Black Cody D, Thompson Wade, Welch Vivian, McCarthy Lisa, Rojas-Fernandez Carlos, Lochnan Heather, Shamji Salima, Upshur Ross, Farrell Barbara
Bruyère Research Institute, Ottawa, ON, Canada.
School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada.
Diabetes Ther. 2017 Feb;8(1):23-31. doi: 10.1007/s13300-016-0220-9. Epub 2016 Dec 15.
Individualizing glycemic targets to goals of care and time to benefit in persons with type 2 diabetes is good practice, particularly in populations at risk of hypoglycemia and adverse outcomes relating to the use of antihyperglycemics. Guidelines acknowledge the need for relaxed targets in frail older adults, but there is little guidance on how to safely deprescribe (i.e. stop, reduce or substitute) antihyperglycemics.
The purpose of this study was to synthesize evidence from all studies evaluating the effects of deprescribing versus continuing antihyperglycemics in older adults with type 2 diabetes. To this end, we searched MEDLINE, EMBASE, and Cochrane Library (July 2015) for controlled studies evaluating the effects of deprescribing antihyperglycemics in adults with type 2 diabetes. All such studies were eligible for inclusion in our study, and two independent reviewers screened titles, abstracts and full-text articles, extracted data, and evaluated risk of bias. Grading of Recommendations Assessment, Development and Evaluation (GRADE) assessment and a narrative summary were completed.
We identified two controlled before-and-after studies, both of very low quality. One study found that an educational intervention decreased glyburide use while not compromising glucose control. The other reported that cessation of antihyperglycemics in elderly nursing home patients resulted in a non-significant increase in glycated hemoglobin (HbA1C). No significant change in hypoglycemia rate was found in the only study with this outcome measure.
There is limited evidence available regarding deprescribing antihyperglycemic medications. Adequately powered, high-quality studies, particularly in the elderly and with clinically important outcomes, are required to support evidence-based decision-making.
CRD42015017748.
将血糖目标个体化以契合护理目标及2型糖尿病患者的获益时间是良好的做法，尤其是在有低血糖风险以及使用降糖药会产生不良后果的人群中。指南认可体弱老年人需要放宽血糖目标，但对于如何安全地停用（即停止、减少或替换）降糖药几乎没有指导意见。
本研究的目的是综合所有评估在老年2型糖尿病患者中停用降糖药与继续使用降糖药效果的研究证据。为此，我们检索了MEDLINE、EMBASE和Cochrane图书馆（2015年7月），以查找评估在成年2型糖尿病患者中停用降糖药效果的对照研究。所有此类研究均符合纳入我们研究的条件，两名独立的评审人员筛选标题、摘要和全文文章，提取数据，并评估偏倚风险。完成了推荐分级评估、制定和评价（GRADE）评估以及叙述性总结。
我们确定了两项前后对照研究，质量均非常低。一项研究发现，一项教育干预措施减少了格列本脲的使用，同时并未影响血糖控制。另一项研究报告称，老年疗养院患者停用降糖药后糖化血红蛋白（HbA1C）有不显著的升高。在唯一一项有此结局指标的研究中，未发现低血糖发生率有显著变化。
关于停用降糖药的证据有限。需要开展有足够效力的高质量研究，尤其是针对老年人且有临床重要结局的研究，以支持基于证据的决策制定。
CRD42015017748。
