# 38歲病人,難治型重度憂鬱,口服fluoxetine 20 mg每日已4週仍無改善。處方醫師計畫轉換為tranylcypromine。下列哪項衛教反映安全的轉換?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375261&lang=zh-tw  
> language: zh-TW  
> subject: Medical Emergencies  
> category: PA

## 題目

38歲病人,難治型重度憂鬱,口服fluoxetine 20 mg每日已4週仍無改善。處方醫師計畫轉換為tranylcypromine。下列哪項衛教反映安全的轉換?

## 選項

1. MAOI與SSRI合併耐受良好,不需清除期。
2. 為避免憂鬱空窗,早晨停用fluoxetine,當晚就開始tranylcypromine。
3. 為過渡期將fluoxetine與tranylcypromine同時服用1週。
4. 停用fluoxetine至少5週後再開始tranylcypromine,MAOI首日同時開始tyramine限制飲食。 **✔ 正確答案**

**正確答案: 4**

## 解析

SSRI(具血清素作用)與MAOI併用會引發血清素症候群(意識改變、自律神經不穩、神經肌肉過度活動)且可能致命。多數抗憂鬱藥與MAOI互換需14天清除期,然而fluoxetine因活性代謝物norfluoxetine半衰期7〜15天較長,需5週(≥35天)清除期。MAOI啟動同時必須開始tyramine限制飲食(避免熟成乳酪、加工肉、發酵豆品、生啤、紅酒、蠶豆等),避免擬交感神經OTC,並攜帶MAOI警示卡。同日開始、重疊或省略清除期皆造成危險的血清素堆積。

## 深入解析

其他抗憂鬱藥轉MAOI的清除期:sertraline、paroxetine、escitalopram、citalopram、venlafaxine、duloxetine、TCA為14天;fluoxetine為5週;轉換MAOI絕不可只用24小時。

## 臨床情境

情境 38歲難治型MDD,服用fluoxetine 20 mg口服每日已4週仍無症狀改善。醫師計畫轉換為tranylcypromine。今日無SI/HI、無醫療禁忌、LFT與BP正常,願意配合飲食限制。其他用藥:口服避孕藥、綜合維他命。無OTC感冒藥。

## 重要概念

- **MAOI清除期** — 多數抗憂鬱藥與MAOI互換需雙向14天清除期。例外:fluoxetine因norfluoxetine半衰期7〜15天,啟用MAOI前需5週清除期。
- **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、震顫)。多重血清素作用藥併用(SSRI/SNRI/TCA + MAOI/tramadol/triptan/St. John wort/linezolid)所致。處置:停藥、支持治療、嚴重時cyproheptadine。
- **MAOI病人衛教** — MAOI首日起執行tyramine限制飲食、攜帶含緊急藥物清單的MAOI警示卡、避免擬交感神經OTC(pseudoephedrine、phenylephrine)、避免meperidine與dextromethorphan、緩慢起身以防姿態性低血壓、出現劇烈頭痛或胸痛立即就醫。

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