2019年整理新诊断2型糖尿病治疗方案探讨参考课件.pptVIP

* * IDF2005年指南指出：只要有肾脏损害的证据或潜在风险，就不要自双胍起始。“Begin with metformin unless evidence or risk of renal impairment”, “Monitor renal function and risk of signifi cant renal impairment (eGFR 60 ml/min/1.73 m2) in people taking metformin”. Metformin is not protein bound and is eliminated unchanged via the kidney by both glomerular ultrafiltration and tubular secretion, with an elimination half-life that has been reported to range from 1.5 to 8.7 hours (10,14). About 90% of a dose is excreted within 12–24 hours (15,16). The estimated incidence of metformin-induced lactic acidosis, which has a mortality of about 30–50%, is approximately 0.03 cases per 1000 patient-years, As GFR declines, metformin accumulates, and this is felt to be a significant risk factor for the development of lactic acidosis. Additional risk factors for metformin-induced lactic acidosis include congestive heart failure, diabetes mellitus, advanced age, alcohol use, administration of iodinated radiographic contrast media (causing acute renal failure), and any other condition associated with hypoxemia and/or hypotension (14). Several case reports have linked metformin-induced lactic acidosis to acute renal failure due to surgery or contrast nephropathy., Because of the risk of lactic acidosis, metformin should not be used in patients with serum creatinine levels of ≥?1.4 mg/dl in women and ≥?1.5 mg/dl in men * * Rosiglitazone and pioglitazone are virtually completely hepatically metabolized, each forming several metabolites Rosiglitazone, which has an elimination half-life of 3–4 hours, has two major metabolites, neither of which is active, and less than 1% of the parent drug appears in the urine in unchanged form 。both rosiglitazone and pioglitazone, there is no accumulation of the parent drug or the major metabolites in the setting of renal insufficiency 。Hemodialysis does not affect the pharmacokinetics of these drugs. It is therefore not necessary to reduce the dosages of pioglitazone and rosiglitazon