1. Journal Club 埼玉医科大学 総合医療センター 内分泌・糖尿病内科 Department of Endocrinology and Diabetes, Saitama Medical Center, Saitama Medical University 松田 昌文 Matsuda, Masafumi 2011 年 9 月 22 日 8:30-8:55 ８階 医局 Harjutsalo V, Forsblom C, Groop PH. Time trends in mortality in patients with type 1 diabetes: nationwide population based cohort study. BMJ. 2011 Sep 8;343:d5364. doi: 10.1136/bmj.d5364.

2. 今年になり当院で １型糖尿病の方が２名死亡しています。 これから高齢の１型糖尿病の方も増えると思われるので ．．．

3. BMJ 2011;343:d5364 doi: 10.1136/bmj.d5364

4. Objective To examine short and long term time trends in mortality among patients with early onset (age 0-14 years) and late onset (15-29 years) type 1 diabetes and causes of deaths over time.

5. Design Population based nationwide cohort study. Setting Finland. Participants All Finnish patients diagnosed as having type 1 diabetes below age 30 years between 1970 and 1999 (n=17,306). Main outcome measures Crude mortality, standardised mortality ratios, time trends, and cumulative mortality.

6. All Finnish citizens with certain chronic diseases such as type 1 diabetes are entitled to full reimbursement of drug costs. Because insulin has been free of charge for patients with diabetes in Finland since 1964, all patients with permanent entitlement to free insulin are entered in the drug reimbursement register.

7. NS=not significant. *Adjusted for age at diagnosis and duration of diabetes. †P value for trend <0.001.

9. Cumulative mortality in patients in Finland with type 1 diabetes diagnosed between 1970 and 1999: early onset cohort (0-14 years)

10. Cumulative mortality in patients in Finland with type 1 diabetes diagnosed between 1970 and 1999: late onset cohort (15-29 years)

11. Predicted standardised mortality ratios according to 5 year age at onset groups

15. Results A total of 1338 deaths occurred during 370 733 person years of follow-up, giving an all cause mortality rate of 361/100 000 person years. The standardised mortality ratio was 3.6 in the early onset cohort and 2.8 in the late onset cohort. Women had higher standardised mortality ratios than did men in both cohorts (5.5 v 3.0 in the early onset cohort; 3.6 v 2.6 in the late onset cohort). The standardised mortality ratio at 20 years’ duration of diabetes in the early onset cohort decreased from 3.5 in the patients diagnosed in 1970-4 to 1.9 in those diagnosed in 1985-9. In contrast, the standardised mortality ratio in the late onset cohort increased from 1.4 in those diagnosed in 1970-4 to 2.9 in those diagnosed in 1985-9. Mortality due to chronic complications of diabetes decreased with time in the early onset cohort but not in the late onset cohort. Mortality due to alcohol related and drug related causes increased in the late onset cohort and accounted for 39% of the deaths during the first 20 years of diabetes. Accordingly, mortality due to acute diabetic complications increased significantly in the late onset cohort.

16. Conclusion Survival of people with early onset type 1 diabetes has improved over time, whereas survival of people with late onset type 1 diabetes has deteriorated since the 1980s. Alcohol has become an important cause of death in patients with type 1 diabetes, and the proportion of deaths caused by acute complications of diabetes has increased in patients with late onset type 1 diabetes.

17. Message/Comments 1970-99 年に 30 歳未満で 1 型糖尿病を発症 した患者（ 1 万 7306 人）を対象に、死亡率の 年次推移をコホート研究で検討。観察人年は 37 万 733 人年で、早期発病（ 0-14 歳）患者 の生存率は時間とともに上昇したが、晩期発 病（ 15-29 歳）患者の生存率は 1980 年代以 降低下していた。重要な死因の 1 つはアル コールだった。［フィンランドでは］ 高齢者１型糖尿病ではまずアルコール禁止！