- 學位論文
台灣慢性阻塞性肺病患者支氣管擴張劑使用型態與抗膽鹼藥物和心肌梗塞之風險
Utilization Pattern of Bronchodilators among COPD Patients in Taiwan and the Risk of Myocardial Infarction associated with Anticholinergic Agents
摘要
簡介：慢性阻塞性肺病 (慢阻肺)是一種可預防及治療的疾病，治療指引建議藥物治療首選為吸入型支氣管擴張劑。抗膽鹼藥物和心肌梗塞的相關性，目前的文獻尚未有定論。研究目的是了解台灣慢阻肺病人支氣管擴張劑使用型態與評估病人使用抗膽鹼藥物後發生心肌梗塞之風險。 方法：(1)處方型態：方法為橫斷面研究，使用衛生福利部統計處衛生福利資料科學中心資料庫，分析2008年至2013年慢阻肺病人歷年處方型態。(2)抗膽鹼藥物和心肌梗塞之風險：研究方法是巢式病例對照研究法，使用衛生福利資料科學中心資料庫執行，總計有142,437名病患納入研究。定義事件組為診斷慢阻肺後發生心肌梗塞之病人；心肌梗塞發生前六個月曾用過任何的抗膽鹼藥物都會被納入分析。在納入的病人中事件組有1,583人，以性別、年齡、共病症以及用藥史，採用一比一傾向分數配對法選出1,583名對照組。條件式邏輯斯回歸用來評估抗膽鹼藥物和心肌梗塞之風險，以勝算比呈現結果。為了消除潛在的干擾因素，使用性別、年齡、共病症以及用藥史來校正勝算比。 結果：(1)處方型態：研究總納入143,133名病人。常處方的藥品前三名為茶鹼類藥物、短效乙二型交感神經刺激劑以及抗膽鹼藥物；然而茶鹼類藥物使用量逐年下降。在短效乙二型交感神經刺激劑處方中，口服劑型的處方量多於吸入劑型處方量。(2)抗膽鹼藥物和心肌梗塞之風險：事件組和對照組相比，使用抗膽鹼藥物會增加心肌梗塞發生的風險 (校正後勝算比1.55，95%信賴區間 1.29-1.85)。 結論：雖然治療指引建議慢阻肺病人治療藥物首選為吸入型支氣管擴張劑，本論文結果顯示台灣的處方型態與指引建議不同。未來研究可朝了解處方原因及偏好執行。慢阻肺病人使用抗膽鹼藥物和心肌梗塞發生有相關性，臨床人員要留意此藥物的安全性。
並列摘要
Introduction: Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease. Guideline recommended that the first choice of pharmacotherapy was inhaled bronchodilators. The association between myocardial infarction (MI) and anticholinergic agents were still in debate. The aim of this study was to investigate the prescribing patterns of bronchodilators among COPD patients and evaluate the association between anticholinergic agents and MI. Methods: (1) Prescribing patterns: This cross-sectional study used Health and Welfare Data Science Center (HWDC) database to analyze annual prescribing patterns of bronchodilators in COPD patients from 2008 to 2013. (2) Anticholinergic agents and MI: A nested-case control study was conducted by HWDC database. A cohort of 142,437 COPD patients was identified from 2008 to 2013. Case group was defined the first diagnosis of MI after COPD diagnosis. Any use of anticholinergic agents within 6 months before MI occurred was analyzed. From this cohort, 1,583 cases were matched to 1,583 controls by one-to-one propensity score matching (PSM). PSM was based on gender, age, comorbidities and medication history. Conditional logistic regression was applied to evaluate the odds ratio (OR) for the risk of MI associated with anticholinergic agents. In order to eliminate the potential confounders, OR was adjusted by gender, age, comorbidities and medication history. Results: (1) Prescribing patterns: A total of 143, 133 patients were included in the study. The first three common prescriptions were xanthines, short-acting beta-2 agonists (SABA) and muscarinic antagonists (MA). However, the utilization of xanthine declined with time. Among of all SABA prescriptions, the utilization of oral form was more than inhaled form. (2) Anticholinergic agents and MI: Case group showed an increase risk of MI compared with control group. [aOR = 1.55, 95% confidence interval (CI): 1.29-1.85] Conclusion: Although guideline recommended that inhaled bronchodilator was first choice for treatments, our study showed that the prescription patterns of Taiwan were different. Future research is to investigate the reasons and preferences of prescriptions. The use of anticholinergic agents in COPD patients was associated with the risk of MI. Clinicians should be alert this drug safety issue.