糖尿病治疗中的餐后血糖控制NXPowerLite.ppt

糖尿病治疗中的餐后血糖控制心内科垂青 2 糖尿病及其并发症的流行病学特征A1C在糖尿病治疗达标中的意义餐后血糖与糖尿病大血管病变餐后血糖与糖尿病微血管病变餐后血糖参与并发症发生的机制 3 糖尿病流行情况 流行病学进行性增加 1985199420002025 百万 4 糖尿病慢性并发症的患病率 InType2patients 80 intype1patients InType2patients 30 intype1patients DecisionResourcereportondiabeticcomplications 50 50 35 25 5 GeissLS etal In DiabetesinAmerica 2nded 1995 Bethesda MD NIH 1995 0 10 20 30 40 50 ofDeaths IschemicHeartDisease OtherHeartDisease Diabetes Cancer Stroke Infection Other 糖尿病患者死亡原因分布 6 糖尿病慢性并发症的经济负担 ForthecountriesGermany Belgium France Italy Netherlands Spain Sweden andUKTangLingetal ChineseHealthEconomics 2003Vol22 12 21 23 7 糖尿病及其并发症的流行病学特征A1C在糖尿病治疗达标中的意义餐后血糖与糖尿病大血管病变餐后血糖与糖尿病微血管病变餐后血糖参与并发症发生的机制 8 DCCTResearchGroup NEnglJMed 1993 329 977 986 OhkuboY etal DiabetesResClinPract 1995 28 103 117 UKPDS33 Lancet1998 352 837 853 StrattonIMetal BMJ 2000 321 405 412 严格血糖控制降低糖尿病并发症的风险 A1cRetinopathyNephropathyNeuropathyCVdisease Type1DCCT19 7 63 54 60 41 Type2Kumamoto29 7 69 70 52 Type2UKPDS38 7 17 21 24 33 16 Notstatisticallysignificantduetosmallnumberofevents Showedstatisticalsignificanceinsubsequentepidemiologicanalysis4 9 A1C10 AdjustedincidenceofmicrovasculardiseaseandMI 1000person yearsbyupdateA1CconcentrationsinUKPDS StrattonIMetal BMJ 2000 321 405 412 10 StrattonIMetal BMJ 2000 321 405 412 11 AmericanDiabetesAssociation DiabetesCare2005 28 s1 S36 AmericanAssociationofClinicalEndocrinologists EndocrinePract2002 8 Suppl 1 40 82 EuropeanDiabetesPolicyGroup DiabetMed1999 16 716 730 IDFWPR2002 ChineseDiabetesPrevention TreatmentGuideline 血糖控制的临床目标 12 确定血糖达标的关键理念 A1C是血糖控制的首要目标目标应个体化儿童老人孕妇等人群需特别考虑低血糖好发或严重者达标放宽更严格的达标 6 0 可进一步降低并发症 但可能增加低血糖危险如餐前血糖达标而A1C未达标 需关注餐后血糖的达标 AmericanDiabetesAssociation DiabetesCare2005 28 s1 S36 13 A1C的重要意义 A1C 金标准 高血糖 A1C升高 并发症增多A1C是目前反映既往2 3个月血糖控制的最准确的指标 14 A1C的局限性 检验方法的差异个体的差异 糖化过程的影响红细胞代谢速度的影响不能反映血糖的波动 餐后高血糖低血糖A1C代谢动力学的影响 Day0 30 50 Day90 120 10 15 HbA1c水平与血浆葡萄糖的关系 IndiagnosedandundiagnoseddiabetesonlyfromNHANESIII 1988 1994 ADA ClinicalPracticeRecommendations DiabetesCare 2004 27 S15 S35 MeanMeanMeanHbA1cFPG2 HourPGHbA1cPlasmaGlucose 9278 15 4432 2410275 15 3 16 A1C的组成 17 A1C与餐后及空腹血糖的相关性 StudyDesign 66patientswithtype2DMenrolledPatientsweretreatedwithdietalone dietplusbiguanidesand orsulfonylureasGlycemicprofileswereobtainedon8 00AM prebreakfastPG 11 00AM prelunch 2 00PM postlunch 5 00PM extendedpostlunch AndA1CObjective toevaluatetherelativevalueofPGatdifferenttimepointsinassessingglucosecontroloftype2DM AvignonA DiabetesCare20 1822 26 1997 18 AvignonA DiabetesCare20 1822 26 1997 5004003002001005004003002001000 4567891011125678910111213 Pre breakfastPG mg dL Post lunchPG mg dL Pre lunchPG mg dL Extendedpost lunchPG mg dL y 17 0 x 29 1r 0 62 y 37 6x 112 6r 0 81 HbA1c y 27 5x 11 3 r 0 65 y 30 8x 90 3 r 0 78 A1C与餐后及空腹血糖的相关性 19 各点血糖谱与A1C的关系 AvignonA DiabetesCare20 1822 26 1997 20 结论 血糖控制良好时 A1C 7 0 血糖谱特征是延迟的餐后血糖低于餐前血糖 而血糖控制恶化时延迟的餐后血糖比餐前血糖升高更多与餐前血糖比较 餐后血糖与A1C的相关性更好 因为多元分析显示只有午餐后及延迟的餐后血糖与A1C值独立及显著相关空腹血糖 胰岛素敏感性 肝糖输出餐后血糖 胰岛素敏感性 肝糖输出 内源性胰岛素分泌 反映了病理生理过程的更全面的改善 AvignonA DiabetesCare20 1822 26 1997 21 MeanHbA1cisnotthemostcompleteexpressionofthedegreeofhyperglycemia Otherfeaturesofdiabeticcontrol whicharenotreflectedbyHbA1cmayaddtoormodifytheriskforcomplications Forexample theriskforcomplicationsmaybemorehighlydependentontheextentofpostprandialglycemicexcursions TheDCCTStudyGroup Diabetes44 968 83 1995 餐后高血糖的临床意义 22 糖尿病及其并发症的流行病学特征A1C在糖尿病治疗达标中的意义餐后血糖与糖尿病大血管病变餐后血糖与糖尿病微血管病变餐后血糖参与并发症发生的机制 23 餐后高血糖与并发症相关的证据 大血管并发症 DECODEStudyDiabetesInterventionStudyHonoluluHeartProgramChicagoHeartStudyWhiteHallStudyHelsinkiPolicemansStudyNursesHealthStudy 24 TheDECODEStudy MortalityandPost ChallengeGlucose Datafrom13prospectiveEuropeancohortstudiesIncludedover25 000personswithandwithoutdiabeteswithameanfollowupof7 3yearsEachsubjectevaluatedatbaselinewithafastinganda2 hpost challenge 75gm glucoselevelRiskofdeathwasassessedaccordingtoglucosecategoriesThehazardratio adjustedforageandgender wasdeterminedforall causemortalitybyfastingand2 hglucoseclassification DECODEStudyGroup Lancet1999 354 617 621 StudyDesign 25 Hazardratio FastingPlasmaGlucose mM 0 1 2 6 1 6 1 6 9 7 0 7 8 7 8 11 0 11 1 DECODEStudy RelativeRiskofMortalityIncreasedwithIncreasing2 HrGlucoseLevel DECODEStudyGroup Lancet1999 354 617 621 26 Conclusions 死亡率增加与糖负荷后2小时血糖显著相关而与空腹血糖水平无关因此糖负荷后2小时血糖是预测高血糖相关死亡率的最重要指标 DECODEStudyGroup Lancet1999 354 617 621 27 TheDiabetesInterventionStudy PostprandialGlucoseAssociatedwithIncreasedMortality Prospective population based multicentertrialOver1 000patientswithnewlydiagnosedtype2diabetes ages30to55years AssessedriskfactorsatbaselineforsubsequentcoronaryheartdiseaseandmortalityInan11 yearfollow up HanefeldM Diabetologia1996 39 1577 1583 StudyDesign 28 10 0mmol L 10 0mmol L PostprandialGlucose P 0 05 0 100 200 300 Rateper1 000 7 8mmol L 7 8mmol L FastingGlucose P NS DiabetesInterventionStudy Postprandial notFastingGlucose AssociatedwithIncreasedAll CauseMortality MIandMortalityrateper1 000 HanefeldM Diabetologia1996 39 1577 1583 29 Conclusion 2型糖尿病患者死亡率是同年龄总体人群死亡率的5 1 7 0倍多元回归分析显示餐后血糖是2型糖尿病患者死亡的独立危险因素餐后血糖而非空腹血糖是预测2型糖尿病患者发生心梗和死亡的重要指标在糖尿病发病早期严格控制餐后血糖对降低大血管并发症和所有原因导致的死亡率有非常重要的意义 HanefeldM Diabetologia1996 39 1577 1583 30 StudyDesign 8 006menofJapaneseancestry ages45to70years 6 394menwithoutDiabetesincludedinanalysisoftherelationshipof1hpostchallengeglucosewithCVDVitalstatusfollowedfor12years Donahue etal Diabetes 1987 36 689 HonoluluHeartProgram 31 Donahue etal Diabetes 1987 36 689 p valuescompare5thquintilewith1stquintile HonoluluHeartProgram RiskofFatalCHD NonfatalMIIncreasesWithIncreasingPost ChallengeGlucoseLevels 32 Conclusions 发生致死性冠心病或致死性冠心病 非致死性心梗的风险随糖负荷后1小时血糖水平的升高而持续增加最高血糖组CHD发生率是最低血糖组的3倍糖负荷后1小时血糖水平是CHD发生的独立而持续的风险因素 Donahue etal Diabetes 1987 36 689 33 ChicagoHeartStudy StudyDesign Lowe etal DiabetesCare 1997 20 163 34 Lowe etal DiabetesCare 1997 20 163 ChicagoHeartStudy RiskofCVDandAll CauseMortalityIncreasesWithIncreasingBloodGlucoseValues Post GlucoseChallengeorDiagnosedDiabetes 35 无论白种或黑种中年男性 无症状性高血糖和临床糖尿病者死亡风险均显著增加 RR1 24 RR1 88 死亡风险的增加与高血糖的程度密切相关提示控制血糖对降低糖尿病死亡风险非常重要 Conclusions Lowe etal DiabetesCare 1997 20 163 36 糖尿病及其并发症的流行病学特征A1C在糖尿病治疗达标中的意义餐后血糖与糖尿病大血管病变餐后血糖与糖尿病微血管病变餐后血糖参与并发症发生的机制 37 微血管并发症 KumamotoStudyGestationalDiabetesPimaIndiansEgyptiansNHANESIII 餐后高血糖与并发症相关的证据 38 TheKumamotoStudy PostprandialBloodGlucoseandMicrovascularComplications Prospective randomized 6 yearparallelgroupstudy110Japanesepatientswithtype2diabeteswithoutretinopathyornephropathyatbaseline orwithsimpleretinopathyandurinaryalbuminexcretion 300mg 24hPatientsrandomizedtoConventionalinsulininjectiontreatment 1or2dailyinjectionsofintermediate actinginsulinMultipleinsulininjectiontreatment short actinginsulinatmeals intermediate actinginsulinatbedtime OhkuboYetal Diabe