课件：糖尿病胰岛素治疗.pptVIP

* 121. 来看一下控制空腹血糖的重要性。这里是24小时平均的血浆葡萄糖水平，是在睡前注射中效胰岛素治疗2型糖尿病。可以看到，如果将空腹血糖水平降到正常，你可以将血糖的曲线下面积降低50％。这就可以将HbA1C从11％降到正常。 * 去年芬兰发表一个报告，病人随机分组，疗程较长（1年）、安慰剂对照，分4组：睡前胰岛素（bedtime Ins,B Ins）分别加格列苯脲，加二甲双胍，加格列苯脲与二甲双胍，加早晨胰岛素。用的剂量为二甲双胍，早、晚餐前各500mg。格列苯脲早餐前3.5mg，晚餐前7.0mg。两种口服安慰剂，开始剂量1单位/1mmol/l空腹血糖。调节的剂量即当空腹血糖测定连续3次大于8mmol/l，再加4单位。如连续3次大于6mmol/l，再加2单位。注意这都是西方的数据，他们的平均体重都大于中国人，根据我们经验，不要用那么大剂量。 * 结果显示在4组中降HbA1c的效果都较好,都差不多降了2％左右，体重在B Ins＋格列苯脲组重了约4kg， B Ins＋二甲双胍组重了不到1kg，最少。B Ins +格列本脲＋二甲双胍组重了约3kg，B Ins ＋晨Ins组重了4kg。低血糖发生次数在B Ins ＋格列、B Ins +格列＋双胍及B Ins ＋晨Ins组均有3次左右。 B Ins +二甲双胍最少，1次左右。这些病人都是肥胖型，对胰岛素不太敏感，剂量用得较大平均二十几单位。并可见B Ins ＋二甲双胍组最终胰岛素用量最多，其HbA1c降得最多，因为其发生低血糖机会少，能够加量。 * 117. 下面看一下胰岛素与口服制剂的联合治疗。 * Conventionally, in view of the continuing action of soluble human insulin injected at breakfast and dinner, a morning and bedtime snack are recommended in children and adolescents using a twice-daily regimen. An afternoon snack is also often required as the NPH insulin administered in the morning is maximally-active between lunch and dinner. When using a rapid-acting insulin analogue which has a shorter duration of action than soluble human insulin, such as NovoRapid?, the size of the morning snack can often be reduced or eliminated entirely; this is often desirable in teenagers at school. If a bedtime snack is used, this should only be reduced if nocturnal hyperglycaemia becomes apparent on blood glucose testing. Given the high risk of nocturnal hypoglycaemia and the peak effects of dinnertime NPH insulin, bedtime snacks are often necessary in the paediatric age-group. * The design of the basal insulin regimen is important for the success of basal-bolus therapy. Several options are available, ranging from a single bedtime injection of NPH insulin to three or more daily basal injections. A balance must be found in each individual between the smoother basal insulin profile provided by multiple NPH insulin injections and the decreased convenience of more complex regimens. In general, bec