社區醫學 陳俊佑 1 陳榮福 2 黃志芳 3 黃偉城 3 王培銘 3 黃致達 3 前言 % 17.9% 7.6% [1] (EBM, Evidence-Based Medicine) hypercholesterolemia Hypertriglyceridemia (mixed hy

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1 陳俊佑 1 陳榮福 2 黃志芳 黃偉城 王培銘 黃致達 前言 % 17.9% 7.6% [1] (EBM, Evidence-Based Medicine) hypercholesterolemia Hypertriglyceridemia (mixed hyperlipidemia) metabolic syndrome EBM 1 高雄長庚家醫科住院醫師 2 高雄長庚新陳代謝科主任 高雄長庚家醫科主治醫師 Hypercholesterolemia, Hypertriglyceridemia, Mixed hyperlipidemia, Statins, Prevent CV outcome 血脂蛋白與心血管疾病 UKPDS(UK Prospective Diabetes Study) [2] LDL, HDL, TG(Triglyceride), TC/HDL LDL/HDL 降血脂藥物的種類 Statins Pravastatin, Lovastatin, Fluvastatin, Simvastatin, Atorvastatin, Rosuvastatin, Pitavastatin Fibric acid derivatives Fenofibrate, Gemfibrozil Nicotinic acid (niacin) Bile acidsequestrants Cholestyrami 78 家庭醫學與基層醫療 第三期

2 ne, Colestipol, Colesevelam Cholesterol absorption inhibitors: Ezetimibe Neomycin, Probucol, Omega-(EPA, DHA) PCSK9 inhibitors: Alirocumab, Evolocumab LDL statinstg HDL Fibric acid Niacin Statins Fibric acid derivatives [,4] Statins 藥物的比較 Statins primary prevent CV outcome secondary prevent CV outcome Pravastatin, Lovastatin Fluvastatin Simvastatin Atorvastatin Rosuvastatin Pitavastatin LDL 45% Atorvastatin Simvastatin Rosuvastatin WOSCOPS, AFCAPS/TexCAPS, the ASCOT-LLA and The JUPITER trialpravastatin, Lovastatin, Atorvastatin Rosuvastatin The Scandinavian Simvastatin Survival Study (4S) the Heart Protection Study 表一 Different classes of lipid lowering drugs on serum lipids Drug class LDL (%) HDL (%) Triglycerides(%) Statins 20 to 60 5 to to Fenofibrate (micronized form) 6 to 20 5 to to 5 Gemfibrozil 10 to 15 5 to 20 5 to 50 Nicotinic acid (niacin) 10 to to 5 25 to 0 Bile acid sequestrants 15 to 0 0 to slight increase No change* Cholesterol absorption inhibitors to 8 Neomycin 20 to 25 No change No change Omega fatty acidsδ 4 to 49 5 to 9 2 to 45 PCSK9 inhibitors 8 to 72 4 to 9 2 to 2 From 2016 uptodate. 資料來源 : 參考資料 4 家庭醫學與基層醫療 第三期 79

3 圖一 Comparison of the efficacy of Statins From 2016 uptodate. 資料來源 : 參考資料 4 Simvastatin the CARE trial Pravastatin the LIVES Study(Postmarketing survey) Pitavastatin 2012FDA Statins Statins ( A) Statins 表二個別 Statin 對於心血管事件的幫助 Statins 初級預防次級預防研究 trials Pravastatin 有幫助 有幫助 WOSCOPS, CARE Lovastatin 有幫助 AFCAPS/TexCAPS Fluvastatin Simvastatin 有幫助 4S, Heart Protection Study Atorvastatin 有幫助 ASCOT-LLA Rosuvastatin 有幫助 JUPITER Pitavastatin 有幫助 有幫助 LIVES 80 家庭醫學與基層醫療 第三期

4 ( B) Statins [5.6] Rosuvastatin 27% Pravastatin 0% Pravastatin Lovastatin, Fluvastatin, Simvastatin, Atorvastatin Rosuvastatin Pravastatin Pravastatin Atorvastatin 22% Rosuvastatin 18% Simvastatin 10% Fluvastatin 5% Lovastatin 1% 圖二 A. Relative risk of experiencing a cardiac event or death by diabetes status B. Risk-benefit of statin initiation in at-risk patients From AHA. 資料來源 : 參考資料 2 家庭醫學與基層醫療 第三期 81

5 [7] J-PREDICT study Pitavastatin 三酸甘油酯的控制 mg/dl400mg/dl 2. 1 TG 200~400 mg/dl TG TG 2 TG 400 mg/dl a.tg LDL Statins Statins LDL TG 0 % Fibric acid Fenofibrate TG LDL Gemfibrozil Gemfibrozil Fenofibrate b.ldl TG 400 mg/dl TG Fibrate Gemfibrozil TG >1,000 mg/dl >500 mg/dl NCEP-ATP-III F ibrate Gemfibrozil 10% [8.9] Gemfibrozil 和 Fenofibrate 的比較 statins gemfibrozil gemfibrozil statins statins Fenofibrate FDA ACCORD study statins fibratestatins 82 家庭醫學與基層醫療 第三期

6 AIM-HIGH study statins niacin statins HDL TG LDL HPS2-THRIVE study statins niacin statins FDA statins + fibrate statin + niacin [10] 結論 1. EBM 2. statins Fibric acid derivatives niacin. 4. statin 參考資料 1. Saydah SH, Fradkin J, Cowie CC: Poor control of riskfactors for vascular disease among adults with previously diagnosed diabetes. JAMA 2004; 291: King P, Peacock I, Donnelly R: The UK Prospective Diabetes Study (UKPDS): clinical and therapeutic implications for type 2 diabetes. Br J ClinPharmacol. 1999; 48: Pignone M: Treatment of lipids (including hypercholesterolemia) in primary prevention. UptodateFeb Rosenson RS: Treatment of lipids (including hypercholesterolemia) in secondary prevention. UptodateSep Rosenson RS: Statins: Actions, side effects, and administration. Uptodate Feb Shah RV, Goldfine AB: Statins and Risk of New- Onset Diabetes Mellitus. Circulation 2012; 126: e Dormuth CR, Filion KB, Paterson JM: Higher potency statins and the risk of new diabetes: multicentre, observational study of administrative databases. BMJ 2014; 48: g O'Riordan M: No More Niacin, Fibrate Combinations with Statins. FDAApril, 家庭醫學與基層醫療 第三期 8