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1、2型糖尿病全球防治指南新特点,内容概括,1.背景资料 2.糖尿病危害性 3.诊断及监测4.治疗概论 5.住院病人治疗原则,1.背景资料,1.根据循证医学原则制定,内容参考近5年来国际上出版的指南、meta分析、及相关刊物。2.根据不同地区、不同医疗资源制定3个等级标准。,三个等级医疗标准,Standard Care,2.糖尿病危害性,1.发病人数日益增长。无论是在发达国家还是在发展中国家，均明显增加。其中90%为2型糖尿病。（见下图）2.发展中国家增长的速度超过了发达国家。（200%比45%），21世纪DM 将在中国、印度等发展中国家流行。3.DM 的主要并发症已经成为病人致残和早亡的主要原因
2、，每年全球约 3 000 000 人口因糖尿病而死亡。4.2型糖尿病占我国糖尿病人群的90%以上，它的血管并发症使人们丧失劳动能力,预期寿命缩短8-12年。,P.Zimmet et al.Bulletin of 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 CV
3、D。Haffner SM,Lehto 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.,糖尿病急性并发症及大血管和微血管等慢性并发症，致死、致残率高，一旦发生，难以逆转，降低病人的生活质量，缩短寿命。,3.诊断及监测,提倡早期诊断,早期诊断的
4、意义；Type 2 diabetes has a long asymptomatic pre-clinical phasewhich frequently goes undetected.At the time of diagnosis,over half have one or more diabetes complications.Retinopathy rates at the time of diagnosis range from 20%to 40%.Of people with Type 2 diabetes,the proportion who areundiagnosed ra
5、nges from 30%to 90%.SM,Meyer LC,Neil HAW,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,Klein R,Welborn TA,Knuiman MW.Onset of NIDDM occurs at
6、 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 type 2 diabetes and associated risk factors.Arch Ophthalmol 1998;116:297-303.,早期诊断,早期诊断的方法-目前全球根据各地区约有30%-90%糖尿病漏诊率.For diagnosis,an oral glucose tol
7、erance test(OGTT)should be performed in people 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 opportunistic screening,it should be repeated fasting,or an OGTT performed.,诊断
8、标准:WHO-1999 criteria,Health Organization.Definition,Diagnosis and Classification of Diabetes Mellitus and its Complications.Report of a WHO Consultation.Part 1:Diagnosis and Classification of Diabetes Mellitus.Geneva:WHO,诊断标准的解释:糖尿病诊断是依据空腹、任意时间或OGTT中2小时血糖值空腹指至少8小时内无任何热量摄入任意时间指一日内任何时间，无论上次进餐时间及食物摄入量O
9、GTT是指以75克无水葡萄糖为负荷量，溶于水内口服(如用1分子结晶水葡萄糖，则为82.5克。OGTT的方法:早餐空腹取血(空腹8-14小时后），取血后于5分钟内服完溶于250-300ml水内的无水葡萄糖75克（如用1分子结晶水葡萄糖，则为82.5克）试验过程中不喝任何饮料、不吸咽、不做剧烈运动，无需卧床从口服第一口糖水时计时，于服糖后30分钟、1小时、2小时及3小时取血（用于诊断可仅取空腹及2小时血）,控制指标水平,血糖控制水平；HbA1c 1.0 mmol/l(39 mg/dl).血压控制水平Aim to maintain blood pressure below 130/80 mmHgAc
10、cept 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 postural hypotension and falls.,每年全面检测一次,检测原则及目的,General principles include:annual review of control and complications;an agreed and con
11、tinually updated diabetes care plan;and involvement of the multidisciplinary team in delivering that plan,centred around the person with diabetes.,临床血糖监测方法,HbA1c performed every 2 to 6 months depending on level and stability of blood glucose control,and change in therapy.Site-of-care capillary plasm
12、a glucose monitoring at random times of day is not generally recommended.,自我血糖监测方法,Self-monitoring of blood glucose(SMBG)should be available to those;For all newly diagnosed people with Type 2 diabetes;those on insulin treatment;to provide information on hypoglycaemia;to assess glucose excursions du
13、e to medications and lifestyle changesto monitor changes during intercurrent illness.SMBG can be considered in relation 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).,对
14、尿糖监测的评价,Urine glucose testing is 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 results do not distinguish between moderately and gr
15、ossly elevated levels,and a negative result does not distinguish between normoglycaemia and hypoglycaemia.,4.治疗概论,生活方式干预治疗,目的：通过调整生活方式，如饮食、运动等更好地控制血糖、血压、血脂等危险因素。关于饮食；专家指导下制定个体营养需求方案;严格限制高热量、高脂食物、食盐及酒精等；根据降糖药（口服药及胰岛素）及运动量调整饮食量。关于运动：Encourage increased duration and frequency of physical activity(where
16、 needed),up to 30-45 minutes on 3-5 days per week,or an accumulation of 150 minutes of physical activity per week.,生活方式干预治疗利益,Randomized controlled trials and outcome studies of medical nutrition therapy(MNT)in the management of Type 2 diabetes have reported improved glycaemic outcomes(HbA1c decreas
17、es 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 a 10-13%decrease in total cholesterol,12-16%decrease in LDL cholesterol and 8%decrease in trigl
18、ycerides.A meta-analysis of studies of non-diabetic people reported that reductions in sodium intake to 2.4 g/day decreased 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 product
19、s,reducing blood pressure.,生活方式干预治疗利益,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 studies of people with Type 2 diabetes,higher physical activity
20、levels predicted lower longterm morbidity and mortality and increases in insulin sensitivity.Interventions included both aerobic exercise(such as walking)and resistance exercise(such as weight-lifting).,口服药物治疗,时机；Pharmacological therapy should be considered if goals are not achieved between 3 and 6
21、months after initiating MNT.,双胍类应用要点,Begin with metformin unless evidence 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 m2)in people ta
22、king 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 use,Lactic acidosis is a rare complication(often fatal)of metformin therapy in people with renal impa
23、irment.Gastro-intestinal intolerance of this drug is very common,particularly at higher dose levels and with fast upward dose titration.,磺脲类应用要点,Use sulfonylureas when metformin fails to control glucose concentrations totarget levels,or as a.rst-line option in the person who is not overweight.Provid
24、e education and,if appropriate,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 glyburide,are known to be associated with severe hypoglycaemia
25、 and rarely death from this,again usually in association with renal impairment.,快速促胰岛素分泌剂应用要点,Rapid-acting insulin secretagogues may be useful as an alternative to sulfonylureas in some insulin-sensitive people with.exible lifestyles.,噻唑烷二酮类应用要点,Use a PPAR-agonist(thiazolidinedione)when glucose conc
26、entrations are notcontrolled to target levels,adding itto metformin as an 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 with diabetes of
27、the possibility of development of signi.cant oedema.,糖酐酶抑制剂类应用要点,Use-glucosidase inhibitors as a further option.They may also have a role in some people intolerant of other therapies.Systematic reviews of the-glucosidase inhibitors have not found reason to recommend them over less expensive and bett
28、er tolerated drugs.,胰岛素治疗要点,时机;Begin insulin therapy when optimized oral glucose-lowering drugs and lifestyle interventions 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.可继续联用 metformin.Additi
29、onally continue sulfonylureas when starting basal insulin therapy.-Glucosidase inhibitors may also be continued.目标血糖：Aim for pre-breakfast and pre-main-evening-meal glucose levels of 6.0 mmol/l(110 mg/dl);,胰岛素治疗要点,三种模式;a basal insulin once daily such as insulin detemir,insulin glargine,or NPH insuli
30、n(risk of hypoglycaemia is higher with the last),or.twice daily premix insulin(biphasic insulin)particularly with higher HbA1c,or.multiple daily injections(meal-time and basal insulin)where blood glucose control is sub-optimal on other regimens,or meal-time exibility is desired.调节方法;Initiate insulin
31、 using a self-titration regimen(dose increases 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 injection sites.,选择皮下注射部位,胰岛素治疗利益,The evidence fr
32、om UKPDS that insulin was among the glucose-lowering therapies which,considered together,reduced vascular complications compared with conventional therapy.Intensified insulin therapy in Type 2 diabetes has been shown to improve metabolic control,improve clinical outcomes、and increase fexibility.Pump
33、 therapy in Type 2 diabetes is potential option in highly selected patients or in very individual settings.,全面控制心血管危险因素,控制血压及降压药的选用ACE-inhibitors and A2RBs may offer some advantages over other agents in some situations(see Kidney damage,Cardiovascular risk protection)start with-adrenergic blockers i
34、n people with angina,-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-adrenergic blockers because of risk of deterioration in metabolic control.,全面控制心血管危险因素,降脂药的
35、推荐使用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 microalbuminuria or assessed as being at particularly high risk.in addition to statin,fenobrate where serum triglycerides are 2.3 mmol/l(200 mg/dl),once LDL cholesterol is as op
36、timally controlled as possible.consideration 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.,全面控制心血管危险因素,小剂量应用抗血小板药物Provide aspirin 75-100 mg daily(unless as
37、pirin intolerant or blood pressure uncontrolled)in people with evidence of CVD or at high risk.Arrange smoking cessation advice in smokers contemplative of reducing or stopping tobacco consumption.,5.住院病人治疗原则,导致患者住院的因素,Hospitalcare for people with diabetes may be required for metabolic emergencies,i
38、n-patient stabilization of diabetes,diabetesrelated complications,intercurrent illnesses,Surgical procedures,and labour and delivery.Prevalence of diabetes in hospitalized adult patients is 12-25%or more.,住院治疗的重点,Evaluate blood glucose control,and metabolic and vascular complications(in particular r
39、enal 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 proceduresand surgical operations.Aim to maintain near-normoglycaemia without hypoglycaemia by
40、regular quality-assured blood glucose testing and intravenous insulin delivery where needed,generally using a glucose/insulin/potassium infusion.,住院治疗的重点,Ensure awareness of special risks to people with diabetes during hospital procedures,including risks from:neuropathy(heel ulceration,cardiac arres
41、t)intra-ocular bleeding from new vessels(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),急症处理原则,Provide access to intensive care units(ICU)for life-threatening
42、illness,ensuring that strict blood glucose control,usually with intravenous insulin therapy,is a routine part of system support for anyone with hyperglycaemia.Provide 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 therapy once stable and eating.,谢谢！,
