本帖最後由 lsc0019 於 2009-7-15 00:26 編輯
作者：Laurie Barclay, MD
出處：WebMD醫學新聞
June 22, 2009 — 一項發表在6月號糖尿病照護期刊的研究結果顯示，密集的降血糖藥物治療可以改善血糖控制，且不會惡化第二型糖尿病患者的精神或是身體健康狀況。
來自密西根大學安納堡分校的Laura N. McEwen博士與其同事們寫到，理想中，糖尿病治療療程應該個人化，且被設計來以預防併發症與併存疾病，同時尊重病患的偏好與最佳化生活品質。目前這項分析被設計來評估降血糖藥物治療對於計劃照護第二型糖尿病患者健康預後變化的影響。進一步的，我們評估密集化降血糖藥物的預測因子，其對於血紅素A1C、體重、焦慮/憂鬱症狀、與健康狀況，最後還有與A1C改善相關的病患特徵。
「Translating Research into Action for Diabetes（TRIAD）」是一項收納大約180,000位第二型糖尿病成人的研究。在這項分析中，研究團隊檢驗接受飲食與運動、降血糖藥物患者TRIAD普查結果、醫療紀錄、與健康計畫資料，這些患者的治療前A1C數值都高於7.2%，且維持同樣的治療或是密集治療達18個月。密集治療的定義是開始或是增加口服降血糖藥物種類數目，或是開始使用胰島素。
在1,093位病患中，520位在研究中加強治療。這一組的平均年齡為58±12歲，糖尿病罹病時間為11±9年，且治療前A1C為9.1%±1.5%。預測加強治療的因子為年紀較輕與較高的A1C數值。
加強治療相較於未加強治療，與A1C數值下降0.49%有關（P<0.0001）、且與體重增加3磅（P=0.003）有關，但不會改變焦慮或是憂鬱（P=0.5）或是健康狀況（P=0.2）。在加強治療病患中，A1C數值改善的預測因子為治療前A1C數值較高、年齡較大、黑人、低收入以及看醫師次數較多的受試者。
研究作者們寫到，研究顯示，加強治療改善血糖控制，且不會惡化焦慮/憂鬱、或是健康狀況，特別是對老人、低收入者或是其他第二型糖尿病少數病患。當病患可能因加強治療與改善血糖控制而受益時，需要介入來克服臨床上的惰性。
這項研究的限制包括依賴藥局的資料來確認降血糖藥物治療、根據新增藥物種類來定義加強治療而非根據增加劑量、以及未能評估服藥順從性。除此之外，無法同步開始新治療，以及所有病患都收納到處理照護健康計畫中，限制了這項研究的普遍性。
研究作者們的結論是，需要更多的研究來比較血糖降低與個體治療藥物的副作用資料，且仔細地考慮對老年病患加強治療的風險。
疾病控制與預防管理局（CDC）（糖尿病分部）與國家糖尿病、消化與腎臟疾病機構贊助這項研究。賽諾菲安萬特藥廠透過與密西根大學的研究服務合約贊助這些分析，且提供其中4位試驗作者研究經費。
Treatment Intensification May Improve Glycemic Control Without Adverse Effects in Type 2 Diabetes
By Laurie Barclay, MD
Medscape Medical News
June 22, 2009 — Antihyperglycemic treatment intensification improves glycemic control with no worsening of mental or physical health status in patients with type 2 diabetes, according to the results of a study reported in the June issue of Diabetes Care.
"Ideally, diabetes treatment regimens should be individually designed to prevent complications and comorbidities while respecting patient preferences and optimizing quality of life," write Laura N. McEwen, PhD, from the University of Michigan in Ann Arbor, and colleagues. "The current analyses were designed to assess the impact of changes in antihyperglycemic therapies on health outcomes in managed care patients with type 2 diabetes. Specifically, we assessed the predictors of intensification of antihyperglycemic therapy, its impact on [hemoglobin] A1C, body weight, symptoms of anxiety/depression, and health status, and patient characteristics associated with improvement in A1C."
Translating Research into Action for Diabetes (TRIAD) is a study of approximately 180,000 adults with diabetes. In this analysis, the investigators examined TRIAD survey, medical record, and health plan administrative data for patients treated with diet and exercise or oral antihyperglycemic medications at baseline, who had A1C levels of more than 7.2%, and who remained with the same treatment or intensified treatment for 18 months. Intensification of therapy was defined as starting or increasing the number of classes of oral antihyperglycemic medications or starting insulin.
Of 1093 patients, 520 intensified treatment during the study. In this group, mean age was 58 ± 12?years, diabetes duration was 11 ± 9 years, and baseline A1C level was 9.1% ± 1.5%. Factors predicting treatment intensification were younger age and higher A1C level.
Treatment intensification vs no intensification was associated with a 0.49% decrease in A1C level (P < .0001), a 3-pound increase in weight (P = .003), and no change in anxiety or depression (P = .5) or in health status (P = .2). In patients who intensified treatment, predictors of improvement in A1C level were higher baseline A1C level, older age, black race/ethnicity, lower income, and more clinician visits.
"Treatment intensification improved glycemic control with no worsening of anxiety/depression or health status, especially in elderly, lower-income, and minority patients with type 2 diabetes," the study authors write. "Interventions are needed to overcome clinical inertia when patients might benefit from treatment intensification and improved glycemic control."
Limitations of this study include reliance on pharmacy claims and utilization data for determination of antihyperglycemic treatment, definition of therapy intensification based on adding classes of medications and not on increasing the dose, and failure to assess medication adherence. In addition, the time of starting new therapies could not be synchronized, and all of the patients were enrolled in managed care health plans, limiting generalizability of the findings.
"More research is needed to define and compare the glucose-lowering and side effect profiles of individual therapeutic medications, and careful consideration is needed regarding the risks of intensification in elderly patients," the study authors conclude.
The Centers for Disease Control and Prevention (Division of Diabetes Translation) and the National Institute of Diabetes and Digestive and Kidney Diseases supported this study. sanofi-aventis supported these analyses through a Research Services Contract to the University of Michigan and provided research grant support to 4 of the study authors.
Diabetes Care. 2009;32:971-976. |
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