胃肠疾病大小15.2g等多个文件-09糖尿病

MichaelE.HerrtageUniversityofCambridgeMANAGEMENTOFFELINEDIABETESMELLITUS猫糖尿病的治疗DIABETESMELLITUS

糖尿病Astateofchronichyperglycaemiacausedbyabnormalitiesofcarbohydrate,proteinandlipidmetabolism,whichmayeitherbeduetoanabsolutelackofinsulinortofactorsthatopposeitsaction.一种慢性高血糖症，由碳水混合物、蛋白质和脂肪代谢异常造成，原因有：胰岛素绝对水平下降胰岛素合成拮抗因子WorldHealthOrganisation1980CLASSIFICATIONOFDIABETESMELLITUS

糖尿病分类Type1diabetes1型糖尿病Insulindependentdiabetesmellitus(IDDM)胰岛素依赖性糖尿病Juvenile-onsetdiabetes青年发病型糖尿病Type2diabetes2型糖尿病Non-insulindependentdiabetesmellitus(NIDDM)非胰岛素依赖性糖尿病Adult-onsetdiabetes成年发病型糖尿病Type3diabetes3型糖尿病Secondarycausesofdiabetes继发性糖尿病DIABETESMELLITUS

POSSIBLEAETIOLOGIES

糖尿病致病原因Genetics 遗传Immune-mediatedisletdestruction 免疫介导性胰岛破坏Obesity 肥胖Infection 感染Pancreatitis 胰腺炎Currentillness 现有疾病Drugtherapy 药物治疗Isletamyloidosis 胰岛淀粉样变性PATHOGENESISOFTYPE2DIABETESMELLITUS

2型糖尿病的发病机理Beta-celldysfunction

β细胞功能不全Insulinresistance

胰岛素不敏感Obesity

肥胖Chronichyperglycaemia

慢性高血糖症Environmentalfactors

环境因素Obesityandphysicalexercise

肥胖和运动Diet

饮食PATHOGENESISOFTYPE2DIABETESMELLITUS

2型糖尿病的发病机理Isletamyloidosis

胰岛淀粉样变性Glucoseandlipidtoxicity

葡萄糖和脂毒性Beta-cellexhaustion

β细胞耗竭PATHOPHYSIOLOGYOF

DIABETESMELLITUS

糖尿病的病理生理学Relativeorabsolutedeficiencyofinsulin

胰岛素相对或绝对不足Decreasedglucoseuptakebyadiposetissueandmuscle

脂肪组织和肌肉摄取葡萄糖减少Increasedcatabolismespeciallyoffats

代谢增加，特别是脂肪代谢增加PATHOPHYSIOLOGYOF

DIABETESMELLITUS

糖尿病的病理生理学高血糖糖尿渗透性利尿：水、电解质流失CLINICALSIGNSOF

DIABETESMELLITUS

糖尿病的临床表现Polyuria

多尿Polydipsia

烦渴Polyphagia

多食Weightloss

体重下降Liverenlargement肝脏肿大PATHOPHYSIOLOGYOF

DIABETESMELLITUS

糖尿病的病理生理学血中游离脂肪酸在肝脏代谢为乙酰辅酶A乙酰乙酸丙酮ß－羟丁酸PATHOPHYSIOLOGYOFDIABETICKETOACIDOSIS

糖尿病酮酸中毒的病理生理学AcetylCoA乙酰辅酶AAcetoacetylCoA乙酰乙酰辅酶ATCAcycleFFA游离脂肪酸Acetoaceticacid乙酰乙酸Acetone丙酮b-hydroxybutyricacidβ-羟丁酸Glucose葡萄糖Amino氨基Acids酸PATHOPHYSIOLOGYOFDIABETICKETOACIDOSIS

糖尿病酮酸中毒的病理生理学CortisolGrowthHormone可的松生长激素Catecholamines儿茶酚胺Lipolysis脂解Ketogenesis酮生成Ketonaemia酮(酸)血症ReducedglucoseUtilisation降低糖利用Hyperglycaemia高血糖Glycogenolysis糖原分解ReducedinsulinRelease胰岛素分泌减少Gluconeogenesis糖原异生Increasedglucagon:insulinRatio肝糖胰岛素比值增高CLINICALSIGNSOFDIABETICKETOACIDOSIS

糖尿病酮酸中毒的临床表现Vomiting,dehydration 呕吐、脱水Depression,weakness,collapse 精神沉郁、虚弱、虚脱Tachypnoea,smellofacetone 呼吸急促、有丙酮味Precipitatingcausee.g.infection,concurrentdisease

易感因素：感染/同时发生的疾病03/861Domesticshorthairedcat8yrFn‘Ebony’短毛家猫，8月龄DSH8yrFn‘EbonyLivedinGermanyuntil1996 在德国住到1996年OwnedbyaG.P. 主人：G.PPolydipsicfor6weeks 烦渴达6周之久Progressivelossofappetitefor2weeks 食欲进行性下降2周Completelyanorexicfor7days 厌食7天Noticeableweightloss 明显的体重下降Vomitingoverlastday 昨天有呕吐History病史DSH8yrFn‘EbonyDullanddepressed 迟钝，精神沉郁Unabletostand,butreactstoexamination 无法站立，但对检查有反应Mucousmembranesdryandjaundiced 可视粘膜干燥，有黄疸Capillaryrefillslow 毛细血管充盈减慢Dehydrated,lossofskinturgor 脱水，皮肤失去弹性Markedweightloss6.2kgto3.6kg 明显的体重减少Palpablyenlargedliver 触诊肝肿大Clinicalexamination临床检查DSH8yrFn‘Ebony9/04/03DSH8yrFn‘Ebony9/04/03DSH8yrFn‘Ebony9/04/03DSH8yrFn‘Ebony9/04/03DSH8yrFn‘Ebony9/04/03DSH8yrFn‘EbonyFibrinogen<1g/l9/04/03DSH8yrFn‘Ebony9/04/03Whatnext?

下一步DSH8yrFn‘EbonyHowwouldyoutreatthiscase?

如何治疗DSH8yrFn‘Ebony0.9%sodiumchloride(36ml/h)i.v. 0.9%Nacl静注输液(36ml/h)5iusolubleinsulin/500ml 5iu可溶性胰岛素于500ml溶液中5mmolKCl/500ml 5mmolKcl于500ml溶液中70mgtoldimfossodium(Foston®)s.c. 70mg托定磷钠s.c.Clavulanatepotentiatedamoxycillini.v. 克拉维酸+阿莫西林i.vSyringe-fedHillsa/devery4hours 注射器喂饲Hillsa/d处方粮，每4小时1次9/04/03DSH8yrFn‘Ebony10/04/03DSH8yrFn‘Ebony11/04/03DSH8yrFn‘Ebony11/04/03DSH8yrFn‘Ebony11/04/03DSH8yrFn‘Ebony14/04/03DSH8yrFn‘Ebony14/04/03DSH8yrFn‘Ebony14/04/03DSH8yrFn‘EbonyStartedeatingvoluntarily14/04/03 开始愿意采食Stopi.v.fluids 停止静脉输液100gRabbitWhiskasBID 100g伟嘉兔肉猫粮，BID3unitsPZIinsulinoncedailys.c. 3单位PZI（长效型）胰岛素,１天１次，s.c.Clavulanatepotentiatedamoxycillinp.o. 克拉维酸+阿莫西林p.o.15/04/03DSH8yrFn‘Ebony17/04/03MANAGEMENTOF

DIABETICKETOACIDOSIS

糖尿病酮酸中毒的处理Intravenousfluidtherapy 静脉输液Insulintherapy 胰岛素治疗Hypokalaemia 低钾血症Hypophosphataemia 低磷血症Acidosis 酸中毒Antibiosis 抗生素FELINEDIABETESMELLITUS

猫糖尿病Affects1in300cats 发病率1/300‘Glucosetoxicity’maybereversible 葡萄糖毒性可以是可逆的Mayrespondtodietandoralhypoglycaemics 饮食管理和口服的降血糖药品可能有效Exogenousinsulintendstobemetabolisedmorequicklyinthecatthaninthedog 外源性胰岛素在猫中比犬中代谢速度更快Profoundhypoglycaemiamaygounnoticed 可能未观察到严重的低血糖症ORALHYPOGLYCAEMICDRUGS

口服降血糖药Impairintestinalglucoseabsorption 小肠对葡萄糖吸收不良a-glucosidaseinhibitor(acarbose) α－葡糖苷酶抑制剂（阿卡玻糖）Promoteinsulinrelease 促进胰岛素释放Glipizide2.5-5.0mgBID 格列吡嗪2.5-5.0mgBIDInhibithepaticglucoseproduction 抑制肝糖生产Metformin2-10mg/kgBID 二甲双呱2-10mg/kgBIDInsulinsensitizingdrugs 胰岛素增敏剂Troglitazone,vanadium,chromium 曲格列酮，钒，铬GLIPIZIDE(Glibenese®)格列吡嗪Sulphonylurea 硫酰脲类Mostappropriatecases: 适合病例Obesecats 肥胖猫Mildlyaffected,otherwisehealthycats? 症状轻微，无其他问题的猫Recenthistoryofdiabetogenicdrugs? 最近有服用致糖尿病（提高血糖）的药物史Usecontra-indicatedin: 禁忌症CatswithDKA，有糖尿病酮酸中毒的猫Emaciatedordebilitatedcats 瘦弱猫Catswithconcurrentdisease 同时患有其他疾病的猫GLIPIZIDE(Glibenese®)格列吡嗪Initialdose2.5mgBIDwithfoodfor2weeks 拌料食用2周，起始用量：2.5mg，BIDCheckliverenzymesbeforeandafter1and2weeks 喂食前和喂食后1－2周检查肝酶Ifnobeneficialresponseincreaseto5mgBID 若疗效不明显，则增加剂量至5mg，BIDRe-assessat2weeklyintervals 2周后再次评估Ceaseifnobeneficialresponseafter12weeks 服用12周仍无效果，则停用GLIPIZIDE(Glibenese®)格列吡嗪Usuallywelltolerated 通常接受度良好Occasionallycausesvomiting,hepatotoxicityorjaundice 偶尔有呕吐，肝毒性或黄疸现象出现Ifgoodcontrolachieved,graduallytaperdoseandeventuallyceaseuse 如果病情控制较好，可逐渐减少剂量， 直到停药STABILISATIONOFDIABETESMELLITUS

糖尿病病情的稳定Requiresunderstandingbytheowner 需要主人的理解Requiresaregulardailyroutine 需要常规治疗(每日)Diabetesinthecatmaybeinsulin-dependentornotandmaybepermanentortemporary 猫的糖尿病可能属胰岛素依赖性或非胰岛素依赖性，也可能为永久性的或暂时的Homeversushospitalisationforinitialstabilisation 在家治疗或住院治疗以达到初步稳定STABILISATIONOFDIABETESMELLITUS

糖尿病病情的稳定Avoidincreasinginsulindosetooquickly 避免过快增加胰岛素剂量Allowatleast3daysforfullresponsetoinsulin 患猫对胰岛素完全产生作用至少需要3天Insulinrequirementsareincreasedbyinfection,concurrentdisease,oestrus,pregnancyandketoacidosis 感染、现有疾病、发情期，妊娠和酮酸中毒时胰岛素需要量增加Entirequeensshouldbespayed 雌猫需要施行节育手术Hypoglycaemiccrisesshouldbeexplainedtoowner 必须向主人解释有低血糖危象INSULINTHERAPY 胰岛素治疗Typeofpreparation 准备的类型Routeofadministration 注射方法Doseofinsulin剂量Timingofinjection时间Frequencyofadministration次数INSULINPREPARATIONS

胰岛素的配制类型STRUCTUREOFINSULIN

胰岛素结构BOVINEINSULINegInsuvetlente®(ScheringPlough)isHOMOLOGOUStofelineinsulin牛胰岛素和猫胰岛素是同源的PORCINEINSULINegCaninsulin®(Intervet)is

HETEROLOGOUStofelineinsulindueto2aminoaciddifferencesintheAchain猪胰岛素与猫胰岛素是异源的，因为Ａ链有２个氨基酸不同ACHAINBCHAINACHAINBCHAINPROINSULININSULINC-peptidessssssss肽DIETARYMANAGEMENT

饮食管理Consistencyofthediet 保持饮食一致性Compositionofthediet 饮食的成分Fibrecontent 含纤维Caloriecontentandcaloricdensity 卡路里含量Feedingschedule 定时喂养DIETARYMANAGEMENT

饮食管理Consistencyofthediet 保持饮食一致性Compositionofthediet 饮食的成分Fibrecontent 含纤维Caloriecontentandcaloricdensity 卡路里含量Feedingschedule 定时喂养STABILISATIONOFDIABETESMELLITUS

糖尿病病情的稳定

Standardroutineforcats 猫的标准治疗方法InjectPZIinsulinsubcutaneously 皮下注射PZI胰岛素Feed1/2thedailyration30minuteslater

注射后30分钟伴料喂食1/2的日量Secondfeed6-8hoursafterinjection

注射后6-8小时拌料喂食另1/2的日量Keepdailyroutineincludingexerciseconstant 每日程序需一致，包含固定时间运动Notit-bitsorscavenging不给零食和人的食物STABILISATIONOFDIABETESMELLITUS

糖尿病病情的稳定Monitorbloodand/orurineglucose 监测血糖/尿糖水平Monitorfluidintake 观察水份摄取量Aimfortraceofglucoseinmorningurinesampleorbloodglucosebetween5-10mmol/l 清晨监测尿糖/血糖水平在5-10mml/l之间Bloodglucoseshouldbelowestbeforethesecondfeed,urineglucoseatthattimeshouldbenegative 第二次喂食前血糖水平应最低，此时尿糖测检测应呈阴性IDEALDIABETICCURVE

理想的胰岛素曲线InsulinFeedMONITORINGTHEDABETICPATIENT

糖尿病患畜的监测Fluidintake 水份摄取Bodyweight 体重Urineglucose/ketones 尿糖/酮Bloodglucose 血糖Serumfructosamine 血清果糖胺Glycosylatedhaemoglobin 硫化血红蛋白DIABETICRECORD糖尿的记录BLOODSAMPLINGTHEDIABETICPATIENTATHOME

糖尿病患畜在家中取血样GLUCOSEMEASUREMENTS

血糖测量1243SERUMFRUCTOSAMINE

血清果糖胺Formedbyanon-enzymaticreactionbetweenglucoseandproteins,mainlyalbumin 葡萄糖和蛋白质（主要是白蛋白）转换产生的的非酶反应物质Thereactionisirreversible 反应是不可逆的Thustheconcentrationoffructosaminedependsondurationandextentofthehyperglycaemiaandthehalf-lifeofalbumin因此，果糖胺的浓度取决于高血糖的持续时间和程度，以及白蛋白的半衰期SERUMFRUCTOSAMINE

血清果糖胺Thehalf-lifeofalbuminisabout8days,thereforeserumfructosaminereflectstheaveragebloodglucoseconcentrationovertheprevious2-3weeks 白蛋白的半衰期约8天，因此血清果糖胺反应了2-3周前的平均血糖浓度Itisnotaffectedbyacutechangesinbloodglucoseconcentrationse.g.feeding,sedation,stress 它不受血糖浓度暂时改变的影响，如饮食、镇静剂、应激INVESTIGATIONOF

THEUNSTABLEDIABETIC

不稳定性糖尿病的诊断Diet 饮食Administrationofinsulin 使用胰岛素Correctdoseofinsulin 胰岛素正确使用剂量Storageofinsulin 胰岛素储备Urinetesting 尿检Infection,concurrentdisease,oestrus,pregnancy 感染，伴发疾病，发情期，妊娠Ketoacidosis 酮酸中毒Check:检查INVESTIGATIONOF

THEUNSTABLEDIABETIC

不稳定性糖尿病的诊断Checkthediabeticrecord 检查糖尿病记录表Monitorbloodglucoseevery2hoursfora24hourperiod 24小时内每2小时监测一次血糖水平MiniMedcontinuousglucosemonitoringsystem(CGMS)

MiniMed持续性血糖监测系统(CGMS)Plotgraphoftheresults 图示结果TheMiniMedcontinuousglucosemonitoringsystem

MiniMed－血糖监测体系TheMiniMedCGMSwasdesignedforuseinhumandiabeticpatientstominimise: 此仪器被设计用于人类糖尿病患以减低：theinconvenienceandfortofrepeatedbloodsampling 重复采集血液样本的不便和不适Thepossibilityofmissingapeakortroughinglucosewhichoccursbetween2samplingtimes 错过发生在2次取样之间的葡萄糖波峰或波谷TheMinimedsystemCGMSvseter

CGMS（持续性血糖检测体系）vs葡萄糖测量仪SampleMiniMedData

MiniMed样本数据CGMSday-to-dayvariability

CGMS每日变异度CGMSlowerlimitofsensor

CGMS的低限制性CGMSbenefitsofacontinuouscurve

CGMS连续曲线的效果INSULIN-INDUCEDHYPERGLYCAEMIA

“Somogyioverswing”

胰岛素诱发的高血糖症InsulinFeedRAPIDMETABOLISMOFINSULIN