使用類固醇病人預防骨質疏鬆之藥物治療使用評估

MUE of Osteoporosis Prophylaxis during Corticosteroid Treatment

蔡春玉(Chun-Yu Tsai)

指導教授 ： 徐鳳麟教授 ； 簡淑真M.S., Pharm.D

臺北醫學大學/藥學院/藥學研究所/碩士(2003年)

摘要

中文摘要 類固醇廣泛地應用於治療過敏及發炎等疾病，長期使用會引起皮膚病變、血糖增加、高血壓、骨質疏鬆等諸多副作用，其中以骨質疏鬆症（CIO）最嚴重，與罹病率及死亡率息息相關。類固醇引起的骨質疏鬆症，迄今仍未獲得適當的診斷及處置，此次研究的目是探討長期接受類固醇治療的病患，有否接受每年一次的骨質密度檢測或藥物防治。研究結果提供健康照護團隊，做為改善類固醇引起骨質疏鬆症防治的參考，並預防CIO導致骨折所引起的罹病率與死亡率的增加。 本研究針對某醫學中心2002年4月到11月，接受口服或注射類固醇治療達三個月以上的風濕免疫科門診或住院病患，依其醫療記錄做回溯性探討。1,432位病患之平均年齡為51.6 ± 15.6歲（範圍：19-89 歲），80%為女性；接受類固醇治療的疾病，以風濕性關節炎（51.3%）最高，紅斑性狼瘡次之（32.8%），其他有自體免疫疾病（4.3%）等。口服類固醇以prednisolone為主，平均每天用9.6 ± 8.0 mg的prednisolone相等量。1,432人中只有430人（30%）接受藥物防治，384人（89.3%）為女性；其中185人（48.2%）併服用含鈣及維生素D製劑，151人（39.3%）服用鈣片，28人（7.3%）服用荷爾蒙，只有10人（2.6%） 接受雙磷酸鹽類治療，而總共只有526人（36.7%）接受骨質密度檢測或藥物治療；ICD-9-CM碼診斷骨質疏鬆症者300人中，只有204人(68%)接受藥物治療；906人(63.3%)需接受藥物防治；810人(56.6%)需接受骨質密度監測。醫療人員對於兩性的CIO藥物防治應該等同視之，年齡愈大更應積極防治。類風濕性關節炎患者，使用低劑量類固醇亦應給予積極的藥物防治。醫療人員對CIO的藥物防治類型中，bisphosphonate使用率偏低，我們應該積極介入加以改善。藥師建議醫師做骨密檢測者有143人，其中90人( 63%)確有骨質流失的現象，而得極重度骨質疏鬆症有22人(n = 90, 24.4%)，重度骨質疏鬆症有15人(n = 90, 15.6%)，應即時給予藥物治療，143人中，骨質疏鬆的發生率亦隨著年齡的增高而增加，由35-49歲的3.3% 提升到大於或等於65歲的24.4%。藥師參與醫療照護團隊，可確立各醫療專業對藥物的使用達到安全、有效的共識；經由醫療行為的分析做為改善的依據，同時藥師應擔起探討非即時醫源性副作用的把關責任。此次研究的進行可同時改善病患的照顧品質，是件可喜的事。 關鍵字：類固醇、骨質疏鬆症、藥師

關鍵字

類固醇 ； 骨質疏鬆症 ； 藥師

並列摘要

Abstract Corticosteroids are widely used in a variety of allergic and inflammatory diseases. The numerous side-effects associated with long-term corticosteroid treatment include skin changes, diabetes, hypertension and osteoporosis. Among these, corticosteroid-induced osteoporosis (CIO) is the most serious side-effect associated with significant morbidity and mortality. However, CIO remains underdiagnosed and often inadequately managed.The objective of this study is to investigate whether patients who are placed on long-term corticosteroid therapy are monitored annually by Bone Mineral Densitometry (BMD) or are receiving prophylactic treatment in a medical center in northern Taiwan. The results of this study can be used by health care providers to improve the prophylactic management of CIO and to help prevent the high morbidity and mortality of CIO-associated fractures. A retrospective review was performed using medical records of 1,432 patients from both the inpatient and outpatient populations who were receiving corticosteoid therapy (either by mouth or by injection) for the period of April to November 2002. The mean age of patients was 51.6 ± 15.6 years (range: 19-89 years) and 80% were female. The most common conditions for which patients were receiving corticosteroid therapy include: rheumatoid arthritis (51.3%), systemic lupus erythematosus (32.8%) and other autoimmune diseases (4.3%). Prednisolone was the most commonly used oral corticosteroid and its mean daily dose was 9.6 ± 8.0 mg. Among the 1,432 patinets, only 430 patients (30%) using corticosteroids for up to 3 months were also receiving medication for osteoporosis prevention and treatment concurrently. 384 patients (n = 430, 89.3%) were female. 185 patients (48.2%) were taking Calcium plus Vitamin D supplements and 151 patients (39.3%) were taking only Calcium supplements. 28 patients (7.3%) were on hormone replacement therapy (HRT), and only 10 patients (2.6%) were taking bisphosphonates. The research data reveal that only 526 patients (36.7%) underwent a bone densitometry scan to confirm osteoporosis. Review of ICD-9-CM diagnostic coding showed an osteoporotic patient population of 300, of whom only 204 (68%) received treatment; 906 patients (63.3%) needed to receive prophylaxis; 810 patients (56.6%) warranted bone densitometry evaluation. Prescription of CIO drug prophylaxis should be based on advancing age and regardless of sex of patients. Patients with rheumatoid arthritis receiving low dose steroids should be provided with adequate prophylaxis. The current low rate of uptake of bisphosphonates by physicians as a CIO prophylactic option should be addressed and improved. As a result of pharmacy intervention, 143 patients were evaluated with (QUS). Of these patients, 90 patients (63%) have been found to suffer bone loss. 22 of the 90 patients (24.4%) had extreme severe osteoporosis and 19 of the 90 patient (15.6%) had severe osteoporosis. These patients should be offered treatment promptly. The incidence of osteoporosis among the 143 subjects were also found to have increased from 3.3% in the 35 to 49-year age group to 24.4% in the over 65-year age group. The involvement of pharmacists in the team of care-providers can assure that drugs are used safely and effectively. The analysis of patterns of drug usage by clinicians forms the basis for clinical improvement. Pharmacists can also help with the monitoring of idiosyncratic pharmaceutical effects of the drugs so used. It is indeed laudable that this research has consequently been able to effect improved quality of patient care. Keywords: corticosteroid, osteoporosis, pharmacist.

並列關鍵字

corticosteroid ； osteoporosis ； pharmacist

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