Department of Internal Medicine, Division of Endocrinology, Diabetes and Nutrition, University of Maryland School of Medicine, Baltimore.
Healthcare for the Homeless, Baltimore, Md.
Am J Med. 2019 Apr;132(4):408-412. doi: 10.1016/j.amjmed.2018.10.033. Epub 2018 Nov 23.
On any given night in the United States, an estimated 553,742 people are homeless. Applying a broader definition of homelessness that includes unstably housed people, an estimated 1.5% of Americans experience homelessness in a given year. Rates of diabetes are increasing among individuals experiencing homelessness. The social, psychological, and physical challenges of homelessness not only contribute to the rate of diabetes, but also complicate management. Unstable housing, limited medical resources, food insecurity, and competing priorities are barriers to diabetes care among patients experiencing homelessness. Homeless patients with diabetes more frequently develop specific comorbidities that require special attention, such as cardiovascular disease, substance abuse, depression, and foot wounds. The Affordable Care Act gave states the option to expand Medicaid to those earning up to 138% of the federal poverty level. This addressed a gap in coverage for low-income individuals not eligible for Medicaid or employer-sponsored insurance. With increased insurance coverage, this has increased the variety of medications available to treat hyperglycemia from type 2 diabetes beyond metformin, sulfonylureas, and insulin. Several of the newer classes of medications have advantages for patients experiencing homelessness, but also have special considerations in this vulnerable patient population. This narrative review will provide a review of dipeptidyl peptidase-4 inhibitors, glucagon-like peptide agonists, sodium glucose cotransporter-2 inhibitors, and thiazolidinediones in individuals experiencing homelessness.
在美国，平均每晚估计有 553742 人无家可归。如果采用更广义的无家可归定义，即包括住房不稳定的人群，那么每年约有 1.5%的美国人会经历无家可归。无家可归者的糖尿病发病率正在上升。无家可归带来的社会、心理和身体方面的挑战不仅导致糖尿病发病率上升，而且使疾病管理更加复杂。不稳定的住房、有限的医疗资源、食品安全和相互竞争的优先级等问题是无家可归者糖尿病护理的障碍。患有糖尿病的无家可归者更容易出现需要特殊关注的特定合并症，如心血管疾病、药物滥用、抑郁和足部伤口。平价医疗法案允许各州将医疗补助扩大到收入达到联邦贫困线 138%的人群。这解决了未符合医疗补助或雇主赞助保险资格的低收入人群的保险覆盖缺口问题。随着保险覆盖范围的扩大，用于治疗 2 型糖尿病高血糖的药物种类也有所增加，除了二甲双胍、磺酰脲类药物和胰岛素以外，还有其他几种新型药物。对于无家可归者，一些新型药物具有优势，但在这一弱势群体中也需要特别考虑。本综述将介绍在无家可归者中使用二肽基肽酶-4 抑制剂、胰高血糖素样肽激动剂、钠-葡萄糖共转运蛋白 2 抑制剂和噻唑烷二酮类药物的情况。
