臺灣博碩士論文加值系統

紅血球生成素(Erythropoietin，簡稱 EPO)是慢性腎病患者因紅血球生成素缺乏引起之貧血的首選藥物。臺大醫院EPO的用量在引進之數年以等比級數成長，1994 年EPO之購入成本就達1千 4 百萬元。面臨全民健保及洗腎包醫制度，評估EPO使用之有效性、適當性、經濟性，不容忽視。以本院血液透析室所有三十二位長期透析病人為研究對象，偵測其已使用一至四年不等之EPO之劑量、療效、副作用，及經濟效益等問題。首先，與院內腎臟專科醫師共同制定本院EPO使用準則。對過去之使用情形、療效、花費先加以紀錄、分析，再依擬定之EPO準則為介入處置依據。先排除鐵、葉酸、維他命 B12 缺乏，鋁過多，發炎或感染造成之貧血。劑量從 3000-6000u/week (75u/kg/week)開始，為病人找出個別能達目標之最小劑量。準則實施後三個月進行評估，和過去使用情形比較，作療效、副作用，及成本分析。
本次研究發現：因勞保規定嚴苛不合理，除勞保病人外全部符合適應症準則。開始使用EPO未作鐵質監測者達53%，只有28%接受鐵劑的補充。沒有一個病人曾事先評估血中鋁質、維生素 B12、葉酸等。起始劑量若以3000-6000u/week 來看有72%合乎準則。平均劑量調整間隔時間6.2±6.4個月，不合理達76%，對療效影響甚巨。鐵質監測只有 61-63% 符合規定。EPO治療後有47%發生鐵質缺乏，其中三分之二口服鐵劑治療失敗。注射鐵劑之七人中71% 給過量，只有一人劑量正確。能在 3個月內到達血比容28-33%僅有9%，第二年30%，第三年也不及40%。檢驗結果沒有病患有維生素 B12 或葉酸缺乏情形，只有一位病患鋁過多。鐵質完全符合規定者僅48%。此次研究對10位病人建議補充鐵劑，有4人在不增加EPO之情形下血比容提高；有4人原因EPO療效不佳增加劑量，待鐵劑補充後發現不必調升劑量；另一人因拒絕接受鐵繼而血比容下降，以致須增加EPO劑量。鐵質足夠而EPO有療效者14人，鐵質不足而EPO沒有療效者8人，以Fisher Exact Test證實鐵劑與療效有顯著的關係。
使用足夠劑量的EPO，再加上嚴密的鐵質監測，血比容達28% 的比例由 55% 增加為 84%，不良反應發生率並沒有增加，且能每年減少醫療成本至少 47 萬。持續進行EPO評估，發揮藥師專業角色，再進一步進行修正EPO用藥準則，期能確立最符合經濟效益之使用。

Chronic renal failure is often associatedwith anemia,
primarily due to inability of the failing kidney to synthesize
sufficient erythropoietin. Erythropoietin (EPO) is the drug of
choice in these patients. Its efficacy is decreased by the
presence of iron, folic acid, or vitamin B12 deficiency or
aluminum overload. The use of EPO at NTU hospital increases
every year by geometric progression, which reached a cost of
NT$14 million in 1994. With the implementation of National
Health Insurance System, and case payment for hemodialysis, a
drug use evaluation (DUE) of EPO is necessary to access the
appropriateness of patient selection, drug dosage, monitoring of
therapy,and cost. All the 32 patients followed by the incenter
hemodialysis were included in this program. An EPO use criteria
concerning the indication, dosage, monitoring contraindication
and precaution, determine by pharmacy and nephrologists through
interdepartmental meeting. A retrospective study of the use,
efficacy, side effects, and cost of EPO in the past 1-4 years is
done first. All the patients then adjust EPO dose according to
the new criteria. Anemia caused by iron, folic acid, or vitamin
B12 deficiency, aluminum overload, inflammation or infection
were are ruled out first. Initial dose in 3000-6000U/week.Dosage is individualized to get the minimum dose that can achieve goal of therapy. Three months after the use of new criteria, patients will be accessed to determine the efficacy, side effects and cost. We then compare results with those obtained from previous retrospective study. The criteria is for EPO use is further modified so as to assure the most cost-effective use.