- 學位論文
氣喘病人使用類固醇結合長效乙二型交感神經作用劑單一吸入劑之氣喘控制指標及醫療資源利用評估
Markers of asthma control and resource utilization with steroid and long-acting beta 2 agonists in a single inhaler in asthma ??
摘要
研究目的：根據臨床試驗結果，吸入性類固醇結合長效乙二型交感神經作用劑治療氣喘，無論於改善肺功能、控制臨床症狀、與生活品質的提升等，較增加類固醇劑量效果佳。因此Global Initiative for Asthma (GINA)氣喘照護指引建議，中至重度氣喘病人可加入長效乙二型交感神經作用劑與低至中度吸入性類固醇同時使用。研究證實類固醇結合長效乙二型交感神經作用劑的單一吸入劑，不論於降低氣喘急性發作或改善病人服藥配合度，都優於該兩種成分分成兩個吸入劑投予。 本研究為回溯性觀察，評估某醫學中心病人將類固醇結合長效乙二型交感神經作用劑利用兩個吸入劑使用，轉換為類固醇結合長效乙二型交感神經作用劑的單一吸入劑後，氣喘控制指標與整體醫療資源利用情形的變化。 研究方法：本研究採取非隨機分派（non-randomized），開放性（open labeled），且自我比較（self-controlled）的回溯性觀察研究（retrospective observational study）。由某醫學中心電腦資訊系統提供91年10月1日至92年10月1日，排除高血壓、心絞痛、心肌梗塞、心衰竭、糖尿病、慢性阻塞性肺疾病等慢性疾病，且符合使用類固醇結合長效乙二型交感神經作用劑單一吸入劑的個案名單，總計原始個案有1,734位。經調閱病歷後，依據個案就診資料及用藥紀錄進行排除與納入。符合條件的個案總共103位。針對符合條件個案，進一步收集轉換類固醇結合長效乙二型交感神經作用劑單一吸入劑之前與之後6個月內氣喘控制指標及服藥配合度的資料。 II 研究結果：納入研究的103位個案，根據所使用的吸入性類固醇藥品品項及轉換情形分組進行評估。 所有符合納入及排除條件的個案，氣喘控制指標，結果確實有顯著的改善。每日吸入性類固醇使用劑量，有顯著減少趨勢（p=0.0001）；短效吸入性乙二型交感神經作用劑的月使用量，由0.34瓶減少為0.25瓶（p=0.009）；口服類固醇日使用量，由0.34粒減少為0.18粒（p=0.001）；theophylline處方人數由57人減少為48人（p=0.022）；白三烯拮抗劑處方人數，由26人減少為13人（p=0.001）；非常規呼吸胸腔就診次數，由0.2次減少為0.03次（p=0.001）；急診、住診人數及健保申報費用部分，未轉換類固醇結合長效乙二型交感神經作用劑單一吸入劑之前，因氣喘住院有2人、急診4人，總共花費健保費用61,659元。但轉換類固醇結合長效乙二型交感神經作用劑單一吸入劑之後，無任何人因氣喘住院與急診。 結論：類固醇結合長效乙二型交感神經作用劑的單一吸入劑，於控制氣喘療效部分確實優於長效乙二型交感神經作用劑與類固醇兩個吸入劑給藥。並且整體醫療資源的利用，它也確實可以降低氣喘照護的醫療預算。
並列摘要
Objective: Based on clinical trials, the use of inhaled corticosteroids (IC) combined with long-acting β2-agonist (LABA) in the treatment of asthma, was more effective than increased doses of IC no matter whether in terms of improving pulmonary function, control of clinical symptoms or enhancing quality of life. Thus the Global Initiative for Asthma (GINA) recommends the simultaneous use of LABA with low to moderate doses of IC. Research has confirmed that a single inhaler with corticosteroid and LABA in combination is superior to the use of separate inhalers in decreasing acute asthma attacks and improving patient adherence. This research was a retrospective study that evaluated the changes in the asthma control index and overall medical resource utilization, after patients at a certain medical center were switched from use of separate IC and LABA inhalers to a single inhaler with IC and LABA in combination. Method: This research used a non-randomized, open labeled, self-controlled, retrospective observational study design. The administration of the medical center provided a total of 1,734 persons from 1st October 2002 to 1st October 2003, who did not have hypertension, angina, myocardial infarction, cardiac failure, diabetes or chronic obstructive pulmonary disease and who could use a single inhaler with IC and LABA. After reviewing records and excluding and including cases based on consultation data and medication records, a total of 103 cases met overall criteria. These cases were targeted to collect further information on the asthma control index and medication adherence during the six months before and after converting to the single inhaler with combined IC and LABA. IV Results: 103 cases were included in the research and were grouped based on the type of IC used and the status of switched inhalers for assessment. For all cases that met the inclusion and exclusion criteria, the asthma control index indeed significantly improved. The daily IC dosage significantly decreased (p=0.0001); the monthly SABA amount decreased from 0.34 to 0.25 inhalers (p=0.009); the daily OC amount decreased from 0.34 to 0.18 tablets (p=0.001); the number of patients taking theophylline decreased from 57 to 48 (p=0.022); the number of patients taking leukotrienes decreased from 26 to 13 (p=0.001) and non-scheduled pulmonology OPD visits decreased from 0.2 to 0.03 times (p=0.001). Regarding the claims for admissions and emergency visits prior to the switch to a single inhaler with combined IC and LABA, there were two admissions and four emergency visits that accounted for NT$61,659 in costs, however. After converting to the single inhaler, no one was admitted and there were no emergency visits. Conclusion: The single inhaler with IC and LABA was superior in asthma control when compared with separate IC and LABA inhalers. Furthermore, in terms of overall medical resource utilization they also effectively lowered the medical budget for treating asthma.
參考文獻
延伸閱讀
- Lipworth BJ、Jackson CM.（2002）。之一、氣喘相關議題：吸入型類固醇的安全性改進。中華民國兒童胸腔醫學會會刊，3(2)，144-144。https://doi.org/10.6322/OBSPP.200204_3(2).0014
- 葉金水、林慶雄、陳正雄、林國川（2008）。全身性類固醇治療慢性阻塞性肺疾病急性發作的最佳治療劑量－文獻回顧暨實證醫學證據。內科學誌，19(5)，387-393。https://doi.org/10.6314/JIMT.2008.19(5).02
- Chin, C. S., Yang, T. Y., & Hsu, J. Y. (2003). 氣喘病人在使用吸入型類固醇加salmeterol合併治療與單獨增加吸入型類固醇之比較. 胸腔醫學, 18(3), 207-213. https://doi.org/10.29806/TM.200306.0003
- Klaassen, E. M. M., Kant, K. D. G. V. D., Jöbsis, Q., Høvig, S. T. P., Schayck, C. P. V., Rijkers, G. T., & Dompeling, E. (2012). Symptoms, but Not a Biomarker Response to Inhaled Corticosteroids, Predict Asthma in Preschool Children with Recurrent Wheeze. Mediators of Inflammation, 2012(), 185-191. https://doi.org/10.1155/2012/162571
- Brooks, S. M. (1977). Bronchial Asthma of Occupational Origin: A Review. Scandinavian Journal of Work, Environment & Health, 3(2), 53-72. https://www.airitilibrary.com/Article/Detail?DocID=03553140-197704-201011160068-201011160068-53-72