胰岛素治疗方案解读讲义.pptVIP

* * * 门冬胰岛素30/50为例，起始方案为： 1.口服降糖药治疗不达标者，推荐早、晚各6U起始；2.正在应用人胰岛素30R/50R者，按等剂量原则转化为诺和锐30治疗，初始采用原方案；3.采用基础胰岛素治疗的患者，以等剂量原则转化为门冬胰岛素30治疗，早、晚餐前剂量以1:1比例分配 剂量调整： 主要根据空腹或餐前血糖水平调整注射剂量，再跟据餐后血糖精细调整剂量；首先调整晚餐前剂量，让空腹血糖达标；然后是调整早餐前剂量，让餐后血糖达标；一般3-5天调整一次，剂量调整指南如表格所示： * * 现有的基础胰岛素治疗方案面临挑战：有超过60%使用基础胰岛素治疗的患者，一年内需要加用第二种胰岛素和第二支注射笔以实现血糖达标。 一项由708名OAD不达标患者参与的非盲多中心对照研究显示，采用基础胰岛素组治疗1年达标率为27.8%，所以71.2%的患者需要加用第二种胰岛素；而另一项由785名患者参与的类似研究中,也得出了相似结论，在14周基础胰岛素治疗的导入期中，288/785即36.7%达标，因此63.3%的患者需要加用第二种胰岛素 * * * 餐后高血糖导致死亡风险增加 DECODA研究是一项著名的针对亚洲人群的流行病学研究，一共入组了6817名受试者，观察监测持续了5－10年。此项研究观察了空腹血糖和餐后血糖与死亡风险之间的关系，结果表明： 无论全因死亡还是心血管死亡，死亡风险并不随着空腹血糖的升高而增加，而随着餐后血糖的升高死亡风险急剧上升，这充分证明了餐后血糖对于减少糖尿病患者心血管患病率及死亡风险是至关重要的。 RESEARCH DESIGN AND METHODS:We undertook a prospective intervention trial to assess the relative contribution of controlling FPG and PPG for achieving recommended HbA1c goals. One hundred and sixty-four patients (90 male and 74 female) with unsatisfactory glycemic control (HbA1c /=7.5%) were enrolled in an individualized forced titration intensified treatment program. RESULTS:After 3 months HbA1c levels decreased from 8.7+/-0.1 to 6.5+/-0.1% (p0.001); FPG decreased from 174+/-4 to 117+/-2mg/dl (p0.001); PPG decreased from 224+/-4 to 159+/-3mg/dl (p0.001) and daylong hyperglycemia (average of premeal, postprandial and bedtime plasma glucose excluding FPG) decreased from 199+/-4 to 141+/-2mg/dl (p0.0001). Patients weight remained unchanged (84.0+/-1.4kg versus 82.9+/-1.5kg, p=0.36). No severe hypoglycemia occurred. Only 64% of patients achieving FPG targets of 100mg/dl achieved an HbA1c target of 7% whereas 94% of patients achieving the postprandial target of 140mg/dl did. Decreases in PPG accounted for nearly twice as much for the decreases in HbA1c as did decreases in FPG. PPG accounted approximately 80% of HbA1c when HbA1c was 6.2% and only about 40% when HbA1c was above 9.0%. CONCLUSIONS:Control of fasting hyperglycemia is necessary but usually insufficient for achieving HbA1c goals 7%. Control of postpr