李茵茵教授,山东省立医院保健科主任 山东省立医院保健内分泌科主任 山东大学教授 硕士研究生导师 山东省骨质疏松学会副主委 山东省老年学会副主委 山东省糖尿病学会委员 山东省女医师协会理事,从事内分泌工作30余年，对甲状腺疾病、甲状旁腺疾病、糖尿病及其并发症、 垂体及肾上腺疾病，骨质疏松 、肥胖症等疾病的诊治积累了丰富经验。,聚焦2013 AACE糖尿病管理路径 深度解析胰岛素治疗流程,山东省立医院 李茵茵 教授,AACE引领全球内分泌领域发展,始于1991年，由全球一流的临床内分泌学领导者创建，现已覆86个国家和地区，吸引全世界最好的临床内分泌医师成为会员 自建立之初制定并发布了内分泌领域众多疾病指南，指导全球内分泌疾病的规范化治疗，引领全球内分泌领域最新潮的治疗理念 协会取得了飞速发展，某种程度上使得美国内科学成果在世界上占有领先地位,AACE制定众多内分泌疾病的临床专科指南,Clinical Practice Guidelines for the Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Patient - 2013 Update: Cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery 2013 Clinical Practice Guidelines for Hypothyroidism in Adults: Cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. 2012 American Association of Clinical Endocrinologists Guidelines for Management of Dyslipidemia and Prevention of Atherosclerosis 2012 AACE Medical Guidelines for Clinical Practice for Diagnosis and Treatment of Menopause 2011 American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for the Diagnosis and Treatment of Acromegaly - 2011 Hyperthyroidism and Other Causes of Thyrotoxicosis: Management Guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists - 2011 American Association of Clinical Endocrinologists Medical Guidelines for Developing a Diabetes Mellitus Comprehensive Care Plan - 2011 American Association of Clinical Endocrinologists Guidelines for Clinical Practice for the Diagnosis and Treatment of Postmenopausal Osteoporosis 2010 American Association of Clinical Endocrinologists, Associazione Medici Endocrinologi, and European Thyroid Association Medical Guidelines for Clinical Practice for the Diagnosis and Management of Thyroid Nodules 2010 American Association of Clinical Endocrinologists Protocol for Standardized Production of Clinical Practice Guidelines - 2010 Update American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for Growth Hormone Use in Growth Hormone-deficient Adults and Transition Patients 2009 Update American Association of Clinical Endocrinologists and American Association of Endocrine Surgeons Medical Guidelines for the Management of Adrenal Incidentalomas 2009 American Association Of Clinical Endocrinologists, The Obesity Society, and American Society For Metabolic & Bariatric Surgery Medical Guidelines For Clinical Practice For The Perioperative Nutritional, Metabolic, And Non Surgical Support Of The Bariatric Surgery Patient 2008 AACE Medical Guidelines for Clinical Practice for Diagnosis and Treatment of Hypertension 2006 AACE Medical Guidelines for the Clinical Use of Dietary Supplements and Nutraceuticals 2003 AACE Medical Guidelines for the Clinical Practice for Evaluation and Treatment of Male Sexual Dysfunction: A Couples Problem- 2003 Update AACE Medical Guidelines for Clinical Practice for Evaluation and Treatment of Hypogonadism in Adult Male Patients- 2002 Update AACE Medical Guidelines for Clinical Practice for Evaluation and Treatment of Hyperthyroidism and Hypothyroidism 2002 AACE/AAES Medical/Surgical Guidelines for Clinical Practice for Management of Thyroid Carcinoma 2001 AACE Medical Guidelines for Clinical Practice for Diagnosis and Treatment of Hyperandrogenic Disorders 2001,https:/www.aace.com/publications/guidelines,AACE糖尿病管理路径更被专科医师所推崇,美国第22届AACE年会于2013年5月1日5日在凤凰城召开 备受瞩目的糖尿病管理路径在会议期间隆重颁布,Garber AJ, et al. Endocr Pract. 2013 Mar-Apr;19(2):327-36.,考来维仑,糖苷酶抑制剂,胰岛素 其他药物,= 较少的不良事件 或可能获益,单药治疗*,就诊时 A1c 7.5%,就诊时 A1c 7.5%,就诊时 A1c 9.0%,无症状,有症状,疾病的进展,* 所列药物顺序为用药推荐等级次序 * * 基于临床3期试验的数据,图例,二甲双胍 GLP-1 受体激动剂 DPP4-抑制剂 糖苷酶抑制剂 SGLT-2 * TZD SU/GLN 若治疗3个月后A1c6.5%， 加用第二种药物 （两药联合治疗）,两药联合治疗* GLP-1 受体激动剂,若3个月未能达标， 则胰岛素强化治疗,三药联合治疗*,血糖控制流程图,生活方式干预(包括医疗干预减轻体重),DPP4-抑制剂,TZD * SGLT-2 基础胰岛素,二甲双胍 或其他 一线药物,SU/GLN,快速释放型溴隐亭,若3个月后 仍未能达标， 则三药联合治疗,二甲双胍 或其他 一线药物,考来维仑,糖苷酶抑制,GLP-1 受体激动剂,TZD * SGLT-2 基础胰岛素,快速释放型溴隐亭,二线药物,DPP4-抑制剂,SU/GLN,两药联合治疗,三药联合治疗,或,加药或胰岛素强化治疗,= 谨慎使用,胰岛素起始及强化治疗方案,基础胰岛素起始治疗（长效）,TDD 0.1-0.2U/kg,TDD 0.2-0.3U/kg,每2-3天调整一次胰岛素剂量以达到血糖控制目标： 固定方案：TDD增加2U 根据FPG调整方案： FBG10mmol/L：增加4U FBG 7.8-10mmol/L：增加2U FBG 6.1-7.7mmol/L：增加1U 如发生低血糖，TDD： BG3.9mmol/L：减少10%-20% BG2.2mmol/L：减少20%-40%,血糖控制不达标*,*血糖目标 大部分T2D患者：A1c7%，空腹及餐前血糖6.1 mmol/L，且无低血糖发生 A1c和FBG目标可根据患者年龄、糖尿病病程、合并症、糖尿病并发症及低血糖风险进行调整,基础胰岛素起始治疗后可考虑停止或减少磺脲类药物（基础胰岛素类似物优于NPH）,加用GLP-1 RA 或DPP4-i,加餐时胰岛素,TDD：0.3-0.5U/kg 50%基础胰岛素类似物 50%餐时胰岛素类似物 NPH联合常规胰岛素治疗方案或预混胰岛素治疗方案不是理想选择，Less desirable,每2-3天调整一次胰岛素剂量以达到血糖控制目标： 增加基础胰岛素剂量： 固定方案：TDD增加2U 根据FPG调整方案： FBG10mmol/L：增加4U FBG 7.8-10mmol/L：增加2U FBG 5.6-7.7mmol/L：增加1U 餐时胰岛素：当餐后2h血糖或下一餐的餐前血糖10mmol/L，餐时胰岛素剂量增加10% 预混胰岛素剂量：当空腹或餐前血糖10mmol/L，预混胰岛素剂量增加10% 如发生晨间低血糖，减少基础胰岛素用量 如发生夜间低血糖，减少基础和/或晚餐前或临睡餐前的短效/速效胰岛素用量 如两餐间发生低血糖，减少上一餐的餐前短效/速效胰岛素用量,强化治疗（餐时控制）,2013AACE糖尿病管理路径 胰岛素治疗流程三大启示,启示一：基础胰岛素“地位提