Less is more, again

Less is more, again

一般醫學上都是告訴我們要幫患者排檢查或是抽血檢查，這篇文章吸收我的注意，是它說我們在穩定的type 2 DM病人，太常抽HbA1c了。

HbA1c overtesting and overtreatment among US adults with controlled type 2 diabetes, 2001-13: observational population based study
BMJ 2015; 351  (Published 08 December 2015) 有全文PDF可供下載

3萬多個穩定(mean index HbA1c 6.2%)，沒用insulin的type 2 DM患者，回溯近12年，發現有近一半患者每年做HbA1c的頻率高於guideline建議的每年2次。多做檢查（就是每年做3-4次），醫生看到A1c增加，理所當然就會增加DM的藥物，就會有overtreatment的風險。

Editorialist writes that "we are prone to treating numbers and not individuals." He advises that more attention be paid to absolute risk reductions accruing from testing, and "much less" to single measures (such as HbA1c). 

沒錯，我們不能只看單一數字來治療，還是要看病人整體的風險，尤其是治療可能會產生的風險。

在台灣，我們目前對於DM的患者是固定3個月追蹤一次HbA1c。目前在本診所洗腎患者中，有些是曾有DM病史，開始透析後改善，進而不用使用任何DM藥物，就是diet control即可，也是一直三個月測A1c，都遠低於6.5%。看到這文章，也讓我思考在這些患者，是不是不用那麼常測A1c。

現在的醫療期刊網站也有提供讀者立即回應的空間，以下就是不同意此文章的回應，在美國這樣開放的社會，這麼大型的研究也是會有不同的聲音的，這位HbA1c 5.8%的讀者願意自費每年做超過2次的A1c檢查。

Re: HbA1c overtesting and overtreatment among US adults with controlled type 2 diabetes, 2001-13: observational population based study

I have type 2 diabetes & have A1C done 4 X year. I find it an extremely helpful tool to keep me motivated or realize I've gone off track. All adult kin in my family have same & younger bro died this past year from diabetic complications as a result of years of erratic Tx compliance. This may seem like an unnecessary cost but it pales in comparison to over prescription of antibiotics. And I could cite many other examples. In my case I'd willing pay myself to unburden the poor starving insurance executives to keep doing this. It is a powerful educational & motivational tool. BTW my most recent A1C was 5.8.

另外，這裡還有訪問研究者的語音檔案可供收聽 (iTunes)
https://itunes.apple.com/tw/podcast/podcast-192-are-we-too-sweet/id292018914?i=358748839&mt=2