Optimizing Glycemic Control of Diabetes Mellitus in Older Adults - A Tailored Approach

應用量身訂造的處置方式達到適當調控年長糖尿病患血糖值的目標

10.6314/JIMT.201904_30(2).08

宋育民(Yuh-Min Song)

Diabetes mellitus ； Glycemic control ； Older adult

內科學誌

30卷2期（2019 / 04 / 01）

132 - 149

英文

The prevalence as well as the incidence of diabetes mellitus has been increasing worldwide. In an aging society, this disorder in older adults contributes to these increases. Older people are more vulnerable than younger people to developing excessive fat deposition and reduction in skeletal muscle because of a sedentary lifestyle, lower energy expenditure, and physical alterations due to aging, which can lead to the development of insulin resistance. The capacity of pancreatic beta cells to regenerate and differentiate is reduced in older people, which predisposes them to insulin deficiency. These two pathophysiological alterations underlie the development of glucose intolerance. With significantly longer life spans thanks to the advances in health care, it is imperative to attain optimal glycemic control in this specific population to prevent diabetes-related chronic complications. In addition to life style modifications such as dietary control and exercise for obese patients and those who could benefit from moderate weight loss, antidiabetic agents are frequently required to achieve prespecified treatment goals. Delivery of these medications in an efficient and safe manner must be tailored to individual requirements to maintain an intricate balance between reasonable glycemic control and hypoglycemia. Older adults with diabetes are vulnerable to hypoglycemia due to a long history of the disease and frailty from aging. As long as factors that impact the pharmacokinetics and pharmacodynamics of these agents are considered, such as renal function and adherence to polypharmacy, oral agents are more welcomed by older people because of convenience of administration and proved clinical efficacy. When oral agents fail, insulin therapy may be unavoidable when trying to pursue an optimal glycemic target.

台灣的社會人口結構已經在2018年的3月底邁入高齡社會，定義是65歲以上的人口比例已超過總人口數的14%。隨著人類壽命增長及高齡化的現象，慢性疾病的盛行率亦明顯上升，糖尿病亦不例外。根據最新的國際糖尿病組織（IDF）的統計數字，全球高齡者的糖尿病盛行率已達18.8%，且預期會持續升高。年長者罹患糖尿病的病生理機制仍因胰臟β細胞製造及分泌胰島素功能不足，及周邊組織器官之胰島素阻抗現象引起，但與較年輕族群比較，因為運動量減少及基礎熱量消耗量下降，導致臟器脂肪更易堆積，但是骨骼肌量反而減少，使血糖代謝異常的程度加劇，引致糖尿病產生。因平均餘命延長，在年長者仍應積極調控血糖以期減少高血糖可能引起之併發症，如腎病變、視網膜病變、神經病變，或感染症，以維持或改善年長者的生活品質。調控血糖的治療策略仍應以生活模式的調整為出發點，尤其在肥胖者，適當的飲食控制加上運動，可以減少脂肪堆積並增加肌肉量，胰島素阻抗現象及血糖控制皆可獲得改善。然大多數病患仍需藥物治療才能達到治療目標，其中口服降糖藥物的投與仍是方便及有效控制血糖的方式，重點是避免過度治療而導致低血糖的發生，低血糖對心血管及神經認知系統會產生極嚴重的傷害，因此學術團體在制定治療指引時，主張在孱弱的年長者要放寬控制目標，以美國糖尿病學會之指引為例，若合併有嚴重程度的慢性病，例如嚴重心衰竭或是腎衰竭，糖化血色素值可至8.5%，但是對於身心功能俱佳的年長者，其控糖目標仍可比照較年輕族群的7%。當口服藥物療效不理想時，可選擇胰島素注射加強治療效果，此時仍應考量年長者對於較複雜療法之接受度及執行能力。在決定年長者糖尿病的治療策略時，需要多面相的考慮，在達到控制血糖目標與避免低血糖之間需求取平衡。