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
2、亡的主要原因，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 pre
3、vious CVD。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
4、及监测,提倡早期诊断,早期诊断的意义；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 w
5、ho areundiagnosed ranges 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
6、, 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 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3
7、0%-90%糖尿病漏诊率. For diagnosis, an oral glucose tolerance 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 (39 mg/dl).血压控制水平Aim to maintain blood pressure
8、 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 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 complicat
9、ions; an agreed and continually 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.Sit
10、e-of-care capillary plasma 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
11、assess glucose excursions due 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-em
12、powerment, changes in therapy).,对尿糖监测的评价,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 d
13、istinguish between moderately and grossly 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
14、 frequency of physical activity (where 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
15、 improved glycaemic outcomes (HbA1c 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 a 10-13 % decrease in total cholesterol, 12-16
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 decreased blood pressure by 5/2 mmHg in hypertensive subjects. beside,that weight loss,increased physical activity, a low-fat diet
17、that includes fruits, vegetables and low-fat dairy products, 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 s
18、tudies 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 resistance exercise (such as weight-lifting).,口服药物治疗,时机； Pharmacological the
19、rapy should be considered if goals are not achieved between 3 and 6 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 ri
20、sk of signi. cant renal impairment eGFR 7.5 % (confirmed) on maximal oral agents.可继续联用 metformin.Additionally 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(40
21、 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 optimally controlled as possible.consid
22、eration 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 aspirin intolerant or blood pressu
23、re 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, in-patient stabilization of dia
24、betes, 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 renal and cardiac statu
25、s) 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 regular quality-assu
26、red 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 arrest)intra-ocular b
27、leeding 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 illness, en
28、suring 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, n
29、ormally using intravenous insulin therapy with transfer to subcutaneous insulin therapy once stable and eating.,谢谢！,pOXLp7v0djZKylHSJr3WxBmHK6NJ2GhiBeFZ7R4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGZ7R4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGshLs50cLmTWN60eo8Wgqv7XAv2OHUm32WGeaUwYDIAW
30、GMeR4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGZ7R4I30kA1DkaGtgKQcWA3PtGZ7R4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGshLs50cLmTWN60eo8Wgqv7XAv2OHUm32WGeaUwYDIAWGMeR4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGZ7R4I30kA1DkaGhn3XtKknBYCUDxqA7FHYi2CHhI92tgKQcWA3PtGshLs50cLmTWN60eo8Wgqv7XAv2OHUm32WGeaUwYDIAWGMes02GshLs50cLmTWN60eo8Wgqv7XAv2OHUm32WGeaUwYDIAWGMes02dLPqafkFGlzcvv2YiRQYHbhR8AI1LKULh3xvjDzkEAMGr8xbwF1bH1oIM30E7xp,
