实证医学临床知识分享.pptVIP

實證醫學臨床知識分享 內科部 神經內科 陳右緯 2007.03.23 EBM 五步驟 Step I: Ask an answerable question(問一個可以回答的問題) StepⅡ: Searching for the best available evidence (搜尋可獲得最佳的證據) Sorry, no RCT fits this search! Why? ? Because the patients with chronic hepatitis are excluded in statin trials. ? Change keywords to “Liver” and “Statin” Patients with elevated liver enzymes are not at higher risk for statin hepatotoxicity Case control study Cohort 1: hyperlipidemic patients with abnormal LFT ? Statin Cohort 2: hyperlipidemic patients with normal LFT ? Statin Cohort 3: patients with baseline abnormal LFT without statin treatment Conclusion: Patients with baseline abnormal LFT DO NOT have higher risk for hepatotoxicity from statins. Gastroenterology 2004;126:1287-1292 Experience with statin use in patients with chronic hepatitis C infection StepⅢ : Critical appraisal- paper result (文獻的分析判斷) Could we apply this conclusion in our patients? An assessment of statin safety by hepatologists StepⅣ: Apply to your patient (實際運用於病人) Algorithm for managing statin therapy in patients with chronic liver disease Step V: self-evaluation and well suggestion (評估實施新介入的結果) The behaviors of Dr. before research The doctors may be too afraid of the side effects to prescribe statins in appropriate patients. The doctors may ignore the importance of monitoring LFT after statin treatment. A mixture of above. The behaviors of Dr. after research Recommendation of FDA Liver function tests should be performed before statin treatment. LFT should be monitored 12 weeks following therapy and any elevation of dosage (Atorvastatin, Fluvastatin, Simvastatin, and Rosuvastatin) More frequent monitoring in patients with higher risks Older, co-mobid conditions, complicated medication (drug-drug interaction) More research and evidence is needed to answer this question!! “Could statins be prescribed safely in an patient at high cardiovascular risk but with chronic non-active hepatitis?” Thank you for your attention!! 謝謝實證醫學部及研