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 %O  =z'$Monitorizacin de la digoxina&    APRM(   CONSECUENCIAS   INTERVENCION  N!CSD  Margen teraputico estrecho: General: 0,8  2 ng/ml ICC: 0,5  1 ng/ml FA: 1,5  2,5 ng/ml&?? ] G=Paciente con CSD < 0,8 ng/ml y se mantiene la dosis habitual >>(@    " . El paciente puede tener CSD subteraputicas /P/&    Aumentar la dosis, excepto en ICC, enfermedad coronaria avanzada o hipotiroidismo donde el lmite inferior es e"0,5 ng/ml). Comprobar que el paciente se toma correctamente la medicacin y que no ha sufrido vmitos en los ltimos das P  P"5Paciente con CSD > 2 ng/ml y no se modifica la dosis 66(@      Riesgo de toxicidad digitlica. !P!&   Interrupcin y posterior reduccin de la dosis especialmente en hipoxia, hipokalemia, hipomagnesemia, hipercalcemia e hipotiroidismo. Excepto en FA y sin signos de toxicidad o en el hipertiroidismo. PZI      V O /Indicaciones para la monitorizacin de digoxina&'   Valoracin del cumplimiento Alteraciones de la funcin renal Sospecha de toxicidad Evaluar la necesidad de continuar tratamiento Situaciones que alteran la respuesta al frmaco Sospecha de Interaccin farmacolgicaD0" @[0" @[=$`  %  f      DOObtencin de CSD en adulto con dosis de 0.25 mg/da, y sin factores de riesgo. PP &-  ! xGasto innecesario y molestias para el paciente. Hasta un 50% de los controles de CSD pueden llegar a ser innecesarios. yPy y Indicar la monitorizacin de CSD en los siguientes casos: Confirmacin de toxicidad Factores que alteran la farmacocintica Fallo teraputico Problemas de adherencia .:PmP:m  ),Distribucin bicompartimental de la digoxina@      6 Distribucin de la digoxina  EBPaciente con una CSD obtenida antes de 6 horas de la ltima dosis CC( C }Da lugar a una interpretacin errnea pues los CSD estarn aumentados ya que no ha finalizado la distribucin de la digoxina.~P~&t    Indicar que las muestras para monitorizar las CSD, deben obtenerse al menos despus de 6 horas de la ltima dosis. Es recomendable hacer constar en la peticin, la hora de muestreo. P  +4Consecucin del estado estacionario para la digoxina&,   F<Muestreo obtenido tras 72 h desde el inicio del tratamiento ==( = VDa lugar a una interpretacin errnea pues no se ha alcanzado el estado estacionario. WZW W Interpretar adecuadamente la CSD. Sin haber dado dosis de carga hay que esperar 5 t (aprox. 7 das en adulto con funcin renal normal) hasta alcanzar el estado estacionario. Z&R  \ R'-Factores que alteran la accin de la digoxina..(&%   Todo lo que empieza por hipo Aumenta el efecto Hipokalemia Hipomagnesemia Hipotiroidismo Excepcin: Hipercalcemia02CCZ2       H0Paciente con CSD>1,5 ng/ml y K+ srico<3 Meq/L. 11(t         TLa hipopotasemia aumenta la sensibilidad del paciente a la toxicidad por digoxina. UZU@  9   8Reducir dosis, manteniendo las CSD entre 0,8- 1,5 ng/ml 9Z9@2     7 FACTORES DE RIESGO CSD ELEVADAS (  ?INSUFICIENCIA RENAL EDAD > 80 AOS INTERACCIONES FARMACOLOGICAS$@0 " d@?  8 Poblacin intoxicada por DGX  :Sintomatologa intoxicacin   ;Sintomatologa intoxicacin   =Factores de riesgo(   <Factores de riesgo asociados   Q#9Paciente con peticin diaria de CSD tras una intoxicacin::( : VAbuso en la determinacin de las CSD. Gasto innecesario y molestias para el paciente. WPW W Dejar transcurrir al menos 1 semivida de eliminacin (t) o ms entre tomas de muestra, excepto en casos de admn de carbn activo. Los CSD disminuyen a la mitad cuando transcurre 1t que, en adulto con funcin renal normal, son 36 h y en insuficiencia renal puede llegar a los 3-6 das. P @6  4   ?Caractersticas del anciano  DISMINUCION DEL GRADO DE FILTRACION GLOMERULAR DISMINUCION DE LA MASA MUSCULAR Y MAGRA DEFICIENCIA EN POTASIO (DIURETICOS) POLITERAPIA PATOLOGIAS CONCOMITANTES Z  @ , UNIVELES SERICOS DE DIGOXINA CON DOSIS DE 0,25 MG/DIA EN PACIENTES MAYORES DE 75 AOS. VU  U  Caractersticas de los pacientes Pacientes= 33 Edad media: 84.5 4.8 aos. Peso medio: 62.7 11.8 kg. Crs= 0.92 0.20 mg/dl Un 33% de pacientes > 75 aos con 0.25mg/d digoxina presentan NSD > 2 ng/ml. !ZaZPZZ!  PM          -      -'Elaboracin del informe farmacocintico&   Valorar: Si el nivel srico corresponde a la dosis Si la extraccin ha sido correcta Tiempo de muestreo Consecucin del estado estacionario Sugerir Cambios en la dosis Medidas a tomar en caso de intoxicacin Dosis en caso de cambio de va de administracinl L7m L7  m  X)Fin   /.1[\]^ _ ` a b cdefghijklmnopqrK ` ~T=f` ffNf` }3f` ffkkfTTze` modb` RRRMMMR|:DDDXx` Td4Q`2}pAN(y` ` 3ff>?" dd@,?sd@ ld ls@ld`ls n?" dd@   @@``PR    @ ` `6p>> xGpGpGG<F(  <AT  < " < c BlCDEF"d @ llll@`"~@\  < " < c BlCDEF" @ llll@`"" < c BlC*DEF" @ *l*l**@`"~ < c BlCDEF" @ ll@`"Q~o < c BlCDEF" @ ll@`"$ ~B   < c BlCDEF" @ ll@`"! ~@   < c BlC$DEF" @ l$l$ll@`"+ ~O   < c BlCDEF" @ llll@`"T ~r   < c BlC$DEF" @ l$l$ll@`" ~   < c BlCDEF" @ llll@`"~ < c BlCDEF" @ llll@`"*~B < c BlCDEF" @ llll@`"~ < c BlC DEF" @ l l ll@`"m~y < c BlCDEF" @ llll@`"~  < c BlC DEF" @ l l ll@`"~ < c BlCDEF" @ llll@`"r~ < c BlCDEF" @ llll@`"~ < c BlCDEF" @ llll@`"~ < c BlCDEF" @ llll@`"~6 < c BlCDEF" @ llll@`"~ < c BlCDEF" @ llll@`"~ < c BlCDEF" @ llll@`"Q~i < c BlCDEF" @ llll@`"X~p < c BlCDEF" @ llll@`"~ < c BlCDEF" @ llll@`"I~[ < c BlCDEF" @ llll@`"~xb ~ <# "~  < c B*CDEF&d @ **@`"! 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r3y`f___PPT10i.b @j+D=' = @B +  Corte<  - SK  (  T   "J  s B#C DEF" @ " ##"@`"H   #  c BCiDEFd@  i  @`#"  i  0h " `    r:Haga clic para modificar el estilo de subttulo del patrn;;   6X #" `` `  d*     6x #" ``   f*     6 #" `` `  f*      <X "Z  c+Haga clic para cambiar el estilo de ttulo ,, B  s *޽h ? r3y`f___PPT10i.b @j+D=' = @B +')0 L7(  L L 0 P    T*   L 0T     V*  d L c $ ?  3 L 0t  0  kHaga clic para modificar el estilo de texto del patrn Segundo nivel Tercer nivel Cuarto nivel Quinto nivel7   l  L 6 _P   T*   L 6 _   V*  H L 0޽h ? 3380___PPT10.=Fa* xp0,(  ,x , c $C@]   P , C (AdigoxinS -6H , 0޽h ? f;v3ff___PPT10i.=%+D=' = @B +j ) `(     0g  C<]|<$D 0      0g  G< <$D0     0g  G<  <$D0    0] 3 ,$D 0  6Z`,$D 0H  0޽h ? ffkkfTTze___PPT10.H>0g+SND ' = @B D' = @BA?%,( < +O%,( < +D' =%(D' =%(D>' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<*%(D' =-m6Bbox(in)*<3<*Dn' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+B#style.visibility<*%(D' =+4 8?\CB#ppt_xBCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?dCB1+#ppt_h/2BCB#ppt_yB*Y3>B ppt_y<*D' =%(D' =%(DT' =A@BBB B0B%(D' =1:Bvisible*o3>+B#style.visibility<*%(D' =-6B'blinds(horizontal)*<3<*D' =%(D' =%(DT' =A@BBB B0B%(D' =1:Bvisible*o3>+B#style.visibility<*%(D' =-6B'blinds(horizontal)*<3<*Dn' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+B#style.visibility<*%(D' =+4 8?\CB#ppt_xBCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?dCB1+#ppt_h/2BCB#ppt_yB*Y3>B ppt_y<*D' =%(D' =%(DX' =A@BBB B0B%(D' =1:Bvisible*o3>+B#style.visibility<*%(D' =-6B+checkerboard(across)*<3<*D' =%(D' =%(DX' =A@BBB B0B%(D' =1:Bvisible*o3>+B#style.visibility<*%(D' =-6B+checkerboard(across)*<3<*++0+ ++0+ ++0+ +0 - `0(  x  c $/ `}   x  c $ `  H  0޽h ? ffkkfTTze80___PPT10.P>`z! )  (     0D5g  C<]|<$D 0      0@6g  G<  <$D0     0<7g  G< I<$D0    0] 3 ,$D 0  6Z`,$D 0H  0޽h ? ffkkfTTze,$___PPT10.H>0g+SND0' = @B D' = @BA?%,( < +O%,( < +D' =%(D' =%(D>' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<*%(D' =-m6Bbox(in)*<3<*Dn' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+B#style.visibility<*%(D' =+4 8?\CB#ppt_xBCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?dCB1+#ppt_h/2BCB#ppt_yB*Y3>B ppt_y<*D' =%(D' =%(DT' =A@BBB B0B%(D' =1:Bvisible*o3>+B#style.visibility<*%(D' =-6B'blinds(horizontal)*<3<*D' =%(D' =%(DT' =A@BBB B0B%(D' =1:Bvisible*o3>+B#style.visibility<*/%(D' =-6B'blinds(horizontal)*<3<*/Dn' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+B#style.visibility<*%(D' =+4 8?\CB#ppt_xBCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?dCB1+#ppt_h/2BCB#ppt_yB*Y3>B ppt_y<*D' =%(D' =%(DX' =A@BBB B0B%(D' =1:Bvisible*o3>+B#style.visibility<*%(D' =-6B+checkerboard(across)*<3<*D' =%(D' =%(DX' =A@BBB B0B%(D' =1:Bvisible*o3>+B#style.visibility<*}%(D' =-6B+checkerboard(across)*<3<*}D' =%(D' =%(DX' =A@BBB B0B%(D' =1:Bvisible*o3>+B#style.visibility<*}%(D' =-6B+checkerboard(across)*<3<*}++0+ ++0+h ++0+h + )  p(     6(Yg  C<]|<$D 0      0$Zg  G<  <$D 0     0 [g  G< <$D 0    0] 3 ,$D 0  6Z`,$D 0H  0޽h ? ffkkfTTze___PPT10.H>0g+]D' = @B D{' = @BA?%,( < +O%,( < +D' =%(D' =%(D>' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<*%(D' =-m6Bbox(in)*<3<*Dn' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+B#style.visibility<*%(D' =+4 8?\CB#ppt_xBCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?dCB1+#ppt_h/2BCB#ppt_yB*Y3>B ppt_y<*D' =%(D' =%(D>' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<*!%(D' =-m6Bbox(in)*<3<*!Dn' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+B#style.visibility<*%(D' =+4 8?\CB#ppt_xBCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?dCB1+#ppt_h/2BCB#ppt_yB*Y3>B ppt_y<*D' =%(D' =%(D>' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<*%(D' =-m6Bbox(in)*<3<*D' =%(D' =%(D>' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<*%(D' =-m6Bbox(in)*<3<*D' =%(D' =%(D>' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<*%(D' =-m6Bbox(in)*<3<*++0+ ++0+ ++0+ + -  Pb(     <P    :~  s *H `}   H  0޽h ? ̙33y___PPT10Y+D=' = @B +"' )  p(     0g  C<]|<$D 0      0Lg  G< <$D 0     04g  G< f <$D 0    0] 3 ,$D 0  6Z`,$D 0H  0޽h ? ffkkfTTze""___PPT10".H>0g+>)D!' = @B D!' = @BA?%,( < +O%,( < +D' =%(D' =%(D>' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<*%(D' =-m6Bbox(in)*<3<*Dn' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+B#style.visibility<*%(D' =+4 8?\CB#ppt_xBCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?dCB1+#ppt_h/2BCB#ppt_yB*Y3>B ppt_y<*D' =%(D' =%(D>' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<*%(D' =-m6Bbox(in)*<3<*D' =%(D' =%(D>' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<*x%(D' =-m6Bbox(in)*<3<*xDn' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+B#style.visibility<*%(D' =+4 8?\CB#ppt_xBCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?dCB1+#ppt_h/2BCB#ppt_yB*Y3>B ppt_y<*D' =%(D' =%(D>' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<*%(D' =-m6Bbox(in)*<3<*D ' =%(D ' =%(D>' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<*:%(D' =-m6Bbox(in)*<3<*:D>' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<*:T%(D' =-m6Bbox(in)*<3<*:TD>' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<*T|%(D' =-m6Bbox(in)*<3<*T|D>' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<*|%(D' =-m6Bbox(in)*<3<*|D>' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<*%(D' =-m6Bbox(in)*<3<*++0+ ++0+h ++0+h + -  {0l(  l~ l s *4 `}    l T ??@ |10 ng/ml 0 2 2    B l  `D?? B l@  `D??` `  l  ` ??U ]u { 0.0 ng/ml 0 2     l  ` ??V /  [T=00   l T ?? p  } 5.5 ng/ml 0 2 2    B  l  `D??@ @ @B  l@  `D??     l  `@ ??  { 0.5 ng/ml 0 2      l T ?? P  ~ 3.25 ng/ml 0 2 2    B  l  `D??P 0 p P B l@  `D?? 0 @   l  ` ??  &  | 0.75 ng/ml 0 2     l T  ?? P  ~ 2.12 ng/ml 0 2 2    B l  `D??` 0 p ` B l@  `D?? 0 @   l  `  ??    } 0.875 ng/ml 0 2     l T ??P0 {1 ng/ml0 22    B l  `D??p0 p pB l@  `D??0 @   l  `x ??   y1 ng/ml02     l  ` ?? p& @ nT=35 min 0 &    l  `t ??` V  nT=70 min 0 &    l  `# ??@ @_ `  o T=105 min 0 &    l  `D( ??P 0 # p ^T=3-4h0  r l  ` ??0 l  ` ??p0` l  `X, ??-  s Conc. tisular0&     l  `- ??V  r Conc. srica 0 &   H l 0޽h ? 3333^ - ^(  ~  s *@ `}     `AuntitledTw  H  0޽h ? 333380___PPT10.ْ> ) (     0`4g  C<]|<$D 0      0Ig  G< <$D 0     0DBg  G< I<$D0    0] 3 ,$D 0  6Z`,$D 0H  0޽h ? ffkkfTTze___PPT10.H>0g+QD' = @B D' = @BA?%,( < +O%,( < +D' =%(D' =%(D>' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<*%(D' =-m6Bbox(in)*<3<*Dn' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+B#style.visibility<*%(D' =+4 8?\CB#ppt_xBCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?dCB1+#ppt_h/2BCB#ppt_yB*Y3>B ppt_y<*D' =%(D' =%(D>' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<*%(D' =-m6Bbox(in)*<3<*D' =%(D' =%(D>' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<*~%(D' =-m6Bbox(in)*<3<*~Dn' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+B#style.visibility<*%(D' =+4 8?\CB#ppt_xBCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?dCB1+#ppt_h/2BCB#ppt_yB*Y3>B ppt_y<*D' =%(D' =%(DX' =A@BBB B0B%(D' =1:Bvisible*o3>+B#style.visibility<*%(D' =-6B+checkerboard(across)*<3<*D' =%(D' =%(DX' =A@BBB B0B%(D' =1:Bvisible*o3>+B#style.visibility<*%(D' =-6B+checkerboard(across)*<3<*++0+ ++0+ ++0+ +X - Pt(  t~ t s *0g+>)D' = @B D{' = @BA?%,( < +O%,( < +D' =%(D' =%(D>' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<*%(D' =-m6Bbox(in)*<3<*Dn' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+B#style.visibility<*%(D' =+4 8?\CB#ppt_xBCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?dCB1+#ppt_h/2BCB#ppt_yB*Y3>B ppt_y<*D' =%(D' =%(D>' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<*%(D' =-m6Bbox(in)*<3<*D' =%(D' =%(D>' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<*W%(D' =-m6Bbox(in)*<3<*WDn' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+B#style.visibility<*%(D' =+4 8?\CB#ppt_xBCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?dCB1+#ppt_h/2BCB#ppt_yB*Y3>B ppt_y<*D' =%(D' =%(D>' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<*%(D' =-m6Bbox(in)*<3<*D' =%(D' =%(D>' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<*%(D' =-m6Bbox(in)*<3<*++0+ ++0+ ++0+ +0 - 0(  x  c $ `}   x  c $ `  H  0޽h ? ffkkfTTze80___PPT10.>(> ) (     0g  C<]|<$D 0      00g  G< <$D 0     0g  G<  <$D0    0] 3 ,$D 0  6Z`,$D 0H  0޽h ? ffkkfTTze___PPT10.H>0g+QD' = @B D' = @BA?%,( < +O%,( < +D' =%(D' =%(D>' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<*%(D' =-m6Bbox(in)*<3<*Dn' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+B#style.visibility<*%(D' =+4 8?\CB#ppt_xBCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?dCB1+#ppt_h/2BCB#ppt_yB*Y3>B ppt_y<*D' =%(D' =%(D>' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<*%(D' =-m6Bbox(in)*<3<*D' =%(D' =%(D>' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<*T%(D' =-m6Bbox(in)*<3<*TDn' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+B#style.visibility<*%(D' =+4 8?\CB#ppt_xBCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?dCB1+#ppt_h/2BCB#ppt_yB*Y3>B ppt_y<*D' =%(D' =%(DX' =A@BBB B0B%(D' =1:Bvisible*o3>+B#style.visibility<*%(D' =-6B+checkerboard(across)*<3<*D' =%(D' =%(DX' =A@BBB B0B%(D' =1:Bvisible*o3>+B#style.visibility<*9%(D' =-6B+checkerboard(across)*<3<*9++0+ ++0+ ++0+ +6 - 6(  ~  s * `}   x  c $D"T   H  0޽h ? 333380___PPT10.D9 - 4,(  ~  s * `}    0  `A ? ?ww  R  0`P  NIVEL MEDIO DE DIGOXINA 3.0 1.1 NG/ML:E0 29  E H  0޽h ? 333380___PPT10. [ - .(  l  0A ??>    0   J 0 2:  s *D% '  VN.S.D. MEDIO 2.7 0.8 Z,0( 2%   ,   6P1    ,N.S.D. MEDIO 3.2 1.0F0   ~  s * `}   H  0޽h ? ffD3f - F>(  l  0A ??p   0P   J 0 2x  c $!   H  0޽h ? ffD3f) - i(    0)   J 0 2  0+'G 1 .- EN TRES DE CADA CUATRO PACIENTES CON N.S.D. LA INTOXICACION SE PRODUCE POR: INSUFICIENCIA RENAL EDAD AVANZADA (>75 AOS) INTERACCIONES FARMACOLOGICAS 2.- LA DOSIS DE CARGA (ANCIANOS) PUEDE CONTRIBUIR A LA INTOXICACION R0 J1 1 E0 RIE  ~  s *l2 `}   H  0޽h ? ffD3f - LD(  l  0A ??   0:   J 0 2~  s *p9 `}   H  0޽h ? ffD3f. ) (     0hFg  C<]|<$D 0      0dGg  G<<$0     0`Hg  G< ]<$0    0 ,$D0  6ZJ#,$D0H  0޽h ? ffkkfTTze___PPT10..H>0g+DhD' = @B D' = @BA?%,( < +O%,( < +D' =%(D' =%(D>' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<*%(D' =-m6Bbox(in)*<3<*D' =%(D' =%(D-' =4@BBBB%(D' =1:Bvisible*o3>+B#style.visibility<*%(D' =-i6B wedge*<3<*D' =%(D)' =%(D' =ABBB@B0B%())))?D' =1:Bvisible*o3>+B#style.visibility<*W%(D' =%(D' =%(D-' =4@BBBB%(D' =1:Bvisible*o3>+B#style.visibility<*%(D' =-i6B wedge*<3<*D' =%(D)' =%(D' =ABBB@B0B%())))?D' =1:Bvisible*o3>+B#style.visibility<* %(++0+ ++0+ ++0+ + - <(  ~  s *> `}   ~  s *? `  H  0޽h ? 3333___PPT10i.+D=' = @B + - og ##(    Zu??`p q!Listado de pacientes con digoxina "0" "    `8y ??p Z ZEdad paciente 0     ` ??pP U No consta 0      `l ??g e TeraTerm(r) 0       `ȃ ??p  U < 75 aos 0     ZX??p` t 75 aos2 0     ` ??C j  jCr srica normal0      ` ??i  #  lCr srica elevada0      `t ??p    hCr srica normal0      ` ??@   jCr srica elevada0     Z??F )  ]Dosis 0,25 mg/d0     Z ??0  _Control niveles 0     `| ?? _Disminucin dosis0      `p ?? }Seguimiento creatininas0&        `\ ??5  _Dosis <0,25 mg/d0  "  # lZHIT??8;" @ # lZHIT??;"  # lZH@FI?? T 8p " @ 3 rZG1HII?? 8m@ "  # lZHEI?? m"  3 rGHI[??:  0  @  `?? Wm"  # lZHI?? p" @ 3 rGH%?I??`P"  # lG *H`I 0??g `" @  fZH6I?? ;p"   fZHI??0 p  Z?? p  Z??    ` ??c  jDosis 0,25 mg/d0 "   # lZG1HIq?? rC " !@ # lZGz,HIC?? rEi " "  fZHtRI??r #@ # lZG1HI1??# E0 H  0޽h ?/@                 !"  # 3333 - p|<(  |~ | s *< `}   ~ | s * `  H | 0޽h ? 3333y___PPT10Y+D=' = @B + - H(  H~ H s *Hݨ `}   ~ H s *ި `  R H C *ABS00559_xH H 0޽h ? 3333y___PPT10Y+D=' = @B +*.  (*(  (x ( c $8 Z  r ( S 4 `    H ( 0޽h ? ffkkfTTze80___PPT10.>PT0 PI(  Pd P c $L,    P s *L @0   3En el informe se ha expresar lo siguiente: Valoracin de si el nivel corresponde a la dosis, si no es as, se ha de valorar los factores del paciente, su enfermedad, tratamiento concomitante o inadecuada obtencin de muestras Si la extraccin no ha sido correcta, estimacin del nivel previsible (nivel que no ha alcanzado el estado estacionario y que se estabilizar en un determinado valor que hay que calcular) Cambios en la dosis. En caso de intoxicacin, medidas que deben tomarse Si es necesario suprimir de forma transitoria la medicacin, se indican el tiempo de supresin y los niveles esperados Si es previsible un cambio de va, se ha de indicar si se debe mantener la misma dosis o si se ha de cambiar. +3wnB    _ H P 0޽h ? a(0 `xW(  xd x c $L,    x s *L @0   AwLas extracciones de muestras deben realizarse teniendo en cuenta los siguientes criterios: - El nivel ha de ser estable, es decir, el paciente debe tomar la misma dosis durante mas de 5 veces la semivida de eliminacin del frmaco. - La concentracin srica debe estar equilibrada con la tisular, por lo que para algunos frmacos como aminoglucsidos, vancomicina, digoxina, la extraccin tiene que realizarse en la fase postdistributiva La extraccin de las muestras debe efectuarse en el momento del da y del intervalo de administracin ptimo que suele ser en el mnimo antes de la primera dosis de la maana L\  zZ`    9   H x 0޽h ? a(0 P4 (  4X 4 C L    4 S L 0   " H 4 0޽h ? 3380___PPT10.>P"0 `8 (  8X 8 C L    8 S +L 0   " H 8 0޽h ? 3380___PPT10.>0z+!0 p< (  <X < C L    < S \L 0   " H < 0޽h ? 3380___PPT10.>0z+0 @ (  @X @ C L    @ S L 0   " H @ 0޽h ? 3380___PPT10.> 2"0 D (  DX D C L    D S d4L 0   " H D 0޽h ? 3380___PPT10.>4 0 H (  HX H C L    H S 9L 0   " H H 0޽h ? 3380___PPT10.>40 L (  LX L C L    L S |?L 0   " H L 0޽h ? 3380___PPT10.>a70 P (  PX P C L    P S EL 0   " H P 0޽h ? 3380___PPT10.>a7 0 T (  TX T C L    T S JL 0   " H T 0޽h ? 3380___PPT10.>90 X (  XX X C L    X S PL 0   " H X 0޽h ? 3380___PPT10.>90 \ (  \X \ C L    \ S TUL 0   " H \ 0޽h ? 3380___PPT10.>@'0 ` (  `X ` C L    ` S ZL 0   " H ` 0޽h ? 3380___PPT10.>GC0 d (  dX d C L    d S t`L 0   " H d 0޽h ? 3380___PPT10.>GC 0  h (  hX h C L    h S fL 0   " H h 0޽h ? 3380___PPT10.>E 0 0l (  lX l C L    l S kL 0   " H l 0޽h ? 3380___PPT10.>H0 @p (  pX p C L    p S  qL 0   " H p 0޽h ? 3380___PPT10.>sJ0 Pt (  tX t C L    t S vL 0   " H t 0޽h ? 3380___PPT10.>L0 `x (  xX x C L    x S 8|L 0   " H x 0޽h ? 3380___PPT10.>L0 p| (  |X | C L    | S āL 0   " H | 0޽h ? 3380___PPT10.>L#0  (  X  C L     S XL 0   " H  0޽h ? 3380___PPT10.>.O0  (  X  C L     S L 0   " H  0޽h ? 3380___PPT10.>.O0  (  X  C L     S pL 0   " H  0޽h ? 3380___PPT10.>ПQ 0  (  X  C L     S L 0   " H  0޽h ? 3380___PPT10.>])0  (  X  C L     S L 0   " H  0޽h ? 3380___PPT10.>_= 0xZkl\G>sw_~leMNFuPnb+ql ֪P?E$JT!$FH@HD*Q;wNmJQf{|9s3ss7ꛫޣ@kKG D~N :}GR0ǼPbz @JzPj+4z<~.zqz6V c /B%_WÏٴfvmJd-F)t^ `]OѹE˯|٦B3i?4 rËϺB-y(VVVqz@  h4$;;-]Vn^>#G'>O uwd(r/9zΞ??q~d2~x|™d2)##2zX3C{~BGK\JEgu+hG 04>GN#64nؐ<O\J at_ A~>>˧!jw ˑM&B1U)a#ÝX.2 ^<6FRڜ2ׁYJ={8,[L.\~lO~xĎ S6Х@Z Y\mz=OSxzϟy Θx9'k3S'Jxf镉㙡`I-EDNij4`ѷm_l.ERcl +!T?;pB6"39Ǘ*(L~^JTC wQg3)eO1jtȷn<%ߊ1 ۯWWO"DDbI1JI_@ϯSS[Zfi͚5xN++#Br̰HۃrDŽ#"MV_כ_r&IKd\,mP/81OZ%>S&LK%eԭ(=ՠu  xqD[@;2 EF6qrRḁ+Ǜн=8]NʒGCK;1/)'X!m3gٳ?z]/-xhl=%ݖKHζN(B %2m4-h[ctP߇]\bV*~GQ:߮ |SuG]ؿT啙@ເ u]5Ͱe|n~ݸP !Aq ^ɨ:]l^ّ[Z.Ћ_,3Gg BǞܱ,>N*Wx&9 #-VRO|݆H.-M:o:m"GbYo|:'.k^Q.\pHsEQ/񛅒1U>?_imCgΏ )s[ӽdc#{A4"Htؒ('䰉g粁97>.{DH葰c8 P8G7Ĩw%O.53l.=ٞ݌;)%ԆI7s%~Yf,Qڢe(T;E*FkѻdFߡs^ό^F/zcqom2gGDN-w-^  ~hE|rɅocyIrq,ϗ9m}ǹW%/ƴ,y6lMj⶷RH~P狲!Sn/bv[-nde^]di 25V^ZOV>E||-"A.=#o/rhxq ~}nL\Ĝ_xf?n3N3NJ|P; !#/EF)h<%WD+`@LY>H[bYّ'd?32mi&C'pUo)-,lm{zOZMkT-B;cQkYLQْ7߮%X'L}\Eis[".ؾU Kw|q7rY!YZFFE7FW3w W.c6*xR얺&q_P~]+6TH Pv[/k^˶ j5ʸ\wPW"<51_D3|Qj F}pСGǎZƳj٫AcVbSKeG*eԱ`ʌWu1p7*Ů6-.R̽(*1rqig-ga!/ 0xZ pTfwH²7i$ ILII~BD@ u:PRut:Lj+3mAEE }l~H0w{ιvKȣ3A\6ZAL0T$<SWi e3 0$}pǬ^hogp{KFF?X^ɴ_^hdkVаzlW^agO9t)7ZV~/EQĢ4~q_glȤ,"M1ȁ~ܫ?翚?Hէq/Wr- :|v(0  ӦP1q~.+1oas* +~p"{t% DbKL&" O\@L% itbq!1E\D&.r _.*Tʹiaמ^}NBH7Wou.?=V;,Ƿ2|e88|j|*|%8hHH%t"M`01D0T.5&K1\!C.#e9FJd*djd˕-#&H3 /?F܌Vbr.b'&K;~L]CDl.u'Z~Д-c9q)T]𒓗=쑻;_#Yn!~ ؆$jD !-ܗ7 ]]D` -^GU]Z#C}ֿvqx18AoaoRazN}^C#18Ul+b+^ pn&E܊A܅}I/^~b^{xxxxxxǰy yCodzq(o4a|L|)q%9(/Q$'Q(0W[̒0!crr|D'Q It"M\"%\f</%zW>h%ab<, 4$'v>@Zu moyWywe(+@PuBP)q2uLs{.0c1M&p88},Dz&-1/>i-3$KfJ"f)seK br/CDL,T"Ežmm ϳ$}U,_I2bFEڳ؁p[CrPҽf5 "bQ9wZd?  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A?ϖA̕O4 \oJfʙlo A6;e8Ndu&ugR>X"9r.x*s wk{B8\ q+<}|Kr?Y!1WHL甚O1V5m)H\5 gvA3au(W'qmbfy|yq[J1".w{ǚJsQjb |OU{ W̸yszynYUSex=?՘X+kБ\'0ֿ?@ TFa9bRP[Ի2\lgY8OWI_*ENMf}}F3~>-u|?2%'_OQOjO@/YZ f\Dt꟯dtH<_^[>ӞQ2<2ߊ֪O}|?A' O ?҉Ab?n89.NbBΘءb'El6!BH⤢ib"PQhK -϶"p$PU)N*W }J(Ri(}ٽs΃Xs;7|ٝxg{O} PlfKEv:H(9QHT B4@"BC&n󪃋>6ԩG邻a(>QߖlU7`sqD̦ ܅}N!{c%??gF^|b^y90_y%11 ļs#&k0_KJBJ9Ӎv?_ y9?Jy|g_6mikizRʦMr$C2Ջ v*31cK7sag"i{xѝCю;v=?66g?ڮ^ß$=\qdplZW gM* 0^\kN Gx9Ql|`Kq1x1uX_MMp=CufA7>mvBA)u`;D*N}Um%:Uz E#טom3 ޅT`t]:Twc#Ux7_:uH'?:Og.m닛5eSlƹ{hgq9K%b} ^׋iR5[9` 2j8GI Šc&y ^lQ&=T4L1 N; Z :&%Tڰ!-y%EEӞ[3Idϟ8{ =MzǞITMxkOS{j+^{nEeS{:iW}5fj c$`Ӟ.殄pW~#-E.0̵oq/_F֋u( x} ܃-a H ԟ#. w,l88t?ueA{SH`UvrW>suvB5]^,| |#h!X'@Ǐ0޴q :0<SS.CtE) j3m':5 hB8bSF҉a$?<Nqbh<0}v%$mY64!+m \+VR_{iMq_-fM0W5斍]mup-z2p[wN/⸐&U9;;۶uJtBȵazل\D[7E7tD D_|RlC:,fGut>_U }$b %4l[Lq=ƝvH*f»yv5imЅ. p}eŊb,M>\xi#6T̎e %t2x:`ՂF]VM D?*Ҷd=()&8Zu iKr#>d3ST,4&m$l;@ 8E -[ w糗4:q@-#o0>-"GE;p+5򶠴m5d. sϧdžxQyV6S_wTg$/ $ڛZxXWCnjb?dZ[[xȿL_P{e>p3܁rM!a$LxYb@ۛzurpG,<2Xysҋg/mZ* bvXD\nUᵆ@3"2}~#`KȂX?f8&bM/錊| -递b"yTZv^P9(z [,wKh'qa&3I2XRhNOqV+?C\=_D)ܷ%3ѽ0)*dKA%aP9!S@T MEï.o(N!{5YDe&c7]yeg)rw>ߦA/B)%ߵ,fORȾ}.do"ʾmecp~7}vGO Xe$[Rk486®& k00а`'@װ5l@Qf[crpNc󤟕i ` ؤ5JXIpXc 9cvOotv~wpMߟE7KHҁ$!%voi늂 }+}\N~ϭӵVaN *$#| qjL;vk b3,O5sZם;e5y؄寱x?`=k3KzXZ4J"4~ &±K0.\uYڣVOe+[ZckyW4C(F|;KsmFmD4 ˓2㽄x!pӎVj/N.3Ԩߣ[$Ze2KTpmDm>Vhر3h,3K.3g JA4oN3[M|UTgfY63t瞙=Rș荆}֡},;>hF'JJ+z[J3ʆ{rɡ;Dڕ[-zhqq .3N{#dYOmwvr>?`7EM3*/gчIH О@A?.Lղ=Ui!S>Lzٴ)?.TS!U*⿢BW!+EZ _;R! _KK!U*.S _lA|f^kn wՕ7,/ռ' sJBx]m98g:;?הpZb,+s`]G^k75#kO53 QghISHOaN) #` gclѽ_yҷC14.IDU {5x[b]30O|$U0itJ5%`uNׂ7꒪=M]=kCvPnӵ$1u "EYku(άzI.ŕ2]*KpRbu $},l< obgto.h5yܩۦ^oA* C?:M_S[32,`׉el-<_,W8^v|ƌ,6c& ^q̊Z.t-M\Nų{Gw v޽k&Ѿ"Mr&Uo{e\)>3SN8dӫX5IVJYi|/zesdm~O?Oqds{%nrVjU*(kZy9+d0g]|Y 0g <322DdNz;'2v~Rdw$̌&afd-v1G*2vWRdl6\pþ{"x gl~iTYO.i3l <75G%EXDlgs܋D;}$Ҭ&~zU|uyqn[Paciente con CSD < 0,8 ng/ml y se mantiene la dosis habitual 6Paciente con CSD > 2 ng/ml y no se modifica la dosis 0Indicaciones para la monitorizacin de digoxinaPObtencin de CSD en adulto con dosis de 0.25 mg/da, y sin factores de riesgo. -Distribucin bicompartimental de la digoxinaDistribucin de la digoxinaCPaciente con una CSD obtenida antes de 6 horas de la ltima dosis 5Consecucin del estado estacionario para la digoxina=Muestreo obtenido tras 72 h desde el inicio del tratamiento .Factores que alteran la accin de la digoxina1Paciente con CSD>1,5 ng/ml y K+ srico<3 Meq/L. FACTORES DE RIESGO CSD ELEVADASPoblacin intoxicada por DGXSintomatologa intoxicacinSintomatologa intoxicacinFactores de riesgoFactores de riesgo asociados:Paciente con peticin diaria de CSD tras una intoxicacinCaractersticas del ancianoDiapositiva 23VNIVELES SERICOS DE DIGOXINA CON DOSIS DE 0,25 MG/DIA EN PACIENTES MAYORES DE 75 AOS.(Elaboracin del informe farmacocinticoFin Fuentes usadasPlantilla de diseoServidores OLE incrustadosTtulos de diapositivaD 4<Version+_sFrancisco J HidalgoFrancisco J Hidalgo  !"#$%&'()*+,-./123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~Root EntrydO)Pictures_Current UserSummaryInformation( UPowerPoint Document(0DocumentSummaryInformation8