁ¨ÐÁÕ
¡ÒÃãªŒÂÒã¹·Ò§·Õè¼Ô´ (Drug abuse)
ÍÂ‹Ò§äÃ¡çµÒÁ ¡Åä¡·ÕèªÑ´à¨¹ã¹¡ÒÃÃÑ¡ÉÒ ADHD ÂÑ§äÁ‹·ÃÒºªÑ´ ¡ÒÃà¾ÔèÁ
ÃÐ´ÑºÊÒÃ Catecholamine (Norepinephrine) ã¹ Frontal lobe à»š¹»ÃÒ¡®¡ÒÃ³
¤ÅŒÒÂ¡Ñº¡ÒÃÃÑº»ÃÐ·Ò¹ÂÒ Methylphenidate â´Â·Õè Atomoxetine ÁÕ¡ÒÃà¾ÔèÁ
»ÃÔÁÒ³ Catecholamine (Norepinephrine) ¢Í§ÊÁÍ§·Õèà©¾ÒÐÊ‹Ç¹ÁÒ¡¡Ç‹Ò
¹Í¡¨Ò¡¹Ñé¹ Atomoxetine à¡ÕèÂÇ¢ŒÍ§¡ÑºÃÐººÊÒÃÊ×èÍ»ÃÐÊÒ·Í×è¹ æ
(Neurotransmitter system) ä´Œá¡‹ Cholinergic, histaminergic, serotonergic
áµ‹ÁÕà¾ÕÂ§àÅç¡¹ŒÍÂà·‹Ò¹Ñé¹
¨Ò¡¡ÒÃÈÖ¡ÉÒ¼Å¡ÒÃÃÑ¡ÉÒ¢Í§ Atomoxetine ¾ºÇ‹ÒÁÕ»ÃÐÊÔ·¸ÔÀÒ¾´Õ áÅÐ
àÁ×èÍà»ÃÕÂºà·ÕÂº¡ÑºÂÒ Methylphenidate ¾ºÇ‹ÒãËŒ¼Å¡ÒÃÃÑ¡ÉÒäÁ‹áµ¡µ‹Ò§¡Ñ¹ â´Â
ÂÒÁÕ»ÃÐÊÔ·¸ÔÀÒ¾·Ñé§ã¹¡ÒÃ¤Çº¤ØÁÍÒ¡ÒÃáÅÐª‹ÇÂ¤§ãËŒ¼ÙŒ»†ÇÂÍÒ¡ÒÃ´Õ ¾ºÇ‹ÒÂÒäÁ‹
·íÒãËŒà¡Ô´ÍÒ¡ÒÃ Tics ËÃ×Í·íÒãËŒÍÒ¡ÒÃ¢Í§âÃ¤Ã‹ÇÁ àª‹¹ Anxiety ¡íÒàÃÔº ´Ñ§¹Ñé¹ã¹
¼ÙŒ»†ÇÂ·ÕèäÁ‹ÊÒÁÒÃ¶ãªŒÂÒ·Õèà»š¹¡ÅØ‹Á·ÕèÁÕÄ·¸Ôì¡ÃÐµØŒ¹ä´Œ à¹×èÍ§¨Ò¡ÁÕ¢ŒÍËŒÒÁ ÍÒ¡ÒÃ Tics
ËÃ×Í anxiety ¡ÒÃãªŒ Atomoxetine ¨Ðà»š¹·Ò§àÅ×Í¡ÊíÒËÃÑº¼ÙŒ»†ÇÂ¡ÅØ‹Á´Ñ§¡Å‹ÒÇ
ÂÒ¶Ù¡´Ù´«ÖÁÍÂ‹Ò§ÊÁºÙÃ³ã¹ÃÐºº·Ò§à´Ô¹ÍÒËÒÃ ÃÙ»áºº¡ÒÃ´Ù´«ÖÁàËÁ×Í¹
¡Ñ¹ã¹·Ø¡¡ÅØ‹ÁÍÒÂØ ÍÒËÒÃäÁ‹Ãº¡Ç¹¡ÒÃ´Ù´«ÖÁ áµ‹ÍÒËÒÃ·Õèä¢ÁÑ¹ÊÙ§¨Ð·íÒãËŒÍÑµÃÒ¡ÒÃ
´Ù´«ÖÁªŒÒÅ§ ÃÐ´ÑºÂÒã¹àÅ×Í´¨ÐÊÙ§ÊØ´ËÅÑ§¨Ò¡·Ò¹ÂÒ 1-2 ªÑèÇâÁ§ ÁÕ¤‹Ò¡ÒÃ¡ÃÐ¨ÒÂ
µÑÇ (Volume of distribution; Vd) ·ÕèÊÀÒÇÐ¤§·Õè (steady state) à·‹Ò¡Ñº
0.85 ÅÔµÃ/¡ÔâÅ¡ÃÑÁ ÂÒ¨Ñº¡Ñºâ»ÃµÕ¹ã¹àÅ×Í´ 98% â´Âà©¾ÒÐ¡Ñº Albumin
¡ÒÃ¡íÒ¨Ñ´ÂÒ à»š¹¡Åä¡ Oxidative metabolism ¼‹Ò¹·Ò§ Cytochrome
P450 2D6 ÊÒÃàÁµÒºÍäÅ·ËÅÑ¡·Õèä´Œ¤×Í 4-hydroxylAtomoxetine «Öè§ÁÕÄ·¸Ôì·Ò§
àÀÊÑ ª ÇÔ · ÂÒ áµ‹ ¾ ºã¹»ÃÔ Á Ò³¹Œ Í Â áÅÐ¶Ù ¡ à»ÅÕè Â ¹á»Å§µ‹ Í ä»´Œ Ç Â¡Åä¡
glucuronidation ä´Œà»š¹ N-desmethylAtomoxetine äÁ‹ÁÄÕ ·¸Ô·ì Ò§àÀÊÑªÇÔ·ÂÒ áÅÐ
¶Ù¡¢ÑºÍÍ¡·Ò§äµ
¨Ò¡¡ÒÃ·Õè Atomoxetine ÁÕ¡ÒÃ·íÒÅÒÂÂÒ¼‹Ò¹ CYP 2D6 «Öè§à»š¹ Enzyme
·ÕèÁÕ¤ÇÒÁáµ¡µ‹Ò§¡Ñ¹·Ò§¾Ñ¹¸Ø¡ÃÃÁ ¤×ÍÁÕ genetic polymorphism ¢Í§ CYP 2D6
¨Ö§·íÒãËŒ¤Ø³ÊÁºÑµÔàÀÊÑª¨Å¹ÈÒÊµÃ¢Í§ Atomoxetine ÁÕ¤ÇÒÁáµ¡µ‹Ò§¡Ñ¹ â´Âáº‹§
ÍÍ¡à»š¹ 2 ¡ÅØ‹Á¤×Í Extensive metabolizers áÅÐ Poor metabolizers «Öè§ã¹
ºØ¤¤Å·Õèà»š¹ poor metabolizers ¾ºà¾ÕÂ§ 7% ¢Í§»ÃÐªÒ¡Ã¼ÔÇ¢ÒÇ (Caucasian)
áÅÐ¾º 1% ¢Í§»ÃÐªÒ¡ÃàÍàªÕ Â «Öè § ¼Å´Ñ § ¡Å‹ Ò Ç·í ÒãËŒ ¤‹ Ò ¾ÒÃÒÁÔ à µÍÃ · Ò§
àÀÊÑª¨Å¹ÈÒÊµÃ (Pharmacokinetics parameters) áµ¡µ‹Ò§¡Ñ¹ã¹ Extensive
metabolizers áÅÐ Poor metabolizers µÒÁµÒÃÒ§·Õè 28 áÅÐ¾ºÇ‹Ò¡Ã³Õ·Õèà»š¹
poor metabolizers ¨ÐÁÕâÍ¡ÒÊà¡Ô´¡ÒÃÊÐÊÁ¢Í§ÂÒ áÅÐ·ÕèÊÀÒÇÐ¤§·Õè (Steady
state) ¨ÐÁÕÃÐ´ÑºÂÒã¹àÅ×Í´ÊÙ§¡Ç‹Ò¡ÅØ‹Á Extensive metabolizers
¤‹Ò¤ÃÖè§ªÕÇÔµ (Half-life) ã¹·Ò§¤ÅÔ¹Ô¡¤×Í 5.2 ªÑèÇâÁ§ ã¹¡ÅØ‹Á¼ÙŒ»†ÇÂ·Õèà»š¹
Extensive metabolizers áÅÐã¹¼ÙŒ»†ÇÂ·Õèà»š¹ Poor metabolizers ¤‹Ò Half-life
¨ÐÂÒÇ¢Öé¹¶Ö§ 21.6 ªÑèÇâÁ§ ÂÑ§äÁ‹ÁÕÊÙµÃ·Õèá¹‹¹Í¹ã¹¡ÒÃ»ÃÑº¢¹Ò´ÂÒ á¾·Â¼ÙŒãªŒÂÒ
¤ÇÃà»š¹¼ÙŒ¾Ô¨ÒÃ³Ò
¼ÙŒ»†ÇÂ·ÕèÁÕ»˜ÞËÒ¡ÒÃ·íÒ§Ò¹¢Í§µÑº¨ÐÁÕ¼Åµ‹Í¡ÒÃ¡íÒ¨Ñ´ÂÒ â´Âã¹¼ÙŒ»†ÇÂ·ÕèµÑº
º¡¾Ã‹Í§ÃÐ´ÑºÃØ¹áÃ§»Ò¹¡ÅÒ§ (Child-Pugh class B) ¨ÐµŒÍ§Å´¢¹Ò´ÂÒÅ§àËÅ×Í
50% ¢Í§¢¹Ò´ÂÒ»¡µÔ áÅÐã¹¼ÙŒ»†ÇÂ·ÕèµÑºº¡¾Ã‹Í§ÃÐ´ÑºÃØ¹áÃ§ (Child-Pugh
class C) ¨ÐµŒÍ§Å´¢¹Ò´ÂÒÅ§ãËŒàËÅ×Íà¾ÕÂ§ 25% ¢Í§¢¹Ò´»¡µÔ ã¹¢³Ð·Õè¼ÙŒ»†ÇÂ
·ÕèÁÕ»˜ÞËÒàÃ×èÍ§äµ äÁ‹¨íÒà»š¹µŒÍ§»ÃÑº¢¹Ò´ÂÒ
ÂÑ§äÁ‹Á¡Õ ÒÃÈÖ¡ÉÒ¤‹Ò Pharmacokinetic parameter ã¹à´ç¡·Õµè Òèí ¡Ç‹Ò 6 ¢Çº áÅÐ
¼ÙŒãËÞ‹·ÕèÍÒÂØÁÒ¡¡Ç‹Ò 65 »‚ áµ‹ã¹à´ç¡·ÕèÍÒÂØÁÒ¡¡Ç‹Ò 6 ¢ÇºÁÕ¤‹Ò Pharmacokinetic
parameter ã¡ÅŒà¤ÕÂ§¡Ñº¼ÙŒãËÞ‹
µÒÃÒ§·Õè 28 áÊ´§¤‹Ò¾ÒÃÒÁÔàµÍÃ·Ò§àÀÊÑª¨Å¹ÈÒÊµÃ (Pharmacokinetics parameters)
ã¹¼ÙŒ»†ÇÂ·Õèà»š¹ Extensive Metabolizers áÅÐ Poor Metabolizers
Parameter Extensive Metabolizers Poor Metabolizers
Bioavailability (%) 63 94
Tmax (hrs) 1-2 3-4
ÙŠćÙøċęÜßĊüĉê (Half-life; ßĆęüēöÜ) 5.2 21.6
đöêćēïĕúìŤ
4-HydroxyAtomoxetine-O-glucuronide
ÙŠćÙøċęÜßĊüĉê (Half-life; ßĆęüēöÜ) 6-8 -
a
AUC (µg•hour/ml) 2.74 0.935
N-desmethylAtomoxetine
ÙŠćÙøċęÜßĊüĉê (Half-life; ßĆęüēöÜ) - 34-40
a
AUC (µg•hour/ml) 0.618 2.82
Tmax = time to maximum concentration; AUC = area under the concentration-time curve.
a
đðŨîÙŠćìĊęĕéšÝćÖÖćøĔĀš÷ćêŠĂđîČęĂÜ×ĂÜ Atomoxetine 20 öĉúúĉÖøĆö 2 ÙøĆĚÜêŠĂüĆî
• ¢¹Ò´ÂÒàÃÔèÁµŒ¹ã¹¼ÙŒ»†ÇÂ·Õè¹éíÒË¹Ñ¡¹ŒÍÂ¡Ç‹ÒËÃ×Íà·‹Ò¡Ñº 70 ¡ÔâÅ¡ÃÑÁ ¤×Í
0.5 ÁÔÅÅÔ¡ÃÑÁ/¡ÔâÅ¡ÃÑÁ/ÇÑ¹ áÅÐ»ÃÑº¢¹Ò´ÂÒàÁ×èÍ¤Ãº 3 ÇÑ¹ ¨¹ä´Œ¢¹Ò´·ÕèµŒÍ§¡ÒÃ
(Target dose) ¤×Í 1.2 ÁÔÅÅÔ¡ÃÑÁ/¡ÔâÅ¡ÃÑÁ/ÇÑ¹
• ¼ÙŒ»†ÇÂ·Õè¹éíÒË¹Ñ¡ÁÒ¡¡Ç‹Ò 70 ¡ÔâÅ¡ÃÑÁ àÃÔèÁµŒ¹´ŒÇÂ¢¹Ò´ 40 ÁÔÅÅÔ¡ÃÑÁ/
ÇÑ¹ »ÃÑº¢¹Ò´ÂÒàÁ×èÍ¤Ãº 3 ÇÑ¹ à»š¹ 80 ÁÔÅÅÔ¡ÃÑÁ/ÇÑ¹ ¢¹Ò´ÂÒÊÙ§ÊØ´äÁ‹¤ÇÃà¡Ô¹
100 ÁÔÅÅÔ¡ÃÑÁ/ÇÑ¹ â´ÂÂÒÊÒÁÒÃ¶áº‹§ãËŒà»š¹ 2 ¤ÃÑé§ áµ‹¨Ò¡¡ÒÃÈÖ¡ÉÒ¾ºÇ‹Ò¡ÒÃãËŒ
ÂÒÇÑ¹ÅÐ¤ÃÑé§¡çãËŒ¼Å¡ÒÃÃÑ¡ÉÒ·ÕèäÁ‹áµ¡µ‹Ò§¨Ò¡¡ÒÃãËŒÇÑ¹ÅÐ 2 ¤ÃÑé§ ã¹¼ÙŒ»†ÇÂâÃ¤µÑº
¨ÐµŒÍ§»ÃÑº¢¹Ò´ÂÒ áµ‹¼ÙŒ»†ÇÂâÃ¤äµäÁ‹µŒÍ§»ÃÑº¢¹Ò´ÂÒ
• ¼ÙŒ»†ÇÂ·ÕèÁÕÀÒÇÐµÑºº¡¾Ã‹Í§ ¶ŒÒÍÂÙ‹ã¹ÃÐ´Ñº»Ò¹¡ÅÒ§ ãËŒ»ÃÑº¢¹Ò´ÂÒ
Å´Å§ 50% ËÒ¡à»š¹ÃÐ´ÑºÃØ¹áÃ§ãËŒ»ÃÑº¢¹Ò´Å´Å§ 75%
• ¡Ã³Õä´ŒÃÑºÂÒÃ‹ÇÁ¡ÑºÂÒ·Õèà»š¹ Enzyme inhibitors ÊíÒËÃÑº CYP 2D6
ãËŒàÃÔèÁ¢¹Ò´ÂÒµÒÁ»¡µÔ áµ‹¡ÒÃ»ÃÑºà¾ÔèÁ¢¹Ò´ÂÒãËŒ·íÒÍÂ‹Ò§ÃÐÁÑ´ÃÐÇÑ§ â´Â»ÃÑº
¢¹Ò´ÂÒÍÕ¡¤ÃÑé§àÁ×èÍä´ŒÃÑºÂÒä»áÅŒÇ»ÃÐÁÒ³ 4 ÊÑ»´ÒË
• Atomoxetine ÍÍ¡Ä·¸ÔìªŒÒ¡Ç‹ÒÂÒã¹¡ÅØ‹Á·ÕèÍÍ¡Ä·¸Ôìáºº¡ÃÐµØŒ¹ â´Â¨Ð
àËç¹¼Å¡ÒÃµÍºÊ¹Í§¢Í§ÂÒ·ÕèÊÑ»´ÒË·Õè 4 ¢Í§¡ÒÃãªŒÂÒ
• ¨Ò¡ÃÒÂ§Ò¹¡ÒÃ·´ÅÍ§ã¹à´ç¡áÅÐÇÑÂÃØ‹¹ »˜ÞËÒ·Õè¾ºº‹ÍÂ·Õè·íÒãËŒ¼ÙŒ»†ÇÂ
ËÂØ´ÂÒ¤×Í ¾ÄµÔ¡ÃÃÁ¡ŒÒÇÃŒÒÇ ©Ø¹à©ÕÂÇ §‹Ç§«ÖÁ ÍÒà¨ÕÂ¹ (â´ÂÍÒ¡ÒÃáµ‹ÅÐÍÂ‹Ò§ÁÕ
ÊÑ´Ê‹Ç¹ 0.5% ¢Í§¨íÒ¹Ç¹¼ÙŒ»†ÇÂ·Ñé§ËÁ´)
• ÍÒ¡ÒÃ¢ŒÒ§à¤ÕÂ§·Õè¾ºº‹ÍÂ ä´Œá¡‹ ¤ÇÒÁÍÂÒ¡ÍÒËÒÃÅ´Å§ (14%),
ÍÒà¨ÕÂ¹ (11%), ÇÔ§àÇÕÂ¹ (6%), Í‹Í¹áÃ§ (4%), ¤Å×è¹äÊŒáÅÐ»Ç´·ŒÍ§ (4%), áÅÐ
ÍÒÃÁ³á»Ã»ÃÇ¹ (2%)
• ÍÒ¡ÒÃ¢ŒÒ§à¤ÕÂ§·Õè¾ºà¾ÔèÁàµÔÁã¹¼ÙŒãËÞ‹ä´Œá¡‹ »Ò¡áËŒ§ (21%), ¹Í¹äÁ‹
ËÅÑº (16%), ·ŒÍ§¼Ù¡ (10%), »˜ÊÊÒÇÐº‹ÍÂ (3-8%), áÅÐÁÕ»˜ÞËÒ·Ò§à¾È (2-7%)
• ÍÒ¡ÒÃ¢ŒÒ§à¤ÕÂ§µ‹Ò§ æ ¨ÐËÁ´ä»àÁ×Íè ä´ŒÃºÑ ÂÒµ‹Íà¹×Íè § 1 à´×Í¹ ÁÕÃÒÂ§Ò¹
¡ÒÃá¾Œáºº Hypersensitivity ºŒÒ§ áµ‹¾º¹ŒÍÂÁÒ¡
• ¶Ö§áÁŒ¡ÒÃãªŒÂÒã¹ª‹Ç§áÃ¡ ¼ÙŒ»†ÇÂ¨ÐÁÕÍÒ¡ÒÃàº×èÍÍÒËÒÃáÅÐ¹éíÒË¹Ñ¡Å´
áµ‹àÁ×èÍãªŒÂÒµ‹Íà¹×èÍ§ÊÑ¡ÃÐÂÐ (¹ŒÍÂ¡Ç‹Ò 10 ÊÑ»´ÒË) ¾ºÇ‹Ò¼Å¢ŒÒ§à¤ÕÂ§´Ñ§¡Å‹ÒÇ
Å´Å§ à´ç¡¡ÅØÁ‹ ·Õäè ´ŒÃºÑ ÂÒ àÁ×Íè à·ÕÂº¡Ñº¡ÅØÁ‹ ÂÒËÅÍ¡ÁÕ¤ÇÒÁáµ¡µ‹Ò§¢Í§¹éÒí Ë¹Ñ¡ÍÂ‹Ò§
ÁÕ¹ÑÂÊíÒ¤ÑÞ ¤×Í –0.4 ¡ÔâÅ¡ÃÑÁ áÅÐ +1.5 ¡ÔâÅ¡ÃÑÁ, ã¹´ŒÒ¹Ê‹Ç¹ÊÙ§ ÁÕ¤ÇÒÁáµ¡µ‹Ò§
àª‹¹¡Ñ¹ ¤×Í +0.9 à«¹µÔàÁµÃ áÅÐ +1.1 à«¹µÔàÁµÃ µÒÁÅíÒ´Ñº
• ÊíÒËÃÑº¡ÒÃÈÖ¡ÉÒ¶Ö§¼ÅÃÐÂÐÂÒÇÂÑ§äÁ‹¾º¢ŒÍÁÙÅ·Õèá¹‹ªÑ´ã¹¡ÒÃÂ×¹ÂÑ¹¼Å
¢Í§ÂÒ ·Õè¡ÃÐ·ºµ‹Í¹éíÒË¹Ñ¡áÅÐÊ‹Ç¹ÊÙ§
• Atomoxetine ÁÕ¼Åã¹¡ÒÃà¾ÔèÁ Catecholamine (Norepinephrine)
«Öè§Ê‹§¼Å¡ÃÐ·ºµ‹ÍÃÐººËÑÇã¨áÅÐËÅÍ´àÅ×Í´ ¨Ö§µŒÍ§ãªŒÍÂ‹Ò§ÃÐÁÑ´ÃÐÇÑ§ã¹¼ÙŒ»†ÇÂ
¤ÇÒÁ´Ñ¹âÅËÔµÊÙ§ (Hypertension), ËÑÇã¨àµŒ¹àÃçÇ (Tachycardia) ËÃ×Í¼ÙŒ·Õè»˜ÞËÒ
à¡ÕèÂÇ¡ÑºÃÐººËÅÍ´àÅ×Í´áÅÐËÑÇã¨ ¨Ò¡¡ÒÃÈÖ¡ÉÒ¾ºÇ‹ÒÂÒ·íÒãËŒªÕ¾¨ÃáÅÐ¤ÇÒÁ´Ñ¹
âÅËÔµÊÙ§¢Öé¹ áµ‹äÁ‹ÁÕ¹ÑÂÊíÒ¤ÑÞ·Ò§Ê¶ÔµÔ áÅÐ¨Ð¡ÅÑºÊÙ‹ÀÒÇÐ»¡µÔËÅÑ§¨Ò¡ËÂØ´ÂÒ äÁ‹ÁÕ
ÃÒÂ§Ò¹¤ÇÒÁ¼Ô´»¡µÔ¢Í§¼ÙŒ»†ÇÂàÃ×èÍ§à¡ÕèÂÇ¡ÑºËÑÇã¨ËÃ×ÍËÅÍ´àÅ×Í´
¢ŒÍ¤ÇÃÃÐÇÑ§ã¹¡ÒÃãªŒÂÒ áÅÐ¢ŒÍËŒÒÁãªŒ
• ¤ÇÃÃÐÁÑ´ÃÐÇÑ§¡ÒÃãªŒã¹¼Ù»Œ Ç† Â·ÕÁè »Õ Þ
˜ ËÒà¡ÕÂè Ç¡ÑºÃÐººËÅÍ´àÅ×Í´ÊÁÍ§,
¤ÇÒÁ´Ñ¹âÅËÔµÊÙ§ áÅÐ¼ÙŒ»†ÇÂ·ÕèÁÕ»˜ÞËÒ»˜ÊÊÒÇÐÅíÒºÒ¡
• ËŒÒÁãªŒã¹¼ÙŒ»†ÇÂµŒÍËÔ¹ª¹Ô´ Narrow angle glaucoma
• ËŒÒÁãªŒã¹¼ÙŒ»†ÇÂ·ÕèÁÕ»˜ÞËÒµÑº
¤íÒàµ×Í¹Í×è¹ æ
• ÂÑ§äÁ‹ÁÕÃÒÂ§Ò¹¤ÇÒÁ»ÅÍ´ÀÑÂã¹¡ÒÃãªŒÊíÒËÃÑºà´ç¡ÍÒÂØµèíÒ¡Ç‹Ò 6 ¢Çº
• ¡ÒÃãªŒã¹à´ç¡ÍÒ¨ÁÕ¼Å¡ÃÐ·ºµ‹Í¡ÒÃà¨ÃÔÞàµÔºâµ
• ÃÐÇÑ§¡ÒÃãªŒã¹¼ÙŒ»†ÇÂ·Õè¡ÒÃ·íÒ§Ò¹¢Í§µÑºº¡¾Ã‹Í§
• ÃÒÂ§Ò¹·ÕèÊíÒ¤ÑÞ¤×Í Atomoxetine ÁÕ¤ÇÒÁÊÑÁ¾Ñ¹¸¡Ñº¤ÇÒÁ¤Ô´¦‹ÒµÑÇµÒÂ
»¯Ô¡ÔÃÔÂÒÃÐËÇ‹Ò§ÂÒ (Drug Interaction)

• »¯Ô¡ÔÃÔÂÒÃÐËÇ‹Ò§¡Ñ¹ÍÂ‹Ò§ÃØ¹áÃ§ àÁ×èÍãªŒ Atomoxetine Ã‹ÇÁ¡Ñº MAOI
(Monoamine Oxidase Inhibitor) ËÒ¡¼ÙŒ»†ÇÂÁÕ¡ÒÃãªŒÂÒã¹¡ÅØ‹Á MAOI ËÃ×Íà¤Âä´Œ
ÃÑºÂÒã¹ª‹Ç§ 2 ÊÑ»´ÒË¡‹Í¹Ë¹ŒÒ äÁ‹¤ÇÃãËŒ Atomoxetine ÍÂ‹Ò§à´ç´¢Ò´ à¾ÃÒÐÍÒ¨
¨Ð¡ÃÐµØŒ¹ãËŒà¡Ô´ Neuroleptic malignant syndrome ËÃ×Í Hypersensitivity
crisis
• »®Ô¡ÔÃÔÂÒÃÐËÇ‹Ò§¡Ñ¹ÃÐ´Ñº»Ò¹¡ÅÒ§ àÁ×èÍãªŒÂÒ Atomoxetine Ã‹ÇÁ¡Ñº
ÂÒ·ÕèÁÕÄ·¸ÔìÂÑºÂÑé§àÍ¹ä«Á CYP 2D6 (CYP 2D6 inhibitors) àª‹¹ Fluoxetine,
Paroxetine áÅÐ Quinidine ¨Ð·íÒãËŒ Atomoxetine ¤§ÍÂÙ‹ã¹Ã‹Ò§¡ÒÂ¹Ò¹¢Öé¹ ÂÒ
ÁÕ¤‹Ò¤ÃÖè§ªÕÇÔµ·ÕèÂÒÇ¢Öé¹ ´Ñ§¹Ñé¹ËÒ¡ÁÕ¡ÒÃãªŒÂÒÃ‹ÇÁ¡Ñ¹ÍÒ¨µŒÍ§¾Ô¨ÒÃ³Ò»ÃÑº¢¹Ò´ÂÒ
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Atomoxetine (Strattera®) à»š¹·Ò§àÅ×Í¡Ë¹Öè§·Õè¨Ð¹íÒÁÒãªŒÃÑ¡ÉÒâÃ¤ÊÁÒ¸Ô
ÊÑé¹ (Attention-deficit-hyperactivity disorder; ADHD) à¹×èÍ§¨Ò¡ÂÒäÁ‹ÁÕÄ·¸Ôì
¡ÃÐµØŒ¹ (Non-stimulant) ÍÒ¡ÒÃ¢ŒÒ§à¤ÕÂ§µèíÒ ¼ÙŒ»†ÇÂÊÒÁÒÃ¶·¹ÂÒä´Œ´Õ äÁ‹·íÒãËŒà¡Ô´
¡ÒÃµÔ´ (Dependence) ÁÕ»ÃÐÊÔ·¸ÔÀÒ¾ã¹¡ÒÃÃÑ¡ÉÒàª‹¹à´ÕÂÇ¡ÑºÂÒ Methylpheni-
date «Öè§à»š¹ÂÒ¡ÅØ‹Á·ÕèÁÕÄ·¸Ôì¡ÃÐµØŒ¹ ´Ñ§¹Ñé¹ Atomoxetine ¹‹Ò¨Ðà»š¹ÂÒ·Õè¶Ù¡àÅ×Í¡ãËŒ
¹íÒÁÒãªŒ¡Ñº¼ÙŒ»†ÇÂ·ÕèäÁ‹ÊÒÁÒÃ¶·¹µ‹ÍÍÒ¡ÒÃ¢ŒÒ§à¤ÕÂ§ËÃ×ÍäÁ‹µÍºÊ¹Í§µ‹ÍÂÒ¡ÅØ‹Á·ÕèÁÕ
Ä·¸Ôì¡ÃÐµØŒ¹ ËÃ×Íã¹¼ÙŒ»†ÇÂ·ÕèÁÕá¹Çâ¹ŒÁ¢Í§¡ÒÃà¡Ô´ Drug abuse ¶ŒÒÁÕ¡ÒÃãªŒÂÒ¡ÅØ‹Á
·ÕèÁÕÄ·¸Ôì¡ÃÐµØŒ¹ áµ‹ÊíÒËÃÑº¼Å¡ÒÃÃÑ¡ÉÒËÃ×ÍÍÒ¡ÒÃÍÑ¹äÁ‹¾Ö§»ÃÐÊ§¤µ‹Ò§ æ ã¹ÃÐÂÐ
ÂÒÇ¨ÐµŒÍ§ÃÍ¡ÒÃÈÖ¡ÉÒµ‹Íä» «Öè§¨Ðà»š¹µÑÇ·ÕèµÑ´ÊÔ¹Ç‹Ò Atomoxetine ¨Ðä´ŒÃÑº¡ÒÃ
ÃÑºÃÍ§ãËŒãªŒà»š¹ÂÒËÅÑ¡ (First line drug) ã¹¼ÙŒ»†ÇÂâÃ¤ÊÁÒ¸ÔÊÑé¹ËÃ×ÍäÁ‹ã¹Í¹Ò¤µ
µ‹Íä»
ÇÃÃ³¾Ñ¡µÃ ¾×ªÁ§¤Å, Side effect of Methyphenidate
¸ÕÃÒÃÑµ¹ á·¹¢íÒ àÍ¡ÊÒÃ»ÃÐ¡Íº¡ÒÃºÃÃÂÒÂ àÃ×èÍ§¡ÒÃãªŒÂÒ¨ÔµàÇª ÊíÒËÃÑºà´ç¡
áÅÐÇÑÂÃØ‹¹: Psychotropics in Child and Adolescent Psychiatric
patient; 31 Á¡ÃÒ¤Á 2556
Buck ML. Atomoxetine: A New Alternative for the Treatment of
Attention-Defecit/Hyperactivity Disorder. In: Medscape; 2003.
Corman SL, Fedutes BA, Culley CM. Atomoxetine: the first nonstimulant
for the management of attention-deficit/hyperactivity disorder.
Am J Health Syst Pharm 2004;61(22):2391-9.
A Pathophysiologic Approach, 8th ed., 2011
Kaplan S, Heiligenstein J, West S, Busner J, Harder D, Dittmann R,
et al. Efficacy and safety of Atomoxetine in childhood
attention-deficit/hyperactivity disorder with comorbid
oppositional defiant disorder. J Atten Disord 2004;8(2):45-52.
Kelsey DK, Sumner CR, Casat CD, Coury DL, Quintana H, Saylor KE,
et al. Once-daily Atomoxetine treatment for children with
attention-deficit/hyperactivity disorder, including an assessment
of evening and morning behavior: a double-blind,
placebo-controlled trial. Pediatrics 2004;114(1):e1-8.
Spencer TJ, Biederman J, Wilens TE, Faraone SV. Novel treatments
for attention-deficit/hyperactivity disorder in children. J Clin
Psychiatry 2002;63 Suppl 12:16-22.
Waknine Y. Strattera Linked to Risk of Suicidal Thinking in
Pediatric Patients. In: Medscape; 2005.
¢¹Ò´¢Í§ÂÒ·Ò§¨ÔµàÇª·ÕèãªŒº‹ÍÂã¹¼ÙŒÊÙ§ÍÒÂØ
µÒÃÒ§·Õè 29 áÊ´§¢¹Ò´¢Í§ÂÒ·Ò§¨ÔµàÇª·ÕèãªŒº‹ÍÂã¹¼ÙŒÊÙ§ÍÒÂØ
ßČęĂ÷ć ×îćé÷ć (mg/day)
Antidepressants
Imipramine 25 -300
Desipramine 10 - 300
Amitriptyline 25 - 300
Nortriptyline 10 - 150
Doxepine 10 - 300
Fluoxetine 5 - 80
Fluvoxamine 25 -150
Paroxetine 5 - 20
Sertraline 50 - 150
Mood stabilizers
Lithium salts 75 - 900
Valproate 250 - 1,000
Carbamazepine 200 - 1,200
Antipsychotic medications
Chlorpromazine 30 - 300
Perphenazine 8 - 32
Trifluoperazine 1 - 15
Thioridazine 25 - 300
Haloperidol 2 - 20
Risperidone 2-4
Antianxiety and hypnotic medication
Alprazolam 0.25 - 2
Diazepam 2 - 60
Flurazepam 15 - 30
Lorazepam 0.5 - 6
Temazepam 15 - 30
Triazolam 0.125 - 0.25
Zolpidem 2.5 - 5
ÊµÃÕµÑé§¤ÃÃÀ¡ÑºÂÒ¨ÔµàÇª
¡ÒÃÈÖ¡ÉÒà¾×èÍ¾ÔÊÙ¨¹¤ÇÒÁà»š¹¾ÔÉ¢Í§ÂÒ (teratogenicity) ·ÕèÁÕµ‹Í·ÒÃ¡ã¹
¤ÃÃÀÁÒÃ´Ò¹Ñ¹é ·íÒä´Œ¤Í‹ ¹¢ŒÒ§ÂÒ¡ ËÒ¡äÁ‹¾ºÃÒÂ§Ò¹Ç‹ÒÂÒµÑÇã´ÁÕ¼Åµ‹Í·ÒÃ¡ã¹¤ÃÃÀ
ÁÒÃ´ÒÁÒ¡‹Í¹ äÁ‹ä´ŒáÊ´§Ç‹ÒÂÒ´Ñ§¡Å‹ÒÇ¹Ñ¹é ÁÕ¤ÇÒÁ»ÅÍ´ÀÑÂ ¢ŒÍÁÙÅ·Õäè ´Œ¨Ò¡¡ÒÃÈÖ¡ÉÒ
ã¹ÊÑµÇ·´ÅÍ§à»š¹à¾ÕÂ§¢ŒÍÁÙÅàµ×Í¹ãËŒÃÐÇÑ§ÍÑ¹µÃÒÂ·ÕèÍÒ¨¨Ðà¡Ô´¡Ñº·ÒÃ¡ã¹¤ÃÃÀ
ÁÒÃ´Ò à¹×èÍ§¨Ò¡Á¹ØÉÂáÅÐÊÑµÇ·´ÅÍ§¹Ñé¹ÁÕ¤ÇÒÁáµ¡µ‹Ò§¡Ñ¹ µÑÇÍÂ‹Ò§ àª‹¹ ¡ÒÃ
ÈÖ¡ÉÒ¾ºÇ‹ÒÂÒ Thalidomide äÁ‹·íÒãËŒà¡Ô´ÀÒÇÐ¼Ô´»¡µÔã¹ÊÑµÇ·´ÅÍ§ áµ‹¡ÅÑº¾º
Ç‹ÒÂÒ´Ñ§¡Å‹ÒÇÁÕ¼Åµ‹Í·ÒÃ¡ã¹¤ÃÃÀÁÒÃ´Ò ´Ñ§¹Ñ¹é ¡ÒÃãªŒÂÒ¨ÔµàÇªã¹ÊµÃÕµ§Ñé ¤ÃÃÀ¤ÇÃ
¾Ô¨ÒÃ³Ò¶Ö§¢ŒÍ´ÕáÅÐ¢ŒÍàÊÕÂ¢Í§ÂÒ·ÕèÍÒ¨ÁÕ¼Åµ‹ÍÊµÔ»˜ÞÞÒáÅÐ¾ÄµÔ¡ÃÃÁ¢Í§à´ç¡·Ñé§
ã¹ÃÐÂÐÊÑé¹áÅÐÃÐÂÐÂÒÇ ÃÇÁ¶Ö§¼Å¡ÃÐ·º·ÕèÍÒ¨à¡Ô´µ‹ÍÁÒÃ´Ò·ÕèäÁ‹ä´ŒÃÑº¡ÒÃÃÑ¡ÉÒ
Í§¤¡ÒÃÍÒËÒÃáÅÐÂÒ¢Í§»ÃÐà·ÈÊËÃÑ°ÍàÁÃÔ¡Ò (Food and Drug Administration,
FDA) ä´Œáº‹§ÃÐ´Ñº¤ÇÒÁàÊÕèÂ§¢Í§ÂÒ·ÕèãªŒã¹ÊµÃÕµÑé§¤ÃÃÀà»š¹ 5 ¡ÅØ‹Á
µÒÃÒ§·Õè 30 áÊ´§ FDA Use-in-Pregnancy Ratings
Category Interpretation
Controlled studies show no risk. Adequate, well-controlled studies in
A
pregnant women have failed to demonstrate risk to the fetus.
No evidence of risk in humans. Either animal findings show risk, but
B human findings do not, or if no adequate human studies have been
done, animal findings are negative.
Risk cannot be ruled out. Human studies are lacking, and animal studies
C are either positive for fetal risk or lacking as well. However, potential
benefits may justify the potential risk.
Positive evidence of risk. Investigational or postmarketing data show risk
D to the fetus. Nevertheless, potential benefits may outweigh the
potential risk.
Contraindicated in pregnancy. Studies in animals or humans, or
X investigational or postmarketing reports have shown fetal risk that
clearly outweighs any possible benefit to the patient.
ËÅÑ¡¡ÒÃãªŒÂÒã¹ÊµÃÕµ§Ñé ¤ÃÃÀà¾×Íè Å´ÍÑµÃÒàÊÕÂè §µ‹Í¡ÒÃà¡Ô´ÍÑ¹µÃÒÂ¡Ñº·ÒÃ¡
ã¹¤ÃÃÀÁÒÃ´Ò ¤×Í
1. ËÅÕ¡àÅÕÂè §¡ÒÃãªŒÂÒ·Ø¡ª¹Ô´ã¹ª‹Ç§äµÃÁÒÊáÃ¡¢Í§¡ÒÃµÑ§é ¤ÃÃÀâ´Âà©¾ÒÐ
ª‹Ç§ÇÑ¹·Õè 17-60 ÇÑ¹ËÅÑ§»¯ÔÊ¹¸Ô à¹×èÍ§¨Ò¡à»š¹ª‹Ç§·ÕèàÊÕèÂ§·ÕèÊØ´µ‹Í¡ÒÃà¡Ô´ÀÒÇÐà»š¹
¾ÔÉµ‹Í·ÒÃ¡ã¹¤ÃÃÀÁÒÃ´Ò
2. ãªŒÂÒ¢¹Ò´µèÒí ·ÕÊè ´Ø áÅÐà½‡ÒÃÐÇÑ§¼Å¢ŒÒ§à¤ÕÂ§·ÕÍè Ò¨¨Ðà¡Ô´µ‹Í·ÒÃ¡ã¹¤ÃÃÀ
ÁÒÃ´ÒÍÂ‹Ò§ã¡ÅŒªÔ´
3. ËÅÕ¡àÅÕèÂ§¡ÒÃãªŒÂÒËÅÒÂ¡ÅØ‹Áà¹×èÍ§¨Ò¡à¾ÔèÁâÍ¡ÒÊàÊÕèÂ§µ‹Í¡ÒÃàÊÃÔÁÄ·¸Ôì
¤ÇÒÁà»š¹¾ÔÉµ‹Í·ÒÃ¡ã¹¤ÃÃÀÁÒÃ´Ò
4. ¾Ô¨ÒÃ³Òà¾ÔÁè ËÃ×ÍÅ´¢¹Ò´ÂÒÅ§ à¹×Íè §¨Ò¡¤Ø³ÊÁºÑµ´Ô ÒŒ ¹àÀÊÑª¨Å¹ÈÒÊµÃ
¢Í§ÂÒã¹ÊµÃÕµÑé§¤ÃÃÀÁÕ¡ÒÃà»ÅÕèÂ¹á»Å§ àª‹¹ ÍÒ¨µŒÍ§à¾ÔèÁ¢¹Ò´ÂÒá¡Œ«ÖÁàÈÃŒÒ¡ÅØ‹Á
tricyclic antidepressants ã¹ª‹Ç§äµÃÁÒÊ·Õè 3 ¢Í§¡ÒÃµÑé§¤ÃÃÀà»š¹ 1.6 à·‹Ò¢Í§
¢¹Ò´ÂÒ·ÕèãªŒã¹ÀÒÇÐ»¡µÔ
ÂÒÃÑ¡ÉÒâÃ¤¨Ôµ (Antipsychotic drug)

¨Ñ´áº‹§¡ÅØ‹ÁÂÒÃÑ¡ÉÒâÃ¤¨ÔµµÒÁ FDA ä´Œ´Ñ§µÒÃÒ§
µÒÃÒ§·Õè 31 áÊ´§¡ÒÃ¨Ñ´áº‹§¡ÅØ‹ÁÂÒµÒÁ Pregnancy Categories ¢Í§ FDA
ÙüćöđÿĊę÷ÜêęĞć ÙüćöđÿĊę÷ÜðćîÖúćÜ ÙüćöđÿĊę÷ÜÿĎÜ
ÖúčŠö÷ćìćÜÝĉêđüß
Category= A Category= B Category= C Category= D Category= X
÷ćøĆÖþćēøÙÝĉê Clozapine - Phenothiazine
(Antipsychotic drug) (Chlorpromazine,
Thioridazine,
Trifluoperazine,
Perphenazine)
- Butyrophenones
(Haloperidol)
- Thioxanthenes
(Flupentixol)
- Risperidone
- Olanzapine
- Quetiapine
- Aripiprazole
- Paliperidone
÷ćøĆÖþćĂćÖćøđýøšć - Fluoxetine - Clomipramine - Amitriptyline
(Antidepressant) - Sertraline - Nortriptyline
- Citalopram
- Fluvoxamine
- Mianserin
- Mirtazapine
- Trazodone
- Venlafaxine
÷ćìĞćĔĀšĂćøöèŤÙÜìĊę - Carbamazepine - Valproate - Lithium
(Mood stabilizer) - Phenobarbital
÷ćÙúć÷ÖĆÜüúĒúą - Clonazepam - Alprazolam
÷ćîĂîĀúĆï - Chlordia-
(Anxiolytic and zepoxide
hypnotics) - Diazepam
- Lorazepam
- Zolpidem
¼Å¢Í§ÂÒÃÑ¡ÉÒâÃ¤¨Ôµµ‹Í·ÒÃ¡
1. Teratogenic effects
¨Ò¡¡ÒÃÈÖ¡ÉÒ·Õ¼è Ò‹ ¹ÁÒ¾ºÇ‹ÒäÁ‹ÁÂÕ ÒÃÑ¡ÉÒâÃ¤¨Ôµª¹Ô´ã´ÁÕ¼Åµ‹Í·ÒÃ¡ã¹¤ÃÃÀ
ÁÒÃ´Òã¹´ŒÒ¹ structural birth defects, behavioral, emotional ËÃ×Í cognitive
abnormalities ÁÕà¾ÕÂ§ÃÒÂ§Ò¹¶Ö§ÀÒÇÐ neurobehavioral abnormalities ã¹ÊÑµÇ
·´ÅÍ§
2. Neonatal effects
ÁÕÃÒÂ§Ò¹¾º·ÒÃ¡áÃ¡à¡Ô´·ÕèÁÒÃ´Òä´ŒÃÑºÂÒÃÑ¡ÉÒâÃ¤¨Ôµ¡ÅØ‹Á low-potency
ÁÕÍÒ¡ÒÃ tachycardia, gastrointestinal dysfunction, sedation áÅÐ hypotension
â´ÂÍÒ¡ÒÃ¨Ð¤§ÍÂÙ‹»ÃÐÁÒ³ 2-3 ÇÑ¹ áÅÐ¤ÇÒÁÃØ¹áÃ§¢Í§ÍÒ¡ÒÃ¢Öé¹ÍÂÙ‹¡ÑºÃÐÂÐàÇÅÒ
·Õ·è ÒÃ¡ä´ŒÃºÑ ÂÒ¢³ÐÍÂÙã‹ ¹¤ÃÃÀÁÒÃ´Ò Ê‹Ç¹·ÒÃ¡áÃ¡à¡Ô´·ÕÁè ÒÃ´Òä´ŒÃºÑ ÂÒÃÑ¡ÉÒâÃ¤¨Ôµ
¡ÅØ‹Á high-potency ¨ÐÁÕÍÒ¡ÒÃ´ŒÒ¹ extrapyramidal àª‹¹ hyperactivity,
hyperactive deep tendon reflexs, motor restlessness, tremors, posturing
ËÃ×Í flapping ¢Í§Á×Í muscle tone à¾ÔèÁ¢Öé¹ áÅÐ abnormal movements «Öè§
ÍÒ¡ÒÃ´Ñ§¡Å‹ÒÇÍÒ¨¤§ÍÂÙ‹¹Ò¹à»š¹àÇÅÒËÅÒÂà´×Í¹
â´Â·ÑèÇä»ÂÒÃÑ¡ÉÒâÃ¤¨Ôµ¡ÅØ‹Á high-medium potency (Fluphenazine,
Haloperidol, Perphenazine, Thiothixene áÅÐ Trifluoperazine) »ÅÍ´ÀÑÂÊíÒËÃÑº
ÊµÃÕµ§Ñé ¤ÃÃÀ à¹×Íè §¨Ò¡ÁÕ¼Å´ŒÒ¹ anticholinergic, hypotension áÅÐ antihistamine
µèíÒ áµ‹¤ÇÃÃÐÇÑ§¼Å´ŒÒ¹ drug-induced extrapyramidal reaction ·ÕèÍÒ¨¨Ðà¡Ô´¡Ñº
·ÒÃ¡ã¹¤ÃÃÀã¹ª‹Ç§ËÅÑ§¤ÅÍ´ Ê‹Ç¹¢ŒÍÁÙÅÈÖ¡ÉÒ¡ÒÃãªŒÂÒ Clozapine ã¹ÊµÃÕµ§Ñé ¤ÃÃÀ
ã¹»˜¨¨Øº¹Ñ ¹Õ¾é ºÇ‹Ò¤‹Í¹¢ŒÒ§»ÅÍ´ÀÑÂ Ê‹Ç¹ÂÒ Olanzapine, Pimozide áÅÐ Risperidone
¹Ñé¹ÂÑ§äÁ‹ÁÕ¢ŒÍÁÙÅ¡ÒÃÈÖ¡ÉÒ·ÕèÂÒÇ¹Ò¹à¾ÕÂ§¾Í·Õè¨ÐÊÃØ»ä´Œ ¹Í¡¨Ò¡¹Õé¤ÇÃËÅÕ¡àÅÕèÂ§¡ÒÃ
ãªŒÂÒ©Õ´ long-action (depot) ã¹¡ÅØ‹Á high-potency (Fluphenazine decanoate,
Haloperidol decanoate) ã¹ÊµÃÕµ§Ñé ¤ÃÃÀ à¹×Íè §¨Ò¡ÍÒ¨ÁÕ¼Åà»š¹¾ÔÉµ‹Í·ÒÃ¡ã¹¤ÃÃÀ
ÁÒÃ´ÒáÅÐã¹ÃÐÂÐËÅÑ§¤ÅÍ´ä´Œã¹ÃÐÂÐàÇÅÒ¹Ò¹ ÍÂ‹Ò§äÃ¡çµÒÁ äÁ‹¾ºÃÒÂ§Ò¹ÀÒÇÐ
¢Ò´ÂÒµŒÒ¹âÃ¤¨Ôµ (withdrawal) µÑÇã´·Ñé§ã¹ÁÒÃ´ÒáÅÐ·ÒÃ¡áÃ¡à¡Ô´
ÂÒÃÑ¡ÉÒÍÒ¡ÒÃàÈÃŒÒ (Antidepressants)
¨Ñ´áº‹§¡ÅØ‹ÁÂÒÃÑ¡ÉÒÍÒ¡ÒÃàÈÃŒÒµÒÁ FDA ´Ñ§µÒÃÒ§
¼Å¢Í§ÂÒÃÑ¡ÉÒÍÒ¡ÒÃàÈÃŒÒµ‹Í·ÒÃ¡
1) Teratogenic effects
äÁ‹ÁÃÕ ÒÂ§Ò¹¤ÇÒÁà»š¹¾ÔÉ¢Í§ÂÒÃÑ¡ÉÒÍÒ¡ÒÃàÈÃŒÒ¡ÅØÁ‹ TCAs, monoamine
oxidase inhibitors, Paroxetine, Sertraline, Venlafaxine áÅÐ Fluoxetine ·ÕèÁÕ
µ‹Í·ÒÃ¡ã¹¤ÃÃÀÁÒÃ´Ò·ÕèªÑ´à¨¹ ¹Í¡¨Ò¡ÃÒÂ§Ò¹¡ÒÃ¾º birth defect ã¹·ÒÃ¡
1 ÃÒÂ ¨Ò¡·ÒÃ¡·Ñé§ËÁ´ 100 ÃÒÂ ·ÕèÁÒÃ´Òä´ŒÃÑºÂÒ Trazodone Ê‹Ç¹¤ÇÒÁ¼Ô´»¡µÔ
ã¹´ŒÒ¹ neurobehavior ¹Ñé¹ ÁÕà¾ÕÂ§ÃÒÂ§Ò¹¡ÒÃà¡Ô´ÀÒÇÐ´Ñ§¡Å‹ÒÇã¹ÊÑµÇ·´ÅÍ§
Ê‹Ç¹·ÒÃ¡ã¹¤ÃÃÀ·ÁÕè ÒÃ´Òä´ŒÃºÑ ÂÒ¡ÅØÁ‹ TCAs ËÃ×Í Fluoxetine ¹Ñ¹é ¾ºÇ‹ÒäÁ‹Á¤Õ ÇÒÁ
¼Ô´»¡µÔ¢Í§ global IQ ËÃ×Í¾Ñ²¹Ò¡ÒÃ´ŒÒ¹ÀÒÉÒáÅÐ¾ÄµÔ¡ÃÃÁ
2) Neonatal effects
ÁÕÃÒÂ§Ò¹·ÒÃ¡áÃ¡à¡Ô´·Õèä´ŒÃÑºÂÒ Desipramine, Imipramine áÅÐ
Nortriptyline ¢³ÐÍÂÙ‹ã¹¤ÃÃÀÁÒÃ´Òã¹ÃÐÂÐËÅÑ§¤ÅÍ´ÁÕÍÒ¡ÒÃ periodic apnea,
cyanosis, tachypnea, irritability, seizure, feeding difficulties, heart failure,
tachycardia, myoclonus, respiratory distress áÅÐ urinary retention
â´Â·ÑèÇä» Nortriptyline ¹ÔÂÁãªŒã¹ÊµÃÕµÑé§¤ÃÃÀà¹×èÍ§¨Ò¡¼Å¢ŒÒ§à¤ÕÂ§´ŒÒ¹
sedation, ÃÐºº·Ò§à´Ô¹ÍÒËÒÃ áÅÐËÑÇã¨ ÃÇÁ·Ñé§¡ÒÃà¡Ô´ hypotension ¨ÐµèíÒ áµ‹
¤ÇÃãªŒ Â Òã¹¢¹Ò´µèí Ò ·Õè ÊØ ´ à¾×è Í ¤Çº¤Ø Á ÍÒ¡ÒÃ ·Ñé § ¹Õé à ¹×è Í §¨Ò¡ÊµÃÕ µÑé § ¤ÃÃÀ ÁÕ ¡ ÒÃ
à»ÅÕèÂ¹á»Å§·Ò§ÊÃÕÃÇÔ·ÂÒã¹´ŒÒ¹ renal function áÅÐ total body water â´Â
à©¾ÒÐª‹Ç§äµÃÁÒÊ·ÕÊè ÒÁ¢Í§¡ÒÃµÑ§é ¤ÃÃÀ «Ö§è ÍÒ¨·íÒãËŒµÍŒ §à¾ÔÁè ¢¹Ò´ÂÒÁÒ¡¡Ç‹Ò·Õãè ªŒ
ã¹ÀÒÇÐ»¡µÔ·ÑèÇä» Ê‹Ç¹ÂÒ Fluoxetine ¹Ñé¹ÁÕ¤ÇÒÁ»ÅÍ´ÀÑÂÊÙ§à·ÕÂºà·‹Ò¡Ñº
Nortriptyline à¹×èÍ§¨Ò¡ äÁ‹ÁÕÃÒÂ§Ò¹¤ÇÒÁàÊÕèÂ§µ‹Í·ÒÃ¡ã¹¤ÃÃÀÁÒÃ´Ò·Õèä´ŒÃÑºÂÒã¹
ª‹Ç§äµÃÁÒÊáÃ¡ áµ‹ÁÃÕ ÒÂ§Ò¹¶Ö§¡ÒÃà¾ÔÁè ¤ÇÒÁàÊÕÂè §µ‹ÍÀÒÇÐ·ÒÃ¡¹éÒí Ë¹Ñ¡µÑÇ¹ŒÍÂ ¶ŒÒ
ä´ŒÃÑºÂÒÍÂ‹Ò§µ‹Íà¹×èÍ§µÑé§áµ‹ÍÒÂØ¤ÃÃÀ 25 ÊÑ»´ÒËà»š¹µŒ¹ä»
¢ŒÍÁÙÅ¡ÒÃÈÖ¡ÉÒÂÒ Fluvoxamine, Paroxetine áÅÐ Sertraline ¨¹¶Ö§
»˜¨¨ØºÑ¹¹ÕéÂÑ§äÁ‹ÁÕÃÒÂ§Ò¹Ç‹Òà¾ÔèÁâÍ¡ÒÊàÊÕèÂ§µ‹Í¡ÒÃà¡Ô´ÀÒÇÐà»š¹¾ÔÉµ‹Í·ÒÃ¡ã¹¤ÃÃÀ
ÁÒÃ´Ò Ê‹Ç¹¡ÒÃãªŒÂÒ monoamine oxidase inhibitors ã¹ÊµÃÕµÑé§¤ÃÃÀ¹Ñé¹¤ÇÃ
ËÅÕ¡àÅÕèÂ§ à¹×èÍ§¨Ò¡à¾ÔèÁâÍ¡ÒÊàÊÕèÂ§µ‹ÍÀÒÇÐ hypertension ã¹ª‹Ç§µÑé§¤ÃÃÀ ¶Ö§áÁŒ
äÁ‹ÁÕÃÒÂ§Ò¹¶Ö§ÀÒÇÐ¾ÔÉµ‹Í·ÒÃ¡ã¹¤ÃÃÀÁÒÃ´Ò¡çµÒÁ Ê‹Ç¹ÂÒ Mirtazapine,
Nefazodone, Trazodone áÅÐ Venlafaxine ¨¹¶Ö§»˜¨¨ØºÑ¹¹ÕéÂÑ§äÁ‹ÁÕ¢ŒÍÁÙÅà¾ÕÂ§
¾Í·Õè¨ÐÊÃØ»¶Ö§¤ÇÒÁ»ÅÍ´ÀÑÂ¨Ö§¤ÇÃËÅÕ¡àÅÕèÂ§¡ÒÃãªŒã¹ÊµÃÕµÑé§¤ÃÃÀ
ÂÒ·íÒãËŒÍÒÃÁ³¤§·Õè (Mood stabilizer)

¨Ñ´áº‹§¡ÅØ‹ÁÂÒ·íÒãËŒÍÒÃÁ³¤§·ÕèµÒÁ FDA ä´Œ´Ñ§µÒÃÒ§
¼Å¢Í§ÂÒ·íÒãËŒÍÒÃÁ³¤§·Õèµ‹Í·ÒÃ¡
ã¹Í´Õµ·Õè¼‹Ò¹ÁÒ¾º¡ÒÃà¡Ô´ congenital cardiovascular malformation
â´Âà©¾ÒÐ Ebstein’s anomaly ¡Ñº·ÒÃ¡ã¹¤ÃÃÀÁÒÃ´Ò·Õèä´ŒÃÑº Lithium ã¹ª‹Ç§
äµÃÁÒÊáÃ¡¢Í§¡ÒÃµÑé§¤ÃÃÀ
Ê‹Ç¹ã¹¡ÅØÁ‹ ÂÒ anticonvulsant ¹Ñ¹é ÁÕÃÒÂ§Ò¹¡ÒÃà¡Ô´ facial dysmorphism,
cleft lip áÅÐ palate, cardiac defects, digitalhypoplasia áÅÐ nail
dysplasia ¡Ñº·ÒÃ¡ã¹¤ÃÃÀÁÒÃ´Ò·Õèä´ŒÃÑºÂÒ Phenytoin, Carbamazepine áÅÐ
Valproate ã¹ÃÐËÇ‹Ò§µÑé§¤ÃÃÀ ¹Í¡¨Ò¡¹Õé¾ºÍÑµÃÒ¡ÒÃà¡Ô´ neural tube defects
(spina bifida) ¨Ò¡¡ÒÃãªŒÂÒ Carbamazepine ÃŒÍÂÅÐ 1 áÅÐ¨Ò¡ÂÒ Valproate
ÃŒÍÂÅÐ 1-2 «Öè§ÊÙ§¡Ç‹ÒÍÑµÃÒ·Õè¾ºã¹¡ÅØ‹Á»ÃÐªÒ¡Ã·ÑèÇä»¶Ö§ 50 à·‹Ò áÅÐ¾ºÇ‹Ò
Valproate ·íÒãËŒà¡Ô´ÀÒÇÐ intrauterine growth retardation, hyperbilirubinemia,
hepatotoxicity, skeletal dysplasia áÅÐ fetal distress
2. Fetal and neonatal effects
·ÒÃ¡ã¹¤ÃÃÀÁÒÃ´Ò·Õèä´ŒÃÑº Lithium ª‹Ç§äµÃÁÒÊ·Õè 2, 3 ¢Í§¡ÒÃµÑé§¤ÃÃÀ
áÅÐã¹ª‹Ç§ËÅÑ§¤ÅÍ´ ÍÒ¨¾ºÀÒÇÐ fetal thyroid goiter, hypothyroidism áÅÐ
¶ŒÒä´ŒÃÑº Lithium ã¹¢¹Ò´·Õèà»š¹¾ÔÉ ·ÒÃ¡áÃ¡¤ÅÍ´¨ÐÁÕÍÒ¡ÒÃ cyanosis,
hypotonia, bradycardia, atrial flutter, hepatomegaly, T-wave inversion,
cardiomegaly, gastrointestinal bleeding, diabetes insipidus, seizure áÅÐ
shock ÍÂ‹Ò§äÃ¡çµÒÁ ÀÒÇÐ´Ñ§¡Å‹ÒÇ¨ÐËÒÂä»ÀÒÂã¹ 1-2 ÊÑ»´ÒËËÅÑ§¤ÅÍ´ Ê‹Ç¹
·ÒÃ¡ã¹¤ÃÃÀÁÒÃ´Ò·Õäè ´ŒÃºÑ ÂÒ Carbamazepine ¹Ñ¹é ÍÒ¨¾ºÀÒÇÐ¡ÒÃ¢Ò´ vitamin
K-dependent clotting factors áººªÑèÇ¤ÃÒÇã¹ª‹Ç§ËÅÑ§¤ÅÍ´ «Öè§ÍÒ¨·íÒãËŒà¡Ô´
àÅ×Í´ÍÍ¡ã¹ÊÁÍ§ áµ‹ÀÒÇÐ´Ñ§¡Å‹ÒÇÊÒÁÒÃ¶»‡Í§¡Ñ¹ä´Œâ´ÂãËŒ vitamin K 10-20
Á¡./ÇÑ¹ á¡‹ÁÒÃ´ÒµÑé§áµ‹ª‹Ç§ÍÒÂØ¤ÃÃÀ 36 ÊÑ»´ÒËà»š¹µŒ¹ä»¨¹¶Ö§ÇÑ¹¤Ãº¡íÒË¹´
¤ÅÍ´ºØµÃ ¹Í¡¨Ò¡¹ÕéÁÕÃÒÂ§Ò¹ÀÒÇÐ fetal Valproate syndrome «Öè§»ÃÐ¡Íº´ŒÇÂ
congenital heart defects Ã‹ÇÁ¡ÑºÀÒÇÐ¢Ò´ÂÒ Valproate â´ÂÁÕÍÒ¡ÒÃ
irritability, jitteriness, hypotonia áÅÐ feeding problems â´ÂÊÒàËµØ¹Ñé¹ÍÒ¨
ÁÒ¨Ò¡·ÒÃ¡ä´ŒÃÑºÂÒ Valproate µÑé§áµ‹ª‹Ç§äµÃÁÒÊáÃ¡¢Í§¡ÒÃµÑé§¤ÃÃÀ áÅÐä´ŒÃÑº
ÂÒã¹¢¹Ò´ÊÙ§
ÂÒ¤ÅÒÂ¡Ñ§ÇÅáÅÐÂÒ¹Í¹ËÅÑº (Anxiolytic and hypnotics)

¨Ñ´áº‹§¡ÅØ‹ÁÂÒ¤ÅÒÂ¡Ñ§ÇÅáÅÐÂÒ¹Í¹ËÅÑºµÒÁ FDA ä´Œ´Ñ§µÒÃÒ§
¼Å¢Í§ÂÒ¤ÅÒÂ¡Ñ§ÇÅáÅÐÂÒ¹Í¹ËÅÑºµ‹Í·ÒÃ¡
¡ÒÃÈÖ¡ÉÒ·Õè¼‹Ò¹ÁÒ¾ºÇ‹Ò ÂÒ¡ÅØ‹Á Benzodiazepines ÁÕ¤ÇÒÁà»š¹¾ÔÉÊÙ§µ‹Í
·ÒÃ¡ã¹¤ÃÃÀÁÒÃ´Ò â´Â¾ºÇ‹Ò ¡ÒÃãªŒÂÒ Chlordiazepoxide ã¹ª‹Ç§ 1 à´×Í¹áÃ¡
¢Í§¡ÒÃµÑé§¤ÃÃÀ¨Ðà¾ÔèÁâÍ¡ÒÊàÊÕèÂ§µ‹Í¡ÒÃà»š¹¾ÔÉµ‹Í·ÒÃ¡ã¹¤ÃÃÀÁÒÃ´Ò¶Ö§ÃŒÍÂÅÐ
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inconsolable crying, tremors or jerking of the extremities, bradycardia,
cyanosis, chewing movements áÅÐ abdominal distention â´ÂÍÒ¡ÒÃ
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respiratory depression ã¹·ÒÃ¡áÃ¡¤ÅÍ´·ÕÁè ÒÃ´Òä´ŒÃºÑ ÂÒ Lorazepam «Ö§è ÁÕÄ·¸Ôì
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ÊÁºÙÃ³à·‹Ò¡Ñº¼ÙŒãËÞ‹
4. ¤ÇÃÊÑ§à¡µÍÒ¡ÒÃäÁ‹¾Ö§»ÃÐÊ§¤¨Ò¡ÂÒáµ‹ÅÐµÑÇã¹·ÒÃ¡ÍÂ‹Ò§ã¡ÅŒªÔ´
5. ã¹¡Ã³Õ·ÕèÁÒÃ´Òä´ŒÃÑºÂÒ¨ÔµàÇªÁÒµÅÍ´ÃÐÂÐàÇÅÒ·ÕèµÑé§¤ÃÃÀ áÅÐÃÐËÇ‹Ò§
¤ÅÍ´ ÍÒ¨¨íÒà»š¹µŒÍ§ä´ŒÃÑºÂÒµ‹Íã¹ÃÐËÇ‹Ò§·ÕèãËŒ¹ÁºØµÃ à¾×èÍ»‡Í§¡Ñ¹¡ÒÃà¡Ô´ withdrawal
symptoms ã¹·ÒÃ¡
6. ¤ÇÃãªŒÂÒã¹¢¹Ò´µèíÒÊØ´·ÕèÊÒÁÒÃ¶¤Çº¤ØÁÍÒ¡ÒÃ¢Í§âÃ¤ä´Œ
µÒÃÒ§·Õè 32 áÊ´§ÂÒ¨ÔµàÇª·Õèá¹Ð¹íÒãËŒãªŒã¹ËÞÔ§ãËŒ¹ÁºØµÃ
ÖúčŠö÷ć ÷ćìĊęĒîąîĞć
÷ćøĆÖþćĂćÖćøđýøšć Sertraline (Recommend)
(Antidepressant) ÷ćøć÷ÖćøĂČęîìĊęĔßšĕéš ÙČĂ Paroxetine, Nortriptyline, Imipramine
÷ćêšćîēøÙÝĉê Olanzapine (Recommend)
(Antipsychotics) ÷ćøć÷ÖćøĂČęîìĊęĔßšĕéš ÙČĂ Haloperidol, Perphenazine,
Trifluoperazine
÷ćìĞćĔĀšĂćøöèŤÙÜìĊę Valproate (Recommend) ĒêŠÙüøđòŜćøąüĆÜÖćøđÖĉéóĉþêŠĂêĆïĔî
(Mood stabilizer) ìćøÖ
÷ćÙúć÷ÖĆÜüúĒúą÷ćîĂîĀúĆï ÷ćÙúć÷ÖĆÜüú ìĊęĒîąîĞćÙČĂ Lorazepam
(Anxiolytic and hypnotics) ÷ćîĂîĀúĆï ìĊĒę îąîĞćÙČĂ Zolpidem
¨ÒÃØÃÔ¹·Ã »µÒ¹Ø¾§È. ÊµÃÕµÑé§¤ÃÃÀ¡ÑºÂÒ¨ÔµàÇª. Ê§¢ÅÒ¹¤ÃÔ¹·ÃàÇªÊÒÃ 2546;
21: 63-70.
ÁÒâ¹ª ËÅ‹ÍµÃÐ¡ÙÅ áÅÐ »ÃÒâÁ·Â ÊØ¤¹ÔªÂ, ºÃÃ³Ò¸Ô¡ÒÃ. ¨ÔµàÇªÈÒÊµÃ. ¡ÃØ§à·¾Ï:
ÊÇÔªÒÞ¡ÒÃ¾ÔÁ¾; 2545.
Teylor D., Paton C., Kapur S.. Prescribing guidelines in psychiatry.
11th ed. New Delhi: Wiley-blackwell; 2012.
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ìČęĂ úĉĚîĒ×ĘÜ îĚĞćúć÷ĕĀú (Trihexyphenidyl, Benadryl)
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EPS)
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ĂüĆ÷üąđóýĕöŠĒ×ĘÜêĆü ÖćøÙčöÖĞćđîĉé (ÖøèĊĕöŠöĊðøąÝĞćđéČĂî)
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Anticonvulsant ĒîąîĞćðøċÖþćĒóì÷Ť
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êšĂĀĉî: glaucoma) Anticonvulsant đĀĘîõćóàšĂî ðüéêć (glaucoma) ĔĀš
óïĒóì÷ŤđóČęĂðøĆï÷ć
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hypotension) Antidepressant ĒîąîĞćÙŠĂ÷ ė účÖ×ċĚîĀøČĂđðúĊę÷îìŠć
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arrhythmia ĔĀšĀ÷čé÷ć ĒúąóïĒóì÷Ť
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đóČęĂðøĆïđóĉęö÷ćìĊęßŠü÷úéĂćÖćøĔÝÿĆęî
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Antidepressant ÜŠüÜîĂîÝąéĊ×ċĚîđöČęĂøĆïðøąìćî÷ć
Anticonvulsant êŠĂđîČęĂÜøą÷ąĀîċęÜ ĒúąĒîąîĞćĔĀš
ĀúĊÖđúĊę÷ÜÖćø×Ćï×Ċę÷ćîóćĀîą ĀøČĂÜćîìĊę
đÖĊę÷ü×šĂÜÖĆïđÙøČęĂÜÝĆÖøÖú
ÖøèĊìĊęøïÖüîßĊüĉêðøąÝĞćüĆîöćÖ ĒîąîĞć
ĔĀšóïĒóì÷ŤđóČĂę ðøĆïđðúĊę÷î÷ć
- îĚĞćĀîĆÖ×ċĚî Antipsychotic drugs ïćÜøć÷ÝąđðŨîĒÙŠøą÷ąĒøÖ ĒîąîĞćĔĀš
Antidepressant ÙüïÙčöĂćĀćøĒúąĂĂÖÖĞćúĆÜÖć÷øŠüöéšü÷
Anticonvulsant Ĕîøć÷ìĊęÝĞćđðŨî Ēóì÷ŤÝąđðúĊę÷î÷ć
- öĊñČęîĒóšĒÿÜ ñĉüĕüêŠĂĒÿÜĒéé Antipsychotic drugs ĒîąîĞćĔĀšìćÙøĊöÖĆîĒéé ĒúąĀúĊÖđúĊę÷Ü
ñĉüÙúĚĞć×ċĚî ĒééìĊęĒøÜÝĆé
- öĊĕ×š đÝĘïÙĂ Antipsychotic drugs ÖøèĊìĊęÿĂïëćöĒúšüđðŨîúĆÖþèą×ĂÜÖćø
Antidepressant êĉéđßČĚĂĔîøąïïìćÜđéĉîĀć÷ĔÝ ĒîąîĞć
óïĒóì÷ŤìĊę øó.ĔÖúšïšćîĒúąĔĀšñĎšðśü÷
ïĂÖĒóì÷ŤüŠćøĆïðøąìćî÷ćìĊęĂćÝÿŠÜñú
ĔĀšêĉéđßČĚĂĕéšÜŠć÷ (Clozapine, Lithium)
ÖøèĊìĊęÿĂïëćöĒúšüĕöŠöĊĂćÖćø×ĂÜ URI
ĒúąñĎšðśü÷ĕéšøĆï÷ć Clozapine, Lithium
ĔĀšóïĒóì÷Ť
- ĂŠĂîđóúĊ÷ øĎšÿÖċ đĀöČĂîĒ×î×ćĕöŠÙŠĂ÷ Antipsychotic drugs Ăíĉïć÷ñĎšðśü÷ĔĀšìøćïüŠćĂćÝöĊĂćÖćø
öĊĒøÜ Antidepressant éĆÜÖúŠćüĕéš ĒêŠëšćđðŨîöćÖĔĀšóïĒóì÷Ť
Antiparkinson ÖøèĊìĊęóïüŠćöĊĂćÖćøĂŠĂîĒøÜđðŨîàĊÖ
ĀøČĂđóúĊ÷öćÖ ĔĀšóïĒóì÷Ť
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Antipsychotic drugs ĕéšøĆï÷ć ĒêŠÖøèĊìĊęðüéÝîøïÖüî
ßĊüĉêðøąÝĞćüĆîĔĀšóïĒóì÷Ť
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Anticonvulsant ðŦâĀćöćÖĒîąîĞćðøċÖþćĒóì÷Ť
- đĀÜČĂÖïüö (Gum Hypertrophy) Anticonvulsant óï ĒîąîĞćĔĀšéĎĒúÿč×õćó×ĂÜðćÖ ēé÷îüé
ïŠĂ÷ĔîñĎšðśü÷ìĊęĕéšøĆï đĀÜČĂÖ ĒðøÜôŦî éĎĒúÙüćöÿąĂćé×ĂÜ
Phenytoin ßŠĂÜðćÖ ĒúąđöČęĂĀ÷čé÷ćÝąéĊ×ċĚî
ëšćöĊðŦâĀćöćÖĒîąîĞćĔĀšðøċÖþć
ìĆîêĒóì÷Ť
- ðüé×šĂ ĒúąÖúšćöđîČĚĂ êąÙøĉü Antipsychotic drugs óïĒóì÷ŤđóČęĂðøĆï÷ć
Anticonvulsant
- đéĉîđà Antipsychotic drugs óïĒóì÷ŤđóČęĂðøĆï÷ć
Anticonvulsant
- éČęöîĚĞćöćÖ ðŦÿÿćüąöćÖ øŠüöÖĆïöĊ Lithium ÿĂïëćöñĎšðśü÷đóĉęöđêĉöëšćóïüŠćđðŨîöćÖ
öČĂÿĆęî ×ċĚîÖüŠćðÖêĉ ĔĀšóïĒóì÷ŤđóČęĂêøüÝøąéĆï
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đõÿĆßÖøđóČęĂĀć×šĂöĎúđóĉęöđêĉö đóČęĂđðŨî
×šĂöĎúðøąÖĂïĔĀšĒóì÷ŤüĉîÝĉ ÞĆ÷
Ā÷čé÷ć ĒúąóïĒóì÷Ť
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ĕéšøĆï ĒúąÿĂïëćöÙüćöøčîĒøÜ ÖøèĊìĊę
đðŨîöćÖ ÿŠÜðøċÖþćĒóì÷Ť
¡ÒÃá¹Ð¹íÒ¼ÙŒ»†ÇÂ¡Ã³Õ¾ºÇ‹Ò¼ÙŒ»†ÇÂäÁ‹Ã‹ÇÁÁ×Íã¹¡ÒÃãªŒÂÒ (Non-Compliance)
¤ÇÒÁÃ‹ÇÁÁ×Íã¹¡ÒÃãªŒÂÒ (Compliance) ËÁÒÂ¶Ö§ ¡ÒÃ·Õè¼ÙŒ»†ÇÂÊÒÁÒÃ¶ãªŒ

ÂÒä´ŒµÒÁá¼¹¡ÒÃÃÑ¡ÉÒ¢Í§á¾·Â «Öè§¢ŒÍÁÙÅ¨Ðä´Œ¨Ò¡¡ÒÃÊÍº¶ÒÁ¼ÙŒ»†ÇÂÇ‹Òä´Œ
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ÿćđĀêčìĊę Non-compliance ĒîüìćÜÖćøĔĀšÙĞćĒîąîĞćĒúąĒÖšĕ×
ĂćÖćøéĊ×ċĚîÙĉéüŠćĀć÷ĒúšüĕöŠ ĒîąîĞćÙüćöÿĞćÙĆâ×ĂÜ÷ćêŠĂēøÙĒúąĂćÖćø×ĂÜñĎšðśü÷
øĆïðøąìćî÷ćêŠĂ/Ā÷čé÷ćđĂÜ
ñĎšðśü÷ĕöŠ÷ĂöÖĉî÷ć ÙšîĀćÿćđĀêč×ĂÜÖćøĕöŠ÷ĂöÖĉî÷ć
ĒîąîĞćĔĀšÙüćöøĎšêćöÿćđĀêčìĊęÙšîóï đßŠîöĊÖćøĒóš÷ć ĔĀšÙćĞ ĒîąîĞć
ñú×šćÜđÙĊ÷Ü×ĂÜÖćøĒóš÷ć ĒúąÿŠÜóïĒóì÷ŤđóČęĂðøċÖþćÖćøĔĀš÷ć
ĒîąîĞćâćêĉĔĀšÙĂ÷éĎĒúĔĀšñĎšðüś ÷Öĉî÷ć, ÙüćöÿĞćÙĆâ×ĂÜ÷ćêŠĂĂćÖćø×ĂÜ
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đðŨî÷ćÞĊé
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đÿîĂĔĀšøĆï÷ćĔÖúšïšćî ĒúąÖøèĊìĊęñĎšðśü÷ÝąĕðøĆï÷ćìĊę øó.ĔÖúšïšćî ĒêŠìĊę
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ĂćÝúéĀøČĂđóĉęö÷ćïćÜßîĉé ìĞćĔĀšđÖĉéĂćÖćø×šćÜđÙĊ÷Ü
ĒîąîĞćÖćøĒÖšĕ×ĂćÖćø×šćÜđÙĊ÷ÜđïČĚĂÜêšî ĒúąÖøèĊìĊęđðŨîöćÖĔĀšöćóï
Ēóì÷ŤđóČęĂðøĆïđðúĊę÷î÷ć
ĕðìĞćÜćîêŠćÜÝĆÜĀüĆéĕöŠĕéšöćøĆï÷ć ĒîąîĞćĔĀšñĎšðśü÷ìøćïëċÜÙüćöÿĞćÙĆâ×ĂÜÖćøøĆïðøąìćî÷ćêŠĂđîČęĂÜ
êŠĂđîČęĂÜ ĒîąîĞćÿëćîïøĉÖćøÿćíćøèÿč×ĔÖúšđÙĊ÷ÜìĊñę Ďšðśü÷ÿćöćøëĕðøĆï÷ćéšü÷
êîđĂÜ ĒúąĒîąîĞćñĎšðśü÷ĕð÷ĆÜÜćîÿŠÜêŠĂ (Refer)
ĒîąîĞćĔĀšâćêĉñĎšðśü÷öćøĆï÷ćĒìî
ĕöŠìøćïüŠćÝąêšĂÜöćøĆï÷ćêŠĂ/ĕöŠöĊ ĒîąîĞćĔĀšñĎšðśü÷ìøćïëċÜÙüćöÿĞćÙĆâ×ĂÜÖćøøĆïðøąìćî÷ćêŠĂđîČęĂÜ
ïĆêøîĆé ĒúąĔĀšöćøĆï÷ćÿöęĞćđÿöĂÖŠĂî÷ćĀöé ēé÷ĔĀšñĎšðśü÷ÿćöćøëöćøĆï÷ćĔîüĆî
(ยื่นบัîตüĆรก
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÷ (øó.öĊน.)ðøąßčöüĉßćÖćø)
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ĒîąîĞćâćêĉĔĀšéĎĒúñĎšðśü÷ĔîÖćøøĆïðøąìćî÷ć
ÙšîĀćÿćđĀêč×ĂÜÖćøúČöøĆïðøąìćî÷ć đßŠî đüúćĔîÖćøøĆïðøąìćî÷ćĕöŠ
ÿąéüÖ ÖøèĊì÷Ċę ĆÜöĊðŦâĀćúČö ĂćÝ×ĂĔĀšĒóì÷ŤðøĆïđüúćøĆïðøąìćîĔĀš
ÿąéüÖ×ċĚî
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ĒîąîĞćĔĀšñĎšðśü÷öćøĆï÷ćÖŠĂî÷ćĀöé ēé÷ĔĀšöćĔîüĆîøćßÖćø ĒúąĂćÝĔĀš
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ĕöŠöĊđüúćöćøĆï÷ć óĉÝćøèćĔĀš÷ćöćÖÖüŠć 1 đéČĂî ēé÷đ×Ċ÷îëċÜÙüćöÝĞćđðŨî ĒúąøćÙć÷ć
ĒÝšÜĔĀšĒóì÷Ťìøćï
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ðøċÖþćĒóì÷ŤđóČęĂðøĆïđðŨî÷ćÞĊé
đïČęĂøĆïðøąìćî÷ć ĒîąîĞćĔĀšñĎšðśü÷ìøćïëċÜĒñîÖćøøĆÖþć×ĂÜĒóì÷Ť ĒúąÙüćöÿĞćÙĆâ×ĂÜ
ÖćøøĆïðøąìćî÷ćêŠĂđîČęĂÜ
Ùüćöđ×šćĔÝđøČĂę Ü÷ćÙúćéđÙúČęĂî đßŠî
ÖĉîđĀúšćĒúšüĕöŠÖĉî÷ć ĒîąîĞćëċÜñúđÿĊ÷×ĂÜÖćøéČęöÿčøć×èąøĆïðøąìćî÷ćêŠĂÖćøéĞćđîĉî×ĂÜ
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ĕöŠÿïć÷ĒúšüĕöŠøĆïðøąìćî÷ć ĒîąîĞćñĎšðśü÷üŠćÖøèĊìĊęĕöŠÿïć÷đúĘÖ ė îšĂ÷ ė đßŠî đðŨîĕ×šĀüĆé ðüéĀĆü
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ĂČęî ė ×ĂĔĀšñðĎš śü÷îĞć÷ćìĊęøĆïðøąìćîðøąÝĞć×ĂÜ øó.óøąýøĊĄ ĔĀšĒóì÷Ť
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÷ć ÖøèĊìĊęÖĉî×šćüĕöŠêøÜđüúćÖĘĔĀšøĆïðøąìćî÷ćêćöđüúćìĊęđÙ÷øĆïðøąìćî
÷ć đßŠî 8.00 î. 12.00 î. 17.00 î. đðŨîêšî
÷ćđĀöČĂîÖĆîĒêŠĒ÷ÖàĂÜ÷ćÝċÜ Ăíĉïć÷ĔĀšñĎšðśü÷ìøćïëċÜ÷ćßîĉéđéĊ÷üÖĆîìĊęĒ÷ÖàĂÜđîČęĂÜÝćÖĒóì÷Ť
øĆïðøąìćîđóĊ÷ÜàĂÜđéĊ÷ü êšĂÜÖćøĔĀšìøćïüĉíĊøĆïðøąìćîĕéšÿąéüÖ×ċĚî éĆÜîĆĚîÝąêšĂÜøĆïðøąìćî
êćöĒóì÷ŤÿĆęÜìčÖàĂÜ
ĒîąîĞćĔĀšâćêĉÝĆé÷ćĔĀšñĎšðśü÷øĆïðøąìćîêćöàĂÜìĊę øó.ÝĆéĔĀš
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ĂćÖćø ÙĞćĒîąîĞćđïČĚĂÜêšî/ÖćøðøĆïđðúĊ÷ę îÖćøøĆÖþć
1. Extrapyramidal Side Effects (EPS)
Acute dystonia (ÙĂïĉé ÖøèĊđÖĉéĂćÖćø ÝąêšĂÜĕéšøĆïÖćøøĆÖþć ēé÷ìĆîìĊ
êĆüïĉé) ĔĀš Benztropine (Cogentin®) 2 mg inj iv/im ĀøČĂ
Diazepam 5 mg iv slowly push
ÝćÖîĆĚîđóĉęö Trihexyphenidyl (Artane®, Benzhexol®)
ĂĊÖ 2-10 mg (Max ĕöŠđÖĉî 15 mg/day)
Akathisia (ÖøąÿĆïÖøąÿŠć÷ ÙĞ ćĒîąîĞ ćđïČĚĂÜêšî
ñčéúčÖñčéîĆęÜ ÖøąüîÖøąüć÷ đÖĉé×ċĚîĕéšĔîßŠüÜøą÷ąđüúć 1-2 ÿĆðéćĀŤĒøÖ ñĎšðśü÷ÝąéĊ×ċĚîĕéš
øŠćÜÖć÷) ÖøèĊĂćÖćøøčîĒøÜ ĀøČĂĕöŠéĊ×ċĚî ÝĞćđðŨîêšĂÜðøĆïÖćøøĆÖþć
ĔĀš Propranolol 10 mg tid Ēúą/ĀøČĂ
Diazepam 2 mg tid ĀøČĂ Lorazepam 0.5 mg tid Ēúą/
ĀøČĂ
đóĉęö Trihexyphenidyl 2-10 mg (Max ĕöŠđÖĉî 15 mg/day)
Parkinsonism (ÖúčŠöĂćÖćø ÖøèĊĂćÖćøøčîĒøÜ ĀøČĂĕöŠéĊ×ċĚî ÝĞćđðŨîêšĂÜðøĆïÖćøøĆÖþć
Ùúšć÷ēøÙóćøŤÖĉîÿĆî) đóĉęö Trihexyphenidyl 2-10 mg (Max ĕöŠđÖĉî 15 mg/day)
- ĂćÖćøÿĆęî (Tremor)
- đÙúČęĂîĕĀüßšć (Bradykinesia)
- ÿĊĀîšćđøĊ÷ïđÞ÷ (Mask face)
- Cogwheel or lead pipe
rigidity
- îĚĞćúć÷ĕĀúöćÖ ÝîøïÖüî
ßĊüĉêðøąÝĞćüĆî
- ×ćÖøøĕÖøĒ×ĘÜ úĉĚîÙĆïðćÖ óĎé
ĕöŠßĆé (Dystonia)
Tardive dyskinesia ÿŠÜóïÝĉêĒóì÷Ť đóČęĂóĉÝćøèćđðúĊę÷îđðŨî÷ćêšćîēøÙÝĉêÖúčŠöĔĀöŠ
(ÙüćöñĉéðÖêĉ×ĂÜÖćø (Clozapine)
đÙúČęĂîĕĀüìĊę ðćÖ úĉĚî öČĂ)
2. Postural/Orthostatic ÙĞćĒîąîĞćđïČĚĂÜêšî
hypotension (ĀîšćöČé đðŨî ĒîąîĞćúčÖîĆęÜ ĀøČĂđðúĊę÷îìŠćßšć ė ÖøèĊđðŨî side effect ÝćÖ÷ć
úöđöČęĂúčÖ×ċĚî÷Čî ÿŠüîĔĀâŠÝąéĊ×îċĚ ĀúĆÜÝćÖĕéšøĆï÷ćĒúšüðøąöćè 2 ÿĆðéćĀŤ
ÖøèĊĂćÖćøøčîĒøÜ ĀøČĂĕöŠéĊ×ċĚî ÝĞćđðŨîêšĂÜðøĆïÖćøøĆÖþć
ĀćÿćđĀêčĂČęî ė ìćÜéšćîøŠćÜÖć÷
ĀćÖĕöŠóïÿćđĀêčĂČęî ĔĀšúé÷ćìĊęđÖĊę÷ü×šĂÜ ĕéšĒÖŠ CPZ ĀøČĂ
Thioridazine úÜøšĂ÷úą 50 ×ĂÜ×îćéđéĉö ðøąöćè 1 ÿĆðéćĀŤ
ĀćÖĕöŠéĊ×ċĚî óĉÝćøèćĀ÷čé CPZ ĀøČĂ Thioridazine ĒúąđðúĊę÷î÷ć
øĆÖþćēøÙÝĉêđðŨî High potency đßŠî Haloperidol
3. Anticholinergic effect (ðćÖĒĀšÜ ìšĂÜñĎÖ êćúć÷ ðŦÿÿćüąúĞćïćÖ)
ðćÖĒĀšÜ ĒîąîĞćÝĉïîĚĞćïŠĂ÷ ė Ēúą/ĀøČĂ
úé Trihexyphenidyl úÜÙøĆĚÜúą 2-5 mg
ìšĂÜñĎÖ éČęöîĚĞćöćÖ ė ĂĂÖÖĞćúĆÜ ÖĉîĂćĀćøìĊęöĊÖćÖ ĔĀš÷ćøąïć÷đðŨîÙøĆĚÜÙøćü
óĉÝćøèćúé÷ćìĊęöĊùìíĉĝ Anticholinergic effect ÿĎÜ ĕéšĒÖŠ
Chlorpromazine, Thioridazine , Trihexyphenidyl,
Amitriptyline đðŨîêšî
êćúć÷ ÿŠÜêøüÝĀćÿćđĀêčÝćÖēøÙêć
ĀćÖĕöŠĔßŠÝćÖēøÙêć ðøċÖþćĒóì÷Ť đóČęĂóĉÝćøèćúé÷ćìĊęöĊùìíĉĝ
Anticholinergic effect ÿĎÜ ĕéšĒÖŠ Chlorpromazine,
Thioridazine , Trihexyphenidyl, Amitriptyline đðŨîêšî
ðŦÿÿćüąúĞćïćÖ ÿŠÜðøċÖþćĒóì÷Ť đóČęĂ R/O Cystitis ÖŠĂî

ĀćÖÿćđĀêčđÖĉéÝćÖ÷ć óĉÝćøèć úé÷ćìĊęöĊùìíĉĝ Anticholinergic
effect ÿĎÜ ĕéšĒÖŠ Chlorpromazine, Thioridazine ,
Trihexyphenidyl, Amitriptyline đðŨîêšî
4. ÜŠüÜàċö ÙĞćĒîąîĞćđïČĚĂÜêšî
ĂćÖćøÜŠüÜîĂîÝąéĊ×ċĚîđöČęĂøĆïðøąìćî÷ćêŠĂđîČęĂÜøą÷ąĀîċęÜ
(ðøąöćè 2 ÿĆðéćĀŤ)
ÖøèĊÖĉî÷ćêĂîÖŠĂîîĂî ĒúąêĂîđßšćêČęîöć÷ĆÜÜŠüÜöćÖ ÿćöćøëðøĆï
đüúćøĆïðøąìćî÷ćĔĀšđøĘü×ċĚî
ÖøèĊĂćÖćøøčîĒøÜ ĀøČĂĕöŠéĊ×ċĚî ÝĞćđðŨîêšĂÜðøĆïÖćøøĆÖþć
øüï÷ćøĆÖþćēøÙÝĉêĕðÖĉîđÞóćąÖŠĂîîĂî Ēúą/ĀøČĂ
úé×îćé÷ć Chlorpromazine ĀøČĂ Benzodiazepine (đßŠî
Diazepam, Lorazepam đðŨîêšî) úÜøšĂ÷úą 25-50
ĀúĊÖđúĊę÷ÜÖćøúé÷ćđĀúŠćîĊĚđóøćąĂćÖćøìćÜÝĉêĂćÝÖĞćđøĉï ĕéšĒÖŠ
- Perphenazine
- Haloperidol
- Trifluoperazine
- Clozapine
- Risperidone
5. Neuroleptic Malignant Ā÷čé÷ćøĆÖþćēøÙÝĉêìčÖßîĉé Stabilize ñĎšðśü÷ Ēúą consult Med.
Syndrome (NMS)
1) ĕ×šÿĎÜ
2) Muscle rigidity
3) Confusion
6. ĂČęî ė
ÖćøĒÖšĕ×ðŦâĀćîĂîĕöŠ ĒîąîĞćÿč×ĂîćöĆ÷ÖćøîĂî Ēúą/ĀøČĂ
ĀúĆï đóĉęö÷ćøĆïðøąìćîÖŠĂîîĂî ĕéšĒÖŠ
a. Chlorpromazine 25-100 mg/day ĀøČĂ
b. Diazepam 2-10 mg/day ĀøČĂ
c. Lorazepam 1-4 mg/day
ĒîüìćÜÖćøêĉéêćöñĎšðśü÷ ÖćøêĉéêćöĂćÖćøđßŠîđéĊ÷üÖĆï×ĂÜ Typical antipsychotics

ìĊęĕéšøĆï÷ć Clozapine êøüÝ CBC ìčÖ 1 đéČĂîĔîðŘĒøÖ ĒúąìčÖ 2-3 đéČĂîĔîðŘêĂŠ ė ĕð
ĀøČĂìčÖÙøĆĚÜìĊęöĂĊ ćÖćøêĉéđßČĚĂ
ÖøèĊ WBC > 3,500 ĀøČĂ Absolute Neutrophil Count (ANC)
> 1,500 ÿćöćøëĔĀš÷ćêŠĂĕéšêćöðÖêĉ
ÖøèĊ WBC < 3,500 ĔĀšóĉÝćøèćÙŠć ANC đðŨîĀúĆÖ ĀćÖ ANC
< 1,500 ĔĀšĀ÷čé Clozapine ìĆîìĊ ĒúąÿŠÜêŠĂ øó.óøąýøĊöĀćēóíĉĝ
õćüą Agranulocytosis (ANC<500)
ĔĀšøĆïĕüšøĆÖþćĔî øó.òść÷Öć÷
øĆÖþćõćüąêĉéđßČĚĂëšćöĊ
êĉéêćö WBCCBC 2 ÙøĆĚÜ/ÿĆðéćĀŤ ÝîÖüŠć WBC > 3,500 ÝċÜÿŠÜêŠĂ
øó. óøąýøĊöĀćēóíĉĝ
á¹Ç·Ò§¡ÒÃ»ÃÑºÂÒ¡Ã³Õ·ÕèÃÒÂ¡ÒÃÂÒ/¤ÇÒÁáÃ§ äÁ‹µÃ§¡Ñº·Õèä´ŒÃÑº¨Ò¡âÃ§¾ÂÒºÒÅ¾ÃÐÈÃÕÁËÒâ¾¸Ôì
ĀúĆÖÖćøðøĆï÷ć
ĔßšĔîÖøèĊìñĊę ðĎš śü÷ĂćÖćøÙÜìĊę/ÿÜïđìŠćîĆîĚ
Ĕßš÷ćÖúčŠöđéĊ÷üÖĆî
Ĕßš÷ćĔĀšöĊÙüćöĒøÜĔÖúšđÙĊ÷ÜÖĆî
-
÷ćïćÜêĆüĀćÖĕöŠöĊêĆüĒìî Ùüø/êšĂÜ Refer ÖúĆï ēé÷đÞóćą÷ć Antipsychotic
ĕöŠĒîŠĔÝđöČęĂĕĀøŠĔĀšēìøöć -
á¾·ÂÊÒÁÒÃ¶â·Ã Consult ¨Ôµá¾·Âä´Œâ´ÂµÃ§ à¾×èÍ»ÃÖ¡ÉÒá¹Ç·Ò§¡ÒÃÃÑ¡ÉÒËÃ×ÍÊ‹§µ‹Í

ðøąđéĘîðŦâĀć ĒîüìćÜÖćøéĞćđîĉîÖćø
1. ÖøèĊ×îćéÙüćöĒøÜ×ĂÜ ĔĀšðøĆï×îćé÷ćêŠĂüĆî ĔĀšđìŠćÖĆïìĊęñĎšðśü÷đÙ÷ĕéšøĆï ēé÷ÖøąÝć÷öČĚĂ÷ć
÷ćĕöŠêøÜ êćöÙüćöđĀöćąÿö ēé÷ÙĞćîċÜëċÜøą÷ąđüúćÖćøĂĂÖùìíĉĝ ĒúąĂćÖćø
×šćÜđÙĊ÷ÜìĊęĂćÝÝąđÖĉé×ċĚî êĆüĂ÷ŠćÜđßŠî
ñĎšðśü÷đÙ÷ĕéšøĆï Perphenazine 16 mg 2xhs ÿćöćøëðøĆïđðŨî
Perphenazine 8 mg 4xhs óøšĂöìĆĚÜĒîąîĞćñĎšðśü÷ëċÜÝĞćîüîđöĘé÷ć
ĀøČĂÿĊđöĘé÷ćìĊöę ĊÖćøđðúĊę÷îĒðúÜ
ñĎšðśü÷đÙ÷ĕéšøĆï Depakine CR 200 mg 2xđßšć, 3xhs (1,000
mg/day) ÿćöćøëðøĆïđðúĊę÷îđðŨî Depakine CR 500 mg 1x2 pc
(1,000 mg/day)
2. ÖøèĊìĊę×îćé÷ćêŠĂüĆî ĔĀš×îćé÷ćÿĎÜĀøČĂêęĞćÖüŠćđéĉöđúĘÖîšĂ÷ đßŠî

ÙĞćîüèĒúšüĕöŠđìŠćđéĉö ñĎšðüś ÷đÙ÷ĕéšøĆï Depakine CR 200 mg 2x2 pc (800 mg/day)
ÿćöćøëðøĆïđðúĊę÷îđðŨî Depakine CR 500 mg 1.5xhs (750
mg/day)
×šĂÿĆÜđÖêđóĉęöđêĉö
ÖøèĊĔĀš×îćéêęĞćÖüŠćđéĉö ÙüøêĉéêćöüŠćöĊĂćÖćøÖĞćđøĉïĀøČĂĕöŠ
ÖøèĊĔĀš×îćéÿĎÜÖüŠćđéĉö ÙüøêĉéêćöüŠćñĎšðśü÷öĊĂćÖćø×šćÜđÙĊ÷Üđóĉęö
öćÖ×ċĚîĀøČĂĕöŠ
ðøąđéĘîðŦâĀć ĒîüìćÜÖćøéĞćđîĉîÖćø
3. ÖøèĊøĎðĒïï÷ćĕöŠêøÜÖĆî ĔĀšðøĆï×îćé÷ćêŠĂüĆî ĔĀšđìŠćÖĆïìĊęñĎšðśü÷đÙ÷ĕéšøĆï ēé÷ÖøąÝć÷öČĚĂ÷ć
đßŠî øĎðĒïï control êćöÙüćöđĀöćąÿö ēé÷ÙĞćîċÜëċÜøą÷ąđüúćÖćøĂĂÖùìíĉĝ ĒúąĂćÖćø
release ÖĆïøĎðĒïï ×šćÜđÙĊ÷ÜìĊęĂćÝÝąđÖĉé×ċĚî đßŠî
prompt release ñĎšðśü÷đÙ÷ĕéšøĆï Depakine CR 500 mg 2xhs (1,000 mg/day)
ÿćöćøëðøĆïđðúĊę÷îđðŨî Depakine 200 mg 2xđßšć , 3xhs (1,000
mg/day)
4. ÖøèĊ÷ćÞĊé Long acting ×šĂÿĆÜđÖê

ìčÖ 2 ÿĆðéćĀŤ êšĂÜÖćø Ĕîøć÷ìĊęĕéš÷ćÞĊéìčÖ 2 ÿĆðéćĀŤ öĆÖđðŨîøć÷ìĊęöĊĂćÖćøøčîĒøÜ ĀøČĂ÷ć
đðúĊ÷ę îđðŨîìčÖ 1 đéČĂî öĆÖĀöéùìíĉĝđøĘüĔîßŠüÜðúć÷ ė đéČĂî
ĒîüìćÜđúČĂÖ
1. ÷Čî÷ĆîĔĀš 2 ÿĆðéćĀŤêćöđéĉö ēé÷ĒÿéÜĔĀšđĀĘîëċÜÙüćöÝĞćđðŨî
2. ìéúĂÜĔĀšÞĊéìčÖđéČĂî ēé÷øüï÷ć (êšĂÜøąüĆÜ Side effect ÝćÖ
Bolus dose ìĊęÿĎÜ×ĂÜ÷ć øüöìĆĚÜÖćøĀöéùìíĉĝ ĔîßŠüÜðúć÷đéČĂî)
¡Ã³ÕäÁ‹ÁÕÃÒÂ¡ÒÃÂÒ´Ñ§¡Å‹ÒÇã¹âÃ§¾ÂÒºÒÅ
- ãËŒÂÒ·´á·¹
- ¤ÇÃà»š¹ÂÒã¹¡ÅØ‹Áà´ÕÂÇ¡Ñ¹ áÅÐà·ÕÂº Dose ãËŒã¡ÅŒ¡Ñ¹
- ¤ÇÃà»š¹ÂÒ·ÕèÁÕÊÃÃ¾¤Ø³ã¡ÅŒà¤ÕÂ§¡Ñ¹
- ÃÐÁÑ´ÃÐÇÑ§ã¹ÂÒ¡ÅØ‹Á Antipsychotic
- â·Ã Consult/áÅ¡ÂÒ/ÊÑè§ÂÒ
- Refer ¡ÅÑº
- ÂÒ·ÕèäÁ‹ÁÕãªŒ·´á·¹ áÅÐà»š¹ÂÒà©¾ÒÐ ËÒ¡äÁ‹ÁÕã¹ Ã¾ª. ¤ÇÃËÒ·Ò§
áÅ¡ÂÒ/¨Ñ´«×éÍ/¨Ñ´ËÒ ËÃ×Í Refer ä´Œá¡‹ Clozapine áÅÐ Lithium
ÖúčŠö÷ć ÷ć øó. óøąýøĊöĀćēóíĉĝ ÷ćĔßšĒìîÿĞćĀøĆï øóß.

Trifluoperazine Haloperidol or
(Stelazine) Perphenazine
Antipsychotic
Fluanxol dec. inj.
Fluphenazine dec. inj.
Haloperidol dec. inj.
Mood stabilizer Depakine CR Depakine
Trazodone
Antidepressants Nortriptyline Amitriptyline
Mianserin (Tolvon)
Clonazepam
Benzodiazpine Diazepam or Lorazepam
Clorazepate
á¹Ç·Ò§¡ÒÃ¨Ñ´¡ÒÃá¡Œä¢ÊÒàËµØ·Õè·íÒãËŒ¼ÙŒ»†ÇÂäÁ‹¡Ô¹ÂÒ/©Õ´ÂÒ
**ÊíÒËÃÑºá¹Ç·Ò§·ÕèãËŒäÇŒÊÒÁÒÃ¶àÅ×Í¡ãªŒà¾×èÍ¡ÒÃ¨Ñ´¡ÒÃ´ŒÇÂÇÔ¸Õ¡ÒÃ¢ŒÍã´¢ŒÍË¹Öè§ËÃ×Í·Ø¡¢ŒÍ
à¾×èÍá¡Œä¢ÊÒàËµØãËŒ¼ÙŒ»†ÇÂä´ŒÁÒ¡·ÕèÊØ´
ÿćđĀêč ÖćøÝĆéÖćøĔî øóß.,øóì.
1. ĕöŠ÷ĂöøĆïÖćøđÝĘïðśü÷ ĔĀšÿč×õćóÝĉêýċÖþć
ÿøšćÜĒøÜÝĎÜĔÝ
ĒîąîĞćâćêĉßŠü÷éĎĒúÝĆé÷ć
óĉÝćøèćĔĀš÷ćÞĊé Long Acting éĎêćöĒîüìćÜÖćøðøĆï÷ćđóČęĂ
øĆÖþćñĎšðśü÷ÝĉêđõììĊęÖúĆïđðŨîàĚĞćÿĞćĀøĆïĒóì÷ŤđüßðäĉïĆêĉìĆęüĕð
ĀøČĂēìøðøċÖþćÝĉêĒóì÷Ť øó.óøąýøĊĄ
2. øĎšÿċÖüŠćđðŨîêøćïćð ÿøšćÜìĆýîÙêĉđßĉÜïüÖêŠĂÖćøđÝĘïðśü÷ ēé÷ÖćøĔĀš×šĂöĎúÖćøéĎĒú
ñĎšðśü÷ ñŠćîĀĂÖøąÝć÷×Šćü ĀøČĂĒñŠîóĆï
ÿøšćÜĒøÜÝĎÜĔÝ
úéêøćïćðĔîÙøĂïÙøĆüĒúąßčößî ēé÷ÖøąïüîÖćøÿøšćÜóúĆÜ
Ă÷ŠćÜÿøšćÜÿøøÙŤ (AIC) ĀøČĂ ÖøąïüîÖćø Empowerments
3. ×ćéÙüćöøĎšÙüćöđ×šćĔÝ ĔĀšÿč×õćóÝĉêýċÖþćĒÖŠñĎšðśü÷Ēúąâćêĉ
đÖĊę÷üÖĆïēøÙĒúąÖćøøĆÖþć ÿøšćÜĒøÜÝĎÜĔÝ
ÖĉÝÖøøöÖúčöŠ đóČęĂîßŠü÷đóČęĂî (Self-Help Group)
4. ĕöŠÿćöćøëéĎĒúêîđĂÜĕéš/×ćé êĉéêŠĂðøąÿćîĀîŠü÷ÜćîÿüĆÿéĉÖćøÿĆÜÙö, óöÝ.
ñĎšéĎĒúĀúĆÖ
5. öĊðŦâĀćÖćøđéĉîìćÜöćøĆï÷ć ðøąÿćîÖĆï PCU đóČęĂĔĀšñĎšðśü÷ĕéšøĆï÷ćĂ÷ŠćÜêŠĂđîČęĂÜ đßŠî ÿŠÜ÷ć
ĀøČĂöĊðŦâĀćđýøþåÖĉÝ/ĕöŠöĊ ĔĀš ĔĀšđÝšćĀîšćìĊęøĆï÷ćĒìî
ÙŠćøë
6. öĊñú×šćÜđÙĊ÷ÜÝćÖÖćøĔßš÷ć ÝĆจัéดÖćøêćöĒîüìćÜÖćøøĆ
การตามแนวทาง การใหÖคþćñú×š ําแนะนํćาÜđÙĊ
เบื้อ÷งต
ÜìĊนęđÖĉและปรั บการรั÷กćษา
éÝćÖÖćøĔßš
กรณี ผ ป
 ู ว
 ยมี อ าการข
ÿĞćĀøĆïĒóì÷ŤđüßðäĉïĆêĉìĆęüĕðา งเคี ย งจากยา (หน า 159)
7. ÖøèĊñĎšðśü÷ Compliance úéÝĞćîüîöČĚĂúÜ ēé÷øüïöČĚĂ÷ćĔĀšđĀúČĂ 1-2 öČĚĂ ēé÷ĔĀš×îćé÷ć
ĕöŠéĊ/úČöøĆïðøąìćî÷ćïŠĂ÷ ė ìĊęĕéšøĆïêŠĂüĆîđìŠćđéĉöÖĆïìĊęđÙ÷ĕéšøĆï
á¹Ç·Ò§¡ÒÃµÃÇ¨·Ò§ËŒÍ§»¯ÔºÑµÔ¡ÒÃ¢Í§¼ÙŒ»†ÇÂ
·Õèä´ŒÃÑºÂÒ¡ÅØ‹Á¤ÇÒÁàÊÕèÂ§ÊÙ§ (High Alert Drugs)
·Õè»¯ÔºÑµÔã¹âÃ§¾ÂÒºÒÅ¾ÃÐÈÃÕÁËÒâ¾¸Ôì
Clozapine
á¹Ç·Ò§¡ÒÃµÔ´µÒÁÃÐ´ÑºàÁç´àÅ×Í´¢ÒÇã¹¼ÙŒ»†ÇÂ·Õèä´ŒÃÑºâ¤Å«Ò»‚¹ ´Ñ§¹Õé¤×Í
Criteria Lab ìĊę êšĂÜđÝćą ÖćøéĞćđîĉîÖćø
1.1. กÖŠอĂนการเริ
îÖćøđøĉ่มęöการรั
ÖćøøĆกÖษา
þć CBC
2.2. ไดĕéšรøับĆ ïยา÷ć6 เดื6 อđéČนแรก
Ă îĒøÖ WBC ìčÖ 1 đéČĂî ÖøèĊñúñĉéðÖêĉ
หรื
ĀøČอĂ WBC count < 3,500 cell/mm3 ĔĀš repeated
มีöĊปðระวั ø ąติผüĆลêĉWBC,
ñ ú WBC, CBC ìĆîìĊ Ēúąøć÷ÜćîĒóì÷Ť
Absolute
Absoluteneutrophil neutrophil Absolute neutrophil count < 1,500 cell/mm3
ðÖêĉ11
ตํêę่าĞćผิñĉดéปกติ ÖćøéĞćđîĉîÖćø
ĔĀšĀ÷čé÷ć Ēúą monitor CBC êŠĂđîČęĂÜìčÖÿĆðéćĀŤ
ÝîÖüŠćÝąđ×šćÿĎŠøąéĆïðÖêĉ
ÖøèĊñĎšðśü÷êšĂÜĕð monitor CBC ìĊęøó.đÙøČĂ×Šć÷
Ēóì÷Ť Ý ąĒîïĒîüìćÜÖćøđòŜ ć øąüĆ Ü ĒúąÖćø
monitor óøšĂöÖĆïÖćøÿĆęÜđÝćą CBC
ëšćêšĂÜ start ÷ćĔĀöŠñĎšðśü÷ÝąêšĂÜ monitor đðŨî
ìčÖ 1 wk êŠĂđîČęĂÜ 18 ÿĆðéćĀŤ ĀøČĂìčÖ visit (ÖøèĊ
OPD ĒúąìĊęøóß.)
1. ได
3. ĕéšรøับĆïยา
÷ć 66เดืđéČอĂน-1ป
î-1 ðŘ WBC ìčÖ 2 đéČĂî ÖøèĊđÙ÷öĊñú lab ñĉéðÖêĉ
Ēúą CBC ìčÖ 1 ðŘ WBC count < 3,500 cell/mm3 ĀøČĂ
Absolute neutrophil count < 1,500 cell/mm3
ĔĀšéĞćđîĉîÖćøêćö×šĂ 2
4. ได
ĕéšรøับĆïยา
÷ć มากกว
öćÖÖüŠา ć1 1ป ðŘ WBC ìčÖ 3 đéČĂî êšĂÜđðŨîñĎšðśü÷ìĊęĕöŠđÙ÷öĊðøąüĆêĉ
ขึ×ċ้นĚîไป
ĕð Ēúą CBC ìčÖ 1 ðŘ WBC count < 3,500 cell/mm3 ĀøČĂ
Absolute neutrophil count < 1,500 cell/mm3
Āöć÷đĀêč ñú WBC, Absolute neutrophil êęĞćñĉéðÖêĉ 1 Āöć÷ëċÜ WBC count < 3,500 cell/mm3
หมายเหตุ
ĀøČĂ Absolute neutrophil count < 1,500 cell/mm3
¡ÒÃÊ‹§»ÃÖ¡ÉÒá¾·Âà©¾ÒÐ·Ò§ (Hematologist)
• ¶ŒÒËÂØ´ÂÒ Clozapine áÅŒÇÁÕ¡ÒÃÅ´Å§ÍÂ‹Ò§µ‹Íà¹×Íè §¢Í§ WBC < 2,000
cell/mm3 áÅÐ absolute neutrophil count < 1,000 cell/mm3
• ËÒ¡ËÅÑ§¨Ò¡¡ÒÃËÂØ´ÂÒ 1 à´×Í¹ ¼Å Follow up CBC ¾ºÇ‹Ò WBC
count ËÃ×Í absolute neutrophil count ÂÑ§äÁ‹ÍÂÙ‹ã¹à¡³±»¡µÔ
¡ÒÃ¤íÒ¹Ç³ Absolute neutrophils count (ANC) = Total WBC x % neutrophil

100
¤‹Ò»¡µÔ ANC = 2,500 – 8,000 cell/mm3
Lithium
Criteria ÖćøêøüÝ Lab ĒúąÖćøêøüÝóĉđýþ Āöć÷đĀêč
1. ÖŠĂîÖćøđøĉęöĕéšøĆï÷ć Lithium blood BUN/Cr, FT3, FT4, TSH
ĀøČĂìčÖÙøĆĚÜìĊę Admit Ēúšüĕéš EKG : ÖøèĊñĎšðüś ÷ìĆÜĚ ßć÷ĒúąĀâĉÜ
Lithium êĆĚÜĒêŠĒøÖøĆï ìĊęĂć÷čöćÖÖüŠć 50 ðŘ ĀøČĂöĊðøąüĆêĉ
cardiac disease
Urine pregnancy test : êøüÝ ÖøèĊđÖĘïðŦÿÿćüąĕöŠĕéš Ùüø
ìčÖÖøèĊìÿĊę ÜÿĆ÷üŠćöĊÖćøêĆĚÜÙøøõŤ consult
(üĆ÷đÝøĉâóĆîíčŤ)
2. ×èąĕéšøĆï÷ć Lithium Blood level ÖćøđÝćąđúČĂé
ĕéšøĆï÷ćÙøĆĚÜĒøÖĀøČĂ ĀúĆÜÝćÖĕéšøĆï÷ćÙøĆĚÜĒøÖ ĀøČĂ ÝąêšĂÜđÝćąÖŠĂîĕéšøĆï÷ćöČĚĂ
ðøĆïđðúĊ÷ę î×îćé÷ć (đóĉöę ĀøČĂ Start ĔĀöŠÙøï 7 üĆî ĀøČĂ Ēúą đßšć (ĀúĆÜÝćÖ÷ćöČĚĂÿčéìšć÷
úé) ĀøČĂ đöČęĂðøĆï×îćé÷ćĔĀöŠ Ùøï 7 üĆî ĕöŠîšĂ÷ÖüŠć 12 ßĆęüēöÜ)
đøĉęööć Start ÷ćĔĀöŠĂĊÖÙøĆĚÜ ÖøèĊÿÜÿĆ÷ Toxic đÝćąđüúć
ĔéÖĘĕéš
öĊ sign üŠćÝąđÖĉé Toxic ìĆîìĊ ÖøèĊìĊęÿÜÿĆ÷ Toxic ïĆ î ìċ Ö đüúćìĊę đ ÝćąđúČ Ă é
ĒúąđüúćìĊę øĆ ï ðøąìćî÷ć
öČĚĂÿčéìšć÷
3. ĕéšøĆï÷ćêŠĂđîČęĂÜ 1 ðŘĒøÖ ĀøČĂ öĊ blood BUN/Cr, FT3, FT4, TSH ÖøèĊöĊñúñĉéðÖêĉ ÿćöćøë
ðøąüĆêĉñúêøüÝ BUN, Cr, TSH, ìčÖ 6 đéČĂîĀúĆÜĕéšøĆï÷ć êøüÝĕéš ïŠ Ă ÷ÖüŠ ć îĆĚ î êćö
EKG ñĉéðÖêĉ EKG ÿĞćĀøĆïñĎðš śü÷ßć÷ĒúąĀâĉÜìĊę ĒñîÖćøøĆÖþć×ĂÜĒóì÷Ť
öĊĂć÷čöćÖÖüŠć 50 ðŘ ĀøČĂöĊ
cardiac disease
4. ĕéšøĆï÷ć öćÖÖüŠć 1 ðŘ ×ċĚîĕð blood BUN/Cr, FT3, FT4, TSH êšĂÜđðŨîñĎšðśü÷ìĊęĕöŠöĊðøąüĆêĉ

ìčÖ 1 ðŘ ÙŠć Lab ĀøČĂñúêøüÝóĉđýþ
EKG ÿĞćĀøĆïñĎðš śü÷ìĊęöĊĂć÷čöćÖÖüŠć ñĉéðÖêĉ
50 ðŘ ĀøČĂöĊ cardiac disease
ìčÖ 1 ðŘ
Carbamazepine
1. ÖŠĂîÖćøđøĉęöÖćøøĆÖþć CBC
2. ×èąĕéšøĆï÷ć Carbamazepine Blood level ÖćøđÝćąđúČĂé
öĊ sign toxic ìĆîìĊ ÖøèĊìĊęÿÜÿĆ÷ Toxic ÖøèĊ ĕ éš øĆ ï ÙøĆĚ Ü ĒøÖ ñĎš ðś ü ÷êš Ă Ü
ĕéšøĆï÷ćöćĕöŠîšĂ÷ÖüŠć 3 ÿĆðéćĀŤ
(đîČęĂÜÝćÖđÖĉé autoinduction )
ÖøèĊ ð øĆ ï ÷ć đÝćąđúČ Ă éĀúĆ Ü ÝćÖ
ðøĆï×îćé÷ćĒúšü 7 üĆî
êšĂÜđÝćąÖŠĂîĕéšøĆï÷ćöČĚĂđßšć
ÖøèĊÿÜÿĆ÷ Toxic đÝćąđüúćĔéÖĘĕéš
ïĆîìċÖđüúćìĊęđÝćąđúČĂé Ēúąđüúć
ìĊęøĆïðøąìćî÷ćöČĚĂÿčéìšć÷
Valproate
1. ñĎš ðś ü ÷đ×š ć đÖèæŤ ×š Ă Ĕé×š Ă Āîċę Ü Liver Function Test (AST, ÖøèĊöĊñúêøüÝñĉéðÖêĉ ĀøČĂöĊ
êŠĂĕðîĊĚ ALT) ÖŠĂîĕéšøĆï÷ć Ēúą ĂćÖćøñĉ é ðÖêĉ ÿćöćøëêøüÝ
öĊðøąüĆêĉēøÙêĆï ìĊę 6 đéČĂîĀúĆÜĕéšøĆï÷ć ĕéš ïŠ Ă ÷ÖüŠ ć îĆĚ î êćöĒñîÖćø
Ĕßš÷ćÖĆîßĆÖĂČęîìĊęöĊóĉþêŠĂêĆï đßŠî øĆÖþć×ĂÜĒóì÷Ť
Carbamazepine, Phenytoin
ĕéšøĆï÷ć Valproate Ĕî×îćé
1,000 mg/day ×ċĚîĕð
2. ñĎšðśü÷êĉéÿčøć Liver Function Test (AST, ÖøèĊöĊñúêøüÝñĉéðÖêĉ ĀøČĂöĊ

ALT) ÖŠĂîĕéšøĆï÷ć, ìĊę 6 đéČĂî ĂćÖćøñĉ é ðÖêĉ ÿćöćøëêøüÝ
ĀúĆÜĕéšøĆï÷ć ĒúąìčÖ 1 ðŘ ĕéš ïŠ Ă ÷ÖüŠ ć îĆĚ î êćöĒñîÖćø
øĆÖþć×ĂÜĒóì÷Ť
3. ×èąĕéšøĆï÷ć Valproate Blood level ÖćøđÝćąđúČĂé
öĊ sign toxic ìĆîìĊ ÖøèĊìĊęÿÜÿĆ÷ Toxic ñĎš ðś ü ÷êš Ă Üĕéš øĆ ï ÷ćöćĕöŠ îš Ă ÷
ÖüŠć 3 üĆî (72 ßĆęüēöÜ) ìĆĚÜÖøèĊ
ĕéšøĆïÙøĆĚÜĒøÖ ĒúąðøĆï÷ć
ÝąêšĂÜđÝćąÖŠĂîĕéšøĆï÷ćöČĚĂđßšć
ÖøèĊÿÜÿĆ÷ Toxic đÝćąđüúćĔé
ÖĘĕéš
ïĆ î ìċ Ö đüúćìĊę đ ÝćąđúČ Ă é Ēúą
đüúćìĊęøĆïðøąìćî÷ćöČĚĂÿčéìšć÷
ËÁÒÂàËµØ Liver function test ¼Ô´»¡µÔ ËÁÒÂ¶Ö§ AST ËÃ×Í ALT ÁÒ¡¡Ç‹Ò 3 à·‹Ò¢Í§ UNL
(upper normal limit)
Phenytoin
1. ÖŠĂîÖćøđøĉęöÖćøøĆÖþć Plasma Albumin
2. ×èąĕéšøĆï÷ć Phenytoin Blood level ÖćøđÝćąđúČĂé
öĊ sign toxic ìĆîìĊ ÖøèĊìĊęÿÜÿĆ÷ Toxic ñĎš ðś ü ÷êš Ă Üĕéš øĆ ï ÷ćöćĕöŠ
ìčÖÙøĆĚÜìĊęđÝćą Blood level ĔĀš îšĂ÷ÖüŠć 2 ÿĆðéćĀŤ (ìĆĚÜ
êøüÝ Plasma Albumin éšü÷ ÖøèĊ ĕ éš øĆ ï ÙøĆĚ Ü ĒøÖ Ēúą
ðøĆï÷ć)
ÝąêšĂÜđÝćąÖŠĂîĕéšøĆï÷ćöČĚĂ
đßšć
ÖøèĊÿÜÿĆ÷ Toxic đÝćąđüúć
ĔéÖĘĕéš
ïĆ î ìċ Ö đüúćìĊę đ ÝćąđúČ Ă é
ĒúąđüúćìĊę øĆ ï ðøąìćî÷ć
öČĚĂÿčéìšć÷
Phenobarbital
1. ÖŠĂîÖćøđøĉęöÖćøøĆÖþć -
2. ×èąĕéšøĆï÷ć Phenobarbital Blood level ÖćøđÝćąđúČĂé
öĊ sign toxic ìĆîìĊ ÖøèĊìĊęÿÜÿĆ÷ Toxic ñĎšðśü÷êšĂÜĕéšøĆï÷ćöćĕöŠîšĂ÷ÖüŠć 3
ÿĆ3 ðสัéćĀŤ
ปดาห(ìĆ(ทัĚ Ü้งÖøèĊ
กรณีไĕดéšรøับĆ ïครัÙøĆ้งแรก
Ě Ü ĒøÖ
และปรั บ
ĒúąðøĆï÷ć) ยา)
ÝąêšĂÜđÝćąÖŠĂîĕéšøĆï÷ćöČĚĂđßšć
ÖøèĊÿÜÿĆ÷ Toxic đÝćąđüúćĔéÖĘĕéš
ïĆîìċÖđüúćìĊęđÝćąđúČĂé ĒúąđüúćìĊę
øĆïðøąìćî÷ćöČĚĂÿčéìšć÷
¤³Ð¼ÙŒ¨Ñ´·íÒ
¹¾.¸Ã³Ô¹·Ã ¡Í§ÊØ¢ ¼ÙŒÍíÒ¹ÇÂ¡ÒÃâÃ§¾ÂÒºÒÅ¾ÃÐÈÃÕÁËÒâ¾¸Ôì ·Õè»ÃÖ¡ÉÒ
À¡.ÇÕÃÐ ´ØÅÂªÙ»ÃÐÀÒ àÀÊÑª¡ÃªíÒ¹ÒÞ¡ÒÃ¾ÔàÈÉ ¼ÙŒ¨Ñ´·íÒ
ÀÞ.ªÁÀÙ¹Øª ÇÕÃÐÇÑ¸¹ªÑÂ àÀÊÑª¡ÃªíÒ¹ÒÞ¡ÒÃ¾ÔàÈÉ ¼ÙŒ¨Ñ´·íÒ
À¡.¾ÔÊÔÉ° á¶Ç¨Ñ¹·Ö¡ àÀÊÑª¡ÃªíÒ¹ÒÞ¡ÒÃ ¼ÙŒ¨Ñ´·íÒ
ÀÞ.ÍÀÔÃ´Õ áÊ§§ÒÁ àÀÊÑª¡ÃªíÒ¹ÒÞ¡ÒÃ ¼ÙŒ¨Ñ´·íÒ
ÀÞ.¡ÁÅÃÑµ¹ âÊÁÃÑ¡É àÀÊÑª¡ÃªíÒ¹ÒÞ¡ÒÃ ¼ÙŒ¨Ñ´·íÒ
ÀÞ.´Ç§ÊØ´Ò ÇÑ²¹ÒäªÂ àÀÊÑª¡Ã»¯ÔºÑµÔ¡ÒÃ ¼ÙŒ¨Ñ´·íÒ
ÀÞ.¾ÔÃØ³ÃÑµ¹ à¾ç§¨Ñ¹·Ã àÀÊÑª¡Ã»¯ÔºÑµÔ¡ÒÃ ¼ÙŒ¨Ñ´·íÒ
ÀÞ.¾Ç§à¾ªÃ ¨ÔÇÇÑ²¹ÒÃÑ¡É àÀÊÑª¡Ã»¯ÔºÑµÔ¡ÒÃ ¼ÙŒ¨Ñ´·íÒ

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Ref: Textbook of Medical Physiology 11th

1. ÍÐ«ÔµÔÅâ¤ÅÕ¹ (Acetylcholine) Ë¹ŒÒ·Õè¢Í§ÍÐ«ÔµÔÅâ¤ÅÕ¹ (Acetylcholine)

Ref: Essentials of Anatomy and Physiology

Dopaminergic Receptors (D)

ÂÒÃÑ¡ÉÒâÃ¤¨Ôµ (Antipsychotics, Neuroleptic, Major tranquilizers)

 0HVROLPELF SDWKZD\

ภาพแสดงอาการของ Parkinsonism หรือČ Pseudoparkinsonism

5) Neuroleptic malignant syndrome ; NMS à»š¹¼Å¢ŒÒ§à¤ÕÂ§·Õè¾ºäÁ‹

¡ÒÃÃÑ¡ÉÒ µŒÍ§ËÂØ´ÂÒ·ÕèÍÍ¡Ä·¸Ôì»´¡Ñé¹ dopamine receptor ·Ñ¹·Õ áÅÐ

»¯Ô¡ÔÃÔÂÒÃÐËÇ‹Ò§ÂÒ (Drug interaction)

ÖćøïøĉĀćø÷ć (Administration)  Injection : ÞĊéđ×šćÖúšćöđìŠćîĆĚî ĀšćöÞĊéđ×šćĀúĂéđúČĂééĞć

µÒÃÒ§·Õè 5 áÊ´§ Pharmacokinetic Parameters ¢Í§ Antipsychotic drugs

áÊ´§¡Åä¡¡ÒÃÍÍ¡Ä·¸Ôì¢Í§ Atypical antipsychotics

Clozapine 150-600 900

Quetiapine 400-600 800

Ziprasidone 80-120 160

á¼¹ÀÒ¾áÊ´§¼Å¢Í§ Atypical antipsychotics µ‹Í¼Å·Ò§´ŒÒ¹ Metabolic syndrome

¼Å·Ò§¤ÅÔ¹Ô¡ Therapeutic Uses

¡ÒÃ¢¨Ñ´ÂÒ (Elimination and Biotransformation pathway)

áÊ´§¡ÃÐºÇ¹¡ÒÃ Metabolism ¢Í§ÂÒ¡ÅØ‹Á Benzodiazepine

ËÅÑ¡ “7 ¶Ù¡” «Öè§à»š¹á¹Ç·Ò§·ÕèÃÇºÃÇÁáÅÐ¤Ñ´ÅÍ¡¨Ò¡Ë¹Ñ§Ê×Í¡ÒÃãªŒÂÒ¤ÅÒÂ

¢. ËÅÑ¡¡ÒÃàÅ×Í¡ÊÑè§ãªŒÂÒ Benzodiazepine µÒÁ¤Ø³ÊÁºÑµÔ·Ò§àÀÊÑª¨Å¹ÈÒÊµÃ

µÒÃÒ§·Õè 12 áÊ´§ÃÙ»áºº¢Í§ÂÒ¡ÅØ‹Á Benzodiazepine

¡ÒÃµÔ´ÂÒ (drug abuse)

¡ÒÃÊÙÞàÊÕÂ¤ÇÒÁ¨íÒ (anterograde amnesia)

¡ÃÐµØŒ¹¡ÒÃËÅÑè§¢Í§ adrenocorticotropic hormone (ACTH)

¡ÃÐµØŒ¹¡ÒÃËÅÑè§ cortisol ¨Ò¡ adrenal cortex

Serotonin Antiagonist and reuptake inhibitors: SARIs

µÒÃÒ§·Õè 15 áÊ´§¤ÇÒÁÊÒÁÒÃ¶ã¹¡ÒÃ¨Ñº Receptor

Monoamine oxidase inhibitors

++++, high; +++, moderate; ++, low; +, very low; 0, absent.

µÒÃÒ§·Õè 17 áÊ´§¡ÒÃ¨Ñº Receptor ·ÕÁè ¼Õ Åã¹¡ÒÃÃÑ¡ÉÒ áÅÐ¡ÒÃà¡Ô´ÍÒ¡ÒÃäÁ‹¾§Ö »ÃÐÊ§¤

Agonist at 5-HT1A Anxiolytic, Antidepressant, Anti-EPS Weight gain

2. D2 Antidepressant Alertness, increased BP/HR

Melatonin receptor: MT1 ÖćøÙüïÙčö Circadian rhythms,

ÂÒã¹¡ÅØ‹Á TCAs à»š¹ÂÒÃÑ¡ÉÒÍÒÃÁ³«ÖÁàÈÃŒÒ·ÕèãªŒ¡Ñ¹ÁÒà»š¹àÇÅÒ¹Ò¹ à¹×èÍ§¨Ò¡

ÖúĕÖÖćøĂĂÖùìíĉĝĀúĆÖÙČĂ Block reuptake ×ĂÜ Serotonin (SRI)

ÂÒ SSRI áµ‹ÅÐµÑÇ¨ÐÁÕ¡ÒÃ¨Ñº·Õè receptor Í×è¹ æ Ã‹ÇÁ´ŒÇÂ ¨Ö§·íÒãËŒÂÒ

Bupropion à»š¹ÂÒ·ÕÁè ¡Õ Åä¡¡ÒÃÍÍ¡Ä·¸Ôµì Ò‹ §¨Ò¡ÂÒÃÑ¡ÉÒÍÒÃÁ³«ÁÖ àÈÃŒÒµÑÇ

5. Noradrenergic and Specific-Serotonergic

Mirtazapine à»š ¹ ÂÒãËÁ‹ ·Õè à ¾Ôè Á ¡ÒÃ·í Ò §Ò¹¢Í§ serotonin áÅÐ

7. Serotonin Antiagonist and Reuptake Inhibitors (SARIs)

µÒÃÒ§·Õè 18 ¼Å¢Í§ Antidepressants µ‹Í¡ÒÃÂÑºÂÑé§¡ÒÃ·íÒ§Ò¹

µÒÃÒ§·Õè 20 áÊ´§ Drug Interactions ¢Í§ÂÒ Antidepressants ¡ÅØ‹ÁãËÁ‹ æ

E-Adrenergic blockers Increased metoprolol serum concentrations; increased

Duloxetine MAOIs Potential for hypertensive crisis, serotonin syndrome,

Serotonin syndrome à»š¹ÍÒ¡ÒÃ·Õàè ¡Ô´ä´Œ¹ÍŒ Â áµ‹àÁ×Íè à¡Ô´¢Ö¹é áÅŒÇ·íÒãËŒàÊÕÂªÕÇµÔ

öČĂÿĆęî - ÖøèĊđðŨîöćÖĔîßŠüÜìĊęøąéĆï÷ćÿĎÜÿčé (peak level) ÙüøðøĆïÖćøĔĀš

ÙúČęîĕÿš ĂćđÝĊ÷î ðüéìšĂÜ ìšĂÜđÿĊ÷ - ÙüøðøĆïÖćøĔĀš÷ćđðŨîĀúć÷ÙøĆĚÜêŠĂüĆî

ĂćÖćøìćÜñĉüĀîĆÜ - ëšćĂćÖćøĕöŠøčîĒøÜöĆÖéĊ×ċĚîđĂÜ ÙüøĔĀšÖćøøĆÖþćĂćÖćøìćÜñĉüĀîĆÜ

ñúêŠĂĀĆüĔÝ - ÙüøĀ÷čé÷ć Lithium

Āîšćïüö ×šĂđìšćïüö - ĀćÖđðŨîñúÝćÖ÷ć Lithium ĂćÖćøöĆÖéĊ×ċĚîđĂÜ

ñúêŠĂêŠĂöĕìøĂ÷éŤ - ðøĆïúé×îćé÷ćĀøČĂĀ÷čé÷ć Lithium

5-10 ēé÷ĕöŠöĊĂćÖćøĒÿéÜ - ÷ĆÜĕöŠÝĞćđðŨîêšĂÜĔĀšĕìøĂ÷éŤăĂøŤēöîđÿøĉö

µÒÃÒ§·Õè 23 áÊ´§ÃÐ´ÑºÂÒã¹àÅ×Í´áÅÐÍÒ¡ÒÃáÊ´§¡Ã³Õà¡Ô´ Lithium intoxication

¡ÒÃ¨Ñ´¡ÒÃá¡Œä¢ Lithium intoxication

ÜŠüÜîĂî đéĉîđà öČĂÿĆęî - ðøĆïĕðĔßš÷ćøĎðĒïï Controlled release (CR) tablets ĂćÝßŠü÷úé

ÖøèĊñĎšðśü÷øĆïðøąìćî÷ć Valproate - ĂćÝóĉÝćøèćĔĀš Activated charcoal (1 ÖøĆö Activated charcoal

Fatal hepatotoxicity - ĒÖšĕ×ēé÷ÖćøĀ÷čé÷ć

Hepatitis, đĂîĕàöŤêĆïđóĉęö×ċĚî - ĀćÖóïüŠć AST, ALT ÿĎÜ×ċĚîĕöŠöćÖ ÙüøêĉéêćöđòŜćøąüĆÜĂ÷ŠćÜêŠĂđîČęĂÜ

Menstrual disorder and PCOS - ĔĀš÷ćÙčöÖĞćđîĉéßîĉéøĆïðøąìćî, Cyclic progesterone, Metformin

Alopecia - ĒîąîĞćñĎšðśü÷ĔĀšðäĉïĆêĉêĆüđóČęĂúéĂćÖćøñöøŠüÜ đßŠî ÖćøĔßšĒßöóĎÿøąñö

ÖøèĊñĎšðśü÷øĆïðøąìćî÷ć Carbamazepine đÖĉî - ĂćÝóĉÝćøèćìĞć gastric larvage

0HVROLPELF SDWKZD\

¡ÒÃÃÑ¡ÉÒ µŒÍ§ËÂØ´ÂÒ·ÕèÍÍ¡Ä·¸Ôì»´¡Ñé¹ dopamine receptor ·Ñ¹·Õ áÅÐ

ÖćøïøĉĀćø÷ć (Administration) Injection : ÞĊéđ×šćÖúšćöđìŠćîĆĚî ĀšćöÞĊéđ×šćĀúĂéđúČĂééĞć

¢. ËÅÑ¡¡ÒÃàÅ×Í¡ÊÑè§ãªŒÂÒ Benzodiazepine µÒÁ¤Ø³ÊÁºÑµÔ·Ò§àÀÊÑª¨Å¹ÈÒÊµÃ

µÒÃÒ§·Õè 17 áÊ´§¡ÒÃ¨Ñº Receptor ·ÕÁè ¼Õ Åã¹¡ÒÃÃÑ¡ÉÒ áÅÐ¡ÒÃà¡Ô´ÍÒ¡ÒÃäÁ‹¾§Ö »ÃÐÊ§¤

ÂÒã¹¡ÅØ‹Á TCAs à»š¹ÂÒÃÑ¡ÉÒÍÒÃÁ³«ÖÁàÈÃŒÒ·ÕèãªŒ¡Ñ¹ÁÒà»š¹àÇÅÒ¹Ò¹ à¹×èÍ§¨Ò¡

Bupropion à»š¹ÂÒ·ÕÁè ¡Õ Åä¡¡ÒÃÍÍ¡Ä·¸Ôµì Ò‹ §¨Ò¡ÂÒÃÑ¡ÉÒÍÒÃÁ³«ÁÖ àÈÃŒÒµÑÇ

ÂÒ·íÒãËŒÍÒÃÁ³¤§·Õè (Mood stabilizer)

ðŦÿÿćüąúĞćïćÖ ÿŠÜðøċÖþćĒóì÷Ť đóČęĂ R/O Cystitis ÖŠĂî

ĒîüìćÜÖćøêĉéêćöñĎšðśü÷ ÖćøêĉéêćöĂćÖćøđßŠîđéĊ÷üÖĆï×ĂÜ Typical antipsychotics

á¾·ÂÊÒÁÒÃ¶â·Ã Consult ¨Ôµá¾·Âä´Œâ´ÂµÃ§ à¾×èÍ»ÃÖ¡ÉÒá¹Ç·Ò§¡ÒÃÃÑ¡ÉÒËÃ×ÍÊ‹§µ‹Í

2. ÖøèĊìĊę×îćé÷ćêŠĂüĆî ĔĀš×îćé÷ćÿĎÜĀøČĂêęĞćÖüŠćđéĉöđúĘÖîšĂ÷ đßŠî

4. ĕéšøĆï÷ć öćÖÖüŠć 1 ðŘ ×ċĚîĕð blood BUN/Cr, FT3, FT4, TSH êšĂÜđðŨîñĎšðśü÷ìĊęĕöŠöĊðøąüĆêĉ

2. ñĎšðśü÷êĉéÿčøć Liver Function Test (AST, ÖøèĊöĊñúêøüÝñĉéðÖêĉ ĀøČĂöĊ