内分泌系统疾病诊治思维课件.pptVIP

* 上图是本指南建议的2型糖尿病高血糖治疗路径。绿色路径是根据药物的卫生经济学、疗效和安全性的临床证据以及我国国情等因素权衡考虑后推荐的主要药物治疗路径，与国际上大部分糖尿病指南中建议的药物治疗路径相似。黄色路径为与绿色路径相应的备选路径。 2型糖尿病药物治疗的首选药物是二甲双胍。如果没有禁忌证，二甲双胍应一直保留在糖尿病的治疗方案中。不适合二甲双胍治疗者可选择胰岛素促分泌剂或?-糖苷酶抑制剂。 如单独使用二甲双胍治疗而血糖仍未达标，则可加用胰岛素促分泌剂或?-糖苷酶抑制剂（二线治疗）。不适合使用胰岛素促分泌剂或?-糖苷酶抑制剂者可选用TZDs或二肽基肽酶-4（DPP-4）抑制剂。不适合二甲双胍者可采用其他口服药间的联合治疗。 两种口服药联合治疗而血糖仍不达标者，可加用胰岛素治疗（每日1次基础胰岛素或每日1~2次预混胰岛素）或采用3种口服药间的联合治疗。胰高血糖素样肽-1（GLP-1）受体激动剂可用于三线治疗。 如基础胰岛素或预混胰岛素与口服药联合治疗控制血糖仍不达标，则应将治疗方案调整为多次胰岛素治疗（基础胰岛素加餐时胰岛素或每日3次预混胰岛素类似物）。采用预混胰岛素治疗和多次胰岛素治疗时应停用胰岛素促分泌剂。 * * * * Sulphonylureas (e.g. glyburide, glipizide, chlorpropamide) lower fasting blood glucose concentrations primarily by stimulating insulin secretion through interaction with potassium-sensitive ATP channels in the pancreatic β-cell membrane, resulting in calcium uptake and insulin release.1 Meglitinides (e.g. repaglinide) bind to ATP-sensitive potassium channels on pancreatic β-cells, increase insulin secretion, and reduce blood glucose.1 Metformin lowers blood glucose by inhibiting hepatic glucose production and enhancing insulin-stimulated glucose transport in skeletal muscle.1 ?-glucosidase inhibitors (e.g. acarbose) slow the rate of carbohydrate digestion, thereby providing an alternative means to reduce postprandial hyperglycaemia.1 DPP-4 inhibitors (e.g. sitagliptin, vildagliptin) prevent the inactivation of glucagon-like peptide-1 (GLP?1). This increases circulating levels of active GLP-1, stimulates insulin secretion and inhibits glucagon secretion, resulting in lowering of glucose levels.2 GLP-1 agonists (e.g. exenatide, liraglutide) mimic the action of GLP-1, a gut hormone released post-prandially, which stimulates insulin secretion and insulin gene expression as well as pancreatic β-cell growth.3 Thiazolidinediones (e.g. rosiglitazone, pioglitazone) decrease insulin resistance in fat, muscle and liver. In addition, they improve estimates of ?-cell function.4 Sodium glucose transporter-2 inhibitors (currently in clinical development,