美国凯撒永久医疗集团Andrew J. Karter团队研究了实时连续血糖监测与胰岛素治疗糖尿病患者血糖控制和急性代谢事件的相关性。2021年6月2日，《美国医学会杂志》发表了该成果。

1型糖尿病患者应重视连续血糖监测（CGM）；胰岛素治疗的2型糖尿病患者进行CGM缺乏观察证据。

为了评价实时CGM启动的临床效果，研究组进行了一项探索性回顾性队列研究，使用差异分析中的差异估计。研究组共招募了41753名接受胰岛素治疗的糖尿病患者（其中5673名为1型糖尿病患者；36080名为2型糖尿病），他们均接受北加州综合医疗服务提供系统（2014-2019年）的护理，且自我监测血糖水平，并且之前没有使用CGM。主要观察指标为基线前12个月和基线后12个月内测量的10个终点：糖化血红蛋白（HbA1c）；低血糖；高血糖；糖化血红蛋白低于7%，低于8%，高于9%；因任何原因发生1次及以上急诊；因任何原因住院1次及以上；门诊量和电话量。

共有3806例患者接受实时CGM，平均年龄为42.4岁，51%为女性；91%为1型糖尿病，9%为2型。37947例未启动CGM，平均年龄为63.4岁，49%为女性；6%为1型糖尿病，94%为2型。实时CGM启动者的基线前平均HbA1c低于非启动者，但实时CGM启动者的基线前低血糖和高血糖发生率较高。

实时CGM启动者的平均HbA1c从8.17%下降到7.76%，非启动者从8.28%下降到8.19%，降幅差异显著。实时CGM启动者的低血糖率从5.1%下降到3.0%，非启动者的低血糖率从1.9%上升到2.3%。校正后的净变化中，两组间糖化血红蛋白低于7%的患者比例差异为9.6%；低于8%的比例差异为13.1%；高于9%的比例差异为−7.1%；门诊就诊次数的差异为−0.4；电话访问的差异为1.1，组间差异均显著。实时CGM的启动与高血糖率、全因急诊就诊或全因住院率的统计学显著变化无关。

总之，在这项回顾性队列研究中，医生对接受胰岛素治疗的糖尿病患者进行实时连续血糖监测，与未实施者相比，患者的糖化血红蛋白显著改善，急诊就诊和低血糖住院率显著降低，但因高血糖或全因急诊就诊或住院的情况无明显变化。

附：英文原文

Title: Association of Real-time Continuous Glucose Monitoring With Glycemic Control and Acute Metabolic Events Among Patients With Insulin-Treated Diabetes

Author: Andrew J. Karter, Melissa M. Parker, Howard H. Moffet, Lisa K. Gilliam, Richard Dlott

Issue&Volume: 2021-06-02

Abstract:

Importance  Continuous glucose monitoring (CGM) is recommended for patients with type 1 diabetes; observational evidence for CGM in patients with insulin-treated type 2 diabetes is lacking.

Objective  To estimate clinical outcomes of real-time CGM initiation.

Design, Setting, and Participants  Exploratory retrospective cohort study of changes in outcomes associated with real-time CGM initiation, estimated using a difference-in-differences analysis. A total of 41753 participants with insulin-treated diabetes (5673 type 1; 36080 type 2) receiving care from a Northern California integrated health care delivery system (2014-2019), being treated with insulin, self-monitoring their blood glucose levels, and having no prior CGM use were included.

Exposures  Initiation vs noninitiation of real-time CGM (reference group).

Main Outcomes and Measures  Ten end points measured during the 12 months before and 12 months after baseline: hemoglobin A1c (HbA1c); hypoglycemia (emergency department or hospital utilization); hyperglycemia (emergency department or hospital utilization); HbA1c levels lower than 7%, lower than 8%, and higher than 9%; 1 emergency department encounter or more for any reason; 1 hospitalization or more for any reason; and number of outpatient visits and telephone visits.

Results  The real-time CGM initiators included 3806 patients (mean age, 42.4 years [SD, 19.9 years]; 51% female; 91% type 1, 9% type 2); the noninitiators included 37947 patients (mean age, 63.4 years [SD, 13.4 years]; 49% female; 6% type 1, 94% type 2). The prebaseline mean HbA1c was lower among real-time CGM initiators than among noninitiators, but real-time CGM initiators had higher prebaseline rates of hypoglycemia and hyperglycemia. Mean HbA1c declined among real-time CGM initiators from 8.17% to 7.76% and from 8.28% to 8.19% among noninitiators (adjusted difference-in-differences estimate, 0.40%; 95% CI, 0.48% to 0.32%; P<.001). Hypoglycemia rates declined among real-time CGM initiators from 5.1% to 3.0% and increased among noninitiators from 1.9% to 2.3% (difference-in-differences estimate, 2.7%; 95% CI, 4.4% to 1.1%; P=.001). There were also statistically significant differences in the adjusted net changes in the proportion of patients with HbA1c lower than 7% (adjusted difference-in-differences estimate, 9.6%; 95% CI, 7.1% to 12.2%; P<.001), lower than 8% (adjusted difference-in-differences estimate, 13.1%; 95% CI, 10.2% to 16.1%; P<.001), and higher than 9% (adjusted difference-in-differences estimate, 7.1%; 95% CI, 9.5% to 4.6%; P<.001) and in the number of outpatient visits (adjusted difference-in-differences estimate, 0.4; 95% CI, 0.6 to 0.2; P<.001) and telephone visits (adjusted difference-in-differences estimate, 1.1; 95% CI, 0.8 to 1.4; P<.001). Initiation of real-time CGM was not associated with statistically significant changes in rates of hyperglycemia, emergency department visits for any reason, or hospitalizations for any reason.

Conclusions and Relevance  In this retrospective cohort study, insulin-treated patients with diabetes selected by physicians for real-time continuous glucose monitoring compared with noninitiators had significant improvements in hemoglobin A1c and reductions in emergency department visits and hospitalizations for hypoglycemia, but no significant change in emergency department visits or hospitalizations for hyperglycemia or for any reason. Because of the observational study design, findings may have been susceptible to selection bias.

DOI: 10.1001/jama.2021.6530

Source: https://jamanetwork.com/journals/jama/fullarticle/2780594