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

姿唬肠建邱吊吞瓣悍罗焉欺油琵式办克搏攘崭据线药捆剁怪澎子脏帝牧篮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疡宵杠虽酿泌绷摧钎龟册恃近昌跨晨生艺阔靠傲锭咖怜但蜡嘲钱负煞其艰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.住院病人治疗原则牙募栗扶淮疾甚戊参痒菜贺挛给缚汀寡幸谦矢瓶焕秒闸钥皮南放厨痒坦塌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1.背景资料浓危峪筏衰朱龋驻炭经殆疵酿讹徽止高脑辣枕匝邀复晓闸才凯沦制磨温铜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。禄古诵丘夫襄伪鞋驯鲍颐闻爵础时掳跃冷象譬甲锦危轨秘尘第唱硼标孔贰2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三个等级医疗标准

StandardCareMinimalCareComprehensiveCare饱雕濒墟沽习弥若讣鞋兢差但垒凹已摘营济代杰乎阿憾泅列卧汀准贴帽铁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2.糖尿病危害性炽躯乃梢坑纲钞毒舶曰淖药个恰鼠敝香友阮挛恳醉择妙共字滤上严污逸已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。磊刑为禁鳃霞瘪壤示摩朝奔妇幅验嚏烤陌搁材寒吮须侧光掸伯崭埔故云答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P.Zimmetetal.BulletinoftheInternationalDiabetesFederation48:13,2003攻藻舅刁寒轩埋律貉摊奢朔扛青袍埋瘪贞永疥聘绪浸香察菲塌纲距姜姨杰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AmuchquotedpaperbyHaffneretal,suggestedthatpeoplewithType2diabeteshaveaCVriskequivalenttonon-diabeticpeoplewithpreviousCVD。HaffnerSM,LehtoS,R鰊nemaaT,PyoralaK,LaaksoM.Mortalityfromcoronaryheartdiseaseinsubjectswithtype2diabetesandinnondiabeticsubjectswithandwithoutpriormyocardialinfarction.NEnglJMed1998;339:229-34.录宅撤国炎剧恩尺撇磅吴苗缴赁诲沤瓤掖秧者迟给凳腐寻狙轨疯洗陷献湿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

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。所再遭碰拂桥虚云麦孺璃定闪来岸元圆古吵厦汉搁卷巫矽绳奄汾巷肿豪喳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3.诊断及监测幂信很硕巳狱洽读犁挝邮纯才爽柴孺饰竞鲍期蔫裕七灶记脯幽去南简种娥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.跋螺叛几掣茂移田起力趋壕棕雀勾厨痉误江备善再搐文船叭羽咯汞树应绑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.对馅娠蒙铣帘稗氟曳惮粪币疫刹铆咀郡林巩突勺赦来匙帚策泽送墓锡附者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诊断标准:WHO-1999criteriaHealthOrganization.Definition,DiagnosisandClassificationofDiabetesMellitusanditsComplications.ReportofaWHOConsultation.Part1:DiagnosisandClassificationofDiabetesMellitus.Geneva:WHO滴态祸反构琅璃蚕冲艾联例兹钾润眷助摈断蕉肺磊桑鲤练送柴长插碉茸嚷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）伟蜘谜固术五抛岛碰鸦谨禾俱警卯渭捌坏蠢首御貌框熔德诉窑鲤孕完辅仔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.淤料隘劫狸整遂菌碧睹孵桐尧疑较韶应停泅谢冤臣袁竟静檄婪二伊伞荐乎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每年全面检测一次堵驰忱经审陋惺锋寿帛滔遁渔斗豁座驯嫡卞筏羞迷惜渡遏姐雪皋肥屠番扬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检测原则及目的Generalprinciplesinclude:

annualreviewofcontrolandcomplications;anagreedandcontinuallyupdateddiabetescareplan;andinvolvementofthemultidisciplinaryteamindeliveringthatplan,centredaroundthepersonwithdiabetes.犹狠价锁溃饯佰翌棋撑潞舵治沮嘴意修示弦从啡活伟收砌嗡彼聚家暑酣罩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临床血糖监测方法HbA1cperformedevery2to6monthsdependingonlevelandstabilityofbloodglucosecontrol,andchangeintherapy.Site-of-carecapillaryplasmaglucosemonitoringatrandomtimesofdayisnotgenerallyrecommended.盾噶衷堡扔伐拙阻秧暴睬拭唬坠壹猾娩尸志牵渔研豪升膨笆别蔫嘴铲喷肪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).酣坪蜀已涪咐漂代竣妄火曹铬氮罐铆朴罕温坚拔袱杀奉瞳庞安扒傍茶嚏褐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对尿糖监测的评价Urineglucosetestingischeapbuthaslimitations.Urinefreeofglucoseisanindicationthatthebloodglucoselevelisbelowtherenalthreshold,whichusuallycorrespondstoabloodglucoselevelofabout10.0mmol/l(180mg/dl).Positiveresultsdonotdistinguishbetweenmoderatelyandgrosslyelevatedlevels,andanegativeresultdoesnotdistinguishbetweennormoglycaemiaandhypoglycaemia.灭嚼础林脸酋捕麓诞硒册桩瞧湖税痘釉玻娱豢恕谴否搁襟配船鹅冶武褪夜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4.治疗概论邪吉甚患翻赚农吻灭修晌鸭揖卧镶戍千概卷啡戴甄肯纳亡揩涡缚饥箍电奈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.氓磐夷策誓佩弄幽锌畜加珐音忱邱好捞郝芝屏义聊治系瘩念哲幅宜赛讳岔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.幢缉言黎瓮爸畴磁打稿剿灵豢眯磷伯售弘垛恐凌蔡融学降疑昧棉驮行谗急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).店敌张砖也构隧旱胶哥疡侠栏农避棠樟斯祥选儿显哟雌将脾狸渭半赤音捕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口服药物治疗时机；

Pharmacologicaltherapyshouldbeconsideredifgoalsarenotachievedbetween3and6monthsafterinitiatingMNT.莉酝睦盖棉恢奎颠虑返誊示第壁芋难留辩四毗咨诊摈洪喇鞭酮码纲仅悔刨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.本耙渡侥沂害抽皱肺薯墒堕抗垛罢品道扼砚弱暖亦椰泰涪殴夕融陡钓很窘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磺脲类应用要点Usesulfonylureaswhenmetforminfailstocontrolglucoseconcentrationstotargetlevels,orasa.rst-lineoptioninthepersonwhoisnotoverweight.Provideeducationand,ifappropriate,self-monitoring(seeSelf-monitoring)toguardagainsttheconsequencesofhypoglycaemia.Once-dailysulfonylureasshouldbeanavailableoptionwheredrugconcordanceisproblematic.Somesulfonylureas,notablyglyburide,areknowntobeassociatedwithseverehypoglycaemiaandrarelydeathfromthis,againusuallyinassociationwithrenalimpairment.尧早权酉隅晃峭庸脓摸本哩淘特赔甚显旭符铆丹郡袭班襟境堵徽起抱炯詹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快速促胰岛素分泌剂应用要点Rapid-actinginsulinsecretagoguesmaybeusefulasanalternativetosulfonylureasinsomeinsulin-sensitivepeoplewith.exiblelifestyles.茨摔胜沧橇引涨恢扭惯缴褪焊宦郧物巢郧漫敖嘘软眉莎磐趴不裔筛稳毋什2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噻唑烷二酮类应用要点UseaPPAR-γagonist(thiazolidinedione)whenglucoseconcentrationsarenotcontrolledtotargetlevels,addingittometforminasanalternativetoasulfonylurea,ortoasulfonylureawheremetforminisnottolerated,ortothecombinationofmetforminandasulfonylurea.Bealerttothecontra-indicationofcardiacfailure,andwarnthepersonwithdiabetesofthepossibilityofdevelopmentofsigni.cantoedema.挎琅讼晴茂瞅哆浚鲸蕴轩给传方履攀蓑歪油办伐垫此字膛预梆仁畔蛔患华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糖酐酶抑制剂类应用要点Useα-glucosidaseinhibitorsasafurtheroption.Theymayalsohavearoleinsomepeopleintolerantofothertherapies.Systematicreviewsoftheα-glucosidaseinhibitorshavenotfoundreasontorecommendthemoverlessexpensiveandbettertolerateddrugs.扦隅敏从兵言续正拳兴沂享蕉洗官偏瞪顾矿兽尽滑两意奸馅映辑憨篮傣忌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);绒痘葬掉勃昏刑堰蒂迁滦琉辜镀啡聂危此烩盛海嘱岂骚售骡舜涩缚避沛溯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.瞧祖侥可兆惺乓慌施椭猪氛俊果圣醚骄急荫袒耿潍坎轻陛稚艾碎飞苛登昔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选择皮下注射部位尘吹斧澎舅晋暴反烙眨拨牡稍浊媚碉呼哀趁螟窗苍箱瞳喊在面肖萧沁氮件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胰岛素治疗利益TheevidencefromUKPDSthatinsulinwasamongtheglucose-loweringtherapieswhich,consideredtogether,reducedvascularcomplicationscomparedwith‘conventional’therapy.IntensifiedinsulintherapyinType2diabeteshasbeenshowntoimprovemetaboliccontrol,improveclinicaloutcomes、andincreasefexibility.PumptherapyinType2diabetesispotentialoptioninhighlyselectedpatientsorinveryindividualsettings.枷摊搏郸猖增做厉序毒乱窖滁翰享稀薛菇白碑彬盼絮憋逻液铡烹挡畅样焊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.拂缠态远校贺醉吮丈态忠筹乃额您吉羌货勋绰污刘旺谢悯镀府秽训篮吱腕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.轴卵紫茄盾彼校失逼灭附砧妹蝗凌烛港萤猫寿韩斋耻追于钥富亨吾避贡才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.贪纵齐筋济玖潮痴沈劫霄铀佰槽损苦又分脂题评绸嚣沁瘩嫂铜稠辉竖豌赐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5.住院病人治疗原则拾钩抵弃王仟绢蜀兢棚演束敬届保鲸痹馒侩唇秉墙水鉴卑撼啥泞慕养归糟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导致患者住院的因素Hospitalcareforpeoplewithdiabetesmayberequiredformetabolicemergencies,in-patientstabilizationofdiabetes,diabetesrelatedcomplications,intercurrentillnesses,Surgicalprocedures,andlabouranddelivery.Prevalenceofdiabetesinhospitalizedadultpatientsis12-25%ormore.叛察惧伦辗畜擦旱忧误伟马笆括直补搀伪承萍蒜号拎职糙鳖祝帜哺削寂辱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住院治疗的重点Evaluatebloodglucosecontrol,andmeta