林中生Lin Chung-Sheng, MD, Ph.D.鄭淑妃Cheng Sue-Fei醫學研究所2026-10-282005-06-302004https://handle.ncl.edu.tw/11296/ms4z77https://scholars.csmu.edu.tw/handle/123456789/35047糖尿病患罹患高血壓的盛行率較一般人高兩倍，當糖尿病患併有高血壓時，即意味著患者大小血管病變的危險性增高，因此糖尿病患合併高血壓的問題一直是受關注的研究範疇；前人的研究結果顯示，糖尿病患的用藥數較其它疾病為高，特別是心臟血管用藥，我們對高昂的醫療支出深感憂慮，迫切的想瞭解糖尿病高血壓病患的用藥趨勢及其合理性，故以現行治療準則，對糖尿病患高血壓之藥物治療型態進行評估。 本研究乃對九十年一月門診病患處方中同時含有降血糖及降血壓藥物之病患進行研究，患者若同時具有心絞痛、鬱血性心臟病、心節律障礙、偏頭痛、甲狀腺功能低下及攝護腺肥大等診斷碼則由研究中剔除。統計方法乃以SPSS10.0版軟體進行分析。統計結果以平均值±標準差表示，以Student t-test比較兩組連續變項之差異，檢定類別變項則使用Chi-Square test (two-tailed)，P值小於0.05視為有顯著性差異。 研究共收載5015名病患，每人平均用藥數為5.7±2.1項，老年組(年齡≧65歲)用藥筆數明顯高於非老年組(5.8±2.1 vs 5.6±2.1項, p<0.01)。糖尿病的藥物治療模式，以採用兩類降血糖藥物之病患佔多數(49.0%)，其中以磺醯尿素類併用雙胍類的組合居多。服用磺醯尿素類藥物的使用居各類藥物之冠，其中以glibenclamide為大宗，其在老年組的使用率有意義的高於非老年組(P< 0.001)，次為gliclazide，使用率為口服降血糖藥之15.1%，藥費之支出卻高達整體口服降血糖藥物之40.3%。就高血壓之治療型態而言，有2322 (46.3%)名病患採用單一抗高血壓藥物療法，使用二類藥物者計有1823 (36.4%)例，以CCB加上ACEI的組合最受青睞。各別藥物分析，雖然現行治療準則並不建議將鈣離子阻斷績列為第一線用藥，但研究發現鈣離子阻斷劑使用率最高，計有3395（38.0%）名病患使用此類藥物，而深獲文獻支持對糖尿病患具實證益處的ACEI，使用量為( 23.6%)，反不如預期。Thiazide利尿劑的每日劑量明顯高於JNC-VI之推薦用量與短效鈣離子阻斷劑-nifedipine的不當使用，都值得關注的問題。 多數病患使用合併治療方式控制血糖與血壓，由於糖尿病為漸進式疾病，合併治療是符於邏輯考量的，選用不同機轉的藥物，既可使血糖控制愈趨理想，亦可藉劑量之調整將副作用降至最低，所以患者往往使用二至三種不同類別的降壓與降血糖藥品。本研究不僅讓我們充份了解糖尿病患治療用藥型態及費用金額分佈，同時也顯露出某些用藥不當之處，整體評估結果，高血壓治療之藥物使用與現行治療準則有部份出入，值得進一步探討。Abstract Aims Diabetes mellitus increases the prevalence of hypertension twofold, and the coexistence of these diseases creates a high risk for macrovascular and microvascular complications. The treatment of hypertension in diabetes remains a consistent research issue. Patients with diabetes tend to use many drugs, particularly cardiovascular agents. Our purpose was to determine the prescription patterns for diabetic hypertensive patients in a Taiwanese medical center and compare them with current guidelines. Methods Patients presenting with a prescription for the month of January 2001 were collected if any antidiabetic concomitantly antihypertensive agent. Patients with angina pectoris, benign prostate hyperplasia, congestive heart failure, dysrhythmias, migraine or thyroid dysfunction were excluded. Statistical analysis was performed using the Statistical Package for Social Science. Results are expressed as mean±SD. Chi-square and Student t tests were used to determine differences between proportions and means All tests were two-sided, and statistical significance was assumed at P < 0.05. Results and Discussion A total of 5015 patients were collected during the one-month study. Each prescription included 5.7 ± 2.1 drugs. Patient &#8805;65 years were prescribed more drugs than those <65 years. (5.8 ± 2.1 vs 5.6 ± 2.1) Sulfonylurea plus metformin was the most popular regimen. Prescriptions for long-acting sulfonylureas did not differ between elderly and younger patients. Expenditure analysis showed that gliclazide accounted for 40.1% of the total costs for oral antidiabetics, though its utilization represented only 15.1% of all oral antidiabetics. For hypertension, 2322 (46.3%) patients received monotherapy. Combination therapy included two (1823, 36.4%), three (691, 13.8%), four (153, 3.1%) or five (26, 0.5%) drugs. The most popular combination was a calcium-channel blockers(CCBs) plus an angiotensin-converting enzyme (ACE) inhibitor. CCBs (3395, 38.0%) were most often prescribed, both as monotherapy and overall, despite guidelines suggesting that CCBs should be second-choice agents. Inappropriate use of immediate-release nifedipine was found. The prescription rate of ACE inhibitors (2108, 23.6%) was lower than expected, though strong evidence supports their use as the preferred class in diabetic hypertensive patients. Atenolol over 100 mg/day and hydrochlorothiazide 50 mg/day (or an equivalent) were extensively used. Conclusion Most our diabetic hypertensive patients need combination therapy for glucose and blood pressure control. Because diabetes is progressive, combination treatment is logical. This prescription survey not only showed the patterns of drug utilization by diabetic hypertension and the distribution of expenditures for these drugs, but also revealed some of the inappropriate prescriptions. Prescribing patterns were relatively consistent with guidelines for diabetic therapy but not with guidelines for hypertension therapy. More studies are required to correlate these findings with clinical outcomes and cost-effectiveness.糖尿病高血壓藥物使用處方分析處方型態Diabetes mellitusHypertensionDrug utilizationPrescription analysisPrescribing patternsthesis