長期治療痛風不佳


  【24drs.com】根據發表於12月23日JAMA期刊的研究通訊,痛風患者依據現有的建議治療時,只有少數患者的適應症需要長期的降尿酸治療。
  
  研究者發現,英國只有三分之一的開業醫師處方降尿酸藥物給適當的患者,因此,作者們建議,對於初次診斷痛風的患者,應提供降尿酸治療資訊給他們。
  
  根據費城賓州大學醫學名譽教授、未參與此次研究的Ralph Schumacher醫師表示,美國的情況反映了英國的模式,美國降尿酸的治療處方不足,大多數痛風患者是因為急性發作就診,太匆忙而無法真正說明高尿酸值的長期影響。他們適當地治療發作,一旦這些狀況結束,要擔心病患的其他狀況,如糖尿病與心臟病,所以往往會忽略長期考量。
  
  Schumacher醫師表示,就他的觀點,關鍵在於及早教育,發作後的處理完成之後,要教育病患疾病資訊,讓患者使用allopurinol這類降尿酸藥物。
  
  對於痛風或相關症狀比較嚴重的病患,目前的指引建議長期治療以降低血中尿酸鹽(尿酸的代謝衍生物)值,藉以預防結晶沉積與促使結晶溶解。台灣桃園長庚紀念醫院過敏免疫風濕科、類風濕顧問郭昶甫醫師等人寫道,不過,第一次診斷之後,還不清楚是否要開始這種治療。
  
  研究者探討初次痛風診斷之後處方降尿酸治療的適當時機,研究對象是52,164名在1997-2010年間偶發痛風的患者。研究樣本來自英國臨床實務研究資料庫,包括約8%英國人口的醫療資訊,資料來自英國486個一般開業診所。
  
  研究對象診斷時的平均年紀為62.5歲,73%的研究對象是男性。發生初次治療狀況的時間中位數是5個月(四分位範圍0 – 29個月),診斷第一年內,急性復發痛風發作的治療適應症是痛風石、尿路結石、慢性腎病、和診斷時使用利尿劑;平均追蹤期為6年(四分位範圍4 – 9年)。
  
  近半數(44%)患者在開始時即符合降尿酸治療適應症,87%在診斷後5年內符合,在任何時間點接受適當治療的只有少數;處方率中位數為32.5% (四分位範圍26.3% - 39.3%;範圍0% - 100%)。
  
  病患符合任何治療適應症的可能性是累積的,從診斷當時的44.26% (95%信心區間[CI],43.83% - 44.69%)以及診斷1年時的61.02% (95% CI,60.60% - 61.44%)到診斷5年時的86.81% (95% CI,86.49% - 87.13%)與診斷10年時的94.27% (95% CI,93.98% - 94.56%)。
  
  在前述時間點開處方的累積可能性分別是0%、16.90% (95% CI,16.58% - 17.22%)、30.39% (95% CI,29.90% - 30.81%)以及40.52% (95% CI,39.96% - 41.08%)。
  
  診斷後第一年內的治療適應症風險比如下:急性發作1.60 (95% CI,1.55 - 1.65);痛風石1.87 (95% CI,1.56 - 2.24);慢性腎臟病1.67 (95% CI,1.60- 1.74);診斷時使用利尿劑1.57 (95% CI,1.51 - 1.63)。
  
  作者們寫道,整體處方差異中,病患與實務層面的因素分別佔7.82%與13.49%;病患因素包括性別、年齡、種族、社會經濟變項;實務因素包括病患總數與痛風病患人數、出生年份中位數、性別比率、執業區域、以及社會經濟狀態。其他近80%的變項可能未被納入資料庫。
  
  作者們寫道,要確認是哪些因素阻礙照護,例如病患與醫師的痛風知識,痛風治療與臨床建議,病患與醫師對治療的偏好等等。
  
  資料來源:http://www.24drs.com/professional/list/content.asp?x_idno=7146&x_classno=0&x_chkdelpoint=Y
  

Long-term Treatment of Gout Is Suboptimal

By Diana Swift
Medscape Medical News

Only a minority of patients with gout whose disease indications made them candidates for long-term urate-lowering therapy were treated according to current recommendations, reports a research letter published in the December 23 issue of JAMA.

The researchers found that only a third of general practitioners in the United Kingdom prescribed urate-lowering therapy to appropriate candidates. Therefore, the authors recommend that urate-lowering treatment be included in information given to patients with gout at the time of first diagnosis.

According to Ralph Schumacher, MD, emeritus professor of medicine, University of Pennsylvania, Philadelphia, who was not involved in the study, the US situation mirrors the UK pattern. "Urate-lowering treatment is underprescribed here because most gout patients consult primary care physicians for acute attacks, and they are too busy to really address the long-term implications of high uric acid levels," he told Medscape Medical News. "They treat the attacks adequately, but once these are over, they have other things to worry about in their patients, like diabetes and heart disease, so they tend to ignore the long term."

In his view, early education is key. "What they need to do after the attack is over is to get the patient educated about the disease and get them on a drug like allopurinol to get the uric acid lowered," Dr Schumacher said.

For patients with more severe gout or related conditions, current guidelines recommend long-term treatment to lower blood levels of urate (a metabolite derived from uric acid), thereby preventing crystal deposition and encouraging crystal dissolution. After first diagnosis, however, it remains unclear just when this treatment should be started, write Chang-Fu Kuo, MD, consultant rheumatologist, Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Taoyuan, Taiwan, and colleagues.

The researchers investigated the timing of eligibility for and the prescription of urate-lowering treatment after initial diagnosis in 52,164 patients presenting with incident gout from 1997 to 2010. This sample came from the UK Clinical Practice Research Datalink, which contains medical information on about 8% of the British population recorded from 486 English general practices.

The mean age of the patients at diagnosis was 62.5 years, and 73% of the participants were men. Median time to development of the first treatment indication was 5 months (interquartile range, 0 - 29 months). Indications for treatment were acute recurring gout attacks within the first year of diagnosis, tophi, urolithiasis, chronic kidney disease, and diuretic use at diagnosis. The mean follow-up was 6 years (interquartile range, 4 - 9 years).

Almost half of patients (44%) fulfilled indications for urate-lowering therapy at baseline, and 87% were eligible within 5 years of diagnosis, yet only a minority received appropriate drug therapy at any point. The median prescription rate was 32.5% (interquartile range, 26.3% - 39.3%; range, 0% - 100%).

The probability of patients' fulfilling any of the indications for treatment was cumulative, ranging from 44.26% (95% confidence interval [CI], 43.83% - 44.69%) at 0 years from diagnosis and 61.02% (95% CI, 60.60% - 61.44%) at 1 year to 86.81% (95% CI, 86.49% - 87.13%) at 5 years and 94.27% (95% CI, 93.98% - 94.56%) at 10 years.

The cumulative probabilities for prescription at the same times were 0%, 16.90% (95% CI, 16.58% - 17.22%), 30.39% (95% CI, 29.90% - 30.81%), and 40.52% (95% CI, 39.96% - 41.08%).

The hazard ratios for treatment indications during the first year after diagnosis were as follows: acute attacks, 1.60 (95% CI, 1.55 - 1.65); tophi, 1.87 (95% CI, 1.56 - 2.24); chronic kidney disease, 1.67 (95% CI, 1.60 - 1.74); and diuretic use at diagnosis, 1.57 (95% CI, 1.51 - 1.63).

"Patient- and practice-level factors accounted for 7.82% and 13.49%, respectively, of total prescription variance," the authors write. The former factors included sex, age, race, and socioeconomic variables; the latter included numbers of total patients and patients with gout, median birth year, sex ratio, practice region, and socioeconomic status. Factors accounting for the remaining nearly 80% of variance may not have been recorded in the database.

"Recognized barriers to care include suboptimal patient and physician knowledge of gout, its treatment and clinical recommendations, and patient and physician preferences for treatment," the authors write.

This study was funded by the National Science Council of Taiwan and Chang Gung Memorial Hospital and supported by the University of Nottingham and an Arthritis Research UK clinician scientist award. One coauthor has reported receiving personal fees from Daiichi Sankyo. Another coauthor reported receiving personal fees from AstraZeneca, Menarini, Nordic Biosciences, Novartis, and Pfizer for work on gout and osteoarthritis advisory boards. The authors and Dr Schumacher have disclosed no relevant financial relationships.

JAMA. 2014;312:2684-2686.

    
相關報導
無關節穿刺術的情況下改善痛風診斷
2014/10/13 上午 10:04:05
痛風和心血管疾病風險增加有關
2014/9/2 上午 11:19:13
痛風發生率增加但多數病患未進行治療
2014/1/23 上午 11:52:24

上一頁
   1   2   3   4  




回上一頁