Medical School, University of Western Australia, Fremantle, Australia.
Diabetes Obes Metab. 2018 Dec;20(12):2852-2859. doi: 10.1111/dom.13469. Epub 2018 Aug 10.
To investigate whether tight glycaemic control achieved with metformin, insulin or sulphonylurea-based pharmacotherapy increases all-cause mortality in older people with type 2 diabetes.
We conducted a prospective cohort study of individuals with known diabetes recruited between 2008 and 2011 and followed until 2016. The impact of baseline glycated haemoglobin (HbA1c) on mortality hazards was investigated in participants aged ≥75 years. Proportional hazards models for time to death were constructed from the baseline clinical assessment, then the variables of interest (HbA1c, treatment category and their interactions) were entered.
There were 367 participants (mean age 80.1 ± 3.9 years, median [interquartile range] HbA1c 50 [45-56] mmol/mol or 6.7 [6.3-7.3]%) who were followed for a median (interquartile range) 6.7 (4.5-7.7) years, during which 40.9% of the participants died. At baseline, 60.4% were on metformin-based treatment, 35.3% on sulphonylurea-based treatment and 23.2% on treatment including insulin. Baseline HbA1c was significantly associated with mortality in a model that included interactions between HbA1c and the three treatment-based groups compared with non-pharmacological treatment. The metformin treatment group had higher mortality when HbA1c levels were <48 mmol/mol (<6.5%) and the sulphonylurea and insulin treatment groups had higher mortality when HbA1c levels were <52 mmol/mol (<7.0%), with hazard ratios of 2.63 (95% confidence interval [CI] 1.39-4.97), 2.49 (95% CI 1.14-5.44) and 2.22 (95% CI 1.12-4.43), respectively.
Tight glycaemic control may be hazardous in older people with type 2 diabetes when achieved with pharmacotherapy with metformin, and especially with insulin or sulphonylureas. These data confirm that overtreatment is likely to be an important clinical problem in this vulnerable population.
研究二甲双胍、胰岛素或磺脲类药物治疗实现的严格血糖控制是否会增加 2 型糖尿病老年患者的全因死亡率。
我们进行了一项前瞻性队列研究，纳入了 2008 年至 2011 年间确诊的糖尿病患者，并随访至 2016 年。研究人员在年龄≥75 岁的参与者中，调查了基线糖化血红蛋白（HbA1c）对死亡率风险的影响。通过基线临床评估构建了死亡时间的比例风险模型，然后输入了感兴趣的变量（HbA1c、治疗类别及其相互作用）。
共有 367 名参与者（平均年龄 80.1±3.9 岁，中位数[四分位间距]HbA1c 50[45-56]mmol/mol 或 6.7[6.3-7.3]%）接受了中位（四分位间距）6.7（4.5-7.7）年的随访，在此期间，40.9%的参与者死亡。基线时，60.4%的患者接受二甲双胍治疗，35.3%的患者接受磺脲类药物治疗，23.2%的患者接受包括胰岛素在内的治疗。与非药物治疗相比，在包含 HbA1c 与三种治疗分组之间相互作用的模型中，基线 HbA1c 与死亡率显著相关。当 HbA1c 水平<48mmol/mol（<6.5%）时，二甲双胍治疗组的死亡率更高，当 HbA1c 水平<52mmol/mol（<7.0%）时，磺脲类和胰岛素治疗组的死亡率更高，风险比分别为 2.63（95%置信区间[CI]1.39-4.97）、2.49（95%CI1.14-5.44）和 2.22（95%CI1.12-4.43）。
在接受二甲双胍、胰岛素或磺脲类药物治疗的 2 型糖尿病老年患者中，严格血糖控制可能存在风险，尤其是使用胰岛素或磺脲类药物时。这些数据证实，过度治疗可能是这一脆弱人群的一个重要临床问题。
