CHINESE MEDICINE & INSOMNIA 中藥與失眠 報告醫師 : R2 胡心瀕指導醫師 : 陳星諭醫師報告日期 : 2012/08/13
OUTLINE Background information Introduction of EBM pyramid and appraisal Scenario ASK (PICO) AQUIRE APPRAISAL (VIP) APPLY
OUTLINE Background information Introduction of EBM pyramid and appraisal Scenario ASK (PICO) AQUIRE APPRAISAL (VIP) APPLY
INSOMNIA Definition A complaint of difficulty initiating sleep, difficulty maintaining sleep, or waking up too early. Alternatively, sleep that is chronically nonrestorative or poor in quality. The above sleep difficulty occurs despite adequate opportunity and circumstances for sleep. The impaired sleep produces deficits in daytime function. Overview of insomnia, UpToDate, 2012/04
INSOMNIA Types --- ICSD-2 Acute insomnia (short-term insomnia, stress-related insomnia) Inadequate sleep hygiene Psychophysiological insomnia (primary insomnia, chronic insomnia) Idiopathic insomnia (childhood onset insomnia, life-long insomnia) Paradoxical insomnia (sleep state misperception, subjective insomnia, pseudoinsomnia, and sleep hypochondriasis) Insomnia associated with a medical condition, psychiatric disorder, neurologic disease, sleep disorder, medication, or drug use Unspecified insomnia Overview of insomnia, UpToDate, 2012/04
INSOMNIA Epidemiology Chronic insomnia is prevalent in 10~15% of the adult population. Primary insomnia is estimated to occur in 25% of all chronic insomnia patients. The prevalence of insomnia increases with age. 13~47% elders The Epidemiology and Diagnosis of Insomnia, Karl Doghramji The American Journal of Managed Care, 2006; 12:S214-S220
INSOMNIA Treatment Cognitive behavioral therapy Sleep hygiene --- improvement Stimulus control relaxation Sleep restriction therapy Medications BZD Melatonin agent Antidepressant and antipsychotics Cognitive-behavioral therapy for sleep disturbance in patients undergoing peritoneal dialysis: a pilot randomized controlled trial. Chen HY, Chiang CK, Am J Kidney Dis
OUTLINE Background information Introduction of EBM pyramid and appraisal Scenario ASK (PICO) AQUIRE APPRAISAL (VIP) APPLY
FIVE STEPS TO PRACTICE EBM (5 A) Formulate an answerable question. (Ask: PICO)PICO 由個案的臨床資料形成可回答的臨床問題 Track down the best evidence. (Acquire) 尋找最佳的實證 各種文獻及資料庫, 包括發表及未發表的資料 Critically appraise the evidence for validity, impact, and applicability. (Appraisal) 評估各種醫學報告的可信度 臨床重要性, 及可應用性 Integrate with our clinical expertise and patient values. (Apply) 整合並應用於實際患者的治療決策 臨床應用 Evaluate our effectiveness and efficacy. (Audit) [ 效果評估 ] 以病人可以聽懂的語言, 告知各種處置之可能利益與風險?
FIVE STEPS TO PRACTICE EBM (5 A) Formulate an answerable question. (Ask: PICO)PICO 由個案的臨床資料形成可回答的臨床問題 Track down the best evidence. (Acquire) 尋找最佳的實證 各種文獻及資料庫, 包括發表及未發表的資料 Critically appraise the evidence for validity, impact, and applicability. (Appraisal) 評估各種醫學報告的可信度 臨床重要性, 及可應用性 Integrate with our clinical expertise and patient values. (Apply) 整合並應用於實際患者的治療決策 臨床應用 Evaluate our effectiveness and efficacy. (Audit) [ 效果評估 ] 以病人可以聽懂的語言, 告知各種處置之可能利益與風險?
APPRAISAL (VIP) Validity CAT (clinical appraisal tool) Impact Impact factor of journals Practicability (applicability) ---treatment effect RRR (relative risk reduction) NNT (number needed to treat) NNH (number needed to harm)
VIP 原則證據力分級 --- RCT
OUTLINE Background information Introduction of EBM pyramid and appraisal ASK (PICO) AQUIRE APPRAISAL (VIP) APPLY
SCENARIO 中藥對於失眠的療效如何?
ASK Patient Human Intervention Chinese medicine (formula, herbal medicine) Comparison West medicine / placebo Outcome Efficacy
OUTLINE Background information Introduction of EBM pyramid and appraisal Scenario ASK (PICO) AQUIRE APPRAISAL (VIP) APPLY
SYSTEMATIC REVIEW? EBM review Pubmed Clinical queries
KEYWORDS Insomnia [title] AND Traditional Chinese medicine [mesh] Herb Complimentary medicine [mesh] Systematic/systemic review [title] AND OR
Protocol
IMPACT Impact factor
VALIDITY Clinical appraisal tool (CAT) CEBM for systemic review Jadad score
CHM VS PLACEBO
CHM VS WEST MEDICINE
ADVERSE EFFECT OF CHM
ADVERSE EFFECT OF CHM
ADVERSE EFFECT OF CHM
PRACTICAL/ APPLICABILITY Relative risk change NNT? NNH?
DISCUSSION Meta-analysis of 8 studies with Jadad score of 3 or above found that CHM was equivalent to placebo and Western medicine in treating insomnia. Small number of trials included Heterogeneity in subject characteristics, herbal regimen, and outcome assessment across studies
DISCUSSION The frequency of the adverse events associated with CHM was similar to that of placebo, but lower than with Western medication.
LEVEL OF EVIDENCE
RANDOMIZED CONTROLLED TRIAL AFTER 2010
OUTLINE Background information Introduction of EBM pyramid and appraisal Scenario ASK (PICO) AQUIRE APPRAISAL (VIP) APPLY
中藥對失眠的療效有正面效果, 但仍需更多同質性證據支持 與西藥比較, 副作用較少
CONCLUSION
The latest and upper level of evidence Chinese medicine in treating insomnia