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系統識別號 U0026-1007201713274400
論文名稱(中文) 台灣缺血性中風病患使用抗精神病藥物之處方型態分析
論文名稱(英文) The Prescribing Pattern of Antipsychotics in Patients with Ischemic Stroke in Taiwan
校院名稱 成功大學
系所名稱(中) 臨床藥學與藥物科技研究所
系所名稱(英) Institute of Clinical Pharmacy and Pharmaceutical sciences
學年度 105
學期 2
出版年 106
研究生(中文) 詹皓文
研究生(英文) Hao-Wen Chan
學號 s66041052
學位類別 碩士
語文別 中文
論文頁數 100頁
口試委員 指導教授-高雅慧
口試委員-謝鎮陽
召集委員-鄭靜蘭
口試委員-賴嘉鎮
口試委員-葉鳳英
中文關鍵字 中風後  缺血性中風  抗精神病藥物  處方型態 
英文關鍵字 post-stoke  ischemic stroke  antipsychotics  prescribing pattern 
學科別分類
中文摘要 研究背景:
腦中風是因腦部血管病變所引起的腦部損傷,是常見的神經系統疾病。過去研究顯示,在腦中風存活者當中,約有12%~56%的病患會出現心理及精神相關的症狀,包括:憂鬱、焦慮、認知障礙以及精神病症狀(幻覺、妄想、激動不安)等。依據美國老年學會指引,抗精神病藥物 (antipsychotics) 被認為是治療精神病症狀的第一線用藥。然而抗精神病藥物所帶來的副作用,包含metabolic symptoms和cardiovascular effects,都可能會增加使用者的死亡風險。過去甚少有研究在探討病患在中風後使用抗精神病藥物的藥物使用情況,尤其台灣的情況所知有限。因此,本研究希望藉由分析中風病患接受抗精神病藥物治療的發生率與處方型態,進而提供臨床醫師開立抗精神病藥物之處方參考。

研究方法:
使用2000-2013年全民健保資料庫之回溯型世代研究。
研究一:研究對象為2001-2012年因缺血性中風住院且年齡≥18歲之病患,中風前一年內無任何使用抗精神病藥物之患者,分析其出院後接受抗精神病藥物治療的發生率與藥物種類,再進一步將性別與年齡分層並計算接受抗精神病藥物治療之發生率變化情況。
研究二:研究對象為2000-2013年因缺血性中風住院且年齡≥18歲之病患,中風後180天內開始在門診使用抗精神病藥物之患者。分析病患開立藥物與病患危險因子(risk factors)的關聯性,並自開始用藥後往後追蹤一年,分析藥物使用療程區間及治療改變之原因。

結果:
研究一:經過納入、排除與分組條件後,共有380,057位缺血性中風病患進行後續追蹤接受抗精神病藥物治療之發生率。研究對象平均為68.7歲(SD=12.62)。發現接受抗精神病藥物治療之發生率為49.6/1,000人-年, quetiapine (15.9/1,000人-年)為最常使用之抗精神病藥物,其次依序為haloperidol (14.6/1,000人-年)、risperidone (6.1/1,000人-年)、chlorpromazine (3.9/1,000人-年)、sulpiride(2.6/1,000人-年)。
研究二:經過納入、排除與分組條件後,共11,972人進行後續藥物選擇與危險因子關聯性之分析、藥物療程區間之測量以及分析治療改變之原因。發現當處方醫師具備精神科或神經科專科醫師證照、病患罹患有失智症及譫妄症時,傾向選擇risperidone;病患罹患有憂鬱症時,傾向選擇quetiapine;病患罹患有心血管-代謝症候群時,傾向選擇第一代抗精神病藥物。分析藥物療程區間以quetiapine最長,且相較於其他用藥組別,其住院率較低且存活率較高。

結論:
本研究提供缺血性中風病患使用抗精神病藥物之處方型態分析。其中選擇quetiapine治療之發生率最高、使用藥物療程區間最長之藥物,然而,因risperidone在臺灣被核准使用於失智症之行為及精神症狀,故可觀察在老年或是罹患有失智症之病患較偏好使用risperidone。本研究亦發現缺血性中風病患使用quetiapine相較於其他用藥組別時,其安全性較高,但仍需觀察性研究再進一步確認之。
英文摘要 Psychological complications are one of major problems to influence recovery after a stroke. In addition, when post-ischemic stroke patients are presence of these psychological problems could increase mortality risk. To treat these psychosis, antipsychotics were recommended as first-line therapy. However, there is concern about adverse effects of antipsychotics when prescribed for these patients. Nevertheless, there is limited literature providing epidemiologic information related with antipsychotics use after stroke. Therefore, we aimed to conduct an epidemiological survey to depict prescribing pattern of antipsychotics in Taiwan. The research data source came from NHIRD and our results were divided into three parts. First part of this study indicated the incidence of antipsychotic prescriptions in patients with ischemic stroke was 49.6/1,000 person-year. Besides, risk factors would increase 1-year incidence of antipsychotic use including older age, depression, dementia, delirium, anxiety, congestive heart failure, epilepsy, Parkinson’s disease, chronic kidney disease, antidepressants, benzodiazepines and opioids. The second part of this study is analyzing the factors influencing antipsychotics choice in patients with ischemic stroke. The results revealed elderly patients with dementia and delirium were more likely to be treated by risperidone, and quetiapine was more likely to be prescribed for patient with depression. Moreover, patients with cardio-metabolic syndromes were propensity to be treated by first-generation antipsychotics. The third part of this study is treatment duration of antipsychotics. Quetiapine showed the longest duration, the lowest re-admission rate and the highest survival rate. In summarize above results, we provided evidence-based information to clinical practice for post-ischemic stroke patients using antipsychotics.
論文目次 摘要 I
Extended abstract III
誌謝 VI
目錄 VIII
表目錄 XI
圖目錄 XIII
第一篇、 缺血性中風病患使用抗精神病藥物 1
第一章、 研究背景 1
第二章、 文獻回顧 2
第一節、 缺血性中風的流行病學 2
第二節、 缺血性中風後併發疾病探討 3
一、 缺血性中風後常見併發症 3
二、 缺血性中風後併發精神障礙疾病的研究 4
第三節、 抗精神病藥物的使用 6
一、 抗精神病藥物的機轉與分類 6
二、 抗精神病藥物常見副作用 7
三、 抗精神病藥物之安全性研究 8
四、 現今抗精神病藥物之使用情況 9
第三章、 研究目的與重要性 11
第四章、 研究方法 12
第一節、 研究一:分析缺血性中風病患接受抗精神病藥物治療之發生率 12
一、 研究設計 12
二、 研究名詞、研究變項與操作定義 17
三、 資料處理流程 20
四、 統計方法 21
第二節、 研究二:分析使用抗精神病藥物之處方型態 22
一、 研究設計 22
二、 研究名詞、研究變項與操作定義 26
三、 資料處理流程 29
四、 統計方法 30
第五章、 研究結果 33
第一節、 研究一:分析缺血性中風病患接受抗精神病藥物治療的發生率 33
一、 研究對象收入、排除與分組 33
二、 研究對象基本資料分析 35
三、 接受各組藥物治療之發生率 39
四、 中風後首年接受藥物治療發生率與病患危險因子關聯性 43
第二節、 研究二:分析使用抗精神病藥物之處方型態 47
一、 研究對象收入、排除與分組 47
二、 研究對象基本資料分析 50
三、 研究藥物使用與病患危險因子關聯性 55
四、 研究藥物平均劑量及治療改變之情況 61
第六章、 研究討論 67
第一節、 研究對象收入與排除條件之分析 67
第二節、 研究對象基本資料與人口特性之分析 68
一、 人口特性分析 68
二、 研究對象之基本資料分析 69
第三節、 接受藥物治療之發生率分析 70
一、 接受各組藥物治療之發生率分析 70
二、 接受抗精神病藥物治療與病患危險因子關聯性之分析 72
第四節、 藥物選擇與治療區間之分析 74
一、 研究對象用藥選擇之危險因子分析 74
二、 每日平均劑量 78
三、 研究藥物治療改變之情況 79
第五節、 研究限制 81
第七章、 結論與建議 83
第八章、 未來研究方向 84
第二篇、 臨床藥事服務-老年科門診病患用藥整合服務 85
第一章、 背景與目的 85
第二章、 執行計畫 86
第一節、 服務對象 86
第二節、 服務內容準備 86
第三節、 執行方式 86
第三章、 服務成果與討論 87
第四章、 未來建議 94
參考資料 95
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