用优泌乐25起始胰岛素治疗病例分享.pptx

用优泌乐25起始胰岛素治疗病例分享 郴州市第一人民医院内分泌主任 陶松桔 11月1号病例138岁女性，5年前体检时发现血糖高: FBG 8.6mM, 2hBG 14.2mM，血脂TC 4.2mmol/L，LDL-C 2.3mmol/L，TG 1.9 mmol/L。体重正常（H:160cm, W:55kg)，血压126/78mmHg。有DM家族史。予生活方式干预及二甲双胍治疗。但患者服药后消化道反应明显，体重下降，故患者不愿继续服二甲双胍。停用二甲双胍，改为格列吡嗪５mg Tid治疗，血糖控制尚可，HbA1c维持在6.5%-7%。每年行眼底检查正常，尿ACR正常。近1年患者血糖逐渐升高，空腹血糖7.5mM 左右，餐后血糖10.5-16.7mM，1周前查HbA1c 7.8%，患者希望医生调整治疗方案。从初诊至今体重下降4kg（51kg）病例 1该患者的主要问题：发病年龄早，有DM家族史，体重正常使用磺脲类药物治疗继发性失效，伴体重下降在饮食及活动量基本稳定的情况下血糖波动仍较大目前HbA1c 7.8%该患者的血糖控制目标？下一步治疗方案应如何调整？ 更宽松的控糖方案更严格的控糖方案患者态度和期望的治疗效果依从性高,自我管理能力好依从性低,自我管理能力差低血糖相关风险，其他不良事件发生率低高病程病程长新诊断平均寿命长短重要并发症无少/轻重资源，医疗系统丰富有限Diabetes Care 2012;35:1364-1379Diabetologia 2012;55:1577-1596MetforminInitial drugmonotherapyThree-drugcombinationsTwo-drugcombinationsahighlow riskneutral/lossGl/lactic acidosis lowMetforminMetforminMetforminMetforminHealthy eating,weight control,increased physical activityMetforminMetforminMetforminMetforminMetformin++++++++++MetforminThiazolidine-dioneSulfonylureabDPP-4 InhibitorGLP-1 receptoragonistInsulin(usuallybasal)DPP-4 InhibitorEfficacy( HbA1C)HypoglycemiaWeightSide effects CostsThiazolidine-dioneInsulin(usuallybasal)SulfonylureabGLP-1 receptoragonistIf needed to reach individualized HbA1c target after~3 months,proceed to two-drug combination (order not meant to denote any specific preference): +++++Efficacy( HbA1C)HypoglycemiaWeightMajor side effect(s) Costshighesthigh riskgainhypoglycemiacvariablehighmoderate riskgainhypoglycemiaclowhighlow riskgainEdema,HF,Fx,scHighintermediatelow riskneutralrarechighhighlow riskLossGlchighSUbSUbTZDSUbTZDDPP-4-iorTZDTZDorororDPP-4-iorDPP-4-iInsulindvInsulindvorGLP-1-RAGLP-1-RAGLP-1-RAororororIf needed to reach individualized HbA1c target after~3 months,proceed to three-drug combination (order not meant to denote any specific preference): orInsulindorInsulindvMore complexInsulin strategies If combination therapy that includes basal insulin has failed to achieve HbA1c target after 3-6months, proceed to a