從連續型血糖監測儀(CGMS)的資料中找尋適當的糖尿病治療策略

Deriving the Optimum Diabetes Therapeutic Strategy from CGMS (Continuous Glucose Monitoring System) Data

林世鐸(Shi-Dou Lin)

《內科學誌》 21卷2期 (2010/04) Pp. 148-154

https://doi.org/10.6314/JIMT.2010.21(2).09

摘要

降低糖尿病患者的糖化血色素(HbA1c)值，可以減少其相關併發症的發生。除此之外，短期血糖值的快速變化，如飯後高血糖，也會增加糖尿病相關的併發症。所以單看HbA1c值似乎無法完全掌握血糖控制的情況。過去的研究顯示，連續血糖監測讓糖尿病照護者及病人看出血糖變化的速度及趨勢，可以減少個案暴露在過高或過低血糖值的時間，降低HbA1c值。但有部份研究認爲，對於糖尿病患者而言，使用連續血糖監測儀(continuous glucose monitoring system, CGMS)是否比利用血糖機作自我血糖監測，在改善HbA1c值的效果方面更好，目前並沒有一致的證據。CGMS可以記錄病人的血糖值達72小時以上，且這些數值可用圖形表示。但如何利用CGMS的資料加以判讀，並調整原來的糖尿病治療方式，目前並沒有標準的程序。另外，也很少針對以患者爲中心的議題，如生活品質、遵囑性、提升自我效能等爲研究主軸的研究。但是有些研究顯示：在使用CGMS後，可以藉由各種方法來改善餐後的高血糖：如用胰島素幫浦治療的個案，可以改變餐前大劑量的輸注方式；改變餐前胰島素注射與用餐的時間間隔，可以改變餐後血糖曲線下的面積；或藉由改變運動模式來達到血糖改善的目標。對於使用基礎胰島素合併或不合併口服降血糖藥物的第二型糖尿病病患而言，CGMS可以讓我們看出此種治療方式的限制性，也容易理解這類個案需要注射一天多次的預混型胰島素的理由。對於沒有時間多做自我血糖監測的第一型糖尿病病患而言，CGMS可以幫忙醫療人員調整治療方式。CGMS可以看出幫浦治療個案其血糖值每五分鐘的變化，進而精確的調整出每個時段的基礎胰島素需求量及碳水化合物 /胰島素比值。到目前爲止，仍然沒有研究探討第二型糖尿病患者如何使用CGMS來調整口服降血糖藥物的種類及劑量。雖然如此，CGMS因可以讓患者看到自己幾天來的血糖曲線圖，似乎可以當作一種教育工具，強化患者的藥物遵從度或是在口服降血糖藥物效果不好時，接受胰島素的注射。CGMS的臨床運用目前只在初期階段，它是否能夠改善糖尿病的治療及患者的生活，仍需要更多大型的隨機的有控制組的臨床試驗才能解答。

關鍵字

連續血糖監測系統 ； 血糖值變異度 ； 血糖控制 ； 治療策略

並列摘要

Lowering the glycosylated hemoglobin (HbA1c) level has been associated with reduction in diabetic complications. However, short-term glycemic variability, particularly postprandial hyperglycemia, has also been suggested to increase the risk of complications. Thus, there is the notion that HbA1c alone may not adequately reflect glycemic control. Historically, continuous glucose monitoring has allowed care providers and/or patients to identify trends and rates of change in blood glucose levels and has helped to lower HbA1C levels while reducing the severity and duration of hyperglycemic and hypoglycemic excursions. However, some studies have shown lack of evidence favoring continuous glucose monitoring system (CGMS) over intensive self-monitoring of blood glucose in improving the HbA1C among diabetic patients. CGMS continuously records patients' glucose levels over 72 hours and the glycemic data are displayed graphically. However, there has been no standardized approach for modifying treatment based on CGMS readings. In addition, patient driven endpoints, like quality of life, compliance, empowerment, etc., were rarely investigated with glucose monitoring. However, in various conditions CGMS may suggest strategies likely to improve postprandial glycemic excursion, including changing bolus method in patients with insulin pump therapy, altering injection time in relation to meal to reduce the area under the glycemic curve, or modifying exercise program to improve metabolic control. In type 2 DM patients treated with insulin and/or oral hypoglycemic agents, CGMS readily identifies the limitation of basal insulin and supports the rationale for multiple daily injections of premixed insulin. For type 1 DM patients too busy to perform SMBG frequently, CGMS can help physicians tailor their treatment regimen. For patients under insulin pump therapy, CGMS can be used to thoroughly trace glycemic changes or to fine tune basal insulin rate and carbohydrate-insulin ratio. Up to now, no study has investigated how CGMS data may be used to determine the choice of oral hypoglycemic agents for type 2 DM patients. However, CGMS may serve as a pedagogical tool to encourage drug adherence or earlier acceptance of insulin treatment in case of ”oral agent failure”. The clinical application of CGMS is still in its infancy. Large randomized controlled trials are much needed to determine its efficacy both in terms of improving diabetes management and in terms of patient lifestyle.

並列關鍵字

Continuous glucose monitoring system, CGMS ； Glycemic variability ； Metabolic control ； Therapeutic strategy