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<title>心臓を守る！ミネラルコルチコイド受容体拮抗薬 | 株式会社文光堂</title>


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<meta name="description" content="ミネラルコルチコイド受容体拮抗薬（MRA）は従来アルドステロン拮抗薬と言われていたものである．近年，ミネラルコルチコイド受容体（MR）の新たな作用機序が続々と明らかになり，高血圧，CKD，メタボ，2型糖尿病，動脈硬化，そして心不全の病態進展に重要な役割を果たすことがわかってきた．本書では，MRの最新の病態生理からMRAの臨床エビデンス，そして次世代の非ステロイド型MRAの可能性までをエキスパートに">

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		<h1 class="catchCopy">最新の作用機序から臨床エビデンスまで，MRAの知識をこの1冊でアップデート！</h1>
		

		<h1 class="title">心臓を守る！ミネラルコルチコイド受容体拮抗薬<span class="version"></span></h1>
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					編集：伊藤　浩（岡山大学大学院医歯薬学総合研究科循環器内科学教授）
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				<ul class="property"><li class="disc">B5判・148頁・2色刷</li><li class="disc">ISBN&nbsp;978-4-8306-1946-5</li><li class="disc">2019年3月5日発行</li></ul>

				
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		<div class="headers"><h3 class="current content">内容</h3><h3 class="preface">序文</h3><h3 class="indexes">主要目次</h3></div><section class="current content">ミネラルコルチコイド受容体拮抗薬（MRA）は従来アルドステロン拮抗薬と言われていたものである．近年，ミネラルコルチコイド受容体（MR）の新たな作用機序が続々と明らかになり，高血圧，CKD，メタボ，2型糖尿病，動脈硬化，そして心不全の病態進展に重要な役割を果たすことがわかってきた．本書では，MRの最新の病態生理からMRAの臨床エビデンス，そして次世代の非ステロイド型MRAの可能性までをエキスパートによる解説でまとめた．</section><section class="preface">序　文<br><br>　ミネラルコルチコイド受容体拮抗薬（MRA）は従来アルドステロン拮抗薬といわれていたものである．スピロノラクトン，エプレレノンは古くからある薬であるが，降圧効果もあまり強くなく，利尿効果も弱い．さらに，高カリウム血症への懸念や糖尿病性腎症で使いにくいなど，ネガティブイメージが先行しているため実際には使用頻度はあまり高くない．これらの薬がアルドステロン拮抗薬ではなくなぜMRAと名称が変更されたのか，その理由すら知らない医師も多いのが現状である．そのため，レニン-アンジオテンシン-アルドステロン系という概念にとらわれるあまり，ACE阻害薬（ARB）でアルドステロンは制御可能であると考えている人も少なくない．ところが，近年，ミネラルコルチコイド受容体（MR）の新しいバイオロジーが続々と明らかになり，高血圧，慢性腎臓病（CKD），メタボリックシンドローム，2型糖尿病，動脈硬化そして心不全の病態進展に重要な役割を果たすことがわかってきた．特に，収縮不全患者ではMRAは必須の薬剤である．さらに，従来のMRAの副作用を軽減させた非ステロイド型MRA が市販され，MRAの降圧を超えた多面的な心血管保護作用を再認識する必要に迫られている．本書はMRの最新の病態生理からMRAの臨床エビデンス，そして非ステロイド型MRAへの展望などをQ＆A形式でわかりやすく各分野のエキスパートに解説していただいている．<br>　日々の循環器診療にどのようにMRA を役立てたらよいかヒントを得ることができたと言っていただければ執筆者一同の喜びである．<br><br>2019年2月<br>伊藤　浩</section><section class="indexes">PART 1 アルドステロンとMRを理解する<br>Q1　ミネラルコルチコイド受容体（MR）はどのようなものでしょうか？ その働きとともに教えてください<br>Q2　MRの腎上皮細胞における作用を教えてください<br>Q3　MRは腎臓以外に広く分布すると聞きました．どのような臓器に分布するのか，そしてその役割についても教えてください<br>Q4　アルドステロンは副腎皮質だけでなく他の組織でも産生されると聞きました．それに関して教えてください<br>Q5　組織にはコルチゾールが高濃度存在し，アルドステロンとほぼ同じ親和性でMRに結合すると聞きました．なぜ，腎上皮細胞ではMRにアルドステロンのみ作用するのでしょうか？<br>Q6　組織にはコルチゾールが高濃度存在し，アルドステロンとほぼ同じ親和性でMR に結合すると聞きました．心筋のMRではコルチゾールとアルドステロンがどのような関係になるのでしょうか？<br>Q7　なぜアルドステロン拮抗薬ではなく，ミネラルコルチコイド受容体拮抗薬（MRA）と呼ぶようになったのでしょうか？<br>Q8　アルドステロンの非上皮作用（腎上皮以外）に関して教えてください<br>Q9　アルドステロンとアンジオテンシンIIおよび交感神経系との相互作用に関して教えてください<br>Q10　アルドステロンのゲノム作用と非ゲノム作用を教えてください<br>Q11　MRはどのようなとき，あるいは刺激で活性化されるのでしょうか？<br>Q12　心不全，CKDや2型糖尿病でMRは活性化されているのでしょうか？<br>Q13　MRAに抗炎症作用効果があると聞きました．その機序に関して教えてください<br>Q14　MR活性化の中枢神経に対する生理的そして病的作用について教えてください<br>Q15　MR活性化の血管に対する病的作用に関して教えてください<br>Q16　MR活性化の心臓に対する病的作用に関して教えてください<br>Q17　MR活性化の腎臓に対する病的作用に関して教えてください<br>Q18　ACE阻害薬そしてARBでも出現するアルドステロンブレークスルーの機序と病的意義を教えてください<br>PART 2 MRAの臨床効果を検証する<br>降圧薬としてのMRA<br>Q19　欧米，日本の高血圧ガイドラインにおけるMRAの位置づけを教えてください<br>Q20　スピロノラクトンとエプレレノンの使い分けに関して教えてください<br>Q21　ACE阻害薬・ARBにMRAを加えるときのメリットと注意点を教えてください<br>Q22　MRAと併用するとより強い降圧効果が得られる組み合わせを教えてください<br>Q23　原発性アルドステロン症の病態と治療方針を教えてください<br>心不全<br>Q24　MRAの多施設共同試験を解説する（HFrEF）：RALES試験<br>Q25　MRAの多施設共同試験を解説する（HFrEF）：EMPHASIS-HF研究とJ-EMPHASISHF研究<br>Q26　HFrEF患者にはtriple blockadeが必要といわれています．なぜ，ACE阻害薬やβ遮断薬にMRAを加えると相加効果を出すのでしょうか？<br>Q27　HFrEF患者ではACE阻害薬やARBを最大限まで使用しないとMRAを併用してはいけないのでしょうか？ あるいは，MRAの先行投与はいけないのでしょうか？<br>Q28　HFrEF患者の入院急性期からMRAを使用したほうがよいでしょうか？<br>Q29　HFrEF患者にMRAを用いる場合に徐々に増量したほうがよいでしょうか？<br>Q30　ガイドラインではNYHA II度からMRAが推奨されていますが，NYHA I度の患者には使用すべきでしょうか？<br>Q31　超重症のHFrEF患者にもMRAは使うべきでしょうか？<br>Q32　MRAはHFrEF患者の突然死を減少させると聞きました．そのエビデンスと機序を教えてください<br>Q33　MRAの多施設共同試験を解説する（HFpEF）：TOPCAT試験<br>Q34　HFpEF患者にはMRA は無効なのでしょうか？ 軽症例に使用するメリットはあるでしょうか？<br>Q35　MRAの多施設共同試験を解説する（心筋梗塞）：EPHESUS試験<br>Q36　MRAには交感神経抑制作用があるのでしょうか？<br>Q37　どのような心筋梗塞患者にMRAが推奨されるのでしょうか？<br>Q38　MRAの心肥大抑制効果に関して教えてください<br>Q39　MRAでしばしば高K血症が問題になりますが，心不全患者における適正な血清K値に関して教えてください<br>血管保護作用<br>Q40　MRAの血管内皮機能とスティフネスに対する効果を教えてください<br>Q41　MRAの心血管イベント予防効果とその機序に関して教えてください<br>利尿薬としてのMRA<br>Q42　ループ利尿薬単独よりもMRAを加えたほうがよいといわれています．なぜなのでしょうか？ その理由を教えてください<br>Q43　慢性心不全患者の利尿におけるMRAそしてサイアザイドの役割を教えてください<br>腎保護効果<br>Q44　MRAは腎不全患者で使いにくい印象があります．腎保護効果はあるのでしょうか？<br>Q45　MRAは糖尿病性腎症の蛋白尿に対する効果があると聞きました．そのエビデンスと機序を教えてください<br>状況別使用法<br>Q46　75歳以上の高齢高血圧患者に対するMRAの適応と注意点に関して教えてください<br>Q47　高血圧を合併する2型糖尿病患者にMRAを使用するメリットと注意点を教えてください<br>MRA の副作用とその対策<br>Q48　MRAで誘発される高K血症の機序とそのハイリスク群を教えてください<br>Q49　MRAの高K血症対策：どこまで許容し，どのように対応したらよいのか教えてください<br>Q50　MRAの禁忌に関して教えてください<br>PART 3次世代MRAの可能性を探る<br>Q51　非ステロイド型MRAとはどのようなものでしょうか？<br>Q52　非ステロイド型MRAはスピロノラクトン，エプレレノンと異なり，どのような利点があるのでしょうか？<br>Q53　非ステロイド型MRAにはどのようなものがあるのでしょうか？<br>Q54　非ステロイド型MRAの降圧効果に関して教えてください<br>Q55　非ステロイド型MRAの腎保護効果の機序と糖尿病性腎症に対する効果に関して教えてください<br>Q56　非ステロイド型MRAの心不全に対する効果に関して教えてください<br>Q57　非ステロイド型MRAの副作用に関して教えてください<br>索引</section></article>
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