Global Guideline for Type 2 Diabetes 2型糖尿病全球防治指南新特點 ntsGlobal Guideline for Type 2 Diabetes ntsGlobal Guideline for Type 2 Diabetes 內(nèi)容概括 1.背景資料 2.糖尿病危害性 3.診斷及監(jiān)測 4.治療概論 5.住院病人治療原則 ntsGlobal Guideline for Type 2 Diabetes 1.背景資料 ntsGlobal Guideline for Type 2 Diabetes 1. 根據(jù)循證醫(yī)學(xué)原則制定 ,內(nèi)容參考近 5年來國際上出版的指南、 meta分析、及相關(guān)刊物。 2. 根據(jù)不同地區(qū)、不同醫(yī)療資源制定 3個等級標(biāo)準(zhǔn)。 ntsGlobal Guideline for Type 2 Diabetes 三個等級醫(yī)療標(biāo)準(zhǔn) Standard Care Minimal Care Comprehensive Care ntsGlobal Guideline for Type 2 Diabetes 2.糖尿病危害性 ntsGlobal Guideline for Type 2 Diabetes 1. 發(fā)病人數(shù)日益增長。 無論是在發(fā)達國家還是在發(fā)展中國家，均明顯增加。其中 90%為 2型糖尿病 。（見下圖） 2. 發(fā)展中國家增長的速度超過了發(fā)達國家。（ 200%比45%）， 21世紀(jì) DM 將在中國、印度等發(fā)展中國家流行 。 3. DM 的主要并發(fā)癥已經(jīng)成為病人致殘和早亡的主要原因， 每年全球約 3 000 000 人口因糖尿病而死亡。 4. 2型糖尿病占我國糖尿病人群的 90%以上，它的血管并發(fā)癥使人們喪失勞動能力 ,預(yù)期壽命縮短 8-12年。 ntsGlobal Guideline for Type 2 Diabetes P.Zimmet et al.Bulletin of the International Diabetes Federation 48:13,2003 ntsGlobal Guideline for Type 2 Diabetes A much quoted paper by Haffner et al, suggested that people with Type 2 diabetes have a CV risk equivalent to non-diabetic people with previous CVD。 Haffner SM, Lehto S, R鰊 nemaa T, Pyorala K, Laakso M.Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction. N Engl J Med 1998; 339: 229-34. ntsGlobal Guideline for Type 2 Diabetes 糖尿病急性并發(fā)癥及大血管和微血管等慢性并發(fā)癥，致死、致殘率高，一旦發(fā)生，難以逆轉(zhuǎn)，降低病人的生活質(zhì)量，縮短壽命。 ntsGlobal Guideline for Type 2 Diabetes 3. 診斷及監(jiān)測 ntsGlobal Guideline for Type 2 Diabetes 提倡早期診斷 早期診斷的意義； Type 2 diabetes has a long asymptomatic pre-clinical phase which frequently goes undetected. At the time of diagnosis, over half have one or more diabetes complications. Retinopathy rates at the time of diagnosis range from 20 % to 40 %. Of people with Type 2 diabetes, the proportion who are undiagnosed ranges from 30 % to 90 %. SM, Meyer LC, Neil HAW, Ross IS, Turner RC,Holman RR. Complications in newly diagnosed type 2 diabetic patients and their association with different clinical and biochemical risk factors. UKPDS 6. Diabetes Res 1990; 13: 1-11. Harris MI, Klein R, Welborn TA, Knuiman MW. Onset of NIDDM occurs at least 4-7 yr before clinical diagnosis.Diabetes Care 1992; 15: 815-19. UKPDS Group. UK Prospective Diabetes Study 30: Diabetic retinopathy at diagnosis of type 2 diabetes and associated risk factors. Arch Ophthalmol 1998; 116: 297-303. ntsGlobal Guideline for Type 2 Diabetes 早期診斷 早期診斷的方法 -目前全球根據(jù)各地區(qū)約有 30%-90%糖尿病漏診率 . For diagnosis, an oral glucose tolerance test (OGTT) should be performed in people with a fasting plasma glucose 5.6 mmol/l (100 mg/dl) and 1.0 mmol/l (39 mg/dl). 血壓控制水平 Aim to maintain blood pressure below 130/80 mmHg Accept that even 140/80 mmHg may not be achievable with 3 to 5 antihypertensive drugs in some people. Revise individual targets upwards if there is signi. cant risk of postural hypotension and falls. ntsGlobal Guideline for Type 2 Diabetes 每年全面檢測一次 ntsGlobal Guideline for Type 2 Diabetes 檢測原則及目的 General principles include: annual review of control and complications; an agreed and continually updated diabetes care plan; and involvement of the multidisciplinary team in delivering that plan, centred around the person with diabetes. ntsGlobal Guideline for Type 2 Diabetes 臨床血糖監(jiān)測方法 HbA1c performed every 2 to 6 months depending on level and stability of blood glucose control,and change in therapy. Site-of-care capillary plasma glucose monitoring at random times of day is not generally recommended. ntsGlobal Guideline for Type 2 Diabetes 自我血糖監(jiān)測方法 Self-monitoring of blood glucose (SMBG) should be available to those; For all newly diagnosed people with Type 2 diabetes; those on insulin treatment; to provide information on hypoglycaemia; to assess glucose excursions due to medications and lifestyle changes to monitor changes during intercurrent illness. SMBG can be considered in relation to: outcomes (a decrease in HbA1c with the ultimate aim of decreasing risk of complications) safety (identifying hypoglycaemia) process (education, self-empowerment, changes in therapy). ntsGlobal Guideline for Type 2 Diabetes 對尿糖監(jiān)測的評價 Urine glucose testing is cheap but has limitations. Urine free of glucose is an indication that the blood glucose level is below the renal threshold, which usually corresponds to a blood glucose level of about 10.0 mmol/l (180 mg/dl). Positive results do not distinguish between moderately and grossly elevated levels, and a negative result does not distinguish between normoglycaemia and hypoglycaemia. ntsGlobal Guideline for Type 2 Diabetes 4.治療概論 ntsGlobal Guideline for Type 2 Diabetes 生活方式干預(yù)治療 目的： 通過調(diào)整生活方式，如飲食、運動等更好地控制血糖、血壓、血脂等危險因素。 關(guān)于飲食； 專家指導(dǎo)下制定個體營養(yǎng)需求方案 ; 嚴(yán)格限制高熱量、高脂食物、食鹽及酒精等； 根據(jù)降糖藥（口服藥及胰島素）及運動量調(diào)整飲食量。 關(guān)于運動： Encourage increased duration and frequency of physical activity (where needed), up to 30-45 minutes on 3-5 days per week, or an accumulation of 150 minutes of physical activity per week. ntsGlobal Guideline for Type 2 Diabetes 生活方式干預(yù)治療利益 Randomized controlled trials and outcome studies of medical nutrition therapy (MNT) in the management of Type 2 diabetes have reported improved glycaemic outcomes (HbA1c decreases of 1.0-2.0 %, depending on the ration of diabetes). In a meta-analysis of non-diabetic people, MNT restricting saturated fats to 7-10 % of daily energy and dietary cholesterol to 200-300 mg daily resulted in a 10-13 % decrease in total cholesterol, 12-16 % decrease in LDL cholesterol and 8 % decrease in triglycerides. A meta-analysis of studies of non-diabetic people reported that reductions in sodium intake to 2.4 g/day decreased blood pressure by 5/2 mmHg in hypertensive subjects. beside,that weight loss,increased physical activity, a low-fat diet that includes fruits, vegetables and low-fat dairy products, reducing blood pressure. ntsGlobal Guideline for Type 2 Diabetes 生活方式干預(yù)治療利益 A meta-analysis of exercise (aerobic and resistance training)reported an HbA1c reduction of 0.66 %, independent of changes in body weight, in people with Type 2 diabetes. In long-term prospective cohort studies of people with Type 2 diabetes, higher physical activity levels predicted lower longterm morbidity and mortality and increases in insulin sensitivity. Interventions included both aerobic exercise (such as walking) and resistance exercise (such as weight-lifting). ntsGlobal Guideline for Type 2 Diabetes 口服藥物治療 時機； Pharmacological therapy should be considered if goals are not achieved between 3 and 6 months after initiating MNT. ntsGlobal Guideline for Type 2 Diabetes 雙胍類應(yīng)用要點 Begin with metformin unless evidence or isk of renal impairment, titrating the dose over early weeks to minimize discontinuation due to gastro-intestinal intolerance.Monitor renal function and risk of signi. cant renal impairment eGFR 7.5 % (confirmed) on maximal oral agents. 可繼續(xù)聯(lián)用 metformin. Additionally continue sulfonylureas when starting basal insulin therapy. -Glucosidase inhibitors may also be continued. 目標(biāo)血糖： Aim for pre-breakfast and pre-main-evening-meal glucose levels of 40 yr old (or all with declared CVD). a statin at standard dose for all 20 yr old with microalbuminuria or assessed as being at particularly high risk. in addition to statin, fenobrate where serum triglycerides are 2.3 mmol/l(200 mg/dl), once LDL cholesterol is as optimally controlled as possible. consideration of other lipid-lowering drugs (ezetimibe, sustained release nicotinic acid, concentrated omega 3 fatty acids) in those failing to reach lipidlowering targets or intolerant of conventional drugs. ntsGlobal Guideline for Type 2 Diabetes 全面控制心血管危險因素 小劑量應(yīng)用抗血小板藥物 Provide aspirin 75-100 mg daily (unless aspirin intolerant or blood pressure uncontrolled) in people with evidence of CVD or at high risk. Arrange smoking cessation advice in smokers contemplative of reducing or stopping tobacco consumption. ntsGlobal Guideline for Type 2 Diabetes 5.住院病人治療原則 ntsGlobal Guideline for Type 2 Diabetes 導(dǎo)致患者住院的因素 Hospitalcare for people with diabetes may be required for metabolic emergencies, in-patient stabilization of diabetes, diabetesrelated complications, intercurrent illnesses, Surgical procedures, and labour and delivery. Prevalence of diabetes in hospitalized adult patients is 12-25 % or more. ntsGlobal Guideline for Type 2 Diabetes 住院治療的重點 Evaluate blood glucose control, and metabolic and vascular complications (in particular renal and cardiac status) prior to planned procedures; provide advice on the management of diabetes on the day or days prior to the procedure. Ensure the provision and use of an agreed protocol for in-patient proceduresand surgical operations. Aim to maintain near-normoglycaemia without hypoglycaemia by regular quality-assured blood glucose testing and intravenous insulin delivery where needed, generally using a glucose/insulin/potassium infusion. ntsGlobal Guideline for Type 2 Diabetes 住院治療的重點 Ensure awareness of special risks to people with diabetes during hospital procedures, including risks from: neuropathy (heel ulceration, cardiac arrest) intra-ocular bleeding from new vessels (vascular and other surgery requiring anticoagulation) drug therapy (risks of acute renal failure causing lactic acidosis in people on metformin, for example with radiological contrast media) ntsGlobal Guideline for Type 2 Diabetes 急癥處理原則 Provide access to intensive care units (ICU) for life-threatening illness, ensuring that strict blood glucose control, usually with intravenous insulin therapy, is a routine part of system support for anyone with hyperglycaemia. Provide protocol-driven care to ensure detection and immediate control of hyperglycaemia for anyone with a presumed acute coronary event or stroke, normally using intravenous insulin therapy with transfer to subcutaneous insulin therapy once stable and eating. ntsGlobal Guideline for Type 2 Diabetes nts