糖尿病防治首席医生培训（2013年）.pptVIP

* 在上述胰岛素起始治疗的基础上，经过充分的剂量调整，如患者的血糖水平仍未达标或出现反复的低血糖，需进一步优化治疗方案。可以采用餐时+基础胰岛素或每日3次预混胰岛素类似物进行胰岛素强化治疗。 多次皮下注射胰岛素：开始使用餐时+基础胰岛素方案时，可在基础胰岛素的基础上采用仅在一餐前（如主餐）加用餐时胰岛素的方案。之后根据血糖的控制情况决定是否在其他餐前加用餐时胰岛素。 持续皮下胰岛素输注（CSII）：是胰岛素强化治疗的一种形式，需要使用胰岛素泵来实施治疗。经CSII给入的胰岛素在体内的药代动力学特征更接近生理性胰岛素分泌模式。 与多次皮下注射胰岛素的强化胰岛素治疗方法相比，CSII治疗与低血糖发生的风险减少相关。在胰岛素泵中只能使用短效胰岛素或速效胰岛素类似物。 * 于血糖较高的初发2型糖尿病患者，口服药物很难在短期内使血糖得到满意的控制和改善高血糖症状。临床试验显示在血糖水平较高的初发2型糖尿病患者中采用胰岛素治疗可显著改善高血糖所导致的胰岛素抵抗和β细胞功能下降。故新诊断的2型糖尿病伴有明显高血糖时可以短期使用胰岛素治疗，在高血糖得到控制和症状缓解后可根据病情调整治疗方案，如改用口服药治疗或单纯的医学营养治疗和运动治疗。应注意加强血糖的监测，及时调整胰岛素剂量，并注意尽量避免低血糖的发生。 * 患者可以根据个人需要和经济状况选择胰岛素注射装置（胰岛素注射笔，（胰岛素笔或者特充装置）、胰岛素注射器或胰岛素泵。 胰岛素注射装置的合理选择和正确的胰岛素注射技术是保证胰岛素治疗效果的重要环节。 * * * Biguanide (metformin) has additional clinical benefits such as weight stabilisation/reduction, reduction in hypertriglyceridaemia, lowering plasma fatty acids and HDL cholesterol. Common adverse events include abdominal discomfort and other gastrointestinal adverse effects. The most serious adverse event associated with metformin is lactic acidosis; although rare, the mortality rate is high.1 Sulphonylureas (e.g. glimepiride, glipizide) have been extensively used for the treatment of type 2 diabetes for nearly 50 years. Hypoglycaemia is the most common adverse effect of sulphonylurea therapy. Weight gain is regarded as a class effect of sulphonylurea therapy, typically amounting to 1–4kg and stabilising after approximately 6 months. Thiazolidinediones (e.g. pioglitazone, rosiglitazone) improve whole-body insulin sensitivity via multiple actions on gene regulation. Thiazolidinediones are associated with fluid retention with increased plasma volume, a reduced haematocrit and a decrease in haemoglobin concentration.1 Meglitinides (e.g. nateglinide, repaglinide) have a rapid onset of action and a short duration of hypoglycaemic effect which make them suitable for pre-prandial administration. A small increase in bodyweight can be expected in patients. Among insulin therapies (e.g. insulin aspart, insulin glulisine