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研究生:羅雅貞
研究生(外文):Ya-Chen Lo
論文名稱:新近抗憂鬱劑之使用評估於某家醫學中心之研究
論文名稱(外文):Evaluation for Prescribing Patterns of Newer Antidepressants in a Medical Center
指導教授:楊延光楊延光引用關係高雅慧高雅慧引用關係林嘉音林嘉音引用關係
指導教授(外文):Yen-Kuang YangYa-Hui KaoChia-Yin Lin
學位類別:碩士
校院名稱:國立成功大學
系所名稱:臨床藥學研究所
學門:醫藥衛生學門
學類:藥學學類
論文種類:學術論文
論文出版年:2003
畢業學年度:91
語文別:中文
論文頁數:178
中文關鍵詞:服藥順服性藥物交互作用處方型態抗憂鬱劑
外文關鍵詞:compliancedrug interactionantidepressantsprescribing pattern
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世界衛生組織 (WHO, The World Health Organization) 評估憂鬱性疾患為目前世界第四大疾病,此疾患會造成個人身心及社會功能之重大損失。預估於公元2020年憂鬱性疾患將成為世界第二大疾病,而憂鬱性疾患是導致自殺的主要原因。自殺為2002年台灣第九大死因,因此治療憂鬱性疾患是個重要之議題。自1980年代晚期,新一類的抗憂鬱劑如選擇性血清素抑制劑 (selective serotonin reuptake inhibitor, SSRI) 和選擇性正腎上腺素抑制劑 (serotonin norepinephrine reuptake inhibitor, SNRI)開始被廣泛的使用。SSRI 和 SNRI之效果和三環抗憂鬱劑 (tricyclic antidepressant, TCA)相同,但新一類之抗憂鬱劑有較佳之耐受性 (tolerability),較易被醫師和病患所接受;在抗憂鬱劑之使用上,劑量是否足夠與治療時間是否夠長,為兩個影響著是否能達到憂鬱症之治療目標的主要因素,因為在適合的治療下不只能緩解病患之憂鬱症狀,同時能增進病患之生活功能,並降低再次復發的機率。
此為回顧性之研究,目的在評估此新一類抗憂鬱劑之處方型態。藥品包括SSRI (fluoxetine, paroxetine, sertraline, fluvoxamine) 和 SNRI (venlafaxine),分析門診病患之年齡、性別、疾病診斷、處方劑量和接受治療時間之長短,比較各變因在精神科與非精神科之差異,同時也評估新一類抗憂鬱劑藥物交互作用之發生情形。資料來源為成功大學醫學院附設醫院資訊室,搜集由2001年七月初至2002年6月底為期一年,成大醫學中心門診病患之所有使用研究藥品。
在研究期間,門診所有使用SSRI, SNRI的門診病患為2477人,總人次為11,536,其中sertraline佔總人次的34.13%,其次為fluoxetine佔總人次的29.45 %,在各種藥品之使用年齡,非精神科組之平均年齡大於精神科(54 ± 16 vs. 41 ± 18, p < 0.001);在任何一科,病患平均使用劑量皆達90 %以上之醫師處方劑量,在fluoxetine, sertraline, fluvoxamine中精神科之處方劑量高於非精神科(p < 0.001, <0.05, <0.05);強迫性疾患在fluoxetine, paroxetine, sertraline之使用劑量皆高於其他疾患,疾病與處方天數也具差異性(p<0.001),其中強迫性疾患之處方時間較其他疾患之處方時間長(平均156.95 ± 122.65 天, p < 0.01);研究藥品雖都在建議治療劑量範圍以內,但國人使用劑量明顯比國外文獻建議劑量低。第一次經歷憂鬱症宜至少治療4-6個月,然本研究達4個月以上治療者佔49.32 %,達6個月者只佔38.53 %。精神科就診之病患使用研究藥品之處方時間與非精神科之病患並無統計上差異 (p =0.708)。在服藥順服性方面,精神科優於非精神科(p < 0.001);研究藥品與藥物交互作用藥品併用率高,SNRI之藥物交互作用比率較SSRIs少(2-3 % vs. 30-40 %)。
本研究之對象在劑量之使用落於較低之建議劑量範圍,在治療時間上明顯不足,這可能造成治療的失敗,因此增加病患之服藥順服性是重要的議題,藥物交互作用藥品在SSRI類有較高的併用率,醫療照護人員應該了解藥物交互作用藥品,並監測藥物交互作用可能發生之症狀。
The World Health Organization estimates that currently, major depression is the forth most important cause worldwide of loss in disability-adjusted life-years and will be the second most important cause by 2020. A frequent complication of depression is suicide. In 2002, suicide was the ninth leading cause of death in Taiwan. The uses of the newer antidepressants, selective serotonin reuptake inhibitor (SSRI) and serotonin norepinephrine reuptake inhibitor (SNRI) have been increasing since their introduction in the late 1980s and are effective in treating depressive disorder. Although just as efficacious as the tricyclic antidepressants (TCA), the newer antidepressants are associated with a more tolerable side-effects profile, leading to easier use for both the provider and the patient. Dose and duration are two important factors in achieving the goals of antidepressant treatment. They affect not only symptoms resolution, but also restoration of patients’ functioning and prevention of relapse or recurrent episodes.
The aim of the present study was to evaluate the prescribing patterns of newer antidepressants, SSRIs and SNRI (venlafaxine), by patients’ age, sex, clinical diagnosis, dosage and duration of treatment. The patterns of newer antidepressants use were compared between psychiatric and non-psychiatric clinics. This study evaluated the possibility of drug interaction when newer antidepressants were used concomitantly with other medications. Data were derived from the Department of Informatics, College of Medicine, National Cheng-Kung University. The study included all outpatient users of newer antidepressants in the National Cheng-Kung University Hospital from July 1, 2001 to June 30, 2002.
There were 2,477 patients representing 11,536 prescriptions. Fluoxetine and sertraline are the most used newer antidepressants (29.45 % vs. 34.13 % of prescriptions, respectively). The ages of nonpsychiatric patients are greater than psychiatric patients (55 ±17 vs. 42 ± 17 years, respectively, p < 0.001). In both the psychiatric and non-psychiatric clinics, patients took over 90 % of the doctor’s prescribing dosage. The prescribing dosages of fluoxetine, fluovoxamine, and sertraline in psychiatry are higher than those in non-psychiatry (p< 0.001, < 0.05, < 0.05). The prescribing dosages of fluoxetine, paroxetine, and sertraline for obsessive-compulsive disorder (OCD) are higher than those in other disorders. The OCD patients take longer duration of medicine as compared with other disorders (p < 0.01). The prescribing dosages of all the newer antidepressants are within the lower range of recommended dose in each disorder. Although the treatment guideline recommended 4 to 6 months for maintenance of treatment, 49.32 % of patients take newer antidepressants longer than 4 months, and 38.53 % longer than 6 months. The duration of patients in psychiatric outpatient clinics is similar to those in nonpsychiatric O.P.D (p= 0.708). Nevertheless, the compliance of psychiatric patients is even superior. The percentage of potential drug interaction is high. The SNRI has much less drug interaction than SSRIs.
Both the dose and duration for depressive treatment were not sufficient compared with the recommended regimen, which may lead to the treatment failure and early relapse or recurrence.
中文摘要……………………………………………………………………………I
英文摘要…………………………………………………………………………III
誌謝…………………………………………………………………………………V
目錄………………………………………………………………………………VI
表目錄……………………………………………………………………….………IX
圖目錄……………………………………………………………………….……....XI
研究背景……………………………………………………………………….…….1
第一章 憂鬱性疾患……………………………………………………………….3
第一節、流行病學…………….…………………………………………………3
第二節、病理機轉…………….…………………………………………………5
第三節、臨床表徵…………….…………………………………………………7
第四節、治療原則…………….…………………………………………………9
第五節、藥物之副作用…….…………………………………………………..11
第六節、復發率.………………………………………………………………..14
第二章 焦慮性疾.………………………………………………………………..17
第一節、流行病學……………………………………………………………...17
第二節、臨床表徵……………………………………………………………...19
第三節、治療原則…………………………………………………………….. 21
第四節、藥物治療…………………………………………………………….. 22
第五節、SSRI與SNRI之臨床研究………………………………………….. 24
第三章 飲食性疾患………………………………………………………………30
第一節、流行病學…………………………………………………………….. 30
第二節、病理機轉…………………………………………………………….. 33
第三節、臨床表徵…………………………………………………………….. 35
第四節、治療原則…………………………………………………………….. 39
第五節、治療之評估…………………………………………………………..45
第六節、SSRI與SNRI之臨床研究…………………………………………..46
第四章 強迫性疾患………………………………………………………………50
第一節、流行病學……………………………………………………………..50
第二節、病理機轉……………………………………………………………..52
第三節、臨床表徵……………………………………………………………..53
第四節、治療原則……………………………………………………………..55
第五節、藥物治療……………………………………………………………..56
第五章 處方型態……………………………………………………………….64
第一節、抗憂鬱劑之使用情形………………………………………………..64
第二節、使用劑量與治療時間………………………………………………...66
第三節、使用之適應症………………………………………………………...68
第六章 藥物交互作用…………………………………………………………..69
第一節、背景…………………………………………………………………..69
第二節、SSRI、SNRI之代謝…………………………………………………71
第一項、Fluoxetine…………………………….…………………………….71
第二項、Fluvoxamine………………………………..………………………76
第三項、Paroxetine………….……………………………………………….79
第四項、Sertraline……………………………………………………………83
第五項、Venlafaxine…………………………………………………………87
第六項、SSRI、SNRI其他藥物交互作用…………………...…………….89
第七章 憂鬱症病患之服藥順從性……………………………………………..90
第一節、背景………..…………………………………………………………90
第二節、測量服藥順從性之方法……………………………………………..91
第三節、憂鬱症病患服藥順從性之情形……………………………………..92
第四節、影響順從性之原因…………………………………………………..94
第五節、臨床研究與服藥順從性……………………………………………..97
第六節、藥師參與憂鬱症治療之研究………………………………………..99
第七節、病患衛教…………………………………………………………….103
第八章、研究方法……………………………………………………………….105
第一部份 抗憂鬱劑之處方型態…...…………………………………………105
第一節、研究設計………………..…………………..……………………….105
第二節、研究材料與工具…..…..…………………………………………….106
第三節、研究步驟………..………………………………………………..….109
第四節、變相之定義…..……………………………………………………..110
第五節、研究資料與分析……………………………………………………116
第六節、研究結果…………………………………………………..………..117
一、SSRI與SNRI在精神科與非精神科病人基本資料分佈情形與比較..117
二、SSRI與SNRI藥品劑量在精神科與非精神科使用情形與比較…..…119
三、劑量與疾病…………………………………………………..…….…..120
四、藥品之總處方天數分佈情形……………………….…………………123
五、病患特質與藥品之順服性………………………………………….…126
六、憂鬱性疾患之服藥天數與藥品使用劑量…………………………….127
七、不明診斷之疾病診斷分佈情形…..…………………………………..129
八、換藥情形………………………………………………………………130
九、併用藥物交互作用藥品之發生情形分佈..…………………………..131
第二部分:憂鬱症患者藥物知識評估及用藥指導…………..………………..140
第一節、研究設計…………………………..……………………………...…140
第二節、研究材料…………………………...………………………………..141
第三節、研究步驟…………………………..………………………….……..142
第四節、研究資料與分析..……………………………………….…………..143
第五節、研究結果..…………………………………………………….……..144
第八章、討論………………………………………..……………………..…....152
第一節、使用結果評估..……….……………………………………………..152
第二節、藥物交互作用………………………………………………………161
第三節、病患用藥指導………….…………………………………..………..165
第四節、研究限制…………….………………………………………………166
第五節、結語…………….…..………………………………………….…….167
參考文獻………………………………………………………………….……..168
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