Journal ClubJournal Club
埼玉医科大学 総合医療センター 内分泌・糖尿病内科埼玉医科大学 総合医療センター 内分泌・糖尿病内科
Department of Endocrinology and Diabetes,Department of Endocrinology and Diabetes,
Saitama Medical Center, Saitama Medical UniversitySaitama Medical Center, Saitama Medical University
松田 昌文 松田 昌文
Matsuda, MasafumiMatsuda, Masafumi
2015年11月5日 8:30-8:552015年11月5日 8:30-8:55
８階 医局８階 医局
Sussman JB, Kerr EA, Saini SD, Holleman RG, Klamerus ML, Min LC, Vijan S, HoferTP.
Rates of Deintensification of Blood Pressure and Glycemic Medication TreatmentBased on Levels of Control and Life Expectancy in Older Patients With DiabetesMellitus.
JAMA Intern Med. 2015 Oct 26:1-8. doi: 10.1001/jamainternmed.2015.5110.
Martin ET, Kaye KS, Knott C, Nguyen H, Santarossa M, Evans R, Bertran E, Jaber L.
Diabetes and Risk of Surgical Site Infection: A Systematic Review and Meta-analysis.
Infect Control Hosp Epidemiol. 2015 Oct 27:1-12.
1Department of Veterans Affairs Center for Clinical Management Research, AnnArbor, Michigan2Department of Internal Medicine, University of Michigan Medical School, Ann Arbor3Institute of Healthcare Policy and Innovation, University of Michigan, Ann Arbor
JAMA Intern Med. Published online October 26, 2015. doi:10.1001/jamainternmed.2015.5110
Importance Older patients with diabetes mellitusreceiving medical treatment whose bloodpressure (BP) or blood glucose level arepotentially dangerously low are rarelydeintensified. Given the established risks of lowblood pressure and blood glucose, this is a majoropportunity to decrease medication harm.
Objective To examine the rate of BP- and bloodglucose–lowering medicine deintensificationamong older patients with type 1 or 2 diabetesmellitus who potentially receive overtreatment.
Design, Setting, and Participants Retrospective cohort studyconducted using data from the US Veterans Health Administration.Participants included 211 667 patients older than 70 years with diabetesmellitus who were receiving active treatment (defined as BP-loweringmedications other than angiotensin-converting enzyme inhibitors orangiotensin receptor blockers, or glucose-lowering medications otherthan metformin hydrochloride) from January 1 to December 31, 2012.Data analysis was performed December 10, 2013, to July 20, 2015.
Exposures Participants were eligible for deintensification of treatment ifthey had low BP or a low hemoglobin A1c (HbA1c) level in their lastmeasurement in 2012. We defined very low BP as less than 120/65mm Hg, moderately low as systolic BP of 120 to 129 mm Hg or diastolicBP (DBP) less than 65 mm Hg, very low HbA1c as less than 6.0%, andmoderately low HbA1c as 6.0% to 6.4%. All other values were notconsidered low.
Main Outcomes and Measures Medication deintensification, definedas discontinuation or dosage decrease within 6 months after the indexmeasurement.
Figure 3. Predicted Probability of Deintensification by Baseline Blood Pressure(BP) and Hemoglobin A1c (HbA1c) Levels and Life Expectancy
Error bars indicate 95%CI.
Figure 3. Predicted Probability of Deintensification by Baseline Blood Pressure(BP) and Hemoglobin A1c (HbA1c) Levels and Life Expectancy
Error bars indicate 95%CI.
Solid line with arrowheadindicates standard vascular riskcontrol strategy. Dashed lines witharrowheads indicate possiblevascular risk control strategies forrobust and vulnerable patients,with question marks pointing outthe need for a choice. Gray boxpresents the proposed approachfor vulnerable individuals. HbA1cindicates hemoglobin A1c; RCTs,randomized clinical trials; SBP,systolic blood pressure; andT2DM, type 2 diabetes mellitus.To convert HbA1c to a proportionof total hemoglobin, multiply by0.01.
JAMA Intern Med. Published online October 26, 2015. doi:10.1001/jamainternmed.2015.5941
Results The actively treated BP cohort included 211667participants, more than half of whom had moderately or very lowBP levels. Of 104486 patients with BP levels that were not low,treatment in 15.1% was deintensified. Of 25955 patients withmoderately low BP levels, treatment in 16.0% was deintensified.Among 81226 patients with very low BP levels, 18.8% underwentBP medication deintensification. Of patients with very low BPlevels whose treatment was not deintensified, only 0.2% had afollow-up BP measurement that was elevated (BP ≥140/90mm Hg). The actively treated HbA1c cohort included 179991participants. Of 143305 patients with HbA1c levels that were notlow, treatment in 17.5% was deintensified. Of 23769 patients withmoderately low HbA1c levels, treatment in 20.9% wasdeintensified. Among 12917 patients with very low HbA1c levels,27.0% underwent medication deintensification. Of patients withvery low HbA1c levels whose treatment was not deintensified,fewer than 0.8% had a follow-up HbA1c measurement that waselevated (≥7.5%).
Conclusions and Relevance Among olderpatients whose treatment resulted in very lowlevels of HbA1c or BP, 27% or fewer underwentdeintensification, representing a lost opportunityto reduce overtreatment. Low HbA1c or BPvalues or low life expectancy had little associationwith deintensification events. Practice guidelinesand performance measures should place morefocus on reducing overtreatment throughdeintensification.
Message
血糖の強化療法を緩和するという論文がついに出てきた！
“Disintensification!”
そのうち糖尿病の専門家の言うことはほとんど一般開業医には受け入れられなくなるかもしれない。
1 Department of Epidemiology, University of Michigan School of Public Health,Ann Arbor, Michigan
2 Division of Infectious Diseases, Wayne State University and Detroit MedicalCenter, Detroit, Michigan
3 Department of Pharmacy Practice, Eugene Applebaum College of Pharmacyand Health Sciences, Wayne State University, Detroit, Michigan
Infect Control Hosp Epidemiol. 2015 Oct 27:1-12. DOI: http://dx.doi.org/10.1017/ice.2015.249
OBJECTIVE To determine the independentassociation between diabetes and surgicalsite infection (SSI) across multiple surgicalprocedures.
DESIGN Systematic review and meta-analysis.
METHODS Studies indexed in PubMed publishedbetween December 1985 and through July 2015 wereidentified through the search terms “risk factors” or“glucose” and “surgical site infection.” A total of 3,631abstracts were identified through the initial search terms.Full texts were reviewed for 522 articles. Of these, 94articles met the criteria for inclusion. Standardized datacollection forms were used to extract study-specificestimates for diabetes, blood glucose levels, and bodymass index (BMI). A random-effects meta-analysis wasused to generate pooled estimates, and meta-regressionwas used to evaluate specific hypothesized sources ofheterogeneity.
figure 2. Meta-analysis of diabetes and surgical site infection, by surgery type.
figure 2. Meta-analysis of diabetes and surgical site infection, by surgery type.
figure 2. Meta-analysis of diabetes and surgical site infection, by surgery type.
figure 2. Meta-analysis of diabetes and surgical site infection, by surgery type.
figure 2. Meta-analysis of diabetes and surgical site infection, by surgery type.
figure 2. Meta-analysis of diabetes and surgical site infection, by surgery type.
figure 2. Meta-analysis of diabetes and surgical site infection, by surgery type.
figure 3. Meta-analysis of pre-operative hyperglycemia and surgical site infection.
figure 4. Meta-analysis of post-operative hyperglycemia and surgical site infection.
RESULTS The primary outcome was SSI, asdefined by the Centers for Disease Control andPrevention surveillance criteria. The overall effectsize for the association between diabetes andSSI was odds ratio (OR)=1.53 (95% predictiveinterval [PI], 1.11–2.12; I2, 57.2%). SSI class,study design, or patient BMI did not significantlyimpact study results in a meta-regression model.The association was higher for cardiac surgery2.03 (95% PI, 1.13–4.05) compared withsurgeries of other types (P=.001).
CONCLUSIONS These results support theconsideration of diabetes as anindependent risk factor for SSIs for multiplesurgical procedure types. Continued effortsare needed to improve surgical outcomesfor diabetic patients.
Message
糖尿病で術後感染が増加することが再確認された。当然だと感じるが
しかし血糖をよくしたからと言ってよくなるかは不明であるが。