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研究生：	吳紹瑩 Wu, Shao-Ying
論文名稱：	老年人使用抗組織胺藥品與急性尿液滯留之探討 The Association between Antihistamines and Acute Urinary Retention Among Elderly Patients
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：	2009
畢業學年度：	97
語文別：	中文
論文頁數：	89
中文關鍵詞：	抗組織胺藥品、老年人、急性尿液滯留
外文關鍵詞：	elderly patients, antihistamine, acute urinary retention
相關次數：	點閱：143 下載：6
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研究背景
急性尿液滯留為最常見的臨床急症之一，隨著年齡的增長，急性尿液滯留的發生率也不斷上升。根據Beers criteria對於老年人的用藥建議，具強抗膽鹼性質的藥品不建議使用在老年人身上，包含第一代抗組織胺藥品、三環抗憂鬱劑、抗痙攣劑及肌肉鬆弛劑等等，然而老年人仍常使用到這些藥品。特別是第一代抗組織胺藥品，常用來治療過敏性鼻炎等感冒症狀，因此感冒的老年人可能就會使用到這類藥品。故本研究目的為探討老年人使用抗組織胺藥品與發生急性尿液滯留之關聯性。

研究方法
利用2003年~2004年全民健保資料庫，病例組對象為2004年1月1日至12月31日間，第一次出現尿液滯留的老年患者；對照組對象為2004年間完全無發生尿液滯留的老年人。接著以年齡、性別、就醫地區、醫療層級、case組納入時間及攝護腺肥大進行配對，再依此資料，分析使用抗組織胺藥品與發生急性尿液滯留之關聯性。

研究結果
配對完成後，case組有5,164人，control組有36,894人，全部族群共有42,058人。在影響急性尿液滯留因子方面，以心臟疾病(27.35%)為最多，其次為糖尿病(18.55%)及NSAID使用者(17.88%)。過去7日內有使用抗組織胺藥品(adjusted OR, 2.220 [95% CI, 1.981~2.488])會顯著性的增加急性尿液滯留的風險，其中不論是第一代抗組織胺(adjusted OR, 2.746 [95% CI, 2.408~3.132])或第二代抗組織胺(adjusted OR, 1.385 [95% CI, 1.108~1.731])均會增加其風險。另外使用第二代抗組織胺比起第一代抗組織胺可顯著性降低其風險(adjusted OR, 0.384 [95% CI, 0.197~0.748])。

結論
老年人使用抗組織胺藥品在7天內會顯著提高急性尿液滯留的風險，而超過7天則不會有顯著性的影響。在不同種抗組織胺藥品方面，不論是第一代抗組織胺藥品或是第二代抗組織胺藥品皆會提高其風險性，此外使用第二代抗組織胺比起第一代抗組織胺可顯著性降低其風險。

Background
Acute urinary retention (AUR) is a common clinical emergent condition. The incidence of AUR increases with ages. Drugs with potent anticholinergic properties are not inappropriate for elderly patients according to Beers’ criteria. These drugs include first-generation antihistamines, tricyclic antidepressant agents, antispasmodics, and muscle relaxants. However, these medicines are still widely used among elderly patients. Therefore, the aim of this study is to evaluate the association between antihistamines and AUR in elderly patients.

Method
The data source is from non-sampled National Health Insurance in 2003~2004. The case group was defined as elderly patients with the first AUR event between 1 Jan 2004 and 31 Dec 2004. The control group is defined as elderly patients without AUR during 2004. Control subjects were matched to cases for age (±3years), gender, area, hospital level, the date of case included, and benign prostatic hyperplasia. After matching, we analyzed the risk of AUR in elderly patients who took antihistamines. The use of antihistamines is defined as current use (antihistamines within 7 days), past use (within 8~30 days) and no use (did not use antihistamines within 30 days).

Result
We identified 5,164 case patients and 36,894 control patients after matching. More patients have covariant factors of cardiac disease (27.35%), diabetes mellitus (18.55%), and NSAID (17.88%). Current antihistamine use was associated with an increased risk of AUR (adjusted OR, 2.220 [95% CI, 1.981~2.488]). Both first-generation (adjusted OR, 2.746 [95% CI, 2.408~3.132]) and second-generation (adjusted OR, 1.385 [95% CI, 1.108~1.731]) antihistamine use increased the risk of AUR significantly. Compare to first-generation antihistamines, second-generation antihistamines had lower risk of AUR (adjusted OR, 0.384 [95% CI, 0.197~0.748]).

Conclusion
Both first-generation and second-generation antihistamine therapy in the elderly patients within 7 days were associated with an increased risk of AUR. In addition, second-generation antihistamines had lower risk of AUR compared with first-generation antihistamines.

目錄
中文摘要.................................................Ⅰ
英文摘要.......................................................Ⅲ
致謝.....................................................Ⅴ
目錄...........................................................................................................................Ⅵ
表目錄.......................................................................................................................Ⅹ
圖目錄.....................................................................................................................XII
第一篇 抗組織胺藥品影響老年人排尿功能之探討............................................ ..1
第一章 研究緣起.......................................................................................................1
第二章 文獻回顧.......................................................................................................3
第一節	急性尿液滯留簡介..............................................................................3
        2.1.1定義與臨床表徵................................................................................3
        2.1.2 流行病學...........................................................................................3
        2.1.3 急性尿液滯留之不良影響...............................................................4
        2.1.4 急性尿液滯留之處理與預防...........................................................5
第二節	急性尿液滯留的誘發因子..................................................................7
        2.2.1 年齡與尿液滯留之相關性...............................................................7
        2.2.2 造成尿液滯留常見的疾病因素...................................................... 8
        2.2.3 造成尿液滯留的常見藥品.............................................................10
第三節	抗組織胺藥品簡介............................................................................14
2.3.1 抗組織胺藥品之分類.....................................................................14
2.3.2 藥品動力學特性.............................................................................15
2.3.3 藥理作用與臨床用途.....................................................................16
2.3.4 常見不良反應.................................................................................17
第三章 研究目的.....................................................................................................19
第四章 研究方法.....................................................................................................20
第一節	研究類型.............................................................................................20
第二節	研究材料與工具.................................................................................20
        
4.2.1 全民健康保險資料庫....................................................................20
        4.2.2 國際疾病傷害及死因分類標準ICD-9-CM 2001年版................21
        4.2.3 健保給付藥品Anatomical Therapeutic Chemical (ATC) classification代碼對照檔(高雅慧、郭垂文、洪輝榮、郭士禎所編定) .............................................................................................21
第三節	研究對象............................................................................................21
    4.3.1 納入對象........................................................................................21
    4.3.2 排除條件........................................................................................22
第四節	研究變項及操作定義說明................................................................23
    4.4.1 研究名詞定義................................................................................23
    4.4.2 影響急性尿液滯留相關因子定義................................................25
    4.4.3 抗組織胺藥品使用時間定義........................................................26
    4.4.4 第一代及第二代抗組織胺藥品分組定義....................................26
        4.4.5 次族群分析分組............................................................................27
第五節	資料處理流程....................................................................................27
    4.5.1 健保資料庫檔案串連....................................................................27
        4.5.2 研究流程........................................................................................29
第六節	統計方法............................................................................................31
    4.6.1 統計工具........................................................................................31
    4.6.2 統計模式設定................................................................................31
        4.6.3 資料分析方法................................................................................31
第五章 研究結果....................................................................................................33
第一節	病患基本資料....................................................................................33
5.1.1	病患選取與分組流程...................................................................33
5.1.2	病患基本特性分佈.......................................................................34
    第二節 抗組織胺藥品處方型態分析............................................................39
第三節	急性尿液滯留共病症與發生急性尿液滯留之相關性....................42
    5.2.1 疾病共病症與發生急性尿液滯留之相關性................................42
    5.2.2 藥品共變項與發生急性尿液滯留之關聯性................................42

第四節	抗組織胺藥品與發生急性尿液滯留之關聯性................................45
        5.3.1 抗組織胺藥品使用與發生急性尿液滯留之關聯性....................45
        5.3.2 不同種類抗組織胺藥品與發生急性尿液滯留之關聯性............45
第五節	次族群分析─抗組織胺藥品與發生急性尿液滯留之關聯性..........47
    5.4.1 女性老年族群.................................................................................47
    5.4.2 男性老年族群.................................................................................47
    5.4.3 攝護腺肥大族群.............................................................................48
第六章 研究討論.....................................................................................................58
第一節	研究設計討論.....................................................................................58
        6.1.1 研究族群選取.................................................................................58
        6.1.2 尿液滯留定義.................................................................................59
第二節	抗組織胺藥品處方型態討論.............................................................59
第三節	影響急性尿液滯留因子探討.............................................................60
    6.3.1 疾病共病項討論.............................................................................60
        6.3.2 藥品共變項討論.............................................................................60
第四節	抗組織胺藥品之探討.........................................................................63
    6.4.1 使用抗組織胺藥品與急性尿液滯留之相關性.............................63
    6.4.2 不同種抗組織胺藥品與急性尿液滯留之相關性.........................67
第五節	次族群分析與比較.............................................................................67
        6.5.1 性別.................................................................................................67
        6.5.2 攝護腺肥大.....................................................................................68
第七章 研究限制.....................................................................................................69
第八章 結論與建議.................................................................................................70
第九章 未來研究方向.............................................................................................71
第二篇 臨床藥事服務─住院病人之藥品整合評估..............................................72
第一章 服務背景.....................................................................................................72
第二章 服務方法.....................................................................................................73
第三章 服務結果.....................................................................................................74
第四章 心得與建議.................................................................................................81
參考文獻...................................................................................................................82
附錄一 本研究相關藥品之ATC code...................................................................86
附錄二 本研究相關疾病診斷碼及處置碼 (ICD-9-CM)......................................87
作者簡介..................................................................................................................89



























表目錄
表1-1-1  造成急性尿液滯留的常見原因與發生率................................................8
表1-1-2  常用抗組織胺藥品分類..........................................................................15
表1-1-3  常用抗組織胺藥品之藥物動力學特性..................................................16
表1-5-1  病患基本特性分佈..................................................................................37
表1-5-2  抗組織胺藥品使用情形..........................................................................40
表1-5-3  常用之複方抗組織胺藥品及其成份......................................................41
表1-5-4  共病症與發生急性尿液滯留之相關性..................................................46
表1-5-5  抗組織胺藥品與發生急性尿液滯留之相關性......................................46
表1-5-6  不同種類抗組織胺藥品與發生急性尿液滯留之相關性......................46
表1-5-7  第一代抗組織胺藥品與第二代抗組織胺藥品發生急性尿液滯留相關 性比較.....................................................................................................46
表1-5-8  女性老年族群─共變項與發生急性尿液滯留之相關性.......................49
表1-5-9  女性老年族群─抗組織胺藥品與發生急性尿液滯留之相關性...........51
表1-5-10 女性老年族群─不同種類抗組織胺藥品與發生急性尿液滯留之
相關性.....................................................................................................51
表1-5-11 男性老年族群─共變項與發生急性尿液滯留之相關性.......................52
表1-5-12 男性老年族群─抗組織胺藥品與發生急性尿液滯留之相關性...........54
表1-5-13 男性老年族群─不同種類抗組織胺藥品與發生急性尿液滯留之相關  性.............................................................................................................54
表1-5-14 攝護腺肥大族群─共變項與發生急性尿液滯留之相關性...................55
表1-5-15 攝護腺肥大族群─抗組織胺藥品與發生急性尿液滯留之相關性.......57
表1-5-16 攝護腺肥大族群─不同種類抗組織胺藥品與發生急性尿液滯留之相關性.........................................................................................................57
表1-6-1  敏感性分析─共變項與發生急性尿液滯留之相關性..........................64
表1-6-2  敏感性分析─抗組織胺藥品與發生急性尿液滯留之相關性..............66
表1-6-3  敏感性分析─不同種類抗組織胺藥品與發生急性尿液滯留之
相關性.....................................................................................................66
表2-3-1  訪談病患基本資料..................................................................................75
表2-3-2  用藥相關問題及臨床實例......................................................................76
表2-3-3  藥師建議情形及臨床實例......................................................................78
表2-3-4  藥師建議與醫師回覆情形......................................................................80




























圖目錄
圖1-1-1 年齡與急性尿液滯留發生率關係圖.........................................................7
圖1-1-2 泌尿系統生理機轉簡圖............................................................................10
圖1-4-2 研究流程一................................................................................................29
圖1-4-3 研究流程二................................................................................................30
圖1-5-1 研究流程─case組選取過程.....................................................................35
圖1-5-2 研究流程─control組選取與配對過程.....................................................36
                                    

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