2型糖尿病全球防治指南新特點(diǎn)

1、2型糖尿病全球防治指南新特點(diǎn),內(nèi)容概括,1.背景資料 2.糖尿病危害性 3.診斷及監(jiān)測(cè)4.治療概論 5.住院病人治療原則,1.背景資料,1. 根據(jù)循證醫(yī)學(xué)原則制定,內(nèi)容參考近5年來國際上出版的指南、meta分析、及相關(guān)刊物。2. 根據(jù)不同地區(qū)、不同醫(yī)療資源制定3個(gè)等級(jí)標(biāo)準(zhǔn)。,三個(gè)等級(jí)醫(yī)療標(biāo)準(zhǔn),,Standard Care,,2.糖尿病危害性,1. 發(fā)病人數(shù)日益增長。無論是在發(fā)達(dá)國家還是在發(fā)展

2、中國家，均明顯增加。其中90%為2型糖尿病。（見下圖）2. 發(fā)展中國家增長的速度超過了發(fā)達(dá)國家。（200%比45%），21世紀(jì)DM 將在中國、印度等發(fā)展中國家流行 。3. DM 的主要并發(fā)癥已經(jīng)成為病人致殘和早亡的主要原因，每年全球約 3 000 000 人口因糖尿病而死亡。4. 2型糖尿病占我國糖尿病人群的90%以上，它的血管并發(fā)癥使人們喪失勞動(dòng)能力,預(yù)期壽命縮短8-12年。,P.Zimmet et al.Bulletin o

3、f the International Diabetes Federation 48:13,2003,,A much quoted paper by Haffner et al, suggested that people with Type 2 diabetes have a CV risk equivalent to non-diabetic people with previous CVD。Haffner SM, Leh

4、to S, R鰊nemaa T, Pyorala K, Laakso M.Mortality from coronary heart disease in subjects with type 2diabetes and in nondiabetic subjects with and without prior myocardial infarction. N Engl J Med 1998; 339: 229-34.,糖尿病急性并

5、發(fā)癥及大血管和微血管等慢性并發(fā)癥，致死、致殘率高，一旦發(fā)生，難以逆轉(zhuǎn)，降低病人的生活質(zhì)量，縮短壽命。,3. 診斷及監(jiān)測(cè),提倡早期診斷,早期診斷的意義；Type 2 diabetes has a long asymptomatic pre-clinical phasewhich frequently goes undetected. At the time of diagnosis,over half have one or mo

6、re diabetes complications.Retinopathy rates at the time of diagnosis range from 20 %to 40 %.Of people with Type 2 diabetes, the proportion who areundiagnosed ranges from 30 % to 90 %. SM, Meyer LC, Neil HAW,

7、Ross IS, Turner RC,Holman RR. Complications in newly diagnosed type 2 diabetic patients and their association with different clinical and biochemical risk factors. UKPDS 6. Diabetes Res 1990; 13: 1-11. Harris MI,

8、Klein R, Welborn TA, Knuiman MW. Onset of NIDDM occurs at least 4-7 yr before clinical diagnosis.Diabetes Care 1992; 15: 815-19. UKPDS Group. UK Prospective Diabetes Study 30: Diabetic retinopathy at diagnosis of t

9、ype 2 diabetes and associated risk factors. Arch Ophthalmol 1998; 116: 297-303.,早期診斷,早期診斷的方法----目前全球根據(jù)各地區(qū)約有30%-90%糖尿病漏診率. For diagnosis, an oral glucose tolerance test (OGTT) should be performed in people

10、 with a fasting plasma glucose ≥5.6 mmol/l (≥100 mg/dl) and <7.0 mmol/l (<126 mg/dl); Where a random plasma glucose level ≥5.6 mmol/l (≥100 mg/dl) and <11.1 mmol/l (<200 mg/dl) is detected on

11、opportunistic screening, it should be repeated fasting, or an OGTT performed.,診斷標(biāo)準(zhǔn):WHO-1999 criteria,,Health Organization. Definition, Diagnosis and Classification of Diabetes Mellitus and its Complications.Report o

12、f a WHO Consultation. Part 1: Diagnosis and Classification of Diabetes Mellitus. Geneva: WHO,診斷標(biāo)準(zhǔn)的解釋:糖尿病診斷是依據(jù)空腹、任意時(shí)間或OGTT中2小時(shí)血糖值空腹指至少8小時(shí)內(nèi)無任何熱量攝入任意時(shí)間指一日內(nèi)任何時(shí)間，無論上次進(jìn)餐時(shí)間及食物攝入量OGTT是指以75克無水葡萄糖為負(fù)荷量，溶于水內(nèi)口服 (如用1分子結(jié)晶水葡萄糖，則為82.

13、5克。OGTT的方法:早餐空腹取血(空腹8-14小時(shí)后），取血后于5分鐘內(nèi)服完溶于250-300ml水內(nèi)的無水葡萄糖75克（如用1分子結(jié)晶水葡萄糖，則為82.5克）試驗(yàn)過程中不喝任何飲料、不吸咽、不做劇烈運(yùn)動(dòng)，無需臥床從口服第一口糖水時(shí)計(jì)時(shí)，于服糖后30分鐘、1小時(shí)、2小時(shí)及3小時(shí)取血（用于診斷可僅取空腹及2小時(shí)血）,控制指標(biāo)水平,血糖控制水平；HbA1c 1.0 mmol/l (>39 mg/dl).血壓控制水平A

14、im to maintain blood pressure below 130/80 mmHgAccept that even 140/80 mmHg may not be achievable with 3 to 5 antihypertensive drugs in some people.Revise individual targets upwards if there is signi. cant risk of post

15、ural hypotension and falls.,每年全面檢測(cè)一次,檢測(cè)原則及目的,General principles include: annual review of control and complications; an agreed and continually updated diabetes care plan; and involvement of the multidiscipl

16、inary team in delivering that plan, centred around the person with diabetes.,臨床血糖監(jiān)測(cè)方法,HbA1c performed every 2 to 6 months depending on level and stability of blood glucose control,and change in therapy.Site-of-care capi

17、llary plasma glucose monitoring at random times of day is not generally recommended.,自我血糖監(jiān)測(cè)方法,Self-monitoring of blood glucose (SMBG) should be available to those;For all newly diagnosed people with Type 2 diabetes;tho

18、se on insulin treatment; to provide information on hypoglycaemia;to assess glucose excursions due to medications and lifestyle changesto monitor changes during intercurrent illness.SMBG can be considered in relation

19、to:outcomes (a decrease in HbA1c with the ultimate aim of decreasing risk of complications)safety (identifying hypoglycaemia)process (education, self-empowerment, changes in therapy).,對(duì)尿糖監(jiān)測(cè)的評(píng)價(jià),Urine glucose testing is

20、 cheap but has limitations. Urine free of glucose is an indication that the blood glucose level is below the renal threshold, which usually corresponds to a blood glucose level of about 10.0 mmol/l (180 mg/dl).Positive

21、 results do not distinguish between moderately and grossly elevated levels, and a negative result does not distinguish between normoglycaemia and hypoglycaemia.,4.治療概論,生活方式干預(yù)治療,目的：通過調(diào)整生活方式，如飲食、運(yùn)動(dòng)等更好地控制血糖、血壓、血脂等危險(xiǎn)因素。關(guān)于飲食

22、；專家指導(dǎo)下制定個(gè)體營養(yǎng)需求方案;嚴(yán)格限制高熱量、高脂食物、食鹽及酒精等；根據(jù)降糖藥（口服藥及胰島素）及運(yùn)動(dòng)量調(diào)整飲食量。關(guān)于運(yùn)動(dòng)：Encourage increased duration and frequency of physical activity (where needed), up to 30-45 minutes on 3-5 days per week, or an accumulation of 150

23、minutes of physical activity per week.,生活方式干預(yù)治療利益,Randomized controlled trials and outcome studies of medical nutrition therapy (MNT) in the management of Type 2 diabetes have reported improved glycaemic outcomes (HbA1c

24、decreases of 1.0-2.0 %, depending on the ration of diabetes).In a meta-analysis of non-diabetic people, MNT restricting saturated fats to 7-10 % of daily energy and dietary cholesterol to 200-300 mg daily resulted in

25、a 10-13 % decrease in total cholesterol, 12-16 % decrease in LDL cholesterol and 8 % decrease in triglycerides.A meta-analysis of studies of non-diabetic people reported that reductions in sodium intake to ≤2.4 g/day d

26、ecreased blood pressure by 5/2 mmHg in hypertensive subjects. beside,that weight loss,increased physical activity, a low-fat diet that includes fruits, vegetables and low-fat dairy products, reducing blood pressure.,

27、生活方式干預(yù)治療利益,A meta-analysis of exercise (aerobic and resistance training)reported an HbA1c reduction of 0.66 %, independent of changes in body weight, in people with Type 2 diabetes.In long-term prospective cohort studie

28、s of people with Type 2 diabetes, higher physical activity levels predicted lower longterm morbidity and mortality and increases in insulin sensitivity.Interventions included both aerobic exercise (such as walking) and

29、resistance exercise (such as weight-lifting).,口服藥物治療,時(shí)機(jī)； Pharmacological therapy should be considered if goals are not achieved between 3 and 6 months after initiating MNT.,雙胍類應(yīng)用要點(diǎn),Begin with metformin unless evidenc

30、e or isk of renal impairment, titrating the dose over early weeks to minimize discontinuation due to gastro-intestinal intolerance.Monitor renal function and risk of signi. cant renal impairment eGFR <60 ml/min/1.73

31、m2) in people taking metformin.The outcome-based evidence from the UKPDS for the use of metformin in overweight people with Type 2 diabetes, exceeding that for any other drug, leads to its recommendation for . rst-line

32、use,Lactic acidosis is a rare complication (often fatal) of metformin therapy in people with renal impairment. Gastro-intestinal intolerance of this drug is very common, particularly at higher dose levels and with fast

33、upward dose titration.,磺脲類應(yīng)用要點(diǎn),Use sulfonylureas when metformin fails to control glucose concentrations totarget levels, or as a . rst-line option in the person who is not overweight.Provide education and, if appropria

34、te, self-monitoring (see Self-monitoring) to guard against the consequences of hypoglycaemia.Once-daily sulfonylureas should be an available option where drug concordance is problematic.Some sulfonylureas, notably glyb

35、uride, are known to be associated with severe hypoglycaemia and rarely death from this, again usually in association with renal impairment.,快速促胰島素分泌劑應(yīng)用要點(diǎn),Rapid-acting insulin secretagogues may be useful as an alternative

36、 to sulfonylureas in some insulin-sensitive people with . exible lifestyles.,噻唑烷二酮類應(yīng)用要點(diǎn),Use a PPAR-γ agonist (thiazolidinedione) when glucose concentrations are notcontrolled to target levels, adding itto metformin as a

37、n alternative to a sulfonylurea, orto a sulfonylurea where metformin is not tolerated, orto the combination of metformin and a sulfonylurea.Be alert to the contra-indication of cardiac failure, and warn the person wi

38、th diabetes of the possibility of development of signi. cant oedema.,糖酐酶抑制劑類應(yīng)用要點(diǎn),Use α-glucosidase inhibitors as a further option. They may also have a role in some people intolerant of other therapies.Systematic review

39、s of the α-glucosidase inhibitors have not found reason to recommend them over less expensive and better tolerated drugs.,胰島素治療要點(diǎn),時(shí)機(jī); Begin insulin therapy when optimized oral glucose-lowering drugs and lifestyle inte

40、rventions are unable to maintain blood glucose control at target levels--------generally when DCCT-aligned HbA1c has deteriorated to >7.5 % (confirmed) on maximal oral agents.可繼續(xù)聯(lián)用 metformin.Additionally continue s

41、ulfonylureas when starting basal insulin therapy.α-Glucosidase inhibitors may also be continued..目標(biāo)血糖： Aim for pre-breakfast and pre-main-evening-meal glucose levels of <6.0 mmol/l(<110 mg/dl);,胰島素治療要點(diǎn),三種模式;a ba

42、sal insulin once daily such as insulin detemir, insulin glargine, or NPH insulin (risk of hypoglycaemia is higher with the last), or.twice daily premix insulin (biphasic insulin) particularly with higher HbA1c, or.mult

43、iple daily injections (meal-time and basal insulin) where blood glucose control is sub-optimal on other regimens, or meal-time ?exibility is desired.調(diào)節(jié)方法; Initiate insulin using a self-titration regimen (dose increases

44、of 2 units every 3 days) or by weekly or more frequent contact with a health-care professional注射部位;abdominal area (most rapid absorption) or thigh (slowest), with the gluteal area (or the arm) as other possible injec

45、tion sites.,選擇皮下注射部位,胰島素治療利益,The evidence from UKPDS that insulin was among the glucose-lowering therapies which, considered together, reduced vascular complications compared with ‘conventional’ therapy.Intensified insu

46、lin therapy in Type 2 diabetes has been shown to improve metabolic control, improve clinical outcomes、and increase fexibility.Pump therapy in Type 2 diabetes is potential option in highly selected patients or in very in

47、dividual settings.,全面控制心血管危險(xiǎn)因素,控制血壓及降壓藥的選用ACE-inhibitors and A2RBs may offer some advantages over other agents in some situations (see Kidney damage, Cardiovascular risk protection)start with β-adrenergic blockers in p

48、eople with angina, β-adrenergic blockers or ACE-inhibitors in people with previous myocardial infarction, ACEinhibitors or diuretics in those with heart failure.care should be taken with combined thiazide and β-adrenerg

49、ic blockers because of risk of deterioration in metabolic control.,全面控制心血管危險(xiǎn)因素,降脂藥的推薦使用a statin at standard dose for all >40 yr old (or all with declared CVD).a statin at standard dose for all >20 yr old with mic

50、roalbuminuria or assessed as being at particularly high risk.in addition to statin, feno?brate where serum triglycerides are >2.3 mmol/l(>200 mg/dl), once LDL cholesterol is as optimally controlled as possible.co

51、nsideration of other lipid-lowering drugs (ezetimibe, sustained release nicotinic acid, concentrated omega 3 fatty acids) in those failing to reach lipidlowering targets or intolerant of conventional drugs.,全面控制心血管危險(xiǎn)因素,小

52、劑量應(yīng)用抗血小板藥物Provide aspirin 75-100 mg daily (unless aspirin intolerant or blood pressure uncontrolled) in people with evidence of CVD or at high risk.Arrange smoking cessation advice in smokers contemplative of reducing

53、 or stopping tobacco consumption.,5.住院病人治療原則,導(dǎo)致患者住院的因素,Hospitalcare for people with diabetes may be required for metabolic emergencies, in-patient stabilization of diabetes, diabetesrelated complications, intercurrent

54、 illnesses, Surgical procedures, and labour and delivery.Prevalence of diabetes in hospitalized adult patients is 12-25 % or more.,住院治療的重點(diǎn),Evaluate blood glucose control, and metabolic and vascular complications (in

55、particular renal and cardiac status) prior to planned procedures; provide advice on the management of diabetes on the day or days prior to the procedure.Ensure the provision and use of an agreed protocol for in-patient

56、proceduresand surgical operations.Aim to maintain near-normoglycaemia without hypoglycaemia by regular quality-assured blood glucose testing and intravenous insulin delivery where needed, generally using a glucose/insul

57、in/potassium infusion.,住院治療的重點(diǎn),Ensure awareness of special risks to people with diabetes during hospital procedures, including risks from:neuropathy (heel ulceration, cardiac arrest)intra-ocular bleeding from new vesse

58、ls (vascular and other surgery requiring anticoagulation)drug therapy (risks of acute renal failure causing lactic acidosis in people on metformin, for example with radiological contrast media),急癥處理原則,Provide access to

59、intensive care units (ICU) for life-threatening illness, ensuring that strict blood glucose control, usually with intravenous insulin therapy, is a routine part of system support for anyone with hyperglycaemia.Provide

60、protocol-driven care to ensure detection and immediate control of hyperglycaemia for anyone with a presumed acute coronary event or stroke, normally using intravenous insulin therapy with transfer to subcutaneous insulin