第2型糖尿病病患發生嚴重低血糖之相關因素探討

Study on the Related Factors of Severe Hypoglycemia in Patients with Type 2 Diabetes Mellitus

張鳳梅(Feng-Mei Chang)

指導教授 ： 柯黃盛

高雄醫學大學/藥學院/藥學研究所碩士在職專班/碩士(2011年)

https://doi.org/10.6832/KMU.2011.00101

摘要

【研究背景】
低血糖是急診室常見的急症之一，嚴重低血糖可致命但亦可預防。根據美國糖尿病控制與併發症試驗(Diabetes Control and Complications Trial; DCCT) 及英國前瞻性糖尿病研究(U.K. Prospective Diabetes Study; UKPDS) 兩個大型研究發現，積極的血糖控制可以有效降低或預防糖尿病併發症的發生；但也相對的增加嚴重低血糖的風險。因此嚴重低血糖也成了積極血糖控制的限制之一。
【研究目的】
在糖尿病治療的各種相互影響變項中，探討第2 型糖尿病病患發生嚴重低血糖之相關因素，並預測發生嚴重低血糖之危險因子，以提供臨床醫療照護之參考。
【研究方法】
研究設計採病例回溯性對照研究（case-control study）。研究對象為2009 年1月至2010 年12 月南部某教學醫院第2 型糖尿病病患，研究樣本分兩組，病例組為發生嚴重低血糖而至急診就醫之第2 型糖尿病住院病患；對照組為第2 型糖尿病門診病患。藉由結構性「低血糖個案資料登錄表」為工具，回顧審閱病歷，擷取包括人口學屬性、生化學檢查、疾病狀況、併用藥物等四大層面資料變項進行資料收集。使用SPSS 17.0 for windows 套裝軟體進行分析，統計方法以百分比、平均數及標準差等進行描述性統計，及以Chi-Square、邏輯式迴歸分析進行推論性統計。
【研究結果】
病例組比對照組病患在合併症數(3.4±1.7 比2.2±1.4)和用藥總數(5.8±2.4 比3.8±2.7)較多，且達顯著差異(p＜0.05)。病例組比對照組在藥物使用情形有用腎素-血管收縮素系統抑制劑(28.2%比13.3%)和鎮靜劑(28.2%比15%)有較高比例的使用，且達顯著差異。病例組比對照組在合併症數方面，腦血管病變(28.8%比14.9%)、腎臟病變(53.6%比17.5%)、感染(16%比7%)和腎絲球過濾率小於60ml/min(68.6%比25.2%)等都有較高比例共病現象。病例組比對照組在身體質量指數(23.0±4.8 比25.7±4.9)、糖化血色素(6.8±1.6 比8.0±1.9)和雙胍類(42%比62.8%)等有較低平均值，且達顯著差異。最後以多變項迴歸分析(multivariate logistic regression analysis)分析發生嚴重低血糖的風險對比值(odds ratio; OR)，結果呈現身體質量指數每增加一單位比未增加者，其發生嚴重低血糖機率為原來之0.91 倍風險(OR=0.91; p=0.038)；合併症數每增加一種比未增加者，其為原來1.41 倍風險(OR=1.41; p=0.024)、糖化血色素每增加1%比未增加者，其為原來之0.61 倍風險(OR=0.61; p＜0.001)、腎絲球過濾率小於60 ml/min，比大於60 ml/min 時，則增加2.74 倍風險(OR=2.74;p=0.029)。
【結論】
研究發現身體質量指數低於23 kg/m2、合併症數高於3.4 種、糖化血色素低於6.8%和腎絲球過濾率小於60 ml/min/1.73m2 者，為第2 型糖尿病病患發生嚴重低血糖之危險因子。此研究結果可提供臨床醫療上之參考，對於住院族群中具有相同特性之高危險群病患，除了提供個別化之藥物治療外，給予病患充分的衛教及血糖監測觀念，將有助於病患將血糖控制至接近目標值，且將發生低血糖之傷害降至最低程度，並增加病患自我照護能力。

關鍵字

第2 型糖尿病 ； 低血糖 ； 糖化血色素 ； 合併症

並列摘要

Background :
Hypoglycemia is an acute episode presenting in the emergency department (ED) which may cause fatality but can be prevented. According to two large-scale research conducted, the Diabetes Control and Complications Trial (DCCT) and U.K. Prospective Diabetes Study (UKPDS), intensive blood glucose control may reduce or prevent complications of diabetes mellitus (DM) but increases the incidence of severe hypoglycemia. This somewhat limits the use of intensive glycemic control.

Objective :
The purpose of this study is to identify risk factors for severe hypoglycemia in diabetic patients, as to provide information on clinical care. To discuss the determinants and to predict the risk factors of severe hypoglycemia in patients diagnosed as type 2 DM.

Methods :
This is a retrospective case-control study, conducted at a teaching hospital in southern area. The study group consisted of patients with type 2 DM presenting to the ED during a 2-year period from January 2009 to December 2010 and hospitalized for severe hypoglycemia. The control group consisted of ambulatory care diabetic patients. Using standardized「Hypoglycemia data collection sheet」, including demographics, biochemical examination, comorbidities and concomitant medications. Data was analyzed using SPSS 17.0 for Windows and logistic regression with statistical data expressed as percentage, mean value, standard deviation, and tested with Chi-Square test.

Results:
The study group had a significantly higher comorbidities (3.4±1.7 vs. 2.2±1.4) and concomitant medications (5.8±2.4 vs. 3.8±2.7) as compared to the control group (p＜0.05). It had a higher percentage of patients taking renin-angiotensin system inhibitors,RAS inhibitors (28.2% vs. 13.3%), benzodiazepines (28.2% vs. 15%). When examining comorbidities, the study group had a significantly higher percentage of cerebrovascular disease (28.8% vs. 14.9%), estimated GFR ＜60 ml/min(68.6% vs. 25.2%) and infection (16% vs. 7%); however, the study group was found to have a lower percentage of body mass index, BMI (23.0±4.8 vs. 25.7±4.9), HbA1c (6.8±1.6 vs. 8.0±1.9) and use of biguanides (42% vs. 62.8%). Multivariate logistic regression analysis revealed that patients with lower BMI (OR=0.91; p=0.038), comorbidities (OR=1.41; p=0.024), who had lower HbA1c (OR=0.61; p＜0.001) or who had renal insufficiency (OR=2.74; p=0.029) were at risk (odds ratio; OR) for severe hypoglycemia.

Conclusion:
The study revealed that BMI, comorbidities, glycated hemoglobin, eGFR are the variables for severe hypoglycemia in patients diagnosed as type 2 DM. These findings provide information for hospitalized diabetic patients with high risk factors, so as to provide individualized pharmaceutical care, enhance the importance of patient education and self-care, monitoring blood glucose level and placing patients at normalized level may reduce harm due to episodes of severe hypoglycemia.

並列關鍵字

type 2 diabetes mellitus ； hypoglycemia ； glycated hemoglobin、comorbidities

參考文獻

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