KJFPpISSN 2233-909 eissn 2233-96 Korean J Fam Pract. 205;5(3, suppl. 2):688-694 Original Article 제 2 형당뇨병환자에서경구혈당강하제최초투여 2 주후당화혈색소목표달성과관련된요인 노혜리, 문현수, 이정아, 선우성, 최윤선 2, 원장원 3, 김대현 4, 박영규 5, 김영식,* 울산대학교의과대학서울아산병원가정의학과, 2 고려대학교의과대학구로병원가정의학과, 3 경희대학교의과대학경희의료원가정의학과, 4 계명대학교의과대학동산의료원가정의학과, 5 분당제생병원가정의학과 Factors associated with target achievement of HbAC in drug naive patients with type 2 diabetes after 2 weeks of taking oral hypoglycemic agent Hye-Ri Roh, Hyeon-Su Mun, Jung-Ah Lee, Sung Sunwoo, Yun-Sun Choi 2, Chang-Won Won 3, Dae-Hyun Kim 4, Young-Gyu Park 5, Young-Sik Kim,* Departments of Family medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul; 2 Departments of Family medicine, Korea University Guro Hospital, Korea University college of Medicine, Seoul; 3 Departments of Family medicine, Kyung Hee University Medical Center, Kyung Hee University School of Medicine, Seoul; 4 Departments of Family medicine, Dongsan Medical Center, Keimyung University School of Medicine, Daegu; 5 Departments of Family medicine, Bundang Jesaeng General Hospital, Seoungnam, Korea Background: Lowering hemoglobin AC(HbAC) is important in reducing complications associated with diabetes. However, the factors associated with achievement of target HbAc levels have not been well established, especially in primary care patients. Thus, we aimed to evaluate the rate of successful treatment of diabetes and to identify the factors associated with achievement of target HbAc in drug-naive patients with type 2 diabetes. Methods: From March 2006 to December 2007, 24 patients with type 2 diabetes mellitus who were newly diagnosed were enrolled. Target achievement was defined as HbAc levels under 6.5% after 2 weeks of taking gliclzide. We analyzed socio-demograraphic characteristics and diabetes mellitus-related factors as variables which could affect target achivement. Results: The mean age of subjects was 58.3±0.9 years, and 42.5% achieved target HbAc. Male gender (OR 0.43; 95% CI.28~4.23) and high income (OR 0.03; 95% CI 0.4~0.79) were strongly associated with target achivement. Higher initial HbAc (OR 2.57; 95% CI.8~3.67), poor compliance with nutritional education (OR 5.8; 95% CI.04~222.07) and adherence to drug administration less than 80% (OR 5.04; 95% CI.29~9.69) were associated with failure to reach target achivement. Conclusion: The rate of achieving target HbAc levels in drug-naive patients with type 2 diabetes was less than half. Factors associated with low achievement of HbAc goals were female gender, low income, higher initial HbAc, poor compliance with nutritional education and poor adherence to drug administration. Keywords: Type 2 diabetes mellitus, Oral hypoglycemic agent, Target achivement, Adherence 서론당뇨병은미세혈관및대혈관합병증을일으켜심혈관계질환으로인한장애, 사망률을높이는질환으로, -3) 2035년에는전세계적인환자수가 5억9천2백만명까지증가할것으로예상되고있으며 4) 한국에서도지난 40년간유병률이.5% 에서 9% 로증가하고있어사회적경각심이요구되는질환이다. 5) 철저한혈당조절이미세혈관합병증예방에중요하다는것은최초제형당뇨병환자들을대상으로한연구에서밝혀졌다. 4) 이후제2형당뇨병에서도적극적혈당조절이미세혈관의합병증예방에중요하다는연구결과들이발표되었다. 대표적인연구로제2형당뇨병환자를대상으로시행된 United Kingdum Prospective Diabetes Study에서는당화혈색소 7.0% 미만으로엄격히혈당을조절한군에서그렇지않은군에비해미세혈관합병증발생이 25% 감소하는 Received February 2, 205 Revised September 2, 205 Accepted September 7, 205 Corresponding Author Young-Sik Kim Tel: +82-2-300-38, Fax: +82-2-300-385 E-mail: youngkim@amc.seoul.kr Copyright 205 The Korean Academy of Family Medicine This is an open-access article distributed under the terms of the Creative Commons Attribution n-commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 688 www.kafm.or.kr
노혜리외. 제 2 형당뇨병환자에서경구혈당강하제최초투여 2 주후당화혈색소목표달성과관련된요인 KJFP 것으로나타났다. 5) 대혈관합병증의경우연구결과들이일치하지않는다. 특히당뇨병진단후시일이경과한환자들에서는철저한혈당조절이대혈관합병증발생을예방하지못하는것으로나타났다. 6, 7) 그러나새로진단된당뇨병환자들을 0년동안추적관찰한연구에서초기철저한혈당조절을한경우대혈관합병증발생이유의하게 (Risk reduction 5%, P =0.0) 감소하였다. 8) 따라서초기당뇨병환자의경우혈당을적극적으로조절하는것이중요하며당화혈색소목표달성에어떠한요인이영향을끼치는지알아내는것이혈당조절에도움이될수있다. 국내에서혈당조절과연관된요인에대하여연구한논문이몇편있기는하지만일부도시지역에한정된연구이거나 9), 순응도와같은특정요인에대한분석에초점이맞춰져있는연구들이대부분이었다. 0,) 따라서본연구에서는경구혈당강하제복용을시작하는환자들을대상으로국내초기당뇨병환자들의특성을알아보고당화혈색소목표달성에영향을끼치는요소를살펴보고자하였다. IPAQ) 을이용하였으며 3) MET-minutes per week로점수화하여 3 단계로범주화하였다. (2) 신체계측및혈액검사경구혈당강하제처방전신장 (m) 과체중 (kg) 을측정하여체중을키의제곱으로나누어체질량지수 (kg/m 2 ) 를구하였고, 혈압을측정하였다. 0시간이상공복상태에서혈액검사를시행하여혈당, 당화혈색소, 총콜레스테롤, 중성지방, 고밀도지단백콜레스테롤, 저밀도지단백콜레스테롤을측정하였다. 2) 경구혈당강하제투여및추적조사연구대상자모두 sulfonylurea계경구혈당강하제인 gliclazide 30mg을최초 일 회처방하였으며담당의사의판단에의해용량을조절하였다. 4주, 8주, 2주에내원하도록하여체중과허리둘레를측정하고, 혈액검사를시행하였으며약물복용상태및유해사례발생여부에대하여담당의사가평가하였다. 방법. 연구대상 2006년 3월 5일부터 2007년 2월 3일까지서울, 경기, 대구지역 8개병원 명의가정의학과의사를방문한환자에서제2형당뇨병으로새롭게진단되었거나기존의혈당강하제복용자중최근 4주이상복용을중단한환자를대상으로하였다. 참여자들을대상으로서면동의를받았으며서울아산병원임상심의위원회의승인을받아연구를진행하였다. 2. 연구방법 ) 연구자료의수집 () 기본적자료연령, 성별, 교육수준, 결혼상태등사회인구학적요인과병용약물의유무, 당뇨병영양교육의유무는경구혈당강하제처방전환자가문진표를직접작성하도록하여수집하였다. 당뇨병영양교육은단일문항으로당뇨병관련영양교육을받은적이있느냐는질문에예 / 아니오로대답한것으로평가하였다. 영양교육을받았다고응답한경우지침을지키고있는지를확인하였으며 항상지킨다, 가끔지킨다, 지키지않는다 로평가하였다. 흡연상태는흡연군과비흡연군으로분류하였다. 음주량은주당마시는횟수, 술의종류, 양을조사하여 L의맥주는 40g으로, L의와인은 20g으로, L의소주는 250g으로, L의양주는 400g으로환산하여섭취한알코올의총양을 gram으로계산하였다. 2) 신체활동량은한국어판단문형국제신체활동설문 (International Physical Activity Questionnaire, 3) 약물순응도및목표달성률의정의 2주째담당의사가약물의투여상황을직접확인하여 80% 이상복용한경우약물순응군으로그외의경우는비순응군으로분류하였다. 또한당화혈색소 6.5% 를기준으로치료 2주째당화혈색소가 6.5% 미만인경우를목표달성군, 6.5% 이상인군을목표실패군으로정의하였다. 3. 통계분석전체연구대상자의사회인구학적요인과질병관련요인, 신체계측및혈액검사를평균과표준편차, 빈도및백분율로표시하였다. 치료전후신체계측및혈액검사변화를대응표본 t 검정을이용하여분석하였다. 당화혈색소에영향을끼치는인자를사회인구학적요인 ( 성별, 연령, 흡연상태, 음주량, 신체활동량, 교육수준, 소득수준, 결혼상태 ) 과당뇨병연관요인 ( 체질량지수, 고혈압, 이상지질혈증, 최초공복혈당, 최초당화혈색소, 당뇨병영양교육유무및실천여부, 병용약물, 약물순응도 ) 으로나누어분석하였다. 각각의변수들을독립변수로하여실패군에대한단변량로지스틱회귀분석을시행하였고, 성별과연령을포함하여다변량로지스틱회귀분석을시행하였다. 모든통계분석은 Statistical Package for the Social Sciences (SPSS) ver. 4.0 (SPSS Inc., Chicago, IL, USA) 프로그램을이용하였고유의성검정은 P<0.05 인경우통계적으로유의한것으로판정하였다. Korean J Fam Pract. 205;5(3, suppl. 2):688-694 www.kafm.or.kr 689
KJFP Hye-Ri Roh, et al. Factors associated with target achievement of HbAC in drug naive patients with type 2 diabetes after 2 weeks of taking oral hypoglycemic agent 결과 Table. Baseline characteristics of study subjects (n=24). 연구대상자의일반적특성및치료전후신체계측및혈액검사변화본연구의최초참여자는총 34명으로 2주후추적방문이나당화혈색소를측정하지않은 00명을제외한 24명 (68.2%) 을대상으로분석을진행하였다. 남자는 27명 (59.3%) 이었고, 여자는 87명 (40.7%) 이었으며평균연령은 58.3 ± 0.9 세이었다. 29.9% 인 64명이당뇨병영양교육을받았으며, 64명중 60명이영양교육준수여부에대한질문에대답하였고항상지키는군, 가끔지키는군, 지키지않는군은각각 3명 (2.7%), 39명 (65.0%), 8명 (8.0%) 이었다 (Table ). 경구혈당강하제투여 2주뒤측정한당화혈색소수치가 6.5% 미만으로목표달성에성공한환자는 9명 (42.5%) 이었으며, 6.5% 이상으로목표달성에실패한환자는 23명 (57.5%) 이었다. 처음내원시당화혈색소평균은 8.±.5% 이었으며 gliclazide 투여 2주후측정한당화혈색소는 6.8±0.8% 로평균.3%(P<0.00) 유의하게감소하였다. 또한공복혈당, 수축기혈압, 이완기혈압, 중성지방, 저밀도지단백콜레스테롤도유의하게감소하였다 (P<0.05). 체질량지수, 고밀도지단백콜레스테롤은유의한차이를보이지않았다 (P>0.05) (Table 2). 2. 당화혈색소목표달성에영향을주는요인사회인구학적요인을대상으로단변량분석을시행한결과, 남성이여성보다 (P=0.005), 교육수준상위군이하위군보다 (P=0.024), 월수입상위군이최하위군보다 (P=0.003), 결혼한군이그렇지않은군 (P=0.043) 에비해목표달성률이높았다. 성별과나이를보정한경우남성이여성보다 (OR 0.43; 95% CI.28~4.23), 월수입상위군이최하위군 (OR 0.33; 95% CI 0.4~0.79) 보다목표달성률이높았다 (Table 3). 당뇨병연관인자들을대상으로단변량분석을시행한결과, Characteristics Male, n=27 Mean(SD) or n(%) Female, n=87 Total Age, yrs 56.0(0.8) 6.8(0.0) 58.3(0.9) Marital status Married Unmarried Education level, yrs <2 2~5 6 Monthly Income, 0,000 Korean won < 200 200~399 400 Smoking status Current smoker n-smoker 8(95.9%) 5(4.%) 70(56.9%) 44(35.8%) 9(7.3%) 22(9.3%) 4(36.0%) 5(44.7%) 05(83.3%) 2(6.7%) 66(79.5%) 7(20.5%) 73(89.0%) 8(9.8%) (.2%) 27(38.6%) 26(37.%) 7(24.3%) 7(8.0%) 80(92.0%) 84(89.3%) 22(0.7%) 43(69.8%) 52(25.3%) 0(4.9%) 49(26.6%) 67(36.4%) 68(37.0%) 2(52.6%) 0(47.4%) Alcohol intake, g/d 45.5(5.8) 26.4(34.3) 43.6(50.5) Physical activity, MET-min/wk <480 480~,499,500 Nutritional education Compliance of nutritional education Excellent Fair Poor Adherence to drug, % 80 <80 Abbreviations: BMI, body mass index 24(2.%) 4(36.0%) 49(43.0%) 9(7.7%) 36(28.3%) 8(23.5%) 2(6.8%) 5(4.7%) 23(96.6%) 4(3.%) 3(38.3%) 32(39.5%) 8(22.2%) 59(67.8%) 28(32.2%) 5(9.2%) 8(69.2%) 3(.5%) 85(97.7%) 2(2.3%) 55(28.2%) 73(37.4%) 67(34.4%) 50(70.%) 64(29.9%) 3(2.7%) 39(65.0%) 8(8.0%) 208(97.2%) 6(2.8%) 병용약물이있는경우 (P =0.020), 최초당화혈색소가높을수록 (P<0.00), 약물비순응군 (P=0.028) 이목표달성률이낮았다. 연 령, 성별, 월수입을보정하였을때에는최초당화혈색소가높을수 Table 2. Changes of laboratory profiles after 2 weeks treatment of gliclazide in drug naive patients with type 2 diabetes Variables Baseline Mean(SD) After 2 weeks Mean(SD) % Change(SD) P value * Fasting glucose, mg/dl 68.8(49.2) 26.0(24.3) - 25.4(29.2) <0.00 HbAc, % 8.(.5) 6.8(0.8) - 6.0(5.6) <0.00 BMI, kg/m 2 25.3(3.2) 25.4(3.2) 0.4(3.0) 0.206 Systolic blood pressure, mmhg 30.9(6.0) 27.8(2.7) - 2.4(0.9) 0.003 Diastolic blood pressure, mmhg 80.9(0.2) 79.0(8.0) - 2.4(0.2) 0.002 Triglyceride, mg/dl 92.6(46.0) 52.4 (88.0) - 20.9(72.9) 0.00 HDL-cholesterol, mg/dl 48.6(3.6) 47.5(2.4) - 2.2(5.8) 0.6 LDL-cholesterol, mg/dl 22.7(39.2) 06.3(27.2) - 3.3(29.4) <0.00 Abbreviations: HbAc, hemoglobin Ac; HDL, high density lipoprotein; LDL, low density lipoprotein * P values were calculated by the paired t-test. 690 www.kafm.or.kr Korean J Fam Pract. 205;5(3, suppl. 2):688-694
노혜리외. 제 2 형당뇨병환자에서경구혈당강하제최초투여 2 주후당화혈색소목표달성과관련된요인 KJFP Table 3. Comparison between target achieved and failed groups according to socio-demographic factors Variables Age, yrs <50 Sex 50~59 60~69 70 Female Male Smoking n-smoker Current smoker Alcohol intake, g/d ne <30 30 Physical activity, MET-min/wk <480 480~,499,500 Education, yrs <2 2~5 6 Monthly Income, 0,000 Korean won <200 200~399 400 Marital status Married Others Achieved group (n=9) Failed group (n=23) Unadjusted OR Adjusted OR * (%) (%) OR (95% CI) P value OR (95% CI) P value 26(28.6%) 25(27.5%) 27(29.7%) 3(4.3%) 27(29.7%) 64(70.3%) 36(39.6%) 55(60.4%) 47(5.6%) 24(26.4%) 20(22.0%) 22(26.5%) 25(30.%) 36(43.4%) 56(63.6%) 24(27.3%) 8(9.%) 5(8.8%) 25(3.3%) 40(50.0%) 85(94.4%) 5(5.6%) 28(22.8%) 40(32.5%) 37(30.%) 8(4.6%) 60(48.8%) 63(5.2%) 65(53.3%) 57(46.7%) 77(62.6%) 25(20.3%) 2(7.%) 33(29.5%) 48(42.9%) 3(27.7%) 87(74.4%) 28(23.9%) 2(.7%) 34(32.7%) 42(40.4%) 28(26.9%) 99 (85.3%) 7(4.7%).49.27.29 (0.72~3.09) (0.6~2.64) (0.53~3.3) 0.289 0.57 0.580 0.44 (.27~4.00) 0.005 0.57 (0.33~.00) 0.048 0.64 0.64 0.57.28 0.75 0.6 0.74 0.3 (0.33~.24) (0.32~.3) (0.28~.8) (0.62~2.64) (0.40~.43) (0.03~0.79) (0.34~.62) (0.4~0.67) 0.84 0.22 0.32 0.504 0.38 0.024 0.454 0.003 2.92 (.03~8.25) 0.043.35 0.97 0.98 (0.64~2.84) (0.45~2.09) (0.39~2.48) 0.43 0.945 0.970 0.43 (.28~4.23) 0.006.08 (0.47~2.50) 0.85 0.92 0.92 0.69.38 0.96 0.22 0.77 0.33 (0.42~.99) (0.40~2.08) (0.32~.46) (0.66~2.90) (0.47~.93) (0.04~.3) (0.33~.77) (0.4~0.79) 0.826 0.832 0.326 0.398 0.898 0.070 0.534 0.02 2.34 (0.79~6.88) 0.24 * Adjusted for age and sex P values were calculated by the logistic regression analysis 록 (OR 2.57; 95% CI.8~3.67), 약물비순응군 (OR 5.04; 95% CI.29~9.69) 에서목표달성률이낮았다. 또한당뇨병영양교육을받았는지의유무는목표달성과유의한상관관계가없었으나 (P>0.05) 영양교육을받은군에대해하위그룹분석결과, 영양교육을잘지키지않은군 (OR 5.8; 95% CI.04~222.07) 은잘지킨군과비교하여유의하게목표달성률이낮았다 (P<0.05) (Table 4). 고찰본연구에서는경구혈당강하제치료를시작하는환자들을대상으로 2주간추적조사를통해당화혈색소목표달성률과함께목표달성과관련있는요인들을알아보았다. 목표달성률은 42.5% 로반수이상이목표를달성하지못하였으며, 성별, 월수입, 최초당화혈색소, 약물순응도, 당뇨병영양교육의실천정도가관련있는요인이었다. 2주추적관찰하였을때당화혈색소감소량은평균.3% 로최초당화혈색소에비해서 6.0% 감소하였다. 이는독일에서 gliclazide 투여 0주후평균당화혈색소감소량을측정하였을때.0 ±.%(P =0.022) 로나타난이전연구와유사한수치이다. 4) 이를통하여볼때평균당화혈색소감소량이비교적일정하기때문에최초당화혈색소가낮은군에서목표달성률이높을것으로추정할수있으며본연구에서는 2주라는짧은기간추적관찰하였기때문에최초당화혈색소가목표달성에큰영향을미쳤을것이라생각한다. 약물순응도는환자가의료제공자의조언에따라약물을복용하는정도로서만성질환에서치료성패를결정짓는중요한요소중의하나이다. 5) 본연구에서는약물복용률이 80% 미만으로순응도가나쁜경우당화혈색소목표에달성하지못할가능성이 5.04배증가하였다. 이전연구에서약물순응도가 0% 증가할때당화혈색소는 0.6% 감소한다고보고되고있으며, 6) metformin을투여중인환자들을대상으로조사한다른연구에서는순응군과비순응군의당화혈색소가각각평균 8.0 ±.2%, 8.5 ±.6%(P <0.0) 로 Korean J Fam Pract. 205;5(3, suppl. 2):688-694 www.kafm.or.kr 69
KJFP Hye-Ri Roh, et al. Factors associated with target achievement of HbAC in drug naive patients with type 2 diabetes after 2 weeks of taking oral hypoglycemic agent Table 4. Comparison between target achieved and failed groups according to diabetes mellitus related factors Variables Achieved group (n=9) Failed group (n=23) Unadjusted OR Adjusted OR * (%) or Mean(SD) (%) or Mean(SD) OR (95% CI) P value OR (95% CI) P value BMI, kg/m 2 <23.0 23(26.%) 28(23.9%) 23.0~24.9 7(9.3%) 35(29.9%).69 (0.76~3.76) 0.98.93 (0.75~4.99) 0.73 25.0 48(54.5%) 54(46.2%) 0.92 (0.47~.82) 0.89 0.86 (0.37~.97) 0.76 Hypertension 2(8.2%) 5(7.4%) 54(8.8%) 7(82.6%).05 (0.46~2.43) 0.906.3 (0.43~2.98) 0.82 Dyslipidemia (2.8%) 6(5.0%) 75(87.2%) 9(85.0%) 0.83 (0.37~.9) 0.667 0.87 (0.33~2.27) 0.772 Initial fasting glucose,mg/dl <30 20(23.0%) 7(5.0%) 30 67(77.0%) 96(85.0%).69 (0.82~3.46) 0.54.6 (0.69~3.75) 0.272 Initial HbAc, % 7.33(.9) 8.6(.46) 2.25 (.69~3.00) <0.00 2.57 (.8~3.67) < 0.00 Nutritional education 27(29.7%) 37(30.%) 64(70.3%) 86(69.9%) 0.98 (0.54~.77) 0.948. (0.56~2.20) 0.775 Compliance of nutritional education Excellent 8(32.0%) 5(4.3%) Fair 5(69.0%) 24(68.6%) 2.560 (0.7~9.30) 0.5 3.55 (0.66~9.7) 0.40 Poor 2(8.0%) 6(7.%) 4.800 (0.68~33.80) 0.2 5.8 (.04~222.07) 0.047 Concomitant medication 68(76.4%) 09(88.6%) 2(23.6%) 4(.4%) 0.42 (0.20~0.87) 0.020 0.07 (0.25~.46) 0.267 Adherence to drug, % 80 <80 63(95.5%) 3(4.5%) 86(83.5%) 7(6.5%) 4.5 (.7~4.78) 0.028 5.04 (.29~9.69) 0.020 Abbreviations: BMI, body mass index * Adjusted for age, sex and income P values were calculated by the logistic regression analysis 순응군에서더낮은것으로나타났다. 7) sulfonylurea, metformin, thiazolidinedione 등다양한약물을투여중인환자들을대상으로시행한연구에서도순응군의당화혈색소는평균 7.7 ±.5% 로비순응군의평균인 8.±.9% 보다더낮았다 (P<0.0). 8) 본연구에서도순응군에서당화혈색소목표달성률이유의하게높은것으로나타났으며이는순응도의중요성을뒷받침하는결과라생각된다. 본연구에서당뇨병영양교육을받은경우는 64명 (29.9%) 이었으며당뇨병영양교육의유무자체는목표달성률과연관이없었다. 하지만영양교육받은군을대상으로실행정도에대한하위그룹분석을추가시행한결과영양교육을잘지키는군은그렇지않은군과비교하였을때유의하게목표달성률이높은것으로확인되었다. 이전연구에따르면국내당뇨병환자들의식이요법에대한순응도는약 2% 로매우저조하게보고되고있다. 9) 본연구에서도항상지키는군은 2.7% 로낮게나타났으며초기당뇨병환자를대상으로하였기때문에자각증상이적어실천도가낮았을가능성이있다. 하지만당뇨병초기의철저한식이습관실천이혈당조절및합 병증예방에중요하기때문에영양교육과정보가지속적이며구체적인형태로강화되어야함을시사한다. 본연구에서는월수입이최하위군에비해최상위군에서당화혈색소목표달성률이높은것으로나타났다. 소득수준은당뇨병조절에영향을미치는인자중하나로저소득층은당뇨병조절을위한자가행동이낮으며, 20) 경제적인이유로약물복용에대한순응도가떨어질가능성이높은것으로알려져있다. 2) 당뇨병은지속적인혈당관리및약물복용과더불어식습관, 운동등자기관리가중요한질환으로 22) 경제적여유가있을수록자기관리에투자할시간이많을거라예상할수있으며따라서소득수준이높은대상자들이당화혈색소목표달성에더욱유리할것으로판단된다. 본연구에서여성이남성보다당화혈색소목표달성률이낮았다. 이에대하여추가분석을시행한결과여성의경우남성보다저소득층이많았으며 (P=0.00) 신체활동량이유의하게적은것으로확인되었다 (P=0.00). 또한남성은식이요법을실천할수있도록배우자의도움을받을수있는반면, 여성은남편이나자녀의기호에맞 692 www.kafm.or.kr Korean J Fam Pract. 205;5(3, suppl. 2):688-694
노혜리외. 제 2 형당뇨병환자에서경구혈당강하제최초투여 2 주후당화혈색소목표달성과관련된요인 KJFP 는식단을주로준비하며자신의식사를따로준비하는것에대한어려움을호소한다는사실이보고된바있다. 23) 가족의지지와도움이많을수록당뇨병관리가잘이루어진다고알려져있으나 24) 여성의경우이러한면에서는취약하다고볼수있다. 따라서여성당뇨병환자진료시가족의응원과지지를받을수있도록노력하는것이필요하며, 가족교육을병행하는것도좋은방법이될것이다. 또한국내여성의혈당조절과관련된취약성에대하여향후추가적인연구가이루어져야할것으로사료된다. 본연구의제한점은연구대상자가주로종합병원가정의학과에내원한환자를대상으로하였으므로전체일차의료의당뇨병환자를대표할수없다는점이다. 또한 gliclazide 투여기간이 2주로비교적짧았기때문에장기적인약물효과및그에영향을미치는인자들에대해서판단하기힘들다는점이있다. 그럼에도불구하고본연구는전국 8개병원의가정의학과환자를대상으로하였으며연구에참여한병원이서울, 경기, 대구등다양한지역에분포해있다는점에의의가있다. 또한경구혈당강하제치료를시작하는환자들을대상으로약물처방후 2주간전향적으로추적관찰한연구라는점이큰장점이다. 또한당화혈색소목표달성에영향을미치는인자에대해서가정의학과에내원한환자들을대상으로조사하였으므로향후 차의료에방문하는제 2형당뇨병환자들의당화혈색소조절에도움이될것으로생각된다. 이번연구결과처음경구혈당강하제를복용하는환자에서여성, 저소득층, 높은당화혈색소, 낮은약물순응도, 낮은당뇨병영양교육실천도를보이는환자에서는당화혈색소목표달성률이낮은것으로나타났다. 따라서일차의료에서당뇨병환자진료시처음으로경구혈당강하제를투여하는경우상기환자군에서는보다관심을가지고추적관리해야하며, 약물복용과식이습관조절을잘해나갈수있도록지속적, 심층적인교육을제공하는것이혈당조절에도움을줄수있을것으로사료된다. 요약연구배경 : 당뇨병환자의합병증발생을감소시키기위해서당화혈색소를낮추는것이중요하다고알려져있다. 하지만어떠한요인이당화혈색소감소에영향을미치는지에대하여국내당뇨병환자들을대상으로한연구는부족한실정이다. 저자는국내제 2형당뇨병환자에서경구혈당강하제복용을시작하는환자들을대상으로당화혈색소목표달성률을알아보고이와더불어당화혈색소목표달성에영향을끼치는인자들에대해알아보고자하였다. 방법 : 본연구는 2006년 3월부터 2007년 2월까지당뇨병을처음진단받거나경구혈당강하제를 4주간중단하였던환자를대상으로 진행하였다. 경구혈당강하제복용 2 주후당화혈색소수치가 6.5% 미만으로측정되는환자를목표에달성한군으로정하였으며사회 인구학적요인과당뇨병연관요인으로나누어어떠한요인이목표 달성에영향을끼치는지분석하였다. 결과 : 연구대상자의평균나이는 58.3±0.9 세였고 43.5% 환자 가목표를달성하였다. 인구사회학적요인에서남성 (OR 0.43; 95% CI.28~4.23) 과월수입이 400 만이상인군 (OR 0.33; 95% CI 0.4~0.79) 이유의하게목표달성률이높았다. 당뇨병연관요인중 최초당화혈색소가높을수록 (OR 2.57; 95% CI.8~3.67), 당뇨 영양교육을잘지키지않는군 (OR 5.8; 95% CI.04~222.07), 순응도가 80% 미만인군 (OR 5.04; 95% CI.29~9.6) 에서목표 달성률이낮았다. 결론 : 경구혈당강하제복용을시작한환자들에서당화혈색소목표 를달성한경우는과반수를넘지못하였으며여성, 저소득층, 치료 시작시당화혈색소가높을수록, 당뇨병교육과약물에낮은순응 도를보이는환자에서당화혈색소목표달성률이낮은것으로나타 났다. 중심단어 : 제 2 형당뇨병, 경구혈당강하제, 목표달성, 약물순응도 REFERENCES. Prevalence of heart disease--united States, 2005. MMWR Morb Mortal Wkly Rep 2007;56:3-8. 2. Saydah SH, Fradkin J, Cowie CC. Poor control of risk factors for vascular disease among adults with previously diagnosed diabetes. Jama 2004;29:335-42. 3. Malik S, Lopez V, Chen R, Wu W, Wong ND. Undertreatment of cardiovascular risk factors among persons with diabetes in the United States. Diabetes research and clinical practice 2007;77:26-33. 4. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. The Diabetes Control and Complications Trial Research Group. N Engl J Med 993;329:977-86. 5. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group. Lancet 998;352:837-53. 6. Gerstein HC, Riddle MC, Kendall DM, Cohen RM, Goland R, Feinglos MN, et al. Glycemia treatment strategies in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial. Am J Cardiol 2007;99:34i-43i. 7. Patel A, MacMahon S, Chalmers J, Neal B, Billot L, Woodward M, et al. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med 2008;358:2560-72. Korean J Fam Pract. 205;5(3, suppl. 2):688-694 www.kafm.or.kr 693
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