血管張力素轉化酶抑制劑與血管張力素受體阻斷劑於慢性腎臟病患者之處方型態探討

Prescription Patterns of Angiotensin Converting Enzyme Inhibitors and Angiotensin Receptor Blockers in Patients with Chronic Kidney Disease

王珮慈(Pei-Tzu Wang)

指導教授 ： 黃耀斌

共同指導教授 ： 黃尚志(Shang-Jyh Hwang)

高雄醫學大學/藥學院/臨床藥學研究所/碩士(2008年)

摘要

研究背景與目的: 慢性腎臟疾病(CKD)影響全球超過五千萬人口，其中每年又有超過一百萬人接受腎臟替代療法。根據美國腎臟病資料登錄系統2007年報，台灣在 2005 年末期腎臟病(ESRD)發生率與盛行率均位居全球第一，顯示腎臟病在台灣之嚴重性。所幸，血管張力素轉化酶抑制劑(ACEI)及血管張力素受體阻斷劑(ARB)的使用不僅可控制血壓，臨床研究業已證實其對於延緩腎功能惡化具顯著成效。由於國內針對不同CKD分期之ACEI/ ARB使用現況及相關檢驗值監測度的研究仍有限，固本研究針對CKD與高危險群患者，分析ACEI/ARB之使用現況與相關檢驗值監測情形，並進一步地探討影響醫師開藥與監測之因素。
研究方法: 本研究採回溯性次級資料分析，主要資料來源為高雄市某區域醫院，擷取2004年1月1日至2005年12月31日曾於門診監測過血清肌酸酐值(Scr)之所有病患資料，並利用簡易版MDRD公式算出估計腎絲球過濾速率(eGFR)以進行分組，經排除資料不全者、未滿18歲等，共得5714位之研究樣本。資料統計分析方法包括描述性統計分析、卡方檢定、t檢定、變異數分析、對數迴歸分析。
研究結果: 研究發現，一年觀察期內約56%的CKD與高危險群患者被開立ACEI/ARB。其中高危險群、Stage 1+2、Stage 3A、Stage 3B、Stage 4與Stage 5的開藥比例分別為50%、67%、51%、70%、80%與64%。在對數迴歸分析結果方面，相較於未滿50歲患者，年紀較大者，特別是當年齡在60-69歲與80歲以上分別降低了38%與47%選用ACEI/ARB的可能性；此外，腎功能不全、糖尿病或高血壓的患者較易被開立ACEI/ARB。在監測的部份，使用ACEI/ARB一年之995位研究對象中，Scr監測率高達92%，但僅38%的患者監測過鉀離子。在對數迴歸分析方面，結果顯示醫師較易針對腎功能不全與過去有鉀離子基準值的患者監測Scr與鉀離子。
結論與建議: 近六成之CKD與高危險群患者被開立ACEI/ARB，尤以合併有高血壓與糖尿病的開藥比例最高，值得注意的是，在Scr未滿1.5 mg/dl但已是CKD患者之開藥率卻未滿五成。再者，使用ACEI/ARB一年的患者高達九成監測過Scr，但卻有超過六成患者未監測過鉀離子。藥師的參與除可提供監測相關檢驗值等建議之餘，更可進一步地協同照護CKD患者。

關鍵字

慢性腎臟疾病 ； 血管張力素轉化酶抑制劑 ； 血管張力素受體阻斷劑 ； 鉀離子 ； 血清肌酸酐

並列摘要

Background and objectives: Chronic kidney disease (CKD) affected more than 50 million people, and more than 1 million of them received kidney replacement therapy. Based on data from the US Renal Data System, the highest rates of incident and prevalent end stage renal disease (ESRD) were reported by Taiwan in 2005. It showed a seriousness of kidney disease in Taiwan. Fortunately, angiotensin converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) not only can manage hypertension, but also can delay the progression of renal disease. However, little is known about prescription rates of ACEI/ARB among patients with CKD between different renal function and laboratory monitoring among patients prescribed ACEI/ARB. Therefore, the primary objective of this study is to assess prescription rates of ACEI/ARB and factors associated with prescription of ACEI/ARB. The secondary objective is to evaluate the laboratory monitoring of potassium and serum creatinine (Scr) and factors associated with laboratory monitoring.
Methods: Databases used in this retrospective study were from a regional hospital in Kaohsiung, and we searched subjects with Scr measurement at outpatient visit from 2004 to 2005. The simplified Modification of Diet in Renal Disease (MDRD) equation was used to calculate estimated glomerular filtration rate (eGFR). Totally 5714 study population was enrolled. Statistical methods included chi-square test, two-sample t-test, one-way ANOVA, and logistic regression.
Results: Overall, approximately 56% of the cohort was prescribed ACEI/ARB in study period. ACEI/ARB was prescribed to 50% of patients at risk, 67% of patients with stage 1+2, 51% of patients with stage 3A, 70% of patients with stage 3B, 80% of patients with stage 4, and 64% of patients with stage 5. In logistic regression analyses, failure to prescribe ACEI/ARB was associated significantly with older age. Greater prescription rates of ACEI/ARB were found in patients with renal dysfunction, diabetes and/or hypertension.
Within one year time period of ACEI/ARB therapy, approximately 92% of patients had Scr evaluated at least once and 38% of those had potassium evaluated at least once. In logistic regression analyses, renal dysfunction and patients who had potassium data before index date were more likely to monitor both Scr and potassium level.
Conclusions and suggestions: Approximately 56% of patients with CKD and high risk groups were prescribed ACEI/ARB. The highest prescription rates were found in patients with both diabetes and hypertension. Remarkably, prescription rates were less than half of patients with CKD whose Scr were below 1.5 mg/dl. Moreover, approximately 92% of patients prescribed ACEI/ARB had Scr evaluated at least once, but only 38% of those had potassium evaluated at least once. Therefore, there are still many opportunities for pharmacists not only to improve the frequency of laboratory monitoring, but also can collaborate with physicians to improve the care of patients with CKD.

並列關鍵字

chronic kidney disease ； angiotensin converting enzyme inhibitors ； angiotensin receptor blockers ； potassium ； serum creatinine

參考文獻

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