型糖尿病全球防治指南新特点.ppt

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,StandardCare,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。,P.Zimmetetal.BulletinoftheInternationalDiabetesFederation48:13,2003,AmuchquotedpaperbyHaffneretal,suggestedthatpeoplewithType2diabeteshaveaCVriskequivalenttonon-diabeticpeoplewithpreviousCVD。HaffnerSM,LehtoS,R鰊nemaaT,PyoralaK,LaaksoM.Mortalityfromcoronaryheartdiseaseinsubjectswithtype2diabetesandinnondiabeticsubjectswithandwithoutpriormyocardialinfarction.NEnglJMed1998;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.,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)shouldbeperformedinpeoplewithafastingplasmaglucose5.6mmol/l(100mg/dl)and7.0mmol/l(126mg/dl);Wherearandomplasmaglucoselevel5.6mmol/l(100mg/dl)and11.1mmol/l(39mg/dl).血压控制水平Aimtomaintainbloodpressurebelow130/80mmHgAcceptthateven140/80mmHgmaynotbeachievablewith3to5antihypertensivedrugsinsomepeople.Reviseindividualtargetsupwardsifthereissigni.cantriskofposturalhypotensionandfalls.,每年全面检测一次,检测原则及目的,Generalprinciplesinclude:annualreviewofcontrolandcomplications;anagreedandcontinuallyupdateddiabetescareplan;andinvolvementofthemultidisciplinaryteamindeliveringthatplan,centredaroundthepersonwithdiabetes.,临床血糖监测方法,HbA1cperformedevery2to6monthsdependingonlevelandstabilityofbloodglucosecontrol,andchangeintherapy.Site-of-carecapillaryplasmaglucosemonitoringatrandomtimesofdayisnotgenerallyrecommended.,自我血糖监测方法,Self-monitoringofbloodglucose(SMBG)shouldbeavailabletothose;ForallnewlydiagnosedpeoplewithType2diabetes;thoseoninsulintreatment;toprovideinformationonhypoglycaemia;toassessglucoseexcursionsduetomedicationsandlifestylechangestomonitorchangesduringintercurrentillness.SMBGcanbeconsideredinrelationto:outcomes(adecreaseinHbA1cwiththeultimateaimofdecreasingriskofcomplications)safety(identifyinghypoglycaemia)process(education,self-empowerment,changesintherapy).,对尿糖监测的评价,Urineglucosetestingischeapbuthaslimitations.Urinefreeofglucoseisanindicationthatthebloodglucoselevelisbelowtherenalthreshold,whichusuallycorrespondstoabloodglucoselevelofabout10.0mmol/l(180mg/dl).Positiveresultsdonotdistinguishbetweenmoderatelyandgrosslyelevatedlevels,andanegativeresultdoesnotdistinguishbetweennormoglycaemiaandhypoglycaemia.,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-diabeticpeoplereportedthatreductionsinsodiumintaketo2.4g/daydecreasedbloodpressureby5/2mmHginhypertensivesubjects.beside,thatweightloss,increasedphysicalactivity,alow-fatdietthatincludesfruits,vegetablesandlow-fatdairyproducts,reducingbloodpressure.,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).,口服药物治疗,时机；Pharmacologicaltherapyshouldbeconsideredifgoalsarenotachievedbetween3and6monthsafterinitiatingMNT.,双胍类应用要点,Beginwithmetforminunlessevidenceoriskofrenalimpairment,titratingthedoseoverearlyweekstominimizediscontinuationduetogastro-intestinalintolerance.Monitorrenalfunctionandriskofsigni.cantrenalimpairmenteGFR7.5%(confirmed)onmaximaloralagents.可继续联用metformin.Additionallycontinuesulfonylureaswhenstartingbasalinsulintherapy.-Glucosidaseinhibitorsmayalsobecontinued.目标血糖：Aimforpre-breakfastandpre-main-evening-mealglucoselevelsof20yroldwithmicroalbuminuriaorassessedasbeingatparticularlyhighrisk.inadditiontostatin,fenobratewhereserumtriglyceridesare2.3mmol/l(200mg/dl),onceLDLcholesterolisasoptimallycontrolledaspossible.considerationofotherlipid-loweringdrugs(ezetimibe,sustainedreleasenicotinicacid,concentratedomega3fattyacids)inthosefailingtoreachlipidloweringtargetsorintolerantofconventionaldrugs.,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.,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.,住院治疗的重点,Evaluatebloodglucosecontrol,andmetabolicandvascularcomplications(inparticularrenalandcardiacstatus)priortoplannedprocedures;provideadviceonthemanagementofdiabetesonthedayordayspriortotheprocedure.Ensuretheprovisionanduseofanagreedprotocolforin-patientproceduresandsurgicaloperations.Aimtomaintainnear-normoglycaemiawithouthypoglycaemiabyregularquality-assuredbloodglucosetestingandintravenousinsulindeliverywhereneeded,generallyusingaglucose/insulin/potassiuminfusion.,住院治疗的重点,Ensureawarenessofspecialriskstope