Morris A D, Boyle D I, McMahon A D, Greene S A, MacDonald T M, Newton R W
Department of Medicine, University of Dundee Ninewells Hospital and Medical School, Scotland, UK.
Lancet. 1997 Nov 22;350(9090):1505-10. doi: 10.1016/s0140-6736(97)06234-x.
Intensive insulin treatment effectively delays the onset and slows the progression of microvascular complications in insulin-dependent diabetes mellitus (IDDM). Variable adherence to insulin treatment is thought to contribute to poor glycaemic control, diabetic ketoacidosis, and brittle diabetes in adolescents and young adults with IDDM. We assessed the association between the prescribed insulin dose and the amount dispensed from all community pharmacies with the Diabetes Audit and Research in Tayside Scotland (DARTS) database.
We studied 89 patients, mean age 16 (SD 7) years, diabetes duration 8 (4) years, and glycosylated haemoglobin (HbA1c) 8.4 (1.9)%, who attended a teaching hospital paediatric or young-adult diabetes clinic in 1993 and 1994. The medically recommended insulin dose and cumulative volume of insulin prescriptions supplied were used to calculate the days of maximum possible insulin coverage per annum, expressed as the adherence index. Associations between glycaemic control (HbA1c), episodes of diabetic ketoacidosis, and all hospital admissions for acute complications and the adherence index were modelled.
Insulin was prescribed at 48 (19) IU/day and mean insulin collected from pharmacies was 58 (25) IU/day, 25 (28%) of the 89 patients obtained less insulin than their prescribed dose (mean deficit 115 (68; range 9-246] insulin days/annum). There was a significant inverse association between HbA1c and the adherence index (R2 = 0.39; p < 0.001). In the top quartile (HbA1c > 10%), 14 (64%) of individuals had an adherence index suggestive of a missed dose of insulin (mean deficit 55 insulin days/annum). There were 36 admissions for complications related to diabetes. The adherence index was inversely related to hospital admissions for diabetic ketoacidosis (p < 0.001) and all hospital admissions related to acute diabetes complications (p = 0.008). The deterioration in glycaemic control observed in patients aged 10-20 years was associated with a significant reduction (p = 0.01) in the adherence index.
We found direct evidence of poor compliance with insulin therapy in young patients with IDDM. We suggest that poor adherence to insulin treatment is the major factor that contributes to long-term poor glycaemic control and diabetic ketoacidosis in this age group.
强化胰岛素治疗能有效延缓胰岛素依赖型糖尿病（IDDM）微血管并发症的发生并减缓其进展。胰岛素治疗依从性的差异被认为是导致IDDM青少年和年轻成人血糖控制不佳、糖尿病酮症酸中毒及脆性糖尿病的原因。我们利用苏格兰泰赛德糖尿病审计与研究（DARTS）数据库评估了处方胰岛素剂量与所有社区药房配药量之间的关联。
我们研究了1993年和1994年就诊于一家教学医院儿科或青年成人糖尿病门诊的89例患者，平均年龄16（标准差7）岁，糖尿病病程8（4）年，糖化血红蛋白（HbA1c）为8.4（1.9）%。用医学推荐的胰岛素剂量和所提供胰岛素处方的累积量来计算每年最大可能胰岛素覆盖天数，以依从性指数表示。对血糖控制（HbA1c）、糖尿病酮症酸中毒发作以及所有因急性并发症入院情况与依从性指数之间的关联进行建模。
胰岛素处方剂量为每日48（19）国际单位，从药房收集的胰岛素平均剂量为每日58（25）国际单位，89例患者中有25例（28%）获得的胰岛素量低于其处方剂量（平均缺量为115（68；范围9 - 246）胰岛素日/年）。HbA1c与依从性指数之间存在显著负相关（R2 = 0.39；p < 0.001）。在四分位数最高组（HbA1c > 10%）中，14例（64%）个体的依从性指数提示有胰岛素漏服情况（平均缺量为55胰岛素日/年）。有36例因糖尿病相关并发症入院。依从性指数与糖尿病酮症酸中毒入院情况呈负相关（p < 0.001），与所有因急性糖尿病并发症入院情况也呈负相关（p = 0.008）。10 - 20岁患者中观察到的血糖控制恶化与依从性指数显著降低相关（p = 0.01）。
我们发现了IDDM年轻患者胰岛素治疗依从性差的直接证据。我们认为胰岛素治疗依从性差是导致该年龄组长期血糖控制不佳和糖尿病酮症酸中毒的主要因素。
