臺灣博碩士論文加值系統

多重用藥在老年人非常常見，長期多重用藥可能因為潛在性不適當用藥與藥物不良事件增加老年人跌倒、身體與認知功能損傷、住院、甚至死亡，造成健康保險系統高成本負擔。氫離子幫浦阻斷劑（ ，簡稱PPIs）能顯著抑制胃酸分泌，慢性使用會增加困難梭狀桿菌感染、骨質流失與骨折的風險，老年病人長期使用而不進行重新評估，提高多重用藥，使病人面臨增加潛在藥物不良事件和藥物交互作用的風險（例如與困難梭狀桿菌感染有關的腹瀉、肺炎、低鎂血症和骨折）。處方優化是逐漸減少、停止或撤回藥物的過程，確保每項用藥的適當性，達成管理多重用藥和改善結果。本研究旨在評估對慢性使用PPI老年人進行處方優化方案是安全、有效和可行的介入措施，以改善老年人的用藥安全和健康結果。
本研究自線上相關電子資料庫（PubMed、EMBASE等）搜尋文獻，包含各資料庫從收錄年代至2019年2月21日。使用Cochrane偏誤風險評比工具（Cochrane risk of bias tool）評估偏誤風險。選取符合研究主題:慢性使用PPI持續超過8週之老年人，並排除需要慢性使用PPI提供胃保護作用者，評估老年人PPI處方優化相關的影響。
符合選取標準納入的研究有3篇，探討PPI處方優化措施之安全性:胃腸道症狀控制與藥物戒斷事件；探討PPI處方優化措施之有效性:藥物負擔與藥物花費；探討PPI處方優化措施之可行性:參與者滿意度。
3篇文獻所用處方優化方式不同，包括停止、逐漸減少劑量與需要時使用，結果發現:停止PPI容易導致腸胃道症狀復發(RR=3.02; 95% CI=1.74 to 5.24)，達顯著差異；藥物戒斷事件以內視鏡檢查是否復發(RR=3.41; 95% CI=1.91 to 6.09)，達顯著差異。逐漸減少劑量的方式停用PPI的成功率可能比較高，但未達顯著差異。而需要時使用PPI的方式似乎足以維持胃食道逆流疾病病人的治療，症狀緩解之比較未達顯著差異；每日消耗藥丸數量比較低(MD= -0.50; 95% CI= -0.65 to -0.35)，達顯著差異；不論是藥物的便利性或是主觀滿意度，和繼續使用組比較都未達顯著差異。
由於符合選取納入的研究篇數只有3篇，證據等級雖良好，但篇數太少，難以進行統合分析、次族群與敏感性分析，可預期分析結果代表性也有限；本研究的臨床問題「慢性使用PPI的老年人進行處方優化其安全性與健康結果如何?」目前的證據尚不足以證明，需要更多研究針對此議題進行調查，特別是更嚴謹的RCT研究。

Polypharmacy are very common in the elderly. Long-term polypharmacy may increase incidents of falls, physical and cognitive impairment, hospitalization and even death, result in high cost burden on the health insurance system due to potentially inappropriate medications and adverse drug events. is the process of tapering, discontinuing, or withdrawing drugs, which may manage polypharmacy and improve outcomes. Chronic use of (PPIs) without reassessment may aggravate polypharmacy, increase the risk of potential adverse drug events and drug interactions (e.g., diarrhea associated with Clostridium difficile infections, pneumonia, hypomagnesemia, and fractures). The aim of this study is to evaluate the safety, effectiveness and feasibility of the intervention conducted by of long-term PPIs for the improvement of medication safety and health outcomes among .
We searched online electronic databases (e.g., PubMed, EMBASE) from the earliest record to February 21, 2019. Each study was assessed for bias with the Cochrane risk of bias tool. The inclusion criteria is the studies that evaluated who took PPIs for more than 8 weeks. The exclusion criteria is the chronic use of PPI was to provide gastroprotection. The effects associated with PPI in were determined.
There were 3 studies that met the inclusion criteria. To explore the safety of PPI deprescription, gastrointestinal symptom control and drug withdrawal were applied. To explore the effectiveness of PPI deprescription, drug burden and drug costs were applied. The participant satisfaction was applied to explore the feasibility of PPI deprescription.
The 3 studies used different deprescription methods including discontinuation, tapering and on-demand. The results showed the discontinuation method easily led to the recurrence of gastrointestinal symptoms (RR=3.02; 95% CI=1.74 to 5.24), drug withdrawal (RR=3.41; 95% CI=1.91 to 6.09), with significant differences. The successful discontinuation rate of tapering method was higher, however with statistically nonsignificant. On-demand method appeared to be sufficient for maintenance treatment in gastroesophageal reflux disease patients, and the symptom alleviation with statistically nonsignificant, but the number of pills consumed daily were lower (MD= -0.50; 95% CI= -0.65 to -0.35), with significant differences. No significant differences was found for convenience of medication and subjective satisfaction.
Since only 3 studies were enrolled, though the evidence of the individual literature was good, the studies were not enough for meta-analysis, subgroup analysis and sensitivity analysis. The result of this study in regarding the of long-term PPIs for medication safety and health outcome
among is not conclusive. Further rigorous randomized controlled trials are required for the exploration of the relevant issues in the future.

摘要 II
Abstract IV
目錄 1
圖目錄 3
表目錄 4
第一章 緒論 5
第一節 研究背景 5
第二節 研究動機及目的 7
第三節 研究問題 9
第四節 名詞界定 10
第二章 文獻查證 12
第一節 多重用藥的現況、影響及對策 12
第二節 處方優化 14
第三節 PPI的作用機轉、適應症及副作用 15
第四節 PPI的使用現況、影響與處方優化 17
第五節 老年人PPI處方優化的策略 20
第六節 系統性回顧與統合分析介紹 22
第三章 研究方法 23
第一節 研究設計 23
第二節 研究步驟 24
第三節 倫理考量 32
第四章 結果 33
第一節 納入研究的描述 33
第二節 研究特色 34
第三節 專家研究品質評量 39
第四節 研究中的偏誤風險 41
第五節 研究的成果 45
第六節 結果合成 46
第五章 討論 55
第一節 老年人PPI處方優化相關的影響 55
第二節 老年人PPI處方優化的其他研究 57
第六章 研究限制 62
第七章 結論與建議 63
參考文獻 64
附錄一、偏誤風險評估工具表 76
附錄二、數據提取表 77
A表 二元資料數據提取表 78
B表 連續性資料數據提取表 79
附錄三、納入研究的特色 80
二元資料數據提取表-胃腸道症狀復發率 83
二元資料數據提取表-以內視鏡檢查是否復發 84
二元資料數據提取表-成功停止PPI使用 88
二元資料數據提取表-以胃灼熱強度確定症狀緩解 91
二元資料數據提取表-以胃灼熱頻率確定症狀緩解 92
二元資料數據提取表-以逆流強度確定症狀緩解 93
二元資料數據提取表-以逆流頻率確定症狀緩解 94
連續性資料數據提取表-比較每日消耗藥丸數量 95
連續性資料數據提取表-比較每日消耗藥物劑量 96
連續性資料數據提取表-藥物的便利性 97
連續性資料數據提取表-主觀滿意度 98
附錄四、排除研究的特色 99
圖目錄
圖一 研究步驟圖 24
圖二 文獻篩選流程圖(基於PRISMA聲明) 28
圖三 文獻篩選流程圖 33
圖四 偏誤風險總結 43
圖五 偏誤風險圖 44
圖六 成功停止PPI 49
圖七 胃腸道症狀復發率 49
圖八 以胃灼熱強度確定症狀緩解 50
圖九 以胃灼熱頻率確定症狀緩解 50
圖十 以逆流強度確定症狀緩解 51
圖十一 以逆流頻率確定症狀緩解 51
圖十二 比較每日消耗藥丸數量 52
圖十三 比較每日消耗藥物劑量 52
圖十四 以內視鏡檢查是否復發 53
圖十五 藥物的便利性 53
圖十六 主觀滿意度 54
表目錄
表一 在慢性使用PPI老年人進行處方優化的PICO問題 9
表二 納入研究的資料 37
表三 文獻品質評論者評分表 40
表四 納入隨機對照試驗的偏誤風險 42
表五 老年人PPI處方優化的其他研究 61

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