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2015年《血脂异常老年人使用他汀类药物中国专家共识》解读

2015-07-17 佚名 中国医学信息导报

老年人是动脉粥样硬化性心血管疾病(ASCVD)的高危人群,是他汀类药物治疗的适宜人群。而出于对老年人应用他汀类药物是否获益及安全性的担忧,老年人他汀类药物的应用严重不足。2015年第5期《中华内科杂志》发表了《血脂异常老年人使用他汀类药物中国专家共识)》(以下简称“共识”)。本版共识是在2010年发表的《血脂异常老年人使用他汀类药物中国专家共识》的基础上,结合近年血脂异常治疗的进展,综合众多老

老年人是动脉粥样硬化性心血管疾病(ASCVD)的高危人群,是他汀类药物治疗的适宜人群。而出于对老年人应用他汀类药物是否获益及安全性的担忧,老年人他汀类药物的应用严重不足。2015年第5期《中华内科杂志》发表了《血脂异常老年人使用他汀类药物中国专家共识发布》(以下简称“共识”)。本版共识是在2010年发表的《血脂异常老年人使用他汀类药物中国专家共识》的基础上,结合近年血脂异常治疗的进展,综合众多老年心脑血管疾病专家的建议更新而成的,本文就该共识推出的背景及要点进行解读。


一、“共识”推出的背景


近年血脂异常治疗领域更新了多部指南。2013年国际动脉粥样硬化学会(IAS)发布的“全球血脂异常诊治建议”推荐对<80岁人群进行长期风险管理,提出依据ASCVD的一级或二级预防达到不同的调脂目标值。2013年美国心脏病学学会/美国心脏协会(ACC/AHA)降脂治疗指南推荐他汀类药物用于ASCVD一级预防、心功能尚好和非透析患者的二级预防,推荐年龄>75岁的ASCVD老年患者使用中等强度[使低密度脂蛋白胆固醇(LDL-C)降低30%~40%]他汀类药物治疗。2014年美国国家脂质协会(NLA)发布的“血脂异常管理建议”推荐生活方式干预对血脂异常患者预防ASCVD至关重要,治疗强度应根据患者发生ASCVD事件的绝对危险进行调整。2014年英国国家优化卫生与保健研究所(NICE)新版血脂管理指南推荐根据患者危险分层进行不同强度的他汀类药物治疗。2014年“中国胆固醇教育计划血脂异常防治专家建议”推荐根据患者的具体情况确定个体化的他汀类药物用药剂量,仍以LDL-C为治疗靶点。因缺乏老年人群他汀类药物治疗的大规模临床试验证据,各指南缺乏对老年人应用他汀类药物的细化措施。


二、“共识”的要点


“共识”指出,我国人群血脂水平随年龄增长而升高,与西方人群不同,我国老年人的血脂水平以轻中度升高为主。为此,我国老年人的降脂治疗不能照搬国外的血脂治疗指南。


“共识”分别对老年人血脂异常的特点、他汀类药物在老年人中应用的临床证据、老年人血脂异常的治疗及监测、老年人应用他汀类药物的安全性等方面进行阐述,并对老年人使用他汀类药物提出建议及注意事项。


1.血脂异常老年人应用他汀类药物治疗明确获益


“共识”汇集了多项老年人心脑血管疾病一级和二级预防的临床研究或荟萃分析,临床证据表明,血脂异常老年人应用他汀类药物降低心脑血管事件发生率及病死率。


2.老年人应用他汀类药物治疗安全性良好


大量临床研究证实,老年人应用常规剂量他汀类药物安全性良好。


肝酶异常是他汀类药物最常见的不良反应,丙氨酸氨基转移酶(ALT)升高>3倍正常上限的发生率为0.5%~2.0%,多发生在开始用药后的3个月内。


他汀类药物治疗诱发横纹肌溶解的风险为0.04%~0.20%,相关肌肉症状的发生率为1.5%~3.0%,其中老年人为0.8%~13.2%。老年、瘦弱女性、肝肾功能异常、多种疾病并存、多种药物合用、围手术期患者容易发生他汀类药物相关的肌病。大剂量他汀类药物增加肝酶、肌酶异常及其他不良事件发生的风险。


他汀类药物对肾功能无不良影响,使慢性肾脏病(CKD)患者获益,降低CKD1~5期非透析患者的心血管事件及死亡风险,但是相对获益随着肾功能下降而降低;对于透析(5D期)患者尚缺乏获益证据。不同他汀类药物对CKD患者肾功能的影响差异无统计学意义。老年人使用他汀类药物应同时认真评估肾功能(如血肌酐、肾小球滤过率),并关注肾功能变化,及时调整药物剂量和种类。


他汀类药物可增加新发糖尿病风险并可升高血糖,糖耐量异常者更容易发生他汀类药物相关的糖尿病糖尿病风险与大剂量他汀类药物的使用与年龄相关。他汀类药物治疗使心血管病高危患者明显获益,而新增糖尿病的风险远低于其心血管获益。


他汀类药物对认知功能的影响存在争议,尽管2012年美国食品与药品监督管理局(FDA)对他汀类药物可引起认知功能障碍发出了警示,近期的荟萃分析未发现他汀类药物对认知功能的影响。如患者在他汀类药物治疗过程中出现神经系统症状,应评估是否为他汀类药物的不良反应,必要时停药观察。


值得注意的是,老年人常合并多种疾病并联合多种药物治疗,应用他汀类药物时需注意药物之间相互作用的影响,并密切监测药物不良反应。


3.老年人血脂异常治疗的目标


“共识”提出,使用他汀类药物治疗前应认真评估老年人ASCVD危险因素,充分权衡他汀类药物治疗的获益/风险,根据个体特点确定他汀类药物治疗的目标、种类和剂量。调脂治疗目标见表1。



4.老年人血脂异常治疗的监测


使用他汀类药物的老年患者应监测不良反应,观察有无肌痛、肌肉压痛、肌无力、乏力和消化道症状等。在服药前、服药后4周复查血脂、肝酶、肌酶及肾功能;3~6个月未达标者,应调整他汀类药物剂量或种类,达标后每6~12个月复查。


5.老年人使用他汀类药物的建议和注意事项


鼓励所有血脂异常的老年患者进行生活方式治疗,不提倡老年人过分严格控制饮食和过快减轻体质量。应根据老年人个体特点选择调脂药物,如无特殊原因或禁忌证,应鼓励具有多种ASCVD危险因素的老年人使用他汀类药物。对于不能耐受他汀类药物的老年患者,可考虑:(1)更换另一种药代动力学特征不同的他汀类药物;(2)减少他汀类药物的剂量;(3)隔日用药。


老年ASCVD患者使用他汀类药物应从小或中等剂量开始,以后根据他汀类药物疗效调整剂量,以减少不良反应。对于急性冠状动脉综合征等极高危患者,可使用中等剂量他汀类药物,尽快使血脂达标。对具有多种心血管疾病危险的老年人,可考虑使用小剂量他汀类药物进行一级预防。


老年人的生理变化导致肝肾功能减退,并经常使用多种药物,因此要重视药物间的相互作用。应尽量选择使用在肝内或体内不同代谢途径的药物。年龄不应成为高龄老年人(≥80岁)使用他汀类药物的障碍,应根据心血管疾病的危险分层,结合生理年龄、肝肾功能、伴随疾病、合并用药、预期寿命等,充分权衡调脂治疗的利弊,积极、稳妥地选择调脂药物。


使用他汀类药物使血脂达标后,应坚持长期用药,可根据血脂水平调整剂量甚至更换不同的他汀类药物,如无特殊原因不应停药。


三、“共识”的亮点


(1)聚焦老年人群,根据老年人血脂异常、肝肾功能、代谢、药物相互作用等特点,为老年人血脂管理提出具体建议。


(2)基于老年人使用他汀类药物治疗的临床证据,强调他汀类药物是一类安全、有效、能改善老年患者预后的治疗药物。


(3)对老年人使用他汀类药物的治疗目标、注意事项、药物不良反应的监测和处理提出建议。


原始出处:


中华医学信息导报2015年6月12日第30卷第11期


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    2015-07-21 qingfengqishi5

    收藏了

    0

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    2015-07-19 aa6081

    学习中

    0

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  7. [GetPortalCommentsPageByObjectIdResponse(id=1844457, encodeId=bca3184445eeb, content=<a href='/topic/show?id=5d2f206482e' target=_blank style='color:#2F92EE;'>#专家共识#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=20648, encryptionId=5d2f206482e, topicName=专家共识)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=568152, createdName=snowpeakxu, createdTime=Wed Sep 09 21:56:00 CST 2015, time=2015-09-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2044376, encodeId=4bd720443e6c4, content=<a href='/topic/show?id=644725344b1' target=_blank style='color:#2F92EE;'>#他汀类药#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=74, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=25344, encryptionId=644725344b1, topicName=他汀类药)], attachment=null, authenticateStatus=null, createdAvatar=https://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTIibticIBly5jCSic5ZElW4He3rO4DMpUHUFaFX57OicNMnzckWaicBNeStwugWHFCuOdicoakApM4HGmtw/132, createdBy=f8672500006, createdName=ms6390871039024434, createdTime=Sat Apr 02 12:56:00 CST 2016, time=2016-04-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1741350, encodeId=e02f1e4135044, content=<a href='/topic/show?id=c2c621665c4' target=_blank style='color:#2F92EE;'>#中国专家共识#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=74, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=21665, encryptionId=c2c621665c4, topicName=中国专家共识)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4c37265, createdName=zhaojie88, createdTime=Sun Jun 26 20:56:00 CST 2016, time=2016-06-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=33180, encodeId=66bf3318095, content=收藏了, beContent=null, objectType=article, channel=null, level=null, likeNumber=176, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzTetibytbqFDmFITWHyBWbxU7S9MYibgPSqvu0sYteH0N6zXqbU0Kf3Mbdb7yWM1Kud3zPgYBibE2SZ/0, createdBy=da7696924, createdName=qingfengqishi5, createdTime=Tue Jul 21 00:19:00 CST 2015, time=2015-07-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=33097, encodeId=7b2e3309e92, content=学习中, beContent=null, objectType=article, channel=null, level=null, likeNumber=145, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c09d1605573, createdName=aa6081, createdTime=Sun Jul 19 10:50:00 CST 2015, time=2015-07-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1253710, encodeId=37591253e1030, content=<a href='/topic/show?id=cbd48992056' target=_blank style='color:#2F92EE;'>#血脂异常#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=95, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=89920, encryptionId=cbd48992056, topicName=血脂异常)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=30bd35, createdName=bugit, createdTime=Sun Jul 19 01:56:00 CST 2015, time=2015-07-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=33034, encodeId=91cc33034f5, content=老年人的并发症比较多,所以他汀类使用也要相对慎重一些, beContent=null, objectType=article, channel=null, level=null, likeNumber=215, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=96871613250, createdName=medcardio, createdTime=Sat Jul 18 11:27:00 CST 2015, time=2015-07-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=33033, encodeId=e7d833033a2, content=看看, beContent=null, objectType=article, channel=null, level=null, likeNumber=133, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ed101627734, createdName=Messichen1992, createdTime=Sat Jul 18 10:32:00 CST 2015, time=2015-07-18, status=1, ipAttribution=)]
    2015-07-18 medcardio

    老年人的并发症比较多,所以他汀类使用也要相对慎重一些

    0

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    2015-07-18 Messichen1992

    看看

    0

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