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研究生： 劉玟琦
Liu, Wei-Chi
論文名稱： 臺灣全身性類固醇處方型態分析
Prescribing Pattern of Systemic Corticosteroids in Taiwan
指導教授： 高雅慧
Kao, Yea-Huei
學位類別： 碩士
Master
系所名稱： 醫學院 - 臨床藥學研究所
Institute of Clinical Pharmacy
論文出版年： 2010
畢業學年度： 98
語文別： 中文
論文頁數： 89
中文關鍵詞： 處方型態分析 、糖皮質類固醇 、類固醇 、健保資料庫
外文關鍵詞： Prescribing pattern, Corticosteroids, Glucocorticoids, Steroids
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    • 研究背景
    全身性類固醇在全球被廣泛使用在內分泌疾病、發炎、過敏及免疫系統異常等疾病上，不過長期使用會導致許多的副作用。英美國家已有需多類固醇的處方型態研究和類固醇使用與副作用間的關聯性。然而，關於類固醇使用之情形在臺灣尚未有流病學資料，而坊間也常傳聞類固醇不適當使用的事例。因此本研究致力於探討臺灣使用類固醇的處方現況，以利後續相關議題的討論和深入研究。
    研究方法
    利用2000~2004年全民健康保險資料庫，健保給付藥品ATC代碼對照檔藥品代碼開頭為「H02」者為全身性類固醇的使用，再與門診和住院醫令明細檔串檔，定義為全身性類固醇的使用者。
    本研究有兩種不同研究族群：
    1) 處方型態分析：對象為2004年1月1日至2004年12月31日期間，接受過一次全身性類固醇處方者。
    2) 長期使用者：對象為2001年1月1日至2003年12月31日期間，連續使用全身性類固醇超過3個月(92天)處方者。
    研究結果
    在處方型態分析中，有4,416,874人曾使用過一次以上的類固醇，盛行率為每千人195人。將近72%的使用者，只接受過1至2次處方箋。Prednisolone 是最常被處方的藥品，耗用量是4.8 DDD/inhabitant/day。住院病患中90至95歲的老年人有最高耗用量(11 DDD)，在門診病人中則是75至85歲有最高的耗用量(12.5 DDD)。住院病人最常見的疾病是腫瘤，而門診診患者則是呼吸系統疾病。

    在長期使用者中，有123,159人長期使用類固醇，2003年盛行率是每千人2.9人。而在小於20歲、20至64歲和大於64歲者之盛行率分別是每千人0.5、2.4、12.6人。最常使用的劑量是每天5至7.5毫克。而最常見的疾病是呼吸系統疾病(32%)，其次是風濕性疾病(23%)。然有高達24%的長期使用者無相對應長期使用類固醇合適的診斷。
    結論
    藉由全民健康保險資料庫，本研究發現臺灣類固醇使用人數遠高於其他國家，在門診大部分都是短期的使用者，常用於治療上呼吸道感染。使用全身性類固醇治療一般的上呼吸道感染之適當性，仍需仔細評估。
    長期使用者的盛行率與其他國家相似，約每千人有3人長期使用。然而，盛行率和每天劑量(不同年齡層的比例)隨著年紀增加而上升，因此，在臨床上需更注意老年人在如此高劑量的暴露下是否發生副作用。
    關鍵字
    處方型態分析、糖皮質類固醇、類固醇、健保資料庫。

    Background
    Systemic corticosteroids (CSs) are used to treat patients with endocrine, inflammatory, allergic, or immunological disorders, which may cause in many adverse effects in chronic use. There are lots of studies about the prescription patterns of CSs and the association between CSs use and adverse effects in western countries. However, information describing the population-based use of corticosteroids in Taiwan remains unavailable. Therefore, this study was aimed to investigate utilization of systemic CSs in Taiwan.
    Methods
    We included systemic CSs users who were documented prescriptions of H02 in ATC code from the non-sampled National Health Insurance Research Database (NHIRD).
    There were two groups to classified for the analysis:
    1) who had received one or more prescriptions of systemic CSs during 1 January 2004 and 31 December 2004 .
    2) who had continued treatment more than 3 months (92 days) during 1 January 2001 and 31 December 2003
    Results
    In the cross-sectional study, we enrolled 4,416,874 CSs users, and the prevalence was 195 per 1000 persons. Nearly 72% of CSs users received only 1 or 2 prescriptions in 2004. Prednisolone was the most frequently prescribed CSs, and the consumption was 4.8 DDD/inhabitant/day. The highest consumption of CSs was found with people between 90 and 95 years of age (11 DDD) in impatient service and 75 and 85 years of age (12.5 DDD) in ambulatory patients. The most frequently recorded diagnosis associated with CSs use was neoplasm, and respiratory disease in impatient service and ambulatory care, respectively.
    In the part of long-term users, we enrolled 123,159 CSs long-term users, and the annual prevalence was 2.9 per 1000 people in 2003. The prevalence of long-term users <20, 20 to 64, and >64 years of age was 0.5, 2.4 and 12.6, respectively. The most frequently prescribed dose was between 5 and 7.5 mg/day. The most common diagnosis associated CSs use was respiratory disease (32%), followed by rheumatic disease (23%). Nearly 24% of long-term users had no documented diagnosis indicating the appropriateness of CSs use.

    Conclusions
    A large number of patients enrolled in NHIRD had received one or more CSs in 2004 which was more prevalent than other countries. Most of them were short-term users, and the most frequently diagnosis associated CSs use was upper respiratory tract infection. The utilization pattern awakes future investigate.
    The prevalence of long-term users was similar with other country. While age was increasing, the prevalence raised as well as the percentage of daily dose. The risk and benefit of systemic CSs in the elderly should be concerned.
    Keywords
    Prescribing pattern, Corticosteroids, Glucocorticoids, Steroids

    中文摘要 I Abstract III 誌謝 V 目錄表目錄 VI 表目錄 IX 圖目錄 X 第一篇 臺灣全身性類固醇處方型態分析 1 第一章 研究背景 1 第二章 文獻回顧 2 第一節 內生性和人工合成皮質類固醇簡介 2 2.1.1腎上腺皮質激素11 2 2.1.1.1糖皮質激素 2 2.1.1.2礦物皮質激素11 3 2.1.2腎上腺皮質激素藥物11 4 2.1.2.1糖皮質類固醇藥物 4 2.1.2.2礦物皮質類固醇藥物 5 第二節 糖皮質類固醇導致的副作用 7 2.2.1皮膚和軟組織的副作用 7 2.2.2庫欣氏症候群和體重增加 8 2.2.3眼部的副作用 8 2.2.4心血管的副作用 9 2.2.5腸胃道的副作用 10 2.2.6腎臟和循環系統的副作用 10 2.2.7生殖系統的副作用 11 2.2.8骨骼肌肉的副作用 11 2.2.9中樞神經的副作用 13 2.2.10新陳代謝或內分泌的副作用 13 2.2.11血液學的副作用 13 2.2.12 總結 14 第三節 類固醇處方型態分析 15 2.3.1 各國處方型態 15 2.3.2 總結 17 第三章 研究目的 19 第四章 研究方法 20 第一節 研究設計 20 4.1.1 研究類型 20 4.1.2 研究材料及工具 20 4.1.3 納入條件 21 4.1.4 排除標準 22 第二節 研究變項及操作定義 23 4.2.1 研究藥品 23 4.2.2 研究名詞定義 24 第三節 資料處理流程 28 4.3.1檔案串檔 28 4.3.2研究流程 29 第四節 統計分析 30 4.4.1 統計工具 30 4.4.2 統計模式設定 30 4.4.3 資料分析方法 30 第五章 研究結果 31 第一節 處方型態分析 31 5.1.1 類固醇藥品 31 5.1.2 研究族群人口特性 32 第二節 長期使用者 41 第六章 研究討論 48 第一節 處方型態分析 48 6.1.1 研究族群人口特性 48 第二節 長期使用者 52 第三節 研究限制 56 第七章 結論與建議 57 第二篇 臨床藥事服務口服類固醇之用藥衛教和類固醇引起的骨質疏鬆症之衛教 58 第一章 服務緣起 58 第二章 服務方法 60 第一節 服務對象 60 第二節 服務材料 60 第三節 服務流程 61 第三章 服務結果 62 第一節 病患特性 62 第二節 類固醇藥品和骨質疏鬆藥品衛教 64 第四章 心得 66 參考文獻 67 附錄一 75 附錄二 78 作者簡介 89

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