不同降糖方案对2型糖尿病合并结直肠腺瘤患者行内镜下腺瘤切除术后腺瘤复发的影响研究

目的　分析采用不同降糖方案治疗的2型糖尿病合并结直肠腺瘤患者行内镜下腺瘤切除术后腺瘤复发的风险，为临床筛查提供循证医学证据。方法　选取2006年1月—2016年6月于深圳市蛇口人民医院检查的2型糖尿病合并结直肠腺瘤行内镜下腺瘤切除术的患者273例，根据降糖药物治疗的不同，将患者分为未使用药物组（50例）、磺脲类药物组（94例）、噻唑类药物组（52例）、二甲双胍组（45例）和胰岛素组（32例）。回顾患者的随访资料，随访时间约为5年，未满5年者随访截止时间为2016年7月，记录血糖控制情况、降糖药物使用情况、阿司匹林服用状况、他汀类药物服用状况等。结果　Kaplan-meier曲线分析显示，未使用药物组、磺脲类药物组、噻唑类药物组、胰岛素组腺瘤复发率均高于二甲双胍组（χ2=15.14、18.34、46.83、34.29，P<0.01）。多因素Cox回归分析结果显示，高血压病史〔HR=2.96，95%CI（1.40，6.24）〕、糖尿病持续时间≥48个月〔HR=2.84，95%CI（1.03，7.81）〕、血糖控制差（血糖水平>6.1 mmol/L）〔HR=4.97，95%CI（1.74，14.22）〕、最大腺瘤内超过20%为绒毛状腺瘤〔HR=5.73，95%CI（1.86，17.61）〕、服用磺脲类药物〔HR=3.19，95%CI（1.42，7.14）〕、使用胰岛素〔HR=3.48，95%CI（1.70，7.13）〕均为2型糖尿病患者结直肠腺瘤复发的危险因素（P<0.05），服用二甲双胍为2型糖尿病患者结直肠腺瘤复发的保护因素〔HR=0.25，95%CI（0.09，0.73），P<0.05〕。结论　磺脲类药物、二甲双胍、胰岛素是2型糖尿病合并结直肠腺瘤患者行内镜下腺瘤切除术后腺瘤复发的影响因素。在2型糖尿病患者后续的降糖治疗中，可能需选择腺瘤复发风险较小的药物。

Influence of Different Glucose-lowering Therapies on Colorectal Adenoma Recurrence in Endoscopic Post-polypectomy Type 2 Diabetic Patients

Objective　To analyze the influencing factors of colorectal adenoma recurrence in endoscopic post-polypectomy type 2 diabetic patients treated with different glucose-lowering therapies，providing an evidence-based reference for clinical identification of such cases with recurrence risks.Methods　A total of 273 type 2 diabetic patients with colorectal adenoma who were diagnosed and treated by endoscopic resection of colorectal adenoma in Shenzhen Shekou People's Hospital during January 2006 to June 2016 were included in the cohort and divided into untreated group（n=50），sulfonylureas-treated group（n=94），thiazole-treated group（n=52），metformin-treated group（n=45） and insulin-treated group（n=32） based on the treatment regimen.We obtained the patients' follow-up data. The follow-up period was about 5 years，and the patients who were followed up for less than 5 years were followed up for July 2016. Blood sugar control，hypoglycemic drugs usage，status of aspirin and statins use were recorded.Results　Kaplan-meier curve analysis showed that untreated group，sulfonylureas-treated group，thiazole-treated group and insulin-treated group demonstrated higher colorectal adenoma recurrence rate compared with metformin-treated group（χ2=15.14，18.34，46.83，34.29，P<0.01）．Multivariate Cox regression analysis further demonstrated that history of hypertension〔HR=2.96，95%CI（1.40，6.24）〕，suffering from diabetes for 48 months or longer 〔HR=2.84，95%CI（1.03，7.81）〕，poor glycemic control（fasting plasma glucose>6.1 mmol/L）〔HR=4.97，95%CI（1.74，14.22）〕，more than 20% of the largest adenoma volume was villous adenoma 〔HR=5.73，95%CI（1.86，17.61）〕 and use of sulfonylureas〔HR=3.19，95%CI（1.42，7.14）〕，use of insulin〔HR=3.48，95%CI（1.70，7.13）〕 were risk factors for recurrence of colorectal adenoma，whereas use of metformin could significantly reduce the recurrence〔HR=0.25，95%CI（0.09，0.73），P<0.05〕.Conclusion　Sulfonylureas，metformin and insulin could significantly influence colorectal adenoma recurrence in post-polypectomy type 2 diabetic patients.In view of this，glucose-lowering drugs that can cause lower risk for adenoma recurrence should be used for subsequent treatment as much as possible.