臺灣博碩士論文加值系統

背景：糖尿病是一個全球性的公共衛生問題。高血壓和高血脂症是糖尿病患常見的共病症。高血糖、高血壓、高血脂(三高疾病)會增加糖尿病患罹患大血管及小血管併發症的危險。合理的使用藥物治療以控制三高疾病，可以預防或降低糖尿病併發症的發生。
目的：調查我國糖尿病門診病患使用口服抗糖尿病藥物、降血壓藥物、降血脂藥物之長期演變趨勢，並探究藥物的使用與近年來發表的臨床試驗結果和臨床治療準則是否具有一致性。
材料與方法：本研究以1997年∼2003年全民健康保險研究資料庫進行橫斷分析，材料包括門診處方及治療明細檔及門診處方醫令明細檔，篩選年齡在18歲或18歲以上的糖尿病門診病患為研究對象，分析口服抗糖尿病藥物、降血壓藥物、降血脂藥物處方的趨勢。處方趨勢以每年各類藥物的處方率和處方型態表示。
結果：在此七年研究期間，磺醯脲素類是醫師每年最常處方的口服抗糖尿病藥物，第二種則是雙胍類，在所有的口服抗糖尿病藥物處方中，以acarbose處方的成長幅度最大。在口服抗糖尿病藥物的處方型態中，「合併藥物」治療呈現逐年上升的趨勢，其中以任意兩種口服抗糖尿病藥物的合併使用最為常見。鈣離子通道阻斷劑是醫師每年最常處方的降血壓藥物，但是此類藥物的處方率逐年衰減，乙型阻斷劑和其它類降血壓藥物的處方率也呈現下滑的趨勢，作用於腎素血管收縮素系統的藥物是唯一處方率呈現成長趨勢的降血壓藥物。在降血壓藥物的處方型態中，「合併藥物」治療呈現逐年成長的趨勢，其中以合併兩種藥物的給藥方式佔最多數。在1997年∼2000年間，纖維酸類是最廣泛被處方的降血脂藥物，但是此類藥物的處方率逐年下降，菸鹼酸及其衍生物和probucol的處方率也呈現逐年下滑的趨勢，3-羥基-3-甲基戊二醯輔酶A還原酶抑制劑是唯一處方率呈現成長趨勢的降血脂藥物。在降血脂藥物的處方型態中，「單一藥物」治療是最常見的處方型態。
結論：糖尿病門診病患使用口服抗糖尿病藥物、降血壓藥物、降血脂藥物的趨勢是逐漸從老藥轉向新藥。口服抗糖尿病藥物和降血壓藥物的處方型態是從「單一藥物」治療逐漸轉向「合併藥物」治療，降血脂藥物的處方型態以「單一藥物」治療為主。整體而言，三高疾病的藥物處方趨勢與近年來發表的臨床試驗結果和臨床治療準則具有一致性，但是我們的結果也反映出這些藥物的使用仍有改善的空間。

Background: Diabetes mellitus is one of the major challenges to public health in the world. Hypertension and hyperlipidemia are the most common co-morbid conditions in patients with diabetes. Hyperglycemia, hypertension and hyperlipidemia substantially increase the risk of both macrovascular and microvascular complications. Rational and effective drug therapy for diabetic patients is aimed at controlling these diseases to prevent or decrease complications of diabetes.
Objective: To investigate recent prescribing trends of oral antidiabetic drugs (OADs), antihypertensive drugs (AHDs) and lipid-lowering drugs (LLDs) for outpatients with diabetes in Taiwan in the 7-year period from 1997 to 2003 and to evaluate whether the trends are consistent with concurrent clinical trial outcomes and published guidelines.
Materials & Methods: A cross-sectional survey was implemented using National Health Insurance Research Database, including files of ambulatory care expenditures by visits and details of ambulatory care orders, between January 1997 and December 2003. Adult outpatients who had diagnoses of diabetes and who had concurrent antidiabetic drug claim were identified for the trend analyses of the use of OADs, AHDs and LLDs. The annual trends were described in terms of the prescribing rates and patterns of medications.
Results: During the 7-year period, the drugs of sulfonylurea class were the most commonly used OADs, followed by the biguanide class. In all OADs, the largest increase in prescribing rates was for acarbose use. In the prescribing patterns of OADs, a trend towards combination therapy was observed away from monotherapy, and dual therapy was the most commonly prescribed regimens. Calcium channel blockers were the most widely prescribed major class of AHDs throughout the study period, but the rates declined over time. A significant downward trend was also observed for beta-blockers and other classes. Drugs acting on the RAS were the only class exhibiting a significant expansion in prescribing rates with time. In the prescribing patterns of AHDs, combination therapies showed markedly increasing with time and two-drug regimens accounted for the majority of combination therapies. Between 1997 and 2000, fibrates were the most widely prescribed major class of LLDs, while the rates showed a significant decline over time. A significant downward trend was also observed for niacin and derivatives and probucol. HMG-CoA reductase inhibitors were the only class exhibiting a significant expansion in prescribing rates with time. In the prescribing patterns of LLDs, monotherapy was the most prominent prescribing pattern.
Conclusions: Trends in the use of OADs, AHDs and LLDs in patients with diabetes changed dramatically over the past few years in Taiwan. The prescribing rates of OADs, AHDs and LLDs are shifting from the older drugs to the newer drugs. The prescribing patterns of OADs and AHDs are moving toward combination therapies, however, monotherapy in LLD use was the major prescribing regimen. These findings may imply that the management of hyperglycemia and hypertension as well as hyperlipidemia in patients with diabetes had a positive trend toward to recent clinical trial outcomes and guideline’s recommendation. However, the results of our survey reflect as well that there are rooms for improvement in the pharmacologic management.

中文摘要……………………………………………………… i
英文摘要……………………………………………………… iii
致謝…………………………………………………………… vi
目錄…………………………………………………………… vii
表目錄………………………………………………………… x
圖目錄………………………………………………………… xiii
第一章 緒論
第一節 研究緣起…………………………………………… 1
第二節 研究目的…………………………………………… 6
第二章 文獻探討
第一節 糖尿病流行病學…………………………………… 7
第二節 糖尿病疾病生理學………………………………… 11
第三節 成人糖尿病患者高血糖的治療…………………… 15
第四節 成人糖尿病患者高血壓的治療…………………… 23
第五節 成人糖尿病患者高血脂的治療…………………… 33
第六節 抗糖尿病藥物使用研究回顧……………………… 43
第七節 降血壓藥物使用研究回顧………………………… 46
第八節 降血脂藥物使用研究回顧………………………… 49
第三章 研究材料與方法
第一節 研究架構………………………………………… 54
第二節 研究假設…………………………………………… 55
第三節 研究設計………………………………………… 56
第四節 資料處理與統計分析…………………………… 77
第四章 研究結果
第一節 糖尿病門診病患使用口服抗糖尿病藥物之趨勢分析 79
第二節 糖尿病門診病患使用降血壓藥物之趨勢分析…… 87
第三節 糖尿病門診病患使用降血脂藥物之趨勢分析…… 96
第五章 討論
第一節 糖尿病門診病患使用口服抗糖尿病藥物之探討… 104
第二節 糖尿病門診病患使用降血壓藥物之探討………… 111
第三節 糖尿病門診病患使用降血脂藥物之探討………… 118
第四節 研究限制…………………………………………… 122
第六章 結論與建議
第一節 在口服抗糖尿病藥物使用方面…………………… 124
第二節 在降血壓藥物使用方面…………………………… 127
第三節 在降血脂藥物使用方面…………………………… 129
第七章 文章發表…………………………………………… 131
參考資料
英文部份……………………………………………………… 133
中文部份……………………………………………………… 163
附錄
中英縮寫對照表……………………………………………… 166

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