Metformin失败之后 延迟强化治疗常见


  【24drs.com】一篇新研究认为,在新诊断的第二型糖尿病患与其它未达到血糖目标者,metformin失败之后,延迟强化治疗很常见。
  
  俄亥俄州克里夫兰诊所内分泌科医师Kevin M Pantalone等人在在线发表于2016年8月12日糖尿病照护期刊的报告中写道,为了获得血糖控制,医师与患者应即时且尽早提升治疗介入。
  
  美国临床内分泌医师协会(AACE)最近发表的指引呼吁,如果以metformin单方治疗3个月之后,HbA1c未达到目标,应积极强化降血糖治疗。然而,本研究发现,介入的时间中位数是14个月,延迟强化治疗与缺乏实现HbA1c目标值有关。
  
  Pantalone医师等人指出,本研究的结果似乎可以支持[AACE]指引。
  
  这篇研究包括了新诊断第二型糖尿病的5,239名患者,这些人于2005-2013年间曾以metformin单方治疗至少3个月,在那时候,他们的平均HbA1c是6.4%,不过,22%的HbA1c值依旧大于7%、13%大于7.5%、8%大于8%。
  
  这三组患者,在HbA1c升高 —定义为经历「临床惯性」—的6个月内未接受介入的百分比,HbA1c大于7%者有38%、大于7.5%者有31%、大于8%者有28%。
  
  校正干扰因素之后,相较于延迟或未接受介入者,6个月内接受介入的患者比较可能达到他们的HbA1c目标(起初/开始时HbA1c > 7%;风险比[HR], 0.57;P = .001;起初/开始时 HbA1c > 7.5%;HR, 0.25;P = .01;起初/开始时HbA1c > 8%;HR, 0.25;P = .04)。
  
  相较于在6个月内接受介入的62%患者,经历临床惯性HbA1c大于7%的38%患者略为年长:56.0 vs 54.2岁(P = .038)。
  
  审视随机取样的20名延迟强化治疗的患者,11个案例中,这个惯性是患者驱动,其它9人是医师驱动。研究团队写道,对于患者,每个实例显示出多种未遵医嘱行为,包括失约(临床、实验室、或营养咨询)和未遵循治疗方案(药物、饮食、或运动)。
  
  另一方面,医师惯性的实例就是与医师未能指示强化治疗以提升HbA1c有关。
  
  资料来源:http://www.24drs.com/
  
  Native link:Delay in Intensified Therapy Common After Metformin Failure

Delay in Intensified Therapy Common After Metformin Failure

By Miriam E Tucker
Medscape Medical News

A delay in intensification of treatment after metformin failure is common in newly diagnosed type 2 diabetes and often hinders achievement of glycemic targets, suggests a new study.

"To obtain glycemic control, clinicians and patients need to escalate the therapeutic interventions earlier in the disease course and in a timelier manner," write Kevin M Pantalone, DO, an endocrinologist at the Cleveland Clinic, Ohio, and colleagues in their report published online August 12, 2016 in Diabetes Care

The most recent guidelines from the American Association of Clinical Endocrinologists (AACE) call for aggressive intensification of glucose-lowering therapy if individualized HbA1c goals aren't met after 3 months of metformin monotherapy. By contrast, in this study, the median time to intervention was 14 months, and delay to intensification was associated with a lack of achieving target HbA1c levels.

"The results of this study would seem to provide support for the…[AACE] guidelines," Dr Pantalone and colleagues note.

The study included 5239 patients with newly diagnosed type 2 diabetes who had been treated with metformin monotherapy for at least 3 months from 2005 to 2013. At that point, their mean HbA1c was 6.4%. However, 22% still had HbA1c levels above 7%, 13% above 7.5%, and 8% above 8%.

The percentages of patients in each of those three groups who did not receive an intervention within 6 months of the elevated HbA1c — defined as experiencing "clinical inertia" — were 38% for HbA1c above 7%, 31% for above 7.5%, and 28% of those above 8%.

After adjustments for confounders, patients who underwent intervention within 6 months were more likely to meet their target HbA1c levels compared with those who underwent later or no intervention (initial/baseline HbA1c > 7%; hazard ratio [HR], 0.57; P = .001; initial/baseline HbA1c > 7.5%; HR, 0.25; P = .01; initial/baseline HbA1c > 8%; HR, 0.25; P = .04).

Compared with the 62% for whom there was an intervention within 6 months, the 38% who experienced clinical inertia with HbA1c greater than 7% were slightly older: 56.0 vs 54.2 years (P = .038).

In a review of 20 randomly selected patients for whom intensification had been delayed, the inertia had been patient-driven in 11 cases and physician-driven in the other nine. With the patients, every instance "demonstrated multiple noncompliance behaviors, including missed appointments (clinical, laboratory, or nutrition consultations) and nonadherence to treatment regimens (medications, diet, or exercise)," the group writes.

On the other hand, the instances of physician inertia "were simply related to the physician's failure to intensify therapy as indicated to address an HbA1c elevation."

The study was funded by Merck Sharp & Dohme. Dr Pantalone reports receiving research funding from Novo Nordisk and Merck; receiving consulting fees from Sanofi, Novo Nordisk, Eli Lilly, and Merck; and receiving honoraria from Eli Lilly, Merck, AstraZeneca, Bristol-Myers Squibb, Sanofi, and Novo Nordisk for speaking/educational activities within the past 36 months. Disclosures for the coauthors are listed in the article.

Diabetes Care. Published online August 12, 2016.

    
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