专家建议:高血压治疗中钙拮抗剂/ACEI单片复方制剂如何用?

2016-04-18 指南君 中华高血压杂志

联合用药近年高血压治疗的一个潮流。其中单片复方制剂有利于提高患者依从性。在众多的药物组合中,钙拮抗剂与血管紧张素转换酶抑制剂(ACEI)的联合被认为是个“黄金搭档”而被国内外指南推荐。 近期,中国医师协会高血压专业委员会制定了钙拮抗剂/血管紧张素转换酶抑制剂单片复方制剂在高血压治疗中的应用中国专家建议,小编将其主要内容整理如下。 协同作用机制 首先,钙拮抗剂具有直

联合用药近年高血压治疗的一个潮流。其中单片复方制剂有利于提高患者依从性。在众多的药物组合中,钙拮抗剂与血管紧张素转换酶抑制剂(ACEI)的联合被认为是个“黄金搭档”而被国内外指南推荐。

近期,中国医师协会高血压专业委员会制定了钙拮抗剂/血管紧张素转换酶抑制剂单片复方制剂在高血压治疗中的应用中国专家建议,小编将其主要内容整理如下。

协同作用机制

首先,钙拮抗剂具有直接扩张动脉的作用,反射性激活肾素血管紧张素醛固酮系统(RAAS),ACEI可抑制激活的RAAS。钙拮抗剂的利钠和轻度利尿作用能够增强ACEI的降压疗效,两者联合应用提高降压疗效。

再次,钙拮抗剂兼有扩张肾入球和出球小动脉作用,而ACEI主要扩张肾小球出球小动脉,两者联用对肾小球内压有良好效应,协同保护肾脏。

此外,钙拮抗剂使毛细血管阻力增加,导致踝部水肿,而ACEI同时扩张动脉和静脉,可减少钙拮抗剂所致水肿。

因此,钙拮抗剂联合ACEI具有协同降压作用,能更好地保护靶器官,同时可减轻彼此的不良反应。

安全性与不良反应

两类药物对于血糖、血脂和尿酸代谢均无不良影响,是较为理想的降压药物。

ACEI主要不良反应是咳嗽,以干咳为主。可见于所有ACEI药物,机制与药物抑制内源性缓激肽降解有关,停药后可缓解并消失。另一严重的不良反应为血管神经性水肿,但较为少见。

钙拮抗剂常见不良反应为踝、足和小腿部水肿,既有剂量依赖现象(主要是外周水肿),又有非剂量依赖现象,前者更为常见。这是由于钙拮抗剂主要扩张动脉,而对静脉扩张能力不足所致。ACEI兼有动脉和静脉扩张作用,可减少水肿发生。另外,钙拮抗剂可导致牙龈增生。

临床应用

1. 适用人群

(1)血压≥160/100mm Hg,或高于目标血压20/10mm Hg的患者,如无禁忌证可作为起始和维持治疗药物。

(2)正在接受降压药物治疗,包括单药治疗或非单片复方制剂联合治疗的患者,如血压未能达标,可以替换或加用钙拮抗剂/ACEI单片复方制剂。

(3)已服用2种降压药自由联合治疗且血压已达标的高血压患者,为简化治疗,提高患者依从性,建议直接改用钙拮抗剂/ACEI单片复方制剂。

(4)尤其适用于高血压伴有多种危险因素、靶器官损害或临床疾患高危人群:冠心病、糖尿病、CKD、蛋白尿、左心室肥厚、老年高血压、脑卒中、肥胖、代谢综合征、外周血管病等。

2. 慎用和禁用人群

(1)对钙拮抗剂或ACEI过敏者。

(2)服用钙拮抗剂或ACEI出现过不良反应者,尤其是ACEI引起明显的咳嗽或血管神经性水肿者。

(3)急性充血性心力衰竭。

(4)高血钾症。

(5)严重肾功能衰竭[估算的肾小球滤过率(eGFR)<30 mL/(min·1.73m2)]。

(6)妊娠或哺乳期。

(7)双侧肾动脉狭窄。

3. 注意事项

(1)常用剂量为1片/d,血压控制欠佳时可增加至2片。因病情需要可加用第3种降压药,但不建议加用血管紧张素受体拮抗剂(ARB)。

(2)氨氯地平/贝那普利固定复方制剂的组分剂量不同,应根据患者病情选择服用。

(3)因老年人群服用降压药可引起症状性低血压,建议从较低剂量的单片复方开始;甚至从低剂量的单药开始,然后改用单片复方制剂,以防低血压发生。

(4)对于CKD患者,用药后应密切监测血肌酐和血钾水平,尤其联合使用保钾利尿剂、钾补充剂和(或)含有钾盐替代品的患者。服药后血肌酐和血钾升高一般都是可逆的。若血钾≥5.5mmol/L或eGFR升高>30%,应及时调整药物剂量甚至停药。

(5)用药后血压迅速下降时,应警惕是否合并肾动脉狭窄。

(6)因病情需要调整其中一个组分剂量时,不适宜选择固定剂量单片复方制剂,应个体化治疗。

特殊人群中的应用

1 高血压合并冠心病患者

钙拮抗剂能扩张冠状动脉,增加心肌血供,同时能抑制心肌收缩、降低耗氧量,因此能缓解心绞痛和减少心绞痛发作。

2013年欧洲稳定型冠状动脉疾病管理指南和2015年美国心脏协会/美国心脏病学会/美国高血压协会(AHA/ACC/ASH)冠心病患者高血压治疗联合声明指出:合并急性冠状动脉综合征(ACS)的高血压患者,当使用ACEI血压控制不佳时,可联合钙拮抗剂降压治疗或换用钙拮抗剂/ACEI单片复方制剂;合并稳定型冠心病的高血压患者,可起始或维持使用钙拮抗剂/ACEI单片复方制剂。

2. 高血压合并糖尿病患者 

ACEI和钙拮抗剂是众多糖尿病指南推荐的首选降压药物,因为两者均对糖、脂代谢无不利影响。高血压合并糖尿病患者肾脏局部RAAS激活和水钠潴留更为显著,对此类变化ACEI具有独到作用。另外,ACEI还能改善糖尿病患者的代谢。

《中国高血压防治指南2010》指出,高血压合并糖尿病患者的降压治疗应强调血压严格达标,目标血压<130/80mm Hg。为实现降压达标,多数高血压合并糖尿病患者需联合用药。钙拮抗剂/ACEI或钙拮抗剂/ARB为优化联合降压方案。建议患者起始或维持使用钙拮抗剂/ACEI单片复方制剂。

3. 高血压合并CKD患者

容量负荷增加和RAAS激活是CKD合并高血压的重要发病机制。ACEI可降低肾小球囊内压,改善高灌注和高滤过,减少尿蛋白,延缓肾功能损害,具有良好的肾脏保护作用。因此,ACEI是CKD 患者首选降压药物。

CKD合并高血压的患者血压通常难以控制,需多种降压药物联合应用。2014年美国JNC8和2012年KDIGO指南明确指出,ACEI可联合钙拮抗剂或利尿剂使用。联用钙拮抗剂可更好地降低血压,进而减轻体循环压力,改善肾小球内高滤过、高灌注状态,保护肾脏功能。当eGFR<30mL/(min·1.73m^2)时氢氯噻嗪疗效显著下降,此时ACEI与钙拮抗剂联用可能更为合适。

4. 高血压合并左心室肥厚患者

 《中国高血压防治指南2010》和2013年欧洲高血压学会/欧洲心脏病学会(ESH/ESC)高血压管理指南指出:钙拮抗剂、ACEI和ARB对延缓和逆转左心室肥厚效果优于β受体阻滞剂与利尿剂。

5. 高血压合并脑卒中患者

研究显示钙拮抗剂能更有效地降低远期脑卒中的发生风险,而β受体阻滞剂的效果最差。高血压合并脑卒中患者多数需要联合降压药物以达到目标血压,因此,钙拮抗剂和ACEI或ARB的单片复方制剂适用于高血压伴脑卒中患者。

6. 老年高血压患者

老年高血压患者的肾脏特点包括:肾小球数量逐渐减少,eGFR降低;利钠物质生成减少以及钠排出减少;近端肾小管钠重吸收增加,导致容量负荷增高;肾动脉粥样硬化导致有效肾血浆流量减少,局部RAAS激活。老年人合并心血管病危险因素和疾病较多。

钙拮抗剂、ACEI和ARB可用于老年高血压患者的起始和维持治疗。我国老年人群降压达标率低。大多数老年患者需要联合降压治疗,但是老年患者的记忆减退,容易漏服药物。服用多片药物会导致依从性降低。单片复方制剂的使用可以增加患者的依从性。

以上为指南君学习笔记,整理自:中国医师协会高血压专业委员会,钙拮抗剂/血管紧张素转换酶抑制剂单片复方制剂在高血压治疗中的应用中国专家建议,中华高血压杂志.2016,24(1):19-25.

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    2016-10-26 shanyongle
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    2016-05-10 QQ6709219e

    看的不爽,老是那么多问号?

    0

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  4. [GetPortalCommentsPageByObjectIdResponse(id=1655736, encodeId=783b1655e3642, content=<a href='/topic/show?id=2a011829d7' target=_blank style='color:#2F92EE;'>#ACE#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=80, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=1829, encryptionId=2a011829d7, topicName=ACE)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=635024767990, createdName=shanyongle, createdTime=Wed Oct 26 12:31:00 CST 2016, time=2016-10-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=85239, encodeId=49dc852391d, content=看的不爽,老是那么多问号?, beContent=null, objectType=article, channel=null, level=null, likeNumber=190, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=172d1721528, createdName=QQ6709219e, createdTime=Tue May 10 10:59:00 CST 2016, time=2016-05-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2019949, encodeId=cb7d201994919, content=<a href='/topic/show?id=fbe496341a6' target=_blank style='color:#2F92EE;'>#钙拮抗剂#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=75, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=96341, encryptionId=fbe496341a6, topicName=钙拮抗剂)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4b632500090, createdName=h.y200607_23674418, createdTime=Sat Apr 30 14:31:00 CST 2016, time=2016-04-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=82548, encodeId=cdd8825482a, content=写的很详细, beContent=null, objectType=article, channel=null, level=null, likeNumber=178, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=9ebb1716792, createdName=黑心天使, createdTime=Sun Apr 24 20:54:00 CST 2016, time=2016-04-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1511643, encodeId=e0331511643a3, content=<a href='/topic/show?id=90d75628960' target=_blank style='color:#2F92EE;'>#拮抗剂#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=91, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56289, encryptionId=90d75628960, topicName=拮抗剂)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=474c10379153, createdName=ms5236388012055669, createdTime=Wed Apr 20 04:31:00 CST 2016, time=2016-04-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1601045, encodeId=084816010459b, content=<a href='/topic/show?id=dd43426460c' target=_blank style='color:#2F92EE;'>#复方制剂#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=92, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=42646, encryptionId=dd43426460c, topicName=复方制剂)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=a12645, createdName=智慧医人, createdTime=Wed Apr 20 04:31:00 CST 2016, time=2016-04-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=79694, encodeId=d9fae96949a, content=注意事项4、eGFR升高>30%停药不对吧!, beContent=null, objectType=article, channel=null, level=null, likeNumber=126, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=f9521712779, createdName=arex2009, createdTime=Tue Apr 19 19:04:00 CST 2016, time=2016-04-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=79423, encodeId=5c21e9423b2, content=写的不错, beContent=null, objectType=article, channel=null, level=null, likeNumber=179, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=240a1683959, createdName=李继凯, createdTime=Tue Apr 19 00:53:00 CST 2016, time=2016-04-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=79383, encodeId=2781e9383a5, content=现在临床中都是这么用,讲的挺好的, beContent=null, objectType=article, channel=null, level=null, likeNumber=171, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=e31c1656664, createdName=永圣, createdTime=Mon Apr 18 19:27:00 CST 2016, time=2016-04-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=79364, encodeId=73e7e936493, content=学习了,很好, beContent=null, objectType=article, channel=null, level=null, likeNumber=111, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=387d1660055, createdName=dhzzm, createdTime=Mon Apr 18 15:59:00 CST 2016, time=2016-04-18, status=1, ipAttribution=)]
    2016-04-24 黑心天使

    写的很详细

    0

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  6. [GetPortalCommentsPageByObjectIdResponse(id=1655736, encodeId=783b1655e3642, content=<a href='/topic/show?id=2a011829d7' target=_blank style='color:#2F92EE;'>#ACE#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=80, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=1829, encryptionId=2a011829d7, topicName=ACE)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=635024767990, createdName=shanyongle, createdTime=Wed Oct 26 12:31:00 CST 2016, time=2016-10-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=85239, encodeId=49dc852391d, content=看的不爽,老是那么多问号?, beContent=null, objectType=article, channel=null, level=null, likeNumber=190, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=172d1721528, createdName=QQ6709219e, createdTime=Tue May 10 10:59:00 CST 2016, time=2016-05-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2019949, encodeId=cb7d201994919, content=<a href='/topic/show?id=fbe496341a6' target=_blank style='color:#2F92EE;'>#钙拮抗剂#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=75, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=96341, encryptionId=fbe496341a6, topicName=钙拮抗剂)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4b632500090, createdName=h.y200607_23674418, createdTime=Sat Apr 30 14:31:00 CST 2016, time=2016-04-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=82548, encodeId=cdd8825482a, content=写的很详细, beContent=null, objectType=article, channel=null, level=null, likeNumber=178, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=9ebb1716792, createdName=黑心天使, createdTime=Sun Apr 24 20:54:00 CST 2016, time=2016-04-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1511643, encodeId=e0331511643a3, content=<a href='/topic/show?id=90d75628960' target=_blank style='color:#2F92EE;'>#拮抗剂#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=91, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56289, encryptionId=90d75628960, topicName=拮抗剂)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=474c10379153, createdName=ms5236388012055669, createdTime=Wed Apr 20 04:31:00 CST 2016, time=2016-04-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1601045, encodeId=084816010459b, content=<a href='/topic/show?id=dd43426460c' target=_blank style='color:#2F92EE;'>#复方制剂#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=92, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=42646, encryptionId=dd43426460c, topicName=复方制剂)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=a12645, createdName=智慧医人, createdTime=Wed Apr 20 04:31:00 CST 2016, time=2016-04-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=79694, encodeId=d9fae96949a, content=注意事项4、eGFR升高>30%停药不对吧!, beContent=null, objectType=article, channel=null, level=null, likeNumber=126, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=f9521712779, createdName=arex2009, createdTime=Tue Apr 19 19:04:00 CST 2016, time=2016-04-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=79423, encodeId=5c21e9423b2, content=写的不错, beContent=null, objectType=article, channel=null, level=null, likeNumber=179, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=240a1683959, createdName=李继凯, createdTime=Tue Apr 19 00:53:00 CST 2016, time=2016-04-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=79383, encodeId=2781e9383a5, content=现在临床中都是这么用,讲的挺好的, beContent=null, objectType=article, channel=null, level=null, likeNumber=171, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=e31c1656664, createdName=永圣, createdTime=Mon Apr 18 19:27:00 CST 2016, time=2016-04-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=79364, encodeId=73e7e936493, content=学习了,很好, beContent=null, objectType=article, channel=null, level=null, likeNumber=111, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=387d1660055, createdName=dhzzm, createdTime=Mon Apr 18 15:59:00 CST 2016, time=2016-04-18, status=1, ipAttribution=)]
  7. [GetPortalCommentsPageByObjectIdResponse(id=1655736, encodeId=783b1655e3642, content=<a href='/topic/show?id=2a011829d7' target=_blank style='color:#2F92EE;'>#ACE#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=80, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=1829, encryptionId=2a011829d7, topicName=ACE)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=635024767990, createdName=shanyongle, createdTime=Wed Oct 26 12:31:00 CST 2016, time=2016-10-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=85239, encodeId=49dc852391d, content=看的不爽,老是那么多问号?, beContent=null, objectType=article, channel=null, level=null, likeNumber=190, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=172d1721528, createdName=QQ6709219e, createdTime=Tue May 10 10:59:00 CST 2016, time=2016-05-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2019949, encodeId=cb7d201994919, content=<a href='/topic/show?id=fbe496341a6' target=_blank style='color:#2F92EE;'>#钙拮抗剂#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=75, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=96341, encryptionId=fbe496341a6, topicName=钙拮抗剂)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4b632500090, createdName=h.y200607_23674418, createdTime=Sat Apr 30 14:31:00 CST 2016, time=2016-04-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=82548, encodeId=cdd8825482a, content=写的很详细, beContent=null, objectType=article, channel=null, level=null, likeNumber=178, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=9ebb1716792, createdName=黑心天使, createdTime=Sun Apr 24 20:54:00 CST 2016, time=2016-04-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1511643, encodeId=e0331511643a3, content=<a href='/topic/show?id=90d75628960' target=_blank style='color:#2F92EE;'>#拮抗剂#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=91, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56289, encryptionId=90d75628960, topicName=拮抗剂)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=474c10379153, createdName=ms5236388012055669, createdTime=Wed Apr 20 04:31:00 CST 2016, time=2016-04-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1601045, encodeId=084816010459b, content=<a href='/topic/show?id=dd43426460c' target=_blank style='color:#2F92EE;'>#复方制剂#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=92, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=42646, encryptionId=dd43426460c, topicName=复方制剂)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=a12645, createdName=智慧医人, createdTime=Wed Apr 20 04:31:00 CST 2016, time=2016-04-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=79694, encodeId=d9fae96949a, content=注意事项4、eGFR升高>30%停药不对吧!, beContent=null, objectType=article, channel=null, level=null, likeNumber=126, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=f9521712779, createdName=arex2009, createdTime=Tue Apr 19 19:04:00 CST 2016, time=2016-04-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=79423, encodeId=5c21e9423b2, content=写的不错, beContent=null, objectType=article, channel=null, level=null, likeNumber=179, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=240a1683959, createdName=李继凯, createdTime=Tue Apr 19 00:53:00 CST 2016, time=2016-04-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=79383, encodeId=2781e9383a5, content=现在临床中都是这么用,讲的挺好的, beContent=null, objectType=article, channel=null, level=null, likeNumber=171, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=e31c1656664, createdName=永圣, createdTime=Mon Apr 18 19:27:00 CST 2016, time=2016-04-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=79364, encodeId=73e7e936493, content=学习了,很好, beContent=null, objectType=article, channel=null, level=null, likeNumber=111, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=387d1660055, createdName=dhzzm, createdTime=Mon Apr 18 15:59:00 CST 2016, time=2016-04-18, status=1, ipAttribution=)]
    2016-04-19 arex2009

    注意事项4、eGFR升高>30%停药不对吧!

    0

  8. [GetPortalCommentsPageByObjectIdResponse(id=1655736, encodeId=783b1655e3642, content=<a href='/topic/show?id=2a011829d7' target=_blank style='color:#2F92EE;'>#ACE#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=80, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=1829, encryptionId=2a011829d7, topicName=ACE)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=635024767990, createdName=shanyongle, createdTime=Wed Oct 26 12:31:00 CST 2016, time=2016-10-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=85239, encodeId=49dc852391d, content=看的不爽,老是那么多问号?, beContent=null, objectType=article, channel=null, level=null, likeNumber=190, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=172d1721528, createdName=QQ6709219e, createdTime=Tue May 10 10:59:00 CST 2016, time=2016-05-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2019949, encodeId=cb7d201994919, content=<a href='/topic/show?id=fbe496341a6' target=_blank style='color:#2F92EE;'>#钙拮抗剂#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=75, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=96341, encryptionId=fbe496341a6, topicName=钙拮抗剂)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4b632500090, createdName=h.y200607_23674418, createdTime=Sat Apr 30 14:31:00 CST 2016, time=2016-04-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=82548, encodeId=cdd8825482a, content=写的很详细, beContent=null, objectType=article, channel=null, level=null, likeNumber=178, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=9ebb1716792, createdName=黑心天使, createdTime=Sun Apr 24 20:54:00 CST 2016, time=2016-04-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1511643, encodeId=e0331511643a3, content=<a href='/topic/show?id=90d75628960' target=_blank style='color:#2F92EE;'>#拮抗剂#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=91, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56289, encryptionId=90d75628960, topicName=拮抗剂)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=474c10379153, createdName=ms5236388012055669, createdTime=Wed Apr 20 04:31:00 CST 2016, time=2016-04-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1601045, encodeId=084816010459b, content=<a href='/topic/show?id=dd43426460c' target=_blank style='color:#2F92EE;'>#复方制剂#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=92, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=42646, encryptionId=dd43426460c, topicName=复方制剂)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=a12645, createdName=智慧医人, createdTime=Wed Apr 20 04:31:00 CST 2016, time=2016-04-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=79694, encodeId=d9fae96949a, content=注意事项4、eGFR升高>30%停药不对吧!, beContent=null, objectType=article, channel=null, level=null, likeNumber=126, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=f9521712779, createdName=arex2009, createdTime=Tue Apr 19 19:04:00 CST 2016, time=2016-04-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=79423, encodeId=5c21e9423b2, content=写的不错, beContent=null, objectType=article, channel=null, level=null, likeNumber=179, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=240a1683959, createdName=李继凯, createdTime=Tue Apr 19 00:53:00 CST 2016, time=2016-04-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=79383, encodeId=2781e9383a5, content=现在临床中都是这么用,讲的挺好的, beContent=null, objectType=article, channel=null, level=null, likeNumber=171, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=e31c1656664, createdName=永圣, createdTime=Mon Apr 18 19:27:00 CST 2016, time=2016-04-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=79364, encodeId=73e7e936493, content=学习了,很好, beContent=null, objectType=article, channel=null, level=null, likeNumber=111, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=387d1660055, createdName=dhzzm, createdTime=Mon Apr 18 15:59:00 CST 2016, time=2016-04-18, status=1, ipAttribution=)]
    2016-04-19 李继凯

    写的不错

    0

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    2016-04-18 永圣

    现在临床中都是这么用,讲的挺好的

    0

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    2016-04-18 dhzzm

    学习了,很好

    0

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