Diabetes Mellitus Treatment Deintensification: When Well-Controlled Diabetes Mellitus Becomes Overcontrolled.
Diabetes Mellitus Treatment Deintensification: When Well-Controlled Diabetes Mellitus Becomes Overcontrolled.
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糖尿病治疗去强化：当控制良好的糖尿病变得过度控制时。
DOI：
10.1161/circoutcomes.117.003706
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发表时间：
2017
期刊：
影响因子：
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通讯作者：
Matlock,Daniel
中科院分区：
文献类型：
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作者：
Raghavan,Sridharan;Matlock,Daniel
这项研究增加了越来越多的工作描述糖尿病过度治疗，并表明过度治疗是一个未被认识的问题，在整个光谱的糖尿病患者。减少过度治疗的一个挑战是指导治疗减量的证据基础有限。4-8，11也许对缺乏数据最关键的是随机试验在证据等级中的优先地位，这些试验侧重于治疗效果，较少强调不良事件。此外，研究取消执行本身就具有挑战性，因为它需要提供者和患者接受继续治疗可能比停止治疗更有害的想法。对糖尿病治疗感到舒适的患者，因实现目标血糖控制而获得授权，接受血糖控制的重要性以避免糖尿病并发症，并且从未发生过症状性或重度低血糖，可能会对出于研究目的而被要求停止服用或减少血糖药物剂量感到不安。过度强化糖尿病治疗的主要根本原因之一是过度控制的糖尿病一度得到良好控制。请考虑以下情况。几乎没有慢性医学问题的患者被新诊断为糖尿病，并且基于数十年的预期寿命在诊断后不久就确定了治疗目标。达到了最初的血糖控制目标，赢得了良好控制的标签，并使患者和提供者放心。虽然患者可能需要轻微的，逐渐增加的糖尿病药物，其他医疗问题，一些与糖尿病并发症和其他仅仅是疾病的自然衰老史的一部分。即使提供者承认低血糖的风险，控制良好的糖尿病患者在临床遇到时也会努力优先考虑患者更活跃的问题。这种情况表明，需要指导和证据，以激励转换的静态问题，控制良好的糖尿病在拥挤的问题清单上的糖尿病过度控制的积极问题，有具体的纠正措施。提供者的惰性、患者对护理的满意度以及医疗偏好默认为现状的趋势都有利于治疗的继续。在糖尿病得到良好控制的情况下，医疗服务提供者和患者不愿改变方向，这在某种程度上类似于医疗决策中的损失厌恶和默认效应的概念。12此外，美国糖尿病协会指南所支持的框架，即在众多其他患者因素的背景下制定个性化糖尿病治疗决策，与奖励实现特定HbA 1c值的疾病特异性性能指标相反。因此，实现最佳的糖尿病管理，包括在适当的情况下减少药物治疗，可能需要更广泛地重新制定患者、提供者和卫生系统的糖尿病治疗目标，纳入并反映健康的动态性质。
This study adds to the growing body of work describing diabetes mellitus overtreatment and suggests that overtreatment is an unrecognized problem across the spectrum of patients with diabetes mellitus. A challenge to reducing overtreatment has been the limited evidence base guiding treatment deintensification. 4–8, 11 Perhaps most critical to the lack of data is the priority in the hierarchy of evidence granted to randomized trials, which focus on treatment efficacy, with less emphasis on adverse events. Furthermore, studying deimplementation is inherently challenging because it requires provider and patient buy-in to the idea that treatment continuation is possibly more harmful than discontinuation. Patients who are comfortable on their diabetes mellitus treatment, are empowered by their achievement of goal glycemic control, have embraced the importance of glycemic control to avoid diabetes mellitus complications, and have never experienced symptomatic or severe hypoglycemia might be uncomfortable with being asked to stop taking or reduce the dose of glycemic medications for research purposes. One of the major underlying causes of overly intensive diabetes mellitus treatment is that overcontrolled diabetes mellitus was at one time well controlled. Consider the following scenario. A patient with few chronic medical problems is newly diagnosed with diabetes mellitus, and treatment goals are established shortly after diagnosis based on an expected life expectancy of decades. The initial glycemic control goals are achieved, earning the label of well controlled and placing the patient and provider at ease. Although the patient may require minor, gradual increases in diabetes mellitus medications, other medical problems set in, some related to complications of diabetes mellitus and others merely the diseases that are part of the natural history of aging. Even if the provider acknowledges the risks of hypoglycemia, well-controlled diabetes mellitus struggles for prioritization at a clinical encounter at which the patient’s more active problems are granted primacy. This scenario demonstrates the need for guidance and evidence to motivate the transformation of the quiescent problem of well-controlled diabetes mellitus on a crowded problem list into the active problem of overcontrolled diabetes mellitus for which there are specific corrective actions. Provider inertia, patient satisfaction with care, and the tendency for healthcare preferences to default to the status quo all favor treatment continuation. This reluctance to change course on the part of providers and patients in the setting of well-controlled diabetes mellitus is in some ways similar to the concepts of loss aversion and default effects in healthcare decision-making. 12 Furthermore, the framework espoused by American Diabetes Association guidelines, namely basing personalized diabetes mellitus treatment decisions in the context of numerous other patient factors, is in opposition to disease-specific performance measures that reward achieving specific HbA1c values. Therefore, achieving optimal diabetes mellitus management, including medication deintensification when appropriate, likely requires a broader reframing of the goals of diabetes mellitus treatment for patients, providers, and health systems that incorporates and reflects the dynamic nature of health.