Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, WA, USA.
Seattle Epidemiologic Research and Information Center, VA Puget Sound Health Care System, Seattle, WA, USA.
J Gen Intern Med. 2018 Feb;33(2):155-165. doi: 10.1007/s11606-017-4219-3. Epub 2017 Nov 27.
For patients with type 2 diabetes and chronic kidney disease (CKD), high-quality evidence about the relative benefits and harms of oral glucose-lowering drugs is limited.
To evaluate whether mortality risk differs after the initiation of monotherapy with either metformin or a sulfonylurea in Veterans with type 2 diabetes and CKD.
Observational, national cohort study in the Veterans Health Administration (VHA).
Veterans who received care from the VHA for at least 1 year prior to initiating monotherapy treatment for type 2 diabetes with either metformin or a sulfonylurea between 2004 and 2009.
Metformin and sulfonylurea use was assessed from VHA electronic pharmacy records. The CKD-EPI equation was used to estimate glomerular filtration rate (eGFR). The outcome of death from January 1, 2004, through December 31, 2009, was assessed from VHA Vital Status files.
Among 175,296 new users of metformin or a sulfonylurea monotherapy, 5121 deaths were observed. In primary analyses adjusted for all measured potential confounding factors, metformin monotherapy was associated with a lower mortality hazard ratio (HR) compared with sulfonylurea monotherapy across all ranges of eGFR evaluated (HR ranging from 0.59 to 0.80). A secondary analysis of mortality risk differences favored metformin across all eGFR ranges; the greatest risk difference was observed in the eGFR category 30-44 mL/min/1.73m (12.1 fewer deaths/1000 person-years, 95% CI 5.2-19.0).
Initiation of metformin versus a sulfonylurea among individuals with type 2 diabetes and CKD was associated with a substantial reduction in mortality, in terms of both relative and absolute risk reduction. The largest absolute risk reduction was observed among individuals with moderately-severely reduced eGFR (30-44 mL/min/1.73m).
对于 2 型糖尿病合并慢性肾脏病（CKD）的患者，关于口服降糖药物相对益处和危害的高质量证据有限。
评估在 Veterans 卫生保健系统（VHA）中，2 型糖尿病合并 CKD 患者起始使用二甲双胍或磺酰脲类药物单药治疗后，其死亡率风险是否存在差异。
在 Veterans 卫生保健系统（VHA）中进行的观察性、全国队列研究。
2004 年至 2009 年间，在接受 Veterans 卫生保健系统（VHA）至少 1 年治疗的 Veterans 中，起始使用二甲双胍或磺酰脲类药物单药治疗 2 型糖尿病。
通过 Veterans 卫生保健系统（VHA）电子药房记录评估二甲双胍和磺酰脲类药物的使用情况。使用 CKD-EPI 方程估计肾小球滤过率（eGFR）。通过 Veterans 卫生保健系统（VHA）生存状况文件评估 2004 年 1 月 1 日至 2009 年 12 月 31 日期间的死亡结局。
在 175296 例新使用二甲双胍或磺酰脲类药物单药治疗的患者中，观察到 5121 例死亡。在调整了所有测量的潜在混杂因素后，在所有评估的 eGFR 范围内（HR 范围为 0.59 至 0.80），与磺酰脲类药物单药治疗相比，二甲双胍单药治疗与较低的死亡率风险比（HR）相关。在所有 eGFR 范围内，对死亡率风险差异的二次分析均倾向于二甲双胍；在 eGFR 为 30-44ml/min/1.73m 2 的患者中，风险差异最大（每 1000 人年减少 12.1 例死亡，95%CI 为 5.2-19.0）。
在 Veterans 卫生保健系统（VHA）中，2 型糖尿病合并 CKD 患者起始使用二甲双胍而非磺酰脲类药物与死亡率显著降低相关，无论从相对风险降低还是绝对风险降低的角度来看都是如此。在 eGFR 中度至重度降低（30-44ml/min/1.73m 2 ）的患者中，观察到的绝对风险降低最大。
