Diminishing efficacy of combination therapy, response-heterogeneity, and treatment intolerance limit the attainability of tight risk factor control in patients with diabetes.
Diminishing efficacy of combination therapy, response-heterogeneity, and treatment intolerance limit the attainability of tight risk factor control in patients with diabetes.
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联合治疗的疗效下降、反应异质性和治疗不耐受限制了糖尿病患者严格控制危险因素的可能性。
DOI：
10.1111/j.1475-6773.2009.01075.x
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发表时间：
2010
影响因子：
3.4
通讯作者：
Vijan,Sandeep
中科院分区：
文献类型：
--
作者：
Timbie,JustinW;Hayward,RodneyA;Vijan,Sandeep
目的：评估三种糖尿病危险因素严格的危险因素控制目标的可达性，并评估所需多药的程度。数据来源/研究设置。国家健康和营养检查调查-III。研究设计。我们模拟了一种“治疗目标”的策略，让受试者接受一系列治疗，直到达到低密度脂蛋白-胆固醇(100 mg/dL)、血红蛋白A1c(7%)和血压(130/80 mm Hg)的目标或直到所有治疗用完为止。数据收集/提取方法：我们从安慰剂对照试验和荟萃分析中选择参数估计。主要发现：在理想疗效条件下，77、和58%的受试者分别达到了低密度脂蛋白、糖化血红蛋白和血压目标。成功的控制在很大程度上取决于受试者的基线治疗次数。使用对治疗耐受性最不有利的假设，成功率降低了11-17个百分点。大约57%的受试者需要五种或五种以上的药物治疗。结论：尽管使用了大剂量的多种常规治疗，但仍有相当比例的糖尿病患者无法达到目标。这些发现引发了人们对严格风险因素控制的可行性和多药负担的担忧，以及使用严格控制措施评估糖尿病护理质量的问题。
Objective.To evaluate the attainability of tight risk factor control targets for three diabetes risk factors and to assess the degree of polypharmacy required.Data Sources/Study Setting.National Health and Nutrition Examination Survey‐III.Study Design.We simulated a strategy of “treating to targets,” exposing subjects to a battery of treatments until low‐density lipoprotein (LDL)‐cholesterol (100 mg/dL), hemoglobin A1c (7 percent), and blood pressure (130/80 mm Hg) targets were achieved or until all treatments had been exhausted. Regimens included five statins of increasing potency, four A1c‐lowering therapies, and eight steps of antihypertensive therapy.Data Collection/Extraction Methods.We selected parameter estimates from placebo‐controlled trials and meta‐analyses.Principal Findings.Under ideal efficacy conditions, 77, 64, and 58 percent of subjects achieved the LDL, A1c, and blood pressure targets, respectively. Successful control depended highly on a subject's baseline number of treatments. Using the least favorable assumptions of treatment tolerance, success rates were 11–17 percentage points lower. Approximately 57 percent of subjects required five or more medication classes.Conclusions.A significant proportion of people with diabetes will fail to achieve targets despite using high doses of multiple, conventional treatments. These findings raise concerns about the feasibility and polypharmacy burden needed for tight risk factor control, and the use of measures of tight control to assess the quality of care for diabetes.
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