型糖尿病全球防治指南新特點(diǎn)課件

型糖尿病全球防治指南新特點(diǎn)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(cè)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(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(gè)等級(jí)標(biāo)準(zhǔn)。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三個(gè)等級(jí)醫(yī)療標(biāo)準(zhǔn)

StandardCareMinimalCareComprehensiveCare三個(gè)等級(jí)醫(yī)療標(biāo)準(zhǔn)

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(zhǎng)。無論是在發(fā)達(dá)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(zhǎng)的速度超過了發(fā)達(dá)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(dòng)能力,預(yù)期壽命縮短8-12年。1.發(fā)病人數(shù)日益增長(zhǎng)。無論是在發(fā)達(dá)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(cè)3.診斷及監(jiān)測(cè)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(biāo)準(zhǔn):WHO-1999criteriaHealthOrganization.Definition,DiagnosisandClassificationofDiabetesMellitusanditsComplications.ReportofaWHOConsultation.Part1:DiagnosisandClassificationofDiabetesMellitus.Geneva:WHO診斷標(biāo)準(zhǔn):WHO-1999criteriaHealthO診斷標(biāo)準(zhǔn)的解釋:糖尿病診斷是依據(jù)空腹、任意時(shí)間或OGTT中2小時(shí)血糖值空腹指至少8小時(shí)內(nèi)無任何熱量攝入任意時(shí)間指一日內(nèi)任何時(shí)間，無論上次進(jìn)餐時(shí)間及食物攝入量OGTT是指以75克無水葡萄糖為負(fù)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(shí)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(yàn)過程中不喝任何飲料、不吸咽、不做劇烈運(yùn)動(dòng)，無需臥床從口服第一口糖水時(shí)計(jì)時(shí)，于服糖后30分鐘、1小時(shí)、2小時(shí)及3小時(shí)取血（用于診斷可僅取空腹及2小時(shí)血）診斷標(biāo)準(zhǔn)的解釋:控制指標(biāo)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(biāo)水平血糖控制水平；每年全面檢測(cè)一次每年全面檢測(cè)一次檢測(cè)原則及目的Generalprinciplesinclude:

annualreviewofcontrolandcomplications;anagreedandcontinuallyupdateddiabetescareplan;andinvolvementofthemultidisciplinaryteamindeliveringthatplan,centredaroundthepersonwithdiabetes.檢測(cè)原則及目的Generalprinciplesincl臨床血糖監(jiān)測(cè)方法HbA1cperformedevery2to6monthsdependingonlevelandstabilityofbloodglucosecontrol,andchangeintherapy.Site-of-carecapillaryplasmaglucosemonitoringatrandomtimesofdayisnotgenerallyrecommended.臨床血糖監(jiān)測(cè)方法HbA1cperformedevery自我血糖監(jiān)測(cè)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(cè)方法Self-monitoringofblo對(duì)尿糖監(jiān)測(cè)的評(píng)價(jià)Urineglucosetestingischeapbuthaslimitations.Urinefreeofglucoseisanindicationthatthebloodglucoselevelisbelowtherenalthreshold,whichusuallycorrespondstoabloodglucoselevelofabout10.0mmol/l(180mg/dl).Positiveresultsdonotdistinguishbetweenmoderatelyandgrosslyelevatedlevels,andanegativeresultdoesnotdistinguishbetweennormoglycaemiaandhypoglycaemia.對(duì)尿糖監(jiān)測(cè)的評(píng)價(jià)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(yùn)動(dòng)等更好地控制血糖、血壓、血脂等危險(xiǎn)因素。關(guān)于飲食；專家指導(dǎo)下制定個(gè)體營(yíng)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(yùn)動(dòng)量調(diào)整飲食量。關(guān)于運(yùn)動(dòng)：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(yùn)動(dòng)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(shí)機(jī)；

Pharmacologicaltherapyshouldbeconsideredifgoalsarenotachievedbetween3and6monthsafterinitiatingMNT.口服藥物治療時(shí)機(jī)；雙胍類應(yīng)用要點(diǎn)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(diǎn)Beginwithmetforminun磺脲類應(yīng)用要點(diǎn)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(diǎn)Usesulfonylureaswhen快速促胰島素分泌劑應(yīng)用要點(diǎn)Rapid-actinginsulinsecretagoguesmaybeusefulasanalternativetosulfonylureasinsomeinsulin-sensitivepeoplewith.exiblelifestyles.快速促胰島素分泌劑應(yīng)用要點(diǎn)Rapid-actinginsu噻唑烷二酮類應(yīng)用要點(diǎn)UseaPPAR-γagonist(thiazolidinedione)whenglucoseconcentrationsarenotcontrolledtotargetlevels,addingittometforminasanalternativetoasulfonylurea,ortoasulfonylureawheremetforminisnottolerated,ortothecombinationofmetforminandasulfonylurea.Bealerttothecontra-indicationofcardiacfailure,andwarnthepersonwithdiabetesofthepossibilityofdevelopmentofsigni.cantoedema.噻唑烷二酮類應(yīng)用要點(diǎn)UseaPPAR-γagonist糖酐酶抑制劑類應(yīng)用要點(diǎn)Useα-glucosidaseinhibitorsasafurtheroption.Theymayalsohavearoleinsomepeopleintolerantofothertherapies.Systematicreviewsoftheα-glucosidaseinhibitorshavenotfoundreasontorecommendthemoverlessexpensiveandbettertolerateddrugs.糖酐酶抑制劑類應(yīng)用要點(diǎn)Useα-glucosidasei胰島素治療要點(diǎn)時(shí)機(jī);

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

metformin.Additionallycontinuesulfonylureaswhenstartingbasalinsulintherapy.α-Glucosidaseinhibitorsmayalsobecontinued..目標(biāo)血糖：Aimforpre-breakfastandpre-main-evening-mealglucoselevelsof<6.0mmol/l(<110mg/dl);胰島素治療要點(diǎn)時(shí)機(jī);胰島素治療要點(diǎn)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(diǎn)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(xiǎn)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(xiǎn)因素控制血壓及降壓藥的選用全面控制心血管危險(xiǎn)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(xiǎn)因素降脂藥的推薦使用全面控制心血管危險(xiǎn)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(xiǎn)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(dǎo)致患者住院的因素Hospitalcareforpeoplewithdiabetesmayberequiredformetabolicemergencies,in-patientstabilizationofdiabetes,diabetesrelatedcomplications,intercurrentillnesses,Surgicalprocedures,andlabouranddelivery.Prevalenceofdiabetesinhospitalizedadultpatientsis12-25%ormore.導(dǎo)致患者住院的因素Hospitalcareforpeop住院治療的重點(diǎn)Evaluatebloodglucosecontrol,andmetabolicandvascularcomplications(inparticularrenalandcardiacstatus)priortoplannedprocedures;provideadviceonthemanagementofdiabetesonthedayordayspriortotheprocedure.Ensuretheprovisionanduseofanagreedprotocolforin-patientproceduresandsurgicaloperations.Aimtomaintainnear-normoglycaemiawithouthypoglycaemiabyregularquality-assuredbloodglucosetestingandintravenousinsulindeliverywhereneeded,generallyusingaglucose/insulin/potassiuminfusion.住院治療的重點(diǎn)Evaluatebloodglucose住院治療的重點(diǎn)Ensureawarenessofspecialriskstopeoplewithdiabetesduringhospitalprocedures,includingrisksfrom:neuropathy(heelulceration,cardiacarrest)intra-ocularbleedingfromnewvessels(vascularandothersurgeryrequiringanticoagulation)drugtherapy(risksofacuterenalfailurecausinglacticacidosisinpeopleonmetformin,forexamplewithradiologicalcontrastmedia)住院治療的重點(diǎn)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(diǎn)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(cè)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(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(gè)等級(jí)標(biāo)準(zhǔn)。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三個(gè)等級(jí)醫(yī)療標(biāo)準(zhǔn)

StandardCareMinimalCareComprehensiveCare三個(gè)等級(jí)醫(yī)療標(biāo)準(zhǔn)

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(zhǎng)。無論是在發(fā)達(dá)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(zhǎng)的速度超過了發(fā)達(dá)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(dòng)能力,預(yù)期壽命縮短8-12年。1.發(fā)病人數(shù)日益增長(zhǎng)。無論是在發(fā)達(dá)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(cè)3.診斷及監(jiān)測(cè)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(biāo)準(zhǔn):WHO-1999criteriaHealthOrganization.Definition,DiagnosisandClassificationofDiabetesMellitusanditsComplications.ReportofaWHOConsultation.Part1:DiagnosisandClassificationofDiabetesMellitus.Geneva:WHO診斷標(biāo)準(zhǔn):WHO-1999criteriaHealthO診斷標(biāo)準(zhǔn)的解釋:糖尿病診斷是依據(jù)空腹、任意時(shí)間或OGTT中2小時(shí)血糖值空腹指至少8小時(shí)內(nèi)無任何熱量攝入任意時(shí)間指一日內(nèi)任何時(shí)間，無論上次進(jìn)餐時(shí)間及食物攝入量OGTT是指以75克無水葡萄糖為負(fù)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(shí)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(yàn)過程中不喝任何飲料、不吸咽、不做劇烈運(yùn)動(dòng)，無需臥床從口服第一口糖水時(shí)計(jì)時(shí)，于服糖后30分鐘、1小時(shí)、2小時(shí)及3小時(shí)取血（用于診斷可僅取空腹及2小時(shí)血）診斷標(biāo)準(zhǔn)的解釋:控制指標(biāo)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(biāo)水平血糖控制水平；每年全面檢測(cè)一次每年全面檢測(cè)一次檢測(cè)原則及目的Generalprinciplesinclude:

annualreviewofcontrolandcomplications;anagreedandcontinuallyupdateddiabetescareplan;andinvolvementofthemultidisciplinaryteamindeliveringthatplan,centredaroundthepersonwithdiabetes.檢測(cè)原則及目的Generalprinciplesincl臨床血糖監(jiān)測(cè)方法HbA1cperformedevery2to6monthsdependingonlevelandstabilityofbloodglucosecontrol,andchangeintherapy.Site-of-carecapillaryplasmaglucosemonitoringatrandomtimesofdayisnotgenerallyrecommended.臨床血糖監(jiān)測(cè)方法HbA1cperformedevery自我血糖監(jiān)測(cè)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(cè)方法Self-monitoringofblo對(duì)尿糖監(jiān)測(cè)的評(píng)價(jià)Urineglucosetestingischeapbuthaslimitations.Urinefreeofglucoseisanindicationthatthebloodglucoselevelisbelowtherenalthreshold,whichusuallycorrespondstoabloodglucoselevelofabout10.0mmol/l(180mg/dl).Positiveresultsdonotdistinguishbetweenmoderatelyandgrosslyelevatedlevels,andanegativeresultdoesnotdistinguishbetweennormoglycaemiaandhypoglycaemia.對(duì)尿糖監(jiān)測(cè)的評(píng)價(jià)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(yùn)動(dòng)等更好地控制血糖、血壓、血脂等危險(xiǎn)因素。關(guān)于飲食；專家指導(dǎo)下制定個(gè)體營(yíng)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(yùn)動(dòng)量調(diào)整飲食量。關(guān)于運(yùn)動(dòng)：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(yùn)動(dòng)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(shí)機(jī)；

Pharmacologicaltherapyshouldbeconsideredifgoalsarenotachievedbetween3and6monthsafterinitiatingMNT.口服藥物治療時(shí)機(jī)；雙胍類應(yīng)用要點(diǎn)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(diǎn)Beginwithmetforminun磺脲類應(yīng)用要點(diǎn)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(diǎn)Usesulfonylureaswhen快速促胰島素分泌劑應(yīng)用要點(diǎn)Rapid-actinginsulinsecretagoguesmaybeusefulasanalternativetosulfonylureasinsomeinsulin-sensitivepeoplewith.exiblelifestyles.快速促胰島素分泌劑應(yīng)用要點(diǎn)Rapid-actinginsu噻唑烷二酮類應(yīng)用要點(diǎn)UseaPPAR-γagonist(thiazolidinedione)whenglucoseconcentrationsarenotcontrolledtotargetlevels,addingittometforminasanalternativetoasulfonylurea,ortoasulfonylureawheremetforminisnottolerated,ortothecombinationofmetforminandasulfonylurea.Bealerttothecontra-indicationofcardiacfailure,andwarnthepersonwithdiabetesofthepossibilityofdevelopmentofsigni.cantoedema.噻唑烷二酮類應(yīng)用要點(diǎn)UseaPPAR-γagonist糖酐酶抑制劑類應(yīng)用要點(diǎn)Useα-glucosidaseinhibitorsasafurtheroption.Theymayalsohavearoleinsomepeopleintolerantofothertherapies.Systematicreviewsoftheα-glucosidaseinhibitorshavenotfoundreasontorecommendthemoverlessexpensiveandbettertolerateddrugs.糖酐酶抑制劑類應(yīng)用要點(diǎn)Useα-glucosidasei胰島素治療要點(diǎn)時(shí)機(jī);

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

metformin.Additionallycontinuesulfonylureaswhenstartingbasalinsulintherapy.α-Glucosidaseinhibitorsmayalsobecontinued..目標(biāo)血糖：Aimforpre-breakfastandpre-main-evening-mealglucoselevelsof<6.0mmol/l(<110mg/dl);胰島素治療要點(diǎn)時(shí)機(jī);胰島素治療要點(diǎn)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(diǎn)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(xiǎn)因素控制血壓及降壓藥的選用ACE-inhibitorsandA2RBsmayoffersomeadvantagesoverotheragentsinsomesituations(seeKidneydamage,Cardiovascularriskprotection)startwithβ-adrenergicblockersinpeoplewithangina,β-adrenergicblockersorACE-inhibitorsinpeoplewithpreviousmyocardialinfarction,ACEinhibitorsordiureticsinthosewithheartfailure.ca