影響門診老年糖尿病病患潛在性不適當處方的危險因子

前言：近年來隨著台灣人口老化，糖尿病盛行率日益升高，病患因不適當用藥而造成的病況惡化情形屢見不鮮。因老化和慢性疾病狀態，潛在性不適當處方可能會增加老人族群產生許多嚴重的後果，像是導致病患殘廢或加速死亡。然而，儘管老人潛在性不適當用藥在國內外一直是不容忽視的問題，卻尚無有效改善的方法，本研究想藉由目前創建於美國最為廣泛使用的 AGS Beers Criteria準則，針對門診患有糖尿病慢性病的老人進行評估，並找出潛在性不適當處方之盛行率以及相關危險因子。方法：本研究設計使用臺灣中部醫學中心的65歲以上並領取慢性處方箋的老年糖尿病門診的患者，統計2015年4月至6月共三個月，納入的7666病患中電子病歷紀錄之病患年齡、性別、處方藥物、慢性病等資料，並計算Charlson共病指數。接著使用2023年 Beers Criteria 評估患者潛在性不適當處方，將病患分為有、無潛在性不適當處方兩組，並檢定兩組病患之差異性，再以羅吉斯迴歸進行多變項分析找出潛在性不適當處方之危險因子。結果：本研究共納入7660名65歲以上門診糖尿病患者，平均年齡為75.27±7.65歲，女性佔50.8%。平均每位病患使用5.72種藥物，診斷5.05種慢性病，Charlson共病指數為1.49±0.75。根據Beers Criteria分析，潛在性不適當用藥（PIM）之盛行率為51.2%。常見PIM藥物為Glimepiride（32.6%）、Estazolam（7.1%）、Zolpidem（6.2%），以藥物分類而言，以磺醯尿素類(Sulfonylurea)最常見（41.5%）。多變項羅吉斯迴歸分析結果顯示，每病患處方數 > 4種 (勝算比為4.8；95%信賴區間為4.3-5.3）、生殖泌尿道系統疾病（勝算比為2.1；95%信賴區間為1.8-2.4）、消化道系統疾病（勝算比為1.8；95%信賴區間為1.6-2.1）、精神系統疾病（勝算比為1.6；95%信賴區間為1.4-1.8）、循環系統疾病（勝算比為1.6；95%信賴區間為1.4-1.8）、Charlson共病指數>1（勝算比為1.4；95%信賴區間為1.2-1.6）皆為PIM使用之顯著危險因子。結論：根據研究結果顯示，潛在不適當處方在門診老年糖尿病患中，對於磺醯尿素類(Sulfonylurea)的使用、多種藥物處方、循環系統疾病、生殖泌尿道系統疾病、Charlson共病指數較高、消化道系統疾病及精神系統疾病等患者，具有較高比例盛行率，臨床醫師應多方考慮其高風險性潛在不適當處方的可能性，落實以病患為中心的老年糖尿病病患用藥安全管理，以達到減少藥物相關不良事件的發生。

Background: In recent years, with the aging population in Taiwan, the prevalence of diabetes has steadily increased. Clinical deterioration due to inappropriate medication use among patients has become increasingly common. Among older adults, aging and the presence of chronic diseases elevate the risk of potentially inappropriate medications (PIM), which may result in serious consequences such as disability or even accelerated mortality. Despite the growing recognition of PIM in the elderly both domestically and internationally, effective strategies for addressing this issue remain limited. This study aims to evaluate the prevalence and associated risk factors of PIM among older outpatients with diabetes using the AGS Beers Criteria—the most widely adopted guideline in the United States for identifying inappropriate medication use in older adults.Methods: This study included outpatient diabetic patients aged 65 years and older who received chronic medication prescriptions at a medical center in central Taiwan. Data were collected from electronic medical records over a three-month period between April and June 2015, encompassing a total of 7,666 patients. Extracted variables included age, sex, prescribed medications, and comorbid chronic conditions. The Charlson's Comorbidity Index score (CCI) was calculated for each patient. PIM were identified based on the 2023 American Geriatrics Society (AGS) Beers Criteria. Patients were categorized into two groups: those with and without PIM. Group differences were analyzed, and multivariate logistic regression was performed to identify risk factors associated with PIM.Results: A total of 7,660 outpatient diabetic patients aged 65 years and older were included in this study. The mean age was 75.27 ± 7.65 years, and 50.8% were female. On average, each patient was prescribed 5.72 medications and diagnosed with 5.05 chronic conditions, with a mean Charlson's Comorbidity Index of 1.4 ±0.75. Based on the Beers Criteria, the prevalence of potentially inappropriate medication (PIM) use was 51.2%. The most commonly PIM were Glimepiride (32.6%), Estazolam (7.1%), and Zolpidem (6.2%). In terms of drug categories, sulfonylureas were the most frequently used (41.5%). Multivariate logistic regression analysis revealed the following significant risk factors for PIM use: being prescribed more than four medications (odds ratio [OR] 4.8; 95% confidence interval [CI], 4.3–5.3), having genitourinary diseases (OR 2.1; 95% CI, 1.8–2.4), gastrointestinal diseases (OR 1.8; 95% CI, 1.6–2.1), psychiatric disorders (OR 1.6; 95% CI, 1.4–1.8), cardiovascular diseases (OR 1.6; 95% CI, 1.4–1.8), and a Charlson's Comorbidity Index >1 (OR 1.4; 95% CI, 1.2–1.6).Conclusion: According to the study results, the prevalence of potentially inappropriate prescriptions among older outpatient diabetes patients was higher in those using sulfonylureas, receiving polypharmacy, or having cardiovascular diseases, genitourinary system diseases, higher Charlson's Comorbidity Index scores, gastrointestinal diseases, and psychiatric disorders. Clinicians should carefully consider the potential risks of inappropriate prescribing in these high-risk groups and implement patient-centered medication safety strategies for older adults with diabetes, in order to reduce the incidence of medication-related adverse events.