影響思覺失調症合併糖尿病患者血糖控制之危險因子探討

Exploration of Risk Factors of Glycemic Control in Patients with Schizophrenia and Diabetes

曾秋玉(Chiu-Yu Tseng)

指導教授 ： 柯黃盛

高雄醫學大學/藥學院/藥學系碩士在職專班/碩士(2017年)

摘要

【研究背景】
近年來已有許多研究發現睡眠品質與血糖控制有高度相關，然而卻鮮少有研究深入探討血糖、睡眠品質與藥物之間的相關性，特別是許多思覺失調症(schizophrenia)患者，往往不只單一使用抗精神病藥物，經常合併情緒穩定劑使用。
【研究目的】
探討思覺失調症合併糖尿病之住院患者，對血糖控制成效與睡眠品質、藥物、生理疾病之間的相關性，並預測主要影響血糖控制不良之危險因子。
【研究方法】
本研究為回溯性分析，研究對象為2013年1月1日至2014年12月31日，中部某精神專科醫院思覺失調症合併糖尿病之住院患者，以糖化血色素(glycated hemoglobin, HbA1c)為分組依據，HbA1c低於7%為血糖控制良好(A)組，高於7%則為血糖控制不良(B)組。藉由回溯的方式審閱病歷，擷取包括睡眠時間、併用藥物(抗精神病藥、糖尿病用藥、安眠藥及情緒穩定劑)、生化學檢查、疾病狀況等多項與影響血糖控制之相關因子，進行Chi-Square及邏輯式迴歸分析。
【研究結果】
總共納入183位為思覺失調合併糖尿病之住院患者，其中89位為血糖控制不良(B)組、94位為血糖控制良好(A)組，平均年齡為52.9±11.8歲，B組比A組在糖尿病罹病年(8.79±3.31比6.21±2.58)較長，且達顯著差異(p＜0.001)。B組比A組在疾病方面罹患高血壓(38.2%比23.4%)、高血脂(33.7%比13.8%)人數比例較多，且達顯著差異。B組比A組在藥物使用情形第二代抗精神藥品以clozapine (46.1%比27.7%)和情緒穩定劑(33.7%比14.9%)有較高比例的使用，且達顯著差異。在糖尿病藥物治療以metformin (23.6%比69.1%)，B組比A組有較低比例的使用，且達顯著差異。以多元邏輯斯迴歸分析，調整過其他影響因子後，發現糖尿病罹病年每增加1年，就增加了1.29倍血糖控制不良的機率(95% CI=1.12~1.51, p=0.001)，身體質量指數每增加一單位，就增加了1.38倍血糖控制不良的機率(95% CI=1.18~1.63, p<0.001)，睡眠小於5小時相較於睡眠大於7小時，血糖控制不良的機率增加4.31倍(95% CI=1.49~12.53, p=0.007)；同時使用clozapine和情緒穩定劑相較於未合併者，發生血糖控制不良的機率增加8.22倍(95% CI=2.01~33.54, p=0.003)；有使用metformin相較於未使用者，發生血糖控制不良的機率增加0.16倍(95% CI=0.06~0.38, p<0.001)。
【結論】
本研究發現BMI高於27.7、睡眠時間小於5小時、糖尿病罹病年較長者與同時使用clozapine和情緒穩定劑藥物者，為主要影響血糖控制不良之危險因子，而使用metformin可以減少84%血糖控制不良的機率，此研究結果可針對醫護人員對於照護思覺失調合併糖尿病住院患者，提供血糖控制及相關藥物選擇之參考建議。

關鍵字

思覺失調症合併糖尿病 ； 血糖控制不良 ； 糖化血色素

並列摘要

Background:
In recent years, many studies have found that sleep quality and glycemic control are highly correlated, but few studies have extensively investigated the relations of glycemic control, sleep quality and drugs. Especially in many patients with schizophrenia are not only using a single anti- psychotropic drugs but also using mood stabilizers.

Objective:
This study was aimed to investigate the relations of glycemic control efficacy, quality of sleep, drugs and physiological diseases in hospitalized patients with schizophrenia and Diabetes. Also analysis the result to predict the risk factors mainly affects glycemic control.

Methods:
This study is a retrospective case-control study and conducted schizophrenia inpatients with diabetes in a hospital in the central region of Taiwan during the period from 2013 to 2014. The patients were divided into the good glycemic control group (glycated hemoglobin, HbA1c<7%) and the poor glycemic control group (HbA1c≧7 %). The information including the use of drugs (antipsychotics, antidiabetic drug, hypnotics and mood stabilizers), biochemical tests, disease status and other related factors that affect blood glucose control were collected from their medical records. Data was analyzed using logistic regression and tested with Chi-Square test.

Results:
A total of 183 schizophrenia patients with diabetes were enrolled in this study. Among them, 89 patients were poor glycemic control group and 94 patients were good glycemic control group with an average age of 52.9±11.8 years old. Patients in poor glycemic control group with diabetes mellitus was longer than those in good glycemic control (8.79±3.31 vs 6.21±2.58) and had a significant difference (p<0.001). In terms of disease, it had the higher percentage of poor glycemic control group with high blood pressure (38.2% vs 23.4%) and hyperlipidemia (33.7% vs 13.8%), and significant differences were observed. In the case of drug use, the poor glycemic control group resulted in a higher proportion of clozapine (46.1% vs 27.7%) and mood stabilizer (33.7% vs 14.9%) use, and significant differences were observed. In the treatment of diabetes with metformin, the poor glycemic control group had a lower proportion of it’s use (23.6% vs 69.1%), and significant differences were observed. After adjusting for other factors, the multiple logistic regression analysis results showed that the risk of poor glycemic control increased by 1.29-fold for each additional year with diabetes year (95% CI=1.12~1.51, p=0.001). The body mass index (BMI) for every additional unit increased the risk of poor glycemic control increased by 1.38 -fold (95% CI =1.18-1.63, p<0.001). Sleep less than 5 hours compared to sleep more than 7 hours , the risk of poor glycemic control increased by 4.31-fold (95% CI=1.49-12.53, p=0.007). Co-administration of clozapine and mood stabilizer compared to non-users , the risk of poor glycemic control increased by 8.22-fold (95% CI=2.01-33.54, p=0.003). With the use of metformin compared to non-users, the risk of poor glycemic control was increased by 0.16-fold (95% CI=0.06-0.38, p<0.001).

Conclusion:
This study revealed that BMI (>27.7), sleep time (<5 hours), diabetes extended disease duration, and combined use of clozapine and emotional stabilizers are main risk factors of poor glycemic control. And the use of metformin can reduce the chance of 84% of poor glycemic control. These findings provide medical care information for hospitalized schizophrenia patients with diabetic, so as to provide pharmaceutical care to control blood glucose level.

並列關鍵字

schizophrenia with diabetes ； poor glycemic control ； glycated hemoglobin

參考文獻

第七章 參考文獻

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