附錄 A — 附錄 A. 藥物劑量速查表 / Appendix A. Drug Dosage Quick Reference Table

版本： 草稿 v0.1 | ⚠️ 所有劑量需經臨床團隊確認

Version: Draft v0.1 | ⚠️ All dosages require confirmation by the clinical team

A.1 A.1 免疫抑制劑 / A.1 Immunosuppressive Agents

藥物 劑量 給藥方式 監測 主要副作用
Tacrolimus 0.03 mg/kg/h IV → oral BID IV → PO Trough level（見下方） 腎毒性、糖尿病、神經毒性
Cyclosporine 5 mg/kg/day in 2 doses PO BID Trough level 腎毒性、牙齦增生
MMF <50kg: 500mg/day; ≥50kg: 1000mg/day PO BID CBC GI、骨髓抑制
Azathioprine 1-2 mg/kg/day PO QD CBC 骨髓抑制、肝毒性
Prednisolone 維持 5 mg/day PO QD 血糖、骨密度 骨鬆、糖尿病、感染
Methylprednisolone 500-1000 mg（術中）；500 mg x 3（pulse） IV — —
Basiliximab 20 mg Day 0 & Day 4 IV — 過敏（罕見）
ATG (Thymoglobulin) 1.5 mg/kg/day x 3-5 days IV CBC（淋巴球） 嚴重白血球低下、感染
Rituximab 375 mg/m² IV CD20 感染、infusion reaction
Sirolimus 1-2 mg/day（目標 5-8 ng/mL） PO QD Trough level ⚠️ 術後 3 月內禁用
Everolimus 0.75 mg BID（目標 3-8 ng/mL） PO BID Trough level 口腔潰瘍、高血脂

| Drug | Dose | Route | Monitoring | Major Side Effects | |—|—|—|—|—| | Tacrolimus | 0.03 mg/kg/h IV → oral BID | IV → PO | Trough level (see below) | Nephrotoxicity, diabetes, neurotoxicity | | Cyclosporine | 5 mg/kg/day in 2 doses | PO BID | Trough level | Nephrotoxicity, gingival hyperplasia | | MMF | <50kg: 500mg/day; ≥50kg: 1000mg/day | PO BID | CBC | GI toxicity, myelosuppression | | Azathioprine | 1-2 mg/kg/day | PO QD | CBC | Myelosuppression, hepatotoxicity | | Prednisolone | Maintenance 5 mg/day | PO QD | Blood glucose, bone density | Osteoporosis, diabetes, infection | | Methylprednisolone | 500-1000 mg (intraoperative); 500 mg x 3 (pulse) | IV | — | — | | Basiliximab | 20 mg Day 0 & Day 4 | IV | — | Hypersensitivity (rare) | | ATG (Thymoglobulin) | 1.5 mg/kg/day x 3-5 days | IV | CBC (lymphocytes) | Severe leukopenia, infection | | Rituximab | 375 mg/m² | IV | CD20 | Infection, infusion reaction | | Sirolimus | 1-2 mg/day (target 5-8 ng/mL) | PO QD | Trough level | ⚠️ Contraindicated within 3 months post-op | | Everolimus | 0.75 mg BID (target 3-8 ng/mL) | PO BID | Trough level | Oral ulcers, hyperlipidemia |

A.1.1 Tacrolimus 目標濃度 / Tacrolimus Target Levels

術後時間 Trough 目標（ng/mL）
0-3 個月 9-12
3-6 個月 8-11
> 6 個月 7-10
感染期間 5-7

| Post-Transplant Period | Trough Target (ng/mL) | |—|—| | 0-3 months | 9-12 | | 3-6 months | 8-11 | | > 6 months | 7-10 | | During infection | 5-7 |

A.2 A.2 抗感染藥物 / A.2 Anti-Infective Agents

A.2.1 抗生素 / Antibiotics

藥物 劑量 適應症 備註
Piperacillin-Tazobactam 4.5 g IV q6h 周術期 empiric
Meropenem 1 g IV q8h 替代 empiric
Vancomycin 15-20 mg/kg IV q8-12h MRSA coverage Trough 15-20
TMP-SMX SS 1 tab QD 或 DS 3x/週 PCP 預防 終生
Azithromycin 250 mg PO QOD CLAD（BOS） 長期

| Drug | Dose | Indication | Notes | |—|—|—|—| | Piperacillin-Tazobactam | 4.5 g IV q6h | Perioperative empiric | | | Meropenem | 1 g IV q8h | Alternative empiric | | | Vancomycin | 15-20 mg/kg IV q8-12h | MRSA coverage | Trough 15-20 | | TMP-SMX | SS 1 tab QD or DS 3x/week | PCP prophylaxis | Lifelong | | Azithromycin | 250 mg PO QOD | CLAD (BOS) | Long-term |

A.2.2 抗病毒 / Antivirals

藥物 劑量 適應症 備註
Valganciclovir 900 mg PO QD（預防）；900 mg BID（治療） CMV 依 eGFR 調量
Ganciclovir 5 mg/kg IV q12h CMV tissue disease
Acyclovir 400 mg PO BID（預防）；10 mg/kg IV q8h（治療） HSV/VZV
Oseltamivir 75 mg PO BID x 5 days Influenza

| Drug | Dose | Indication | Notes | |—|—|—|—| | Valganciclovir | 900 mg PO QD (prophylaxis); 900 mg BID (treatment) | CMV | Adjust for eGFR | | Ganciclovir | 5 mg/kg IV q12h | CMV tissue disease | | | Acyclovir | 400 mg PO BID (prophylaxis); 10 mg/kg IV q8h (treatment) | HSV/VZV | | | Oseltamivir | 75 mg PO BID x 5 days | Influenza | |

A.2.3 Valganciclovir 腎功能調整 / Valganciclovir Renal Dose Adjustment

eGFR (mL/min) 預防劑量 治療劑量
≥ 60 900 mg QD 900 mg BID
40-59 450 mg QD 450 mg BID
25-39 450 mg QOD 450 mg QD
10-24 450 mg 2x/週 450 mg QOD

| eGFR (mL/min) | Prophylaxis Dose | Treatment Dose | |—|—|—| | ≥ 60 | 900 mg QD | 900 mg BID | | 40-59 | 450 mg QD | 450 mg BID | | 25-39 | 450 mg QOD | 450 mg QD | | 10-24 | 450 mg 2x/week | 450 mg QOD |

A.2.4 抗黴菌 / Antifungals

藥物 劑量 適應症 備註
Amphotericin B 霧化 院內 protocol 吸入性預防 術後 3-6 月
Voriconazole 6 mg/kg IV q12h D1 → 4 mg/kg q12h 侵入性 Aspergillosis ⚠️ Tac 交互作用
Itraconazole 200 mg PO BID 預防/治療 ⚠️ Tac 交互作用
Caspofungin 70 mg D1 → 50 mg/day 替代/救援
Amphotericin B liposomal 3-5 mg/kg/day IV 救援 腎毒性

| Drug | Dose | Indication | Notes | |—|—|—|—| | Amphotericin B nebulized | Institutional protocol | Inhaled prophylaxis | 3-6 months post-op | | Voriconazole | 6 mg/kg IV q12h D1 → 4 mg/kg q12h | Invasive Aspergillosis | ⚠️ Tac interaction | | Itraconazole | 200 mg PO BID | Prophylaxis/treatment | ⚠️ Tac interaction | | Caspofungin | 70 mg D1 → 50 mg/day | Alternative/salvage | | | Amphotericin B liposomal | 3-5 mg/kg/day IV | Salvage | Nephrotoxicity |

A.3 A.3 止痛與鎮靜 / A.3 Analgesia and Sedation

藥物 劑量 用途 備註
Propofol 0.5-3 mg/kg/h IV ICU 鎮靜 首選
Dexmedetomidine 0.2-0.7 μg/kg/h IV 輔助鎮靜 助 weaning
Remifentanil 0.05-0.2 μg/kg/min IV ICU 止痛 超短效
Fentanyl 25-100 μg/h IV 替代 opioid
Acetaminophen 1 g IV/PO q6h（max 4g/day） 非 opioid 肝功能注意
Gabapentin 100-300 mg TID Neuropathic pain 腎調量
Ketamine 0.1-0.3 mg/kg/h IV Opioid-sparing 低劑量

| Drug | Dose | Use | Notes | |—|—|—|—| | Propofol | 0.5-3 mg/kg/h IV | ICU sedation | First-line | | Dexmedetomidine | 0.2-0.7 μg/kg/h IV | Adjunctive sedation | Facilitates weaning | | Remifentanil | 0.05-0.2 μg/kg/min IV | ICU analgesia | Ultra-short acting | | Fentanyl | 25-100 μg/h IV | Alternative opioid | | | Acetaminophen | 1 g IV/PO q6h (max 4g/day) | Non-opioid | Monitor hepatic function | | Gabapentin | 100-300 mg TID | Neuropathic pain | Renal dose adjustment | | Ketamine | 0.1-0.3 mg/kg/h IV | Opioid-sparing | Low dose |

A.4 A.4 VTE 預防 / A.4 VTE Prophylaxis

藥物 劑量 時機 備註
Enoxaparin 4000 IU SC QD 術後 6-8h 標準
Enoxaparin（ECMO 中） 0.5 mg/kg SC BID ECMO 期間 Vienna protocol
UFH（ECMO 中） continuous IV（依 aPTT） ECMO 期間 替代方案

| Drug | Dose | Timing | Notes | |—|—|—|—| | Enoxaparin | 4000 IU SC QD | 6-8h post-op | Standard | | Enoxaparin (on ECMO) | 0.5 mg/kg SC BID | During ECMO | Vienna protocol | | UFH (on ECMO) | continuous IV (per aPTT) | During ECMO | Alternative |

A.5 A.5 其他常用藥物 / A.5 Other Commonly Used Medications

藥物 劑量 用途 備註
Norepinephrine 0.01-0.5 μg/kg/min IV 升壓 首選 vasopressor
Dobutamine 2-10 μg/kg/min IV 強心
Milrinone 0.25-0.75 μg/kg/min IV 強心 + 降肺壓
iNO 10-20 ppm 肺高壓
Furosemide 20-80 mg IV/PO 利尿 目標 negative balance
Amlodipine 5-10 mg PO QD 高血壓 首選降壓
Pravastatin 20-40 mg PO QHS 高血脂 CYP3A 交互作用小
Pantoprazole 40 mg PO/IV QD 胃酸抑制
Calcium 1200 mg/day PO 骨鬆預防
Vitamin D 800-1000 IU/day PO 骨鬆預防 目標 25-OH-D > 30

| Drug | Dose | Use | Notes | |—|—|—|—| | Norepinephrine | 0.01-0.5 μg/kg/min IV | Vasopressor | First-line vasopressor | | Dobutamine | 2-10 μg/kg/min IV | Inotrope | | | Milrinone | 0.25-0.75 μg/kg/min IV | Inotrope + pulmonary vasodilator | | | iNO | 10-20 ppm | Pulmonary hypertension | | | Furosemide | 20-80 mg IV/PO | Diuresis | Target negative balance | | Amlodipine | 5-10 mg PO QD | Hypertension | First-line antihypertensive | | Pravastatin | 20-40 mg PO QHS | Hyperlipidemia | Minimal CYP3A interaction | | Pantoprazole | 40 mg PO/IV QD | Acid suppression | | | Calcium | 1200 mg/day PO | Osteoporosis prevention | | | Vitamin D | 800-1000 IU/day PO | Osteoporosis prevention | Target 25-OH-D > 30 |

A.6 A.6 藥物交互作用警示表 / A.6 Drug Interaction Alert Table

合併用藥 影響 Tacrolimus 處理
Voriconazole ⬆⬆⬆ 預先減量 Tac 至 1/3-1/5，48-72h 抽 level
Itraconazole ⬆⬆⬆ 同上
Fluconazole ⬆⬆ 可能需減量
Erythromycin ⬆⬆ 避免或密切監測
Diltiazem ⬆⬆ 避免用於降壓
Nirmatrelvir-Ritonavir ⬆⬆⬆⬆ 暫停 Tac，密切監測
Rifampin ⬇⬇⬇ 禁用 → 改 Rifabutin
Phenytoin ⬇⬇ 需大幅增量 Tac
Simvastatin 橫紋肌溶解風險 改用 Pravastatin
Grapefruit ⬆ 衛教避免

| Concomitant Drug | Effect on Tacrolimus | Management | |—|—|—| | Voriconazole | ⬆⬆⬆ | Pre-emptively reduce Tac to 1/3-1/5, check level at 48-72h | | Itraconazole | ⬆⬆⬆ | Same as above | | Fluconazole | ⬆⬆ | May require dose reduction | | Erythromycin | ⬆⬆ | Avoid or monitor closely | | Diltiazem | ⬆⬆ | Avoid for antihypertensive use | | Nirmatrelvir-Ritonavir | ⬆⬆⬆⬆ | Hold Tac, monitor closely | | Rifampin | ⬇⬇⬇ | Contraindicated → switch to Rifabutin | | Phenytoin | ⬇⬇ | Significant Tac dose increase required | | Simvastatin | Rhabdomyolysis risk | Switch to Pravastatin | | Grapefruit | ⬆ | Patient education to avoid |

⚠️ 此表為速查用途，完整交互作用請查閱藥典或諮詢藥師。

⚠️ This table is for quick reference only. For complete drug interaction information, consult the pharmacopoeia or a pharmacist.