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Zmieniać czy nie zmieniać – oto jest pytanie – wątpliwości przy zmianie terapii w cukrzycy

By Medycznie.eu lip 3, 2016 ,

W dniach 10-14 czerwca odbędzie się doroczny 76 Kongres Naukowy Amerykańskiego Towarzystwa Diabetologicznego. Co roku kongres ADA jest miejscem wymiany doświadczeń dla blisko 15 tysięcy lekarzy, pielęgniarek oraz przedstawicieli organizacji pacjenckich z całego świata. Eksperci prezentują również najnowsze dane z badań prowadzonych nad innowacyjnymi terapiami. O tym jak wygląda nowoczesne leczenie cukrzycy, czy cukrzyca warta jest powikłań i kiedy należy myśleć o zmianie terapii mówi prof. dr hab. n. med. Leszek Czupryniak, kierownik Kliniki Chorób Wewnętrznych i Diabetologii WUM.

  1. Jak nieleczona cukrzyca typu 2 wpływa na życie chorego i czy mimo dolegliwości odczuwanych jest on w stanie sprawnie funkcjonować?

Leczenie cukrzycy wynika z tego, że duża ilość glukozy kumulująca się w organizmie uszkadza naczynia krwionośne i nerwy obwodowe. Oznacza to, że jeżeli pacjent ma źle leczoną cukrzycę i ma okresowo mniej lub bardziej podwyższony poziom cukru, wcześniej czy później nieuchronnie rozwiną się u niego tzw. późne powikłania naczyniowe. U większości pacjentów późne powikłania naczyniowe nie są rozpoznawane na etapie diagnozy cukrzycy. Bywa jednak, że część chorych ma rozpoznawaną cukrzycę właśnie poprzez obraz powikłań, np. kiedy człowiek dostaje zawału serca, specjaliści z oddziału kardiologii są w stanie stwierdzić, że ma cukrzycę już od bardzo dawna. W przypadku, kiedy pacjent ma źle leczoną cukrzycę, nieuchronnie zmierza do niewydolności nerek, choroby niedokrwiennej serca, choroby naczyniowej mózgu, upośledzenia widzenia, upośledzenia czucia w obrębie stopy itd.

  1. Jakie są dzisiaj niezaspokojone potrzeby w insulinoterapii?

Można powiedzieć, że niezaspokojone potrzeby w insulinoterapii są dwojakie. Z jednej strony dostęp do najnowocześniejszych preparatów insuliny, które w skali Europy nie są już wcale takie nowoczesne, jest nierówny. Chorzy mają bezpłatny lub minimalnie płatny dostęp do insulin ludzkich. Insuliny analogowe, jeśli nawet są refundowane, a nie są refundowane dla wszystkich chorych, to są droższe. Plan refundacji leczenia powinien wyglądać tak, że nawet jeśli przystaniemy na rozpoczęcie leczenia chorego na cukrzycę od insulin ludzkich, to w sytuacji gdy z czasem okaże się, że u chorego niezbędne jest zastosowanie insulin analogowych to powinny one być w zasięgu potrzeb pacjenta, a nie niestety tak nie jest. Za właściwy dla siebie lek musi płacić więcej niż za tradycyjny środek. Jest to istotna bariera w dostępie pacjentów do optymalnego dla nich modelu leczenia. Po za tym nie bez znaczenia są ograniczenia refundacyjne: chory musi spełniać konkretne kryteria, żeby uzyskać refundację analogów insuliny, chociaż i tak są one refundowane jedynie na poziomie 70%. W tej sytuacji lekarze sięgają po nie mniej chętnie, bo muszą dokładnie sprawdzić, czy dany pacjent spełnia kryteria refundacyjne. Są to sztucznie tworzone bariery, które ograniczają przepisywanie analogów insuliny.


Drugi problemem dotyczy leczenia cukrzycy w ogóle, w tym także insulinoterapii. Nadal bardzo słabo w Polsce rozwinięta jest edukacja w zakresie leczenia chorych na cukrzycę. Mamy bardzo mało pielęgniarek edukacyjnych, mimo że od paru lat pielęgniarki mogą robić specjalizację z diabetologii. Wynika to z tego, że NFZ nie finansuje odrębnie porady edukacyjnej, czyli edukacji pacjenta diabetologicznego – a to w skutecznej insulinoterapii ma kluczowe znaczenie.

  1. Czy w społecznej debacie nie poświęca się za dużo czasu tematowi refundacji i metod terapii cukrzycy zamiast wykorzystywać leki w ramach dostępnych refundacji?

Wszystkie te elementy są ważne. Cukrzyca typu 2 jest chorobą, której patomechanizm jest złożony. Nie jest to sytuacja, kiedy na przykład ktoś złamie nogę, nogę się naprawia i pacjent chodzi tak jak przed wypadkiem. To, że ktoś ma cukrzycę typu 2 może wynikać z różnych elementów: z nadwagi, niedoboru insuliny, insulinooporności, z defektu inkretynowego i tak naprawdę do skutecznej terapii potrzebujemy wszystkich leków.

Należałoby określić różne profile pacjentów wraz z modelami ich leczenia i ustalić, aby właściwe dla tych pacjentów leki były dostępne na preferencyjnych warunkach. Jeżeli natomiast w terapii nie możemy wykorzystać insuliny analogowej, np. z powodu jej ceny, i zastosujemy insulinę ludzką, również uzyskamy efekt terapeutyczny. Leczenie cukrzycy insuliną ludzką wiąże się z większym prawdopodobieństwem przyrostu masy ciała i niedocukrzeniami. Insuliny analogowe zmniejszają to ryzyko, a nowe leki – leki inkretynowe podawane w zastrzykach, często o sile działania takiej jak insulina, niwelują to ryzyko zupełnie, więc także ich potrzebujemy. Można tu dla przykładu przytoczyć sytuację, kiedy do budowy domu możemy użyć gliny, cegły tradycyjnej, płyty betonowej albo bloczków wysoko izolujących. Jednak umawiamy się, że domy będziemy budować tylko z gliny i cegły tradycyjnej, bo przecież tak się da. Uda się tylko w ten sposób wybudować domy, ale nie wszystkim będzie to wystarczało. Niektórzy potrzebują innej konstrukcji domu – kwestia różnorodności leczenia cukrzycy jest podobna.

  1. Czy są takie modele terapii, jeśli tak to jakie, które pozwalają na efektywne wyrównanie cukrzycy bez kompromisu – czyli niedocukrzeń.

Każdy model terapii pozwala nam na to. Wszystko zależy u jakiego pacjenta. Są pacjenci, którym wystarcza jeden zastrzyk insuliny i są pacjenci, którzy musza brać insulinę do każdego posiłku i długodziałającą insulinę na noc. Wówczas zdecydowanie preferujemy stosowanie analogów długodziałających. Nie ma schematu leczenia optymalnego dla wszystkich chorych, jednak stwierdzenie, że ilu chorych, tyle jest modeli leczenia jest za mocne. Wspólnym elementem dla różnych modeli leczenia z użyciem insuliny jest jego początek. Zaczynamy leczenie cukrzycy od podawania jednej dawki insuliny długodziałającej na noc. Jest to zarówno dla pacjenta, jak i lekarza najwygodniejszy i stosunkowy prosty sposób na wprowadzenie insulinoterapii. U niektórych chorych schemat ten nie wystarcza do dobrego wyrównania glikemii.

  1. Kiedy jest dobry moment na wprowadzenie zmian w leczeniu cukrzycy?

W naszej naturze jest to, że opieramy się zmianom. Zgodnie z przysłowiem „lepsze jest wrogiem dobrego” w sytuacji, kiedy pacjent osiągnął, dzięki stosowanemu leczeniu, poziom równowagi, nie widzi on powodów, aby modyfikować leczenie. Cukrzyca jest chorobą postępującą, a głównym motorem postępu choroby jest wygaszanie produkcji własnej insuliny przez organizm pacjenta. Z jednej strony pacjent nie chce nic zmieniać, bo dobrze radzi sobie ze znanym mu leczeniem, weszło mu to w nawyk. Z drugiej strony lekarz nie chce zmieniać nic w leczeniu, bo każda zmiana wymaga edukowania pacjenta, dołożenia nowego leku, kolejnego zastrzyku – wszystko zdaje się być skomplikowane i czasochłonne. W efekcie, nie intensyfikujemy leczenia pacjenta, tak jak powinniśmy. Tak naprawdę przy każdej wizycie widząc pacjenta nie powinniśmy zastanawiać się co zrobić, żeby utrzymać terapię, tylko czy jest jakiś powód, aby wprowadzić zmiany. Na leczenie naszych pacjentów należy patrzeć aktywnie, bo taka właśnie jest natura choroby. Powinniśmy przebudować nasze myślenie, bo póki co wiele badań w różnych krajach wskazuje na tzw. inercję kliniczną – lekarze mogliby leczyć lepiej i uzyskiwać lepsze wyrównanie cukrzycy, musieliby tylko bardziej aktywnie do tego podchodzić.

By Medycznie.eu

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