从药物不良反应谈老年高血压患者未来的社区管理

目的　将高血压药物不良反应（ADR）与慢性非传染性疾病（简称慢性病）患者的社区管理政策相结合，分析高血压患者ADR现状，并从社区管理的角度提出政策建议。方法　2017年1—6月采用实证研究法，从2013年1月—2015年12月陕西省高血压患者ADR终端用户数据平台选取高血压ADR病例报告5 405例。从高血压ADR病例报告中筛选出9种数量最多的药物（硝苯地平、氨氯地平、卡托普利、依那普利、美托洛尔、吲达帕胺、氢氯噻嗪、厄贝沙坦、替米沙坦），统计分析病例报告的年龄、用药情况、ADR分类及主要临床表现。结果　5 405例高血压ADR病例报告中，>50岁3 621例（66.99%）。使用的药物类别为：（1）钙离子拮抗剂（CCB）：硝苯地平1 364例（25.24%，其中联合用药424例），氨氯地平623例（11.53%，其中联合用药192例）；（2）血管紧张素转化酶抑制剂（ACEI）：卡托普利1 024例（18.94%，其中联合用药287例），依那普利899例（16.63%，其中联合用药308例）；（3）β-受体阻滞剂：美托洛尔380例（7.03%，其中联合用药173例）；（4）利尿剂：吲达帕胺429例（7.94%，其中联合用药156例），氢氯噻嗪253例（4.68%，其中联合用药78例）；（5）血管紧张素Ⅱ受体阻滞剂（ARB）：替米沙坦266例（4.92%，其中联合用药88例），厄贝沙坦167例（3.09%，其中联合用药45例）。共发生ADR 6 770例次，主要为中枢及外周神经系统损害（22.38%）、呼吸系统损害（21.21%）、胃肠系统损害（19.23%）。CCB所致ADR主要为中枢及外周神经系统损害（42.59%）；ACEI所致ADR主要为呼吸系统损害（67.90%）；β-受体阻滞剂所致ADR主要为胃肠系统损害（45.78%）；利尿剂所致ADR主要为胃肠系统损害（52.53%）；ARB所致ADR主要为中枢及外周神经系统损害（41.25%）。结论　高血压作为常见的慢性病，老年患者居多，患者常用药物服用基数大、联合用药较多、ADR较多，累及器官和系统广泛。因此，针对老年高血压患者的社区管理，应重视用药安全并积极开展健康宣教，丰富慢性病管理内容，合理使用基本药物，加强专业人员配备，建立慢性病管理数据信息平台。

Adverse Reactions to Antihypertensive Drugs in Older Hypertensive Patients and Targeted Suggestions Concerning Community-based Management

Objective　To analyze the adverse reactions to antihypertensive drugs in older patients with hypertension（a chronic non-communicable disease），and based on this，giving targeted suggestions from a perspective of community-based management.Methods　This empirical study was conducted between January and June 2017.From Shaanxi End User Data Platform of Hypertensive Patients with Adverse Reactions to Antihypertensive Drugs，the data of 5 405 cases reported from January 2013 to December 2015 were collected.Then age，use of classes of antihypertensive drugs〔with a detailed analysis of 9 most common antihypertensive drugs（nifedipine，amlodipine，captopril，enalapril，metoprolol，indapamide，hydrochlorothiazide，irbesartan，telmisartan）〕，classification of the adverse reactions to these drugs，and major clinical manifestations were analyzed.Results　Of the 5 405 cases，3 621（66.99%）were older than 50 years.The classes of antihypertensive drugs used in them were as follows：（1）calcium ion antagonist（CCBs）：1 364（25.24%）used nifedipine，including 424 used it combinatively，623（11.53%）used amlodipine，including 192 used it combinatively;（2）angiotensin-converting enzyme inhibitors（ACEIs）：1 024（18.94%）used captopril，including 287 used it in combination with other drugs，899（16.63%）used enalapril，including 308 used it in combination with other drugs;（3）β-blockers：380（7.03%）administered metoprolol，including 173 used it combinatively;（4）diuretics：429（7.94%）took indapamide，including 156 took it combinatively，253（4.68%）took hydrochlorothiazide，including 78 took it combinatively;（5）angiotensin Ⅱ receptor blockers（ARBs）：266（4.92%）used telmisartan，including 88 used it combinatively，167（3.09%）used erbesartan，including 45 used it combinatively.Totaled 6 770 adverse drug events occurred，which mainly involved central and peripheral nervous system（22.38%），respiratory system（21.21%）and gastrointestinal system（19.23%）.Adverse reactions caused by CCBs，ACEIs，β-blockers，diuretics，ARBs mainly were central and peripheral nervous system damage（42.59%），respiratory damage（67.90%），gastrointestinal damage（45.78%），gastrointestinal damage（52.53%），central and peripheral nervous system damage（41.25%），respectively.Conclusion　Hypertension is a common chronic disease in older people.Generally，due to concomitant use（including combinative use）of several antihypertensive drugs，they may frequently have adverse reactions involving multiple organs or systems.In view of this，community-based management for this population should be focused on rationally using basic antihypertensive drugs，strengthening the awareness of safety of antihypertensive drugs，actively carrying out health education on hypertension control，enhancing the services for chronic disease，increasing the number of professional care providers，establishing a chronic disease management information platform.