型糖尿病全球防治指南新特点课件

2型糖尿病全球防治指南新特点

2型糖尿病全球防治指南新特点

型糖尿病全球防治指南新特点课件内容概括1.背景资料2.糖尿病危害性3.诊断及监测4.治疗概论5.住院病人治疗原则内容概括1.背景资料1.背景资料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。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三个等级医疗标准

StandardCareMinimalCareComprehensiveCare三个等级医疗标准

StandardCareMinimal2.糖尿病危害性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，每年全球约3000000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。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P.Zimmetetal.BulletinoftheInternationalDiabetesFederation48:13,2003P.Zimmetetal.BulletinofthAmuchquotedpaperbyHaffneretal,suggestedthatpeoplewithType2diabeteshaveaCVriskequivalenttonon-diabeticpeoplewithpreviousCVD。HaffnerSM,LehtoS,R鰊nemaaT,PyoralaK,LaaksoM.Mortalityfromcoronaryheartdiseaseinsubjectswithtype2diabetesandinnondiabeticsubjectswithandwithoutpriormyocardialinfarction.NEnglJMed1998;339:229-34.AmuchquotedpaperbyHaffn

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。糖尿病急性并发症及大血管和微血管等慢性并发症，致死、3.诊断及监测3.诊断及监测提倡早期诊断早期诊断的意义；Type2diabeteshasalongasymptomaticpre-clinicalphasewhichfrequentlygoesundetected.Atthetimeofdiagnosis,overhalfhaveoneormorediabetescomplications.Retinopathyratesatthetimeofdiagnosisrangefrom20%to40%.OfpeoplewithType2diabetes,theproportionwhoareundiagnosedrangesfrom30%to90%.SM,MeyerLC,NeilHAW,RossIS,TurnerRC,HolmanRR.Complicationsinnewlydiagnosedtype2diabeticpatientsandtheirassociationwithdifferentclinicalandbiochemicalriskfactors.UKPDS6.DiabetesRes1990;13:1-11.HarrisMI,KleinR,WelbornTA,KnuimanMW.OnsetofNIDDMoccursatleast4-7yrbeforeclinicaldiagnosis.DiabetesCare1992;15:815-19.UKPDSGroup.UKProspectiveDiabetesStudy30:Diabeticretinopathyatdiagnosisoftype2diabetesandassociatedriskfactors.ArchOphthalmol1998;116:297-303.提倡早期诊断早期诊断的意义；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.

Fordiagnosis,anoralglucosetolerancetest(OGTT)shouldbeperformedinpeoplewithafastingplasmaglucose≥5.6mmol/l(≥100mg/dl)and<7.0mmol/l(<126mg/dl);

Wherearandomplasmaglucoselevel≥5.6mmol/l(≥100mg/dl)and<11.1mmol/l(<200mg/dl)isdetectedonopportunisticscreening,itshouldberepeatedfasting,oranOGTTperformed.早期诊断早期诊断的方法----目前全球根据各地区约有30%-诊断标准:WHO-1999criteriaHealthOrganization.Definition,DiagnosisandClassificationofDiabetesMellitusanditsComplications.ReportofaWHOConsultation.Part1:DiagnosisandClassificationofDiabetesMellitus.Geneva:WHO诊断标准:WHO-1999criteriaHealthO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OGTT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）诊断标准的解释:控制指标水平血糖控制水平；HbA1c<6.5%Equivalenttargetlevelsforcapillaryplasmaglucoselevelsare<6.0mmol/l(<110mg/dl)beforemeals,and<8.0mmol/l(<145mg/dl)1-2haftermeals.血脂控制水平Reassessatallroutineclinicalcontactstoreviewachievementoflipidtargets:LDLcholesterol<2.5mmol/l(<95mg/dl),triglyceride<2.3mmol/l(<200mg/dl),HDLcholesterol>1.0mmol/l(>39mg/dl).血压控制水平Aimtomaintainbloodpressurebelow130/80mmHgAcceptthateven140/80mmHgmaynotbeachievablewith3to5antihypertensivedrugsinsomepeople.Reviseindividualtargetsupwardsifthereissigni.cantriskofposturalhypotensionandfalls.控制指标水平血糖控制水平；每年全面检测一次每年全面检测一次检测原则及目的Generalprinciplesinclude:

annualreviewofcontrolandcomplications;anagreedandcontinuallyupdateddiabetescareplan;andinvolvementofthemultidisciplinaryteamindeliveringthatplan,centredaroundthepersonwithdiabetes.检测原则及目的Generalprinciplesincl临床血糖监测方法HbA1cperformedevery2to6monthsdependingonlevelandstabilityofbloodglucosecontrol,andchangeintherapy.Site-of-carecapillaryplasmaglucosemonitoringatrandomtimesofdayisnotgenerallyrecommended.临床血糖监测方法HbA1cperformedevery自我血糖监测方法Self-monitoringofbloodglucose(SMBG)shouldbeavailabletothose;ForallnewlydiagnosedpeoplewithType2diabetes;thoseoninsulintreatment;toprovideinformationonhypoglycaemia;toassessglucoseexcursionsduetomedicationsandlifestylechangestomonitorchangesduringintercurrentillness.SMBG

canbeconsideredinrelationto:outcomes(adecreaseinHbA1cwiththeultimateaimofdecreasingriskofcomplications)safety(identifyinghypoglycaemia)process(education,self-empowerment,changesintherapy).自我血糖监测方法Self-monitoringofblo对尿糖监测的评价Urineglucosetestingischeapbuthaslimitations.Urinefreeofglucoseisanindicationthatthebloodglucoselevelisbelowtherenalthreshold,whichusuallycorrespondstoabloodglucoselevelofabout10.0mmol/l(180mg/dl).Positiveresultsdonotdistinguishbetweenmoderatelyandgrosslyelevatedlevels,andanegativeresultdoesnotdistinguishbetweennormoglycaemiaandhypoglycaemia.对尿糖监测的评价Urineglucosetesting4.治疗概论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：Encourageincreaseddurationandfrequencyofphysicalactivity(whereneeded),upto30-45minuteson3-5daysperweek,oranaccumulationof150minutesofphysicalactivityperweek.生活方式干预治疗目的：通过调整生活方式，如饮食、运动等更好地生活方式干预治疗利益Randomizedcontrolledtrialsandoutcomestudiesofmedicalnutritiontherapy(MNT)inthemanagementofType2diabeteshavereportedimprovedglycaemicoutcomes(HbA1cdecreasesof1.0-2.0%,dependingontherationofdiabetes).Inameta-analysisofnon-diabeticpeople,MNTrestrictingsaturatedfatsto7-10%ofdailyenergyanddietarycholesterolto200-300mgdailyresultedina10-13%decreaseintotalcholesterol,12-16%decreaseinLDLcholesteroland8%decreaseintriglycerides.Ameta-analysisofstudiesofnon-diabeticpeoplereportedthatreductionsinsodiumintaketo≤2.4g/daydecreasedbloodpressureby5/2mmHginhypertensivesubjects.beside,thatweightloss,increasedphysicalactivity,alow-fatdietthatincludesfruits,vegetablesandlow-fatdairyproducts,reducingbloodpressure.生活方式干预治疗利益Randomizedcontrolle生活方式干预治疗利益Ameta-analysisofexercise(aerobicandresistancetraining)reportedanHbA1creductionof0.66%,independentofchangesinbodyweight,inpeoplewithType2diabetes.Inlong-termprospectivecohortstudiesofpeoplewithType2diabetes,higherphysicalactivitylevelspredictedlowerlongtermmorbidityandmortalityandincreasesininsulinsensitivity.Interventionsincludedbothaerobicexercise(suchaswalking)andresistanceexercise(suchasweight-lifting).生活方式干预治疗利益Ameta-analysisofe口服药物治疗时机；

Pharmacologicaltherapyshouldbeconsideredifgoalsarenotachievedbetween3and6monthsafterinitiatingMNT.口服药物治疗时机；双胍类应用要点Beginwithmetforminunlessevidenceoriskofrenalimpairment,titratingthedoseoverearlyweekstominimizediscontinuationduetogastro-intestinalintolerance.Monitorrenalfunctionandriskofsigni.cantrenalimpairmenteGFR<60ml/min/1.73m2)inpeopletakingmetformin.Theoutcome-basedevidencefromtheUKPDSfortheuseofmetformininoverweightpeoplewithType2diabetes,exceedingthatforanyotherdrug,leadstoitsrecommendationfor.rst-lineuse,Lacticacidosisisararecomplication(oftenfatal)ofmetformintherapyinpeoplewithrenalimpairment.Gastro-intestinalintoleranceofthisdrugisverycommon,particularlyathigherdoselevelsandwithfastupwarddosetitration.双胍类应用要点Beginwithmetforminun磺脲类应用要点Usesulfonylureaswhenmetforminfailstocontrolglucoseconcentrationstotargetlevels,orasa.rst-lineoptioninthepersonwhoisnotoverweight.Provideeducationand,ifappropriate,self-monitoring(seeSelf-monitoring)toguardagainsttheconsequencesofhypoglycaemia.Once-dailysulfonylureasshouldbeanavailableoptionwheredrugconcordanceisproblematic.Somesulfonylureas,notablyglyburide,areknowntobeassociatedwithseverehypoglycaemiaandrarelydeathfromthis,againusuallyinassociationwithrenalimpairment.磺脲类应用要点Usesulfonylureaswhen快速促胰岛素分泌剂应用要点Rapid-actinginsulinsecretagoguesmaybeusefulasanalternativetosulfonylureasinsomeinsulin-sensitivepeoplewith.exiblelifestyles.快速促胰岛素分泌剂应用要点Rapid-actinginsu噻唑烷二酮类应用要点UseaPPAR-γagonist(thiazolidinedione)whenglucoseconcentrationsarenotcontrolledtotargetlevels,addingittometforminasanalternativetoasulfonylurea,ortoasulfonylureawheremetforminisnottolerated,ortothecombinationofmetforminandasulfonylurea.Bealerttothecontra-indicationofcardiacfailure,andwarnthepersonwithdiabetesofthepossibilityofdevelopmentofsigni.cantoedema.噻唑烷二酮类应用要点UseaPPAR-γagonist糖酐酶抑制剂类应用要点Useα-glucosidaseinhibitorsasafurtheroption.Theymayalsohavearoleinsomepeopleintolerantofothertherapies.Systematicreviewsoftheα-glucosidaseinhibitorshavenotfoundreasontorecommendthemoverlessexpensiveandbettertolerateddrugs.糖酐酶抑制剂类应用要点Useα-glucosidasei胰岛素治疗要点时机;

Begininsulintherapywhenoptimizedoralglucose-loweringdrugsandlifestyleinterventionsareunabletomaintainbloodglucosecontrolattargetlevels--------generallywhenDCCT-alignedHbA1chasdeterioratedto>7.5%(confirmed)onmaximaloralagents.可继续联用

metformin.Additionallycontinuesulfonylureaswhenstartingbasalinsulintherapy.α-Glucosidaseinhibitorsmayalsobecontinued..目标血糖：Aimforpre-breakfastandpre-main-evening-mealglucoselevelsof<6.0mmol/l(<110mg/dl);胰岛素治疗要点时机;胰岛素治疗要点三种模式;abasalinsulinoncedailysuchasinsulindetemir,insulinglargine,orNPHinsulin(riskofhypoglycaemiaishigherwiththelast),or.twicedailypremixinsulin(biphasicinsulin)particularlywithhigherHbA1c,or.multipledailyinjections(meal-timeandbasalinsulin)wherebloodglucosecontrolissub-optimalonotherregimens,ormeal-timeflexibilityisdesired.调节方法;Initiateinsulinusingaself-titrationregimen(doseincreasesof2unitsevery3days)orbyweeklyormorefrequentcontactwithahealth-careprofessional注射部位;abdominalarea(mostrapidabsorption)orthigh(slowest),withtheglutealarea(orthearm)asotherpossibleinjectionsites.胰岛素治疗要点三种模式;选择皮下注射部位选择皮下注射部位胰岛素治疗利益TheevidencefromUKPDSthatinsulinwasamongtheglucose-loweringtherapieswhich,consideredtogether,reducedvascularcomplicationscomparedwith‘conventional’therapy.IntensifiedinsulintherapyinType2diabeteshasbeenshowntoimprovemetaboliccontrol,improveclinicaloutcomes、andincreasefexibility.PumptherapyinType2diabetesispotentialoptioninhighlyselectedpatientsorinveryindividualsettings.胰岛素治疗利益TheevidencefromUKPDS全面控制心血管危险因素控制血压及降压药的选用ACE-inhibitorsandA2RBsmayoffersomeadvantagesoverotheragentsinsomesituations(seeKidneydamage,Cardiovascularriskprotection)startwithβ-adrenergicblockersinpeoplewithangina,β-adrenergicblockersorACE-inhibitorsinpeoplewithpreviousmyocardialinfarction,ACEinhibitorsordiureticsinthosewithheartfailure.careshouldbetakenwithcombinedthiazideandβ-adrenergicblockersbecauseofriskofdeteriorationinmetaboliccontrol.全面控制心血管危险因素控制血压及降压药的选用全面控制心血管危险因素降脂药的推荐使用astatinatstandarddoseforall>40yrold(orallwithdeclaredCVD).astatinatstandarddoseforall>20yroldwithmicroalbuminuriaorassessedasbeingatparticularlyhighrisk.inadditiontostatin,fenofibratewhereserumtriglyceridesare>2.3mmol/l(>200mg/dl),onceLDLcholesterolisasoptimallycontrolledaspossible.considerationofotherlipid-loweringdrugs(ezetimibe,sustainedreleasenicotinicacid,concentratedomega3fattyacids)inthosefailingtoreachlipidloweringtargetsorintolerantofconventionaldrugs.全面控制心血管危险因素降脂药的推荐使用全面控制心血管危险因素小剂量应用抗血小板药物Provideaspirin75-100mgdaily(unlessaspirinintolerantorbloodpressureuncontrolled)inpeoplewithevidenceofCVDorathighrisk.Arrangesmokingcessationadviceinsmokerscontemplativeofreducingorstoppingtobaccoconsumption.全面控制心血管危险因素小剂量应用抗血小板药物5.住院病人治疗原则5.住院病人治疗原则导致患者住院的因素Hospitalcareforpeoplewithdiabetesmayberequiredformetabolicemergencies,in-patientstabilizationofdiabetes,diabetesrelatedcomplications,intercurrentillnesses,Surgicalprocedures,andlabouranddelivery.Prevalenceofdiabetesinhospitalizedadultpatientsis12-25%ormore.导致患者住院的因素Hospitalcareforpeop住院治疗的重点Evaluatebloodglucosecontrol,andmetabolicandvascularcomplications(inparticularrenalandcardiacstatus)priortoplannedprocedures;provideadviceonthemanagementofdiabetesonthedayordayspriortotheprocedure.Ensuretheprovisionanduseofanagreedprotocolforin-patientproceduresandsurgicaloperations.Aimtomaintainnear-normoglycaemiawithouthypoglycaemiabyregularquality-as