循證醫(yī)學(xué)展示

1、 氯沙坦降低高血壓合并痛風(fēng)患者血尿酸水平的循證治療實(shí)踐 姜之賢 鄧?yán)?劉棋 葉正病例患者，男，45 歲，于2012-5-30因反復(fù)關(guān)節(jié)腫痛7 年，加重1周入院。【現(xiàn)病史】患者7 年前無(wú)明顯誘因突然出現(xiàn)雙足背疼痛，伴有局部發(fā)熱、腫脹，以第一跖趾關(guān)節(jié)最為明顯。自服秋水仙堿后明顯緩解。4 年前患者因飲用啤酒后再次出現(xiàn)雙足背發(fā)熱、腫脹，性質(zhì)如前。同時(shí)伴有雙側(cè)肘關(guān)節(jié)腫脹，經(jīng)口服秋水仙堿后可緩解。近1年來(lái)，患者上述癥狀發(fā)作頻繁，每1-2 個(gè)月發(fā)作一次，時(shí)有雙膝關(guān)節(jié)發(fā)熱、腫痛。經(jīng)口服秋水仙堿后癥狀緩解不明顯。后至外院就診，檢測(cè)尿酸為685mol /L，考慮為痛風(fēng)，給予口服別嘌呤醇，早3片，晚2 片后，尿酸降

2、至480mol /L，疼痛稍有緩解。近1 周來(lái)，無(wú)明顯誘因患者上述癥狀加重，口服藥物后無(wú)緩解，在外院給予“地塞米松”靜滴，至我院門診就診，給予莫比可，7.5mg,2/日， 口服，后癥狀有所緩解( 具體不詳)?，F(xiàn)為求進(jìn)一步診治而入住我科。【查體】心、肺無(wú)特殊; 腹稍隆起; 右側(cè)膝關(guān)節(jié)較對(duì)側(cè)腫脹，皮溫稍高，活動(dòng)自如，無(wú)肌萎縮; 四肢關(guān)節(jié)無(wú)畸形?！据o助檢查】1.血常規(guī)、電解質(zhì)、隨機(jī)尿蛋白定量正常，肝炎病原學(xué)、HIV、梅毒為陰性; 肝功能正常; 腎功能尿酸485mol /L，升高; 尿常規(guī)示尿潛血1 +，白細(xì)胞12 個(gè)/l，予復(fù)查回報(bào)未見(jiàn)異常; 心電圖示: 竇性心動(dòng)過(guò)速，考慮與患者疼痛有關(guān)，囑其定期復(fù)

3、查；2.心臟彩超示: ( 1) 室間隔增厚( 符合高血壓心臟改變) 。(2) 主動(dòng)脈鈣化并少量反流，糖耐量試驗(yàn)，胰島素C 肽釋放試驗(yàn)，ACTH，COR節(jié)律未見(jiàn)異常?！驹\斷】(1) 痛風(fēng)性關(guān)節(jié)炎慢性遷延期; (2)高血壓3 級(jí)(極高危組);(3)脂肪肝4.甲狀腺結(jié)節(jié)?！局委煛壳锼蓧A，碳酸氫鈉片，丹參多酚酸，依托考昔，立加利仙，氯沙坦提出問(wèn)題氯沙坦是血管緊張素II受體拮抗劑，可以阻斷血管緊張素受體，避免血管緊張素II結(jié)合到受體上，防止血管收縮，最終達(dá)到降低血壓的目的。該患者患有高血壓合并痛風(fēng)，血尿酸水平明顯升高。氯沙坦是否能降低高血壓合并痛風(fēng)患者血尿酸水平？4根根據(jù)PICO提出的臨床問(wèn)題Anti

4、hypert-ensive drugsDecreased of blood uric losartanIInterventionCcomparison Ooutcome hypertension with goutPpatient檢索證據(jù)檢索結(jié)果 題目 ：Antihypertensive drugs and risk of incident gout among patients with hypertension: population based case-control study 來(lái)源 ：PubMed Published online 2012 Jan 12. 結(jié)論 ：Current

5、use of losartan among those with hypertension was associated with a lower risk of developing gout. The association was not significantly different among those without hypertension , but the frequency of losartan use in the group without hypertension was low . The multivariate relative risks accordin

6、g to duration of use among those with hypertension were 0.97 for less than one year, 0.86 for 1-1.9 years, and 0.70 for two or more years. The inverse association tended to be stronger with high dose use of losartan than with medium or low dose use (multivariate relative risk 0.66 v 0.88; P=0.06, ta

7、ble 4).證據(jù)評(píng)價(jià) 分組是否隨機(jī)（是） All incident cases of gout (n=24768) among adults aged 20-79 and a random sample of 50000 matched controls. 分配是否隱藏（否） 是否采用盲法（否）證據(jù)評(píng)價(jià)-真實(shí)性基線是否一致（是）After adjusting for age, sex, body mass index, visits to the general practitioner, alcohol intake, and pertinent drugs and comorbiditi

8、es, the multivariate relative risks of incident gout associated with current use of antihypertensive drugs among those with hypertension (n=29138) were 0.87 (95% confidence interval 0.82 to 0.93) for calcium channel blockers, 0.81 (0.70 to 0.94) for losartan, 2.36 (2.21 to 2.52) for diuretics, 1.48

9、(1.40 to 1.57) for blockers, 1.24 (1.17 to 1.32) for angiotensin converting enzyme inhibitors, and 1.29 (1.16 to 1.43) for non-losartan angiotensin II receptor blockers. 證據(jù)評(píng)價(jià)-真實(shí)性隨訪時(shí)間是否足夠（是）We carried out a nested case-control study using data from the health improvement network database between Janu

10、ary 2000 and December 2007. The source population included all adults aged 20-89 with permanent registration status or who had died in the last update of the database. All participants in the study cohort were followed up and contributed person time from their respective start date until the earlies

11、t of one of the following end points: detection of gout, 90th birthday, death, or end of study period, whichever came first. The final cohort encompassed 1775505 people followed for an average of 5.2 years.證據(jù)評(píng)價(jià)-真實(shí)性是否進(jìn)行了意向性分析（否）Using unconditional logistic regression we estimated the odds ratios and

12、95% confidence intervals for gout associated with use of calcium channel blockers, losartan, and other antihypertensive drug classes. Our multivariate analyses were adjusted for the frequency matched variables, visits to a general practitioner, and the covariates of body mass index (five categories)

13、, alcohol use (six categories), smoking (four categories), ischaemic heart disease, hypertension, hyperlipidaemia, and renal failure. 證據(jù)評(píng)價(jià)-真實(shí)性 除試驗(yàn)方案外，其他治療方案是否一致 由于本試驗(yàn)是基于人群的病例對(duì)照研究，不能確定其他治療方案是否一致。證據(jù)評(píng)價(jià)-重要性 治療證據(jù)的效應(yīng)強(qiáng)度大小治療證據(jù)的效應(yīng)強(qiáng)度大小： 療效強(qiáng)度療效強(qiáng)度： 相對(duì)危險(xiǎn)降低率相對(duì)危險(xiǎn)降低率RRR=(CER-EER)/CERRRR=(CER-EER)/CER 絕對(duì)危險(xiǎn)降低率絕對(duì)危險(xiǎn)降低率

14、ARR=CER-EERARR=CER-EER NNT=1/ARR NNT=1/ARR （CERCER：對(duì)照組事件率；：對(duì)照組事件率；EEREER：試驗(yàn)組事件率）：試驗(yàn)組事件率） 因本研究沒(méi)有給出治療有效及發(fā)生不良反應(yīng)的具體人數(shù)因本研究沒(méi)有給出治療有效及發(fā)生不良反應(yīng)的具體人數(shù)或事件發(fā)生率，不能計(jì)算效應(yīng)強(qiáng)度大小或事件發(fā)生率，不能計(jì)算效應(yīng)強(qiáng)度大小Use of antihypertensivesNo (%) of controls (n=16 280)No (%) of cases (n=12 858)Adjusted relative risk* (95% CI)DiureticsNever6076

15、 (37.32)2761 (21.47)1Current (365 days)2349 (14.43)1132 (8.80)0.98 (0.90 to 1.08)Calcium channel blockers:Never9127 (56.06)6685 (51.99)1Current (365 days)1899 (11.66)2115 (16.45)1.13 (1.04 to 1.23)Losartan:Never15 551 (95.52)12 141 (94.42)1Current (365 days)170 (1.04)237 (1.84)1.10 (0.89 to 1.37)Use of antihypertensivesNo (%) of controls (n=16 280)No (%) of cases (n=12 858)Adjusted relative risk* (95% CI) blockers:Never8089 (49.69)5079 (39.50)1Current (365 days)2771 (17.02)2187 (17.01)1.03 (0.96 to 1.11)Angiotensin converting enzyme inhibitors:Never9238 (56.74)5630 (43.79)1Current (3