RevMan Nifedipine Amlodipine 摘要 中山醫學大學附設醫院藥劑科藥師張益通 中山醫學大學醫學研究所教授蔡崇弘 Norvasc Adalat Adalat Norvasc Norvasc OVID Medline PubMed 11 RevMan dihydropyridine amlodipine nifedipine calcium 壹 前言 channel blocks amlodipine nifedipine 60 (Archie Cochrane) (systematic reviews) (meta- 30 4 Dec. 31 2014 藥學雜誌 121 31 綜合評論RevMan 統合分析 Nifedipine 與 Amlodipine
綜Commentary 合評論analysis) 1 amlodipine (TOMHS study) 2 placebo doxazosin amlodipine amlodipine amlodipine nifedipine nifedipine ENCORE nifedipine INSIGHT ACTION nifedipine nifedipine 貳 研究方法 DHP amlodipine nifedipine ( RCT) metaanalysis RevMan 3 一 納入的條件 RCT GNC7 state1 state2 4 4 amlodipine nifedipine 二 排除的條件 nifedipine 20 mg 40 mg MD SD 三 研究步驟 PubMed Cochrane library Medline PubMed hypertinsion ( 32 THE JOURNAL OF TAIWAN PHARMACY Vol.30 No.4 Dec. 31 2014
RevMan Nifedipine Amlodipine blockers and dihydropyridines and nifedipine and amlodipine Medical Subject Headings (MeSH term) filters (clinical trial) PubMed 338 (clinical trial) 119 81 12 OVID Medline 165 57 11 PubMed Cochrane library 100 98 11 10 PubMed 1 PubMed 13 ( ) 1/10 11 5-15 Jadad Score 綜合評論 high blood pressure) and calcium channel 3 RevMan 四 資料處理與分析 Review Manager (RevMan) outcome date (Continuous) (MD) (SD) 參 研究結果一 收縮壓下降的比較 11 amlodipine 30 mg 515 nifedipine 5 mg 437 0.29 (95%CI 0.25-0.84) (I 2 = 0.93) ( ) 0 amdodipine nifedipine ( ) ( ) 藥學雜誌 121 33 30 4 Dec. 31 2014
Commentary 綜合評論 Forest plot of comparison: 1 Std. Mean Fixed, outcome: 1.1 Systolic Blood Pressure (Fixed). 圖一 Amlodipine 與 Nifedipine 對於收縮壓降壓效果分析森林圖 ( 固定模式 ) Forest plot of comparison: 2 Std. Mean Random, outcome: 2.1 Systolic Blood Pressure (Random). 圖二 Amlodipine 與 Nifedipine 對於收縮壓降壓效果分析森林圖 ( 隨機模式 ) Funnel plot of comparison: 1 Std. Mean Fixed, outcome: 1.1 Systolic Blood Pressure (Fixed). 圖三 Amlodipine 與 Nifedipine 對於收縮壓降壓效果分析漏斗圖 ( 固定模式 ) 34 THE JOURNAL OF TAIWAN PHARMACY Vol.30 No.4 Dec. 31 2014
RevMan Nifedipine Amlodipine 二 舒張壓下降的比較 10 amlodipine 30 mg 396 nifedipine 5 mg 401 0.09 (95%CI -0.33~0.52) (I 2 = 0.93) ( ) 0 amdodipine nifedipine ( ) ( ) 圖四 Amlodipine 與 Nifedipine 對於舒張壓降壓效果分析森林圖 ( 固定模式 ) Forest plot of comparison: 2 Std.Mean Random, outcome: 2.2 Diastolic Blood Pressure (Random). 圖五 Amlodipine 與 Nifedipine 對於舒張壓降壓效果分析森林圖 ( 隨機模式 ) 30 4 Dec. 31 2014 藥學雜誌 121 35 綜合評論Forest plot of comparison: 1 Std. Mean Fixed, outcome: 1.2 Diastolic Blood Pressure (Fixed).
綜合評論 Commentary 免單一研究誤差 增加其可信度 相對於一 般分析最大的不同點就是統合分析文獻資料 納入樣本有經過軟體加權處理 因為每篇研 究樣本數不同 研究結果也不同 如果將每 篇研究視為同等 或忽視其95信賴區間 則 較精確或樣本數大的研究會被忽略 因為95 信賴區間越小 表示研究精確度越高 可信 度也越高 而樣本數越大 誤差相對也會越 小 代表性也越高 因此統合分析所做的權 重調整如以公式來看即為樣本數除以標準 Funnel plot of comparison: 1 Std. Mean Fixed, outcome: 1.2 Diastolic Blood Pressure (Fixed). 圖六 Amlodipine 與 Nifedipine 對於舒張壓降 壓效果分析漏斗圖 (固定模式) 肆 討論 差 樣本數越大 標準差越小則表示該研究 結果在統合分析中所占權重越大 如此更能 真實的反映出所有研究在不同條件及結果之 下的統合分析數據 雖然作統合分析會遭遇 蒐尋文獻全文的困難及耗費較長的時間 但 本次統合分析結果中兩種藥品臨床降壓 其將臨床問題所有個別研究的數據進行統計 效果並無明顯差異 但這並非無意義 反而在 學的量化分析 歸結出一個證據力更強的結 臨床上有重要參考價值 臨床上降壓效果相 論 這也是其臨床參考文獻等級最高的原因 同 則可更明確地以劑型使用 服藥方便性或 之所在 副作用等加以考量更適合患者的給藥選擇 利用統合分析方法最重要就在於目前 無具體可供參考之大型實驗數據時 蒐尋所 有相關之小型研究統合而成的結果 更可避 36 THE JOURNAL OF TAIWAN PHARMACY Vol.30 No.4 Dec. 31 2014 伍 誌謝 感謝中山醫學大學附設醫院專題研究計 畫經費補助 (CSH-2012-A-030)
RevMan Nifedipine Amlodipine Abstract (EBM) A Meta-Analysis Yi-Tung Chang 1, Chung-Hung Tsai 2 Department of Pharmacy 1 Professor, Institude of Medicine, Chung Shan Medical University 2 According to statistics, the blood pressure lowering drugs is the best selling drug in Taiwan. Hypertension is the important cause of stroke and coronary heart disease, Norvasc topped the list for several years, another calcium channel blocker adalat OROS was the next best. Dosage form design technology for the adalat film, using laser hole to sustained release of active ingredients and achieve long-term controlling blood pressure-stable. Pharmacokinetics should be better than Norvasc, but the actual prescribing is reverse. Literature search for evidence-based medicine approach to online databases of OVID Medline, PubMed and through the literature appraisal to filter appropriate documentation, then meta-analysis software to analyze the results. Finally we included 11 randomized controlled clinical trials into our study, compared the anti-hypertensive effect between amlodipine and nifedipine, and use the meta-analysis software RevMan software to get the survey results. Regarding to lowering the systolic and diastolic blood pressure, the forest plot across the broken center line revealed that lowering the systolic blood pressure had no significant difference between amlodipine and nifedipine. We could find that the decline in systolic or diastolic blood pressure between amlodipine and nifedipine had similar antihypertensive effect. It is helpful for clinical prescription proposal. Based on the similar antihypertensive effect, we should consider other factors like dosage form and patient's tolerance. It can be applied to clinical decision-making to choose a optimal calcium channel blocker. 30 4 Dec. 31 2014 藥學雜誌 121 37 綜合評論Comparison of Nifedipine with Amlodipine
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