Polypharmacy in the Aging Patient: A Review of Glycemic Control in Older Adults With Type 2 Diabetes.
Polypharmacy in the Aging Patient: A Review of Glycemic Control in Older Adults With Type 2 Diabetes.
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DOI：
10.1001/jama.2016.0299
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发表时间：
2016-03-08
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影响因子：
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通讯作者：
Lee SJ
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作者：
Lipska KJ;Krumholz H;Soones T;Lee SJ
老年2型糖尿病患者的最佳血糖控制存在很大的不确定性。四项大型随机临床试验（RCT），规模从1791到11440例患者，提供了用于指导糖尿病治疗的大部分证据。大多数强化与标准血糖控制的RCT排除了80岁以上的成年人，使用替代终点来评价微血管结局，并提供了关于哪些亚组最有可能受益于特定治疗或受到损害的有限数据。来自随机临床试验的现有数据表明，强化血糖控制至少10年不会减少老年人的主要大血管事件。此外，强化血糖控制至少在8年内不会改善以患者为中心的微血管结局。来自随机临床试验的数据一致表明，强化血糖控制立即增加严重低血糖的风险1.5至3倍。基于这些数据和观察性研究，对于大多数65岁以上的成年人，与低于7.5%或高于9%的血红蛋白A1c（HbA1c）目标相关的危害可能超过受益。然而，最佳目标取决于患者因素，用于达到目标的药物，预期寿命和患者对治疗的偏好。如果仅需要低治疗负担和低血糖风险的药物（如二甲双胍），则较低的HbA1c目标可能是合适的。如果患者强烈希望避免注射或频繁的手指针刺监测，则可以适当地采用更高的HbA1c目标，以避免对胰岛素的需求。缺乏关于老年人血糖治疗的高质量证据。最佳决策需要与患者合作做出，包括获益和危害的可能性以及患者对治疗和治疗负担的偏好。对于大多数老年人来说，HbA1c目标在7.5%至9%之间将最大限度地提高益处并最大限度地减少危害。
There is substantial uncertainty about optimal glycemic control in older adults with type 2 diabetes mellitus. Four large randomized clinical trials (RCTs), ranging in size from 1791 to 11440 patients, provide the majority of the evidence used to guide diabetes therapy. Most RCTs of intensive vs standard glycemic control excluded adults older than 80 years, used surrogate end points to evaluate microvascular outcomes and provided limited data on which subgroups are most likely to benefit or be harmed by specific therapies. Available data from randomized clinical trials suggest that intensive glycemic control does not reduce major macrovascular events in older adults for at least 10 years. Furthermore, intensive glycemic control does not lead to improved patient-centered microvascular outcomes for at least 8 years. Data from randomized clinical trials consistently suggest that intensive glycemic control immediately increases the risk of severe hypoglycemia 1.5- to 3-fold. Based on these data and observational studies, for the majority of adults older than 65 years, the harms associated with a hemoglobin A1c (HbA1c) target lower than 7.5% or higher than 9% are likely to outweigh the benefits. However, the optimal target depends on patient factors, medications used to reach the target, life expectancy, and patient preferences about treatment. If only medications with low treatment burden and hypoglycemia risk (such as metformin) are required, a lower HbA1c target may be appropriate. If patients strongly prefer to avoid injections or frequent fingerstick monitoring, a higher HbA1c target that obviates the need for insulin may be appropriate. High-quality evidence about glycemic treatment in older adults is lacking. Optimal decisions need to be made collaboratively with patients, incorporating the likelihood of benefits and harms and patient preferences about treatment and treatment burden. For the majority of older adults, an HbA1c target between 7.5% and 9% will maximize benefits and minimize harms.