新治療的思覺失調症病人抗精神藥物使用的趨勢

Abstract

研究目的 分析2002-2012年間新診斷且新治療的思覺失調症患者診斷後一年內藥品使用狀況是否隨著年代而有顯著的變化，以及分析不同用藥方式與患者背景特性間的關係，來探討醫師開出的第一筆處方的原因，以說明什麼樣的特徵會影響患者的藥品形式，來解釋用藥選擇背後的成因。由於不同國家間的用藥方式不盡相同，究竟台灣新診斷且新治療的思覺失調症患者使用抗精神病藥物於這些年的變化趨勢以及背後的原因是一個值得探討的問題。 研究方法 使用2000年1月1日至2013年12月31日之臺灣全民健康保險資料，於2002年1月1日至2012年12月31日初次被診斷為思覺失調症，且為初次使用抗精神病藥物之就醫記錄者，及需大於18歲，並進行一年藥品使用的追蹤。分析患者於診斷後一年內的歷年藥品使用狀況的趨勢分析，使用multivariate logistic regression以及Spearman’s partial rank correlation test，以評估變項是否隨著時間而有特別的變化趨勢。為了解釋用藥選擇背後的成因，藉由multinomial logistic regression進行分析，以說明什麼樣的特徵會影響患者的用藥方式。此外，亦分析不同用藥方式造成的後續住院狀況是否有所不同，以探討什麼樣的用藥方式療效較好，並解釋用藥趨勢背後的原因。 結果與討論 2002至2012年間，患者於診斷後第一筆抗精神病藥物的開方趨勢有明顯的變化，FGAs由77.8%下降至32.9%， SGAs的使用量則從29.8%上升至81.9%。隨著用藥趨勢的改變，為了減輕抗精神病藥物的副作用造成錐體外症候群而使用抗膽鹼藥品的比例由78.9%下降至49.7%，此結果與FGAs使用量大幅下降有著密切的關係。患者所在的醫院層級對於開方的影響很大，於醫學中心就診的患者中，第一筆開方單獨使用SGAs的比例為57.6%，FGAs則為 29.1%，然而隨著醫院層級的降低，發現到基層診所SGAs的使用量下降至36.0%，反之，FGAs則大幅則增加至59.6%，表示醫院層級較高的醫院較傾向開出SGAs之處方。需特別注意的是，醫生似乎不太會因為患者的共病症而影響開方。而初次開方為單獨使用SGAs的患者，其住院率與後續住院天數都比單獨使用FGAs的來的低，可能是因為SGAs的療效較好，藉此解釋用藥趨勢背後的原因。 結論 於2002-2012年研究期間，SGAs逐漸取代FGAs成為治療新診斷且新治療思覺失調症的主要用藥。隨著用藥趨勢的改變，FGAs使用量的下降使得治療錐體外症候群的抗膽鹼藥品的使用比例有下降的趨勢。而患者所在的醫院層級對於藥品的選擇扮演重要的角色，但不太會因為患者的性別、年齡與共病症而影響開方。此外，由於SGAs的使用量增加，其療效、藥物副作用與成本需加以評估。

Purpose This study aimed to describe the patterns in antipsychotic prescription of newly treated and diagnosed with schizophrenia from 2002 to 2012, and analyzed the trend in the first-year pharmacological treatment of newly diagnosed and treated schizophrenia patients. To explore the reason behind the trends in treatment, we also examined which baseline characteristic influenced the first antipsychotics prescription. Every country has different prescription pattern. Therefore, trends in the first-year pharmacological treatment of newly treated and diagnosed with schizophrenia patients in Taiwan and its reasons are important questions. Method The data source was Taiwan National Health Insurance Research Database (2000-2013). The study identified all schizophrenic patients aged 18 years and older who were newly diagnosed between January 1, 2002 and December 31, 2012. We excluded subjects who had antipsychotics treatment before schizophrenia diagnosis. The following-up time for each patient was one year. Changes in the first year of treatment were assessed by multivariate logistic regression and Spearman’s partial rank correlation. Multinomial logistic regression was used to analyze the relation between different antipsychotics and characteristics of the patients and to explain the reason behind the trends in treatment. In addition, to explore the efficacy of antipsychotics, we examined patients’ hospitalization in different prescription pattern. Result and Discussion The percentage of prescriptions of SGAs increased from 29.8% to 81.9%; however, FGAs declined from 77.8% to 32.9%. As a result of the change of the trend of antipsychotic prescription, the percentage of anticholinergic agents decreased from 78.9% to 49.7%. Different hospital level would influence prescription. The percentage of prescriptions of SGAs and FGAs were 57.6% and 29.1% in academic medical center respectively. With the declined of hospital level, the use of SGAs decreased to 36.0% but the use of FGAs increased to 59.6% in clinic. However, it should be noticed that prescriptions were not influenced by patient’s comorbidity. Besides, patients who used SGAs had lower hospitalization rate and average hospitalization days, it may due to SGAs’ great efficacy. Conclusion In the first-year treatment of newly treated patients with a diagnosis of schizophrenia between 2002 and 2012, SGAs replaced FGAs as the first choice for therapy. With the change of the trend of antipsychotics prescription, the percentage of anticholinergic agents decreased due to decreasing of FGAs. Hospital level played an important role in the selection of antipsychotics, but patient’s gender, age and comorbidity didn’t influence prescription. Moreover, drug efficacy, side effect and cost of the changes due to the increasing trends in prescribing SGAs should be further investigate