Diabetes Obes and Metab:聚焦精准治疗:如何通过日常空腹血糖预测HbA1c水平?

2019-09-17 国际糖尿病编辑部 国际糖尿病

在患者日常指尖血糖监测中,空腹血糖(FBG)相对更易获得。那么是否可以通过自测FBG来预测HbA1c水平呢?近期在Diabetes Obesity and Metabolism发表的BEYOND III研究发现:FBG与HbA1c水平显著正相关,且得出了具体计算公式。这一结果使FBG与HbA1c之间的关系变得更具体、更实用。公式如何使用?现在就让我们一起来揭秘。

在患者日常指尖血糖监测中,空腹血糖(FBG)相对更易获得。那么是否可以通过自测FBG来预测HbA1c水平呢?近期在Diabetes Obesity and Metabolism发表的BEYOND III研究发现:FBG与HbA1c水平显著正相关,且得出了具体计算公式。这一结果使FBG与HbA1c之间的关系变得更具体、更实用。公式如何使用?现在就让我们一起来揭秘。

BEYOND III研究概述

BEYOND III研究是一项24周、开放标签、随机对照的治疗达标(treat-to-target)研究,旨在2型糖尿病(T2DM)患者中比较三种不同空腹血糖目标值对HbA1c达标率的影响。该项研究由中日友好医院杨文英教授牵头,全国44个研究中心参与。结果证实大多数中国T2DM患者的最佳FBG目标范围是3.9~6.1 mmol/L,与FBG目标3.9~7.0 mmol/L相比,该目标可以提升患者HbA1c达标率,且不增加低血糖风险(图1)。



aP < 0.025 for Bonferroni-adjusted analysis;
bnominal P < 0.05 vs FBG ≤7.0 mmol/L
图1. 不同空腹血糖目标值人群在24周时的血糖达标率

探索性终点揭示FBG 与HbA1c的相关性

除此以外,该研究还探索了按照24周实际FBG水平分层的HbA1c达标率,结果显示,与24周时实际FBG水平6.1~7.0 mmol/L的患者HbA1c<7%达标率(43.6%)相比,FBG水平≤5.6 mmol/L(68.7%,P<0.001)和5.6~6.1 mmol/L(58.2%,P=0.013)的患者达标率显著更高,提示在不考虑低血糖的情况下,FBG水平越低则患者的HbA1c达标率越高。

而进一步的线性回归分析显示通过FBG预测HbA1c的公式如下:

•治疗早期:HbA1c(%)= 4.734 + 平均FBG(1-12周) × 0.371, P<0.001, R2 = 0.21

通过公式计算得知,当平均FBG水平为7.0、6.1、5.6 mmol/L时,相应的HbA1c水平分别为7.3%、7.0%和6.8%(图2A)。

•治疗后期HbA1c(%)= 4.055 + 平均FBG(13-24周) × 0.480, P<0.001, R2 = 0.23

通过公式计算得知,当平均FBG水平为7.0、6.1、5.6 mmol/L时,相应的HbA1c水平分别为7.4%、7.0%和6.7%(图2B)。

可以看到,无论在治疗早期(1~12周)还是后期(13~24周),平均FPG水平越低,HbA1c水平也越低,且两个公式的预测结果也极为接近。即使在校正基线参数(包括年龄、性别、体质指数、糖尿病病程、FPG、HbA1c和餐后血糖)之后,上述FBG与HbA1c之间的相关性依然存在。




图2. FBG与HbA1c的线性回归分析

研究结果的临床意义及思考

空腹血糖的重要性更加明确

目前大多数糖尿病指南,包括2019美国糖尿病协会(ADA)指南和中国2型糖尿病防治指南(2017年版),均将HbA1c<7%作为大多数T2DM患者的血糖控制金标准;而在临床实践、尤其是患者自我血糖监测中,空腹血糖的测定较HbA1c更为简便。若能在FBG与HbA1c之间建立起一个简单明了的关系,将大大有助于患者了解和控制自己的血糖状况。

BEYOND III研究的探索性终点结果显示,FBG越低则HbA1c越低,该相关性在校正基线特征后依然存在。根据以上公式,FBG水平为5.6 mmol/L时,对应的HbA1c为6.7%~6.8%。该研究同时显示,24周时FBG水平≤5.6 mmol/L的患者HbA1c达标率高达约69%。结合考虑这些结果,提示对于较年轻、病程较短、并发症较少、低血糖风险较低的T2DM患者,将FBG控制到5.6 mmol/L以下可能获益更大。但对于大多数患者而言,若能将空腹血糖控制在≤6.1 mmol/L的水平,即也可达到HbA1c<7%的目标。

FBG与HbA1c的相关性公式简单直观,易于计算和理解,实用性强,为医生和患者精准管理血糖提供了一种全新的参考,具有较高临床价值。

需进一步探索FBG与HbA1c的相关性

目前研究关于FBG预测HbA1c的计算公式仍存在一定局限性。需注意到,线性回归分析中R2值为0.21~0.23,该决定系数反映的是x对y的影响力,提示单纯FBG对HbA1c的影响力有限。实际上,HbA1c的水平是由基础血糖和餐后血糖漂移共同来决定的,而这通常需要7点血糖谱或动态血糖监测的曲线下面积计算而得。由于本研究并未搜集这些数据,因此无法分析基础血糖或餐后血糖漂移与HbA1c的相关性。

结语

BEYOND III研究进一步探索了FBG与HbA1c之间存在相关性,通过简单公式可由日常FBG水平来计算患者的HbA1c水平,这不仅证实了空腹血糖的重要性,而且为血糖监测方案提供了新思路。期待今后开展更多设计良好的研究来进一步探索和验证这种相关性,并将之早日推广于临床,以使患者从中获益。

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    2020-08-17 一闲
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    2020-08-09 guojianrong
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encryptionId=33108494c1, topicName=HbA)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c48a270, createdName=Smile2680, createdTime=Sat Nov 02 23:06:00 CST 2019, time=2019-11-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1761202, encodeId=44da1e61202fb, content=<a href='/topic/show?id=9bea33520d' target=_blank style='color:#2F92EE;'>#BET#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=3352, encryptionId=9bea33520d, topicName=BET)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=9a1a37427546, createdName=ms5439512287675881, createdTime=Mon Jul 27 16:06:00 CST 2020, time=2020-07-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1902317, encodeId=3924190231ebf, content=<a href='/topic/show?id=c097591ed5' target=_blank style='color:#2F92EE;'>#Diabetes#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=12, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=5917, encryptionId=c097591ed5, topicName=Diabetes)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=0045169, createdName=木头人513, createdTime=Mon Jan 13 14:06:00 CST 2020, time=2020-01-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1304990, encodeId=81be1304990bf, content=<a href='/topic/show?id=1970e539018' target=_blank style='color:#2F92EE;'>#空腹血糖#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=75390, encryptionId=1970e539018, topicName=空腹血糖)], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160723/IMG57937A3BB59F33185.jpg, createdBy=7642322, createdName=手留余香, createdTime=Thu Sep 19 11:06:00 CST 2019, time=2019-09-19, status=1, ipAttribution=), 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  4. 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encryptionId=33108494c1, topicName=HbA)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c48a270, createdName=Smile2680, createdTime=Sat Nov 02 23:06:00 CST 2019, time=2019-11-02, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1761202, encodeId=44da1e61202fb, content=<a href='/topic/show?id=9bea33520d' target=_blank style='color:#2F92EE;'>#BET#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=3352, encryptionId=9bea33520d, topicName=BET)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=9a1a37427546, createdName=ms5439512287675881, createdTime=Mon Jul 27 16:06:00 CST 2020, time=2020-07-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1902317, encodeId=3924190231ebf, content=<a href='/topic/show?id=c097591ed5' target=_blank style='color:#2F92EE;'>#Diabetes#</a>, beContent=null, 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createdAvatar=https://thirdwx.qlogo.cn/mmopen/vi_32/DYAIOgq83epQX9hfEIBiaPg0e9KvLYVBCSGYydH6K6OQxBh3RaOC0TYP9HYy2v0XdHib1LFnZNU5Siak0P8oh8Aqw/132, createdBy=acd92440184, createdName=shijzhiewnjhch, createdTime=Thu Sep 19 11:06:00 CST 2019, time=2019-09-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=372856, encodeId=d47d3e285664, content=学习了,学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=74, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzTetibytbqFDmFITWHyBWbxU7S9MYibgPSqvu0sYteH0N6zXqbU0Kf3Mbdb7yWM1Kud3zPgYBibE2SZ/0, createdBy=da7696924, createdName=qingfengqishi5, createdTime=Tue Sep 17 21:55:26 CST 2019, time=2019-09-17, status=1, ipAttribution=)]
    2019-11-02 Smile2680
  5. 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  6. 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    2019-09-17 qingfengqishi5

    学习了,学习了

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