Schmidt Morten, Mansfield Kathryn E, Bhaskaran Krishnan, Nitsch Dorothea, Sørensen Henrik Toft, Smeeth Liam, Tomlinson Laurie A
Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.
Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark.
BMJ Open. 2017 Jan 9;7(1):e012818. doi: 10.1136/bmjopen-2016-012818.
To examine adherence to serum creatinine and potassium monitoring and discontinuation guidelines following initiation of treatment with ACE inhibitors (ACEI) or angiotensin receptor blockers (ARBs); and whether high-risk patients are monitored.
A general practice-based cohort study using electronic health records from the UK Clinical Practice Research Datalink and Hospital Episode Statistics.
UK primary care, 2004-2014.
223 814 new ACEI/ARB users.
Proportion of patients with renal function monitoring before and after ACEI/ARB initiation; creatinine increase ≥30% or potassium levels >6 mmol/L at first follow-up monitoring; and treatment discontinuation after such changes. Using logistic regression models, we also examined patient characteristics associated with these biochemical changes, and with follow-up monitoring within the guideline recommendation of 2 weeks after treatment initiation.
10% of patients had neither baseline nor follow-up monitoring of creatinine within 12 months before and 2 months after initiation of an ACEI/ARB, 28% had monitoring only at baseline, 15% only at follow-up, and 47% both at baseline and follow-up. The median period between the most recent baseline monitoring and drug initiation was 40 days (IQR 12-125 days). 34% of patients had baseline creatinine monitoring within 1 month before initiating therapy, but <10% also had the guideline-recommended follow-up test recorded within 2 weeks. Among patients experiencing a creatinine increase ≥30% (n=567, 1.2%) or potassium level >6 mmol/L (n=191, 0.4%), 80% continued treatment. Although patients with prior myocardial infarction, hypertension or baseline potassium >5 mmol/L were at high risk of ≥30% increase in creatinine after ACEI/ARB initiation, there was no evidence that they were more frequently monitored.
Only one-tenth of patients initiating ACEI/ARB therapy receive the guideline-recommended creatinine monitoring. Moreover, the vast majority of the patients fulfilling postinitiation discontinuation criteria for creatinine and potassium increases continue on treatment.
研究在开始使用血管紧张素转换酶抑制剂（ACEI）或血管紧张素受体阻滞剂（ARB）治疗后，患者对血清肌酐和钾监测以及停药指南的遵循情况；以及高危患者是否得到监测。
一项基于英国临床实践研究数据链和医院病历统计的电子健康记录的全科队列研究。
英国初级医疗保健，2004 - 2014年。
223814名新使用ACEI/ARB的患者。
ACEI/ARB开始使用前后进行肾功能监测的患者比例；首次随访监测时肌酐升高≥30%或血钾水平>6 mmol/L；以及出现此类变化后停药情况。使用逻辑回归模型，我们还研究了与这些生化变化以及在治疗开始后2周内指南推荐的随访监测相关的患者特征。
10%的患者在开始使用ACEI/ARB前12个月和开始后2个月内既没有基线肌酐监测也没有随访监测，28%的患者仅在基线时有监测，15%仅在随访时有监测，47%在基线和随访时都有监测。最近一次基线监测与开始用药之间的中位时间为40天（四分位间距12 - 125天）。34%的患者在开始治疗前1个月内进行了基线肌酐监测，但<10%的患者在2周内也进行了指南推荐的随访检测。在肌酐升高≥30%（n = 567，1.2%）或血钾水平>6 mmol/L（n = 191，0.4%）的患者中，80%继续治疗。尽管既往有心肌梗死、高血压或基线血钾>5 mmol/L的患者在开始使用ACEI/ARB后肌酐升高≥30%的风险较高，但没有证据表明他们接受监测的频率更高。
开始使用ACEI/ARB治疗的患者中只有十分之一接受了指南推荐的肌酐监测。此外，绝大多数符合肌酐和血钾升高后停药标准的患者仍继续治疗。
