循证医学展示

1、 氯沙坦降低高血压合并痛风患者血尿酸水平的循证治疗实践 姜之贤 邓磊 刘棋 叶正病例患者，男，45 岁，于2012-5-30因反复关节肿痛7 年，加重1周入院。【现病史】患者7 年前无明显诱因突然出现双足背疼痛，伴有局部发热、肿胀，以第一跖趾关节最为明显。自服秋水仙碱后明显缓解。4 年前患者因饮用啤酒后再次出现双足背发热、肿胀，性质如前。同时伴有双侧肘关节肿胀，经口服秋水仙碱后可缓解。近1年来，患者上述症状发作频繁，每1-2 个月发作一次，时有双膝关节发热、肿痛。经口服秋水仙碱后症状缓解不明显。后至外院就诊，检测尿酸为685mol /L，考虑为痛风，给予口服别嘌呤醇，早3片，晚2 片后，尿酸降

2、至480mol /L，疼痛稍有缓解。近1 周来，无明显诱因患者上述症状加重，口服药物后无缓解，在外院给予“地塞米松”静滴，至我院门诊就诊，给予莫比可，7.5mg,2/日， 口服，后症状有所缓解( 具体不详)。现为求进一步诊治而入住我科。【查体】心、肺无特殊; 腹稍隆起; 右侧膝关节较对侧肿胀，皮温稍高，活动自如，无肌萎缩; 四肢关节无畸形。【辅助检查】1.血常规、电解质、随机尿蛋白定量正常，肝炎病原学、HIV、梅毒为阴性; 肝功能正常; 肾功能尿酸485mol /L，升高; 尿常规示尿潜血1 +，白细胞12 个/l，予复查回报未见异常; 心电图示: 窦性心动过速，考虑与患者疼痛有关，嘱其定期复

3、查；2.心脏彩超示: ( 1) 室间隔增厚( 符合高血压心脏改变) 。(2) 主动脉钙化并少量反流，糖耐量试验，胰岛素C 肽释放试验，ACTH，COR节律未见异常。【诊断】(1) 痛风性关节炎慢性迁延期; (2)高血压3 级(极高危组);(3)脂肪肝4.甲状腺结节。【治疗】秋水仙碱，碳酸氢钠片，丹参多酚酸，依托考昔，立加利仙，氯沙坦提出问题氯沙坦是血管紧张素II受体拮抗剂，可以阻断血管紧张素受体，避免血管紧张素II结合到受体上，防止血管收缩，最终达到降低血压的目的。该患者患有高血压合并痛风，血尿酸水平明显升高。氯沙坦是否能降低高血压合并痛风患者血尿酸水平？4根根据PICO提出的临床问题Anti

4、hypert-ensive drugsDecreased of blood uric losartanIInterventionCcomparison Ooutcome hypertension with goutPpatient检索证据检索结果 题目 ：Antihypertensive drugs and risk of incident gout among patients with hypertension: population based case-control study 来源 ：PubMed Published online 2012 Jan 12. 结论 ：Current

5、use of losartan among those with hypertension was associated with a lower risk of developing gout. The association was not significantly different among those without hypertension , but the frequency of losartan use in the group without hypertension was low . The multivariate relative risks accordin

6、g to duration of use among those with hypertension were 0.97 for less than one year, 0.86 for 1-1.9 years, and 0.70 for two or more years. The inverse association tended to be stronger with high dose use of losartan than with medium or low dose use (multivariate relative risk 0.66 v 0.88; P=0.06, ta

7、ble 4).证据评价 分组是否随机（是） All incident cases of gout (n=24768) among adults aged 20-79 and a random sample of 50000 matched controls. 分配是否隐藏（否） 是否采用盲法（否）证据评价-真实性基线是否一致（是）After adjusting for age, sex, body mass index, visits to the general practitioner, alcohol intake, and pertinent drugs and comorbiditi

8、es, the multivariate relative risks of incident gout associated with current use of antihypertensive drugs among those with hypertension (n=29138) were 0.87 (95% confidence interval 0.82 to 0.93) for calcium channel blockers, 0.81 (0.70 to 0.94) for losartan, 2.36 (2.21 to 2.52) for diuretics, 1.48

9、(1.40 to 1.57) for blockers, 1.24 (1.17 to 1.32) for angiotensin converting enzyme inhibitors, and 1.29 (1.16 to 1.43) for non-losartan angiotensin II receptor blockers. 证据评价-真实性随访时间是否足够（是）We carried out a nested case-control study using data from the health improvement network database between Janu

10、ary 2000 and December 2007. The source population included all adults aged 20-89 with permanent registration status or who had died in the last update of the database. All participants in the study cohort were followed up and contributed person time from their respective start date until the earlies

11、t of one of the following end points: detection of gout, 90th birthday, death, or end of study period, whichever came first. The final cohort encompassed 1775505 people followed for an average of 5.2 years.证据评价-真实性是否进行了意向性分析（否）Using unconditional logistic regression we estimated the odds ratios and

12、95% confidence intervals for gout associated with use of calcium channel blockers, losartan, and other antihypertensive drug classes. Our multivariate analyses were adjusted for the frequency matched variables, visits to a general practitioner, and the covariates of body mass index (five categories)

13、, alcohol use (six categories), smoking (four categories), ischaemic heart disease, hypertension, hyperlipidaemia, and renal failure. 证据评价-真实性 除试验方案外，其他治疗方案是否一致 由于本试验是基于人群的病例对照研究，不能确定其他治疗方案是否一致。证据评价-重要性 治疗证据的效应强度大小治疗证据的效应强度大小： 疗效强度疗效强度： 相对危险降低率相对危险降低率RRR=(CER-EER)/CERRRR=(CER-EER)/CER 绝对危险降低率绝对危险降低率

14、ARR=CER-EERARR=CER-EER NNT=1/ARR NNT=1/ARR （CERCER：对照组事件率；：对照组事件率；EEREER：试验组事件率）：试验组事件率） 因本研究没有给出治疗有效及发生不良反应的具体人数因本研究没有给出治疗有效及发生不良反应的具体人数或事件发生率，不能计算效应强度大小或事件发生率，不能计算效应强度大小Use of antihypertensivesNo (%) of controls (n=16 280)No (%) of cases (n=12 858)Adjusted relative risk* (95% CI)DiureticsNever6076

15、 (37.32)2761 (21.47)1Current (365 days)2349 (14.43)1132 (8.80)0.98 (0.90 to 1.08)Calcium channel blockers:Never9127 (56.06)6685 (51.99)1Current (365 days)1899 (11.66)2115 (16.45)1.13 (1.04 to 1.23)Losartan:Never15 551 (95.52)12 141 (94.42)1Current (365 days)170 (1.04)237 (1.84)1.10 (0.89 to 1.37)Use of antihypertensivesNo (%) of controls (n=16 280)No (%) of cases (n=12 858)Adjusted relative risk* (95% CI) blockers:Never8089 (49.69)5079 (39.50)1Current (365 days)2771 (17.02)2187 (17.01)1.03 (0.96 to 1.11)Angiotensin converting enzyme inhibitors:Never9238 (56.74)5630 (43.79)1Current (3