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作者：Nancy Fowler Larson  
出處：WebMD醫學新聞

　　March 25, 2010 — 根據線上發表於3月23日糖尿病照護(Diabetes Care)期刊的研究，新診斷有第2型糖尿病的患者服用阿斯匹靈可以增加平均約 4個月的生命，但是增加的費用不到2000美元。
　　
　　糖尿病患者發生心血管疾病(cardiovascular disease，CVD)的風險達2-4倍，為了預防CVD，美國糖尿病協會建議40歲以上病患服用阿斯匹靈，其指引支持每個30歲以上、CVD風險增加者，只要可以耐受阿斯匹靈就應該服用。以前有研究探討過整個族群使用阿斯匹靈避開CVD風險的成本效益。
　　
　　疾病控制預防中心糖尿病資訊轉譯組Rui Li博士等人寫道，這些研究結論為，使用阿斯匹靈可節省成本、有成本效益，不知道對於糖尿病患是否可以有相同的結論。
　　
　　研究目的在證明診斷有第2型糖尿病的40歲以上患者終身服用阿斯匹靈治療(每天80 mg)具有成本效益，研究者使用一個證明過的成本效益模式來模擬第2型糖尿病病程和併發症：腎病變、神經病變、視網膜病變、冠心病與中風，用此模式推算病患從診斷到死亡或到94歲時的標準照護費用加上阿斯匹靈藥費。
　　
　　根據該模式，那些使用阿斯匹靈的第2型糖尿病患者存活較久且相對花費低。
　　* 服用阿斯匹靈的病患壽命增加0.31年(LYs)或調整品質後存活人年(QALYs)達0.19。
　　* 增加的費用約1700美元。
　　* 使用阿斯匹靈時每增加1年壽命的成本效益比率為5428美元、每QALY為8801美元。
　　* 對於女性，增加的成本效益比率為每1人命年(LY)需13,833美元、男性為每1人命年(LY)需5752美元，或者，分別是每一校正生活品質-年(QALY)需22,259美元與每一校正生活品質-年(QALY)需3633美元，這些數據依據研究參數而有所不同。
　　
　　服用阿斯匹靈的病患，冠心病的累積發生率降低3.91%，因冠心病死亡機率降低4.65%，不過，中風累積發生率增加0.51%，中風死亡率增加0.28%。
　　
　　雖然研究者結論表示持續服用阿斯匹靈有成本效益，但是並未發現它可以節省成本。
　　
　　作者們寫道，首先，阿斯匹靈的胃腸道出血效果增加了服用此藥者的整體醫療費用。其次，阿斯匹靈治療組存活較久，則其糖尿病和高血壓所需的額外治療資源也較多。第三，使用阿斯匹靈只能影響糖尿病患的大血管併發症，對於微血管併發症則無幫助。
　　
　　研究者提出此研究的兩個限制：糖尿病患的阿斯匹靈效果並未完全建立；如同其他模式，此成本效益模式是根據一些單純的假設。
　　
　　根據研究者，使用阿斯匹靈來避免CVD仍有所爭論，需要後續研究，最近分別發表於美國醫學會期刊以及英國醫學期刊的兩篇大型隨機試驗，即「Japanese Primary Prevention of Atherosclerosis with Aspirin for Diabetes」和「Prevention of Progression of Arterial Disease and Diabetes」等試驗，指出這類病患使用低劑量阿斯匹靈並不會預防心血管事件。
　　
　　作者們寫道，需要後續試驗以進一步瞭解阿斯匹靈是否對於第2型糖尿病患有效；這些研究也需要額外的成本效益分析。
　　
　　疾病控制預防中心支持該研究，研究作者皆宣告沒有相關財務關係。
　　
　　Diabetes Care. 線上發表於2010年3月23日。


Aspirin Use in Newly Diagnosed Diabetics May Be Cost-Effective, but the Practice Remains Controversial

By Nancy Fowler Larson
Medscape Medical News

March 25, 2010 — Patients with newly diagnosed type 2 diabetes who take aspirin can gain an average of nearly 4 months of life for an incremental cost of less than $2000, according to a study published online March 23 in Diabetes Care.

The risk of developing cardiovascular disease (CVD) is 2 to 4 times greater for those with diabetes. To prevent CVD, the American Diabetes Association recommends aspirin therapy for diabetics older than 40 years. Its guidelines support the use of aspirin for everyone older than 30 years with an elevated risk for CVD if they can tolerate the drug. Prior research has analyzed the cost-effectiveness of aspirin for warding off CVD among the overall population.

"These studies concluded that aspirin use was cost-saving or cost-effective," write Rui Li, PhD, from the Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Georgia, and colleagues. "It is not known if the same conclusion holds for persons with diabetes."

The study was designed to document the cost-effectiveness during a lifetime of aspirin therapy (80 mg daily) in those aged 40 years and older with a recent type 2 diabetes diagnosis. Researchers used a validated cost-effectiveness model to simulate type 2 diabetes' progression and its complications: nephropathy, neuropathy, retinopathy, coronary heart disease, and stroke. The model projects the patients' costs for standard care and for standard care plus aspirin from diagnosis until death, or until the age of 94 years.

According to the model, those with type 2 diabetes who used aspirin live longer for a relatively low expense.

Patients undergoing aspirin therapy achieved 0.31 life years (LYs) or 0.19 quality-adjusted LYs (QALYs).
The gain came at an incremental cost of $1700.
Aspirin use had an incremental cost-effectiveness ratio of $5428 per LY gained, or $8801 per QALY gained.
For women, the incremental cost-effectiveness ratio was $13,833/QALY compared with $5752 in men, or $22,259/QALY vs $3633, respectively, depending on study parameters.
Patients receiving aspirin lowered their cumulative incidence of coronary heart disease events by 3.91%, reducing the rate of deaths from coronary heart disease by 4.65%. However, subjects' cumulative incidence of stroke increased by 0.51%, elevating the stroke mortality rate by 0.28%.

Although the investigators concluded that ongoing aspirin therapy is cost-effective, they did not find it to be cost-saving.

"First, aspirin's effect on gastrointestinal bleeding increased the total medical costs of the group taking aspirin. Second, the aspirin treatment group lived longer and required additional resources for treatment of diabetes and hypertension," the authors write. "Third, aspirin treatment affects diabetes macrovascular complications but not microvascular ones."

Two limitations to the study were noted by the researchers: the effectiveness of aspirin in those with diabetes has not been fully established, and the cost-effectiveness model is rooted in the simplification of hypotheses, as are all models.

The use of aspirin to ward off CVD is still controversial and merits further study, according to the investigators. In 2 large, randomized trials recently published in the Journal of the American Medical Association and the British Medical Journal, respectively — namely, the Japanese Primary Prevention of Atherosclerosis with Aspirin for Diabetes trial and the Prevention of Progression of Arterial Disease and Diabetes trial — low-dose aspirin use in this population did not prevent cardiovascular events.

"Future clinical trials are needed to better understand if aspirin is efficacious for people with type 2 diabetes; additional cost-effectiveness analyses, accounting for these studies, might be needed," the authors write.

The Centers for Disease Control and Prevention supported the study. The study authors have disclosed no relevant financial relationships.

Diabetes Care. Published online March 23, 2010.