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Ñàìîêîíòðîëü óðîâíÿ ãëþêîçû êðîâè
Efficacy of self-monitoring of blood glucose in patients with newly diagnosed type 2 diabetes (ESMON study): randomised controlled trial
Maurice J O’Kane et al. Objectives To assess the effect of self monitoring of blood glucose concentrations on glycaemic control and psychological indices in patients with newly diagnosed type 2 diabetes mellitus. Design Prospective randomised controlled trial of self monitoring versus no monitoring (control). Setting Hospital diabetes clinics. Participants 184 (111 men) people aged <70 with newly diagnosed type 2 diabetes referred to the participating diabetes clinics. Major exclusion criteria were secondary diabetes, insulin treatment, previous self monitoring of blood glucose. Interventions Participants were randomised to self monitoring or no monitoring (control) groups for one year with follow-up at three monthly intervals. Both groups underwent an identical structured core education programme. The self monitoring group received additional education on monitoring. Main outcome measures Between group differences in HbA1c, psychological indices, use of oral hypoglycaemic drugs, body mass index (BMI), and reported hypoglycaemia rates. Results 96 patients (55 men) were randomised to monitoring and 88 (56 men) to control. There were no baseline differences in mean (SD) age (57.7 (11.0) in monitoring group v 60.9 (11.5) in control group) or HbA1c (8.8 (2.1)% v 8.6 (2.3)%, respectively). Those in the monitoring group had a higher baseline BMI (34 (7) v 32 (6.2)). There were no significant differences between groups at any time point (12 months values given) in HbA1c (6.9 (0.8)% v 6.9 (1.2)%, P=0.69; 95% confidence interval for difference –0.25% to 0.38%), BMI (33.1 (6.4) v 31.8 (6.0); adjusted for baseline BMI, P=0.32), use of oral hypoglycaemic drugs, or reported incidence of hypoglycaemia. Monitoring was associated with a 6% higher score on the depression subscale of the well-being questionnaire (P=0.01). Conclusions In patients with newly diagnosed type 2 diabetes self monitoring of blood glucose concentration has no effect on glycaemic control but is associated with higher scores on a depression subscale. Trial registration ISRCTN 49814766. [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] Óâàæàåìûå êîëëåãè, ýíäîêðèíîëîãè! Ïðàâèëüíî ëè ÿ ïîíÿë èç ðàáîòû O’Kane, ÷òî ñàìîêîíòðîëü ãëþêîçû êðîâè äîðîã, íå ìåíÿåò ñóððîãàòíûå èñõîäû è ÷àùå ïðèâîäèò ê äåïðåññèè? Òîãäà ïî÷åìó ýòî ïðîèñõîäèò?  êîíòðîëüíîé ãðóïïå ïàöèåíòû íå èçìåðÿëè ãëþêîçó, íî êàæäûå 3 ìåñÿöà ïðèõîäèëè íà âèçèò ê âðà÷ó. Ò.å., ãëþêîìåòð+âðà÷ íå ëó÷øå, ÷åì ïðîñòî âðà÷? |
#2
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Åñëè ìîíèòîðèíã ïðåâðàòèòü â öåëü, òî îí ìàëî ÷òî äàñò, êðîìå ñíèæåíèÿ êà÷åñòâà æèçíè (áîëüíî, äîðîãî, ñòðàøíî).
Åñëè æå åãî äåëàþò ñðåäñòâîì äëÿ ïîñëåäóþùåé îöåíêè ñèòóàöèè è àäåêâàòíûõ äåéñòâèé, òî îí çíà÷èòåëüíî ñïîñîáñòâóåò êîìïåíñàöèè äèàáåòà. Íî äëÿ ýòîãî ìàëî îáó÷èòü áîëüíîãî ñàìîêîíòðîëþ, íàäî ãðàìîòíî îáó÷èòü åãî â Øêîëå äèàáåòà. |
#3
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Öèòàòà:
Íî åñëè âðà÷ àäåêâàòíûé è ïàöèåíò îáó÷åí, òî íóæåí ëè ñàìîêîíòðîëü ãëþêîçû? |
#4
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Èãîðü, ýòî óæå õîðîøî èçâåñòíàÿ ïóáëèêàöèÿ ( è íå îäíà ) è åå ñìûñë â òîì , ÷òî ÑÀÌÎÊÎÍÒÐÎËÜ ïðè äèàáåòå 2 ( ÂÒÎÐÎÃÎ ) òèïà íà ïåðîðàëüíîé òåðàïèè ÍÅ óëó÷øàåò êîìïåíñàöèè - ïîòîìó êàê íå âëèÿåò íà ïðèíÿòèå ðåøåíèÿ, ýòî æå íå èíñóëèíîòåðïèÿ, ãäå ÿ , óçíàâ ãëþêîçó, ìåíÿþ äîçó ( ðèôìà)
Çäåñü èíà÷å - ïðèíÿòèå ðåøåíèÿ îá èçìåíåíèè äîçèðîâîê/ ðåæèìà/ êîìáèíàöèé èäåò âñëåä çà èíôîðìàöèåé î ãëèêîãåìîãëîáèíå ( ðàç â òðè ìåñ, âðà÷) Äåëî íå â òîì, ÷òî ïëîõî îáó÷àþò - ñàìè ïî ñåáå öåëè îáó÷åíèÿ ðàçëè÷íû, è ìû íèêàê íå ïåðåïðûãíåì ÷åðåç òî îáñòîÿòåëüñòâî, ÷òî ïðè âòîðîì òèïå íà òàáëåòêàõ íè îäíî ãîñóäàðñòâî ìèðà íå ñòàíåò îïëà÷èâàòü áåçóìíûå äåíüãè íà ÷àñòûé ìîíèòîðèíã ãëþêîçû áåç ìîìåíòàëüíîé îáðàòíîé ñâÿçè ( óñëîâíî ãîâîðÿ, ðàç â äâå - òðè íåäåëè îòïðàâëåíèå âðà÷ó ïî ïî÷òå äàííûõ õîòÿ áû íàòîùàêîâîé è ïîñòïðàíäèàëüíîé â ðàçíûå òî÷êè â äåíü ãëèêåìèè ïîçâîëÿëî áû áîëåå îïåðàòèâíî ðåøàòü âîïðîñû) Ðå÷ü èìåííî îá îáðàòíîé ñâÿçè - èëè î äðóãîì íàçíà÷åíèè  êîììåíòàõ ê ýòîé è ïîõîæèì ( âîò íå ïîéäó íà ïëàõó, íî, ïî ìîåìó, ýòîé èñòîðèè óæå ãîäà òðè - ÷åðòûðå ) òåêñò òàêîé - ÑÀÌ ÏÎ ÑÅÁÅ ãëèêåìè÷åñêèé ñàìîêîíòðîëü ïðè 2 òèïå íà òàáëåòêàõ íè÷åãî íå ìåíÿåò è äîëæåí ðàññìàòðèâàòüñÿ â ñîâîêóïíîñòè ñ ïðèíÿòèåì ðåøåíèé êàê ñòðàòåãè÷åñêèõ ( ÷àùå ÷åì ðàç â 3 ìåñ) , òàê è òàêòè÷åñêèõ ( ÷òî-òî ìíå ïëîõî ñòàëî ) À ó÷àò áîëüíûõ äàëåêî íå òàê õîðîøî, êàê õîòåëîñü áû, íå òîëüêî ó íàñ Øàíòåëàó ñêàçàë ìíå - åñòü òàêèå ëþäè, êîòîðûé îáó÷èò òîëüêî Ãîñïîäü
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Ã.À. Ìåëüíè÷åíêî |
#5
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Åñëè ïàöèåíò îáó÷åí ïðàâèëüíî, ñàìîêîíòðîëü ïî îïðåäåëåíèþ íå áóäåò âûçûâàòü äåïðåññèþ. È â Èñëàíäèè åñòü ïðîáëåìû ñ îáó÷åíèåì áîëüíûõ äèàáåòîì. Ïðè÷¸ì ýòè ïðîáëåìû ìàëî îòëè÷àþòñÿ îò ðîññèéñêèõ. Åñëè áû ýòî áûëî íå òàê, Åâðîïåéñêàÿ Àññîöèàöèÿ ïî Èññëåäîâàíèþ Äèàáåòà ñ÷èòàëà áû ñåãîäíÿøíþþ ñèòóàöèþ ñ îáó÷åíèåì áîëüíûõ óäîâëåòâîðèòåëüíîé. Óâû, ïîêà ýòî íå òàê...
ß áû, êñòàòè, ïðåäëîæèëà ñ÷èòàòü îäíèì èç êðèòåðèåâ ýôôåêòèâíîñòè îáó÷åíèÿ ïàöèåíòîâ ñ äèàáåòîì èõ îòíîøåíèå ê ñàìîêîíòðîëþ. |
#6
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Öèòàòà:
Ïðîøó íå ñóäèòü ñòðîãî çà âîïðîñû. Åñëè îíè íå äàþò ïîêîÿ ñðåäíåñòàòèñòè÷åñêîìó êàðäèîëîãó, òî è äðóãèì íåýíäîêðèíîëîãàì ìîãóò áûòü èíòåðåñíûìè. Åñëè ýòî ëèêáåç è àçû, òî ïîøëèòå ìåíÿ ïî ññûëêå êóäà-íèáóäü. Ñòàâèò ëè ïîäîáíàÿ ñòàòüÿ öåëåñîîáðàçíîñòü ñàìîêîíòðîëÿ ïîä âîïðîñ ñ ýêîíîìè÷åñêîé òî÷êè çðåíèÿ? Âëèÿåò ëè ñàìîêîíòðîëü íà ïðèíÿòèå ðåøåíèÿ (áûñòðîãî èëè îòñðî÷åííîãî)? Êàêèå ïîêàçàíèÿ äëÿ ñàìîêîíòðîëÿ ó ïàöèåíòîâ ñ ÑÄ 2 òèïà íà òàáëåòêàõ? Ìíå ó ìàìû çàáðàòü ãëþêîìåòð èëè ïîêà îñòàâèòü? |
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Óâàæàåìûé Èãîðü!
Ñàìîêîíòðîëü - ýòî äîðîãî, íî îïðàâäàííî. Èìåííî ïîòîìó, ÷òî åãî ðåçóëüòàòû âëèÿþò íà ïðèíÿòèå ðåøåíèÿ (êàê áûñòðîãî, òàê è îòñðî÷åííîãî). Ïðè ñàõàðíîì äèàáåòå 2-ãî òèïà íà òàáëåòêàõ ÷àùå âñòðå÷àþòñÿ íåîáó÷åííûå (ïëîõî îáó÷åííûå) ïàöèåíòû. Äëÿ íèõ ñàìîêîíòðîëü òîæå ìîæåò ñòàòü âàæíåéøèì èíñòðóìåíòîì â óïðàâëåíèè äèàáåòîì. Íî äëÿ ýòîãî è èõ íàäî êà÷åñòâåííî îáó÷àòü. À íå ãëþêîìåòðû ó íèõ îòáèðàòü. |
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#8
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Ìàìèí ãëèêîãåìîãëîáèí?
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Ã.À. Ìåëüíè÷åíêî |
#9
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#10
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Èãîðü, Âû øóòèòå? Êèðîâîãðàäñêàÿ îáëàñòü? Êàêàÿ äåðåâíÿ, çåìëÿê?
À ñàõàðà ìàìà êîíòðîëèðóåò è êòî èõ ñìîòðèò?
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Ã.À. Ìåëüíè÷åíêî |
#11
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Öèòàòà:
ß íåñêîëüêî ìåñÿöåâ íàçàä âèäåë èññëåäîâàíèå (êàæåòñÿ, íà Medscape), íî ñåé÷àñ íå ìîãó åãî íàéòè.  íåì àíàëèçèðîâàëàñü ýôôåêòèâíîñòü ñàìîêîíòðîëÿ ïðè ÑÄ 2 áåç èíñóëèíà, âûâîä - ñíèæåíèå HbA1c íà 0,5% â ñëó÷àå, åñëè íà äàííûå ñàìîêîíòðîëÿ îïåðàòèâíî ðåàãèðóþò (âðà÷ è ïàöèåíò). Ñåé÷àñ èñêàë åãî, íàøåë òîëüêî Êîõðåéíîâñêèé îáçîð: (ëåæèò íà [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ], íî ïðèâîæó òåêñò, ò.ê. Medscape òðåáóåò ðåãèñòðàöèè): Self ‐ monitoring of blood glucose in patients with type 2 diabetes mellitus who are not using insulin Posted 07/01/2007 Introduction Date of Most Recent Substantive Amendment: 2005 02 23 Background Self – monitoring of blood glucose (SMBG) has been found to be effective for patients with type 1 diabetes and for patients with type 2 diabetes using insulin. There is much debate on the effectiveness of SMBG as a tool in the self – management for patients with type 2 diabetes who are not using insulin. Objectives The objective of this review was to assess the effects of SMBG in patients with type 2 diabetes mellitus who are not using insulin. Search strategy Studies were obtained from searches of multiple electronic bibliographic databases supplemented with hand searches of references of retrieved articles. Date of last search: September 2004. Selection criteria We included randomised controlled trails investigating the effects of SMBG compared with usual care and/or with self – monitoring of urine glucose in patients with type 2 diabetes who where not using insulin. Included studies should have used at least one of the following outcome measures: glycaemic control, quality of life, well – being, patient satisfaction, or hypoglycaemic episodes. Data collection and analysis Two reviewers independently extracted data from included studies and assessed study quality. Data from the studies were compared to decide whether they were sufficiently homogeneous to pool in a meta – analysis. Main results Six randomised controlled trials were included in the review. Four trials compared SMBG with usual care, one trial compared SMBG with self – monitoring of urine glucose and there was one three – armed trial comparing SMBG with self – monitoring of urine glucose and usual care. Because of the differences in patient characteristics, interventions and outcomes between the studies, it was not possible to perform a meta – analysis. The methodological quality of studies was low. Two of the six studies reported a significant lowering effect of self – monitoring of blood glucose on HbA1c. However, one of these studies had a co – intervention with education on diet and lifestyle. There were few data on the effects of other outcomes and these effects were not statistically significant. Authors' conclusions From this review we concluded that self – monitoring of blood glucose might be effective in improving glycaemic control in patients with type 2 diabetes who are not using insulin. To assess the potential beneficial effects of SMBG in these patients a large and well – designed randomised controlled trial is required. This long – term trial should also investigate patient – related outcomes like quality of life, well – being and patient satisfaction, and provide adequate education to the patient to allow SMBG to be effective. Cochrane Rev Abstract. 2007; ©2007 The Cochrane Collaboration  îáùåì, èññëåäîâàíèé íà ýòó òåìó ìîæåò áûòü ìíîãî. È ó ìåíÿ òóò ïî õîäó âîçíèêëà ìûñëü: íà ïðîñòîðàõ áûâøåãî ÑÑÑÐ â òåõ ìåñòàõ, ãäå âîîáùå íåäîñòóïåí HbA1c, ñàìîêîíòðîëü ìîæåò áûòü íåêîé åãî çàìåíîé (õîòü òàê ýíäîêðèíîëîã ìîæåò ïîëó÷èòü èíôîðìàöèþ î òîì, êàêîâ óðîâåíü ñàõàðà âå÷åðîì, ïîñëå åäû è ò.ï.). |
#12
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P.S.
Íàøåë!
Èññëåäîâàíèå Guerci àæ 2003 ã, ìîæíî ïîñìîòðåòü çäåñü: [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] Íî íàâåðíîå, îíî âîøëî â òîò Êîõðåéíîâñêèé àíàëèç... |
#13
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Îëåã, ìû òóò ðàçãîâàðèâàëè äîâîëüíî äîëãî ñ Åëåíîé Ãåðãèåâíîé ( èíäóöèðîâàíî ïèñüìîì ýíäîêðèíîëîãà ïîëèêëèíèêè )
Ñ ìîåé òî÷êè çðåíèÿ, ñìûñë íàøåãî ðàçãîâîðà áûë â ñëåäóþùåì - â çàâèñèìîñòè îò ñîâîêóïíîñòè ñîöèàëüíûõ è ìåäèöèíñêèõ ïàðàìåòðîâ âûáèðàåòñÿ òà èëè èíàÿ ñòðàòåãèÿ ôîðìà îáó÷åíèÿ - ñêàæåì, Ìàðü Âàííó íà ÏÑÑÒ èç äåðåâíè Âåëèêèå Ãðÿçè íàäî îáó÷èòü ( ïðè óñëîâèè, ÷òî îíà óìååò ïèñÀòü è ïÈñàòü ) ñìîòðåòü ìî÷ó ïîñëå åäû - ïîìî÷èëàñü - ïîåëà - çàïèñàëà , ÷òî ñúåëà -ñîáðàëà ìî÷ó, ïîñìîòðåëà è îöåíèëà, ïðàâèëüíî ëè ïèòàåòñÿ ( ýòîìó íàäî îáó÷èòü), Èâàíà Ôèëèïïîâè÷à -õîòü îí òîæå íà ÏÑÑÒ ( ó íåãî ðîäñòâåííèê â Ìîñêâå ) èç òîé æå äåðåâíè íàäî îáó÷èòü êîíòðîëþ ãëèêåìèè è îáåñïå÷èòü òåëåôîííîé ñâÿçüþ ñ äîêòîðîì â îáëàñòè, Èðî÷êó ( ïåðâûé òèï ) îáåñïå÷èòü ãëþêîìåòðîì è ìåéë - ñâÿçüþ ñ äîêòîðîì ..Ïî èòîãàì îöåíêà äåÿíèé - ãëèêîãåìîãëîáèí ðàç â òðè ìåñ ( åñëè ìîãóò äîåõàòü) Èòîãî ( ýòî ÿ ïðèìåðíî ) - êòî è êàêèì îáðàçîì ìîæåò îáåñïå÷èòü ïëàòíóþ / áåñïëàòíóþ ñîñòàâëÿþùóþ ëå÷åíèÿ è ñàìîêîíòðîëÿ ( ó÷åñòü âàðèàíòû ïîëîñîê, ãëþêîìåòðîâ è òîò ôàêò, ÷òî öåíòðàëèçîâàííî ðàñõîäíèêè íå çàêóïàþòñÿ ïî îïðåäëåíèþ ) Ïðè ðàçãîâîðîðàõ îá èíñóëèíàõ òà æå ïðîáåëìà - â ïðèíèöïå, ìîæíî êîìïíåñèðîâàòü è áåç øïðèö -ðó÷åê è ñâèíûìè èíñóëèíàìè - äåøåâëå â ãîñìàñøòàáå Íî ÷òî äåëàòü ñ ïîíÿòèåì óäîáíåå? Ëåã÷å? Áîëüøå ñâîáîäû? Ñëîâîì, êàê äîëæåí áûòü ïîñòðîåí ðàáî÷èé ãðàôèê ýíäîêðèíîëîãà? ×òî äîëæíà äåëàòü åãî ìåäñåñòðà? Êàê îðãíàèçîâàòü ïðèîáðåòåíèå âñåãî òîãî, ÷òî ãîñóäàðñòâî íåðàçóìíî âçÿëî íà ñåáÿ - õîòü â ìèðå ñóùåñòâóþò ñòðàõîâûå êîìïàíèè? Çàâòðà ìû ñòîëêíåìñÿ ñ íîâîé ( âïîëíå ñïðàâåäëèâîé èäååé )- êàê ÷àñòî íàäî ìåíÿòü èãëû â ðó÷êàõ? ×òî îïÿòü äîëæíî ñäåëàòü ãîñóäðàñòâî?×òî - ðåãèîíàëüíûå îðãàíû? ìû èìååì äåëî ñ ÷ðåçâû÷àéíî çàòðàòíîé áîëåçíüþ - çàâòðà ïðèäóò áàéåòà è ÿíóâèÿ, ðèìîíàáîíò è ïàíàãîíèñòû, ôèáðàüû è ñòàòèíû ñòó÷àòñÿ â äâåðü óæå ñåãîäíÿ.. Ýíäîêðèíîëîã íå ìîæåò âûïèñàòü áåñïëàíòûåì ãèïîòåíçèâíûå è ñòàòèíû ..íàäî èäòè ê êàðäèîëîãó ×òî äåëàåò è åñòü ëè â ñåðâèñå âðà÷ îáùåé ïðàêòèêè - òàéíà âåëèêàÿ ñóòü .. Ó íàñ áîëüøå âñåãî âðà÷åé íà îäíîãî áîëüíîãî ñ äèàáåòîì - 2 500 000 -3 000000 áîëüíûõ ðàçäåëèòü íà 640 000 âðà÷åé - íî íàó÷èòü íåêîìó è íåêîãäà , âñåãî íå õâàòàåò ..Êàê íàì ðåîðãàíèçîâàòü ðàáêðèí?
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Ã.À. Ìåëüíè÷åíêî |
#14
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Íàâåðíîå, äèàáåòîëîãèÿ äîëæíà ñòàòü ñàìîñòîÿòåëüíîé ñïåöèàëüíîñòüþ, îòïî÷êîâàâøèñü îò ýíäîêðèíîëîãèè, êàê, íàïðèìåð, êàðäèîëîãèÿ îò òåðàïèè. Ïîäãîòîâêà ñïåöèàëèñòîâ - íà áàçå òåðàïèè.
Âðà÷è-äèàáåòîëîãè â ïîëèêëèíèêàõ; ìåäèöèíñêèå ñ¸ñòðû, ñïåöèàëèçèðîâàííûå ïî äèàáåòîëîãèè; îòäåëåíèÿ äèàáåòîëîãèè â ñòàöèîíàðàõ... Âîçìîæíî, òàêàÿ ðåîðãàíèçàöèÿ îò÷àñòè ðåøèò ïðîáëåìó... Âïðî÷åì, íå çíàþ... |
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Îòîðâåòñÿ - ïîòåðÿåì Êóøèíãîâ ( âèäåëè è òàêîå , èõ õîòü è ìàëî, äà óìèðàþò ) è ñî÷åòàíèÿ ( à ñ óçëîì, áàòåíüêà, ýòî â äðóãóþ î÷åðåäü )
Îðãàíèçàöèîííî íàäî ñêîðåå äåëåãèðîâàòü ïîëíîìî÷èÿ îáó÷åííûì ñåñòðàì è âðà÷àì îáùåé ïðàêòèêè, íî íà êëèíè÷åñêîì ýòàïå íåëüçÿ îòðûâàòüñÿ Ïî ìíå òàê êëþ÷åâîå - äåíü îáó÷åíèÿ Òî åñòü îäèí äåíü â ïëèêëèíèêå â íåäåëþ ( äâàæäû ïî òðè ÷àñà ) äåíü îáó÷åíèÿ ( ñåñòðà + îáó÷åííûé âðà÷ îáùåé ïðàêòèêè + ýíäîêðèíîëîã )- ðàçíûå ïðîãðàììû
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Ã.À. Ìåëüíè÷åíêî |