型糖尿病全球防治指南新特點課件

型糖尿病全球防治指南新特點課件內(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.住院病人治療原則內(nèi)容概括1.背景資料1.背景資料1.背景資料1.根據(jù)循證醫(yī)學原則制定,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個等級標準。1.根據(jù)循證醫(yī)學原則制定,內(nèi)容參考近5年來國際上出版的指南三個等級醫(yī)療標準

StandardCareMinimalCareComprehensiveCare三個等級醫(yī)療標準

StandardCareMinimal2.糖尿病危害性2.糖尿病危害性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3000

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。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P.Zimmetetal.BulletinoftheInternationalDiabetesFederation48:13,2003P.Zimmetetal.BulletinofthAmuchquotedpaperbyHaffneretal,suggestedthatpeoplewithType2diabeteshaveaCVriskequivalenttonon-diabeticpeoplewithpreviousCVD。HaffnerSM,LehtoS,R鰊nemaaT,PyoralaK,LaaksoM.Mortalityfromcoronaryheartdiseaseinsubjectswithtype2diabetesandinnondiabeticsubjectswithandwithoutpriormyocardialinfarction.NEnglJMed1998;339:229-34.AmuchquotedpaperbyHaffn

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。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、3.診斷及監(jiān)測3.診斷及監(jiān)測提倡早期診斷早期診斷的意義；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.提倡早期診斷早期診斷的意義；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.

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.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%-診斷標準:WHO-1999criteriaHealthOrganization.Definition,DiagnosisandClassificationofDiabetesMellitusanditsComplications.ReportofaWHOConsultation.Part1:DiagnosisandClassificationofDiabetesMellitus.Geneva:WHO診斷標準:WHO-1999criteriaHealthO診斷標準的解釋:糖尿病診斷是依據(jù)空腹、任意時間或OGTT中2小時血糖值空腹指至少8小時內(nèi)無任何熱量攝入任意時間指一日內(nèi)任何時間，無論上次進餐時間及食物攝入量OGTT是指以75克無水葡萄糖為負荷量，溶于水內(nèi)口服(如用1分子結(jié)晶水葡萄糖，則為82.5克。OGTT的方法:早餐空腹取血(空腹8-14小時后），取血后于5分鐘內(nèi)服完溶于250-300ml水內(nèi)的無水葡萄糖75克（如用1分子結(jié)晶水葡萄糖，則為82.5克）試驗過程中不喝任何飲料、不吸咽、不做劇烈運動，無需臥床從口服第一口糖水時計時，于服糖后30分鐘、1小時、2小時及3小時取血（用于診斷可僅取空腹及2小時血）診斷標準的解釋:控制指標水平血糖控制水平；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).血壓控制水平Aimtomaintainbloodpressurebelow130/80mmHgAcceptthateven140/80mmHgmaynotbeachievablewith3to5antihypertensivedrugsinsomepeople.Reviseindividualtargetsupwardsifthereissigni.cantriskofposturalhypotensionandfalls.控制指標水平血糖控制水平；每年全面檢測一次每年全面檢測一次檢測原則及目的Generalprinciplesinclude:

annualreviewofcontrolandcomplications;anagreedandcontinuallyupdateddiabetescareplan;andinvolvementofthemultidisciplinaryteamindeliveringthatplan,centredaroundthepersonwithdiabetes.檢測原則及目的Generalprinciplesincl臨床血糖監(jiān)測方法HbA1cperformedevery2to6monthsdependingonlevelandstabilityofbloodglucosecontrol,andchangeintherapy.Site-of-carecapillaryplasmaglucosemonitoringatrandomtimesofdayisnotgenerallyrecommended.臨床血糖監(jiān)測方法HbA1cperformedevery自我血糖監(jiān)測方法Self-monitoringofbloodglucose(SMBG)shouldbeavailabletothose;ForallnewlydiagnosedpeoplewithType2diabetes;thoseoninsulintreatment;toprovideinformationonhypoglycaemia;toassessglucoseexcursionsduetomedicationsandlifestylechangestomonitorchangesduringintercurrentillness.SMBG

canbeconsideredinrelationto:outcomes(adecreaseinHbA1cwiththeultimateaimofdecreasingriskofcomplications)safety(identifyinghypoglycaemia)process(education,self-empowerment,changesintherapy).自我血糖監(jiān)測方法Self-monitoringofblo對尿糖監(jiān)測的評價Urineglucosetestingischeapbuthaslimitations.Urinefreeofglucoseisanindicationthatthebloodglucoselevelisbelowtherenalthreshold,whichusuallycorrespondstoabloodglucoselevelofabout10.0mmol/l(180mg/dl).Positiveresultsdonotdistinguishbetweenmoderatelyandgrosslyelevatedlevels,andanegativeresultdoesnotdistinguishbetweennormoglycaemiaandhypoglycaemia.對尿糖監(jiān)測的評價Urineglucosetesting4.治療概論4.治療概論生活方式干預(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；專家指導下制定個體營養(yǎng)需求方案;嚴格限制高熱量、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：Encourageincreaseddurationandfrequencyofphysicalactivity(whereneeded),upto30-45minuteson3-5daysperweek,oranaccumulationof150minutesofphysicalactivityperweek.生活方式干預(yù)治療目的：通過調(diào)整生活方式，如飲食、運動等更好地生活方式干預(yù)治療利益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.生活方式干預(yù)治療利益Randomizedcontrolle生活方式干預(yù)治療利益Ameta-analysisofexercise(aerobicandresistancetraining)reportedanHbA1creductionof0.66%,independentofchangesinbodyweight,inpeoplewithType2diabetes.Inlong-termprospectivecohortstudiesofpeoplewithType2diabetes,higherphysicalactivitylevelspredictedlowerlongtermmorbidityandmortalityandincreasesininsulinsensitivity.Interventionsincludedbothaerobicexercise(suchaswalking)andresistanceexercise(suchasweight-lifting).生活方式干預(yù)治療利益Ameta-analysisofe口服藥物治療時機；

Pharmacologicaltherapyshouldbeconsideredifgoalsarenotachievedbetween3and6monthsafterinitiatingMNT.口服藥物治療時機；雙胍類應(yīng)用要點Beginwithmetforminunlessevidenceoriskofrenalimpairment,titratingthedoseoverearlyweekstominimizediscontinuationduetogastro-intestinalintolerance.Monitorrenalfunctionandriskofsigni.cantrenalimpairmenteGFR<60ml/min/1.73m2)inpeopletakingmetformin.Theoutcome-basedevidencefromtheUKPDSfortheuseofmetformininoverweightpeoplewithType2diabetes,exceedingthatforanyotherdrug,leadstoitsrecommendationfor.rst-lineuse,Lacticacidosisisararecomplication(oftenfatal)ofmetformintherapyinpeoplewithrenalimpairment.Gastro-intestinalintoleranceofthisdrugisverycommon,particularlyathigherdoselevelsandwithfastupwarddosetitration.雙胍類應(yīng)用要點Beginwithmetforminun磺脲類應(yīng)用要點Usesulfonylureaswhenmetforminfailstocontrolglucoseconcentrationstotargetlevels,orasa.rst-lineoptioninthepersonwhoisnotoverweight.Provideeducationand,ifappropriate,self-monitoring(seeSelf-monitoring)toguardagainsttheconsequencesofhypoglycaemia.Once-dailysulfonylureasshouldbeanavailableoptionwheredrugconcordanceisproblematic.Somesulfonylureas,notablyglyburide,areknowntobeassociatedwithseverehypoglycaemiaandrarelydeathfromthis,againusuallyinassociationwithrenalimpairment.磺脲類應(yīng)用要點Usesulfonylureaswhen快速促胰島素分泌劑應(yīng)用要點Rapid-actinginsulinsecretagoguesmaybeusefulasanalternativetosulfonylureasinsomeinsulin-sensitivepeoplewith.exiblelifestyles.快速促胰島素分泌劑應(yīng)用要點Rapid-actinginsu噻唑烷二酮類應(yīng)用要點UseaPPAR-γagonist(thiazolidinedione)whenglucoseconcentrationsarenotcontrolledtotargetlevels,addingittometforminasanalternativetoasulfonylurea,ortoasulfonylureawheremetforminisnottolerated,ortothecombinationofmetforminandasulfonylurea.Bealerttothecontra-indicationofcardiacfailure,andwarnthepersonwithdiabetesofthepossibilityofdevelopmentofsigni.cantoedema.噻唑烷二酮類應(yīng)用要點UseaPPAR-γagonist糖酐酶抑制劑類應(yīng)用要點Useα-glucosidaseinhibitorsasafurtheroption.Theymayalsohavearoleinsomepeopleintolerantofothertherapies.Systematicreviewsoftheα-glucosidaseinhibitorshavenotfoundreasontorecommendthemoverlessexpensiveandbettertolerateddrugs.糖酐酶抑制劑類應(yīng)用要點Useα-glucosidasei胰島素治療要點時機;

Begininsulintherapywhenoptimizedoralglucose-loweringdrugsandlifestyleinterventionsareunabletomaintainbloodglucosecontrolattargetlevels--------generallywhenDCCT-alignedHbA1chasdeterioratedto>7.5%(confirmed)onmaximaloralagents.可繼續(xù)聯(lián)用

metformin.Additionallycontinuesulfonylureaswhenstartingbasalinsulintherapy.α-Glucosidaseinhibitorsmayalsobecontinued..目標血糖：Aimforpre-breakfastandpre-main-evening-mealglucoselevelsof<6.0mmol/l(<110mg/dl);胰島素治療要點時機;胰島素治療要點三種模式;abasalinsulinoncedailysuchasinsulindetemir,insulinglargine,orNPHinsulin(riskofhypoglycaemiaishigherwiththelast),or.twicedailypremixinsulin(biphasicinsulin)particularlywithhigherHbA1c,or.multipledailyinjections(meal-timeandbasalinsulin)wherebloodglucosecontrolissub-optimalonotherregimens,ormeal-time?exibilityisdesired.調(diào)節(jié)方法;Initiateinsulinusingaself-titrationregimen(doseincreasesof2unitsevery3days)orbyweeklyormorefrequentcontactwithahealth-careprofessional注射部位;abdominalarea(mostrapidabsorption)orthigh(slowest),withtheglutealarea(orthearm)asotherpossibleinjectionsites.胰島素治療要點三種模式;選擇皮下注射部位選擇皮下注射部位胰島素治療利益TheevidencefromUKPDSthatinsulinwasamongtheglucose-loweringtherapieswhich,consideredtogether,reducedvascularcomplicationscomparedwith‘conventional’therapy.IntensifiedinsulintherapyinType2diabeteshasbeenshowntoimprovemetaboliccontrol,improveclinicaloutcomes、andincreasefexibility.PumptherapyinType2diabetesispotentialoptioninhighlyselectedpatientsorinveryindividualsettings.胰島素治療利益TheevidencefromUKPDS全面控制心血管危險因素控制血壓及降壓藥的選用ACE-inhibitorsandA2RBsmayoffersomeadvantagesoverotheragentsinsomesituations(seeKidneydamage,Cardiovascularriskprotection)startwithβ-adrenergicblockersinpeoplewithangina,β-adrenergicblockersorACE-inhibitorsinpeoplewithpreviousmyocardialinfarction,ACEinhibitorsordiureticsinthosewithheartfailure.careshouldbetakenwithcombinedthiazideandβ-adrenergicblockersbecauseofriskofdeteriorationinmetaboliccontrol.全面控制心血管危險因素控制血壓及降壓藥的選用全面控制心血管危險因素降脂藥的推薦使用astatinatstandarddoseforall>40yrold(orallwithdeclaredCVD).astatinatstandarddoseforall>20yroldwithmicroalbuminuriaorassessedasbeingatparticularlyhighrisk.inadditiontostatin,feno?bratewhereserumtriglyceridesare>2.3mmol/l(>200mg/dl),onceLDLcholesterolisasoptimallycontrolledaspossible.considerationofotherlipid-loweringdrugs(ezetimibe,sustainedreleasenicotinicacid,concentratedomega3fattyacids)inthosefailingtoreachlipidloweringtargetsorintolerantofconventionaldrugs.全面控制心血管危險因素降脂藥的推薦使用全面控制心血管危險因素小劑量應(yīng)用抗血小板藥物Provideaspirin75-100mgdaily(unlessaspirinintolerantorbloodpressureuncontrolled)inpeoplewithevidenceofCVDorathighrisk.Arrangesmokingcessationadviceinsmokerscontemplativeofreducingorstoppingtobaccoconsumption.全面控制心血管危險因素小劑量應(yīng)用抗血小板藥物5.住院病人治療原則5.住院病人治療原則導致患者住院的因素Hospitalcareforpeoplewithdiabetesmayberequiredformetabolicemergencies,in-patientstabilizationofdiabetes,diabetesrelatedcomplications,intercurrentillnesses,Surgicalprocedures,andlabouranddelivery.Prevalenceofdiabetesinhospitalizedadultpatientsis12-25%ormore.導致患者住院的因素Hospitalcareforpeop住院治療的重點Evaluatebloodglucosecontrol,andmetabolicandvascularcomplications(inparticularrenalandcardiacstatus)priortoplannedprocedures;provideadviceonthemanagementofdiabetesonthedayordayspriortotheprocedure.Ensuretheprovisionanduseofanagreedprotocolforin-patientproceduresandsurgicaloperations.Aimtomaintainnear-normoglycaemiawithouthypoglycaemiabyregularquality-assuredbloodglucosetestingandintravenousinsulindeliverywhereneeded,generallyusingaglucose/insulin/potassiuminfusion.住院治療的重點Evaluatebloodglucose住院治療的重點Ensureawarenessofspecialriskstopeoplewithdiabetesduringhospitalprocedures,includingrisksfrom:neuropathy(heelulceration,cardiacarrest)intra-ocularbleedingfromnewvessels(vascularandothersurgeryrequiringanticoagulation)drugtherapy(risksofacuterenalfailurecausinglacticacidosisinpeopleonmetformin,forexamplewithradiologicalcontrastmedia)住院治療的重點Ensureawarenessofspe急癥處理原則Provideaccesstointensivecareunits(ICU)forlife-threateningillness,ensuringthatstrictbloodglucosecontrol,usuallywithintravenousinsulintherapy,isaroutinepartofsystemsupportforanyonewithhyperglycaemia.Provideprotocol-drivencaretoensuredetectionandimmediatecontrolofhyperglycaemiaforanyonewithapresumedacutecoronaryeventorstroke,normallyusingintravenousinsulintherapywithtransfertosubcutaneousinsulintherapyoncestableandeating.急癥處理原則Provideaccesstointens謝謝！謝謝！型糖尿病全球防治指南新特點課件內(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.住院病人治療原則內(nèi)容概括1.背景資料1.背景資料1.背景資料1.根據(jù)循證醫(yī)學原則制定,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個等級標準。1.根據(jù)循證醫(yī)學原則制定,內(nèi)容參考近5年來國際上出版的指南三個等級醫(yī)療標準

StandardCareMinimalCareComprehensiveCare三個等級醫(yī)療標準

StandardCareMinimal2.糖尿病危害性2.糖尿病危害性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3000

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。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P.Zimmetetal.BulletinoftheInternationalDiabetesFederation48:13,2003P.Zimmetetal.BulletinofthAmuchquotedpaperbyHaffneretal,suggestedthatpeoplewithType2diabeteshaveaCVriskequivalenttonon-diabeticpeoplewithpreviousCVD。HaffnerSM,LehtoS,R鰊nemaaT,PyoralaK,LaaksoM.Mortalityfromcoronaryheartdiseaseinsubjectswithtype2diabetesandinnondiabeticsubjectswithandwithoutpriormyocardialinfarction.NEnglJMed1998;339:229-34.AmuchquotedpaperbyHaffn

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。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、3.診斷及監(jiān)測3.診斷及監(jiān)測提倡早期診斷早期診斷的意義；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.提倡早期診斷早期診斷的意義；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.

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.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%-診斷標準:WHO-1999criteriaHealthOrganization.Definition,DiagnosisandClassificationofDiabetesMellitusanditsComplications.ReportofaWHOConsultation.Part1:DiagnosisandClassificationofDiabetesMellitus.Geneva:WHO診斷標準:WHO-1999criteriaHealthO診斷標準的解釋:糖尿病診斷是依據(jù)空腹、任意時間或OGTT中2小時血糖值空腹指至少8小時內(nèi)無任何熱量攝入任意時間指一日內(nèi)任何時間，無論上次進餐時間及食物攝入量OGTT是指以75克無水葡萄糖為負荷量，溶于水內(nèi)口服(如用1分子結(jié)晶水葡萄糖，則為82.5克。OGTT的方法:早餐空腹取血(空腹8-14小時后），取血后于5分鐘內(nèi)服完溶于250-300ml水內(nèi)的無水葡萄糖75克（如用1分子結(jié)晶水葡萄糖，則為82.5克）試驗過程中不喝任何飲料、不吸咽、不做劇烈運動，無需臥床從口服第一口糖水時計時，于服糖后30分鐘、1小時、2小時及3小時取血（用于診斷可僅取空腹及2小時血）診斷標準的解釋:控制指標水平血糖控制水平；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).血壓控制水平Aimtomaintainbloodpressurebelow130/80mmHgAcceptthateven140/80mmHgmaynotbeachievablewith3to5antihypertensivedrugsinsomepeople.Reviseindividualtargetsupwardsifthereissigni.cantriskofposturalhypotensionandfalls.控制指標水平血糖控制水平；每年全面檢測一次每年全面檢測一次檢測原則及目的Generalprinciplesinclude:

annualreviewofcontrolandcomplications;anagreedandcontinuallyupdateddiabetescareplan;andinvolvementofthemultidisciplinaryteamindeliveringthatplan,centredaroundthepersonwithdiabetes.檢測原則及目的Generalprinciplesincl臨床血糖監(jiān)測方法HbA1cperformedevery2to6monthsdependingonlevelandstabilityofbloodglucosecontrol,andchangeintherapy.Site-of-carecapillaryplasmaglucosemonitoringatrandomtimesofdayisnotgenerallyrecommended.臨床血糖監(jiān)測方法HbA1cperformedevery自我血糖監(jiān)測方法Self-monitoringofbloodglucose(SMBG)shouldbeavailabletothose;ForallnewlydiagnosedpeoplewithType2diabetes;thoseoninsulintreatment;toprovideinformationonhypoglycaemia;toassessglucoseexcursionsduetomedicationsandlifestylechangestomonitorchangesduringintercurrentillness.SMBG

canbeconsideredinrelationto:outcomes(adecreaseinHbA1cwiththeultimateaimofdecreasingriskofcomplications)safety(identifyinghypoglycaemia)process(education,self-empowerment,changesintherapy).自我血糖監(jiān)測方法Self-monitoringofblo對尿糖監(jiān)測的評價Urineglucosetestingischeapbuthaslimitations.Urinefreeofglucoseisanindicationthatthebloodglucoselevelisbelowtherenalthreshold,whichusuallycorrespondstoabloodglucoselevelofabout10.0mmol/l(180mg/dl).Positiveresultsdonotdistinguishbetweenmoderatelyandgrosslyelevatedlevels,andanegativeresultdoesnotdistinguishbetweennormoglycaemiaandhypoglycaemia.對尿糖監(jiān)測的評價Urineglucosetesting4.治療概論4.治療概論生活方式干預(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；專家指導下制定個體營養(yǎng)需求方案;嚴格限制高熱量、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：Encourageincreaseddurationandfrequencyofphysicalactivity(whereneeded),upto30-45minuteson3-5daysperweek,oranaccumulationof150minutesofphysicalactivityperweek.生活方式干預(yù)治療目的：通過調(diào)整生活方式，如飲食、運動等更好地生活方式干預(yù)治療利益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.生活方式干預(yù)治療利益Randomizedcontrolle生活方式干預(yù)治療利益Ameta-analysisofexercise(aerobicandresistancetraining)reportedanHbA1creductionof0.66%,independentofchangesinbodyweight,inpeoplewithType2diabetes.Inlong-termprospectivecohortstudiesofpeoplewithType2diabetes,higherphysicalactivitylevelspredictedlowerlongtermmorbidityandmortalityandincreasesininsulinsensitivity.Interventionsincludedbothaerobicexercise(suchaswalking)andresistanceexercise(suchasweight-lifting).生活方式干預(yù)治療利益Ameta-analysisofe口服藥物治療時機；

Pharmacologicaltherapyshouldbeconsideredifgoalsarenotachievedbetween3and6monthsafterinitiatingMNT.口服藥物治療時機；雙胍類應(yīng)用要點Beginwithmetforminunlessevidenceoriskofrenalimpairment,titratingthedoseoverearlyweekstominimizediscontinuationduetogastro-intestinalintolerance.Monitorrenalfunctionandriskofsigni.cantrenalimpairmenteGFR<60ml/min/1.73m2)inpeopletakingmetformin.Theoutcome-basedevidencefromtheUKPDSfortheuseofmetformininoverweightpeoplewithType2diabetes,exceedingthatforanyotherdrug,leadstoitsrecommendationfor.rst-lineuse,Lacticacidosisisararecomplication(oftenfatal)ofmetformintherapyinpeoplewithrenalimpairment.Gastro-intestinalintoleranceofthisdrugisverycommon,particularlyathigherdoselevelsandwithfastupwarddosetitration.雙胍類應(yīng)用要點Beginwithmetforminun磺脲類應(yīng)用要點Usesulfonylureaswhenmetforminfailstocontrolglucoseconcentrationstotargetlevels,orasa.rst-lineoptioninthepersonwhoisnotoverweight.Provideeducationand,ifappropriate,self-monitoring(seeSelf-monitoring)toguardagainsttheconsequencesofhypoglycaemia.Once-dailysulfonylureasshouldbeanavailableoptionwheredrugconcordanceisproblematic.Somesulfonylureas,notablyglyburide,areknowntobeassociatedwithseverehypoglycaemiaandrarelydeathfromthis,againusuallyinassociationwithrenalimpairment.磺脲類應(yīng)用要點Usesulfonylureaswhen快速促胰島素分泌劑應(yīng)用要點Rapid-actinginsulinsecretagoguesmaybeusefulasanalternativetosulfonylureasinsomeinsulin-sensitivepeoplewith.exiblelifestyles.快速促胰島素分泌劑應(yīng)用要點Rapid-actinginsu噻唑烷二酮類應(yīng)用要點UseaPPAR-γagonist(thiazolidinedione)whenglucoseconcentrationsarenotcontrolledtotargetlevels,addingittometforminasanalternativetoasulfonylurea,ortoasulfonylureawheremetforminisnottolerated,ortothecombinationofmetforminandasulfonylurea.Bealerttothecontra-indicationofcardiacfailure,andwarnthepersonwithdiabetesofthepossibilityofdevelopmentofsigni.cantoedema.噻唑烷二酮類應(yīng)用要點UseaPPAR-γagonist糖酐酶抑制劑類應(yīng)用要點Useα-glucosidaseinhibitorsasafurtheroption.Theymayalsohavearoleinsomepeopleintolerantofothertherapies.Systematicreviewsoftheα-glucosidaseinhibitorshavenotfoundreasontorecommendthemoverlessexpensiveandbettertolerateddrugs.糖酐酶抑制劑類應(yīng)用要點Useα-glucosidasei胰島素治療要點時機;

Begininsulintherapywhenoptimizedoralglucose-loweringdrugsandlifestyleinterventionsareunabletomaintainbloodglucosecontrolattargetlevels--------generallywhenDCCT-alignedHbA1chasdeterioratedto>7.5%(confirmed)onmaximaloralagents.可繼續(xù)聯(lián)用

metformin.Additionallycontinuesulfonylureaswhenstartingbasalinsulintherapy.α-Glucosidaseinhibitorsmayalsobecontinued..目標血糖：Aimforpre-breakfastandpre-main-evening-mealglucoselevelsof<6.0mmol/l(<110mg/dl);胰島素治療要點時機;胰島素治療要點三種模式;abasalinsulinoncedailysuchasinsulindetemir,insulinglargine,orNPHinsulin(riskofhypoglycaemiaishigherwiththelast),or.twicedailypremixinsulin(biphasicinsulin)particularlywithhigherHbA1c,or.multipledailyinjections(meal-timeandbasalinsulin)wherebloodglucosecontrolissub-optimalonotherregimens,ormeal-time?exibilityisdesired.調(diào)節(jié)方法;Initiateinsulinusingaself-titrationregimen(doseincreasesof2unitsevery3days)orbyweeklyormorefrequentcontactwithahealth-careprofessional注射部位;abdominalarea(mostrapidabsorption)orthigh(slowest),withtheglutealarea(orthearm)asotherpossibleinjectionsites.胰島素治療要點三種模式;選擇皮下注射部位選擇皮下注射部位胰島素治療利益TheevidencefromUKPDSthatinsulinwasamongtheglucose-loweringtherapieswhich,consideredtogether,reducedvascularcomplicationscomparedwith‘conventional’therapy.IntensifiedinsulintherapyinType2diabeteshasbeenshowntoimprovemetaboliccontrol,improveclinicaloutcomes、andincreasefexibility.PumptherapyinType2diabetesispotentialoptioninhighlyselectedpatientsorinveryindividualsettings.胰島素治療利益TheevidencefromUKPDS全面控制心血管危險因素控制血壓及降壓藥的選用ACE-inhibitorsandA2RBsmayoffersomeadvantagesoverotheragentsinsomesituations(seeKidneydamage,Cardiovascularriskprotection)startwithβ-adrenergicblockersinpeoplewithangina,β-adrenergicblockersorACE-inhibitorsinpeoplewithpreviousmyocardialinfarction,ACEinhibitorsordiureticsinthosewithheartfailure.ca