# 60歲女性,纖維肌痛與重度憂鬱,duloxetine 60 mg每日已1年。每晚飲紅酒2〜3杯。急診因腰部扭傷新開立tramadol 50 mg每6小時PRN。護理師最適當的行動為何?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375258&lang=zh-tw  
> language: zh-TW  
> subject: Medical Emergencies  
> category: PA

## 題目

60歲女性,纖維肌痛與重度憂鬱,duloxetine 60 mg每日已1年。每晚飲紅酒2〜3杯。急診因腰部扭傷新開立tramadol 50 mg每6小時PRN。護理師最適當的行動為何?

## 選項

1. 安撫病人:低劑量tramadol與duloxetine併用是安全的。
2. 將每日飲酒與新處方tramadol通報處方醫師,要求肝功能檢查、血清素症候群安全評估與替代止痛藥討論。 **✔ 正確答案**
3. 要病人在腰痛緩解前自行停用duloxetine。
4. 僅建議減少飲酒,並依處方未經評估開始tramadol。

**正確答案: 2**

## 解析

本病人兩種風險疊加。(1)肝毒性:duloxetine於大量飲酒(≥3杯/日或慢性)或已有肝病患者為禁忌,合併暴露會升高ALT/AST,罕見肝衰竭。(2)血清素症候群:duloxetine + tramadol併用兩種血清素作用藥物,且tramadol會降低癲癇閾值。應通報處方醫師:評估酒精使用、LFT、改用非血清素作用鎮痛(注意肝功能的acetaminophen、lidocaine貼片、評估腸胃風險的NSAID),並衛教血清素症候群警訊(陣攣、反射亢進、躁動、發燒)。安撫、自行停藥或單純少喝酒皆未對應實際安全問題。

## 深入解析

雙重問題:酒精+duloxetine=肝、duloxetine+tramadol=血清素。兩者必須同時處理。

## 臨床情境

情境 60歲女性,MDD+纖維肌痛,服用duloxetine 60 mg每日已1年。每晚紅酒2〜3杯。急診因急性腰部扭傷新處方tramadol 50 mg PO q6h PRN。病歷無既往LFT、無黃疸或asterixis、AOx3、生命徵象穩定。用藥列表無SSRI/MAOI/triptan/St. John wort。

## 重要概念

- **Duloxetine肝毒性** — 警語:大量飲酒或慢性肝病患者應避免duloxetine。肝損傷常於2個月內發生但也可能延遲;有風險因子者監測LFT,ALT >3倍正常上限即停藥。
- **血清素症候群** — 三聯徵:意識改變、自律神經不穩、神經肌肉過度活動(陣攣、反射亢進)。多重血清素作用藥併用(SSRI/SNRI+tramadol/triptan/MAOI/St. John wort/linezolid)所致。處置:停藥、支持治療、嚴重時cyproheptadine。
- **Tramadol注意事項** — Schedule IV鴉片類兼SNRI作用;降低癲癇閾值,與其他血清素藥併用易致血清素症候群。癲癇病史、12歲以下、扁桃切除後兒童、有高風險併用者須先評估再開立。

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