中山附設醫院 內科部 新陳代謝科 楊宜瑱醫師 糖尿病臨床照護指引 • 流行病學 • 診斷 • 病理生理學 • 篩檢與預防 • 治療: 目標, 糖尿病治療原則 ,糖尿病藥物 • 急性併發症 • 低血糖 • 體重管理
治療目標
• 1. Glycemic control
• 2. minimize microvascular complications
• 3. minimize macrovascular complications and
treatment of CVD risk factor
19
treatment of CVD risk factor
治療目標
• 1. Glycemic control
• 2. minimize microvascular complications
• 3. minimize macrovascular complications and
treatment of CVD risk factor
20
treatment of CVD risk factor
治療目標
• 1. Glycemic control
• 2. minimize microvascular complications
• 3. minimize macrovascular complications and
treatment of CVD risk factor
22
treatment of CVD risk factor
Diabetic
Retinopathy
Leading cause
of blindness
in adults1,2
Cardiovascular
Stroke
2- to 4-fold increase in cardiovascular mortality and stroke5
Type 2 diabetes is associated with serious
complications
in adults1,2
Diabetic
Nephropathy
Leading cause of
end-stage renal disease3,4
Cardiovascular
Disease
Diabetic
Neuropathy
Leading cause of
non-traumatic lower
extremity amputations7,8
8/10 individuals with
diabetes die from CV
events6
1UK Prospective Diabetes Study Group. Diabetes Res 1990; 13:1–11. 2Fong DS, et al. Diabetes Care 2003; 26 (Suppl. 1):S99–S102. 3The Hypertension in Diabetes Study Group. J
Hypertens 1993; 11:309–317. 4Molitch ME, et al. Diabetes Care 2003; 26 (Suppl. 1):S94–S98. 5Kannel WB, et al. Am Heart J 1990; 120:672–676.6Gray RP & Yudkin JS. Cardiovascular disease in diabetes mellitus. In Textbook of Diabetes 2nd Edition, 1997. Blackwell Sciences. 7King’s Fund. Counting the cost. The real impact of
non-insulin dependent diabetes. London: British Diabetic Association, 1996. 8Mayfield JA, et al. Diabetes Care 2003; 26 (Suppl. 1):S78–S79.
每下降每下降每下降每下降 1% HbA1c風險降低風險降低風險降低風險降低(P<0.0001)
Diabetes-
related
deaths
UKPDS: 改善HbA1c控制可減少糖尿病相關併發症發生
120
140
160
Any diabetes endpoint
Microvascular endpoint
Myocardial infarcation
Ad
just
ed
in
cid
en
ce
pe
r 1
00
0 p
ers
on
ye
ars
(%
)
N=4585
Incidence of Complications Relative Risk
N=3642
Type 2
1%
Myocardial
infarctions
Microvascular
complications
Amputations or
deaths from
peripheral vascular
disorders
0
20
40
60
80
100
5 6 7 8 9 10 11
Data adjusted for age, sex, and ethnic group, expressed for white men aged 50–54 years at diagnosis and with mean duration of diabetes of 10 years.
Adapted with permission from Stratton IM et al. UKPDS 35. BMJ 2000;321:405–412.
Ad
just
ed
in
cid
en
ce
pe
r 1
00
0 p
ers
on
ye
ars
(%
)
Mean HbA1c (%)
Type 1
治療目標
• 1. Glycemic control
• 2. minimize microvascular complications
• 3. minimize macrovascular complications and
treatment of CVD risk factor
26
treatment of CVD risk factor
ADA
A1C
FPG
PPG
< 7.0 %
70-130 mg/dl
<180 mg/dl
Recommendations for Adults with Diabetes
28
BP < 130/80 mmHg
LDL-C
HDL-C
TG
< 100 mg/dl
> 40 mg/dl
< 150 mg/dl
Diabetes Care 2006; 29(s1): S4-S42.2006 Type 2 DM practice guideline
口服抗糖尿病藥物(Oral antidiabetic agents,OAD)
•磺醯尿素類磺醯尿素類磺醯尿素類磺醯尿素類((((Sulfonylureas))))
• Meglitinide異構物類異構物類異構物類異構物類((((glinides))))– 安息香酸類安息香酸類安息香酸類安息香酸類((((Benzoic acid))))衍生物衍生物衍生物衍生物::::repaglinide
– D-苯基丙氨酸類苯基丙氨酸類苯基丙氨酸類苯基丙氨酸類((((D-phenylalanine))))衍生物衍生物衍生物衍生物::::nateglinide
•解苷酶雙胍類解苷酶雙胍類解苷酶雙胍類解苷酶雙胍類((((Biguanide):):):):metformin
36
•解苷酶雙胍類解苷酶雙胍類解苷酶雙胍類解苷酶雙胍類((((Biguanide):):):):metformin
• Thiazolidinediones類類類類((((glitazones):):):):pioglitazone
• αααα-葡萄糖抑制劑類葡萄糖抑制劑類葡萄糖抑制劑類葡萄糖抑制劑類(αααα-glucosidase inhibitors):):):):acarbose
• Incretin hormone (DPP-4 inhibitor)
39
Pla
sma
insu
lin le
vels NPH
Regular
Aspart, Lispro, Glulisine
Profiles Human Insulin and Insulin Analogs
Basal Insulin
Prandial Insulin
0 2 4 6 8 10 12 14 16 18 20 22 24
Pla
sma
insu
lin le
vels
Hours
Glargine
Detemir
糖尿病臨床照護指引
• 流行病學• 診斷• 病理生理學• 篩檢與預防• 治療: 目標,糖尿病治療原則 ,糖尿病藥物
• 急性併發症• 低血糖• 體重管理
糖尿病酮酸血症糖尿病酮酸血症糖尿病酮酸血症糖尿病酮酸血症 Diabetic ketoacidosis (DKA)高滲透壓高血糖症高滲透壓高血糖症高滲透壓高血糖症高滲透壓高血糖症Hyperosmolar hyperglycemic state
(HHS)
• 基本的原理– 胰島素釋放減少– 使血糖升高的的激素 (counterregulatory hormones) 增多
• Glucagon 升糖素
• Catecholamines 腎上腺素及正腎上腺素
• Cortisol 腎上腺皮質素
• Growth hormone 生長激素
• 機制– 增加肝臟及腎臟產生葡萄糖– 減少週邊組織利用葡萄糖的能力
促使因子
• 感染﹕最常見• 腦中風• 心肌梗塞• 酗酒• 胰臟炎• 外傷• 壓力• 壓力• 初診斷• 精神方面疾病﹕如飲食過多• 不規則用藥• 藥物引起
– 類固醇 Corticosteroids– 利尿劑 Diuretics– 交感神經興奮劑 Sympathomimetic agents
診斷-病史及理學檢查
• DKA and HHS–三多 (吃多、喝多、尿多) 及體重減少–脫水﹕心跳加速、低血壓及皮膚乾
• In DKA• In DKA–噁心、嘔吐及腹痛–呼吸急速、喘
• In HHS–意識變差
診斷標準
• DKA: – 血糖 >250 mg/dl
– 動脈血 pH < 7.3 or bicarbonate < 15 mEq/l
– 有 ketonuira, ketonemia– 有 ketonuira, ketonemia
• HHS– 血糖 > 600 mg/dl
– 動脈血 pH >7.3 and bicarbonate > 15 mEq/l
– effective serum osmolality >320 mOsm/kg/H2O
治療原則
• 處理及矯正– 脫水 dehydration– 高血糖 hyperglycemia– 電解質不平衡 electrolyte imbalances
•• 監控及追蹤– 脫水 dehydration– 高血糖 hyperglycemia– 電解質不平衡 electrolyte imbalances
• 確定造成的促使因子