[Identification of factors predicting early evolution of secondary oral hypoglycaemic agent failure and evaluation of clinical standards applied by primary care physicians during qualification to insulin therapy of patients with type 2 diabetes].
Effective control of metabolic disturbances, in particular hyperglycaemia, hypertension and lipid abnormalities, is a prerequisite condition for clinically important reduction in the risk of death related to diabetes and its complications. It appears that type 2 diabetes is a progressive disease and hyperglycaemia aggravates with time. Secondary failure of oral hypoglycaemic agents is a common evolution of long-standing type 2 diabetes and placement on insulin is necessary when maximal sulfonylurea therapy is inadequate. This study was designed to identify factors predicting early hyperglycaemia progression and evolution of secondary oral hypoglycaemic agent (OHA) failure, estimate the prevalence of metabolic disturbances associated with type 2 diabetes and evaluate clinical practices of family physicians during qualification to insulin therapy. Medical records of 56 diabetic patients, 24 males and 32 females with a mean age of 65 years (42-91 yrs), were analyzed. Information about fasting plasma glucose and lipid levels, blood pressure, body mass, kidney status, coronary artery disease and other complications, and treatment were retrospectively extracted from patient charts. All patients were treated by their family physicians. The duration of the disease ranged from 1 to 18 years. All patients were started on insulin during the last three years. Metabolic abnormalities, especially hypertension, lipid abnormalities and obesity, were common findings in type 2 diabetes patients. Hypertension occurred in 77% of patients. Treatment of hypertension was generally not effective and only 16% of patients fulfilled recommendations of ADA. Lipid abnormalities were common. EDPG and ADA criteria were met by 30% and 18% of the patients, respectively. BMI lower than 25 kg/m2 was found in 23% of patients. A multiple regression model and analysis of proportional hazard regression according to Cox were used to identify factors independently associated with early progression of hyperglycaemia and early evolution of secondary OHA failure. It was found that high fasting glycaemia in the early phase of OHA treatment and history of hypertension prior to diabetes, in particular high diastolic pressure, were independent predictors of early progression of hyperglycaemia and necessity of adding insulin to the hypoglycaemic regimen. Hypertension prior to diabetes increased by more than twice the relative risk of exceeding 150 and 180 mg% for glycaemia and the risk of switching to insulin. Assessment of compliance with clinical recommendations by family physicians revealed a significant delay in qualification to insulin therapy. Treatment with OHA was continued in spite of clear signs of metabolic decompensation. On the average, OHA were continued for 4.5 years after fasting glycaemia exceeded 150 mg%. Insulin was added to the hypoglycaemic regimen when fasting glycaemia reached an average of 234 mg% and the maximal postprandial glycaemia reached 390 mg%.


CONCLUSIONS
The present findings suggest that compliance with clinical recommendations in primary care as a measure to retard complications in patients with type 2 diabetes should be improved, especially with regard to control of hyperglycaemia, hypertension and dyslipidemia.
Machoy
Michał
M
Studium Doktoranckie, Klinika Nefrologii, Transplantologii i Chorób Wewnetrznych Pomorskiej Akademii Medycznej w Szczecinie al Powstańców Wlkp 72, Szczecin.
D000284:Administration, Oral; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016022:Case-Control Studies; D015897:Comorbidity; D003924:Diabetes Mellitus, Type 2 / Q000188:drug therapy*; D018450:Disease Progression; D004359:Drug Therapy, Combination; D004363:Drug Utilization / Q000592:standards* / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D006949:Hyperlipidemias / Q000453:epidemiology; D006973:Hypertension / Q000453:epidemiology; D007004:Hypoglycemic Agents / Q000008:administration & dosage; D007328:Insulin / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D009765:Obesity / Q000453:epidemiology; D011044:Poland; D011159:Population Surveillance; D010818:Practice Patterns, Physicians' / Q000592:standards*; D011237:Predictive Value of Tests; D011320:Primary Health Care / Q000592:standards*; D012044:Regression Analysis; D013453:Sulfonylurea Compounds / Q000008:administration & dosage*; D017211:Treatment Failure
D007004:Hypoglycemic Agents; D007328:Insulin; D013453:Sulfonylurea Compounds