安立泽病例(刘洲君)

安立泽联合用药的选择江苏省中西医结合医院内分泌代谢病院区刘洲君CasereportTreatmentexperienceSummaryContentsPartI

CasereportGeneraldataandbriefhistoryGenderMaleAge50OccupationClerkChiefcomplaintElevatedbloodglucosefor4yearsHistoryofpresentillnessBGwastestedinhighlevel4yearsago,hetook

metforminandglimepirideorally,FBG8-9mmol/L.Oneyearago,hewasdiagnosedwithT2DM,diabeticperipheralvasculardiseaseinourdepartment,thenhewastreatedwithmetforminandglargine,withoutdietarytherapy.Glargine16uqn,metformin0.5bidoftheadmissionwithoutpolydipsia,polyuria,weightloss.BriefhistoryPastmedicalhistoryNohistoryof

hypertension,CHDExposurehistoryofinfectiousdiseasesUnremarkableAllergichistoryNoPersonalhistorySmokingcessationfor4yeas,abstinencefor2monthsFamilyhistoryHismotherhasT2DMPhysicalexaminationT36.5oCP74bpmR16BP115/75Ht1.83mWt93kgBMI27.77Kg/m2WC97cmNootherpositivesignsLaboratorydataBRTURTWBC4.16X109/LGlu++RBC4.15X1012/Lketone+Hb138g/LPro--N53%L40%EKGNormalLaboratorydataBloodglucoseHepaticandrenalfunctionRBG15.5mmol/LALT10IU/LFPG12.13mmol/LAST10IU/LPPG19.3mmol/LBUN3.96mmol/LHbA1c9.7%Cr65mmol/LUA322μmol/LLaboratorydataLipidprofileTC4.85mmol/LTG2.86mmol/LHDL0.89mmol/LLDL3.17mmol/LMicroalbuminuria/Cr1.89mg/gImagestudies

Fundoscopy:nodiabeticretinopathyAbdomenUS:mildfattyliver,gallstoneDopplerforarteryoflowerextremity:arteriosclerosiswithmultipleplaqueformationCarotidUS:softplaquesformationinbilateralcommoncarotidsinusesHistorysummaryOnsetsecretivelyinmiddleage,

nopronetospontaneousketosiswithSUstreatmentFamilyhistoryofDMOverweight,WC>90cmComplicatedbyseveralriskfactors(peripheralvasculardisease,dyslipidemia)Combinedwithfattyliver,gallstoneTheBGispoorcontrolledthoughcombinationtherapywithglargineandMETDiagnosisT2DMDiabeticperipheralvasculardiseaseDyslipidemiaFattyliverGallstone

MetabolicsyndromeFurthertreatment？IntensivelifestylemodificationAddinginsulindosage？AGI？SUs？TZD?Newdrug：DPP-4inhibitor

DPP-4inhibitormarkedlyreduceHbA1c

levelPhungOJetal.

JAMA.2010;303:1410-1418.-2.0-1.5-1.0-0.500.5SUsGLNTZDAGIDPP-4iGLP-1

RA-0.79（-1.15,-0.43）-0.71（-1.24,-0.18）-1.00（-1.62,-0.38）-0.65（-1.11,-0.19）-0.79（-0.94,-0.63）-0.99（-1.19,-0.78）AverageHbA1creducing

level（%）（95%CI）Ametaanalysis

enrolled27

studiesincluded11198

T2DM

patientsaged53-62,HbA1clevelfluctuatedform

6.4%to9.3%DPP-4inhibitorwithrarelyoccurrenceofhypoglycemiaPhungOJetal.

JAMA.2010;303:1410-141.0102050SUsGLNTZDAGIDPP-4iGLP-1

RA2.63（0.76,9.13）7.92（1.45,43.21）2.04（0.50,8.23）0.60（0.08,4.55）0.67（0.30,1.50）0.94（0.42,2.12）incidenceofhypoglycemia（%）（95%CI）Ametaanalysis

enrolled27

studiesincluded11198

T2DM

patientsaged53-62,HbA1clevelfluctuatedform

6.4%to9.3%DPP-4inhibitorwithnearlynoaffectsonthebodyweight-5-2.502.55SUsGLNTZDAGIDPP-4iGLP-1

RA1.99（0.86,3.12）0.91（0.35,1.46）2.30（1.70,2.90）-1.80（-2.83,-0.77）-0.09（-0.47,0.30）-1.76（-2.90,-0.62）Averageofweightchange（%）（95%CI）Ametaanalysis

enrolled27

studiesincluded11198

T2DM

patientsaged53-62,HbA1clevelfluctuatedform

6.4%to9.3%PhungOJetal.

JAMA.2010;303:1410-1418.IncretintherapyisfailuretoincreasetheCVDriskinT2DM

0.010.1110100Sitagliptin(100mgqd)Vildagliptin(50mgbid)Alogliptin(25mgqd)Saxagliptin

(2.5-10mgqd)exenatide(5/10μgbid)HighCVDriskpatientsVildagliptin(50mgbid)Alogliptin(25mgqd)incidenceIncretinvs.control0.6%1.32%0.28%0.7%0.86%3.72%0.46%0.9%1.64%0.50%1.4%1.10%5.08%0.60%RRBettertreatmenteffectWorsetreatmenteffect

vs.controlSchweizer,etal.DiabetesObesMetab.2010.White,etal.ADA.2010;Poster:391-P.Ratner,etal.CardiovascDiabetol.2011.WilliamsHerman,etal.BMCEndocrDisord.2010.Frederich,etal.PostgradMed.2010..DemandingofnewdrugsSafty(hypoglycimia,CVDrisk)文本3complianceValidity(short/longterm)cost-effectiveCefaluWT.DiabetesCare..2012Jun;35(6):1201-3.CerielloA,etal.Diabetologia..2012Oct;55(10):2853-2855.InzucchiSE,etal.Diabetologia.

2012Apr20.HOMAimprovementaftercombinationtherapyofonglyzaandMETDeFronzoRA,etal.DiabetesCare.

2009

Sep;32(9):1649-55.HOMA-2βvariationcomparetobasline(%)5mgSaxagliptin+METn=166Placebo+METn=180Arandomized,double-blind,placebocontrol

study，743

individualswithT2DM，treatedwithMET,baselineHbA1c7.0%-10.0%,βcellfunctionvariationpre-andpost-treatmentwithsaxagliptinorplaceboafter24weeksTreatmentplanlifestyleinterventionDietaryandexerciseinstruction,diabeticeducationMedicaltherapy1.Glargine

20Uqn2.MET

0.5Bid3.Plusonglyza

5mg/dayBGmonitoringDatefastingpostmealpremealpostmealpremealpostmealremarks5-0515.513.3Glargine20uqn5-0612.618.418.614.85-0810.115.514.212.2Glargine20uqn+

MET0.5bid+onglyza

5mgqd5-1214.612.311.3Glargine23uqn+

MET0.5bid+onglyza

5mgqd5-137.211.912.715.28-156.58.07.68.5Glargine20uqn+

MET0.5bid+ongl