心内科医生应掌握的糖尿病知识.ppt
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?-细胞的胰岛素分泌调节
不同糖耐量状态个体在OGTT试验中的血糖曲线
Nomenclature and description term
defined by FPG and 2hr PPG
Nomenclature and description term
defined by FPG and 2hr PPG
Nomenclature and description term
defined by FPG and 2hr PPG
空腹和餐后血糖增高的临床表现
Impaired glucose tolerance is a cardiovascular risk factor (Funagata Study)
糖尿病是冠心病的等位症
UKPDS研究中心梗与不同治疗间的关系
Introduction
? ± 30% of patients in surgical ICUs need >5 days intensive care (long-stay patients)
? Long-stay ICU patients
- 20% risk of death in ICU
- High morbidity due to specific complications
? Sepsis and inflammation
? Multiple organ failure
? Wasting, polyneuropathy, weakness
- Consume large fraction of scarce ICU resources
Hyperglycaemia in ICU
? Current practice:
- Hyperglycaemia is common
- Caused by insulin resistance
- Adaptive?
- Only treated when blood glucose >215 mg/dL (>12 mmol/L)
? Key hypothesis:
- Hyperglycaemia (>110 mg/dL, >6.1 mmol/L)
predisposes to specific ICU complications,prolonged intensive care dependency, and death
Prospective, randomised, controlled trial
All mechanically ventilated patients admitted to ICU
Consent from closest family member
Stratified for on-admission diagnosis and randomised to:
Study design
? Protocol
- Standard feeding regimen started on admission
- Insulin by continuous i.v. infusion (syringe pump)
- Whole blood glucose monitored every 1 to 4 hours
- Insulin dose adjusted by ICU nurses and a study physician not involved in clinical decision making
? Primary outcome measure
- Death from any cause in ICU
(cause of death confirmed by autopsy-blinded pathologist)
? Secondary outcome measures
- In-hospital mortality
Study design
? Secondary outcome measures: morbidity
- Bloodstream infections*
- Inflammation*
- Acute renal failure and need for dialysis/haemofiltration*
- Anaemia and need for red-cell transfusions*
- Hyperbilirubinaemia*
- Critical illness polyneuropathy by weekly EMG screening*
- Prolonged (>14 days) mechanical ventilation and ICU stay
- Costs (cumulative TISS)
Data analysis
? Intention-to-treat analysis
? Three monthly interim analyses of primary outcome (deaths during intensive care)
? Study terminated for ethical reasons:
significantly reduced ICU mortality at 1 year (N=1548)
Study population at baseline
Blood glucose control
Blood glucose control
Insulin administered
Mortality
Deaths by severity of illness strata
Kaplan-Meier plots for survival
Causes of death
Morbidity
Insulin dose or glycaemic control?
Is strict normoglycaemia essential?
Is strict normoglycaemia essential ?
Results summary
Strict glycaemic control <110 mg/dL with exogenous insulin
? Reduced ICU and hospital mortality of surgical ICU patients
? Reduced ICU morbidity:
- Severe infections and inflammation
- Acute renal failure and need for dialysis
- Anaemia and need for transfusion
- Hyperbilirubinaemia
- Critical illness polyneuropathy and prolonged ventilator dependency
- Prolonged ICU stay
代谢综合症:总死亡率和心血管病死亡率 Kuopio Heart Study
死亡四重奏 "Deadly Quartet"的影响--搭桥手术后随访
糖尿病并发症的病因和危险因素和
Steno-2研究：2型糖尿病患者多因素干预与心血管疾病研究
Steno-2研究
强化治疗组的干预措施
? 饮食干预：脂肪摄入量小于总热量的30%；饱和脂肪酸小于总热量的10%
? 运动干预：30分钟轻中度运动，每周5次
? 鼓励患者及家属戒烟
? 所有患者使用相当于50mg bid开博通剂量的ACEI或相当于50mg bid 络沙坦剂量的ARB
? 所有患者使用阿司匹林(除非有禁忌证)
? 当HbA1c>6.5%, 使用口服药
? 当口服药使用至极量而HbA1c>7.0%，开始使用胰岛素
强化治疗组降糖药物治疗
降糖治疗
对照治疗组强化治疗组P值
(N＝63)(N＝67)
饮食治疗(人数) 410.15
口服药治疗(人数) 38500.14
胰岛素治疗(人数) 34380.91
两种治疗联合(人数) 13220.14
胰岛素剂量(单位)0.91
中位数 6462
区间12-360 12-260
降压治疗
人数对照治疗组强化治疗组P值
(N＝63)(N＝67)
ACEI 32 530.002
ARB 12 310.002
ACEI+ARB0 19<0.001
利尿剂 39 380.42
钙通道拮抗剂 18 240.45
B受体阻滞剂 13 100.35
调脂治疗及其他
人数对照治疗组强化治疗组P值
(N＝63)(N＝67)
降脂药物
他丁类 14 57<0.001
倍特类 3 10.27
两者联合 0 11.00
阿司匹林 35 58<0.001
维生素及微量元素 0 42<0.001
重要信息
Steno-2研究方案所采用的强化多因素干预，包括患者教育、鼓励，严格控制目标值和个体化评估患者的危险因素，应该用于所有有微量白蛋白尿的2型糖尿病患者。这些患者是发生大血管和微血管并发症的高危人群，约占所有2型糖尿病患者的1/3。
口服降糖药分类
* 促胰岛素分泌剂
> 非磺脲类药物:瑞格列奈
> 磺脲类药物:格列吡嗪
* 增加胰岛素敏感性
双胍类药物:二甲双呱
胰岛素增敏剂:罗格列酮
* 葡萄糖苷酶抑制剂:阿卡波糖
口服抗糖尿病药物的主要作用位点
双胍类药物副作用
* 常见有消化道反应
* 恶心、呕吐、腹胀、腹泻
* 乳酸性酸中毒(肝肾功能不全的、缺氧、应激、心衰等尤要注意)
* 与磺脲类或Ins合用时，也可发生低血糖
罗格列酮的副作用
体重增加
- 临床研究中，体重增加与血糖控制相关
- 6-12月体重增加 2-4 kg
- 罗格列酮降低内脏脂肪
体液潴留 (水肿)
- 临床研究中报道率 3% (罗格列酮/磺脲) -- 4.4% (罗格列酮/二甲双胍)
- 报道通常轻到中度，低于1%的病人退出
- 心功能不全的患者慎用， 于胰岛素联合使用时发生心衰的危险性明显增加
血液稀释(贫血)
- 临床研究中，贫血发生在非常少的罗格列酮单药治疗人群中 (~1.9%)
?-细胞的胰岛素分泌调节
不同糖耐量状态个体在OGTT试验中的血糖曲线
Nomenclature and description term
defined by FPG and 2hr PPG
Nomenclature and description term
defined by FPG and 2hr PPG
Nomenclature and description term
defined by FPG and 2hr PPG
空腹和餐后血糖增高的临床表现
Impaired glucose tolerance is a cardiovascular risk factor (Funagata Study)
糖尿病是冠心病的等位症
UKPDS研究中心梗与不同治疗间的关系
Introduction
? ± 30% of patients in surgical ICUs need >5 days intensive care (long-stay patients)
? Long-stay ICU patients
- 20% risk of death in ICU
- High morbidity due to specific complications
? Sepsis and inflammation
? Multiple organ failure
? Wasting, polyneuropathy, weakness
- Consume large fraction of scarce ICU resources
Hyperglycaemia in ICU
? Current practice:
- Hyperglycaemia is common
- Caused by insulin resistance
- Adaptive?
- Only treated when blood glucose >215 mg/dL (>12 mmol/L)
? Key hypothesis:
- Hyperglycaemia (>110 mg/dL, >6.1 mmol/L)
predisposes to specific ICU complications,prolonged intensive care dependency, and death
Prospective, randomised, controlled trial
All mechanically ventilated patients admitted to ICU
Consent from closest family member
Stratified for on-admission diagnosis and randomised to:
Study design
? Protocol
- Standard feeding regimen started on admission
- Insulin by continuous i.v. infusion (syringe pump)
- Whole blood glucose monitored every 1 to 4 hours
- Insulin dose adjusted by ICU nurses and a study physician not involved in clinical decision making
? Primary outcome measure
- Death from any cause in ICU
(cause of death confirmed by autopsy-blinded pathologist)
? Secondary outcome measures
- In-hospital mortality
Study design
? Secondary outcome measures: morbidity
- Bloodstream infections*
- Inflammation*
- Acute renal failure and need for dialysis/haemofiltration*
- Anaemia and need for red-cell transfusions*
- Hyperbilirubinaemia*
- Critical illness polyneuropathy by weekly EMG screening*
- Prolonged (>14 days) mechanical ventilation and ICU stay
- Costs (cumulative TISS)
Data analysis
? Intention-to-treat analysis
? Three monthly interim analyses of primary outcome (deaths during intensive care)
? Study terminated for ethical reasons:
significantly reduced ICU mortality at 1 year (N=1548)
Study population at baseline
Blood glucose control
Blood glucose control
Insulin administered
Mortality
Deaths by severity of illness strata
Kaplan-Meier plots for survival
Causes of death
Morbidity
Insulin dose or glycaemic control?
Is strict normoglycaemia essential?
Is strict normoglycaemia essential ?
Results summary
Strict glycaemic control <110 mg/dL with exogenous insulin
? Reduced ICU and hospital mortality of surgical ICU patients
? Reduced ICU morbidity:
- Severe infections and inflammation
- Acute renal failure and need for dialysis
- Anaemia and need for transfusion
- Hyperbilirubinaemia
- Critical illness polyneuropathy and prolonged ventilator dependency
- Prolonged ICU stay
代谢综合症:总死亡率和心血管病死亡率 Kuopio Heart Study
死亡四重奏 "Deadly Quartet"的影响--搭桥手术后随访
糖尿病并发症的病因和危险因素和
Steno-2研究：2型糖尿病患者多因素干预与心血管疾病研究
Steno-2研究
强化治疗组的干预措施
? 饮食干预：脂肪摄入量小于总热量的30%；饱和脂肪酸小于总热量的10%
? 运动干预：30分钟轻中度运动，每周5次
? 鼓励患者及家属戒烟
? 所有患者使用相当于50mg bid开博通剂量的ACEI或相当于50mg bid 络沙坦剂量的ARB
? 所有患者使用阿司匹林(除非有禁忌证)
? 当HbA1c>6.5%, 使用口服药
? 当口服药使用至极量而HbA1c>7.0%，开始使用胰岛素
强化治疗组降糖药物治疗
降糖治疗
对照治疗组强化治疗组P值
(N＝63)(N＝67)
饮食治疗(人数) 410.15
口服药治疗(人数) 38500.14
胰岛素治疗(人数) 34380.91
两种治疗联合(人数) 13220.14
胰岛素剂量(单位)0.91
中位数 6462
区间12-360 12-260
降压治疗
人数对照治疗组强化治疗组P值
(N＝63)(N＝67)
ACEI 32 530.002
ARB 12 310.002
ACEI+ARB0 19<0.001
利尿剂 39 380.42
钙通道拮抗剂 18 240.45
B受体阻滞剂 13 100.35
调脂治疗及其他
人数对照治疗组强化治疗组P值
(N＝63)(N＝67)
降脂药物
他丁类 14 57<0.001
倍特类 3 10.27
两者联合 0 11.00
阿司匹林 35 58<0.001
维生素及微量元素 0 42<0.001
重要信息
Steno-2研究方案所采用的强化多因素干预，包括患者教育、鼓励，严格控制目标值和个体化评估患者的危险因素，应该用于所有有微量白蛋白尿的2型糖尿病患者。这些患者是发生大血管和微血管并发症的高危人群，约占所有2型糖尿病患者的1/3。
口服降糖药分类
* 促胰岛素分泌剂
> 非磺脲类药物:瑞格列奈
> 磺脲类药物:格列吡嗪
* 增加胰岛素敏感性
双胍类药物:二甲双呱
胰岛素增敏剂:罗格列酮
* 葡萄糖苷酶抑制剂:阿卡波糖
口服抗糖尿病药物的主要作用位点
双胍类药物副作用
* 常见有消化道反应
* 恶心、呕吐、腹胀、腹泻
* 乳酸性酸中毒(肝肾功能不全的、缺氧、应激、心衰等尤要注意)
* 与磺脲类或Ins合用时，也可发生低血糖
罗格列酮的副作用
体重增加
- 临床研究中，体重增加与血糖控制相关
- 6-12月体重增加 2-4 kg
- 罗格列酮降低内脏脂肪
体液潴留 (水肿)
- 临床研究中报道率 3% (罗格列酮/磺脲) -- 4.4% (罗格列酮/二甲双胍)
- 报道通常轻到中度，低于1%的病人退出
- 心功能不全的患者慎用， 于胰岛素联合使用时发生心衰的危险性明显增加
血液稀释(贫血)
- 临床研究中，贫血发生在非常少的罗格列酮单药治疗人群中 (~1.9%)
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