Global Guideline for Type 2 Diabetes2型糖尿病全球防治指南新特点型糖尿病全球防治指南新特点 Global Guideline for Type 2 DiabetesGlobal Guideline for Type 2 Diabetes内容概括内容概括1.背景资料背景资料 2.糖尿病危害性糖尿病危害性 3.诊断及监测诊断及监测4.治疗概论治疗概论 5.住院病人治疗原则住院病人治疗原则Global Guideline for Type 2 Diabetes1.背景资料背景资料Global Guideline for Type 2 Diabetes1. 根据循证医学原则制定根据循证医学原则制定,内容参考内容参考近近5年来国际上出版的指南、年来国际上出版的指南、meta分析、及相关刊物。分析、及相关刊物。2. 根据不同地区、不同医疗资源制根据不同地区、不同医疗资源制定定3个等级标准。个等级标准。Global Guideline for Type 2 Diabetes三个等级医疗标准三个等级医疗标准Standard Care Minimal Care Comprehensive Care Global Guideline for Type 2 Diabetes2.糖尿病危害性糖尿病危害性Global Guideline for Type 2 Diabetes1. 发病人数日益增长。发病人数日益增长。无无论是在是在发达国家达国家还是在是在发展展中国家，均明中国家，均明显增加。其中增加。其中90%90%为2 2型糖尿病型糖尿病。（见下图）。（见下图）2. 发展中国家增展中国家增长的速度超的速度超过了了发达国家。（达国家。（200%200%比比45%45%），），2121世世纪DM 将在中国、印度等将在中国、印度等发展中国家流行展中国家流行 。3. DM 的主要并的主要并发症已症已经成成为病人致残和早亡的主要病人致残和早亡的主要原因，原因，每年全球约每年全球约 3 000 000 人口因糖尿病而死亡。人口因糖尿病而死亡。4. 2 2型糖尿病占我国糖尿病人群的型糖尿病占我国糖尿病人群的90%90%以上，它的血管以上，它的血管并并发症使人症使人们丧失失劳动能力能力, ,预期寿命期寿命缩短短8-128-12年。年。Global Guideline for Type 2 Diabetes P.Zimmet et al.Bulletin of the International Diabetes Federation 48:13,2003Global Guideline for Type 2 Diabetes A much quoted paper by Haffner et al, A much quoted paper by Haffner et al, suggested that people with Type 2 diabetes suggested that people with Type 2 diabetes have a CV risk equivalent to non-diabetic have a CV risk equivalent to non-diabetic people with previous CVDpeople with previous CVD。Haffner SM, Lehto S, R鰊nemaa T, Pyorala K, Laakso M.Mortality from coronary heart disease in subjects with type 2diabetes and in nondiabetic subjects with and without prior myocardial infarction. N Engl J Med 1998; 339: 229-34.Global Guideline for Type 2 Diabetes 糖尿病急性并发症及大血管和微血管等慢性并糖尿病急性并发症及大血管和微血管等慢性并发症，致死、致残率高，一旦发生，难以逆转，发症，致死、致残率高，一旦发生，难以逆转，降低病人的生活质量，缩短寿命。降低病人的生活质量，缩短寿命。Global Guideline for Type 2 Diabetes 3. 诊断及监测诊断及监测Global Guideline for Type 2 Diabetes提倡早期诊断早期诊断的意义；早期诊断的意义；Type 2 diabetes has a long asymptomatic pre-clinical phasewhich frequently goes undetected. At the time of diagnosis,over half have one or more diabetes complications.Retinopathy rates at the time of diagnosis range from 20 %to 40 %.Of people with Type 2 diabetes, the proportion who areundiagnosed ranges from 30 % to 90 %. SM, Meyer LC, Neil HAW, Ross IS, Turner RC,Holman RR. Complications in newly diagnosed type 2 diabetic patients and their association with different clinical and biochemical risk factors. UKPDS 6. Diabetes Res 1990; 13: 1-11. Harris MI, Klein R, Welborn TA, Knuiman MW. Onset of NIDDM occurs at least 4-7 yr before clinical diagnosis.Diabetes Care 1992; 15: 815-19. UKPDS Group. UK Prospective Diabetes Study 30: Diabetic retinopathy at diagnosis of type 2 diabetes and associated risk factors. Arch Ophthalmol 1998; 116: 297-303.Global Guideline for Type 2 Diabetes早期诊断早期诊断的方法早期诊断的方法-目前全球根据各地区约有目前全球根据各地区约有30%-90%糖尿病漏诊率糖尿病漏诊率. For diagnosis, an oral glucose tolerance test (OGTT) should be performed in people with a fasting plasma glucose 5.6 mmol/l (100 mg/dl) and 7.0 mmol/l (126 mg/dl); Where a random plasma glucose level 5.6 mmol/l (100 mg/dl) and 11.1 mmol/l (200 mg/dl) is detected on opportunistic screening, it should be repeated fasting, or an OGTT performed.Global Guideline for Type 2 Diabetes诊断标准诊断标准:WHO-1999 criteriaHealth Organization. Definition, Diagnosis and Classification of Diabetes Mellitus and its Complications.Report of a WHO Consultation. Part 1: Diagnosis and Classification of Diabetes Mellitus. Geneva: WHOGlobal Guideline for Type 2 Diabetes诊断标准的解释诊断标准的解释:糖尿病诊断是依据空腹、任意时间或OGTT中2小时血糖值空腹指至少8小时内无任何热量摄入任意时间指一日内任何时间，无论上次进餐时间及食物摄入量OGTT是指以75克无水葡萄糖为负荷量，溶于水内口服(如用1分子结晶水葡萄糖，则为82.5克。OGTT的方法的方法:早餐空腹取血(空腹8-14小时后），取血后于5分钟内服完溶于250-300ml水内的无水葡萄糖75克（如用1分子结晶水葡萄糖，则为82.5克）试验过程中不喝任何饮料、不吸咽、不做剧烈运动，无需卧床从口服第一口糖水时计时，于服糖后30分钟、1小时、2小时及3小时取血（用于诊断可仅取空腹及2小时血）Global Guideline for Type 2 Diabetes控制指标水平血糖控制水平；血糖控制水平；HbA1c HbA1c 6.5 % 6.5 %Equivalent target levels for capillary plasma glucose levels are 6.0 mmol/l(110 Equivalent target levels for capillary plasma glucose levels are 6.0 mmol/l(110 mg/dl) before meals, and 8.0 mmol/l (145 mg/dl) 1-2 h after meals.mg/dl) before meals, and 8.0 mmol/l (145 mg/dl) 1-2 h after meals.血脂控制水平血脂控制水平Reassess at all routine clinical contacts to review achievement of lipid targets:Reassess at all routine clinical contacts to review achievement of lipid targets:LDL cholesterol 2.5 mmol/l (95 mg/dl), LDL cholesterol 2.5 mmol/l (95 mg/dl), triglyceride 2.3 mmol/l(200 mg/dl), triglyceride 2.3 mmol/l(1.0 mmol/l (39 mg/dl).HDL cholesterol 1.0 mmol/l (39 mg/dl).血压控制水平血压控制水平Aim to maintain blood pressure below 130/80 mmHgAim to maintain blood pressure below 130/80 mmHgAccept that even 140/80 mmHg may not be achievable with 3 to 5 antihypertensive Accept that even 140/80 mmHg may not be achievable with 3 to 5 antihypertensive drugs in some people.drugs in some people.Revise individual targets upwards if there is signi. cant risk of postural Revise individual targets upwards if there is signi. cant risk of postural hypotension and falls.hypotension and falls.Global Guideline for Type 2 Diabetes每年全面检测一次Global Guideline for Type 2 Diabetes检测原则及目的General principles include: annual review of control and complications; an agreed and continually updated diabetes care plan; and involvement of the multidisciplinary team in delivering that plan, centred around the person with diabetes.Global Guideline for Type 2 Diabetes临床血糖监测方法临床血糖监测方法HbA1c performed every 2 to 6 months HbA1c performed every 2 to 6 months depending on level and stability of blood depending on level and stability of blood glucose control,and change in therapy.glucose control,and change in therapy.Site-of-care capillary plasma glucose Site-of-care capillary plasma glucose monitoring at random times of day is not monitoring at random times of day is not generally recommended.generally recommended.Global Guideline for Type 2 Diabetes自我血糖监测方法自我血糖监测方法Self-monitoring of blood glucose (SMBG) should be available to those;For all newly diagnosed people with Type 2 diabetes;For all newly diagnosed people with Type 2 diabetes;those on insulin treatment; those on insulin treatment; to provide information on hypoglycaemia;to provide information on hypoglycaemia;to assess glucose excursions due to medications and lifestyle changesto assess glucose excursions due to medications and lifestyle changesto monitor changes during intercurrent illness.to monitor changes during intercurrent illness.SMBG can be considered in relation to:can be considered in relation to:outcomes (a decrease in HbA1c with the ultimate aim of decreasing risk outcomes (a decrease in HbA1c with the ultimate aim of decreasing risk of complications)of complications)safety (identifying hypoglycaemia)safety (identifying hypoglycaemia)process (education, self-empowerment, changes in therapy).process (education, self-empowerment, changes in therapy).Global Guideline for Type 2 Diabetes对尿糖监测的评价对尿糖监测的评价Urine glucose testing is cheap but has limitations. Urine Urine glucose testing is cheap but has limitations. Urine free of glucose is an indication that the blood glucose free of glucose is an indication that the blood glucose level is below the renal threshold, which usually level is below the renal threshold, which usually corresponds to a blood glucose level of about 10.0 mmol/l corresponds to a blood glucose level of about 10.0 mmol/l (180 mg/dl).(180 mg/dl).Positive results do not distinguish between moderately and Positive results do not distinguish between moderately and grossly elevated levels, and a negative result does not grossly elevated levels, and a negative result does not distinguish between normoglycaemia and hypoglycaemia.distinguish between normoglycaemia and hypoglycaemia.Global Guideline for Type 2 Diabetes4.治疗概论治疗概论Global Guideline for Type 2 Diabetes生活方式干预治疗生活方式干预治疗目的：通过调整生活方式，如饮食、运动等更好地控制血糖、通过调整生活方式，如饮食、运动等更好地控制血糖、血压、血脂等危险因素。血压、血脂等危险因素。关于饮食；专家指导下制定个体营养需求方案专家指导下制定个体营养需求方案; ;严格限制高热量、高脂食物、食盐及酒精等；严格限制高热量、高脂食物、食盐及酒精等；根据降糖药（口服药及胰岛素）及运动量调整饮食量。根据降糖药（口服药及胰岛素）及运动量调整饮食量。关于运动：Encourage increased duration and frequency of physical activity (where Encourage increased duration and frequency of physical activity (where needed), up to 30-45 minutes on 3-5 days per week, needed), up to 30-45 minutes on 3-5 days per week, or an accumulation of 150 minutes of physical activity per week.or an accumulation of 150 minutes of physical activity per week.Global Guideline for Type 2 Diabetes生活方式干预治疗利益生活方式干预治疗利益Randomized controlled trials and outcome studies of medical nutrition therapy (MNT) in the management of Type 2 diabetes have reported improved glycaemic outcomes (HbA1c decreases of 1.0-2.0 %, depending on the ration of diabetes).In a meta-analysis of non-diabetic people, MNT restricting saturated fats to 7-10 % of daily energy and dietary cholesterol to 200-300 mg daily resulted in a 10-13 % decrease in total cholesterol, 12-16 % decrease in LDL cholesterol and 8 % decrease in triglycerides.A meta-analysis of studies of non-diabetic people reported that reductions in sodium intake to 2.4 g/day decreased blood pressure by 5/2 mmHg in hypertensive subjects. beside,that weight loss,increased physical activity, a low-fat diet that includes fruits, vegetables and low-fat dairy products, reducing blood pressure.Global Guideline for Type 2 Diabetes生活方式干预治疗利益生活方式干预治疗利益A meta-analysis of exercise (aerobic and resistance training)reported an HbA1c reduction of 0.66 %, independent of changes in body weight, in people with Type 2 diabetes.In long-term prospective cohort studies of people with Type 2 diabetes, higher physical activity levels predicted lower longterm morbidity and mortality and increases in insulin sensitivity.Interventions included both aerobic exercise (such as walking) and resistance exercise (such as weight-lifting).Global Guideline for Type 2 Diabetes口服药物治疗口服药物治疗时机；时机； Pharmacological therapy should be considered if Pharmacological therapy should be considered if goals are not achieved between 3 and 6 months goals are not achieved between 3 and 6 months after initiating MNT.after initiating MNT.Global Guideline for Type 2 Diabetes双胍类应用要点双胍类应用要点Begin with metformin unless evidence or isk of renal impairment, Begin with metformin unless evidence or isk of renal impairment, titrating the dose over early weeks to minimize discontinuation titrating the dose over early weeks to minimize discontinuation due to gastro-intestinal intolerance.Monitor renal function and due to gastro-intestinal intolerance.Monitor renal function and risk of signi. cant renal impairment eGFR 60 ml/min/1.73 m2) risk of signi. cant renal impairment eGFR 7.5 generally when DCCT-aligned HbA1c has deteriorated to 7.5 % (confirmed) on maximal oral agents.% (confirmed) on maximal oral agents.可继续联用可继续联用 metformin.metformin.Additionally continue sulfonylureas when starting basal insulin therapy.Additionally continue sulfonylureas when starting basal insulin therapy.-Glucosidase inhibitors may also be continued.-Glucosidase inhibitors may also be continued. .目标血糖：目标血糖： Aim for pre-breakfast Aim for pre-breakfast and and pre-main-evening-meal glucose pre-main-evening-meal glucose levels of 6.0 mmol/l(110 mg/dl);levels of 6.0 mmol/l(40 yr old (or all with declared CVD).a statin at standard dose for all 40 yr old (or all with declared CVD).a statin at standard dose for all 20 yr old with microalbuminuria or a statin at standard dose for all 20 yr old with microalbuminuria or assessed as being at particularly high risk.assessed as being at particularly high risk.in addition to statin, fenoin addition to statin, fenofibrate where serum triglycerides are 2.3 brate where serum triglycerides are 2.3 mmol/l(200 mg/dl), once LDL cholesterol is as optimally controlled as mmol/l(200 mg/dl), once LDL cholesterol is as optimally controlled as possible.possible.consideration of other lipid-lowering drugs (ezetimibe, sustained consideration of other lipid-lowering drugs (ezetimibe, sustained release nicotinic acid, concentrated omega 3 fatty acids) in those release nicotinic acid, concentrated omega 3 fatty acids) in those failing to reach lipidlowering targets or intolerant of conventional failing to reach lipidlowering targets or intolerant of conventional drugs.drugs.Global Guideline for Type 2 Diabetes全面控制心血管危险因素全面控制心血管危险因素小剂量应用抗血小板药物小剂量应用抗血小板药物Provide aspirin 75-100 mg daily (unless aspirin intolerant Provide aspirin 75-100 mg daily (unless aspirin intolerant or blood pressure uncontrolled) in people with evidence of or blood pressure uncontrolled) in people with evidence of CVD or at high risk.CVD or at high risk.Arrange smoking cessation advice in Arrange smoking cessation advice in smokers contemplative of reducing or smokers contemplative of reducing or stopping tobacco consumption.stopping tobacco consumption.Global Guideline for Type 2 Diabetes5.住院病人治疗原则住院病人治疗原则Global Guideline for Type 2 Diabetes导致患者住院的因素导致患者住院的因素Hospitalcare for people with diabetes may be Hospitalcare for people with diabetes may be required for required for metabolic emergencies, metabolic emergencies, in-patient stabilization of diabetes, diabetesrelated in-patient stabilization of diabetes, diabetesrelated complications, complications, intercurrent illnesses, intercurrent illnesses, Surgical procedures, Surgical procedures, and labour and delivery.and labour and delivery.Prevalence of diabetes in hospitalized adult Prevalence of diabetes in hospitalized adult patients is 12-25 % or more.patients is 12-25 % or more.Global Guideline for Type 2 Diabetes住院治疗的重点住院治疗的重点Evaluate blood glucose control, and metabolic and vascular Evaluate blood glucose control, and metabolic and vascular complications (in particular renal and cardiac status) complications (in particular renal and cardiac status) prior to planned procedures; provide advice on the prior to planned procedures; provide advice on the management of diabetes on the day or days prior to the management of diabetes on the day or days prior to the procedure.procedure.Ensure the provision and use of an agreed protocol for in-Ensure the provision and use of an agreed protocol for in-patient proceduresand surgical operations.patient proceduresand surgical operations.Aim to maintain near-normoglycaemia without hypoglycaemia Aim to maintain near-normoglycaemia without hypoglycaemia by regular quality-assured blood glucose testing and by regular quality-assured blood glucose testing and intravenous insulin delivery where needed, generally using intravenous insulin delivery where needed, generally using a glucose/insulin/potassium infusion.a glucose/insulin/potassium infusion.Global Guideline for Type 2 Diabetes住院治疗的重点住院治疗的重点Ensure awareness of special risks to people with diabetes Ensure awareness of special risks to people with diabetes during hospital procedures, including risks from:during hospital procedures, including risks from:neuropathy (heel ulceration, cardiac arrest)neuropathy (heel ulceration, cardiac arrest)intra-ocular bleeding from new vessels (vascular and other surgery intra-ocular bleeding from new vessels (vascular and other surgery requiring anticoagulation)requiring anticoagulation)drug therapy (risks of acute renal failure causing lactic acidosis in drug therapy (risks of acute renal failure causing lactic acidosis in people on metformin, for example with radiological contrast media)people on metformin, for example with radiological contrast media)Global Guideline for Type 2 Diabetes急症处理原则急症处理原则Provide access to intensive care units (ICU) for life-Provide access to intensive care units (ICU) for life-threatening illness, ensuring that strict blood glucose threatening illness, ensuring that strict blood glucose control, usually with intravenous insulin therapy, is a control, usually with intravenous insulin therapy, is a routine part of system support for anyone with routine part of system support for anyone with hyperglycaemia.hyperglycaemia.Provide protocol-driven care to ensure detection and Provide protocol-driven care to ensure detection and immediate control of hyperglycaemia for anyone with a immediate control of hyperglycaemia for anyone with a presumed acute coronary event or stroke, normally using presumed acute coronary event or stroke, normally using intravenous insulin therapy with transfer to subcutaneous intravenous insulin therapy with transfer to subcutaneous insulin therapy once stable and eating.insulin therapy once stable and eating.Global Guideline for Type 2 Diabetes