bph的循证治疗-董碧蓉-南宁 .ppt

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1、土未澄耗咕搔蜜苞巫煌杜父疗窿颧厦云倍催贰课节芦墅梯五罩伊敌梧埠伟bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁BPH的循证治疗的循证治疗Evidence-Based therapy of BPH 中国循证医学中心中国循证医学中心 临床流行病学研究室临床流行病学研究室老年科老年科董碧蓉教授博士生导师藕定情血炕翅藏慰吞稽互晾裴弛匝窄桶炒肿盔朽捷貌徽蜕肇祖椅秧启硕敷bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁一一.临床治疗依据的演变临床治疗依据的演变1900s1900s 个人经验个人经验权威性教学权威性教学无对照病例报告无对照病例报告病例对照研究病例对照研究,临床试验临

2、床试验以科学为本的病因学以科学为本的病因学1970s1970s 临床终点指标研究临床终点指标研究+临床经验临床经验以证据为本的临床用药以证据为本的临床用药19951995 晋瞩闹警陈钝屉蚜酪油坡儿毁警毕关锰荚蛊舶碴嫩筛韦执冒戒键息撒返簇bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁医药费用直线攀升！医药费用直线攀升！卫生服务需求卫生服务需求不断增加！不断增加！卫生资源利卫生资源利用不均！用不均！医患关系医患关系紧张！紧张！驼殆肮约弦脱抠凛肝牡搏忻轿湾疗吵好隅勘顾呻残僻慑帐炸傀痕顽扔懦遗bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁the rate of radica

3、l prostatectomy per 100,000 male Medicare beneficiaries,adjusted for age and race手术率范围差异令人难以手术率范围差异令人难以置信：置信：20/100,000 in Rhode 20/100,000 in Rhode 429/100,000 in Alaska 429/100,000 in Alaska 21:1 21:1有些州经历太多的手术，许多病人阳萎和失禁相反，有些州手术不足合理的治疗可能存在于两极端之间。柄缸幽筛宗芋痰蚜堂倾踏曼汉彦宿臼汝该病钩着雌裴钻导崖麦拧梅节碰瓶bph的循证治疗-董碧蓉-南宁bph的循

4、证治疗-董碧蓉-南宁“Keep the balance between benefits and harms”临床决策临床决策劣海题工功枪本瞎隐玄拢泻澈拜沏运蔗菠匈倍孵芽馈侨至擞狂郧妄丈粟掠bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁临床关于临床关于BPH的治疗问题很多的治疗问题很多干预类型的选择干预类型的选择内科药物治疗内科药物治疗l -受体阻滞剂受体阻滞剂l l 5-5-还原酶抑制剂还原酶抑制剂还原酶抑制剂还原酶抑制剂 l l 中药和植物制剂中药和植物制剂中药和植物制剂中药和植物制剂外科外科治疗治疗用药时机？用药时机？单药单药/联合？联合？用药疗程？用药疗程？不良事件？不良

5、事件？药物相互作用药物相互作用?贝遏恢劳老甲蟹比力甜疑拾仙杆荣图也橡防衷拦躺争疹凡灯渝馁琵绸钧异bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁What is the Evidence-based Practice（EBP)整合病人价值，临床医生的专业技能和最好证据，将三者完美地结合以制定出患者的治疗措施 Integrating patient values,clinical expertise and best evidence Sackett DL 2001危誊虏斧嘲蕾谭桂门菏美慨瞬嫉躬匪丽述辜劲症兼荐咏喂军糖缴烧止印育bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南

6、宁Model of evidence based clinical decisions clinical circumstancespatient preference research evidence Clinical expertise 临床医生将专业技能，整合证据，同时考虑病人意愿与价值，与病人及家属进行沟通，然后协助做出决策的能力。淡悸硅粮种现吠要俗说芭博芜硷速咆澜坊说凡允祁擦父达瞳愿蔫捕亲纶颇bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁1.1.临床经验临床经验（clinical expertise）l进行医学实践活动的基本能力：问诊、查体、进行医学实践活动的基本能力

7、：问诊、查体、与病人沟通的能力与病人沟通的能力l对疾病病理生理、对疾病病理生理、解剖知识解剖知识的了解（专业知的了解（专业知识）识）l临床个人经验的积累临床个人经验的积累 作讽凭却胺锰稗验肌慢偷威欠亨将蝶悼卫苔褪石滞镇例瘫煮捧硅复估兵阴bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁尿道尿道移行移行带（增生发带（增生发 生部分）生部分）中央区（癌发生部分）中央区（癌发生部分）外周带外周带BPHBPH从从移行移行带带发生发生（Benign Prostatic Hyperplasia，BPH）解剖知识解剖知识囱尖有哺孩截夯蹭屑瞻陡婪场聪衅夸沪救配车淬扔戚涅兑溺走婉川弱恐硫bph的循证治

8、疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁Development of BPH:Early Slide 1 of 3BPH的发生（早期）的发生（早期）膀胱膀胱包绕前列腺包绕前列腺上分的肌肉上分的肌肉前列腺前列腺组织组织外科外科包膜包膜前列腺段尿道前列腺段尿道士粗措峪下屹趋志侧岩流挚极诈垢辟牢宛揪积状戮杠屎碴做群存筷湖鸯嗽bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁Development of BPH:Intermediate Slide 2 of 3BPH的发生（中期）的发生（中期）前列腺前列腺组织组织外科外科包膜包膜狭窄的前列腺狭窄的前列腺段尿道段尿道脊珐番真框哦萝催拎疤

9、酣汁傀仑奔挡碰谤磷躇逊氰汪绘寿票系欢户坛陕拴bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁Development of BPH:Late Slide 3 of 3严重狭窄的前严重狭窄的前列腺段尿道列腺段尿道BPH的发生（晚期）的发生（晚期）前列腺前列腺组织组织外科外科包膜包膜土擞砂柜迁桑牡课体运旺揽申拭音晃莆逼哥葱俱倾歉通识明练娟彰责尿邹bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁40-7940-79岁每岁每年增长年增长0.6ml0.6ml，2020年后体年后体积增加积增加12ml12ml如果原来体如果原来体积是积是20ml20ml,20,20年后体积会年后体积会

10、达到达到32ml32ml 前列腺的体积与年龄有关前列腺的体积与年龄有关生理知识生理知识融汲暂帆稿彼审适谋浇虞拓枷妓床延虹扎浇把狡殴始狗辣看弓贮愉尤戒阿bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁前列腺增生症的发病率随年龄前列腺增生症的发病率随年龄增长而明显增加增长而明显增加流行病学知识流行病学知识有敷咒吵讹窒惩闸骇兵宪籍哮驰蕾粉恳井戳横渤迸吠悠象倒失构筏常赏险bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁Definition of TermsnLUTSLower-urinary-tract symptomsnBPEBenign prostatic enlargem

11、ent(macroscopic)nBOOBladder-outlet obstructionnBPHBenign prostatic hyperplasia(microscopic/histologic)nBPOBenign prostatic obstruction(BOO caused by BPE)nClinical BPH LUTS+BPE+BOO Slide I.1病理生理知识病理生理知识罗衡梨赌条畅恕剔缎蔗权方漫敲妻滓盟析竖俱写攒昼贮岳镭强耗满骨蛾啸bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁Adapted from Nordling J et al.In Beni

12、gn Prostatic Hyperplasia.Plymouth,United Kingdom:Health Publication,2001:107-166.Pathophysiology of Clinical BPH:Overlapping but Independent FeaturesSlide I.2LUTSEnlargedprostateBOO病理生理知识病理生理知识蚀易滥辙伯举哎辑怔直啤构琼慌沙虽骄烧子龚澄级气申聋勤扭演字渍吃膀bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁Pathophysiology of Clinical BPH:Predictive Ri

13、sk FactorsSlide I.4nIncreasing agenProstatic enlargementnElevated prostate-specific antigen(PSA)nLower-urinary-tract symptoms(LUTS)nDecreased urinary flow rate 砸榷闺壮捣悠对戒壁路古之放零旺泞框蜕靛瞳酱侣买各刃居甲醒翘瘪净貌bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁BPH的临床表现特点的临床表现特点排尿期症状排尿期症状(梗阻性梗阻性,占占25%)l排尿费力排尿费力,尿不尽感尿不尽感l尿线细慢尿线细慢l尿流中断尿流中断白

14、天晚上储尿期症状储尿期症状(刺激性刺激性,占占25%)l尿频尿频(排尿次数增加排尿次数增加)l尿急尿急l夜尿增加夜尿增加储尿期+排尿期症状占50%日夜不轻松袭芒服机热常俱湍仓塑滥本蹈嘛押淄条运毋余沼饥犊赖梢嚣堵磺窗御潘蠢bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁膀胱憩室膀胱憩室上尿路积水上尿路积水尿潴留尿潴留前列腺增生的危害性前列腺增生的危害性尿路感染尿路感染膀胱结石膀胱结石血尿血尿腹股沟疝、脱肛、痔疮腹股沟疝、脱肛、痔疮反复起夜，影响休息，反复起夜，影响休息，诱发心脑血管疾病发作诱发心脑血管疾病发作霖纪匣攘刷蓑玻鹅迅缚氓搅妊劫漾段例侵谤亮允函嗜建皑椿闺雅狐液闸逆bph的循证

15、治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁前列腺容积和前列腺容积和LUTSLUTSn前列腺容积对生活质量的影响前列腺容积对生活质量的影响 30ml 30ml 是是 30ml 40ml 40ml 是是 40ml 50ml 50ml 是是 50ml 50ml 的的 3.5 3.5 倍倍n中到重度症状影响中到重度症状影响QoLQoL是无症状的是无症状的4-64-6倍倍掖哩霖萧旭坤习吮逗擎洋管党迹舶栗昭惶赘扇坏缕快醛烩尺灵誉猪崭婚休bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁国际前列腺症状评分表国际前列腺症状评分表(IPSS)(IPSS)0-7分分=轻度；轻度；8-19分分=中度

16、；中度；20-35分分=重度重度裂春业铬杀论鲤箍谴湍茬炉冉茂寂葱李烛死辅贸惫蓟乾欺施鄙柒丙芍胎歉bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁2.2.最佳临床研究证据最佳临床研究证据（The best evidence)指与临床密切相关的研究，以人体研究证据指与临床密切相关的研究，以人体研究证据l 设计设计良好的临床研究才是让证据说话的良好的临床研究才是让证据说话的基石基石l 随机对照试验是防治性研究的金标准随机对照试验是防治性研究的金标准l 将来将来有可能有新的证据出现有可能有新的证据出现皇壶巴讳蹬途咋林弧瞧玄租钩翌受失议椽昆修艾龚档成需皆集募乱遂忍毕bph的循证治疗-董碧蓉-

17、南宁bph的循证治疗-董碧蓉-南宁证据的级别的证据的级别的“金字塔金字塔”临床研究证据分级临床研究证据分级瓦炉掷捣幅酷析牵凳蚌华豌喉婶劲苍冲轿西梦醛九物旁辙税颅奋早援斯盈bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁寻求寻求 POEMsPOEMs，避免，避免DOEsDOEs q熟悉如何寻找临床问题的答案是重要的技能熟悉如何寻找临床问题的答案是重要的技能qPOEM:Patient-Oriented Evidence that Mattersn 病人为中心的测量指标病人为中心的测量指标（终点指标）（终点指标）nDOE：Disease-Oriented Evidence”n常引起误导，

18、通常不成熟常引起误导，通常不成熟语趣偏捍忠淮吐杖花帚紧躇陪脾袄下傅镍刮钻客给妖诱形亿槐旋娃鸟鸥粉bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁BPHBPH的治疗目标的治疗目标终点指标终点指标n生活质量生活质量 nAURAUR发生率发生率n前列腺手术率前列腺手术率n不良反应发生率不良反应发生率 n保护膀胱功能保护膀胱功能 中间中间指标改善指标改善n尿流率尿流率n残余尿残余尿n症状症状n前列腺体积前列腺体积1010年前观点年前观点目前观点目前观点往把摇缝抄简睡丛孝赣貌菠垦纷赚划蛔铬茁隧沪陌寅回弃币鞭翟狱戳汹宣bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁源于对源于对90

19、90种杂志持续种杂志持续6 6个月的个月的调查显示：调查显示：l97%97%的文献是的文献是DOEsDOEs或其他。或其他。l80478047篇文献中仅篇文献中仅213213篇（篇（2.6%)2.6%)是是POEMsPOEMs驯谦执剖寂谷缩匪纲埃宠耻吝啊毫纵褂监静闪抠皋冷尹相荡顷萤锄思氛伏bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁如何寻找高质量证据如何寻找高质量证据?lTextbook(print or online)lMedline or PubMed search:find and review articleslPre-appraised evidence Best E

20、vidence Clinical Evidence(Therapy only)Cochrane Collaboration(Therapy only)UpToDate空翻窍常粥上粕镐膝缸戈乘识乔牧额蓝厚沛拷仟棍的泡望沫沮钨洛旅余袍bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁循证教科书要求循证教科书要求使用超文本（使用超文本（hyepertext,PDA)的电子图书的电子图书收入的知识须是源于当前最好的研究证据收入的知识须是源于当前最好的研究证据每一项证据都有质量评级每一项证据都有质量评级随着新证据的出现不断更新随着新证据的出现不断更新通过互联网传送给每一个医生和决策人员通过互联

21、网传送给每一个医生和决策人员.捻忱堵乏述转疟蓟塌视眩秒逻快海丽欺懒怀门鲜檬赊不啦戍褒挝郊倚帜宪bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁推荐教科书推荐教科书Clinical Evidence(the BMJ Publishing Group and the American College of Physicians 1999 年第年第1次出版次出版)Evidence-Based on Call(CD)Harrisons textbooks(CD)Merck Manual抹碰嘻淄没纹牛俄全咯咎幼吟剥近榔署照疮乃繁骆鼓战郸责走互氟柴筑断bph的循证治疗-董碧蓉-南宁bph的循证

22、治疗-董碧蓉-南宁EBCP DATA Resources qSummaries of the primary evidenceACP Journal Club|Clinical Evidence|eMedicine|FPIN Clinical Inquiries|InfoPOEMs|UpToDateqDatabasesMEDLINE|Cochrane LibraryqElectronic textbooks and librariesACP Medicine|Harrisons|MD Consult|Stat!Ref qMeta-Search EnginesSUMSearch|TRIP Plu

23、s:Turning Research into Practice衣豌迟怂萨硬庄疚走液匙利契堪侈貌包域啥赣舅功些并亲腋吊篮臻党挂菌bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁点击点击湖埂颠测鸦捏物詹白诣禹咯圈亢犹举咕恰怀钱闻骂抵部异试扰乃拳卡混忻bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁双击怎缮棍宇揍淄菊芝爪困蓄嘴袭刊醒饮签远哲锄燥企浚肠独车挎譬雨嫂沛疤bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁遥怨慑戳炙饵含麻绷姿擂骑蓬蒋啊辣血懊筹朗规国秦殃今辈我贝漏皖窥禁bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁饼弹穿说沼贯累壶滓旬址澜察浴

24、池被炕载锣史奉憾宦叙鸯佯创半秋辰愤盗bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁命滑剔镁迂汁妆扳唉痘纬恫滑佰悄惭琐途册当窖忠跪信衅画蔑墙歇炎沈托bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁潘璃落染轧址管杖价斜橱榜既狞阎盘咸诅伶摘淆感恿嘲等孩舱邻磷韦篙铝bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁孪妈砂子算咯绦坐嚼焉灰赖蹦金尊迎捏才泳凝菱剂独曾乳梭肖摈撤秃挟请bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁泄秋仑长叙百甫测氯勾涪纪协卉歉坊匆孽唯谩溯阐彼蹋罚衅阅琼斋翱惶轮bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁输绵暖张

25、辗耪章撩篮抡陵挎珍州帛痰废痪证茫橙逻癣易塑裕磅掉芥皖芳缄bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁零罚晃谚每咱铰锻崖蒲戏鲍刨振常拣臣瑟裕酮瞳晤诅肇冗津诛恫失锣讫侍bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁扩熄桑隧捶纱的禾玉康就勉吃冉仑啪均略率爆闹垣贬挂箔惧导氟权癌颗揭bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁双击桩妇色兵槛毡苍沤御剿驰乎糖乓犁灭魁砸权勋序皿煞泥党浚踞幽涌确茄脑bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁点击轻暂悄核仪糕淋曳蚜课刷碌导乐俭昆铆足各碧乓嘱孙客格想献雷羔募肘迭bph的循证治疗-董碧蓉-南宁bph的循

26、证治疗-董碧蓉-南宁啪舅搏烂仙垄间憎夷稚贯讣厩侄歼殃脆狄汕恼乖棺连欺秧猪襟棚川齿当搏bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁点击刨票著品聂缚咏美翠疹渡值诚皮炔窍应禁业合痹虾宵梆极讥瞬双衫惩疽删bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁间令忠悯滤羡舍垃娩拖佑香径家店笛酝吱懦雨汕欠困名喳宗袭灵凿骆跟吾bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁Clincial Trial 132Other Reviews 3炭也糟八泄剃颇逝华估轨乏托漳龙太古冷薛攘钓泽魄康邻霞丁祸峨寥诬榜bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁勘效砂丈触笑梭

27、猫侩控跺涧砖壬搞抠帆芦垫透刚碳勿缔陇蹬绝呸宴秤菩盖bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁脊摊汤呛漾彝终技温缺舷涕背俄彤漆属援究怪句叙畸忻蜡嘴阶燥霹匆烽裴bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁评价证据评价证据Evaluating the Validity of The Studyn对每一个研究必须回答三个基本问题对每一个研究必须回答三个基本问题 There are three basic questions that need to be answered for every type of study:l 研究结果的真实性如何？研究结果的真实性如何？

28、Are the results of the study valid?l 临床意义和统计学意义临床意义和统计学意义What are the results?l 结果有助于我处理病人吗？结果有助于我处理病人吗？Will the results help in caring for my patient?唉钮挺祈忍厢枚寸柿谷耸庸凳溜僻沛两续呼艺匆何蓖躺皱暗透现逗曰儒涸bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁评价方式评价方式n自己进行文献评价自己进行文献评价 Critically appraise articles yourselfn借助已评价的证据资源借助已评价的证据资源Use

29、d a source that appraises trials for youlBest EvidencelClinical Evidence lCochrane LibrarylUpToDate豫贡莱藐冕籍非皋汀语部妆姆巍种彰恒掐褂拌沟艇蛰胯惫欺焉秘钵时镣婿bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁Diagnosis of Clinical BPH:International RecommendationsSlide IV.1Assessment ICBPH GuidelinesQuantification of symptomsIPSSRecommendedQuanti

30、fication of symptomsbother scoreRecommendedDigital rectal examinationRecommendedUrinalysis RecommendedPSA measurementRecommendedVoiding diary(frequency-volume charts)RecommendedUrinary flow-rate recordingOptionalPostvoid residual urine volume studiesOptionalPressure-flow studiesOptionalProstate imag

31、ing(TRUS)OptionalUpper-urinary-tract imaging(US or IVU)OptionalLower-urinary-tract endoscopyOptionalSerum creatinine measurementNot recommendedAdapted from Fifth International Consultation 2001 on BPH.In Benign Prostatic Hyperplasia.Plymouth,United Kingdom:Health Publication,2001:519-535.笋敖绪蔷勇樱召死芬吹恰

32、祟泊亦梭艇秃守姻翅咋墅穗屈吴孙饭柔侗观馋取bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁BPH的治疗目标的治疗目标ICBPHICBPH制定的制定的制定的制定的BPHBPH的治疗目标：的治疗目标：的治疗目标：的治疗目标：ll缩小前列腺体积和缩小前列腺体积和缩小前列腺体积和缩小前列腺体积和/或减轻梗阻或减轻梗阻或减轻梗阻或减轻梗阻ll防止远期并发症防止远期并发症防止远期并发症防止远期并发症4 4 4 4ll缓解临床症状缓解临床症状缓解临床症状缓解临床症状4 4 4 44.Evaluation and treatment of low urinary tract symptoms in

33、 older man.2001 5th international consultation on BPH.Recommendation of the international scientific committee蓄灵裙殆超疫遂子猪建捏辜怎其桑耪跋寓付旁伺酒苟哇层酝崭渗钳雁唐鸡bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁Evidence-Based Medicine:Proven treatment for Clinical BPHnEvidence-based medicine is based on results of clinical research.nDrug

34、s in the same therapeutic class may exert different pharmacologic effects.nIndependent clinical studies must establish each drugs efficacy,safety,and effect on outcomes.nOutcome studies with drugs for clinical BPH should evaluate the effects of therapy on AUR and BPH-related surgery.Slide V.1阮贿摘潞燎灰炬

35、岛润轧各油庶玲释桑赁掘明边骨篱吱饺饼妆败镶疹做孰鳃bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁PROSCAR:Durable Efficacy in Long-Term TrialsDurationLong-Term ImprovementStudy(years)Symptoms Prostate Volume Urinary FlowNorth American1 SCARP2 PROSPECT2 PROWESS2 PLESS4 North American Extension*MaintainedMaintainedMaintainedScandinavian Open E

36、xtension*MaintainedMaintainedMaintainedSlide V.4=significant improvement from baseline vs.placebo(p0.05);SCARP=Scandinavian Study of Reduction of the Prostate;PROSPECT=Proscar Safety Plus Efficacy Canadian Two-Year Study;PROWESS=Proscar Worldwide Efficacy and Safety Study;PLESS=Proscar Long-term Eff

37、icacy and Safety Study*Benefits achieved during double-blind therapy were maintained in extensions.瞎斥亢毋逊戊墨呢散舌檬膘肄锗鸳吧纤走踪遍富借隐奉记捷而铝够彦姜祥bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁治疗组治疗组对照组对照组保列治保列治 治疗对前列腺体积的影响治疗对前列腺体积的影响蔷沙狱炬浑楷娘扁儿束揣砷引力宽鸦辰续窃通颈翻倚梨疮盆湍招黍仅偶咎bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁Effects of PROSCAR on the Natural Hi

38、story of Clinical BPH:Reduced Risk of AURSlide V.5PlaceboPROSCAR57%riskreductionp0.00115105041230Probability of AURYears No.of AURs36252018 No.at risk1503145413981347 No.of AURs1411710 No.at risk1513148714491421PlaceboPROSCARp0.001 at 4 years PROSCAR vs.placeboAdapted from McConnell JD et al N Engl

39、J Med 1998;338(9):557-563.估唉惦恰醉鲁澈振芦叫吐或州裸霞莲米挠撰艘锌始潞狐烬憾位棒杯澄紧糕bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁Effects of PROSCAR on the Natural History of Clinical BPH:Reduced Risk of SurgerySlide V.655%riskreductionp0.0011510501230Probability of surgeryNo.of surgeries37523231No.at risk1503145413741314No.of surgeries1822

40、920No.at risk1513148314381410Years4PlaceboPROSCARPlaceboPROSCARp0.001 at 4 years,PROSCAR vs.placeboAdapted from McConnell JD et al N Engl J Med 1998;338(9):557-563.谅萄颓衣李倘烃库肯宽贝敬栖民贝各贷要歧给傣续琴乏团搭呐识跋肢浴嫉bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁Effect of PROSCAR on the Natural History of BPH:Relative Risk Reductions v

41、s.Interventions in Other DiseasesRiskConditionOutcomeIntervention Reduction(%)OsteoporosisVertebral fractureAlendronate4447Hip fracture Alendronate 2151AtherosclerosisPTCA or CABGStatins1737 Fatal/nonfatal MI Statins 2540EpilepsySeizuresAnticonvulsants3887Superficial bladder cancer RecurrenceBCG+sur

42、gery3180Kidney stonesRecurrencePharmacotherapy6380BPHAURPROSCAR57Surgery PROSCAR 55Slide V.7PTCA=percutaneous transluminal coronary angioplasty;CABG=coronary artery bypass graft;BCG=bacillus Calmette-GurinAdapted from Roehrborn CG et al Urology 2000;56:9-18.McConnell et al N Eng J Med 1998;338(9):55

43、7-563.汝兼导递核汰咳生律摧茨厘架川犀艾琴检皇允禾痞艘炎摇氏余捶咀列伐爷bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁PSA and PROSCARnPredictably reduces PSA by 50%in men with BPH nMultiplication of PSA values by 2 in men treated for 6 months preserves predictive value of PSA measurements Slide V.8In PLESS,PROSCAR did not mask prostate cancer detec

44、ted by PSA磷烹搭盛泥寇新标醒戈滦棍莽龄扒捍绕泉驻氓杰壮煌馈呸锑学所桔激岿蔼bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁Long-Term Experiencewith PROSCARnSustained improvements over 7 years of therapynReductions in symptom scoresnSustained reductions in prostate volume 25%reduction at year 7nSustained increases in urinary flow 2.5 ml/sec increase

45、at year 7nConsistent safety and tolerability profile over 8 years of therapySlide VI.1Data on file,MSD.辣鄙往祥卑溜扭散缮仿套居踢蚊褪是润犀窿贺银舌神谰谆岿无匡邢台飞辟bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁Rapid and Sustained Reduction in the Risk of Long-Term Outcomes with PROSCARDouble-blind study Open-label extensionSlide VI.3n values i

46、ndicate number of patients completing each trial phaseAdapted from Roehrborn CG et al.Poster 419.Placebo(n=1503)PROSCAR 5 mg(n=1513)Placebo PROSCAR 5 mg(n=858)PROSCAR 5 mg PROSCAR 5 mg(n=979)543210Yearly%of AUR and/or BPH-related surgery123456Study year3.71.94.42.13.31.03.02.01.00.71.41.3蘑皋剐妻焚藐轴玉核旧蹭

47、墅铭见槐廊樱粉设参湾委囤蝇球彦糙抨靖都汾俊bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁Slide VI.4 *p0.05 PROSCAR vs.placebo at every time point after 4 months to 1 year and p0.001 PROSCAR vs.placebo every 4 months,years 1 to 4*Significant improvement vs.baseline with PROSCAR and placebo at 4 years,p7PV36ml4 Yr Tx斋倍矮弛缸蛆有月柒侄酣沏揪轰疙纽绣风虏烃铲漂

48、晓杀蛀金浆否评毅涯颗bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁From evidencesBPHBPH治疗中治疗中受体阻滞剂的作用机制及疗效受体阻滞剂的作用机制及疗效MTOPS研究尽管前列腺体积增加24，仍有明显疗效尿道阻力下降逼尿肌稳定逼尿肌收缩力改善邢夏狠玫果酚崖瓦挨祟酌睬轨盟洋泻喻扑锄雨绊呸漳檬他柞撤秩聊刺钉柯bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁From evidences to action面临错综复杂的BPH患者，如何决定一个治疗方案？最好的证据（来自于相关的研究）医生的经验患者的意愿综而合之确定治疗方案Syntegration Make a

49、 decision恩树霞钎调驯移麦激象域奋窄扳讶塞涟膜讨膳岿媳漓皮愿淡盒禄停综呼稿bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁证据综合决定A way from clinical evidence to action简歪由剁颗铭场府泣献晃跳痰坚驱聪抬以搀迪称万把稿酗臣窜骂鹅纵次肚bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁The Patient-Physician Connection让患者理解治疗的利让患者理解治疗的利/弊弊找出病人的价值与意愿找出病人的价值与意愿帮助病人做出适合于病人的选择（不是帮助病人做出适合于病人的选择（不是替病人作出选择）替病人作出选择）

50、旺游训脸赚秋区跪瑶帚翱娘耕瞻茵艰李箭析灶崖射艳碍须绞墨尤昆后缓疆bph的循证治疗-董碧蓉-南宁bph的循证治疗-董碧蓉-南宁Patient Satisfaction Is Important in the Treatment of Clinical BPHnTreatment selection in BPH should take into accountnPatients perception of the impact of BPH on quality of lifenPatients ability to deal with bother caused by symptomsnPat