Transcript PowerPoint - 埼玉医科大学総合医療センター 内分泌・糖尿病内科

Journal Club
Bell CM, Brener SS, Gunraj N, Huo C, Bierman AS, Scales DC, Bajcar J, Zwarenstein
M, Urbach DR.
Association of ICU or hospital admission with unintentional discontinuation of
medications for chronic diseases.
JAMA. 2011 Aug 24;306(8):840-7.
Jenkins DJ, Jones PJ, Lamarche B, Kendall CW, Faulkner D, Cermakova L, Gigleux I,
Ramprasath V, de Souza R, Ireland C, Patel D, Srichaikul K, Abdulnour S, Bashyam B,
Collier C, Hoshizaki S, Josse RG, Leiter LA, Connelly PW, Frohlich J.
Effect of a dietary portfolio of cholesterol-lowering foods given at 2 levels of intensity of
dietary advice on serum lipids in hyperlipidemia: a randomized controlled trial.
JAMA. 2011 Aug 24;306(8):831-9.
2011年9月1日 8:30-8:55
８階 医局
埼玉医科大学 総合医療センター 内分泌・糖尿病内科
Department of Endocrinology and Diabetes,
Saitama Medical Center, Saitama Medical University
松田 昌文
Matsuda, Masafumi
JAMA. 2011;306(8):840-847
Departments of Health Policy, Management, and Evaluation (Drs
Bell, Bierman, Zwarenstein, and Urbach and Ms Brener),
Medicine (Drs Bell and Bierman and Ms Brener), and Surgery (Dr
Urbach), Keenan Research Centre in Li Ka Shing Knowledge
Institute at St Michael’s Hospital (Dr Bell and Ms Brener),
Interdepartmental Division of Critical Care (Dr Scales), Lawrence
S. Bloomberg Faculty of Nursing (Dr Bierman), Leslie Dan
Faculty of Pharmacy (Dr Bajcar), Centre for Patient Safety (Dr
Bell), and University Health Network (Dr Urbach), University of
Toronto, Toronto, Ontario, Canada; Institute for Clinical
Evaluative Sciences, Toronto, Ontario, Canada (Drs Bell,
Bierman, Scales, Zwarenstein, and Urbach and Mss Gunraj and
Huo); and Departments of Critical Care Medicine (Dr Scales) and
Pharmacy (Dr Bajcar), Sunnybrook Health Sciences Centre,
Toronto, Ontario, Canada.
Context Patients discharged from acute
care hospitals may be at risk for
unintentional discontinuation of
medications prescribed for chronic
diseases. The intensive care unit (ICU)may
pose an even greater risk because of the
focus on acute events and the presence of
multiple transitions in care.
Objective To evaluate rates of potentially
unintentional discontinuation of
medications following hospital or ICU
admission.
Design, Setting, and Patients A population-based cohort
study using administrative records from 1997 to 2009 of all
hospitalizations and outpatient prescriptions in Ontario,
Canada; it included 396,380 patients aged 66 years or
older with continuous use of at least 1 of 5 evidence-based
medication groups prescribed for long-term use: (1) statins,
(2) antiplatelet/anticoagulant agents, (3) levothyroxine, (4)
respiratory inhalers, and (5) gastric acid–suppressing drugs.
Rates of medication discontinuation were compared across
3 groups: patients admitted to the ICU, patients hospitalized
without ICU admission, and nonhospitalized patients
(controls). Odds ratios (ORs) were calculated and adjusted
for patient demographics, clinical factors, and health
services use.
Main Outcome Measures The primary outcome was
failure to renew the prescription within 90 days after
hospital discharge.
linked administrative records between 1997 and 2009 of all hospitalizations in
Ontario, Canada
aged 66 years or older who had at least 1 year of continuous medication use in at
least 1 of 5 medication groups:
(1) statins;
(2) antiplatelet or anticoagulant agents;
(3) levothyroxine;
(4) respiratory inhalers; and
(5) gastric acid–suppressing drugs
This time frame was selected because previous research suggests that patients
who are nonadherent to their prescribed medication regimen for chronic diseases
typically stop using their medications within the first few months.
3 distinct cohorts:
(1) patients who were discharged after a hospitalization that included an ICU
admission;
(2) patients who were discharged after a hospitalization that did not include an ICU
admission; and
(3) patients who were not hospitalized (controls)
Results Patients admitted to the hospital (n=187 912) were more likely
to experience potentially unintentional discontinuation of medications
than controls (n=208 468) across all medication groups examined. The
adjusted ORs (AORs) ranged from 1.18 (95% CI, 1.14-1.23) for
discontinuing levothyroxine in 12.3% of hospitalized patients (n=6831)
vs 11.0% of controls (n=7114) to an AOR of 1.86 (95% CI, 1.77- 1.97)
for discontinuing antiplatelet/anticoagulant agents in 19.4% of
hospitalized patients (n=5564) vs 11.8% of controls (n=2535). With ICU
exposure, the AORs ranged from 1.48 (95% CI, 1.39-1.57) for
discontinuing statins in 14.6% of ICU patients (n=1484) to an AOR of
2.31 (95% CI, 2.07-2.57) for discontinuing antiplatelet/ anticoagulant
agents in 22.8% of ICU patients (n=522) vs the control group. Admission
to an ICU was associated with an additional risk of medication
discontinuation in 4 of 5 medication groups vs hospitalizations without
an ICU admission. One-year follow-up of patients who discontinued
medications showed an elevated AOR for the secondary composite
outcome of death, emergency department visit, or emergent
hospitalization of 1.07 (95% CI, 1.03-1.11) in the statins group and of
1.10 (95% CI, 1.03-1.16) in the antiplatelet/anticoagulant agents group.
Conclusions Patients prescribed
medications for chronic diseases were
at risk for potentially unintentional
discontinuation after hospital
admission. Admission to the ICU was
generally associated with an even
higher risk of medication
discontinuation.
Message/Comments
入院中にICUに入る状態になった場合に，
慢性疾患の管理に用いられた薬物が中断と
なるケースが結構ある。
死亡や救急入院がスタチンや抗血小板剤や
抗凝固薬の中断で増加していた！
（甲状腺薬、気管支の薬、胃薬では差がな
かった！？）
日本では？ このような解析であると（処
方継続忘れでなく）中断できた例が良かっ
たりする可能性もあるが。
JAMA. 2011;306(8):831-839
Clinical Nutrition and Risk Factor Modification Center (Drs Jenkins,
Kendall, Faulkner, de Souza, Bashyam, Josse, and Leiter and Mr
Ireland and Mss Patel, Srichaikul, and Abdulnour) and Department of
Medicine (Drs Jenkins, Josse, and Leiter), St Michael’s Hospital,
Toronto, Ontario; Departments of Nutritional Sciences (Drs Jenkins,
Kendall, Faulkner, de Souza, Bashyam, Josse, and Leiter and Mr
Ireland and Mss Patel and Srichaikul) and Medicine (Drs Jenkins, Josse,
and Leiter), University of Toronto, Toronto, Ontario; Richardson Center
for Functional Foods and Nutraceuticals, University of Manitoba,
Winnipeg (Drs Jones and Ramprasath); Institute of Nutraceuticals and
Functional Foods, Laval University, Quebec City, Quebec (Dr Lamarche
and Ms Gigleux); Department of Pathology and Laboratory Medicine,
University of British Columbia, Vancouver (Dr Frohlich and Mss
Cermakova, Collier, and Hoshizaki); Department of Clinical
Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario
(Dr de Souza); Institute of Medical Science, University of Toronto,
Toronto, Ontario (Ms Abdulnour); and Keenan Research Center of the
Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario
(Drs Jenkins, Josse, Leiter, and Connelly), Canada.
Context Combining foods with recognized
cholesterol-lowering properties (dietary
portfolio) has proven highly effective in
lowering serum cholesterol under
metabolically controlled conditions.
Objective To assess the effect of a dietary
portfolio administered at 2 levels of
intensity on percentage change in lowdensity lipoprotein cholesterol (LDL-C)
among participants following self-selected
diets.
Design, Setting, and Participants A parallel-design
study of 351 participants with hyperlipidemia from 4
participating academic centers across Canada (Quebec
City, Toronto, Winnipeg, and Vancouver) randomized
between June 25, 2007, and February 19, 2009, to 1 of
3 treatments lasting 6 months.
Intervention Participants received dietary advice for 6
months on either a low−saturated fat therapeutic diet
(control) or a dietary portfolio, for which counseling was
delivered at different frequencies, that emphasized
dietary incorporation of plant sterols, soy protein,
viscous fibers, and nuts. Routine dietary portfolio
involved 2 clinic visits over 6 months and intensive
dietary portfolio involved 7 clinic visits over 6 months.
Main Outcome Measures Percentage change in
serum LDL-C.
CHD indicates
coronary heart
disease; LDL-C, lowdensity lipoprotein
cholesterol.
aThe number of
individuals that did not
meet inclusion criteria
included 218 with lipids
not in study range, 109
with concurrent
disorders, 15 with food
allergies, 7 with acute
and chronic infections,
5 with excess alcohol
intake, 5 with high BMI,
4 who were
premenopausal, 3 who
did not stop taking
statins, 2 with weight
not stable, 1 with high
family risk for cancer, 1
with concern about
adherence to study
diet, and 1 with a
hostile attitude.
Abbreviations: BMI, body mass
index, calculated as weight in
kilograms divided by height in
meters squared; CI, confidence
interval; HDL-C, high-density
lipoprotein cholesterol; LDL-C, lowdensity lipoprotein cholesterol; TC,
total cholesterol. SI conversions: To
convert TC, HDL-C, and LDL-C to
mmol/L, multiply by 0.0259; and
triglycerides to mmol/L, multiply by
0.0113.
aP
values for between-group
differences used generalized linear
model analysis of variance for
continuous variables and Fisher
exact test for categorical variables,
in which the null hypothesis is that
the portion of participants receiving
each medication was the same
across all treatments.
bIncluded those participants of
mixed race and those whose
race/ethnicity could not be selfdetermined.
cParticipants who entered the study
taking lipid-lowering drugs were
required to discontinue them at
least 2 weeks before randomization.
dAn additional participant started
estrogen at week 12.
LDL-C indicates low-density lipoprotein cholesterol; TC, total cholesterol; HDL-C, high-density
lipoprotein cholesterol. To convert LDL-C to mmol/L, multiply by 0.0259. Error bars indicate SE.
Results In the modified intention-to-treat analysis of 345
participants, the overall attrition rate was not significantly different
between treatments (18% for intensive dietary portfolio, 23% for
routine dietary portfolio, and 26% for control; Fisher exact test,
P=.33). The LDL-C reductions from an overall mean of 171 mg/dL
(95% confidence interval [CI], 168-174 mg/dL) were −13.8% (95%
CI, −17.2% to −10.3%; P<.001) or −26 mg/dL (95% CI, −31 to −21
mg/dL; P<.001) for the intensive dietary portfolio; −13.1% (95% CI,
−16.7% to −9.5%; P<.001) or –24 mg/dL (95% CI, −30 to −19
mg/dL; P<.001) for the routine dietary portfolio; and −3.0% (95%
CI, −6.1% to 0.1%; P=.06) or −8 mg/dL (95% CI, −13 to −3 mg/dL;
P=.002) for the control diet. Percentage LDL-C reductions for
each dietary portfolio were significantly more than the control diet
(P<.001, respectively).The 2 dietary portfolio interventions did not
differ significantly (P=.66). Among participants randomized to one
of the dietary portfolio interventions, percentage reduction in LDLC on the dietary portfolio was associated with dietary adherence
(r=−0.34, n=157, P<.001).
Conclusion Use of a dietary portfolio
compared with the low−saturated fat
dietary advice resulted in greater LDLC lowering during 6 months of followup.
Trial Registration clinicaltrials.gov
Identifier: NCT00438425
Message/Comments
LDL-Cを低下させる食事療法介入は２回（60,40
分）で13%の低下効果があることが示された。
ドロップアウトが23%もあった。
２回以上７回やってもあまり違いはなかった。
で、栄養指導はまぁ２回。スタチンはイベント
低下には必須？日本人ならもっとまじめにやる
のできっと結果はもうすこしよいかもしれない
が。