Metformin失敗之後 延遲強化治療常見


  【24drs.com】一篇新研究認為,在新診斷的第二型糖尿病患與其他未達到血糖目標者,metformin失敗之後,延遲強化治療很常見。
  
  俄亥俄州克里夫蘭診所內分泌科醫師Kevin M Pantalone等人在線上發表於2016年8月12日糖尿病照護期刊的報告中寫道,為了獲得血糖控制,醫師與患者應即時且儘早提升治療介入。
  
  美國臨床內分泌醫師協會(AACE)最近發表的指引呼籲,如果以metformin單方治療3個月之後,HbA1c未達到目標,應積極強化降血糖治療。然而,本研究發現,介入的時間中位數是14個月,延遲強化治療與缺乏實現HbA1c目標值有關。
  
  Pantalone醫師等人指出,本研究的結果似乎可以支持[AACE]指引。
  
  這篇研究包括了新診斷第二型糖尿病的5,239名患者,這些人於2005-2013年間曾以metformin單方治療至少3個月,在那時候,他們的平均HbA1c是6.4%,不過,22%的HbA1c值依舊大於7%、13%大於7.5%、8%大於8%。
  
  這三組患者,在HbA1c升高 —定義為經歷「臨床慣性」—的6個月內未接受介入的百分比,HbA1c大於7%者有38%、大於7.5%者有31%、大於8%者有28%。
  
  校正干擾因素之後,相較於延遲或未接受介入者,6個月內接受介入的患者比較可能達到他們的HbA1c目標(起初/開始時HbA1c > 7%;風險比[HR], 0.57;P = .001;起初/開始時 HbA1c > 7.5%;HR, 0.25;P = .01;起初/開始時HbA1c > 8%;HR, 0.25;P = .04)。
  
  相較於在6個月內接受介入的62%患者,經歷臨床慣性HbA1c大於7%的38%患者略為年長:56.0 vs 54.2歲(P = .038)。
  
  審視隨機取樣的20名延遲強化治療的患者,11個案例中,這個慣性是患者驅動,其他9人是醫師驅動。研究團隊寫道,對於患者,每個實例顯示出多種未遵醫囑行為,包括失約(臨床、實驗室、或營養諮詢)和未遵循治療方案(藥物、飲食、或運動)。
  
  另一方面,醫師慣性的實例就是與醫師未能指示強化治療以提升HbA1c有關。
  
  資料來源: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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