2022-台灣高血脂初級預防指引-6 LDL目標值-高風險族群

2025-12-09 11:08AM
2022台灣血脂治療指引(英文版)下面中文使用google自動翻譯

LDL-C 目標值：高風險族群（糖尿病、慢性腎臟病、LDL-C ≥ 190 mg/dL）：

對於患有糖尿病、非透析慢性腎臟病或 LDL-C ≥ 190 mg/dL 的受試者，本指南建議 LDL-C 水平達到 100 mg/dL 時開始治療。由於 ASCVD 風險較高，應立即開始降血脂治療並進行生活方式介入。目前尚無僅針對 LDL-C ≥ 190 mg/dL 受試者的他汀類藥物治療的隨機、安慰劑對照試驗。 WOSCOPS 試驗是一項針對高膽固醇血症（平均 LDL-C 水平為 192±17 mg/dL）且無血管疾病史的受試者進行的普伐他汀（40 mg/天）隨機、安慰劑對照試驗。 ³⁸ 普伐他汀的使用顯著降低了心肌梗塞和心血管死亡的發生率。 WOSCOPS試驗中2560名基線LDL-C水平為190 mg/dL的受試者的事後分析顯示，他汀類藥物治療在試驗初期和超過20年的隨訪期內均顯著降低了主要不良心血管事件（MACE）的風險。 ³² 由於ASCVD風險較高，LDL-C水平為190 mg/dL的受試者的治療目標為LDL-C <100 mg/dL。鑑於基線LDL-C水平較高，建議LDL-C水平為190 mg/dL的受試者使用中高強度他汀類藥物合併依折麥布治療。

建議：對於患有糖尿病、非透析慢性腎臟病且低密度脂蛋白膽固醇（LDL-C）≥190 mg/dL 的患者，應立即開始降血脂治療，LDL-C 目標值為 <100 mg/dL。 （證據等級 I，證據等級 B）對於 LDL-C ≥190 mg/dL 的患者，建議使用中高強度他汀類藥物合併依折麥布。 （證據等級 I，證據等級 B）

LDL-C target High risk (DM, CKD, LDL-C ‡ 190 mg/dL) For subjects with DM, non-dialysis CKD, or LDL-C ‡190 mg/ dL, this guideline suggests the LDL-C level for initiation of therapy and treatment target is 100 mg/dL. Because the ASCVD risk is high, lipid lowering therapy should be started immediately with lifestyle modification. There has been no randomized, placebo-controlled trial of statin therapy performed only in subjects with LDL-C
190 mg/dL. The WOSCOPS trial was a randomized placebo-controlled trial of pravastatin (40 mg/day) for subjects with hypercholesterolemia (mean LDL-C level of 192  17 mg/ dL) and without history of vascular disease.38 The use of pravastatin significantly reduced the incidence of MI and CV mortality. The post hoc analyses among the 2560 subjects in the WOSCOPS trial with baseline LDL-C
190 mg/dL showed that statin therapy significantly reduced the risk of major adverse cardiovascular events (MACE) in the initial trial phase and over 20 years of follow-up.32 Because of the high risk for ASCVD, the treatment target of LDL-C is <100 mg/ dL in subjects with LDL-C
190 mg/dL. Since the baseline LDL-C level is high, moderate-to high-intensity statins combined with ezetimibe is recommended for subjects with LDL-C
190 mg/dL

Recommendation In subjects with DM, non-dialysis CKD, LDL-C
190 mg/dL, immediate lipid lowering therapy should be started and the LDL-C target is <100 mg/ dL. (COR I, LOE B) In subjects with LDL-C
190 mg/dL, moderate-to high-intensity statins combined with ezetimibe is recommended. (COR I, LOE B)

2022-台灣高血脂初級預防指引-5. 無風險因子的民眾

2025-12-09 11:08AM2022台灣血脂治療指引(英文版)

下面中文使用google自動翻譯

無高風險受試者
對於無糖尿病、慢性腎臟病且低密度脂蛋白膽固醇（LDL-C）低於190 mg/dL的受試者，應評估其他動脈粥狀硬化性心血管疾病（ASCVD）危險因子。這些因素包括：

（1）高血壓；

（2）男性年齡大於45歲或女性年齡大於55歲或已停經；

（3）早期冠心病（CAD）家族史（男性小於55歲或女性小於65歲）；

（4）男性高密度脂蛋白膽固醇（HDL-C）低於40 mg/dL或女性低於50 mg/dL；5）

（5）吸菸。

由於一些研究也認為中心性肥胖、糖尿病前期和三酸甘油酯（TG）是ASCVD的危險因素，因此本指南將包含所有這些因素的代謝症候群視為第六個獨立危險因子。

代謝症候群的定義參照美國國家膽固醇教育計畫成人治療組第三次報告（NCEP ATP III）中針對亞洲人群的修訂版。

符合以下五項標準中三項或三項以上者，即可診斷為代謝症候群：

(1) 男性腰圍大於90 cm，女性腰圍大於80 cm；

(2) 血壓≥130/85 mmHg或正在服用降血壓藥物；

(3) 空腹血糖≥100 mg/dL或正在服用降血糖藥物

(4) 空腹甘油三酯（1095 mg）；男性高密度脂蛋白膽固醇（HDL-C）<40 mg/dL，女性HDL-C<50 mg/dL

基於上述危險因子評估，初級預防對象可分為下列風險類別。

高風險族群指患有糖尿病 (DM)、慢性腎臟病 (CKD) 或低密度脂蛋白膽固醇 (LDL-C) ≥ 190 mg/dL 的受試者。

對於未患有 DM、CKD 或 LDL-C ≥ 190 mg/dL 的族群，中度風險指具有 2 項或以上風險因子的受試者，低風險指有 1 項風險因子的受試者，極低風險指無風險因子的受試者。

高風險族群需要立即接受降血脂治療以達到建議的 LDL-C 目標值。對於非高風險族群，建議先進行 3 個月的生活方式乾預，然後再考慮降血脂治療。初級預防的總體風險類別總結於表 2。

建議

對於初級預防，患有糖尿病、非透析慢性腎臟病或低密度脂蛋白膽固醇（LDL-C）≥190 mg/dL 的個體發生動脈粥狀硬化性心血管疾病（ASCVD）的風險較高，需要立即進行降血脂治療。 （證據等級 I，證據等級 A）

對於未患糖尿病、慢性腎臟病或 LDL-C≥190 mg/dL 的個體，應根據危險因子將 ASCVD 風險分為極低、低或中等。 （證據等級 I，證據等級 C）


Subjects without high risk
In subjects without DM, CKD, and LDL-C
190 mg/dL, other risk factors of ASCVD should be evaluated. These include: (1) hypertension, (2) age greater than 45 years in men or greater than 55 years in women or menopausal women, (3) family history of premature CAD (less than 55 years in men or less than 65 years in women), (4) high-density lipoprotein cholesterol (HDL-C) less than 40 mg/dL in men or less than 50 mg/dL in women and (5) smoking.35 Because central obesity, prediabetes and triglyceride (TG) are also considered to be ASCVD risk factors in some studies, metabolic syndrome that include all these items is regarded as the sixth independent risk factor in this guideline. Metabolic syndrome is defined according to the modified National Cholesterol Education Program Adult Treatment Panel III for Asians.36,37 Patients who meet three or more of the following criteria are considered to have metabolic syndrome: (1) waist circumference greater than 90 cm in men or greater than 80 cm in women, (2) blood pressure of 130/ 85 mmHg or higher or use of antihypertensive medication, (3) fasting glucose level of 100 mg/dL or higher or use of antidiabetic drug, (4) fasting TG level of 150 mg/dL or higher or use of lipid-lowering agent for increased TG, and (5) HDL-C less than 40 mg/dL in men or less than 50 mg/dL in women (Table 1). Based on the above-mentioned risk factor evaluation, the subjects with primary prevention can be classified into the following risk categories. High risk indicates subjects with DM, CKD or LDL-C
190 mg/dL. In those without DM, CKD or LDL-C
190 mg/dL, moderate risk indicates subjects with 2 or more risk factors, low risk indicates with 1 risk factor and minimal risk indicates no risk factor. Subjects with high risk need immediate lipid lowering therapy to reach the recommended LDL-C target. Lifestyle modification first is recommended for 3 months before considering lipid lowering therapy in the subjects without high risk. The overall risk categories for primary prevention are summarized in Table 2.


Recommendation
For primary prevention, subjects with DM, nondialysis CKD, or LDL-C
190 mg/dL are at high risk of ASCVD and immediate lipid lowering therapy is necessary. (COR I, LOE A) In subjects without DM, CKD, or LDL-C
190 mg/dL, the risk of ASCVD should be classified as minimal, low, or moderate according to the risk factors. (COR I, LOE C)

2022-台灣高血脂初級預防指引-4. 風險分級

2025-12-09 11:08AM
2022台灣血脂治療指引(英文版)下面中文使用google自動翻譯

風險類別

高風險族群（糖尿病、慢性腎臟病和低密度脂蛋白膽固醇≥190 mg/dL）：本一級預防指南決定沿用傳統的目標值控制方法，低密度脂蛋白膽固醇的治療目標值根據心血管危險因子的存在情況進行調整。由於動脈粥狀硬化性心血管疾病是糖尿病和慢性腎臟病患者死亡的主要原因，因此這兩類患者被認為是高風險族群。糖尿病的診斷和糖尿病血脂異常的管理策略已在2017年台灣高風險患者血脂指南¹⁰中進行了描述。對於慢性腎臟病，蛋白尿是用於檢測和診斷慢性腎臟病的重要生物標記。蛋白尿是指尿液中白蛋白排泄量增加。非定時尿液樣本中的尿液白蛋白與肌酸酐比值 (UACR) 已取代 24 小時尿液白蛋白排泄量，成為測量蛋白尿的首選方法。 23e26 蛋白尿液定義為 UACR ≥ 30 mg/g，可進一步分為微量白蛋白尿 (UACR 30-300 mg/g) 和大量白蛋白尿 (UACR > 300 mg/g)。美國國家腎臟基金會腎臟疾病預後品質倡議（KDOQI）指引將慢性腎臟病（CKD）定義為腎損傷（尿液白蛋白/肌酸酐比值[UACR] ≥ 30 mg/g）或腎小球濾過率（GFR）< 60 mL/min/1.73 m²，且持續至少三個月。 ^27,28 GFR通常根據血清肌酸酐水平，以腎臟疾病飲食改良（MDRD）²⁹或慢性腎臟病流行病學協作組（CKD-EPI）³⁰方程式進行估算。對於合併糖尿病和非透析CKD的患者，建議立即進行降血脂治療。嚴重高膽固醇血症（定義為低密度脂蛋白膽固醇[LDL-C] ≥ 190 mg/dL）會增加動脈粥狀硬化性心血管疾病（ASCVD）和過早心血管事件的風險。這些族群罹患冠心病的風險比一般人高5至6倍，男性罹患冠心病的時間比一般人早10至20年，女性早20至30年。 ³¹早期開始降血脂治療可顯著降低這些族群的發生率和死亡率。 ³²低密度脂蛋白膽固醇（LDL-C）≥190 mg/dL顯著增加家族性高膽固醇血症（FH）的發生率。 LDL-C≥190 mg/dL的族群中約有7%可能符合FH的診斷標準。 ³³應考慮這類族群進行基因檢測以診斷FH。先前研究表明，與LDL-C<130 mg/dL且未檢測到FH基因突變的參考組相比，LDL-C≥190 mg/dL且未檢測到FH基因突變的受試者發生冠心病的風險高出6倍，而LDL-C≥190 mg/dL且同時攜帶FH基因突變的受試者發生冠心病的風險則高出sup.22</sup>202倍。由於LDL-C≥190 mg/dL是一個非常特殊且高風險的群體，具有顯著的長期臨床預後，因此被歸類為高風險族群。與糖尿病和慢性腎臟病一樣，由於這些患者的心血管風險極高，建議立即進行降血脂治療並強化LDL-C控制。

Risk category

High risk (DM, CKD and LDL-C ‡ 190 mg/dL) This primary prevention guideline decides to keep a conventional target approach and the LDL-C treatment targets are tailored according to the presence of CV risk factors. Since ASCVD is a major problem contributing to significant mortality in populations with DM and CKD, these 2 groups of patients are considered at high risk. The diagnosis of DM and management strategy of diabetic dyslipidemia was described in the 2017 Taiwan Lipid Guidelines for High Risk Patients.10 For CKD, albuminuria is an important biomarker which is used to detect and define CKD. Albuminuria refers to increased urinary excretion of albumin. The urine albumin-to-creatinine ratio (UACR) in an untimed urine specimen has replaced 24-h urine albumin excretion as the preferred method for measuring albuminuria.23e26 Albuminuria is defined as a UACR
30 mg/g and can be further categorized into microalbuminuria (UACR 30e300 mg/g) and macroalbuminuria (UACR > 300 mg/g). The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines defined CKD as kidney damage (UACR
30 mg/g) or a glomerular filtration rate (GFR) < 60 mL/min/1.73 m2 for at least three months.27,28 The GFR is usually estimated from the serum creatinine level according to equations of the Modification of Diet in Renal Disease (MDRD)29 or the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI).30 Immediate lipid lowering therapy is recommended for DM and non-dialysis CKD. Severe hypercholesterolemia, defined as having an LDLC
190 mg/dL, carries a high risk of ASCVD and premature CV events. These individuals have a 5 to 6-fold higher risk of CAD and develop CAD 10e20 years earlier in men and 20e30 years earlier in women than general population.31 Early initiation of lipid-lowering therapy can significantly reduce morbidity and mortality in these subjects.32 LDL-C
190 mg/dL significantly increases the likelihood for the presence of FH. Approximately 7% of the subjects with LDLC
190 mg/dL may fulfill the diagnostic criteria of FH.33 Genetic testing should be considered for this group of subjects for diagnosis of FH. Previous study demonstrated that, compared with a reference group with LDL-C <130 mg/dL without detected FH genetic mutation, subjects with LDL-C
190 mg/dL without detected FH mutation had a 6-fold higher risk for CAD, whereas those with both LDL-C
190 mg/dL and an FH mutation demonstrated a 22-fold increased risk.34 Because LDL-C
190 mg/dL is a very unique and high risk group with a distinct long-term clinical outcome, it is classified as high risk. Just like DM and CKD, immediate lipid lowering therapy with intensive LDL-C control is recommended because the CV risk is so high in these patients.

2022-台灣高血脂初級預防指引-3.風險計算

2025-12-09 11:08AM
2022台灣血脂治療指引(英文版)下面中文使用google自動翻譯

風險計算

對於初級預防，通常使用基於人群研究的動脈粥狀硬化性心血管疾病（ASCVD）風險評估計算，例如弗雷明漢風險評分，來決定受試者是否應接受降血脂治療。近年來，美國心臟病學會（ACC）和美國心臟協會（AHA）開發了合併隊列方程式。歐洲心臟學會（ESC）和歐洲動脈粥狀硬化學會（EAS）使用SCORE（系統性冠狀動脈風險評估）進行ASCVD風險評估。英國國家健康與臨床優化研究所（NICE）指引使用QRISK2作為ASCVD風險評估工具。儘管有許多針對特定族群的風險評估工具，但目前尚無任何模式源自東亞族群或經過前瞻性驗證。美國心臟協會/美國心臟病學會 (AHA/ACC) 總結隊列方程式用於估算 40 至 79 歲黑人和非西班牙裔白人男性和女性的 10 年 ASCVD 事件風險。 此風險預測指標可能高估了華人族群的 ASCVD 風險。  Framingham 風險評分也高估了華裔族群的 ASCVD 風險。

在台灣，20 世紀 90 年代，基於金山社區心血管隊列研究開發了一種基於積分的 10 年冠心病 (CAD) 風險預測模型。 然而，該模型並未明確定義高風險的臨界值。一些檢查，例如踝臂指數、脈搏波速度、頸動脈超音波和冠狀動脈鈣化評分，已被用於 ASCVD 風險評估。這些檢查在地方診所的可近性是一個主要問題。此外，冠狀動脈鈣化評分檢查的費用和輻射暴露也是需要考慮的重要因素。基本上，該指南並不鼓勵對無症狀族群進行亞臨床動脈粥狀硬化的常規篩檢。目前，在台灣，使用危險因子的數量進行風險分層更為便利。

Risk calculator

For primary prevention, population study-derived ASCVD risk estimate calculators, such as the Framingham risk score, are commonly used to decide whether a subject should receive lipid-lowering therapy or not. In recent years, the American College of Cardiology (ACC) and the American Heart Association (AHA) developed the pooled cohort equation.15,16 The European Society of Cardiology (ESC) and European Atherosclerosis Society (EAS) used SCORE (Systematic COronary Risk Evaluation) for ASCVD risk assessment.17,18 The UK National Institute for Health and Care Excellence (NICE) guidelines used the QRISK2 as the ASCVD risk assessment tool.19 Although several populationspecific risk assessment tools exist, none of the currently available models are derived from or prospectively validated in East Asians. The AHA/ACC pooled cohort equation for estimating the 10-year risk of ASCVD event is applicable to black and non-Hispanic white men and women 40 through 79 years of age.15 This risk predictor may overestimate the ASCVD risk in the Chinese population.20 The Framingham risk score also overestimated the ASCVD risk for ethnic Chinese.21 In Taiwan, a point-based prediction model to predict the 10-year risk of CAD was developed from the Chin-Shan Community Cardiovascular Cohort study in 1990s.22 However, the definite cut-off point to define high risk was not indicated. Some examinations, such as ankle-brachial index, pulse wave velocity, carotid ultrasound, and coronary calcium score, have been used in ASCVD risk assessment. The accessibility of these examinations is a major problem in local clinics. Concerns of cost and radiation exposure for examination of coronary calcium score are also important considerations. Basically, this guideline does not encourage to routinely screen the presence of subclinical atherosclerosis in asymptomatic subjects. At current stage, using the numbers of risk factors is a more convenient way for risk stratification in Taiwan.

2022-台灣高血脂初級預防指引-2 初級預防定義

2025-12-09 11:08AM

初級預防是指尚未發生疾病. 但因具備疾病危險因子. 發生疾病機率會提高. 所以採取各種策略降低危險因子. 

2022台灣血脂治療指引(英文版)下面中文使用google自動翻譯

初級預防的定義 

由於這是初級預防指南，因此首先應描述具有臨床意義的動脈粥樣硬化性心血管疾病（ASCVD）的定義。已有研究表明，動脈粥狀硬化最早可追溯至2歲兒童時期。一系列病理學研究，從朝鮮戰爭和越南戰爭中陣亡士兵的屍檢，到最近的青少年動脈粥樣硬化病理生物學決定因素研究和博加盧薩心臟研究，均表明冠狀動脈脂肪紋在生命早期形成，並且一部分青少年體內存在晚期纖維斑塊。過去幾十年來的大量證據表明，吸菸、血脂異常、高血壓、胰島素抗性、肥胖和糖尿病等心血管危險因子會加速整個生命週期的動脈粥狀硬化進程。 「初級預防」的主要目的是透過消除或改變危險因子來預防具有臨床意義的動脈粥狀硬化性心血管疾病（ASCVD）。

具有臨床意義的ASCVD包括：

（1）冠狀動脈疾病（CAD），例如運動負荷試驗陽性的心絞痛和/或影像學檢查顯示主要冠狀動脈直徑狹窄>50%；

（2）急性冠脈綜合徵（ACS），例如心肌梗塞和不穩定型心絞痛；

（3）腦血管疾病，如短暫性腦缺血發作、缺血性中風和影像學檢查顯示頸動脈狹窄>50%；

（4）週邊動脈疾病（PAD），影像學檢查顯示主要肢體動脈直徑狹窄>50%；以及

（5）主動脈粥樣硬化性疾病，如影像學檢查顯示腹主動脈瘤。

對於臨床顯著的動脈粥狀硬化性心血管疾病（ASCVD）患者，血脂異常的治療應參考2017年台灣高風險族群血脂指引及其更新版的建議。本初級預防指引闡述了無臨床顯著ASCVD族群血脂控制的一般原則。

風險分層是決定一級預防降血脂策略的第一步。

建議：
臨床上顯著的ASCVD患者需要立即強化降低低密度脂蛋白膽固醇（LDL-C）水準。 （建議等級I，證據等級A）

對於無臨床顯著ASCVD族群的一級預防，需要進行風險分層以確定降血脂策略。 （建議等級I，證據等級B）
Definition of primary prevention Since this is a primary prevention guideline, the definitions of clinically significant ASCVD should be described first. It has been demonstrated that atherosclerosis originates in childhood as early as 2 years of age. A series of pathology studies, from autopsies of soldiers killed in the Korean and Vietnam Wars to the more recent Pathobiological Determinants of Atherosclerosis in Youth12 and Bogalusa Heart studies,13 demonstrated that coronary fatty streaks develop early in life and advanced fibrous plaques are present in a proportion of adolescents. During the past decades, convincing evidence has emerged that CV risk factors, such as cigarette smoking, dyslipidemia, hypertension, insulin resistance, obesity, and DM, accelerate the atherosclerotic process throughout the life span.14 The major purpose of “primary prevention” refers to prevention of clinically significant ASCVD by removing or modifying risk factors. The clinically significant ASCVD include: (1) CAD, such as angina with positive stress test and/or major coronary artery diameter stenosis >50% by imaging studies; (2) ACS, such as myocardial infarction and unstable angina; (3) cerebrovascular disease, such as transient ischemic attack, ischemic stroke, and carotid artery stenosis >50% by imaging studies; (4) PAD with major extremity artery diameter stenosis >50% by imaging studies; and (5) aortic atherosclerotic disease, such as abdominal aortic aneurysm by imaging studies. Treatment of dyslipidemia for clinically significant ASCVD should be referred to the recommendations in the 2017 Taiwan Lipid Guidelines for High Risk Patients and its focused update. This primary prevention guideline addresses the general principles of lipid control in subjects without clinically significant ASCVD. Risk stratification is the first step to determine the lipid lowering strategy in primary prevention.
Recommendation
Clinically significant ASCVD needs immediate and intensive reduction of LDL-C. (COR I, LOE A) For primary prevention in subjects without clinically significant ASCVD, risk stratification is necessary to determine the lipid lowering strategy. (COR I, LOE B)

2022-台灣高血脂初級預防指引-1 引言

2026-09-04 15:31

2025 台灣血脂管理臨床路徑共識-2026健保給付規定新制*高血脂治療指引

2025-12-09 11:08AM
2022台灣血脂治療指引(英文版)下面中文使用google自動翻譯

引言 

心血管疾病（CVD），包括動脈粥狀硬化性心血管疾病（ASCVD），是台灣地區的主要死因之一。多項實驗室、流行病學和遺傳學研究證據表明，循環中低密度脂蛋白膽固醇（LDL-C）水平升高會導致膽固醇在動脈壁加速沉積，進而引發血管發炎和動脈粥狀硬化。許多臨床試驗進一步證實了LDL-C與ASCVD之間的因果關係，結果表明，強化降低LDL-C水平是減緩冠狀動脈粥樣硬化進展和改善心血管預後的有效療法。 近期研究表明，對於未確診冠狀動脈粥樣硬化的個體，早期開始使用他汀類藥物降低LDL-C水平，可以獲得與未接受治療的低LDL-C水平個體相似的心血管風險。  顯然，在生命早期維持適當的LDL-C水平是預防ASCVD的有效介入措施。然而，台灣的低密度脂蛋白膽固醇（LDL-C）控制率令人失望。即使在動脈粥狀硬化性心血管疾病（ASCVD）患者中，僅有54%的患者LDL-C水平能達到<100 mg/dL。 台灣血脂與動脈粥狀硬化學會聯合台灣其他七個主要學會於2017年發布了《台灣高危險群血脂指南》。 此指引針對高風險族群，包括冠狀動脈疾病（CAD）、急性冠狀動脈症候群（ACS）、缺血性中風、週邊動脈疾病（PAD）、糖尿病（DM）、慢性腎臟病（CKD）和家族性高膽固醇血症（FH）患者，建議了最佳血脂目標值和治療策略。 2017年版《台灣高危險群血脂指南》在台灣廣受好評，並成為高風險族群血脂異常治療的標準指南。但該指引並未提及不具備上述高風險特徵族群的血脂異常管理。 2005年至2008年台灣營養與健康調查顯示，高膽固醇血症（定義為膽固醇水平≥240 mg/dL）在男性中的盛行率為12.5%，在女性中為10%。 台灣血脂與動脈粥狀硬化學會決定推進一級預防，並制定了一項新的血脂指南，旨在針對無臨床顯著動脈粥樣硬化性心血管疾病（ASCVD）但可能存在其他各種血管危險因素的人群。台灣血脂與動脈粥狀硬化學會於2020年11月至2021年3月召開了諮詢委員會會議。來自台灣家庭醫學會、台灣心臟學會、台灣中風學會、台灣糖尿病學會、台灣糖尿病教育者協會、台灣腎臟病學會和台灣血脂教育者協會的專家和意見領袖出席了諮詢委員會會議並提出了重要建議。科學證據是該指引的主要依據。然而，我們認識到，台灣可能缺乏足夠的數據來支持血脂異常一級預防管理各個方面的建議。許多建議是專家討論後達成的共識。與2017年台灣高風險族群血脂診療指引類似，本指引採用建議等級（COR）和證據等級（LOE）來描述建議的強度及其相關的科學證據。 建議等級分為三級：I級（建議有用、有指徵且必要）、IIa級（建議可能有用且有指徵，但證據強度低於I級）、IIb級（建議可以考慮，但其效果尚不明確）和III級（建議涉及有害、禁忌且不應進行的治療）。

證據等級也分為三級：A級（建議有多項隨機臨床試驗支援）、B級（建議僅來自有限的隨機試驗或觀察性研究）和C級（建議來自專家共識）。


Introduction Cardiovascular (CV) disease, including atherosclerotic cardiovascular disease (ASCVD), is one of the major leading causes of death in Taiwan.1 Multiple evidences from laboratory, epidemiological, and genetic studies indicate that increased circulating low-density lipoprotein cholesterol (LDL-C) causes accelerated deposition of cholesterol in the arterial wall leading to vascular inflammation and atherosclerosis.2,3 The causal link of LDL-C and ASCVD was further proved in many clinical trials showing that intensive reduction of LDL-C is an effective therapy to attenuate the progression of coronary atherosclerosis and improve CV outcomes.4e7 Recent study demonstrated that, in individuals without established coronary atherosclerosis, early initiation of statin therapy to decrease LDL-C could obtain a similar CV risk as those with untreated low LDL-C levels.8 It is clear that maintaining an adequate LDL-C level earlier in life is an effective intervention for prevention of ASCVD. However, the control rate of LDL-C is disappointing in Taiwan. Even in patients with ASCVD, only 54% of them could achieve an LDL-C level <100 mg/dL.9 The Taiwan Society of Lipids and Atherosclerosis, in association with seven other major societies in Taiwan, published the Taiwan Lipid Guidelines for High Risk Patients in 2017.10 The optimal lipid target and treatment strategy were recommended for high risk patients, including those with coronary artery disease (CAD), acute coronary syndrome (ACS), ischemic stroke, peripheral artery disease (PAD), diabetes mellitus (DM), chronic kidney disease (CKD), and familial hypercholesterolemia (FH). The 2017 Taiwan Lipid Guidelines for High Risk Patients received critical acclaim in Taiwan and became the standard guidance for dyslipidemia treatment in high risk patients. The management of dyslipidemia for subjects without the above-mentioned high risk features was not mentioned in the 2017 guidelines. In the Nutrition and Health Surveys in Taiwan performed from 2005 to 2008, hypercholesterolemia defined as a cholesterol level
240 mg/dL was found in 12.5% in men and 10% in women.11 The Taiwan Society of Lipids and Atherosclerosis decided to move forward to primary prevention and developed a new lipid guideline targeting the subjects without clinically significant ASCVD, but may carry other various vascular risk factors. Advisory board meetings were held by the Taiwan Society of Lipids and Atherosclerosis from November 2020 to March 2021. Experts and opinion leaders from the Taiwan Association of Family Medicine, Taiwan Society of Cardiology, Taiwan Stroke Society, Taiwan Diabetes Association, Taiwan Association of Diabetes Educators, Taiwan Society of Nephrology and Taiwan Association of Lipid Educators attended the advisory board meetings and gave important suggestions. Scientific evidence is the major consideration of the guideline. However, we recognized that there may be insufficient data in Taiwan to support the recommendations in every aspect of dyslipidemia management for primary prevention. Many recommendations were consensus from the expert opinions after discussion. Similar to the 2017 Taiwan Lipid Guidelines for High Risk Patients, this guideline uses class of recommendation (COR) and level of evidence (LOE) to describe the intensities of the recommendations and their related scientific evidence.10 The COR includes 3 levels, including class I (the recommendations are useful, indicated, and necessary), class IIa (the recommendations maybe useful and indicated, but their intensity of evidence are less than class I), class IIb (the recommendations could be considered but their effects are less well established) and class III (the recommendations refer to the treatment that is harmful, contraindicated, and should not be done). The LOE also has 3 levels, including LOE A (the recommendations are supported by multiple randomized clinical trials), LOE B (the recommendations are from limited randomized trials or observational studies only), LOE C (the recommendations are from experts’ consensus).

皮質類固醇(屬於類固醇激素的一大類)用於氣喘或高海拔疾病

2025-12-07 20:23
類固醇激素是一個很大的分類. 用於治療氣喘或過敏的類固醇. 通常是指皮質類固醇(Corticosteroids,CS). 除了皮質類固醇CS. 另一大類是性激素 (可參考維基百科-steroid hormone)

皮質類固醇CS用於氣喘的治療. 通常需要四小時才會出現效果, 口服類固醇(OCS)與靜脈注射類固醇效果差不多. 因此能吃藥的就不需要靜脈注射. 另外. 當發生急性全身性嚴重過敏反應 anaphylaxis 的時候, 類固醇不是最優先的藥物. 原因也是它的作用需要時間. 無法立即改善嚴重過敏的休克或呼吸道黏膜腫脹. 

(參考資料 2014年Corticosteroids in the treatment of acute asthma)
Current guidelines recommend that patients with moderate exacerbation should receive three doses of inhaled or nebulized β2-agonist every 15-20 min in the 1st h.[22] Additional doses may be repeated in the next 2-3 h every 30-60 min. All those patients should be treated with systemic corticosteroids at a dose of 2 mg/kg or a maximum dose of 80 mg early in the course of management as it takes at least 4 h to start working.[23] Doses more than 80 mg will not confer any additional benefit. Systemic corticosteroids were found to speed resolution of symptoms, decrease the rate of admission and decrease the rate of relapse if administered for 3-5 days after the acute exacerbation. More detailed discussion about the use of systemic corticosteroids in the treatment of acute asthma can be found below.

類固醇的分類有很多種方式. 例如依照受體分類, 或依照碳原子數/化學式分類. 依照結構(開環)分類等等. 臨床醫師上最常接觸到的類固醇應該是皮質類固醇

依照功能簡單分成三類
1. 皮質類固醇
2. 性激素(性類固醇激素)
3. 其他: 包括神經甾類化合物，膽鹽，氨基甾類神經肌肉阻斷劑，類固醇抗雄性激素（合成的）, 類固醇生成抑制劑（外源性），膜固醇，毒素，維生素 D
** 膽固醇屬於膜固醇類.

皮質類固醇：由腎上腺皮質產生，這些激素調節壓力反應、電解質平衡和免疫功能。可根據抗發炎或鹽分水分滯留作用的強弱再分為葡萄糖皮質素及礦物鹽皮質素(我高中學習的名稱是礦物鹽皮質素, 還有很多其他翻譯, 例如鹽皮質素,礦物皮質固醇等等), 人工合成的類固醇通常具備上面兩種效果. 只是不同種類的類固醇在這兩方面的作用效果有差異. 例如高海拔疾病常用的dexamethasone對於鹽分水分滯留的效果較弱

** 若用於高海拔疾病治療, 水分滯留效果越弱越好

1. 葡萄糖皮質素：參與碳水化合物代謝、抗發炎作用和免疫抑制。

---- 舉例: 皮質醇會在壓力期間提高血糖水平，並抑制免疫活動以防止過度發炎。
2. 礦物鹽皮質素：控制鹽和水的平衡以維持血壓。

---- 舉例: 醛固酮能促進腎臟對鈉的再吸收，進而調節細胞外液容量。

臨床醫師最常用到的類固醇是人工合成的皮質類固醇. 例如 Prednisolone. methylprednisolone. dexamethasome. 下面是不同皮質類固醇對於抗發炎或水分滯留的效果, 數字是與 hydrocortisone 做比較. dexamethasone 幾乎不會造成鹽分滯留(水腫). 

Comparative oral corticosteroid potencies^{[21][22][23][24]}

Name	Glucocorticoid potency	Mineralocorticoid potency	Terminal half-life (hours)
Cortisol (hydrocortisone)	1	1	8
Cortisone	0.8	0.8	8
Prednisone	3.5–5	0.8	16–36
Prednisolone	4	0.8	16–36
Methylprednisolone	5–7.5	0.5	18–40
Dexamethasone	25–80	0	36–54
Betamethasone	25–30	0	36–54
Triamcinolone	5	0	12–36
Deflazacort	6.5	–	1.3
Fludrocortisone acetate	15	200	24
Deoxycorticosterone acetate	0	20	–
Aldosterone	0.3	200–1000	–
Beclometasone	8 sprays 4 times every day equivalent to orally 14 mg prednisone once a day	–	–

下圖來自維基百科: Glucocorticoids at the U.S. National Library of Medicine Medical Subject Headings (MeSH) 裡面將皮質類固醇GCS又分為天然及合成兩大類. 

人工合成的GCS
1. Cortisol-like and related (16-unsubstituted): 

----例如Fluorometholone(眼藥水常用) Methylprednisolone Prednisolone

2. Methasones and related (16-substituted): 

----例如 Betamethasone(藥膏常用) Clobetasol(藥膏常用) Dexamethason(兒科/高海拔疾病)Triamcinolone(注射型常用於治療蟹足腫,痘疤)

3. Cyclic ketals (16,17-cyclized): 

----例如Budesonide(用於氣喘噴劑)

下面是參考資料

下面中文直接拷貝自維基百科Steroid Hormones

按功能

類固醇在多種生理過程中發揮作用，包括新陳代謝、發炎調節、免疫反應、生殖和細胞信號傳導。它們的作用主要透過與特定的細胞內受體結合而介導，進而影響基因轉錄和蛋白質合成。類固醇可根據其主要生物學功能進行大致分類，以下列出了主要的類固醇激素類別，以及一些重要成員及其功能實例。^{[ 51 ] [ 52 ]}

• 皮質類固醇：由腎上腺皮質產生，這些激素調節壓力反應、電解質平衡和免疫功能。
  • 糖皮質激素：參與碳水化合物代謝、抗發炎作用和免疫抑制。
    • 皮質醇會在壓力期間提高血糖水平，並抑制免疫活動以防止過度發炎。
  • 鹽皮質激素：控制鹽和水的平衡以維持血壓。
    • 醛固酮能促進腎臟對鈉的再吸收，進而調節細胞外液容量。
• 性類固醇：主要來自性腺和腎上腺，影響性發育、生殖和第二性徵。
  • 黃體素：對生殖系統做好懷孕準備至關重要。
    • 孕酮透過維持子宮內膜來促進胚胎著床並維持早期懷孕。
  • 雄性激素：促進男性生殖發育和維持。
    • 睪固酮能夠促進精子生成和男性第二性徵（如肌肉量和臉部毛髮）的生長。
  • 雌激素：女性生殖週期和骨骼健康的關鍵。
    • 雌二醇在月經週期中刺激子宮內膜增生，並有助於骨密度。

其他類固醇的作用不僅限於荷爾蒙作用，還包括參與神經保護、消化和神經肌肉活動的化合物：

• 神經甾類化合物，如脫氫表雄酮（DHEA）和別孕烷醇酮，可以調節大腦中的神經傳導物質受體。
• 膽汁酸，例如牛磺膽酸，有助於腸道對脂質的消化和吸收。
• 氨基甾類神經肌肉阻斷劑（合成的），如泮庫溴銨，用於麻醉以誘導肌肉鬆弛。
• 類固醇抗雄性激素（合成的），例如醋酸環丙孕酮，在荷爾蒙治療中阻斷雄性激素受體。
• 類固醇生成抑制劑（外源性），如阿爾法二醇，可抑制類固醇合成以達到治療目的。
• 膜固醇，例如膽固醇（對細胞膜流動性至關重要）、麥角固醇（真菌膜成分）和各種植物固醇（具有降低膽固醇作用的植物來源固醇）。
• 毒素如甾體皂苷（植物防禦化合物）和強心配醣體/心臟糖苷（影響心臟功能）。

具有開環結構的類固醇，稱為開環類固醇，包括：

• 維生素 D 的形式包括麥角鈣化醇（來自植物）、膽鈣化醇（來自動物和陽光）和骨化三醇（調節鈣穩態的活性形式）。

Corticosteroids: Produced by the adrenal cortex, these hormones regulate stress responses, electrolyte balance, and immune function.Glucocorticoids: Involved in carbohydrate metabolism, anti-inflammatory actions, and immunosuppression.Cortisol, which increases blood glucose levels during stress and suppresses immune activity to prevent excessive inflammation.
Mineralocorticoids: Control salt and water balance to maintain blood pressure.Aldosterone, which promotes sodium reabsorption in the kidneys, thereby regulating extracellular fluid volume.
Sex steroids: Derived mainly from the gonads and adrenal glands, these influence sexual development, reproduction, and secondary sexual characteristics.Progestogens: Essential for preparing the reproductive system for pregnancy.Progesterone, which supports implantation and sustains early pregnancy by maintaining the uterine lining.
Androgens: Promote male reproductive development and maintenance.Testosterone, which drives spermatogenesis and the growth of male secondary sex characteristics such as muscle mass and facial hair.
Estrogens: Key to female reproductive cycles and skeletal health.Estradiol, which stimulates endometrial proliferation during the menstrual cycle and contributes to bone density.

Other steroids extend beyond hormonal roles and include compounds involved in neuroprotection, digestion, and neuromuscular activity:

Neurosteroids such as dehydroepiandrosterone (DHEA) and allopregnanolone, which modulate neurotransmitter receptors in the brain.
Bile acids such as taurocholic acid, which aid in lipid digestion and absorption in the intestine.
Aminosteroid neuromuscular blocking agents (synthetic), such as pancuronium bromide, used in anesthesia to induce muscle relaxation.
Steroidal antiandrogens (synthetic), such as cyproterone acetate, which block androgen receptors in hormone therapy.
Steroidogenesis inhibitors (exogenous), such as alfatradiol, which suppress steroid synthesis for therapeutic purposes.
Membrane sterols such as cholesterol (essential for cell membrane fluidity), ergosterol (a fungal membrane component), and various phytosterols (plant-derived sterols with cholesterol-lowering effects).
Toxins such as steroidal saponins (plant defense compounds) and cardenolides/cardiac glycosides (which affect heart function).

Steroids with an open-ring structure, known as secosteroids, include:Vitamin D forms such as ergocalciferol (from plant sources), cholecalciferol (from animal sources and sunlight), and calcitriol (the active form that regulates calcium homeostasis).