臺灣博碩士論文加值系統

背景：糖尿病是國人最重要的慢性病之一，已有相當多的臨床研究證實，長期良好血糖控制，可以減緩併發症之發生，但絕大部分的糖尿病需藉助藥物治療。對於降血糖藥物種類和劑量調整，與糖尿病血糖控制情形過去的研究較少。
目的：探討降血糖藥物種類和劑量調整，與糖尿病血糖控制之關係。
方法：於中部某醫學中心新陳代謝科，選擇自91年08月15日至94年05月31日期間，參與糖尿病共同照護網疾病管理之第2型糖尿病門診病患，完成一年度及二年度複診之個案為研究對象。針對病患之空腹血糖值、糖化血色素及藥物使用情形，加以統計分析並做比較。共有1,375位病患收案滿一年度列為A組，其中455位病患收案滿二年度則列為B組。
結果：藥物種類：於A組患者其收案時與滿一年度相比，有意義的增加（1.65 ± 0.02 vs. 1.71 ± 0.02，p < 0.001）。而B組其藥物種類也有明顯的逐年增加（1.70 ± 0.03 vs. 1.79 ± 0.03 vs. 1.80 ± 0.03 ，p < 0.001）。
糖化血色素：A組收案時與滿一年度相比，有意義的下降，（8.19 ± 0.05% vs. 7.95 ± 0.04%，p < 0.001）。於B組患者比較其收案、滿一年及滿二年時之糖化血色素，滿一年較收案時雖有下降，並無統計學上之差異，而其中滿二年者卻比滿一年者呈現有意義的上升（8.00 ± 0.07 vs. 7.91 ± 0.07 vs. 8.12 ± 0.08，p < 0.001）。
空腹血糖值（mg/dl）：A組收案時與滿一年度相比，沒有明顯改變（172 ± 2 vs. 169 ± 2，p = 0.107）。B組於收案時、滿一年及滿二年相比，也無明顯改變（168 ± 2 vs. 168 ± 2 vs. 168 ± 3，p = 0.775）。此外對於各種口服降血糖藥物劑量調整，我們無法獲得一致性的結果。
糖化血色素分佈百分比；A組經過一年治療後，原控制理想（≦ 7%）之比例由28.8%上升至34.7%；而需更積極治療（≧ 9%）的病患由原先的29.3%下降至22.6%（p < 0.001）。B組控制理想之比例由31.7%上升至32.5%，但在滿第二年時卻下降至30.1%；而需更積極治療的病患由原先的24.4%下降至21.5%，同樣地，在滿第二年時又上升至24.8%（p < 0.001）。顯示雖積極治療，病患糖化血色素之控制第二年度比第一年度差。
空腹血糖值；A組經過一年治療後，原控制理想（≦ 130mg/dl）比例由22.7%上升至39.7%；需更積極治療的病患（＞ 160 mg/dl）則由原先的50.2%下降至38.3%（p < 0.001）。B組控制理想之比例於收案時、滿一年及滿二年時並無明顯改善（22.4% vs. 24.2% vs. 22.6%），而需積極治療之比例亦無改善（48.1% vs. 48.1% vs. 45.3%）。
結論：雖然糖尿病用藥種類隨時間而增加，但血糖只有短暫下降之後又上昇，可能因醫師看到病患血糖高、病情控制不好而加藥，或因疾病持續進行，需要較多種降血糖藥物，才能有效控制血糖值，故病患用藥種類有逐年增加的趨勢。

Background: Type 2 diabetes mellitus (DM) is one of the major chronic diseases in Taiwan. Previous reports indicated that the complications of DM may be delayed if the blood sugar is well-controlled. However, the number and dosage of anti-diabetic drugs used in association with diabetic control are rarely reported.
Aim: To investigate the use of anti-diabetic agents and their dosage adjustments in relation to glucose control in type 2 diabetic subjects.
Methods: A total of 1375 type 2 DM patients who participated in the Diabetes Share Care Disease Management (DSCDM) program in a medical center at central Taiwan from August 2002 to May 2005 was enrolled.Those 1375 patients received a completed follow-up studies in one-year period (defined as group A); 455 patients of them completed follow-up studies in 2-year period (defined as group B). Results: The number of anti-diabetic drugs significantly increased both in group A (1.65 ± 0.02 at the beginning vs. 1.71 ± 0.02 at the end of 1-year period，p < 0.001), and group B (1.70 ± 0.03 at the beginning vs. 1.79 ± 0.03 at the end of 1-year period vs. 1.80 ± 0.03 at the end of 2-year period, p < 0.001).The HbA1C level in group A patients significantly reduced (8.19 ± 0.05% at the beginning vs. 7.95 ± 0.04% at the end of 1-year period, p < 0.001). However, in group B patients, the HbA1C level at the end of 2-year period was significantly greater than that at the end of 1-year period (8.00 ± 0.07% vs. 7.91 ± 0.07 vs. 8.12 ± 0.08%，p < 0.001).There were no significant difference of fasting blood sugar (FBS, mg/dl) level changes at the beginning, the end of 1-year and 2-year treatment in both A (172 ± 2 at the beginning vs. 169 ± 2 at the end of 1-year period，p = 0.107) and B (168 ± 2 at the beginning vs. 168 ± 2 at 1-year period vs. 168 ± 3 at 2-year period，p = 0.775）groups.The well-controlled percentage of the HbA1C level (≦7%) in group A patients increased from 28.8% at the beginning to 34.7% at the end of 1 year. The percentage of HbA1C level ≧ 9% reduced from 29.3% at the beginning to 22.6% at the end of 1 year. In group B patients, well-controlled percentage of HbA1c temporarily increased from 31.7% at the beginning to 32.5% at the end of 1 year, then, reduced to 30.1% at the end of 2 year. The percentage of HbA1C level≧9% temporarily reduced from 24.4% at the beginning to 21.5% at the end of 1 year, then increased to 24.8% at the end of 2 year. In group A patients, the percentage of FBS ≦130 mg/dl increased from 22.7% at the beginning to 39.7% at the end of 1 year, the percentage of FBS ＞160 mg/dl reduced from 50.2 % at the beginning to 38.3 % at the end of 1 year. In group B, no apparent change of FBS could be found.
Conclusion: The number of anti-diabetic agents used increased progressively in the end of one and two years. However, the trend did not coincide with improvement of glucose control in diabetes.

口試委員會審定……………………………………………………………i
博碩士論文授權書…………………………………………………………ii
誌謝…………………………………………………………………………iii
目錄…………………………………………………………………………iv
表目錄………………………………………………………………………vi
中文摘要……………………………………………………………………1
英文摘要……………………………………………………………………4
第一章 緒論………………………………………………………………7
第一節 研究緣起…………………………………………………………7
第二節 研究目的…………………………………………………………13

第二章 文獻探討…………………………………………………………14
第一節 糖尿病及其相關疾病……………………………………………14
第一項、 糖尿病之定義、診斷與分類……………………………………14
一、 糖尿病之定義……………………………………………………14
二、 糖尿病的診斷標準………………………………………………15
三、 糖尿病的分類……………………………………………………15
第二項、 糖尿病的併發症與相關疾病……………………………………17
第三項、 糖尿病的篩檢與診療……………………………………………25
第四項、 糖尿病的流行病學………………………………………………27
第二節 第2型糖尿病之臨床處置 ………………………………………29
第一項、 生活型態之調整…………………………………………………29
一、 適當的飲食控制…………………………………………………29
二、 規律的運動………………………………………………………30
三、 減低危險因子的暴露……………………………………………30
第二項、 糖尿病之藥物治療………………………………………………33
一、 糖尿病藥物治療之重要性………………………………………33
二、 糖尿病之藥物治療………………………………………………34
第三節 糖尿病共同照護計畫……………………………………………39
第一項、 糖尿病共同照護概念……………………………………………39
第二項、 台灣糖尿病照護現況……………………………………………41
第四節 糖尿病治療文獻結論……………………………………………44
第三章 研究設計與方法…………………………………………………46
第一節 研究架構…………………………………………………………46
第二節 研究假說…………………………………………………………46
第三節 資料來源與研究對象……………………………………………47
第四節 研究變項與操作定義……………………………………………48
第五節 資料處理及分析方法……………………………………………50
第四章 研究結果…………………………………………………………51
第一節 收案病患各種基本資料分析……………………………………51
第二節 A 組患者各項變數之檢定分析…………………………………53
第三節 B 組患者各項變數之檢定分析…………………………………59
第四節 病患之血糖控制情形……………………………………………65
第五節 一般線性模型分析結果…………………………………………68
第五章 討論………………………………………………………………71
第一節 資料品質…………………………………………………………71
第二節 研究結果之討論…………………………………………………71
第三節 研究限制…………………………………………………………76
第六章 結論………………………………………………………………78
參考文獻………………………………………………………………………80
表目錄
表 1. 收案病患之基本資料…………………………………………………89
表 2. 病患資料之百分比分佈………………………………………………90
表 3. A 組患者各變數之檢定分析…………………………………………91
表 4. A 組患者之Spearman's 相關性檢定………………………………91
表 5. A 組患者之Spearman's 相關性檢定………………………………92
表 6. 藥物劑量調整與糖化血色素間之檢定分析…………………………93
表 7. 藥物劑量調整與糖化血色素改變量之檢定分析……………………94
表 8. 藥物劑量調整與空腹血糖值間之檢定分析…………………………95
表 9. B 組患者各變數間之檢定分析………………………………………96
表10. B 組患者之Spearman's 相關性檢定………………………………97
表11. B 組患者各種變數與糖化血色素間之檢定分析……………………98
表12. 藥物劑量調整與糖化血色素間之檢定分析…………………………99
表13. 滿一年藥物劑量調整與2年-1年糖化血色素改變量之檢定分析…100
表14. 滿二年藥物劑量調整與2年-1年糖化血色素變化間之檢定分析…101
表15. 藥物劑量調整與空腹血糖值間之檢定分析…………………………102
表16. 各組變項與血糖控制之關係Chi-Square p-value………………103
表17. 一般線性模型分析結果-1……………………………………………104
表18. 一般線性模型分析結果-2……………………………………………105
表19. 收案病患使用降血脂、降血壓藥情形(百分比)……………………106
附表1.口服降血糖藥物之作用機轉及可能之副作用………………………107
附表2.台灣地區糖尿病照護參考指標(中央健保局照護標準)……………108
附表3.糖尿病患特質…………………………………………………………109

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