高收入国家和发展中国家之间的1型糖尿病技术差距:持续血糖监测在巴西仍然是一个挑战。

IF 3.4 3区 医学 Q2 ENDOCRINOLOGY & METABOLISM
Ana Victoria Santos Castro, Karina O. Caneca, Paula M. Garcia, Veridiana Tischer, Luciana C. Theodoro, Isabella S Leão, Letícia B. Cunha, Julia B. Vieira, Ludmila N.R. Campos, Jorge L. Luescher, Joana R. Dantas, Lenita Zajdenverg, Melanie Rodacki
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After 14 days of isCGM, the mean TIR was 50.9% ± 15.1%, TAR 31.7% ± 19.1% and TBR 16.2% ± 11.4%. All metrics were outside the recommended targets. Notably, among individuals with HbA1c &lt; 53 mmol/mol (7%), mean TBR was 21.13% ± 14.1%, with TIR and TAR at 51.9% ± 16.1% and 26.9% ± 18.1%, respectively.<span><sup>2</sup></span></p><p>In a separate case, a 24-year-old woman with T1D using NPH and rapid-acting insulin analogues, an HbA1c of 57 mmol/mol (7.4%) and satisfactory capillary glucose records, underwent a 15-day real-time CGM analysis with no recommended interventions based on CGM data. 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引用次数: 0

摘要

我们非常感兴趣地阅读了德鲁加奇等人最近发表在《糖尿病医学》(diabetes Medicine)上的文章,该文章论述了英国1型糖尿病儿童和青少年(T1D)在获取和使用糖尿病技术方面的不平等。他们的发现与中低收入国家(尤其是巴西)面临的现实产生了强烈共鸣,在这些国家,糖尿病技术的障碍更加明显。胰岛素泵和连续血糖监测(CGM)系统价格昂贵,目前巴西的公共医疗保健系统(SUS)不提供,私人保险也不经常覆盖它们。这造成了糖尿病护理方面的社会经济不平等。虽然富裕的T1D患者可以获得并受益于先进技术,但那些依赖公共医疗保健的人却无法获得这些工具,从而导致血糖控制、并发症风险和整体护理质量方面的差异。即使是间歇性CGM (isCGM),最便宜的CGM选择,对大多数患者来说仍然是遥不可及的。此外,长效胰岛素类似物尚未普遍提供,许多患者仍使用中性鱼精蛋白hagedorn (NPH)胰岛素联合速效类似物治疗。缺乏CGM会损害患者做出明智的胰岛素调整和获得关键血糖控制指标的能力,如范围内时间(TIR)、范围以上时间(TAR)和范围以下时间(TBR),这些指标越来越被认为是T1D预后的重要预测指标。为了评估没有常规CGM治疗的患者的血糖模式,我们在巴西一家公共糖尿病诊所进行了一项观察性研究,涉及92名T1D患者(45名儿童和47名成人)。所有参与者都没有定期接触CGM;他们完全依赖于巴西一家公共医疗诊所每天四到五次的毛细血管葡萄糖测量。平均年龄18.95±10.06岁,糖尿病病程11.15±8.48岁,糖化血红蛋白61 mmol/mol(7.7%±1.2%)。其中,81.5%的患者使用长效胰岛素类似物,18.5%的患者使用NPH胰岛素和速效胰岛素类似物。isCGM治疗14天后,平均TIR为50.9%±15.1%,TAR为31.7%±19.1%,TBR为16.2%±11.4%。所有指标都超出了建议的目标。值得注意的是,在HbA1c和lt为53 mmol/mol(7%)的个体中,平均TBR为21.13%±14.1%,TIR和TAR分别为51.9%±16.1%和26.9%±18.1%。在另一个单独的病例中,一名24岁的T1D女性使用NPH和速效胰岛素类似物,HbA1c为57 mmol/mol(7.4%),毛细血管血糖记录令人满意,接受了15天的实时CGM分析,没有基于CGM数据的推荐干预措施。报告显示,TIR为55%,TAR为30%,TBR为15%,其中10%的读数为3.9 mmol/L (70 mg/dL), 5%的读数为3.0 mmol/L (54 mg/dL),伴有明显的无症状夜间低血糖发作,但在常规护理中均未发现。这些数据强调了CGM在识别次优和潜在危险的血糖模式方面的关键作用,即使在HbA1c水平达到目标范围的患者中也是如此。他们进一步强调了完全依赖毛细血管血糖检测如何掩盖低血糖的风险。先前的研究表明,在T1D诊断后不久,早期开始CGM可显著改善预后,并提供持续的益处。尽管国际上越来越多的人认同转基因的好处,但巴西国家卫生技术合并委员会(CONITEC)最近建议不要将转基因纳入公共卫生保健系统这一决定反映了一个更广泛的挑战:确保在资源有限的情况下公平获得拯救生命的糖尿病技术。正如德鲁盖奇等人在英国所强调的那样,仅仅是技术的存在是不够的:获取和支持的公平是必要的。解决T1D患者在技术使用方面的差异是全世界关注的一个主要问题在巴西和其他发展中国家,克服这些差距需要协调一致的政策行动、公共投资和将服务不足的人口纳入决策过程。如果没有这些措施,改变糖尿病治疗的技术承诺将继续分配不均。这项工作得到了CNPq (Conselho Nacional de Desenvolvimento Científico e Tecnológico)的资助。作者声明无利益冲突。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Type 1 diabetes technology gap between high-income and developing countries: Continuous glucose monitoring access remains a challenge in Brazil

We read with great interest the article by Dlugatch et al., recently published in Diabetic Medicine, which addresses inequalities in the access and use of diabetes technology among children and young people with type 1 diabetes (T1D) in the UK.1 Their findings resonate strongly with the reality faced in low- and middle-income countries, particularly Brazil, where barriers to diabetes technology are even more pronounced.

Insulin pumps and continuous glucose monitoring (CGM) systems are expensive and are not currently provided by Brazil's public healthcare system (SUS), nor do private insurance routinely cover them. This creates socioeconomic inequities in diabetes care. While wealthier individuals with T1D can access and benefit from advanced technologies, those reliant on public healthcare are deprived of these tools, resulting in disparities in glycaemic control, complication risk and overall quality of care.

Even intermittent CGM (isCGM), the least costly CGM option, remains out of reach for most patients. In addition, long-acting insulin analogues are not universally provided, and many patients are still treated with neutral protamine hagedorn (NPH) insulin in combination with rapid-acting analogues. The absence of CGM impairs the ability to make informed insulin adjustments and to obtain key glycaemic control metrics, such as time in range (TIR), time above range (TAR) and time below range (TBR), which are increasingly recognized as important predictors of outcomes in T1D.

To evaluate the glycaemic patterns in patients without routine CGM access, we conducted an observational study involving 92 individuals (45 children and 47 adults) with T1D at a public diabetes clinic in Brazil. None of the participants had regular access to CGM; they relied exclusively on four to five daily capillary glucose measurements in a public healthcare clinic in Brazil. Their mean age, diabetes duration and HbA1c were 18.95 ± 10.06 years, 11.15 ± 8.48 years and 61 mmol/mol (7.7% ± 1.2%), respectively. Of these, 81.5% used long-acting insulin analogues, while 18.5% were using NPH insulin with rapid-acting analogues. After 14 days of isCGM, the mean TIR was 50.9% ± 15.1%, TAR 31.7% ± 19.1% and TBR 16.2% ± 11.4%. All metrics were outside the recommended targets. Notably, among individuals with HbA1c < 53 mmol/mol (7%), mean TBR was 21.13% ± 14.1%, with TIR and TAR at 51.9% ± 16.1% and 26.9% ± 18.1%, respectively.2

In a separate case, a 24-year-old woman with T1D using NPH and rapid-acting insulin analogues, an HbA1c of 57 mmol/mol (7.4%) and satisfactory capillary glucose records, underwent a 15-day real-time CGM analysis with no recommended interventions based on CGM data. The report showed a TIR of 55%, TAR of 30% and TBR of 15%, including 10% of readings <3.9 mmol/L (<70 mg/dL) and 5% < 3.0 mmol/L (<54 mg/dL), with significant episodes of asymptomatic nocturnal hypoglycaemia—none of which had been suspected during routine care.

These data highlight the critical role of CGM in identifying suboptimal and potentially dangerous glycaemic patterns, even in patients with target-range HbA1c levels. They further underscore how the exclusive reliance on capillary blood glucose testing can obscure the risks of hypoglycaemia. It has been previously shown that the early initiation of CGM, soon after T1D diagnosis, leads to significant improvements in outcomes and provides sustained benefits over time.3

Despite growing international consensus on the benefits of CGM, Brazil's National Committee for Health Technology Incorporation (CONITEC) recently advised against incorporating CGM into the public healthcare system.4 This decision reflects a broader challenge: ensuring equitable access to life-saving diabetes technologies in resource-constrained settings. As Dlugatch et al. emphasize in the UK context, the mere existence of technology is insufficient: equity in access and support is imperative.

Addressing disparities in technology use among patients with T1D is a major concern worldwide.5 In Brazil and other developing nations, overcoming these disparities requires coordinated policy action, public investment and inclusion of underserved populations in decision making processes. Without such measures, the promise of technology to transform diabetes care will remain inequitably distributed.6

This work received a grant from CNPq (Conselho Nacional de Desenvolvimento Científico e Tecnológico).

The authors declare no conflicts of interest.

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来源期刊
Diabetic Medicine
Diabetic Medicine 医学-内分泌学与代谢
CiteScore
7.20
自引率
5.70%
发文量
229
审稿时长
3-6 weeks
期刊介绍: Diabetic Medicine, the official journal of Diabetes UK, is published monthly simultaneously, in print and online editions. The journal publishes a range of key information on all clinical aspects of diabetes mellitus, ranging from human genetic studies through clinical physiology and trials to diabetes epidemiology. We do not publish original animal or cell culture studies unless they are part of a study of clinical diabetes involving humans. Categories of publication include research articles, reviews, editorials, commentaries, and correspondence. All material is peer-reviewed. We aim to disseminate knowledge about diabetes research with the goal of improving the management of people with diabetes. The journal therefore seeks to provide a forum for the exchange of ideas between clinicians and researchers worldwide. Topics covered are of importance to all healthcare professionals working with people with diabetes, whether in primary care or specialist services. Surplus generated from the sale of Diabetic Medicine is used by Diabetes UK to know diabetes better and fight diabetes more effectively on behalf of all people affected by and at risk of diabetes as well as their families and carers.”
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