藥師介入對硝酸鹽類藥品之藥效及安全性的影響評估

Effectiveness of Pharmacist Interventions on Efficacy and Safety of Nitrates Therapy

楊于萱(Yu-Hsuan Yang)

指導教授 ： 簡淑真

臺北醫學大學/藥學院/藥學系(碩博士班)/碩士(2014年)

摘要

研究背景：有機硝酸鹽類藥品 (organic nitrates) 被廣為使用於心絞痛及心衰竭的治療上，但硝酸鹽類藥品耐受性 (nitrate tolerance) 使硝酸鹽類藥品的使用受到限制。藉由建立適當的停藥時間 (nitrate-free interval) 可以預防耐受性的發生。臺北醫學大學附設醫院自2014年1月起進行「硝酸鹽類藥品用藥安全促進計畫」，由心臟內科及藥劑部共同制定用藥準則，並進行全院宣導。2014年4月1日至6月30日由藥師介入，口服藥品部分向病人加強衛教，並電訪確認病人服藥時間；靜脈輸注藥品部分，由藥師介入評估並向醫師提出用藥建議。
研究目的：本研究評估「硝酸鹽類藥品用藥安全促進計畫」中，藥師的介入對於促進硝酸鹽類藥品用藥安全的成效。
研究方法：本研究為病歷回溯性的觀察性研究，主要評估藥師加強衛教後病人的服藥順從性，以及藥師介入藥品使用評估並提出用藥建議後，靜脈輸注藥品的使用分別在24、48及72小時內的停藥率。其中靜脈輸注藥品部分，將2014年4月1日至6月30日計畫執行期間使用藥品的病人作為介入組；2013年10月1日至12月31日使用藥品的病人作為對照組。
研究結果：在口服硝酸鹽類藥物治療部分，共95位病人納入分析，電訪實際追蹤到的有75位病人。第一次電訪追蹤結果，服藥順從性達成比例為74.7%；而累積二次電訪結果，服藥順從性達成比例為90.7%。在靜脈輸注硝酸鹽類藥物治療部分，介入組共134人、對照組共117人，介入組在24、48及72小時內的停藥率皆較對照組高，且比例的差距有增加的趨勢，其中48及72小時內的停藥率，介入組與對照組比較達到統計學上的差異 (62.5% vs. 50.3%，p = 0.032；77.5% vs. 64.1%，p = 0.010)。
研究結論：在本研究中，藥師加強衛教以及參與醫療團隊照護能夠減少硝酸鹽類藥品耐受性發生的風險，顯示藥師的介入能使病人獲得更安全有效的藥物治療。

關鍵字

硝酸鹽類藥品 ； 硝酸鹽類藥品耐受性 ； 用藥安全 ； 藥師介入

並列摘要

Background: Nitrates are effective medication therapy for ischemic heart disease. However, patients soon develop tolerance after sustained use of nitrates and the anti-anginal effects attenuate. Currently, nitrate-free interval is the most practical way to prevent the development of nitrate tolerance. With this in mind, the “Hospital-based Pharmacist-initiated Drug Safety Reinforcement Program” was conducted in Taipei Medical University Hospital from Jan. 2014. First, pharmacists worked with cardiologists to establish “Nitrate Medication Safety and Compliance Guideline” for educating medical staffs. Afterwards, pharmacists started to educate the outpatients about the importance of nitrate-free interval. Follow up phone calls were made to ensure the compliance. Moreover, pharmacists made recommendation about the proper use of nitrates to the medical staffs regarding use of iv nitrates for more than 48 hours.
Objective: To evaluate medication safety promotion of nitrate therapy by pharmacist interventions.
Methods: A retrospective observational study was conducted. The endpoint in oral nitrates group was the compliance defined as achievement of a 14-hour daily nitrate-free interval. In iv nitrates group, the rates of discontinuation in 24, 48 and 72 hours were compared between the intervention group and the control group, patients using iv nitrates during Apr.1 ~ June 30, 2014 and Oct. 1 ~ Dec. 31, 2013.
Results: 95 patients in oral nitrates group and 75 of them were followed up. 74.7% patients achieved nitrate-free interval at first follow-up phone call, and totally 90.7% patients achieved nitrate-free interval after second follow-up phone call. In the iv nitrates group, there were 134 patients in the intervention group and 117 patients in the control group. The rates of discontinuation in 24, 48 and 72 hours in the intervention group were increased, and significant increase in 48 and 72 hours were found (62.5% vs. 50.3%, p = 0.032; 77.5% vs. 64.1%, p = 0.010).
Conclusion: Our study showed that patient education reinforcement made by pharmacists help establish a daily nitrate-free interval and preserve clinical efficacy of nitrates. Also, increase of discontinuation of iv nitrates showed that pharmacist interventions help reduce nitrate tolerance and keep the nitrate therapy effective.

並列關鍵字

nitrates therapy ； nitrate tolerance ； medication safety ； pharmacist intervention

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